A 75-year-old man comes to the physician for a sore on his ear that he says "won't heal." He is a retired lineman for an electrical company in a rural area. He first noticed a small lump on the top of his ear 1 year ago. It has grown and opened up into a painful sore that has not responded to a topical antibiotic cream.
He has a history of hypertension, chronic gouty arthritis, hyperlipidemia, and chronic kidney disease with a stable serum creatinine of 2.0 mg/dL. His current medications include atenolol, fosinopril, allopurinol, and simvastatin.
His vital signs are stable. The lesion on his right pinna is shown in the photograph below.

What is the most likely diagnosis for this patient's nonhealing ulcer?

Question

A 75-year-old man comes to the physician for a sore on his ear that he says "won't heal."  He is a retired lineman for an electrical company in a rural area.  He first noticed a small lump on the top of his ear 1 year ago.  It has grown and opened up into a painful sore that has not responded to a topical antibiotic cream.
He has a history of hypertension, chronic gouty arthritis, hyperlipidemia, and chronic kidney disease with a stable serum creatinine of 2.0 mg/dL.  His current medications include atenolol, fosinopril, allopurinol, and simvastatin.
His vital signs are stable.  The lesion on his right pinna is shown in the photograph below.

What is the most likely diagnosis for this patient's nonhealing ulcer?

Quizplus · Accepted Answer

This patient most likely has cutaneous squamous cell carcinoma (SCC). SCC presents as erythematous papules, plaques, or nodules. Hyperkeratosis, hyperpigmentation, and ulceration may also be present. SCCs frequently arise in chronically sun-exposed skin (particularly the scalp, neck, pinna, and lower lip). They can also develop at sites of chronic wounds, chronic inflammation, or scarring. Other risk factors include exposure to PUVA phototherapy, radiation, industrial carcinogens (eg, arsenic), smoking, immunosuppressive treatment, and rare inherited disorders (eg, xeroderma pigmentosa, oculocutaneous albinism). Biopsy is required to confirm the diagnosis of SCC. A shave, punch, or excisional biopsy that extends to at least the mid-reticular dermis is ideal. At the time of diagnosis, patients should be given a full body skin examination with palpation of regional lymph nodes to evaluate for additional cutaneous SCCs and signs of metastatic disease. (Choice A) Actinic keratoses are characterized by rough, scaly, erythematous macules or papules and are typically seen on chronically sun-exposed skin. They can progress to SCC. Actinic keratoses are frequently found in close proximity to SCCs and can resemble early SCC or SCC in situ (Bowen disease). Bleeding, tenderness, and a palpable underlying substance suggest the possibility of SCC and require evaluation by biopsy. Actinic keratoses (Choice B) Calciphylaxis is commonly seen in end-stage renal disease patients on hemodialysis with elevated calcium-phosphorus product. Patients present with extremely painful subcutaneous nodules that can progress to necrotic ulcers. Areas of high adiposity such as the abdominal wall, buttocks, and thighs are most commonly affected. Calciphylaxis (Choice C) Gout tophi are most commonly found on the ear and soft tissues, particularly articular structures or bursae. They appear as white chalky tumors. Gout tophi typically are not painful or tender and do not ulcerate. Gout tophi (Choice D) Pyogenic granuloma is a benign vascular tumor of the skin and mucosa that presents as an erythematous, dome-shaped papule that bleeds easily. The lesions frequently develop over a period of a few days to weeks. Pyogenic granuloma Educational objective: Tender, bleeding, or ulcerated papules, plaques, or nodules in sun-exposed areas or areas of chronic inflammation or scarring merit prompt evaluation for cutaneous squamous cell carcinoma. __________ References: Defining patients with high-risk cutaneous squamous cell carcinoma. (http://www.ncbi.nlm.nih.gov/pubmed/16405479) Mortality risk from squamous cell skin cancer. (http://www.ncbi.nlm.nih.gov/pubmed/15681519)

A 75-Year-Old Man Comes to the Physician for a Sore