What is the differential diagnosis for an elderly female with a history of sun exposure presenting with a flesh-colored raised lesion on the eyebrow?

Differential Diagnosis for Flesh-Colored Raised Lesion on Eyebrow in Elderly Female with Sun Exposure History

The most likely diagnoses for a flesh-colored raised lesion on the eyebrow in an elderly female with chronic sun exposure are basal cell carcinoma (most common), followed by squamous cell carcinoma, actinic keratosis, and seborrheic keratosis.

Primary Differential Considerations

Basal Cell Carcinoma (BCC) - Most Likely

• BCC is the most common skin cancer, comprising approximately 80% of nonmelanoma skin cancers, and typically presents as a shiny, pearly papule with smooth surface, rolled borders, and telangiectatic vessels 1, 2, 3
• The head and neck region, including the eyebrow area, represents the most common site for BCC development due to chronic sun exposure 1
• Elderly patients with fair skin and chronic sun exposure constitute the highest-risk population, with lifetime risk approaching 30% in Caucasians 4
• Nodular BCC is the most common subtype and can present as a flesh-colored raised lesion, though pigmented variants also occur 1, 5

Squamous Cell Carcinoma (SCC)

• SCC commonly appears as a firm, smooth, or hyperkeratotic papule or plaque on sun-exposed areas like the face 3
• Represents approximately 20% of nonmelanoma skin cancers and occurs predominantly on chronically sun-exposed skin 2
• More aggressive than BCC with higher metastatic potential, accounting for 20% of all skin cancer deaths 1

Actinic Keratosis (AK)

• AKs are precancerous keratotic lesions occurring on chronically light-exposed skin, presenting as discrete patches of erythema and scaling in middle-aged and elderly individuals 1, 6
• Prevalence increases dramatically with age: 19-24% of individuals over 60 have at least one AK, rising to over 70% by age 70 1
• While typically rough and scaly rather than smooth, early or hyperkeratotic variants may appear raised and flesh-colored 1
• Less than 1 in 1000 AKs transforms to SCC annually, but presence indicates field cancerization and increased overall skin cancer risk 1

Seborrheic Keratosis

• Benign lesion that can be distinguished from AK by its characteristic "stuck-on" appearance rather than rough, scaly texture with underlying erythema 7
• Common in elderly patients but not specifically associated with sun exposure 7

Critical Assessment Features

High-Risk Characteristics Requiring Urgent Evaluation

• Ill-defined borders, increasing size, ulceration, or bleeding suggest aggressive BCC or SCC 1, 3
• Morpheaform (sclerosing) BCC subtypes and those with perineural or perivascular invasion carry highest recurrence risk 1
• Central facial location (including eyebrow) represents high-risk anatomic site for recurrence 1

Diagnostic Approach

• Biopsy is indicated when clinical doubt exists or when histological subtype will influence treatment selection 1
• Shave biopsy technique is appropriate for raised lesions; punch biopsy for the most abnormal-appearing area 3
• Dermoscopy can enhance diagnostic accuracy when clinical uncertainty exists 1

Common Pitfalls to Avoid

• Do not assume flesh-colored lesions are benign - pigmented BCC can masquerade as melanoma, but non-pigmented BCC is far more common and easily overlooked 5
• Do not delay biopsy in elderly patients with history of sun exposure - this population bears disproportionate burden of skin cancer morbidity and mortality 1
• Do not rely solely on clinical appearance - the differential diagnosis is large, and histological confirmation is essential for definitive diagnosis and treatment planning 1, 4

Risk Stratification Context

The combination of elderly age, female gender, eyebrow location (sun-exposed head/neck area), and chronic sun exposure history places this patient at substantially elevated risk for skin malignancy 1. After one skin cancer diagnosis, the 5-year risk of subsequent skin cancer is 41%, increasing to 82% after more than one diagnosis 3.