The Skin

Last updated (19 November 2003)

Scaly Click on the image to download a larger version
This elderly gentleman was admitted to the hospital with an unrelated condition, the admitting doctor noted this lesion on his left temple which had been slowly enlarging for 10 months or more. The gentleman's only concern about this lesion was that the discharge from it was dirtying his pillow while he slept, he wondered if anything could be done about it.
This image is a picture of a skin lesion on a gentlemans left temple. Describe the lesion?

The answer

There is an eschar on the gentleman's left temple overlying a lesion which measures approximately 10 cm x 10 cm. The eschar has been removed or has fallen off the lower third of the lesion. Where the eschar has been removed there is an ulcer with a considerable amount of purulant material. The edges of the ulcer appear scaly especially in the area adjacent to the forehead.

Close to the eyebrow there is a punched out area with a fresher eschar, this may represent the site of a punch biopsy.

We can see from the way that the purulant material is flowing from the lesion that the patient is lying supine (water flows downhill).

What the student may say

The gentleman appears to be lying comfortably.

There is a 10 cm x 10 cm lesion on the left temple. The lesion is in the main covered by an eschar, but we can see that there is an underlying ulcer beneath the eschar. The ulcer is best seen inferiorly where the eschar has been removed. Purulant material flows from the lesion. On the medial side the skin appears scaly. At this location there is also a small circumscribed area with a fresher eschar that may have been the site of a punch biopsy.

Despite the large amount of purulant material that is flowing from the lesion there is no evidence of surrounding cellulitis.

I don't see any sattelite nodules or large masses in keeping with lymphadenopathy. The forehead appears symmetrical which goes against the possibility of involvement of a branch of the facial nerve, but for fuller assessment I would like to ask the patient to make some facial movements.

Overall I would be concerned about the possibility of a neoplastic process.


Adrian P. Ireland