This young lady had taken some time out of college to see me. This patch of fleshy skin on her lower cheek and been present for months, perhaps a year. She had tried various creams from the chemist, without success. It wasn’t painful and it wasn’t getting bigger. But it wasn’t going away and cosmetically, she was desperate to get rid of it.
Other than this lesion she was entirely healthy. She had been born, and had grown up in Zimbabwe, but had lived and studied in Britain for the last three years.
Differential diagnosis
- A skin infection.
- A skin malignancy.
- Salivary gland, or other oral or dental pathology.
To me this resembled cutaneous Leishmaniasis, an infection caused by the Leishmanial protozoal parasite which is spread by an infected sandfly. I had never seen it in practice, but on the internet it looked just right. Some solitary lesions can be left to heal by themselves, but if they persist treatment involves daily intravenous administration of sodium stibogluconate. This sounded like a job for a tropical diseases hospital.
Of course she was a little young to get a squamous cell carcinoma but I wondered if a concomitant HIV infection could have predisposed to this. Given that she was from sub-Saharan Africa, where there is a population HIV rate of 25%, I did broach the possibility of an HIV test.
The skin lesion looked to overlie the submandibular gland. Perhaps an infection or a malignancy had penetrated the skin to form a fistula, although she hadn’t complained of any dental or oral pain.
Getting on the right track
This skin lesion hadn’t changed in a year, which reassured me that malignancy was unlikely, and the HIV test had come back negative. But the lesion also hadn’t improved with antibiotics. Given that the lesion had arisen in the UK, cutaneous Leishmaniasis, which is most often seen in south America and the middle east also seemed unlikely.
The penny dropped when, during a routine check-up, her dentist suspected an abscess under a tooth on that side, draining through a sinus to the skin. He confirmed this with an X-ray and removed one of the molars on the right lower side. Three days later the skin lesion dried over. I saw her a few months after the dental procedure and her face was back to normal.
Dr Oliver Starr is a GP in Stevenage.
