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Is this lesion a cause for concern?

Joe R. Monroe, PA-C, MPAS

Joe Monroe practices in the dermatology department of the Warren Clinic, Tulsa, Oklahoma, is the department editor for Dermatology Digest, and is the founder and a past president of the Society of Dermatology Physician Assistants. He has indicated no relationships to disclose relating to the content of this article.

CASE

The patient was a 27-year-old woman with a lesion on her ear first noticed by her mother. The mother suggested that the patient have the lesion evaluated by a dermatology specialist. The patient’s sister had a history of low tolerance for sun exposure and had had a melanoma several years earlier. The patient herself also had a history of a low tolerance for sun exposure when she was younger.

The lesion had been present on the patient’s ear for at least several months, did not hurt or itch, and had not demonstrated any growth or other substantive change. The patient was otherwise healthy, was not immunosuppressed, and had been carefully avoiding the sun for several years at the time of this examination.

On physical examination, the dermatology clinic PA noted that the lesion in question was a 4.5-mm, oddly pigmented, brownish-black macule located on the mid-posterior helical rim of the patient’s ear (see Figure 1). On further examination of the patient’s face and head, the skin was quite fair but with little evidence of sun damage. At this crucial point, there are several things to note about this lesion.

WHICH STATEMENT IS TRUE?

The lesion may not be a melanoma because it is flat (macular).
The lesion is suspicious because it is on an area directly exposed to the sun.
The lesion can be safely removed for pathologic examination with a deep shave (saucerization) technique.

DISCUSSION

The third statement is true. Because this is a thin lesion and it is located on thin skin, a deeper shave that reaches into the dermis or even into superficial adipose tissue will collect the entire lesion. Therefore, an adequate specimen can be safely obtained for pathologic examination.

The first statement is false. At least 75% of melanomas are essentially flat, or macular; that is, the lesion has little, if any, raised palpable component. This misconception is, by itself, responsible for the deaths of many patients with melanoma because they assumed incorrectly that their lesion was not at risk of being malignant.

The second statement is false as well. On this patient, this area would not be considered to be directly exposed to the sun. In fact, the helical rims of most women’s ears typically receive very little sun exposure. However, melanomas can develop on virtually any area of skin including areas that receive little, if any, sun exposure. This misconception also has led to much unnecessary morbidity and mortality.

Treatment Saucerization of the lesion was performed, and the specimen was sent for pathologic examination. The lesion was found to be a benign compound nevus without significant atypia. The skin on the patient’s body below the neck was also examined and found to be free of any suspicious lesions, but it was quite fair and sun-damaged.

Comment An equally effective method of removal for potential melanomas is excision, with minimal margins initially. But given the location and thinness of this particular lesion, a deep shave-excision had the advantage of producing less scarring while still providing an adequate specimen.

Even though most melanomas are macular, many are not. As many as 10% are nodular, demonstrating no macular components at all. And by the same token, a significant number of superficial spreading melanomas will have significantly raised portions on the surface. The sobering fact is that melanomas can manifest with many different signs, including no color or even as a skin tag, on virtually anyone. For this reason, clinicians must maintain a low threshold for biopsy of lesions regardless of their suspicious nature. JAAPA