Pigmented Nodule Below the Eye ADAM B

Photo Quiz

Pigmented Nodule Below the Eye ADAM B. WOLDOW, MD, and FARAMARZ H. SAMIE, MD, PhD, Thomas Jefferson University Jefferson Medical College, Philadelphia, Pennsylvania

The editors of AFP wel- The nodule was 1.5 × 1 cm, translucent, and come submissions for located below the right lateral lower eyelid Photo Quiz. Guidelines for preparing and submitting (see accompanying figure). The nodule had a Photo Quiz manuscript not changed in size or color, and there was can be found in the no drainage or bleeding. Authors’ Guide at http:// www.aafp.org/afp/ photoquizinfo. To be con- Question sidered for publication, Based on the patient’s history and physical submissions must meet examination, which one of the following is these guidelines. E-mail submissions to afpphoto@ the most likely diagnosis? aafp.org. Contributing edi- ❑ A. Malignant melanoma. tor for Photo Quiz is John ❑ B. Melanocytic nevus. E. Delzell, Jr., MD, MSPH. ❑ C. Pigmented basal cell carcinoma. A collection of Photo Quiz- ❑ D. Seborrheic keratosis. zes published in AFP is A 58-year-old white man presented to the ❑ available at http://www. E. Solar lentigo. aafp.org/afp/photoquiz. outpatient clinic with a single asymptomatic nodule on his face that had appeared months See the following page for discussion. earlier. He had no history of skin cancer.

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Discussion surgery has the highest cure rate for non- The answer is C: pigmented basal cell carci- melanoma skin cancer and is reserved for noma. Basal cell carcinoma is the most com- high-risk and poorly defined tumors. X-ray mon malignancy, with more than 800,000 radiation therapy is used for patients who new cases diagnosed annually in the United are not surgical candidates or who have States.1 The tumor is more common in men unresectable tumors.6 and persons with light skin. The main risk Malignant melanoma is a malignancy of factor for the disease is a history of ultraviolet melanocytic origin. It often appears as a light exposure.2 Pigmented basal cell carci- multicolored, asymmetric macule or papule noma usually occurs on sun-exposed areas with irregular borders and a diameter of of skin, such as the head and neck. The main greater than 5 mm. The risk of metastasis is clinical features are translucency, overlying directly related to the thickness of the pri- telangiectasia, rolled border, and occasion- mary cutaneous tumor.7 ally ulceration.1 Pigment is present in all or Melanocytic nevus is a benign, verrucous, part of the neoplasm in 6 percent of basal cell polypoid or sessile lesion with uniform pig- carcinomas,3 although this does not affect mentation and a smooth border. The lesion treatment or prognosis. is symmetric, smooth, flesh-to-brown col- The choice of therapy for basal cell ored, and flat or raised.7 carcinoma depends on histologic fea- Seborrheic keratosis is a benign prolifera- tures, location of the lesion, and patient tion of keratinocytes with a rough-to-waxy factors. Topical chemotherapy with fluo- surface. These lesions are often pigmented.7 rouracil,4 the immunomodulator imiqui- Solar lentigo is a brown macule on sun- mod (Aldara),5 and electrodesiccation and exposed skin. This lesion is a marker of curettage can be considered for superficial sun damage, but does not progress to skin lesions. Conventional excision with 3-mm cancer.7 margins is often used for low-risk and well- Address correspondence to Adam B. Woldow, MD, at defined tumors. Mohs micrographic surgery [email protected]. Reprints are not available from is a tissue-sparing technique that allows for the authors. precise identification and removal of the Author disclosure: Nothing to disclose. entire tumor while leaving the surrounding healthy tissue intact. Mohs micrographic REFERENCES

1. Marks JG, Miller JJ. Lookingbill and Marks’ Principles of Dermatology. 4th ed. Philadelphia, Pa.: Saunders; Summary Table 2006. 2. Rubin AI, Chen EH, Ratner D. Basal-cell carcinoma. N Engl J Med. 2005;353(21):2262-2269. Condition Characteristics 3. Rossiello L, Zalaudek I, Cabo H, Ferrara G, Gabriel C, Malignant melanoma Asymmetric, multicolored macule or papule with Argenziano G. Dermoscopic-pathologic correlation in irregular borders; greater than 5 mm in diameter an unusual case of pigmented basal cell carcinoma. Dermatol Surg. 2006;32(12):1509-1512. Melanocytic nevus Verrucous, polypoid or sessile lesion, uniform 4. Newman MD, Weinberg JM. Topical therapy in the pigmentation, smooth border, symmetric, treatment of actinic keratosis and basal cell carcinoma. smooth, flesh-to-brown color, flat or raised Cutis. 2007;79(4 suppl):18-28. Pigmented basal cell A plaque or nodule with translucency, overlying 5. Russo GG. Actinic keratoses, basal cell carcinoma, and carcinoma telangiectasia, rolled border, occasionally squamous cell carcinoma: uncommon treatments. Clin ulceration Dermatol. 2005;23(6):581-586. Seborrheic keratosis Rough-to-waxy surface, often pigmented 6. Skelton LA. The effective treatment of basal cell carcinoma. Br J Nurs. 2009;18(6):346, 348-350. Solar lentigo Brown macule on sun-exposed skin; does not progress to skin cancer 7. James WD, Berger T, Elston DM. Andrews’ Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, Pa.: Saunders; 2005. ■

1138 American Family Physician www.aafp.org/afp Volume 82, Number 9 ◆ November 1, 2010