Part of the Health Insider series on POMConnect
Images in this article are for illustrative purposes only and do not depict any specific patient.
Patient Presentation
The patient, was referred to our clinic for what was initially presumed to be a plantar wart. He had undergone several months of unsuccessful treatment prior to his visit. Upon examination, a friable and ulcerative nodule was noted, raising suspicion for an alternative diagnosis as those characteristics are atypical to plantar warts. Despite the lesion’s unusual presentation, it had been mistakenly treated as a wart until a biopsy was conducted, revealing an unexpected finding of cutaneous malignancy.
Case Discussion
Cutaneous skin cancers typically manifest on sun-exposed areas, making their occurrence on extremities uncommon. In this case, the patient’s lesion exhibited several atypical features. The presence of red flags such as persistent pain and an abnormal clinical appearance prompted further investigation, leading to the discovery of skin cancer.
Complexities in Diagnosis and Treatment
Several complexities complicated the diagnosis and treatment of this case. The patient’s history of arsenic exposure, a known risk factor for skin cancer, emerged during the history taking. This patient was a migrant worker, therefore there was also a language barrier. His existing medical insurance also did not include specialist medical coverage. Our team had to explain to the patient’s employer regarding the need for histological confirmation.
Approach to Diagnosis and Management
The diagnostic approach relies heavily on thorough history taking, physical examination, and dermatoscopic assessment. Clues from the patient’s history, coupled with the unusual clinical presentation, informed the decision to pursue biopsy for a definitive diagnosis. Dermatoscopy aided in distinguishing between benign and malignant causes, and can be an important tool for clinicians.
Ethical Considerations
Ethical considerations surrounding healthcare accessibility and affordability for migrant workers emerged during the course of treatment. The patient’s lack of comprehensive medical coverage further reinforces the calls for initiatives to improve healthcare access for underserved populations. Challenges such as fear of repatriation in the face of severe medical conditions further highlighted the ethical dilemmas inherent in healthcare for migrant workers.
Lessons Learned and Insights
This case serves as a reminder of the importance of maintaining a high index of suspicion for cutaneous malignancies, even in atypical presentations. Despite misconceptions about the rarity of skin cancer in certain demographics, this case demonstrates the need for vigilance in recognizing and addressing such conditions, particularly in populations with unique risk factors.
By sharing insights from this case, healthcare professionals can be aware of the uncommon presentations of cutaneous malignancies. Notably, keeping in mind the distinct differences and risk factors which exist in different populations. Taking melanomas as an example, the acral lentiginous melanoma subtype is more prevalent in Asians compared to the Western population (and also tends to present later and at a more advanced stage). Early detection and comprehensive management are important to achieve good clinical outcomes.
POMConnect would like to thank Dr Kok Wai Leong
for his invaluable insights and contribution to this article.
Dr Kok Wai Leong, MBBS, GDip (Occ Med), FAMS (Dermatology), is a Senior Consultant Dermatologist at StarMed Specialist Centre & Mount Elizabeth Medical Centre, catering to both paediatric and adult dermatology needs. He is an accredited dermatologist with a special interest in eczema, psoriasis, photodermatology, and skin cancers. His expertise extends to the treatment of difficult inflammatory and immunological skin conditions, utilizing biologic therapy and phototherapy, offering comprehensive care encompassing skin surgery, cosmetic, and laser procedures.
To connect with Dr Kok, please visit:
StarMed Specialist Centre
#05-01, 12 Farrer Park Station Road, Singapore 217565
Mount Elizabeth Medical Centre
#12-14, 3 Mount Elizabeth, Singapore 228510
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