She Can’t Turn the Other Cheek on the Lesion

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Cheek lesion

For several years, a 70-year-old woman has had an asymptomatic lesion on her cheek that has been growing slowly and steadily. Her primary care provider has reassured her at multiple visits that it should not cause her worry. Still, because of the lesion’s continued growth and her history of excessive sun exposure when she was young, she self-refers to dermatology for evaluation.

The patient has no history of skin cancer but her 2 sisters do, including a recent diagnosis of melanoma for one of them. During the 1950s, the 3 sisters were often outdoors—all burning easily and often and tanning only with difficulty. Since then, the sisters’ sun-drenched days have ended. All are in otherwise excellent health.

Examination reveals a patient with quite fair (type 2) skin and blue eyes. There is abundant evidence of past overexposure to ultraviolet light, including a weathered effect, scattered telangiectasias, and patches of white mottled skin (otherwise known as solar elastosis).

The lesion in question is quite faint and difficult to see. Magnification shows a 2-cm round patch that is slightly lighter than the surrounding skin and completely macular. No induration is felt on palpation, and no nodes are detected in the region.

An even closer and meticulous examination reveals that the surface adnexal structures—such as pores, skin lines, and even tiny hairs—that should be inside the lesion are completely missing. Slightly yellowish discoloration can be seen in the center of the patch. The rest of her skin shows no other worrisome features or lesions.

Given the findings, the differential diagnosis would not include

Seborrheic keratosis

Basal cell carcinoma

Amelanotic melanoma

Squamous cell carcinoma


The correct answer is seborrheic keratosis (choice “a”).


Seborrheic keratosis could not be in the differential because it is, by definition, an epidermal lesion—that is, “stuck on” the surface of the skin. It creates a rough surface that can be easily scraped off. The lesion could have been an actual scar, but other factors (its continuous growth) and the history of excessive ultraviolet exposure pushed us away from including this condition in the differential.

The differential for this patient included sun-caused skin cancers: basal cell carcinoma (BCC; choice “b”), squamous cell carcinoma (SCC; choice “d”), and amelanotic melanoma (choice “c”). These conditions can have a colorless and scar-like appearance, and they also destroy surface adnexae. Therefore, the lack of hairs, pores, or skin lines in a circumscribed area should raise concern for possible skin cancer, especially in at-risk patients such as this one.

BCC (otherwise known as cicatricial basal cell carcinoma) is by far the most common of all sun-caused skin cancers, but it usually presents as an obvious papule or nodule, often with telltale features such as pearly, rolled borders and focal erosion or ulceration. But there are exceptions, and the scar-like BCC is one.

SCC can also occasionally present in this manner, as can amelanotic melanoma, which is a colorless melanoma and very easy to miss. This case perfectly illustrates the point I often make to the students and residents I teach: When skin cancer is suspected, pay at least as much attention to the owner as to the lesion. Also, when in doubt, biopsy will settle the matter.


For the patient, shave biopsy confirmed the presence of BCC. She was then referred for Mohs micrographic surgery because of the lesion’s size, location, and uncertain visible margins.

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