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A destructive ulcer

An 82-year-old Turkish woman presented with a slowly expanding ulcer on her face. She had first noticed a papular lesion on her nose 20 years earlier. She was otherwise well, with no history of environmental or occupational exposure to arsenic, radiation or psoralen ultraviolet A therapy. She had an extensive, 90 · 100mm, deeply ulcerated lesion on her mid-face involving the forehead, orbits and nose, with destruction of soft tissue and bone (Fig. 1A). She had no lymphadenopathy. X-ray and computerized tomography revealed destruction of the anterior skull. Other laboratory parameters were normal. The ulcer had been treated with multiple modalities at different medical centres, but had not responded. The patient died of wound infection.