A 71-year-old female initially presented to another dermatologist complaining of a bright red, warm and tender plaque on the left lower lip. Her past medical history was significant for 50 pack-years of smoking, psoriasis, and hospitalisation 1 year prior from Legionnaire's disease. She was initially treated for a presumed infection without improvement. She was also referred to ENT, who recommended CT of the face and sinuses, which was negative for any significant findings.
Six months after initial presentation to a dermatologist, the patient presented to our clinic with a 7-month history of a red to violaceous, blanching, oedematous, mildly tender lesion covering the left lower lip and now extending to the chin and anterior neck (Figures 1, 2). The intraoral exam was negative for any changes. However, there was a concern for possible malignancy on this visit, and a 3-mm punch biopsy of involved skin on the left lower cutaneous lip was performed.
Three weeks later, a repeat biopsy was performed and sent to a different laboratory for evaluation. The initial 3-mm punch biopsy was also sent for a second opinion. Initial bloodwork showed haemoglobin of 16.6 and haematocrit of 49.7, CEA of 6.4 (ref: 0–4.7), with ANA and ANCA negative. Age-appropriate cancer screening was also recommended and is still pending at this time. In addition, the patient had an MRI that showed asymmetric prominence of the subcutaneous fat over the left face with no abnormal soft tissue mass or lymphadenopathy.
As the diagnosis was not immediately evident, treatment was initiated with tacrolimus 0.1% ointment b.i.d. While this treatment did not shrink the lesion, it prevented the lesion from growing in size. Once the final diagnosis was made, it was decided to start oral pentoxifylline and intermittent topical steroids, as well as continuing the topical tacrolimus. The patient was on this treatment regimen for one month with no improvement.
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