From the Guidelines
The best course of action for this 81-year-old male patient with a malignant skin lesion that has not healed after a month and has additional suspicious lesions is immediate referral to a dermatologist or surgical oncologist for evaluation and biopsy, as the persistent, non-healing nature of the lesion combined with multiple suspicious areas strongly suggests skin cancer, possibly basal cell carcinoma, squamous cell carcinoma, or melanoma 1.
Key Considerations
- The patient's advanced age and the presence of multiple lesions may indicate more extensive disease requiring comprehensive management.
- Early intervention is crucial as skin cancers, particularly melanoma, can metastasize if left untreated.
- The specialist will likely perform a biopsy of the primary lesion and examine the additional suspicious areas to determine their nature, following guidelines such as those outlined in the NCCN guidelines for melanoma 1.
- Treatment options will depend on the specific diagnosis but may include surgical excision with appropriate margins, Mohs micrographic surgery, topical chemotherapy agents, radiation therapy, or immunotherapy depending on the type and stage of cancer.
Diagnostic Approach
- A full-thickness excisional biopsy with a small side margin is recommended for diagnosis, as it allows for complete histopathologic microstaging of the melanoma to assess Breslow thickness, presence of ulceration, microsatellites, and other factors 1.
- The histology report should follow the American Joint Committee on Cancer (AJCC) classification and include information on the maximum thickness, mitotic rate, presence of ulceration, and clearance of surgical margins 1.
Treatment and Management
- Given the patient's advanced age, the specialist will consider his overall health status when determining the treatment approach.
- The goal of treatment will be to achieve the best possible outcome in terms of morbidity, mortality, and quality of life, taking into account the patient's age, overall health, and the specific characteristics of the cancer.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Malignant Skin Lesion Treatment Options
The patient's malignant skin lesion that has not healed after a month, along with additional suspicious lesions, requires careful consideration of treatment options.
- Topical imiquimod therapy has been shown to be effective in treating basal and squamous cell carcinomas, especially in elderly patients who may not be suitable candidates for surgical excision 2, 3.
- Intralesional 5-fluorouracil is another treatment modality that has been used to treat cutaneous squamous cell carcinoma, particularly in cases where surgical excision is not feasible 4.
Importance of Dermatology Consult
Given the patient's presentation, a dermatology consult is highly appropriate to determine the best course of action.
- Nondermatologists' use of predictive terms for potentially malignant lesions can aid in triage decisions, with terms such as "nonhealing," "ulcerated," and "rule out basal cell carcinoma" indicating a higher likelihood of malignancy 5.
- The increasing burden of skin lesions suspected of malignancy on primary healthcare highlights the need for general practitioners to be trained in diagnosing these lesions to ensure timely referrals and appropriate treatment 6.
Treatment Considerations
When considering treatment options, it is essential to take into account the patient's age, overall health, and the location and severity of the lesions.
- Imiquimod cream 5% has been shown to be safe and well-tolerated in elderly patients, with improved residual tumor and recurrence rates compared to historical rates for electrodesiccation and curettage alone 2.
- The choice of treatment should be individualized based on the patient's specific needs and circumstances, with a multidisciplinary approach involving dermatology and other relevant specialties as needed.