Based on information missing from the patient history, suggest other possible diagnoses and explain why.
Week 2 Discussion Post – Case Study 2
Kristen Bradley
Primary Diagnosis
The primary diagnosis I would choose for K.B. is seborrheic keratosis. This diagnosis is supported by the irregular borders, seborrheic keratosis’ tendency to mimic malignant melanoma, and the patient’s history of UV light exposure including both sunlight and indoor tanning beds (Luba, et al., 2003; Balin, 2018; Buttaro, et al, 2017). Habif, et al. (2012) provides supporting evidence pertaining to this diagnosis, noting seborrheic keratosis can grow rapidly; this would likely draw the patient’s attention to the changes and increase his concerns. Balin (2018) notes that 0.66% of biopsies performed on lesions diagnosed as seborrheic keratosis did come back positive for malignant melanoma; this would warrant further investigation and confirmation with either a punch biopsy or an excisional biopsy (Luba, et al, 2003; Habif, et al, 2012).
Differential Diagnoses
The three differential diagnoses I selected for this patient are malignant melanoma, basal cell carcinoma, and squamous cell carcinoma. Malignant melanoma would be the differential to rule out. Seborrheic keratosis can mimic malignant melanoma in appearance (Habif, et al, 2012; Craythorne & Al-Niami, 2017); using the ABCDE pneumonic, asymmetry is present with the irregular borders and oblong shapes, the border is not well-defined, color is melanocytic, the nevus is dark, and the nevus has increased in size (evolved) (Craythorne & Al-Niami, 2017). Given the compounded concern of the patient’s extensive history of sun exposure and indoor tanning booths, these further paint this in a suspicious light. According to Hartnett and O’Keefe (2016), while less common than non-melanoma skin cancers (NMSCs), malignant melanoma causes the most fatalities, approximately 9,000 lives annually.
Basal cell carcinoma (BCC) is much less likely, but given this patient’s risk factors should still be ruled out. BCC is the most common NMSC and is related to chronic and frequent sun exposure, as in this patient (Craythorne & Al-Niami, 2017). While BCC is typically slow-growing, and unlikely to metastasize in the event of early diagnosis and intervention, an additional risk factor includes the patient’s age, 52 (Craythorne & Al-Niami, 2017). It is more unlikely, however, given the more common presentation as a papule with rolled edges, scabs that are not healing, or scar-like whitened areas (Craythorne & Al-Niami, 2017).
Squamous cell carcinoma (SCC) would be a third differential to consider. Buttaro, et al (2017) describe SCC lesions as “roughened, scaling area that does not heal and readily bleeds when scraped”, as well as explaining this can result in a stacked scaly appearance (p. 246). Given the scaly appearance of K.B.’s nevus, it warrants considering SCC as a possible differential. His additional risk factors include photodamaged skin and fair skin type (Craythorne, Al-Niami, 2017).
Role of History and Physical in Diagnosis
The history and physical play an instrumental role in the diagnosis of this patient. He reports a mole that has not been present since birth, and has changed in color. He reports and extensive history of exposure to sun exposure in his construction job, and having worked outside and utilized indoor tanning beds frequently as a youth. He also has a fair skin complexion. Additionally, the mole is unlike others on his body. Given the above information of risk factors, seborrheic keratosis, malignant melanoma, BCC, and SCC, all of the factors provided in his history and physical guide the practitioner in determining differentials and what to test for.
Potential Treatment Options
Prescriptions: While Balin (2018) references Eskata (40% hydrogen peroxide), AmLactin (lactic acid), and Tri-Chlor (trichloroacetic acid) as potential treatments for seborrheic keratosis, I would not try to utilize any of these until the differentials have been ruled out. The treatments would be different if a malignancy was confirmed on pathology.
Interventions/Lifestyle Changes: K.B. would benefit greatly from lifestyle changes that will minimize his exposure to ongoing UV radiation damage. Even while working his construction job, he may use sunscreen and reapply frequently, wear long sleeves, hats, sunglasses whenever possible to block UV rays from his fair skin. Hartnett and O’Keefe (2016) state, “skin cancer because of overexposure to UV radiation is analogous to lung cancer because of use of tobacco” (p. 127). Minimizing this exposure could prevent him from developing skin cancer or worsening his seborrheic keratosis, if pathology does not confirm a malignancy.
Referrals: I would refer the patient to dermatology. If I were trained and able, I may perform a punch biopsy, but it is possible dermatology would be needed to perform either a punch biopsy or excisional biopsy for pathology confirmation and removal of possible malignancy. If pathology comes back malignant instead of confirming seborrheic keratosis, a referral to an oncologist would be appropriate for the best treatment.
Follow up: Follow up would be appropriate after biopsy, for and after treatment, and routinely for skin exams given his high-risk status.
Education: The most crucial education for this patient is minimizing as much as possible his risk factors; he cannot change his age, skin type, or history, but he can minimize exposure to UV radiation and even harsh chemicals moving forward. Education on self-monitoring is important as well, given his report of other moles. It would be appropriate for him to monitor these for any possible changes as well.
