Pictorial case study

The case: During a routine appointment, this 74-year-old man mentioned that one of his warts had started bleeding.

Patients to check regularly for new or changing lesions
Patients to check regularly for new or changing lesions

He had attended the surgery three years before and the GP had diagnosed seborrhoeic keratoses as the cause of his multiple lesions, had explained the nature of the condition and had provided an information leaflet. The patient had been reassured by this advice and was happy that the warts were benign. However, he found the bleeding a nuisance.

Further questioning revealed that the patient had been a builder and had often worked without a shirt and no sun protection.

Diagnosis and management
Closer inspection revealed the source of the bleeding to be a small cherry red papule adjacent to one of the warts. The likely cause of this was a haemangioma, which I was able to reassure him was benign.

Of more interest was the 1cm diameter annular lesion adjacent to this which had a rolled pearly edge and central ulceration. This had apparently been present for many years and the patient thought it was one of the seborrhoeic warts. However, its appearance raised my suspicion that this was a basal cell carcinoma (BCC).

Diagnosis was made by sending a 4mm punch from the edge of the lesion for histological examination. It was confirmed as a nodular BCC and was excised along with the haemangioma in the surgery.

This is a good example of how different skin lesions may be present close together and how a simple wart may be hiding something more sinister. It highlights the need to ask patients to check regularly for new or changing lesions.

Possible differential diagnoses

  • Seborrhoeic keratoses.
  • Squamous cell carcinoma.
  • Actinic keratosis.

Differential diagnosis
Actinic keratosis

  • These usually occur in areas of sun exposure such as the face, scalp and chest.
  • Most common in the elderly and people with fair skin.
  • They typically have a rough, crusted surface and are red, brown or skin-coloured.
  • Management includes cryotherapy and curettage, topical fluorouracil 5% or imiquimod and minimising sun exposure.
  • Contributed by Dr Stollery, a GP and clinical assistant in dermatology, Leicester.

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