10.5826/dpc.1204a159
Introduction: Biopsy of facial skin lesions is an important supplement to dermatological diagnostics, especially in doubtful cases or suspected of being malignant.
Objectives: The aim of the retrospective study of 2135 histopathological records of lesions on the face was to:
1). establish the most common indications for a skin biopsy in patients with facial lesions,
2). establish the frequency of histopathological diagnoses,
3). evaluate how often clinically suspected inflammatory lesions are identified as tumors in histopathology,
4). evaluate the accuracy of clinical diagnoses of the most common skin tumors and dermatoses.
Methods: It was a retrospective study. Histopathological records from the lesions on the face from years 2010-2017 were analyzed.
Results: The mean age of patients was 69.3 [7-98]. 58.28% of the patients were women. Among 2135 clinical diagnoses skin tumors were suspected in 1905 cases. Among 2169 obtained histopathological results (34 biopsies showed two diseases), we identified skin tumors in 1940 cases, with 1388 confirmed as malignant. The clinical diagnosis of a specific benign or malignant skin tumor was accurate in 1013/1634 subjects, in comparison to inflammatory lesions, which were correct in 67/148 cases, (p=0.0001). Among all preliminary inflammatory diagnoses, 33/204 lesions were identified as skin tumors in histopathology.
Conclusions:In conclusion in most cases of skin tumors the clinical diagnosis is confirmed by histopathological examination. In case of facial inflammatory lesions, the accuracy of clinical diagnosis is lower, with a significant number of facial lesions appearing inflammatory in clinical evaluation but being diagnosed as skin cancers in pathology.
text/xml
2160-9381
2001
en
Lidia  Rudnicka
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
inflammatory diseases
The accuracy of clinical diagnosis in 2135 lesions on the face: A retrospective analysis of histopathological records
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-10-31
2021-10-13
2022-10-31
2022-11-29
e2022159
Dermatol Pract Concept
Introduction: Biopsy of facial skin lesions is an important supplement to dermatological diagnostics, especially in doubtful cases or suspected of being malignant.
Objectives: The aim of the retrospective study of 2135 histopathological records of lesions on the face was to:
1). establish the most common indications for a skin biopsy in patients with facial lesions,
2). establish the frequency of histopathological diagnoses,
3). evaluate how often clinically suspected inflammatory lesions are identified as tumors in histopathology,
4). evaluate the accuracy of clinical diagnoses of the most common skin tumors and dermatoses.
Methods: It was a retrospective study. Histopathological records from the lesions on the face from years 2010-2017 were analyzed.
Results: The mean age of patients was 69.3 [7-98]. 58.28% of the patients were women. Among 2135 clinical diagnoses skin tumors were suspected in 1905 cases. Among 2169 obtained histopathological results (34 biopsies showed two diseases), we identified skin tumors in 1940 cases, with 1388 confirmed as malignant. The clinical diagnosis of a specific benign or malignant skin tumor was accurate in 1013/1634 subjects, in comparison to inflammatory lesions, which were correct in 67/148 cases, (p=0.0001). Among all preliminary inflammatory diagnoses, 33/204 lesions were identified as skin tumors in histopathology.
Conclusions:In conclusion in most cases of skin tumors the clinical diagnosis is confirmed by histopathological examination. In case of facial inflammatory lesions, the accuracy of clinical diagnosis is lower, with a significant number of facial lesions appearing inflammatory in clinical evaluation but being diagnosed as skin cancers in pathology.
Lidia  Rudnicka
2022/10/31
10.5826/dpc.1204a159
e2022159
Department of Dermatology, Medical University of Warsaw, Poland
2160-9381
inflammatory diseases
en
e2022159
The accuracy of clinical diagnosis in 2135 lesions on the face: A retrospective analysis of histopathological records
https://dpcj.org/index.php/dpc/article/download/2001/1765
  The Accuracy of Clinical Diagnosis in 2135 Lesions
        on the Face. A Retrospective Analysis
            of Histopathological Records
       Anna Czaplicka1, Magdalena Misiak- Gałązka2, Joanna Czuwara 2, Adam Gałązka3,
                            Barbara Górnicka4, Lidia Rudnicka2


1 Department of Dermatology, Postgraduate Medical Education Center/Central Clinical Hospital of the Ministry of Interior and
  Administration in Warsaw, Warsaw, Poland
2 Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
3 Department of Head and Neck Cancers, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland.
4 Department of Pathology, Medical University of Warsaw, Poland.



Key words: dermatopathology, cancer, standardized skin surface biopsy, face, inflammatory diseases
Citation: Czaplicka A, Misiak- Gałązka M, Czuwara J, Gałązka A, Górnicka B, Rudnicka L. The accuracy of clinical diagnosis in
2135 lesions on the face. A retrospective analysis of histopathological records. Dermatol Pract Concept. 2022;12(4):e2022159.
DOI: https://doi.org/10.5826/dpc.1204a159
Accepted: February 5, 2022; Published: October 2022
Copyright: ©2022 Czaplicka et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.




  ABSTRACT             Introduction: Biopsy of facial skin lesions is an important supplement to dermatological diagnostics,
                       especially in doubtful cases or suspected of being malignant.
                       Objectives: The aim of the retrospective study of 2135 histopathological records of lesions on the
                       face was to: establish the most common indications for a skin biopsy in patients with facial lesions,
                       establish the frequency of histopathological diagnoses, evaluate how often clinically suspected inflam-
                       matory lesions are identified as tumors in histopathology, evaluate the accuracy of clinical diagnoses
                       of the most common skin tumors and dermatoses.
                       Methods: It was a retrospective study. Histopathological records from the lesions on the face from
                       years 2010-2017 were analyzed.
                       Results: The mean age of patients was 69.3 [7-98]. Fifty-eight percent of the patients were women.
                       Among 2135 clinical diagnoses skin tumors were suspected in 1905 cases. Among 2169 obtained his-
                       topathological results (34 biopsies showed 2 diseases), we identified skin tumors in 1940 cases, with
                       1388 confirmed as malignant. The clinical diagnosis of a specific benign or malignant skin tumor was
                       accurate in 1013/1634 subjects, in comparison to inflammatory lesions, which were correct in 67/148
                       cases, (P = 0.0001). Among all preliminary inflammatory diagnoses, 33/204 lesions were identified as
                       skin tumors in histopathology.




Original Article | Dermatol Pract Concept. 2022;12(4):e2022159                                                                      1
                     Conclusions: In conclusion in most cases of skin tumors the clinical diagnosis is confirmed by histo-
                     pathological examination. In case of facial inflammatory lesions, the accuracy of clinical diagnosis is
                     lower, with a significant number of facial lesions appearing inflammatory in clinical evaluation but
                     being diagnosed as skin cancers in pathology.




Corresponding author: Magdalena Misiak-Galazka MD,
PhD. Department of Dermatology Medical University of
                                                                  Methods
Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland, Tel/fax:
0048228242200, E-mail: magdamisiak@o2.pl                          It was a retrospective study performed at the Department
                                                                  of Dermatology, Medical University of Warsaw, Poland.
                                                                  Histopathological records from the lesions on the face from
Introduction                                                      years 2010-2017 were analyzed. Patients for skin biopsies
                                                                  (punch, shave or excisional) were referred from our depart-
Face is one of the special locations in dermatology with skin
                                                                  ment as well as from many outpatients clinics in Warsaw
lesions easily visible having a negative impact on self-esteem
                                                                  area. The patients presented with skin phototypes I-III. The
and decreasing the quality of life. Many dermatoses on the face
                                                                  mean age of patients was 69.3 (range 7-98 years of age), and
are easily diagnosed based on clinical examination and der-
                                                                  58.28% of patients were women. Biopsies taken from the
moscopy, and no skin biopsy is needed. Dermoscopic criteria of
                                                                  scalp and mucous membranes were excluded. A total num-
skin tumors on the face are well established and used in every-
                                                                  ber of 89 cases were nondiagnostic and were excluded from
day clinical practice [1]. Also dermoscopic patterns of common
                                                                  the study. In total 2135 biopsy records were evaluated, 750
facial inflammatory lesions were shown by Lallas et al [2].
                                                                  from cheeks with zygomatic area, 718 from noses, 434 from
    However, in doubtful cases, when malignancy is sus-
                                                                  foreheads, 110 from ears, 71 from lips and 52 from chins.
pected, a histopathological examination is mandatory, de-
                                                                  Because in 34 cases 2 final diagnoses were established a total
spite the fact, that skin biopsy may result in scar formation.
                                                                  number of 2169 of final diagnoses were analyzed.


Objectives                                                        Statistical Analysis
                                                                  The results were computed with Statistica 13.1 software
The aim of the study was to analyze the histopathological
                                                                  (StatSoft Incorporated) licensed to the Medical University of
records from lesions on the face, to define the most common
                                                                  Warsaw. Chi 2 test was used for assessing binary variables.
indications for a skin biopsy, to establish the order of the
                                                                  A P value below 0.05 was considered statistically significant.
common histopathological diagnoses, to evaluate how often
skin biopsies suspected as inflammatory lesions turn out to
be skin tumors, to evaluate the accuracy (the same clinical       Results
and histopathological diagnoses) of the most common skin
                                                                  Among 2135 clinical diagnoses, the skin tumors were sus-
tumors and dermatosis on the face.
                                                                  pected in 1905 (89.23%) cases, and in 1609 (75.36%) cases
                                                                  malignant skin tumor or precancerous lesion were considered.



 Table 1. The most common clinical diagnoses (≥ 3 cases) among 2135 skin biopsies. In some cases,
                          more than one clinical diagnosis was given
                                           Total
                                         number of
                                           cases              %     CHEEK      CHIN      EAR     FOREHEAD         LIPS     NOSE
 Basal cell carcinoma                        984         46.09%      313         18       51          196          27       379
 Actinic keratosis                           424         19.86%      149          5       14          102            4      150
 Seborrheic keratosis                        108          5.06%        40         0         6          30            0        32
 Fibroma                                     105          4.92%        49         5         3          11            6        31
 Squamous cell carcinoma,                     96         4,5%          22         4       17           12          10         31
 keratoacanthoma
 Lupus erythematosus                          88          4.12%        58         1         0          15            0        14


2                                                                     Original Article | Dermatol Pract Concept. 2022;12(4):e2022159
                                              Total
                                            number of
                                              cases              %      CHEEK       CHIN     EAR    FOREHEAD         LIPS   NOSE
 Cutaneous horn                                  52           2.44%       23          3         4            9         2        11
 Melanocytic nevus, blue nevus                   38           1.78%       10          7         0           10         0        11
 Sarcoidosis                                     37           1.73%       13          0         0           13         0        11
 Skin tumor                                      32           1.50%        9          0         3            9         3         8
 Pyogenic granuloma                              23           1.08%        6          1         0            0         7         9
 Verruca vulgaris                                23           1.08%       10          0         2            5         0         6
 Solar lentigo                                   14           0.66%        8          0         0            0         0         6
 Facial granuloma                                13           0.61%        3          0         0            4         0         6
 Rosacea                                         10           0.47%        3          1         0            2         0         4
 Eczema                                            8          0.37%        4          0         3            1         0         0
 Lentigo maligna                                   8          0.37%        6          0         0            2         0         0
 Lymphoma                                          7          0.33%        4          0         0            3         0         0
 Granulomatous cheilitis                           6          0.28%        0          0         0            0         6         0
 Squamous cell carcinoma in situ.                  6          0.28%        4          0         0            2         0         0
 Bowen type
 Annular granuloma                                 6          0.28%        3          0         0            3         0         0
 Sebaceous hyperplasia                             5          0.23%        0          0         0            2         0         3
 Cyst                                              4          0.19%        2          0         0            0         0         2
 Lichen planus                                     4          0.19%        2          0         0            0         2         0
 Lymphocytoma                                      4          0.19%        4          0         0            0         0         0
 Dermatitis (superficial dermal                    3          0.14%        2          1         0            0         0         0
 inflammation)
 Morphea                                           3          0.14%        2          0         1            0         0         0



 Table 2. The most common histopathological diagnoses (≥3 cases) among 2169 skin biopsies. The
number of the correct diagnoses in the most common skin lesions † clinical diagnosis was confirmed
                by histopathological examination; SCC, squamous cell carcinoma
                                                                        Number of
                                                                        the correct                                  Number of
                                                                        diagnoses             Number of             cases with a
                                                                          in total           cases with a          skin tumor in
                                                      Number of             (%)a            skin tumor in        histopathological
                                                      the correct                         histopathological      diagnosis in total
                          Clinical diagnoses        diagnoses (%)a      P = 0.0001          diagnosis (%)         (%) P <0 .0001
 SKIN TUMORS              Basal cell carcinoma      629/984 (63.92)     1013/1634          342/355 (96.33)            583/621
                          Actinic keratosis         282/424 (66.51)      (61.99)           121/142 (85.21)            (93.88)
                          Squamous cell                 2/6 (33.33)                           4/4 (100)
                          carcinoma in situ,
                          Bowen type
                          Squamous cell                29/74 (39.19)                        42/45 (93.33)
                          carcinoma
                          Melanocytic nevus            22/38 (57.89)                         16/16 (100)
                          Seborrheic keratosis         49/108 (45.37)                       58/59 (98.3)
 INFLAMMATORY             Facial granuloma              6/13 (46.15)      67/148             2/7 (28.57)               19/81
 DERMATOSES               Lupus                        49/88 (55.68)      (45.27)           12/39 (30.77)             (23.46)
                          erythematosus
                          Rosacea                      5/10 (50.00)]                          1/5 (20)
                          Sarcoidosis                   7/37 (18.92)                        4/30 (13.33)


Original Article | Dermatol Pract Concept. 2022;12(4):e2022159                                                                       3
    The most common clinical diagnosis was basal cell carci-        In our study, as suspected, the most common clinical and
noma (BCC), followed by actinic keratosis, seborrheic kera-      histopathological diagnosis was a tumor: basal and squa-
tosis, fibroma, and cutaneous lupus erythematosus (Table 1).     mous cell carcinoma, actinic keratosis, seborrheic keratosis,
    Table 2 presents the most common clinical neoplasm and       and fibroma. The most common distributions of squamous
inflammatory diagnoses with the percentages of correct cases     cell carcinoma were the cheeks, nose and forehead, and for
confirmed by histopathological examination. Clinical diag-       basal cell carcinoma were the nose and cheeks. The results
noses of skin tumors were accurate in 1013/1634 (61.99%)         were in line with the study of Kato et al [5]. It was shown
cases, in comparison to inflammatory lesions, which were         in a group of 106 Japanese patients, that the cheek (54.2%)
correct in 67/148 (45.27%) cases (P = 0.0001). Among             and forehead (25.5%) were the most common facial distri-
621 inaccurate clinical diagnoses of the most common skin        bution of squamous cell carcinoma [5].
­tumors, 583 cases turned out to be other skin neoplasms            BCChas correctly resulted as the most frequent skin le-
(93.88%), and among 81 inaccurate clinical diagnoses of the      sion on the face. Among the common skin lesions, the most
most common inflammatory dermatoses 19 turned out to be          incorrect diagnoses occurred in the case of squamous cell
skin neoplasms (23.46%)(P < 0.0001). Among all prelimi-          carcinoma (only 33-39% of cases were correctly diagnosed).
nary inflammatory diagnoses, 33/204 (16.17%) cases turned        Squamous cell carcinoma was misdiagnosed with (in order
out to be skin malignancies, such as basal and squamous          of the most common): BCC, actinic keratosis. Another clin-
cell carcinomas.                                                 ically misdiagnosed pairs of lesions are: for BCC - actinic
    Among 2169 histopathological diagnoses, skin tumors          keratosis, squamous cell carcinoma, seborrheic keratosis,
were diagnosed in 1940 (89.44%) cases, and malignant skin        epidermal nevus, for actinic keratosis - BCC, squamous cell
tumors were diagnosed in 1388 (63.99%) cases. The most           carcinoma, seborrheic keratosis, morbus Bowen, papilloma,
common final diagnosis was basal cell carcinoma, followed        for seborrheic keratosis - papilloma, actinic keratosis, BCC,
by actinic keratosis, squamous cell carcinoma, fibroma,          verruca vulgaris and for fibroma - verruca vulgaris, sebor-
seborrheic keratosis, and cutaneous lupus erythematosus          rheic keratosis, inverted follicular keratosis, cutaneous horn.
(Table 3).                                                          What is interesting, the diagnosis of a skin tumor was
    Majority of basal cell carcinomas were present on the        correct in only 61.99% of cases. This means, that in many
nose (306 cases from 737; 41.5%), followed by cheeks (200;       cases of a clinically suspicious lesion the histopathological
27,13%). The most common locations of actinic k
                                              ­ eratosis         diagnosis was a benign tumor. The results showed that ap-
constituted cheeks (171 out of 447; 38,2%) and nose              proach with taking a diagnostic biopsy before performing
(161; 36%), whilst squamous cell carcinomas were distrib-        surgical procedure is reasonable and the result influences the
uted on the cheeks (49 out of 146; 33.6%), nose (41; 28%)        need and extent of surgery. In case of benign diagnosis, the
and forehead (23; 15.8%) (Table 3).                              remnants of the lesion can be left and no surgical procedure
    The most common diagnosed inflammatory dermatoses            is required.
included cutaneous lupus erythematosus on the first place,          Among inflammatory dermatoses (10.56% of cases),
followed by rosacea, demodicosis, facial granuloma, and          the most common were in order cutaneous lupus erythe-
sarcoidosis. Among patients older than 65 years, 74.83%          matosus, rosacea, demodicosis, facial granuloma, and sar-
(1124/1502) of cases were malignant skin tumors in com-          coidosis. In the study only 45.27% of clinical diagnosis of
parison to incidence of 39.58% (264/667) among patients          inflammatory lesions were consistent with histopathological
aged ≤ 65 years (P < 0.00001).                                   results. Among cases with suspicion of inflammatory der-
    As far as regions of the face are concerned, no statisti-    matoses skin tumors were diagnosed. These results showed
cal difference between numbers of correct diagnoses on the       that in doubtful inflammatory lesions on the face the biopsy
ear, nose, lips, and other regions on the face (cheeks, chin,    is recommended for two reasons. First of all, to exclude a
­forehead) was found (Table 4).                                  malignant tumor. The second reason is to establish a final
                                                                 diagnosis. It should be underlined, that among inflammatory

Conclusions                                                      dermatoses such as cutaneous lupus erythematosus and sar-
                                                                 coidosis, systemic involvement can occur, and patients with
Face, which is constantly exposed to solar radiation is a com-   such diseases need additional laboratory and imaging tests,
mon location for skin tumors. According to study of Ferreira     therefore the correct diagnosis has special importance and
et al on topographic distribution of basal cell carcinomas       requires medical follow-up.
head and neck area was the most frequent location of the            The study has some limitations. It was a single-centre
tumor (75.55%), followed by trunk (10.5%) [3]. In another        study. Another restriction of our study is the fact that some
study, over 60% of nonmelanoma skin tumors presented in          cases of skin tumors are not biopsied due to clear clinical
the head area [4].                                               and dermoscopic aspects. It includes all cases where these



4                                                                    Original Article | Dermatol Pract Concept. 2022;12(4):e2022159
                                                                           Table 3. The number of the correct diagnoses in the most common skin lesions. The most common histopathological diagnoses (> 10 cases)
                                                                                                                                  among 2169 skin biopsies
                                                                                                      Total number                                                                                           Age
                                                                                                         of cases     %      CHEEK     CHIN     EAR      FOREHEAD       LIPS     NOSE       Age <=65a        >65a
                                                                     Skin neoplasms in total           1940/2169     89.44   664/769   43/56   99/105     388/443      58/71     688/725     515/667      1425/1502
                                                                     a
                                                                       P < 0.0001                                                                                                           (77.21%)       (94.87%)
                                                                     Malignant skin tumors in total    1388/2169     63.99   450/769   21/56   83/105     273/443      40/71     521/725     264/667      1124/1502
                                                                     a
                                                                       P < 0.00001                                                                                                          (39.58%)       (74.83%)
                                                                     Basal cell carcinoma                 737        33.98    200       18       40         151         22        306          160           577
                                                                     Actinic keratosis                    447        20.61    171       0        14          92          9        161          77            370
                                                                     Squamous cell carcinoma              146        6.73      49       2        22          23          9         41          22            124
                                                                     Fibroma                              125        5.76      49       5        3           32          4         32          64             63
                                                                     Seborrheic keratosis                 108        4.98      45       0        5           39          0         19          35             73
                                                                     Cutaneous lupus                      57         2.63      37       1        0           7           0         12          50             7
                                                                     erythematosus




Original Article | Dermatol Pract Concept. 2022;12(4):e2022159
                                                                     Melanocytic nevus                    56         2.58      12       9        1           13          1         20          46             18
                                                                     Squamous cell carcinoma in           46         2.12      24       0        6           4           0         12           2             44
                                                                     situ, Bowen type
                                                                     Rosacea                              37         1.71      20       0        0           11          0         6           26             11
                                                                     Inverted follicular keratosis        35         1.61      27       0        2           2           0         4            9             26
                                                                     Keratoacanthoma                      29         1.34      14       2        0           0           0         13           9             20
                                                                     Verruca vulgaris                     27         1.24      10       4        0           3           1         9           18             9
                                                                     Cutaneous horn                       26         1.20      10       0        3           5           0         8            3             23
                                                                     Demodicosis                          22         1.01      10       0        0           7           0         5            9             13
                                                                     Pyogenic granuloma                   21         0.97      9        0        0           1           5         6           16             5
                                                                     Epidermal cyst                       16         0.74      8        0        0           0           1         7            4             12
                                                                     Trichilemmoma                        16         0.74      6        0        0           0           0         10           4             12
                                                                     Facial granuloma                     14         0.65      3        0        0           5           0         6           12             2
                                                                     Sarcoidosis                          13         0.60      6        0        0           3           0         4            9             4
                                                                     Sebaceous hyperplasia                11         0.51      5        0        0           0           0         6            5             6
                                                                     Eczema                               11         0.51      4        2        1           3           1         0            7             4
                                                                 a
                                                                 P < 0.0001




5
            Table 4. The percentage of the correct diagnoses on the different regions of the face
                                                    Number of the correct                    P value with the comparison
           Region of the face                          diagnoses (%)                             to the other regions
 Ear                                                     56/105 (53.33)                                   P = 0.734
 Nose                                                   417/725 (57.52)                                   P = 0.285
 Lips                                                     44/71 (61.97)                                   P = 0.253
 Other regions (cheeks, forehead, chin)                698/1268 (55.05)



lesions are treated with imiquimod, cryotherapy or photody-           diagnosis is confirmed by histopathological examination. In
namic therapy. Moreover, the limitation of the study was the          the case of inflammatory facial lesions, the accuracy of clin-
lack of dermoscopic descriptions and both clinical images             ical diagnosis is lower, with a significant number of facial
and clinical diagnoses were based on experience of the refer-         lesions appearing inflammatory in clinical evaluation but
ring physician. On the other hand, the patients were referred         being diagnosed as skin cancers in pathology.
for punch, shave, or excisional biopsy from numerous public
and private clinics. So, the analysis reflects a need for skin
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