Photo Quiz

Solitary Ulcerated Lesion on the Arm


Am Fam Physician. 2018 Aug 15;98(4):251-252.

A 56-year-old white man with dark hair and blue eyes presented for his annual physical examination. His medical history was significant for type 2 diabetes mellitus, hypertension, hyperlipidemia, and primary hypothyroidism.

The physical examination revealed multiple nevi on his back and a nontender, ulcerated lesion on his left upper arm (Figure 1). It was heterogeneous in color with irregular borders and measured 1.5 × 1.5 × 2.5 cm. The examination findings were otherwise normal.

 Enlarge     Print




Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Dermatofibrosarcoma protuberans.

B. Nodular malignant melanoma.

C. Pyogenic granuloma.

D. Solitary keratoacanthoma.

E. Unilesional (solitary) mycosis fungoides.


The answer is B: nodular malignant melanoma. This is a vertical growth phase melanoma that accounts for 15% to 30% of all melanomas.1 A nodular melanoma is typically more than 2 mm thick and appears as a darkly pigmented, pedunculated or polypoid nodule that may be ulcerated.2,3 Histologically, it appears as a rapidly mitotic pigmented dermal growth of epithelioid cells or spindlelike atypical neoplastic cells without an epidermal component (Figure 2). Nonpigmented nodular melanomas (pink lesions) often have a delayed diagnosis. It is important to recognize the “ugly duckling” lesion that might be darker or larger than the surrounding moles.2,3 Nodular melanoma is treated with surgical excision of the lesion and normal tissue margins.3

 Enlarge     Print

Address correspondence to Hanadi Abou Dargham, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Bay C, Kejs AM, Storm HH, Engholm G. Incidence and survival in patients with cutaneous melanoma by morphology, anatomical site and TNM stage. Cancer Epidemiol. 2015;39(1):1–7....

2. Tsao H, Olazagasti JM, Cordoro KM, et al. Early detection of melanoma: reviewing the ABCDEs. J Am Acad Dermatol. 2015;72(4):717–723.

3. Demierre MF, Chung C, Miller DR, Geller AC. Early detection of thick melanomas in the United States. Arch Dermatol. 2005;141(6):745–750.

4. Gloster HM Jr. Dermatofibrosarcoma protuberans [published correction appears in J Am Acad Dermatol. 1997;36(4):526]. J Am Acad Dermatol. 1996;35(3 pt 1):355–374.

5. Tran DC, Li S, Henry S, et al. An 18-year retrospective study on the outcomes of keratoacanthomas with different treatment modalities at a single academic centre. Br J Dermatol. 2017;177(6):1749–1751.

6. Cerroni L, Fink-Puches R, El-Shabrawi-Caelen L, et al. Solitary skin lesions with histopathologic features of early mycosis fungoides. Am J Dermatopathol. 1999;21(6):518–524.

7. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma). Pediatr Dermatol. 1991;8(4):267–276.

8. Ghodsi SZ, Raziei M, Taheri A, et al. Comparison of cryotherapy and curettage for the treatment of pyogenic granuloma. Br J Dermatol. 2006;154(4):671–675.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

A collection of Photo Quiz published in AFP is available at

Previously published Photo Quizzes are now featured in a mobile app. Get more information at

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at To be considered for publication, submissions must meet these guidelines. E-mail submissions to



Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

Editor's Collections

Related Content

More in Pubmed


Jun 15, 2019

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article