Diagnosis: Lentigo maligna
A 72-year-old female presented with a slowly enlarging, variegated tan-brown patch on her right cheek, which had been present for over two years. The lesion exhibited irregular borders and a non-uniform pigmentation, raising suspicion for a malignant process. Prompt recognition and management are crucial for preventing progression to invasive melanoma.
A 72-year-old female presented with a two-year history of a slowly enlarging, variegated tan-brown patch on her right cheek. The patient reported no associated symptoms such as itching or bleeding. On examination, the lesion was noted to have irregular borders and a mosaic pattern of pigmentation, which raised concern for malignancy.Location: Right cheekSize: Approximately 4 cm in diameterColor: Variegated tan-brownBorder: Irregular and poorly definedSurface: Flat and non-scaly
The lesion began as a small, flat brown spot that gradually increased in size over two years, without any known triggers. The patient has a significant sun exposure history, having spent many years gardening without adequate sun protection. She has no prior history of skin cancer, and her family history is notable for melanoma in a sibling. There are no significant social or occupational exposures reported.Onset: Gradual over two yearsTriggers: History of significant UV exposurePrevious treatments: NonePast medical history: Hypertension, controlledFamily history: Melanoma in a sibling
Acute / First-Line ManagementExcision with clear margins is the gold standard for treatment, typically aiming for a margin of 5 mm to ensure complete removal.For non-surgical candidates or those preferring non-invasive options, topical imiquimod (5% cream) can be used, applied daily for 5 days per week over 6-12 weeks.Workup and Diagnostic ConfirmationA biopsy, preferably an excisional biopsy, is necessary to confirm the diagnosis and assess for invasion.Dermatoscopic evaluation can aid in the assessment of the lesion's characteristics prior to biopsy.Long-Term ManagementRegular follow-up with skin examinations every 3-6 months is recommended to monitor for recurrence or new lesions.Education on sun protection measures is crucial to reduce the risk of new lesions.If invasive melanoma is diagnosed, staging and further management according to oncologic guidelines will be necessary.
Actinic keratosis: Typically presents as rough, scaly patches on sun-exposed skin; less pigmented and has a more defined border.Basal cell carcinoma: Often presents as a pearly nodule or ulcerated lesion; lacks the variegated pigmentation seen in this case.Squamous cell carcinoma: Can appear as a scaly patch or ulcer; usually has a more aggressive behavior and may present with symptoms.Melanocytic nevus: Usually has a uniform color and well-defined borders; may not have the irregular features characteristic of malignant lesions.Solar lentigo: Generally flat and uniformly colored; lacks the variegation and irregular borders of a malignant process.Melanoma: Can present similarly but often has asymmetry and color variation; requires immediate intervention.Dermatofibroma: Firm, raised lesions that are often brown; typically do not have the same border irregularity.Psoriasis: Presents as well-defined plaques with silvery scales, typically not pigmented.
High-Yield PearlsRecognition: Early identification of lentigo maligna is crucial to prevent progression to melanoma.Biopsy: Excisional biopsy is the preferred method for definitive diagnosis and treatment.Sun Protection: Education on sun safety is essential in preventing future lesions.Follow-Up: Regular dermatologic follow-up is necessary to monitor for recurrence or new lesions.Topical Therapy: Imiquimod can be considered for non-surgical candidates, although surgical excision remains the definitive treatment.A thorough understanding of skin lesions and their characteristics is vital in dermatology to ensure timely and effective management of potential malignancies.
Tags: lentigo maligna, melanoma in situ