Access Medicine Clinical Rotation Cases Files Family Medicine, Section - Allergy, Immunological & Skin Conditions, Case Study - Skin Lesions
Discipline: Nursing
Type of Paper: Question-Answer
Academic Level: Undergrad. (yrs 3-4)
Paper Format: APA
Question
A 45-year-old woman presents to your office concerned about a “mole” on her face. She says that it has been present for years, but her husband has been urging her to have it checked. She denies any pain, itching, or bleeding from the site, and the mole has not changed in size. She has no significant past medical history, takes no medications, and has no allergies. She has no history of skin cancer in her family. She is an accountant by occupation.
On examination, the patient is normotensive, afebrile, and in no distress. The physical examination reveals a nontender, symmetric, 4-mm papule that is uniformly reddish-brown in color and located in the right nasolabial fold region. The lesion is well circumscribed, and the surrounding skin is normal in appearance. There are no other lesions in the area.
Questions
What is the most likely diagnosis?
What features indicate a benign versus malignant condition?
What is your next step?
Answers to Case 13: Skin Lesions
Summary: A 45-year-old healthy woman presents with
A skin lesion that is symmetric, with well-defined borders, relatively small (< 6 mm), and with uniform coloration
No obvious growth of the skin lesion and no history of itching or bleeding at the site
No family history of skin cancer
Features indicating benign versus malignant condition: Signs that are reassuring of a benign condition include:
Size less than 6 mm
Symmetric, uniform color
Well-defined borders
Next step: Reassurance and surveillance.
Analysis
Describe an approach to the evaluation of skin lesions. (EPA 1, 2)
Describe the features of a skin lesion in dermatologic terms. (EPA 1)
Describe which features of a lesion are typically benign and which are concerning for malignancy or potential malignancy. (EPA 1, 10)
Considerations
The criteria that are used to predict the likelihood of a benign versus malignant lesion are only guidelines; to be sure, not all malignant skin lesions present in the same manner, and a malignant melanoma is not always visibly pigmented. The bottom line is that all tools available should be used—the history of present illness, medical history of the patient, the family medical history, social and occupational history, and a pertinent review of systems—to arrive at a conclusion that is consistent with the physical examination.
Definitions
ABSCESS: A closed pocket containing pus.
BULLA: A blister greater than 0.5 cm in diameter (plural: bullae).
CYST: A closed, saclike, membranous capsule containing a liquid or semisolid material.
MACULE: A discoloration on the skin that is neither raised nor depressed.
NODULE: An elevated mass of rounded or irregular shape that is greater than 1 cm in diameter.
PAPULE: A small, circumscribed elevated lesion of the skin that is less than 1 cm in diameter.
PLAQUE: A plateau-like, raised, solid area on the skin that covers a large surface area in relation to its height above the skin.
ULCER: A lesion through the skin or mucous membrane resulting from loss of tissue.
VESICLE: A small blister less than 0.5 cm in diameter.
Clinical Approach
Epidemiology
There has been an increase in the morbidity and mortality of skin cancer in the past few decades in the United States. The American Academy of Dermatology estimated that almost 192,000 new cases of melanoma would be diagnosed in 2019, and the incidence is increasing. When considering nonmelanoma skin cancers, including basal cell carcinoma (BCC) or squamous cell carcinoma, approximately 5.5 million new cases of skin cancer are diagnosed annually.
The single most important risk factor for the development of skin cancer is exposure to natural and artificial ultraviolet (UV) radiation. It is also one of the only risk factors that can be avoided, and avoiding it can potentially prevent millions of new cases of skin cancer every year. Other risk factors include a prior history of skin cancer; a family history of skin cancer; fair skin; red or blonde hair; a propensity to burn easily; chronic exposure to toxic compounds such as creosote, arsenic, or radium; and a suppressed immune system.
Pathophysiology
Melanoma In Situ. No invasion has occurred in this type of melanoma, as the malignant melanocytes are localized to the epidermis. If diagnosed early, this type of lesion should be excised with 5- to 10-mm borders.
Superficial Spreading Melanoma. This is the most common type of melanoma in both sexes. As its name implies, this lesion spreads superficially along the top layers of skin before penetrating into the deep layers. The superficial, or radial, growth phase is slower than the vertical phase, which is when the lesion grows into the dermis and can invade other tissues or metastasize. Men are more commonly affected on the upper torso, whereas women are affected mostly on the legs. Common clinical features include raised borders, comprised of dark and light brown color, and also sometimes pinks, whites, grays, or blues.
Lentigo Maligna. Similar to the superficial spreading type, this lesion is most often found in the elderly (commonly diagnosed in the seventh decade of life), usually on chronic sun-damaged skin such as the face, ears, arms, and upper trunk. It is the least common of the four types of melanoma. Clinically, they are characterized as tan-to-brown lesions with very irregular borders.
Amelanotic Melanoma. This is an uncommon (less than 5%) melanoma that is nonpigmented and can clinically present as many other types of noncancerous conditions, including eczema, fungal infections, or basal or squamous cell carcinoma. Because of its lack of pigmentation, this type of melanoma usually remains undiagnosed until a more invasive stage as compared to other melanomas.
Acral Lentiginous Melanoma. This lesion is similar to the other two superficial melanomas in that it begins in situ, but it differs in many ways. This is the most common melanoma found in African Americans and Asians. This melanoma is usually found under the nails, on the soles of the feet, and on the palms of the hands; common clinical features include flat, irregular lesions that are dark brown to black.
Nodular Melanoma. This melanoma, unlike the others, is usually invasive at the time of diagnosis. This is the most aggressive and second most common type of melanoma (Figure 13–1). It is clinically characterized as mostly black, but occasionally brown, blue, gray, red, or tan, lesions that arise from nevi or normal skin.
Figure 13–1.
Examples of nodular melanoma. Reproduced with permission, from Wolff K, Johnson R, Saavedra AP, et al., eds. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 8th ed. 2017. Copyright © McGraw Hill LLC. All rights reserved.
Clinical Presentation
In 1985, it was noted by clinicians studying melanoma that there were several characteristic features of skin lesions that correlated with melanoma. Specifically, color variegation, border irregularity, asymmetry, and size greater than 6 mm in diameter were consistently observed with melanoma. This led to the ABCD acronym, which has been used extensively to determine the likelihood of a cancerous skin lesion (Table 13–1).
CLASSIC ABCDE CRITERIA FOR SUSPICIOUS SKIN LESIONS
One other criterion that is often used is the change in the size or appearance of the skin lesion. This is sometimes cited as E in the ABCD criteria and referred to as evolving and elevation. Benign lesions may present at birth, or any time thereafter, and several benign lesions may also present near the same point in time. However, a benign lesion, once present, will usually remain stable in size and appearance, whereas a malignancy will present as increasing in size or changing in appearance. Thus, it is useful to ask whether a “mole” has recently changed in appearance or has grown in size.
The “ugly duckling sign” may guide physical examination of skin lesions, as it is easy to remember and teach. Simply, as the name suggests, this alludes to the blatantly different appearance of the melanoma as compared to the other lesions the patient may have.
Another procedure that may aid the detection of melanoma in the family care provider’s office is dermoscopy. This is a magnification technique by which a skin lesion can be visualized for more detail regarding its pigment and structure. The dermascopic properties of a lesion may guide management in terms of either observing its evolution or performing a biopsy for further evaluation.
Treatment
Benign nevi need only be monitored visually. The patient can accomplish this after education on what to look for and when to come back for reevaluation.
Excision. In general, any preexisting nevus that has changed or any new pigmented lesion that exhibits any of the ABCDE signs should be excised completely with a 2- to 3-mm margin around the lesion. Larger lesions that may be cosmetically difficult to completely excise may be biopsied in several areas. If the pathology indicates a malignancy, the lesion should then be completely excised with appropriate margins by a physician trained in plastic surgical technique. Complete excision of malignant melanomas requires at least a 5 mm, and sometimes larger, margin. Once a patient has been identified as having a malignant skin lesion, the patient should be observed on an annual basis for any new or changing skin lesions. Excisional biopsies with narrow margins should be performed for suspicious lesions. If the entire lesion cannot be removed due to size or location, biopsies should be taken from the most suspicious parts of the lesion.
Prognosis. The prognosis of a patient with melanoma is based on the TNM stage of the disease. T stands for thickness in millimeters, N for the presence of metastatic lymph nodes, and M for the presence of distant metastases.
Prevention. Prevention is aimed at reducing exposure to UV radiation. When possible, avoid the sun between 10 AM and 4 PM; wear sun-protective clothing when exposed to sunlight; wear a sunscreen with a sun protection factor (SPF) of at least 15; and avoid artificial sources of UV radiation. The US Preventive Services Task Force (USPSTF) recommends behavioral counseling of young adults, adolescents, children, and parents of young children regarding minimizing exposure to UV radiation to reduce risk of skin cancer (grade B). For adults over the age of 24, the USPSTF recommends selective counseling for those with fair skin types to reduce exposure to UV radiation (grade C). The USPSTF, however, finds insufficient evidence to assess the balance of benefits and harms routine screening with whole-body examination in the general population for the early detection of skin cancer in adults (grade I). It should be kept in mind that these recommendations are for the general population. Special populations, including those with family history of skin cancers, prior history of benign or malignant cancer, and other risk factors, should be examined and managed appropriately on an individual basis.
Nonmelanoma Skin Cancers
Both basal cell and squamous cell carcinomas arise from the epidermal layer of the skin. The primary risk for these types of skin cancers is exposure to UV radiation, not only sun exposure but also tanning bed use. A history of actinic keratoses and human papillomavirus infection of the skin also raises the risk of squamous cell carcinomas.
Basal cell carcinomas (BCCs) are the most common of all cancers. They typically appear as pearly papules, often with a central ulceration or with multiple telangiectasias. Patients typically present with a growing lesion and sometimes complain that it bleeds or itches. BCCs rarely metastasize but can grow large and can be locally destructive. The primary treatment is excision.
Squamous cell carcinomas have a higher rate of metastasis than BCCs, but the risk is still low. These lesions are often irregularly shaped plaques or nodules with raised borders. They are frequently scaly, ulcerated, and bleed easily. Complete excision is the treatment of choice.
Case Correlation
See also Case 1 (Adult Male Health Maintenance), Case 11 (Adult Female Health Maintenance), and Case 48 (Fever and Rash).
The preventable risk factor common to all skin cancers is sun exposure. Recommend that your patients limit exposure to sunlight in the middle of the day, wear appropriate protective clothing, and use sunscreen.
The use of tanning beds is a risk factor for skin cancer.
There is no such thing as a “healthy tan.”
Clinicians should be aware that fair-skinned men and women older than 65 years, patients with atypical moles, and those with more than 50 moles constitute known groups at substantially increased risk for melanoma.
Excisional biopsy should be done for any lesion suspicious for melanoma. If the entire lesion cannot be removed due to size or location, full-thickness biopsies should be taken from the most suspicious parts of the lesion.
Question 1 of 4
A 36-year-old man is noted to have a bothersome “mole” that on biopsy reveals malignant melanoma. The pathologist comments that this histology is a very rare type of melanoma and usually escapes diagnosis until a more advanced stage. Which of the following is the most likely diagnosis?
Melanoma in situ
Superficial spreading melanoma
Amelanotic melanoma
Nodular melanoma
You will be able to view all answers at the end of your quiz.
The correct answer is C. You answered C.
Amelanotic melanoma is an uncommon type of melanoma and because of the lack of pigmentation, it often goes undiagnosed until it is more invasive and has progressed to an advanced stage. Answer A (melanoma in situ) is an intraepithelial lesion (stage 0) and consists of pigmented neoplastic cells that have not yet spread and therefore would not be advanced. Answer B (superficial spreading melanoma) is the most common type of melanoma (accounting for about 70% of cases) and spreads horizontally before penetrating deeper; therefore, it is less likely to metastasize. Answer D (nodular melanoma) is a dangerous and rapidly growing type of melanoma that is responsible for about half of melanoma deaths; although it is one that is advanced at the time of diagnosis, this is more due to its rapid growth than “escaping detection.” Nodular melanomas are not rare and account for 15% of melanomas.
Question 2 of 4
A 73-year-old woman presents to the office due to concern about several tan-colored moles on her arms, face, and ears that have progressively grown over the past 6 months. Upon further examination, the moles are determined to be between 6 and 8 mm with very irregular borders. The clinician decides to obtain an excisional biopsy. Which of the following skin lesions should the provider be most suspicious of based on the history and physical examination?
Benign nevus
Superficial spreading melanoma
Lentigo maligna melanoma
Acral lentiginous melanoma
You will be able to view all answers at the end of your quiz.
The correct answer is C. You answered C.
Lentigo maligna is most often found in the elderly, usually on chronic sun-damaged skin such as the face, ears, arms, and upper trunk. Think of this type as tan-colored lesions on sun-damaged skin that have very irregular borders. A benign nevus (answer A) would typically have regular, well-defined borders. Answer B (superficial spreading melanoma) is usually a slow-growing lesion and would not be as consistent with the history of a more rapidly progressive lesion. Answer D (acral lentiginous melanomas) usually presents on the extremities, soles, and hands and under the nails.
Question 3 of 4
A 45-year-old African American woman presents for a routine examination. You notice a 9-mm diameter lesion on the palm of her right hand that is dark black and slightly raised and has a notched border. When asked about it, she says that it has been present for about a year and is growing. A friend told her not to be concerned because, “Black people don’t get skin cancer.” Which of the following is your advice?
Her friend is correct, and this is nothing to worry about.
While anyone can get skin cancer, this lesion has primarily benign features and can be safely observed.
This lesion is suspicious for cancer, but this is most likely a metastasis from breast cancer.
This lesion is suspicious for a primary melanoma and needs further evaluation immediately.
You will be able to view all answers at the end of your quiz.
The correct answer is D. You answered D.
The lesion described is suspicious for an acral lentiginous melanoma, which commonly occurs on the extremities, such as the palms and soles, and needs immediate evaluation. While skin cancers are more common in persons with lighter skin, they can occur in persons with any skin color or tone; acral lentiginous melanomas especially have a higher risk in more darkly pigmented individuals. Therefore, answer A (her friend believes there is nothing to worry about) is incorrect since the lesion may lead to metastases. Answer B (lesion has benign features) is incorrect since the lesion has features that are concerning, such as notched borders and being raised. Answer C (metastatic from breast cancer) would be an unusual presentation as a pigmented lesion. Also, the most common areas for metastases from breast cancer are the chest wall, local lymph nodes, lungs, and liver.
Question 4 of 4
A 70-year-old woman presents for evaluation of a lesion on her left cheek. It has been present for several months. It is slowly enlarging and bleeds if she scratches it. On examination, you find a 7-mm diameter, pearly appearing papule with visible telangiectasias on the surface. Which of the following is the appropriate management of this lesion?
Close observation and reexamination in 3 months
Reassurance of the benign nature of the lesion
Excision
Local destruction by freezing with liquid nitrogen
You will be able to view all answers at the end of your quiz.
The correct answer is C. You answered C.
The lesion is most likely a BCC, which is the most common type of skin cancer, and should be treated with excision. BCCs appear as red patches, open sores, or shiny bumps with rolled edges or central indentation. They often occur on sun-exposed parts of the body. The description of a smooth, pearly tumor with telangiectasia is also a classic description. While the likelihood of metastatic spread is low, these lesions can grow and be locally destructive. The lesion does not appear to be benign (answer B) and should not merely be observed (answer A). Local destructive techniques (answer D) are best for the extremity or trunk because hypertrophic scars or hypopigmentation may occur; thus, local destructive techniques are usually not used on the face.