From the Guidelines
The next step for a 58-year-old male with a non-healing forehead lesion after an incomplete Dermablade biopsy should be a complete excisional biopsy with appropriate margins, as recommended by the most recent guidelines 1. This procedure should be performed by a dermatologist or surgeon to ensure complete removal of the lesion and adequate tissue for histopathological examination. The incomplete biopsy performed with a Dermablade may not have captured the entire lesion, which is concerning given the patient's age and the potential for skin cancer. Key considerations for the excisional biopsy include:
- Ensuring a narrow peripheral margin of 1 to 3 mm around the concerning skin lesion, as suggested by recent guidelines 1
- Extending the biopsy to a depth sufficient to ensure that the lesion is not histologically transected at the deep margin
- Using techniques such as elliptical (fusiform) excision, punch excision, or deep shave/saucerization to accomplish the diagnostic excisional biopsy While waiting for the procedure, the patient should keep the area clean with gentle washing using mild soap and water twice daily, followed by application of petroleum jelly and a non-stick bandage. Sun protection is essential, including wearing a wide-brimmed hat and applying SPF 50+ sunscreen. This approach is necessary because incomplete biopsies can miss portions of potentially malignant tissue, particularly concerning in this age group where skin cancers are more common. The non-healing nature of the lesion raises suspicion for possible basal cell carcinoma, squamous cell carcinoma, or other skin malignancies. Complete histopathological evaluation is crucial for accurate diagnosis and treatment planning, as emphasized by both older 1 and more recent guidelines 1. Following the excisional biopsy, treatment will depend on the pathology results and may include additional surgery, radiation therapy, or topical treatments depending on the diagnosis. Regarding the patient's request for cryotherapy for other lesions on his face, this should be addressed after the excisional biopsy and diagnosis of the current lesion, taking into consideration the overall skin health and potential for other malignancies. The patient's request for acetaminophen renewal should be evaluated separately, considering his current medical condition and potential interactions with future treatments that may arise from the biopsy results.
From the Research
Next Steps for the Patient
The patient has undergone an incomplete skin biopsy with a Dermablade for a non-healing lesion on his forehead. The sample does not represent the whole lesion, which may lead to inaccurate diagnosis. Considering the patient's request for cryotherapy for other lesions on his face, the following steps can be taken:
- Re-biopsy of the lesion to obtain a representative sample for accurate diagnosis 2
- Cryotherapy can be considered for the treatment of other lesions on the face, as it has been shown to be effective in treating actinic keratosis and other skin lesions 2
- The patient's request for acetaminophen renewal can be addressed, and the patient can be informed about the potential benefits and risks of using acetaminophen for pain management 3
Considerations for Biopsy and Treatment
When performing a biopsy, it is essential to obtain a sufficient sample to ensure accurate diagnosis. MRI-guided biopsy has been shown to be effective in diagnosing head and neck lesions with high accuracy and minimal complications 4. Cryotherapy has been used to treat various skin lesions, including actinic keratosis, and has been shown to be safe and effective in providing local tumor control and pain relief 5.
Wound Care and Pain Management
After the biopsy, proper wound care is crucial to promote healing and minimize pain. Occlusive dressing therapy has been shown to be effective in promoting faster healing and reducing pain in skin biopsy sites 6. The patient can be informed about the benefits of occlusive dressing therapy and provided with guidance on wound care and pain management.
Additional Lesions on the Face
For the other lesions on the face, cryotherapy can be considered as a treatment option. The patient's preference for cryotherapy should be taken into account, and the potential benefits and risks of the treatment should be discussed. A thorough evaluation of the lesions should be performed to determine the best course of treatment.