Difficult BCC

From A.R. Pito
Norfolk Island, S.P.

A friend from Australia sent me this photo with the following note.
"A.R.: I just saw this 56 yo man with a two year history of a large ulcero-nodular plaque on his left temple. Biopsy is pending but this appears to be a morpheaform BCC. Assuming this is BCC, what would your therapeutic suggestions be.
Radiotherapy?
Mohs?
In our area, we do not have a specialized cutaneous radiation centre, but he could be sent to Sydney, I suspect."

Thank you for your suggestions. You can post here or send to oslerian@gmail.com. I will append the pathology when my colleague forwards it.

5 year old girl with perioral rash

This 5 year-old girl presents with a 5 month history of a dermatitis at angle of mouth and upper lip. There are areas of patchy erythema with scale and discrete acneiform papules. She has been treated with mupirocin cream, ketoconazole cream, and 1% HC cream. None of these have helped. She is not atopic, has no family history of atopy and is not a lip licker.
Althoug subtle, I think this is perioral dermatitis of childhood. Tetracycline is contraindicated. I wonder if systemic erythromycin would be helpful. Based on the literature, I started her on metronidazole cream and told her mother that this may take weeks to months to get better.
I would appreciate your suggestions.

A Patient from Ghana - Please comment

Anak VGRD members have been asked to comment on a 16 year old Ghanaian girl from a small village without any specialized medical care. In otherwise good health and of normal intelligence, since age two she has a history of small hyperpigmented papules on her face. The larger lesions on her forehead appeared over the last two years. She patient states that she doesn't manipulate any of the lesions and that they are asymptomatic. There has been no treatment. HIV status and family history are unknown. This unfortunate young woman feels like an outcast because of these lesions.

We welcome you thoughts and advice. There are medical students in her community who could perhaps perform diagnostic testing if needed.

? Segmental Neurofibromatosis

The patient is a three year-old girl with 2 cafe au lait spots on right arm and chest since she was a few months old and many small "freckles" on right chest and axilla (see photo). There are a few freckles on the right upper back as well. No pigmented lesions on any other area. Have not looked for Lisch nodules yet.

Athough it may be too early to tell, I suspect this is segmental neurofibromatosis. Most cases of segmental NF are diagnosed because of tumors. There are probably some that only manifest as CLS or freckling. Of course, we will have to wait years in this case to see what develops.

Does anyone have ideas as to wha to tell the parents?

BCC of Eyelid

This is a 75 yo man who came in for an unrelated problem.
This tumor was obvioius, however.
Two years ago, and ENT physician told him he had a "blocked duct."
This 6 mm in diameter lesion looks like a BCC.
I propose to excise it but am worried about pulling down the lower lid.
I don't think C&E or Aldara would be appropriate. Mohs might be overkill.
Do you have any comments? I would, oif course, try to undermine the tissue.

84 yo Man with Atrophie Blanche

The patient is an 84 yo man with a ten year history of extremely painful ulcerations of his lower legs.
Other than whirlpool baths, I have found nothing to be of value.
His health is good and he has bounding dorsalis pedis and posterial tibial pulses.
I assume this is Atrophie Blanche.
Do you have any therapeutic suggestoins?

Localized Hyperkeratosis

39 yo man with > 15 year hx of localized hyperkeratosis of right great toe. No unusual trauma to area. He's used mostly over the counter emollients without much help.

Are you aware of any localized forms of hyperkeratosis?

I have started him on Salex cream.

Pictured below are his affected right and normal left great toes.

Recent Onset Acne in Young Woman

This 21 yo woman experienced the sudden onset of acne one month ago.
No new med. No unusual stresses.
She has never had acne like this before.

Do you think this is a mild case of pyoderma faciale rather than typical acne?