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Stem
A 72-year-old fair-skinned man presents with multiple small, soft, yellowish papules on his forehead, cheeks and nose. Each papule measures 3–5 mm and has a tiny central dell with delicate vessels arranged in a ring at the periphery. The lesions have appeared gradually over two years and are asymptomatic but cosmetically bothersome. He had a renal transplant six years ago and takes tacrolimus, mycophenolate and low-dose prednisolone; he previously took cyclosporin for two years. He has no history of skin cancer.
Questions
a) What is the most likely diagnosis, and what two clinical features in the stem support it? (2 marks)
b) Name the pathognomonic dermoscopic triad and explain how dermoscopy distinguishes this lesion from a nodular basal cell carcinoma. (2 marks)
c) Outline your stepwise management plan for this patient, including the role of oral isotretinoin. (3 marks)
d) The patient asks whether the lesions could be cancer. What red-flag features would prompt biopsy, and what syndrome must you consider if a biopsy reports a sebaceous adenoma rather than hyperplasia? (3 marks)