An online eConsult with a dermatologist enabled a primary care provider to completely avoid a costly referral for a patient who had recently lost his job. 

Case Background

Male has a spot on right side of forehead for maybe 2 months. It bleeds when scratching (on two occasions), it is red, and wife is concerned at how it has changed over time -- has changed shape.


Primary Care Provider's Question

What do you think the lesion is? What evaluation or treatment do you recommend? The patient recently lost his job and wants to avoid a derm visit if possible, so I am sending this as online consult but if you recommend in-person visit with derm, please let me know. 


Specialist's Opinion

Hi--thanks for the case! This lesion appears in the photo to be an approx 4-5mm thin pink papule. Based on the history, the differential diagnosis includes (as you have noted) an actinic keratosis vs irritated/inflammed SK vs early basal cell carcinoma vs early SCCIS/SCC. I think several possible evaluation and treatment pathways are equally reasonable: (1) If your office is equipped to perform a shave biopsy, then this would be my first choice. This would obviate the need for a dermatology referral potential (i.e. if the lesion came back as an AK or if the lesion came back as a BCC but with clear margins on the shave biopsy). This would also obviously confirm the diagnosis. (2) If in-office biopsy is not possible, then I also believe it would be reasonable to empirically treat this lesion with cryotherapy, along with additional follow-up in 3-4 weeks to ensure resolution. If the lesion has not resolved following cryotherapy, then either biopsy or referral to dermatology could be considered. (3) Referral to dermatology, although you have indicated that this is not aligned currently with the patient's interests. So, given the above, I think option 1, if possible, is probably the best route. Regardless, I think the patient will be fine, even if there is a slightly longer than desired delay between confirmatory histopathologic diagnosis and/or dermatology referral, as my clinical ddx does not include any time-sensitive malignancies. Please let me know if this helps and/or if you may need any more information from me. Thanks! 


Primary Care Provider's Feedback

This is one of the best [RubiconMD] consult notes I have received. Thank you. I do shave biopsies, so can do that ...

Access to high-quality healthcare is critical to healthy and equitable communities. However, underserved and low-income patients commonly face barriers in accessing healthcare, especially specialty services like dermatology and psychiatry visits. Factors that can determine a patient's ability to obtain convenient specialty care include finances, insurance status, transportation and wait times for appointments. This inequity in access can lead to adverse health outcomes, as patients are forced to delay or forgo critical medical care. Read more