Facing Up to the Diagnosis

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Face lesion

“Like a berry,” was how a 38-year-old Hispanic man described the lesion that had been slowly growing on his face for 4 years. His family was alarmed by it, but he reasoned that since it didn’t hurt and the surrounding area wasn’t especially red, it likely wasn’t much of a problem.

The patient worked as roofer up to 7 days per week when the weather was good and had been doing so since he was old enough to work. He had no insurance and was not inclined to spend money on a health care visit. When his wife finally convinced him to go to the urgent care clinic, he paid $100 just to be told he needed to see a dermatologist. He was so disgusted he almost refused to wait the 6 weeks it took to get into the dermatology office.

The patient, who had type IV skin with little evidence of sun damage, had an obvious, large, coarsely mamillated nodule on the left upper nasolabial area. The lesion measured 1.8 cm and was reddish blue. It was moderately firm, but no increased warmth could be detected. No nodes could be felt in the area. His skin elsewhere was free of any notable changes.

Which of the following does not belong in the differential?

Congenital nevus

Basal cell carcinoma

Verruca vulgaris

Squamous cell carcinoma


None of the above


All of these items were rightly considered to be in the differential for this lesion, so the answer is choice “f.”


Individuals with type IV skin are less likely than those with types II and III to develop skin cancer. So, although cancer was definitely in the differential, the other items were considered just as, if not more, likely in this case.

The only way to sort through these diagnostic possibilities was to perform a biopsy. In this case, the entire lesion was removed by saucerization technique, under local anesthesia. The specimen provided would be adequate to detect any cancer, which a smaller specimen could easily miss.

The pathology results showed pigmented basal cell carcinoma. Given the patient’s extensive history of sun exposure, and the steady growth of the lesion, this was hardly a surprise. But prior to the biopsy, one could just as easily imagine the lesion to be, for example, a wart.

The take-home message is obvious: Nothing can take the place of biopsy in establishing a precise diagnosis. With that information in hand, the patient was referred for consultation with a Mohs surgeon. Surgical removal and closure would likely set him back several thousand dollars and leave a considerable scar.

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