CASE
A 94-year-old man is referred for evaluation of a lesion first noted several months earlier near the medial aspect of his left eye. Although the lesion was asymptomatic and had not caused any changes in vision, it had been growing, almost doubling in size over a 6-month period. As a young man, the patient had had a great deal of poorly tolerated sun exposure, and over the years, his medical history had included removal of several basal cell carcinomas.
In addition to requiring assessment of his skin lesion, the patient was having a number of other health issues, including cardiac problems, hypertension, and osteoarthritis. He was not immunosuppressed.
On examination, we observed a very dark lesion that measured 2.8 cm and was spread out over the medial aspect of the upper and lower eyelids (Figure 1). The bottom portion of the lesion was a 1-cm, black, shiny nodule on the lower lid and nasal sidewall, surrounded by an irregularly pigmented and bordered black-to-brown macular component. None of the lymph nodes in the region were palpable.
The patient's skin, in general, was quite fair and sun-damaged, with many minor actinic keratoses and solar lentigines.
Despite advice to the contrary, the patient and his family declined treatment.
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