Annular Lesions in a 50 yo woman

This image was sent by Dr. Yogesh Jain from India for diagnostic suggestions.
The only history provided was that the process is present on the hands and feet and has been ongoing for 25 years. The lesions regress after a number of months.

Other than a variant of granuloma annulare or elastosis perforans serpiginosa, what are your thoughts?

Biopsy is important but so is the dermatopathologist who reads it.

What is Right Care?

The patient is a 90 year-old man, homebound with a dementia.  His 87 year-old wife is a steadfast, loving and loyal caregiver.  His dermatologist has made house calls for the past four months. 

There are non-melanoma skin cancers on the left cheek  and mid upper lip.  The former lesion has increased from 1.3 to 1.5 mm in diameter and the the lip lesion has increased from 1.8 to 2.2 mm in diameter in the past two months.  Both are somewhat inflammatory and crusted. He picks on the lip lesion, but because of his dementia he can not articulate what it is that bothers him.

7.28/15

March 2016

6.28.2016

8.11.16

Thoughts: The question is what is the best treatment for this man.  The lesion on the left cheek could be curetted and desiccated in the office. The lesion on the lip is a more complicated problem. 

A trial of topical 5-FU plus imiquimod may be helpful, especially for the lesion on the lip, as a palliative procedure.  The lesion on the malar eminence which grew rapidly ~ 6 months ago and is either a squamous cell or a keratoacanthoma) could be curetted and dessicated.

The patient can not make a decision for himself and his wife wants to just watch these lesions.  She understands that treatment is not likely impact on his quality of life at this point and want’s to spare him the trauma or surgery.

As physicians, we feel compelled to “do something.”  Is this the right time to “not just do something, but to sit there.”

Reference:

1. Linos E. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer.  JAMA Intern Med. 2013 Jun 10;173(11):1006-12

CONCLUSIONS AND RELEVANCE: Most NMSCs are treated surgically, regardless of the patient's life expectancy. Given the very low tumor recurrence rates and high mortality from causes unrelated to NMSC in patients with limited life expectancy, clinicians should consider whether these patients would prefer less invasive treatment strategies.  PubMed.  PMC Free Full Text.

2.  Knocking on Heaven’s Door by Katie Butler is an honest, sobering book that describes what awaits so many elderly people and their caregivers, who are often family members.  It is relevant to how one manages a patient such as the man described and discussed here.