Expert Insights On Diagnosing Pigmented Skin Lesions

By Bradley W. Bakotic, DPM, DO

   During the course of a tightly scheduled office day, a 30-year-old female presents with a painful paronychia involving the lateral border of her right hallux. The painful nail border is acutely inflamed. The doctor temporarily defers a definitive chemical matrixectomy and opts to perform a “slant-back” procedure to remove the offending nail border.    The doctor adducts the patient’s foot ever so slightly to access the problematic portion of the affected nail unit more easily. While doing so, the clinician notices a tan/brown, slightly elevated papule inferior to the lateral malleolus. The lesion is not particularly large (6 mm) and is of uniform color. However, it exhibits moderate asymmetry of shape. The patient says the lesion had been present her “entire life.” The physician removes the offending nail border and the patient goes home believing that her pedal problems are now resolved.    This general scenario is not uncommon. The patient may be a 75-year-old man and the skin lesion may be a small scaly plaque, but the net result is often the same: an early evolving malignancy goes undiagnosed. Incidentally, the aforementioned 30-year-old woman was a real patient but, in this instance, the podiatric clinician insisted on performing a biopsy on the atypical lesion. The biopsy disclosed an early evolving melanoma.

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