A 70-year-old male presented for a complete skin examination in July 2016. He had a history of actinic keratoses (AK) and three basal cell carcinomas. He had new skin lesions on his nose and back.\nHis past medical history is significant for benign paroxysmal positional vertigo (BPPV), hyperlipidemia (treated with atorvastatin), gout (treated with allopurinol), nephrolithiasis and recent stenting of his right coronary artery one month ago and currently receiving (clop nephrolithiasis dogrel).\nThe cutaneous examination was remarkable for 22 erythematous scaling plaques on his scalp, face, and arms, consistent clinically with actinic keratoses. He had yellow longitudinal streaks on his left great and fifth toe, consistent with onychomycosis. On his nasal tip, there was a 3 x 3 mm pearly-colored papule with a red dot of less than 1 mm in the center (Figures -). In addition, there was a 1 x 1 mm black macule with an adjacent 6 x 6 mm white plaque on his upper mid back (Figures -).\nThe actinic keratoses were treated with liquid nitrogen cryotherapy and the patient declined treatment for his toenail fungal infection. The back and nose lesions were each biopsied using a punch and shave technique, respectively. The nasal tip lesion red dot showed superficial buds and nodular aggregates of basaloid tumor cells extending from the epidermis into the dermis; there were also telangiectatic blood vessels in the papillary dermis (Figures -). The upper mid back lesion showed an atypical proliferation of basaloid cells both emanating from the epidermis as oblong clusters and as discrete nests in the dermis; focally, some of the basaloid cells harbored cytoplasmic melanin pigment.\nCorrelation of the clinical presentation and pathologic findings of the nasal tip lesion was a red dot basal cell carcinoma (with superficial and nodular tumor aggregates). The tumor was excised using the Mohs technique. Two stages were required for cancer removal; the size of the defect was 11 x 10 mm. A full-thickness skin graft was used to repair the surgical wound.\nThe pigmented superficial and nodular basal cell carcinoma on his upper mid back was excised and the surgical wounds were closed with complex layered closure. Follow-up examination five months later showed excellent healing of both surgical sites and no evidence of recurrence.
A 74-year-old Hispanic woman presented with an asymptomatic lesion of one-year duration on the nasal tip. Clinical examination showed a nodular tumor; in addition to being black, there was ulceration (Figures -). There was no palpable neck lymphadenopathy. Morphologically, the clinical differential diagnosis included malignant melanoma.\nA biopsy was performed. Microscopic examination showed nodular aggregates of basaloid tumor cells extending from the epidermis into the dermis. There was pigment not only in the tumor cells but also within the melanophages in the adjacent dermis. Correlation of the clinical presentation and pathology established the diagnosis of pigmented nodular basal cell carcinoma.\nMohs surgery was performed. The tumor was cleared after three stages. A left paramedian forehead flap was performed to treat the surgical wound. Follow-up three months later showed excellent healing without recurrence of the skin cancer. However, there was significant hypertrichosis involving the tissue flap on the nasal tip (Figures -). This was remedied by using electrolysis to eliminate the hair.