Background/Aim:
Lentigo maligna (LM) is a subtype of melanoma in situ arising on chronically sun-damaged skin and is potentially progressive to invasive lentigo maligna melanoma. The risk and timing of progression remain incompletely defined, with recent Australian data suggesting an annual progression rate of 3.5%. Management is particularly challenging in anatomically complex regions such as the periocular and nasal subunits, where achieving histological clearance must be balanced against preservation of function and cosmesis. We present a case highlighting the prolonged, recurrent course of facial LM and the complexities of multidisciplinary management.
Case:
A 63-year-old Caucasian female presents with extensive facial lentigo maligna involving the nasal bridge, medial canthus and periocular regions with a history dating back to the 1980s. She had been managed across multiple specialities including dermatology, plastic surgery and radiation oncology.
In 2021, she underwent surgical excision with split thickness skin grafting following multidisciplinary team (MDT) discussion, with histopathology confirming melanoma in situ without dermal invasion. Residual disease persisted at the inferior and medial nasal margins and superior eyelid.
Subsequent MDT discussions supported a conservative approach due to anatomical constraints and risk to function. In 2023, she underwent a trial of topical Imiquimod, but it was ceased early due to significant inflammatory reaction. She experienced progressive changes within the grafted areas in 2025, which promoted repeat biospies showing lentigo maligna without invasion. Ongoing management focused on surveillance with Dermatology, with consideration of further staged surgical intervention.
Conclusion:
This case highlights the challenges of managing lentigo maligna in periocular and nasal subunits, where complete clearance is often limited by functional and anatomical considerations. It supports the concept of LM as a chronic field disease, with persistent melanoma in situ despite multiple treatment modalities. Long-term multidisciplinary surveillance and individualised management strategies are essential in these anatomically high-risk cases.