Photo Rounds

Lesion with vessels

A 52-year-old woman went to her family physician (FP) because she was concerned about a growth on her forehead that she’d had for 2 months. She thought it was a pimple, but decided to see her FP when it did not go away. She denied having any other similar lesions. The FP examined the growth closely using the light from his smartphone and could see that the lesion was pearly, with branching vessels randomly distributed throughout. There was no symmetry in the vessels but they did cross the midline, making sebaceous hyperplasia less likely.

What’s your diagnosis?


The FP performed a shave biopsy with a sharp razor blade after using local anesthesia (lidocaine and epinephrine), and pathology confirmed the suspected diagnosis of a nodular basal cell carcinoma (BCC). While this case of BCC was diagnosed with naked eye examination, dermoscopic examination would have revealed shiny white structures and branching vessels. This would increase the FP’s confidence in a diagnosis of BCC before a biopsy was even performed.

The FP was experienced with skin surgery and performed an elliptical excision with 4 mm margins. The ellipse was oriented horizontally across the patient’s forehead, so that the healing incision would be hidden among her wrinkle lines. A 2-layer closure was employed using absorbable 4-0 Vicryl for the deep sutures and running 5-0 Prolene for the epidermal layer.

At follow-up 6 days later, the incision was healing well without signs of infection and the external sutures were removed. Pathology showed that the margins were clear of tumor. The FP suggested a total body skin exam to make sure there were no other skin cancers in hiding. The patient agreed, and the remainder of the skin exam was clear. The FP also talked to the patient about sun avoidance and protection. A follow-up was scheduled for 6 months later to recheck the skin, since the diagnosis of one BCC increases the risk for additional skin cancers.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Sebaceous hyperplasia. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine . 2nd ed. New York, NY: McGraw-Hill; 2013: 931-934.

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