Basal Cell, Clinical Case, Teledermatology, Transplant



  1. Jacob, Sharon E.


ABSTRACT: Teledermatology is a term to describe the provision of dermatologic medical services through telecommunication technology. In this modality, there is transfer of medical information electronically (including clinical history and visual data) on a patient in one location to a provider who is in another location. The construct of this column is such that cases are presented in a standardized teledermatology reader format. This is a case of a new growth presenting on the forehead in a transplant patient.


Article Content




Chief complaint: presenting for diagnosis of a lesion.


History of present illness: A 56-year-old gentleman presents with a pink and black papule (primary lesion) on his forehead (location) that has been growing and bleeding for 3 months (duration). Prior treatment: none. His primary symptom: slight itch and bleeding. Prior biopsy: none. He has a personal history of nonmelanoma skin cancer (22 squamous cell carcinomas and 16 basal cells), three of which predated his cardiac transplant. He became a cardiac transplant recipient in 1998 and currently is immunosuppressed. Other significant laboratory/study findings: none. Family history: positive for nonmelanoma skin cancer.




Image 1: fully satisfactory.


Image 2: unsatisfactory; focus not acceptable.



Two images were provided. Figure 1 clearly shows a pearly rolled bordered papule with evidence of ulceration and pigmentation on the left forehead. Figure 2 is poorly focused and offers no further information. No size indicator is included in the photograph.

Figure 1 - Click to enlarge in new windowFIGURE 1. Image 1 showing forehead lesion.
Figure 2 - Click to enlarge in new windowFIGURE 2. Image 2 demonstrates the importance of consitution, focus, and light in photographic images in teledermatology.


Lesion A


The presented lesion is highly suspicious for a pigmented basal cell carcinoma.



Skin Care and Treatment Recommendations

Patient is to present to dermatology for a confirmatory biopsy.


Patient is to be advised to utilize broad-spectrum sunscreens and sun protective clothing to avoid prolonged exposure to sunlight between the hours of 10 A.M. and 4 P.M. and have regular skin checks with dermatology.



Type of Visit

Return for a face-to-face evaluative visit with the dermatology nurse practitioner or dermatologist. This patient should have an evaluative visit for this new lesion but also needs to be seen on a regular basis thereafter (e.g., every 4 months).



Regular use of sunscreens has been shown to significantly prevent the development of further actinic keratosis, invasive squamous cell carcinoma, and basal cell carcinoma (to a lesser degree) in organ transplant recipients (OTRs; Ulrich et al., 2009). "Skin cancer is the most common cancer affecting solid OTRs, affecting up to 70 percent of patients within 20 years, and is the result of intense immunosuppressive regimens. Solid organ transplant recipients are up to 65 times more likely to develop skin cancer than people without transplants" (ITSCC, 2014). Dr. Clark C. Otley said, "The patient who impacted me the most was an amazing gentleman who had a cardiac transplant and suffered with more than 500 skin cancers, including 3 metastatic skin cancers. He relentlessly challenged me to help him and would not accept 'standard of care' as good enough. He was the motivating force behind the International Transplant Skin Cancer Collaborative" (Barankin, 2014). In addition, OTRs should be advised to avoid tanning beds and limit ultraviolet light (UV) exposure and should be instructed on performing monthly skin self-examinations.




Barankin B. (2014). Spotlight on Clark Otley. The Dermatologist, Retrieved from[Context Link]


International Transplant Skin Cancer Collaborative - Mission Statement. Retrieved from[Context Link]


Ulrich C., Jurgensen J. S., Degen A., Hackethal M., Ulrich M., Patel M. J., Stockfleth E. (2009). Prevention of non-melanoma skin cancer in organ transplant patients by regular use of a sunscreen: A 24 months, prospective, case-control study. The British Journal of Dermatology, 161 (Suppl. 3), 78-84. [Context Link]


1The standardized teledermatology reader report format is available for authors on the Journal's Web site ( [Context Link]


2Evaluator picks one: fully satisfactory/marginal satisfactory with suggestions for improvement/unsatisfactory. [Context Link]


3Type of visit: Please pick one: return to primary provider for treatment/refer to dermatology clinic for evaluation (face to face)/ lesion is benign, recommend reassurance and follow-up as needed (PRN). [Context Link]