Simple cases
Case 55
35-year-old woman has noticed a lump on her face for a few weeks
History
How long nave you have these changes?
For a few weeks and they seem to be growing.
It is always important to establish if you are dealing with an acute or chronic problem.
Do you spend a lot of time in the sun?
When I was younger, I was a sun worshiper. But today I can't tolerate the heat and avoid the sun most of time.
Sun exposure causes not only acute changes such as sunburn, but also chronic changes such as skin aging and many different tumors.
Have you had facial surgery? Do you have trouble with scars?
No, I have never had facial surgery. I have a scar on my back where they took off a mole and it doesn't look too great.
This question lets us exclude a post-traumatic lesion. An unsatisfactory scar on the back is hardly unusual.
Do you pick at facial lesions, such as pimples.
Sure, when I am stressed.
Manipulating lesions often leads to secondary infection and scarring.
Does anyone else in the family have skin problems?
My mother has psoriasis.
When the history is positive, one has to think of genodermatoses, or disorders such as psoriasis and atopic dermatitis which run in families, even if the genetics is unclear.
Have you treated these lesions?
No, I have not tried anything but cosmetics.
The appearance of skin lesions is often changed by various therapeutic measures.
Are you otherwise in good health?
I had chemo 2 years ago for a lymphoma. So far, so goodall the check-ups have been fine.
This could have easily been overlooked; now you have to think of cutaneous lymphoma, complications of chemotherapy, and cutaneous signs of malignancy.
Lesion
Choose the right efflorescences:
There are excessive small vessels in sites where the early lesions have regressed. On the face, it is always hard to tell if telangiectases are part of the disease picture, or just common innocent bystanders secondary to aging and sun exposure.
There are red-brown nodules which on diascopy have a classic apple jelly color.
There are papules, some of which are arranged in an annular fashion. This skin disease has many different faces.
An ulcer is a deep defect; this disease almost never ulcerates.
Diagnosis
Choose the right diagnosis:
Telangiectatic lesions on sun-exposed skin should suggest basal cell carcinoma, but this tumor develops over years or decades. On close examination, diascopy simply blanches the vessels. In addition, basal cell carcinoma is often ulcerated. If any doubt exists, do a biopsy.
Rosacea features erythema, telangiectases, papules and pustules, but with a far more chronic course.
Sarcoid has lupoid red-brown cutaneous granulomas with a classic appearance on diascopy. Sarcoidosis can start in the skin, sometimes just in scars. The biopsy is diagnostic. This patient deserves a complete evaluation.
Deep bacterial infections of the hair follicle can look granulomatous, but they are acute, painful and much more likely to be solitary.
There is no sign and no history for vesicles on an erythematous base, so this is not a good choice.
Therapy
Choose the right therapy(ies):
A biopsy is reasonable, but sarcoidosis cannot be cured by excision. You will just create scars, but the patient will get new lesions.
A possible choice, but usually not totally satisfactory and may lead to atrophy.
Systemic corticosteroids will definitely help the skin lesions, but in general are reserved for patients with systemic involvement (lungs, eyes).
Another possibility, but no guarantee of success.
Test
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