Forensic Friday, SOLUTION, June 20, 2026

FREE post this weekend!

As we saw yesterday, there was an older man found dead at home in a disheveled state and in an unkempt house. This type of history is nonspecific but can give some insight to the decedent. For instance, is there dementia or mental illness present that prevents him from keeping up with things? Is he physically disabled in some way that prevents him from daily activities? What about substance abuse? It is not uncommon for alcoholics to live in such conditions.

In this case, it was believed this man was suffering from dementia, and when you find out what the diagnosis is from the picture, that fits pretty well. Let’s look at that picture again:

Although no scale/ruler is present in this pic, you can see at the bottom of the picture that these are clearly hairs from an eyebrow. The lesion you see is about 2.5 - 3 cm or 1 to 1.5 inches in maximal dimension. But what is it? I’ve read your guesses, and I know at least one person got this correct.

This is a basal cell carcinoma of the skin demonstrating the classic rat eaten ulcer appearance of a large basal cell carcinoma. Yes, that’s what it is called in the text books.

Basal cell carcinoma is the most common cancer of the skin and usually has a pinkish pearly appearance, often noticed by the patient and effectively completely cured via a shave biopsy or small excision. They are almost never metastatic (rare case reports exist) but like most cancers they will continue to grow if left alone. They expand both radially and deeply and eventually they can get so large that the central part of the tumor starts to become necrotic, which means it becomes ulcerated and dies (but the edges of the tumor remain alive). Notice how at the edges of the tumor there is kind of a ‘rolled’ appearance—this is living tumor.

This was without question the largest basal cell carcinoma I had ever seen, and it would have taken years of growth to get this large. And this is where we come back to the mental status of this patient: A demented patient is not necessarily going to notice a tiny papule that becomes larger over time to become this monstrosity of a basal cell carcinoma.

It is worth noting however, that I have seen large skin cancers of the head/face of patients (both living and dead) who were well aware of it and simply did not want to get it treated.

As for your answers, many people thought this might be a gunshot wound, however gunshot wounds tend to have sharper margins (for entrance wounds that aren’t contact wounds), radial skin tearing and soot for entrance wounds that are contact range (the gun muzzle in contact with the skin), or slit-like lesions without soot for xit wounds.

Thanks for participating, and I’ll see you next week. But we will be back behind the paywall so if you’re interested in this type of learning, please consider subscribing!