BOCA RATON, FLA. — A punch biopsy revealed a malignant neoplasm that was diagnosed as Merkel cell carcinoma. The patient was referred to the University of Florida for further evaluation.
The surgeon at the university wanted to do a wide excision of the lesion and sentinel lymph node. A lymph node dissection was planned in the event that the sentinel node came back positive.
The patient's candidiasis had not improved after 10 days of treatment with ketoconazole, so surgeons referred him to dermatology. The dermatologist examined the 1-cm-by-1-cm raised nodular mass in the patient's left groin surrounded by 10 cm2 of “candidiasis.” The dermatologist suspected extramammary Paget's disease.
The patient underwent removal of the lesion and sentinel node. Pathology revealed that the tumor was not Merkel cell, but an infiltrative apocrine adenocarcinoma. The rash was confirmed to be extramammary Paget's disease, and the sentinel node was positive, said Justin Wasserman, a fourth-year medical student at the university.
“Due to the patient's age and his comorbidity—he had Alzheimer's disease—his family did not want him to have additional surgery,” Mr. Wasserman said at the annual meeting of the Florida Society of Dermatologic Surgeons. So the patient did not undergo lymph node dissection. The extramammary Paget's disease was treated topically with imiquimod.
This case illustrates that, “groin rashes that have been adequately treated without improvement should be biopsied,” Mr. Wasserman said.
The patient was prescribed a 16-week course of imiquimod to be applied three times a week to the visible areas and about 2 inches beyond. After 8 weeks, there was some irritation to the area, but the rash had cleared almost completely except for a small area on the left lateral edge. The patient was instructed to discontinue imiquimod for 6 weeks. If at that time any rash still remained, he was instructed to restart and use the cream three times a week for an additional 16 weeks.