TELEDERMATOLOGY READER REPORT1
History
Chief complaint: presenting for diagnosis of a lesion.
History of present illness: A 56-year-old gentleman presents with a pink and black papule (primary lesion) on his forehead (location) that has been growing and bleeding for 3 months (duration). Prior treatment: none. His primary symptom: slight itch and bleeding. Prior biopsy: none. He has a personal history of nonmelanoma skin cancer (22 squamous cell carcinomas and 16 basal cells), three of which predated his cardiac transplant. He became a cardiac transplant recipient in 1998 and currently is immunosuppressed. Other significant laboratory/study findings: none. Family history: positive for nonmelanoma skin cancer.
IMAGE QUALITY ASSESSMENT (BY TELEDERMATOLOGIST)2
Image 1: fully satisfactory.
Image 2: unsatisfactory; focus not acceptable.
TELEDERMATOLOGY IMAGING READER REPORT
Two images were provided. Figure 1 clearly shows a pearly rolled bordered papule with evidence of ulceration and pigmentation on the left forehead. Figure 2 is poorly focused and offers no further information. No size indicator is included in the photograph.
INTERPRETATION OF IMAGES
Lesion A
Findings
The presented lesion is highly suspicious for a pigmented basal cell carcinoma.
RECOMMENDATIONS
Skin Care and Treatment Recommendations
Patient is to present to dermatology for a confirmatory biopsy.
Patient is to be advised to utilize broad-spectrum sunscreens and sun protective clothing to avoid prolonged exposure to sunlight between the hours of 10 A.M. and 4 P.M. and have regular skin checks with dermatology.
RECOMMENDED FOLLOW-UP3
Type of Visit
Return for a face-to-face evaluative visit with the dermatology nurse practitioner or dermatologist. This patient should have an evaluative visit for this new lesion but also needs to be seen on a regular basis thereafter (e.g., every 4 months).
CLINICAL PEARL
Regular use of sunscreens has been shown to significantly prevent the development of further actinic keratosis, invasive squamous cell carcinoma, and basal cell carcinoma (to a lesser degree) in organ transplant recipients (OTRs; Ulrich et al., 2009). "Skin cancer is the most common cancer affecting solid OTRs, affecting up to 70 percent of patients within 20 years, and is the result of intense immunosuppressive regimens. Solid organ transplant recipients are up to 65 times more likely to develop skin cancer than people without transplants" (ITSCC, 2014). Dr. Clark C. Otley said, "The patient who impacted me the most was an amazing gentleman who had a cardiac transplant and suffered with more than 500 skin cancers, including 3 metastatic skin cancers. He relentlessly challenged me to help him and would not accept 'standard of care' as good enough. He was the motivating force behind the International Transplant Skin Cancer Collaborative" (Barankin, 2014). In addition, OTRs should be advised to avoid tanning beds and limit ultraviolet light (UV) exposure and should be instructed on performing monthly skin self-examinations.
REFERENCES