Can You Identify This Asymptomatic Nodule

An 80-year-old female presented for evaluation of an asymptomatic nodule on her back of at least 3 months duration. She is otherwise healthy and denies any exposure history or new medications.

Your thoughts are to:

A. Prescribe a trial of a topical corticosteroid cream initially for possible insect bite reaction
B. Order a skin biopsy for histological diagnosis
C. Prescribe an antibacterial antibiotic such as doxycycline for 3 weeks
D. Cryosurgery
E. “Wait and watch,” and re-evaluate in 3 months for any changes

(Answer and discussion on next page)

Answer: Order a skin biopsy to decide subsequent course of action and treatment.

Suspicion of cutaneous B cell lymphoma led to a skin biopsy that revealed changes consistent with B-cell lymphoma using histomorphology and cytomorphology, immunohistochemistry and phenotypic features. Subsequent work-up was completely normal including bone marrow and PET scan. It was elected to conservatively watch the patient and lesion. She declined to have it excised as it was asymptomatic. Treatment options include local radiation, three week trials of doxycycline and intralesional steroids.