funDERMentals

Time Won't Heal This Wound


 

An 85-year-old black man presents with a nonhealing, asymptomatic lesion on his cheek. He says the problem began several months ago, during a fishing trip, when some fishing line got caught in his beard, pulling out a few hairs in the process.

An accompanying relative, however, is quite certain that the lesion predates the fishing incident (for which he was present). He believes the lesion has been there for two years. He also advises that the patient’s memory is “not what it used to be.”

The patient has a significant history of sun exposure from his job as a stonemason, which kept him outdoors most of the time. He has been seen by a variety of providers and diagnosed with several infections, including pyoderma—but antibiotics have had no effect on the lesion.

EXAMINATION
Located on the right lateral cheek is a 2.4-cm, full-thickness ulceration that penetrates well into adipose tissue. Little if any redness can be seen around the lesion, and no adjacent nodes are palpable. A shave biopsy of the lesion is obtained.

What is the diagnosis? DISCUSSION
The pathology report showed evidence of a basosquamous cell carcinoma.

This case effectively illustrates a key message: Nonhealing lesions should be considered cancerous until proven otherwise (via biopsy). This remains true even in individuals with darker skin; they may have lower risk for skin cancer than do fair-skinned individuals, but they do not have no risk—especially if there is a lifetime history of sun exposure.

The depth and width of the lesion suggest it had been present for many years, slowing growing. This timeframe, along with the lack of response to antibiotics, made infection unlikely. Furthermore, an infection serious enough to cause ulceration would be red and painful.

The mixed picture on the pathology report is unusual but not at all unknown; it just means the lesion had features of both basal and squamous cell carcinoma. Unfortunately, the biopsy results, in conjunction with the lesion’s dimensions, indicate an increased risk for metastasis (or at least spread to local nodes). There could also be perineural involvement if the cancer cells spread to deeper structures through the penetrating nerves.

The entire clinical picture in this case made the patient a candidate for Mohs surgery, which would ensure two things: clear excision margins and optimal wound closure. Should the surgeon find perineural involvement, he or she might advise postoperative radiation therapy to guarantee complete eradication of the cancer.

TAKE-HOME LEARNING POINTS

  • Nonhealing lesions should be considered cancerous until proven otherwise by biopsy.
  • Even though dark-skinned individuals have far less risk for skin cancer than those with fair skin, a lifetime of sun exposure can overcome the odds.
  • Size and depth of the lesion increases risk for metastasis or perineural involvement (spreading to deeper structures through the nerves).
  • Mohs surgery, as well as postoperative radiation therapy, can be used to completely eradicate the cancer.

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