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October 26, 2012 / molehunter

Small nondescript lesion on nose

A late middle aged white man presented with a 6 month history of a lesion on his nose which had bled or wept several times.

the lesion measured just under 5mm and is a rather nondescript macule. Time to apply the dermoscope.

Dermoscopy reveals several features which are not visible to the naked eye. The second dermoscopic image is ‘autocorrected’.

Note the arborising vessels, globules and irregular pigmented structures.

Autocorrected image. Does this show the features any better? Obviously you would not photoshop in features that weren’t there, but digitally editing for tone, brightness and contrast may help sometimes to see something that is there but subtle.

This has to be a BCC.  Remember the 4 classic dermoscopic features of a BCC-pink colour, tightly focussed tapering tree-like (arborising) vessels, micro ulcers and irregular pigmented structures. You don’t often see all 4 features in any one lesion, but the features we see here are very pronounced. We see typical BCC vessels plus a group of irregular blue/grey globules on the right and a cluster of irregular pigmented structures around the perimeter from 8 o’clock to 2 o’clock. Typical BCC. The site, history, skin type and age group are all right for BCC as well, and there are no features of any other kind of lesion. A sound holistic diagnosis can be made.

PS the light oval structure at 5 o’clock is irrelevant. Most likely its a blocked pore, a common enough finding on the nose.

At this site, excision with the requisite 4mm margin will probably require a technically challenging reconstruction, e.g. a rotation or bi-lobed flap or else a skin graft. This means you need to be sure of the diagnosis before doing the procedure. The dermoscopic findings are sufficiently clear in this case to avoid the need for a pre-operative confirmatory biopsy, thus saving money and time.

Dermoscopy allows a confident diagnosis to be made of this nondescript lesion at a smaller stage. If the patient had been diagnosed a year later with this twice the size, he will still live as BCC’s don’t metastasise, but a larger procedure and bigger scar would be necessary. Dermoscopy is not useful only for melanomas, it allows facial BCs to be detected as a smaller size which reduces morbidity and treatment cost.

LEARNING POINT compare and contrast the vessels within the lesion with the vesels of the backround skin. Can you see the difference?

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