Case Studies

Case 8: Slow-growing skin lesion

A 79-year-old retired farmer was referred to the Oculoplastic clinic. He lived a remote life in a small village and did not believe in seeing doctors. His family had come to see him from Australia (where he had also grown up) and were concerned regarding a lesion under his lower eyelid. You suspect this is a basal cell carcinoma (BCC) as it is a raised, pearly lesion with fine telangiectatic vessels. There is a localized loss of eyelashes (madorosis) and unilateral blepharitis on the lower lid.

• 1. Do you know any risk factors for BCC?

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  Correct answer: An epidemiology study published in 1999 by van Dam et al. suggested that the following are associated with BCC later in life:

  • Being Caucasian and of northern European ancestry
  • Red hair and blue or hazel eyes
  • Tendency to sunburn
  • A high number of blistering sunburns
  • Sun exposure as a teenager
  • In a region with high solar radiation.

  In young patients with multiple lesions, consider the following rare associations:

  • Xeroderma pigmentosa
  • Gorlin syndrome.

• 2. What diagnosis is important to exclude in patients with longstanding unilateral blepharitis?

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  Correct answer: One must exclude sebaceous gland carcinoma, arising from meibomian glands and from the glands of Zeiss in the tarsal plate. They can also masquerade as chronic conjunctivitis or chalazia.

• 3. What must you do to confirm your diagnosis?

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  Correct answer: He must be listed for biopsy of the lesion to get a histological diagnosis and help plan further treatment.

The lesion is confirmed as a BCC. The son is concerned regarding systemic manifestations, as he had heard that skin cancers could spread to the rest of the body. Also, he was worried that his dad’s face would be completely distorted from surgery.

• 4. What types of dermatological malignancies commonly metastasise? Do BCCs usually spread locally or systemically?

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  Correct answer: BCCs are usually locally invasive and metastasise less than 0.1% of the time. Squamous cell carcinoma and melanomas usually have the propensity to metastasise systemically.

• 5. How can you reassure his son about the surgical management of his father?

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  Correct answer: Currently in vogue for treating BCCs is Mohs micrographic surgery, carried out in specialist centres with the involvement of dermatologists and histopathologists. The idea is to preserve as much tissue as possible: hence, they are removed in layers in a topographic fashion, ensuring that whilst only the involved areas are excised, the remainder is left untouched. The residual defect is either left to heal laissez-faire or reconstructed surgically a few days later.