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Simple cases
Case 14
83-year-old man presents with multiple erythematous rough spots on his forehead and cheeks.
History
How long have you had these lesions?
Many years.
Good question, as the time sequence often helps with the diagnosis.
Do you think they are related to anything you eat?
No.
Not a good question, as neither the history nor the appearance suggests a food allergy.
What kind of work did you do?
I was a farmer, and I still work a bit.
Good question, as the location of the lesions in sun-exposed skin suggestions a relationship long-term sun exposure, perhaps from outdoor work.
Do you take any medications?
Yes, a water pill and aspirin.
Reasonable question, as such skin changes sometimes flare with immunosuppressive therapy.
Does anyone else in the family have similar changes?
Yes, my son already has a few such spots on the head.
Not very helpful. A hereditary DNA repair defect is unlikely to be diagnosed at age 83, and almost every gets actinic keratoses. Perhaps father and son both have pale skin.
Do you live alone?
No, my wife who is ten years younger than I am, our son and his family all live in the old farmhouse.
Reasonable question, as when planning some types of therapy, one must be sure that older patients have someone to help them.
Lesion
Choose the right efflorescences:
Reasonable question, as when planning some types of therapy, one must be sure that older patients have someone to help them.
Reasonable question, as when planning some types of therapy, one must be sure that older patients have someone to help them.
An ulcer is a defect in the skin. None is seen here.
Correct. There are many lesions with an erythematous base and adherent scale.
Diagnosis
Choose the right diagnosis:
Allergic and non-allergic intolerance reactions
The clinical course and age of patient speak strongly against tinea faciei. The individual lesions do not show peripheral scale.
Rosacea features erythema, telangiectases, papules and pustules, but not scale.
Rosacea features erythema, telangiectases, papules and pustules, but not scale.
Therapy
Choose the right therapy(ies):
This is the easiest, quickest and cheapest way to treat individual actinic keratoses.
Excision should be reserved for suspicious (thickened, ulcerated, therapy-resistant) actinic keratoses. Otherwise, superficial destructive measures are sufficient because the abnormal cells in an actinic keratosis are confined to the epidermis.
This is the best way to treat numerous actinic keratoses. Treatment takes a long time and requires an very cooperative patient. The lesions eventually become eroded and then re-epithelize.
Actinic keratoses are premalignant, not inflammatory.
This is an elegant new way to treat actinic keratoses. A phototoxic substance, usually delta-amino levulinic acid, is applied to the skin where it is selectively taken up by the actinic keratoses. Radiation with visible or infrared light then destroys the lesions.
