Infiltrating BCC of the Ala

The patient is a 58 yo man in fair health.  He suffers from anxiety and depression as well as diabetes and coronary heart disease and is status past CABG.  He was brought in by his female companion who noticed a lesion of the left ala.

O/E There is a nine mm indurated lesion with some surface erosion.

Image:

A 3 mm punch biopsy was difficult because of his severe agitation.  The pathology showed a deeply infiltrating basal cell.

Questions:

Given this patient’s pervasive anxieties, should one consider XRT over Mohs surgery?  The latter might also cause some deformity and may require a complicated reconstruction.  Of course, I will lay out the choices to the patient and his companion; but I thought this was a good question for our members to consider and weigh in on.  Some great unknown medical sage said, “Sometimes, it is may be more important to treat the patient who has the lesion, than it is to simply treat the lesion the patient has.”

Extensive Pruritic Vulvar Plaque in an 84 year old Woman

An 84-yr-old woman presented with a pruritic vulvar plaque for more than a year.  It was increasing in size extending from the vulva to the surrounding areas. She was otherwise well and did not have any constitutional symptoms such as fever or weight loss. She had seen few doctors and a gynaecologist but did not improve. She was treated with topical fucidin cream, clotrimazole cream and moisturisers. Her past medical history was insignificant.  She is a housewife.

Examination showed an irregular asymmetrical extensive erythematous plaque on the vulva extending to the suprapubic, groins, perianal areas and anus.  Some of the lesions on the periphery appeared hyperpigmented and nodular.  Her regional nodes were not enlarged.

Diagnosis: Extramammary Paget Disease

Differentials needed to be considered included Bowen disease and malignant melanoma

A skin biopsy was done and pending results.  She may need assessment of other malignancy eg urological or gynaecological cancers.

Treatment could be challenging as the plaques are so extensive.  Surgical excision probably not advisable at her age  - may need multi disciplinary surgeons eg O & G, urologist, plastic and colorectal surgeon. Not sure about role of radiotherapy but am starting her on topical imiquimod cream every other day.

A Young Girl with Ulcerated Lips

A 14-yr-old girl had severe blisters on the lower lip of 5 days duration.  It was painful and developed into superficial painful ulcerations of the lips.  Then she experienced eye discomfort with eye discharge esp in early morning.  There were no red eyes though.  She did not have any fever or any polyarthralgia.  No genital ulcerations. She is a secondary school student and stays with parents with no unusual habits. There was no family history of similar illness.  There was no recent drug history including OTC products, supplements and traditional chinese medicines. 

Examination was unremarkable except superficial ulcerations on the lower lip and to a certain extent on the upper lip too. The ulcerations was covered with yellowish slough and crusts.  Superficial erosions were noted on the inner buccal mucosa. No genital ulcerations.  No blisters elsewhere. 

Rest of exam unremarkable.

Diagnosis

Aphthous ulcerations - severe

Differentials considered were First episode orolabial HSV infection, drug eruptions, pemphigus vulgaris, erythema multiforme.

Blood counts and biochemistry was done as well as ANA serology.  HSV I and II serology was not done due to financial reasons. If she does not improve I think this patient may require a biopsy.

She was treated with oral prednisolone 20mg bd, topical triamcinolone gel bd and oral azithromycin 250mg daily. Your comments on this patient would be highly appreciated.

References:

1. Mucosal erosions as the presenting symptom in erythema multiforme: a case report. Spencer S, Buhary T, Coulson I, Gayed S. Br J Gen Pract. 2016 Mar;66(644):e222-4.  Free Full Text.

Follow up: Good response to treatment with oral prednisolone and azithromycin. Lesions were drying up and clearing.

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