Photo Quiz

Chronic Ulcerated Lesion on the Face



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Am Fam Physician. 2001 Dec 1;64(11):1883-1884.

A 65-year-old woman presented with a six-year history of a progressively enlarging exophytic lesion on the left side of the face with central ulceration (see the accompanying figure). The lesion was nontender and had significantly increased in size during the past two years. It started as a small erosion that became indurated with subsequent crusting. The physical examination revealed a centrally ulcerated lesion measuring 4.5 cm × 3.5 cm with involvement of the left eye and central extension to the left aspect of the nose. There was no lymphadenopathy and the rest of the examination was unremarkable. The patient had lived most of her life in Europe, had a history of sun exposure when she was young and no other forms of trauma. She had no other known medical problems and had not seen a physician in the past six years.

Question

Which one of the following is the correct diagnosis, given the history and physical examination?

A. Squamous cell carcinoma.

B. Nodular ulcerative basal cell carcinoma.

C. Granuloma faciale.

D. Cutaneous leishmaniasis.

E. Cavernous hemangioma.

Discussion

The correct answer is A: squamous cell carcinoma (SCC). In this patient, a biopsy confirmed the diagnosis of SCC. After explanation and consideration of the risks of local invasion and metastases, the patient agreed to have an extensive excisional surgery with split thickness skin grafting sacrificing the left eye.

Each year in the United States, 80,000 to 100,000 new cases of SCC are reported.1 Excessive sun exposure and fair skin are the two major risk factors. Other risk factors include exposure to arsenic, burns, scars or previous radiation. SCC is usually a slow-growing skin tumor in sun exposed areas. The tumor can be confined to the epidermis (SCC in situ) or invasive, as in this case. SCC has a tendency to appear on the head, neck and upper extremities. It may also appear in other locations in patients who have undergone treatment with immunosuppressive drugs2 or who have been exposed to organic trivalent arsenic compounds or tars.3 This supports the notion of sun exposure as a causative factor, as does the increasing incidence seen with advancing age.

SCC rarely metastasizes except in long-neglected lesions, as this patient demonstrates. Metastasis rates may be greater with SCC developing on mucosal or genital surfaces, scar tissue, areas of chronic inflammation and in immunocompromised patients.1

SCC is treated in various ways depending on the size and location of the lesion. Excisional surgery, Mohs micrographic surgery, electrodesiccation and curettage, cryosurgery, or radiation therapy are all used.1,4 Less aggressive treatment, such as cryotherapy, is often adequate for small, low-risk lesions that comprise the majority of SCC.

With nodular ulcerative basal cell carcinoma, 80 percent of all basal cell tumors occur on the head and neck. Approximately one half of all basal cell carcinomas will ulcerate. The initial lesion is usually a shiny pinkish papule with telangiectasias. As the lesion enlarges, it outgrows its blood supply and ulcerates, forming a so-called rodent ulcer. Basal cell carcinoma rarely metastasizes but may slowly cause extensive local tissue damage if left untreated.2 It is treated in the same way as SCC.

Granuloma faciale occurs as cutaneous nodules or plaques that are usually solitary. They most often occur on the face but may appear anywhere.5 The lesions are soft, elevated, and sometimes crusted, ranging in size from a few millimeters to several centimeters, and varying in color from bright red to brown or purple. They may ulcerate and are usually asymptomatic and slowly progressive. The etiology of granuloma faciale remains unknown and is often resistant to treatment. Surgical excision, dermabrasion, electrosurgery and cryosurgery may be curative.6 Granuloma faciale is harmless and may be left untreated.7

Leishmaniasis is rarely seen in the United States, but it is endemic in the Mediterranean, Middle East, Africa and Central Asia.8 It may be considered in the differential diagnosis of nonhealing ulcerated papules and nodules, especially in patients with a foreign travel history. Cutaneous leishmaniasis may present as a single, localized cutaneous ulcer that usually appears two to eight weeks after a sandfly bite.8,9 If the infection is localized to the skin, an erythematous papule forms at the site. The lesion progresses to form an ulcer that may persist for months to years.10,11 Typically, the ulcer is round with an indurated border. Definitive diagnosis is made by the demonstration of the infecting protozoal organisms in the tissue biopsy or by growing them in culture. Serologic tests are not useful.10

Cavernous hemangiomas often occur on the face and can grow quite large and appear disfiguring. They can persist into adult life but always start in early infancy. Many lesions will involute without treatment over the span of several years. Disfiguring lesions or those that threaten vision are usually treated with laser ablation.

REFERENCES

1. Whitmore E. Common problems of the skin. In: Barker LR, Burton JR, Zieve PD, eds. Principles of ambulatory medicine. 4th ed. Baltimore: Williams & Wilkins, 1995:1439–79.

2. Shamanin V, zur Hausen H, Lavergne D, Proby CM, Leigh IM, Neumann C, et al. Human papillomavirus infections in non-melanoma skin cancers from renal transplant recipients and nonimmunosuppressed patients. J Natl Cancer Inst. 1996;88:802–11.

3. Preston DS, Stern RS. Nonmelanoma cancers of the skin. N Engl J Med. 1992;327:1649–62.

4. Mackie RM. Epidermal skin tumours. In: Champion RH, Burton JL, Ebling FJ, eds. Textbook of dermatology. 5th ed. London: Blackwell Scientific Publications, 1992:1459–1504.

5. Sears JK, Gitter DG, Stone MS. Extrafacial granuloma faciale. Arch Dermatol. 1991;127:742–3.

6. Welsh JF, Schroeder TL, Levy ML. Granuloma faciale in a child successfully treated with the pulsed dye laser. J Am Acad Dermatol. 1999;41(2 pt 2)351–3.

7. van de Kerkhof PC. On the efficacy of dapsone in granuloma faciale. Acta Derm Venereol. 1994;74:61–2.

8. Magill AJ. Epidemiology of the leishmaniasis. Dermatol Clin. 1995;13:505–23.

9. Lee MB, Gilbert HM. Current approaches to leishmaniasis. Infect Med. 1999;16:34,37–45.

10. Samady JA, Schwartz RA. Old World cutaneous leishmaniasis. Int J Dermatol. 1997;36:161–6.

11. Chaudhry IA, Hylton C, DesMarchais B. Bilateral ptosis and lower eyelid ectropion secondary to cutaneous leishmaniasis. Arch Ophthalmol. 1998;116:1244–5.

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