Retroauricular ulcer in a patient with a history of multiple skin cancers

Presenter: Tony Nakhla, D.O.

Dermatology Program: Western University/Pacific Hospital of Long Beach

Program Director: David C. Horowitz, D.O.

Submitted on: September 17, 2008

CHIEF COMPLAINT: “I have a skin cancer behind my ear”

CLINICAL HISTORY: A 55-year-old white male who presented to our clinic with a 2-week history of a painful sore on the right postauricular region. No prior treatments. The patient has a past medical history of multiple non-melanoma skin cancers including five squamous cell carcinoma and six basal cell carcinomas, three of which required Mohs. He reports no other significant past medical history and is on no medications. He smokes approximately one pack per day. The patient has no medical insurance and was concerned with procedural costs. He was willing to pay for a complete excision but did not want to pay for a biopsy since due to his history, he was convinced it was another skin cancer which needed to be removed.

PHYSICAL EXAM:
Cachectic 55-year-old white male with poor hygiene. Large (approx 4.3x 3.5 cm), tender, ulcerated, erythematous plaque with impetiginized crusts and purulent drainage was present around and within the right retro-auricular sulcus.

LABORATORY TESTS: N/A

DERMATOHISTOPATHOLOGY:

Microscopic examination revealed a dome-shaped, granulomatous infiltrate of foreign body giant cells, lymphocytes, and macrophages. Foreign body giant cells composed of lymphocytes, neutrophils, eosinophils, and macrophages present in the dermis. Numerous encapsulated, round to ovoid spores were present within macrophages and giant cells as well as in free spaces.