Simple cases
Case 39
75-year-old man presents with large brown spot on back.
History
How long have you noticed this spot?
I never even saw it. It is in a spot I can't see. My family doctor found it and sent me to you.
The time course is important when assessing any skin tumor.
Did anyone in your family have melanoma?
Melanoma? Not that I know.
It is reasonable to inquire about the family history, but this question may worry the patient. Be sure to reassure him that he does not have a melanoma.
Does it itch?
No. I never noticed it.
Occasionally these lesions start to itch and this problem then brings the patient to the doctor.
Are you otherwise healthy? Have you ever had cancer?
Last year I had surgery for prostate cancer. Since then, I have been taking an anti-hormone pill.
Good question. Multiple small lesions like this one, appearing suddenly, can be a marker for internal malignancies.
Have you ever had warts? Let me look at your hands.
I have warts as a kid, but they went away on their own, without dangerous treatments.
Although this lesion has a warty or verrucous surface, it has no connection to human papilloma virus and common warts.
What kind of work did you do? Were you in the sun a lot?
I sold insurance. But I was in the sun a lot because we have a sailboat on Lake Zurich. Now we are out a lot.
There is no connection between occupation and these lesions. A history of sun exposure is reasonable for all dark cutaneous lesions.
Lesion
Choose the right efflorescences:
A vesicle is fluid-filled, not the case here.
An erosion is a superficial defect, not seen here.
This lesion is a type of raised lesion or papule, best described as a verruciform plaque.
Diagnosis
Choose the right diagnosis:
The most important differential diagnosis consideration and what each patient worries about! This lesion is verrucous, well-circumscribed and looks as if could be peeled off the skin, so it can usually be separated rapidly from melanoma. Dermatoscopy also helps. If there is any question, then the lesion can be excised.
A melanocytic nevus is rarely verruciform. Dermatoscopy is also usually very helpful in separating the two.
This common lesion in the elderly, usually on trunk, can be identified clinically as verrucous, dark, waxy, and superficial.
This is not macule; it is rough and raised. In addition, café-au-lait macules are usually seen in children and young adults.
Therapy
Choose the right therapy(ies):
No treatment is needed.
Excision is acceptable, but a bit too extensive if the diagnosis is clear. If there is question about the diagnosis, then excision is preferred because the specimen is more suitable for histopathologic evaluation.
While keratolytic agents may eventually work, there are better ways to go.
When the diagnosis is certain, this is the standard approachsafe, cheap and simple with good cosmetic results.
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