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What are the lesions on this woman's leg?

Dr Mike Wyndham was stumped by these unusual lesions and describes how the diagnosis was eventually made

 

The patient

This 83-year-old woman lived in a local nursing home. Like many of her generation, she was a sun-worshipper whose idea of sun protection was to apply baby oil. I came across several similar-looking lesions on her legs to the one pictured when I was called to see her after a fall.

She was in significant pain with a shortened externally rotated leg. She had a fairly extensive surgical history and had been treated for hypertension for the past 20 years – currently with enalapril and amlodipine. I referred her to hospital with a likely fractured femur.

First instinct

One of the nice aspects of dermatology is that it's usually pretty instant. Great when you recognise the condition but tricky when you come across an unfamiliar lesion. There were certainly several similar-looking lesions that were quite unusual in appearance. The skin was a little puckered at the centre and the margins were a raised red rim. From the patient's point of view, there was little problem, as there were no symptoms.

Differential diagnosis

• Necrobiosis lipoidica

• Porokeratosis

• Bowen's disease

Necrobiosis lipoidica commonly occurs on the lower leg and is more likely to occur in women. The centre of the lesions tends to be yellow with visible blood vessels and a red border. Certainly the border of the lesions was red but the inner part did not really look like necrobiosis.

Disseminated superficial actinic porokeratosis usually occurs on the leg and causes little in the way of symptoms. The lesions have an annular shape and have a raised red margin. This would certainly fit.

Bowen's disease usually appears on the lower leg of elderly women. On most occasions that I've encountered the condition the lesions are single but they may sometimes be multiple. They are pink and scaly. These lesions had no scale.

Getting on the right track

To be honest I was stumped but her discharge note came to my aid. While she was in hospital having her fractured femur fixed, a dermatologist reviewed her skin. His diagnosis was indeed disseminated superficial actinic porokeratosis.

Dr Mike Wyndham is a GP in Edgware, north London

Snapshot diagnosis DERMATOLOGY SEMINAR

Primary Care Dermatology seminar

What: This one day clinical seminar looks at the latest advances and best practice in GP dermatology - specifically aimed at the non-specialist GP.

When: May 13th 2010

Where: London

Next steps: Find out more and book

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