A 62-year-old man comes to the physician for a preventive visit. He is being treated for mild hypertension and has no other known medical problems. He drinks alcohol occasionally but does not use tobacco. He works as a rancher. The patient has some lesions on his head, which are pictured below: Palpation of these lesions reveals small, rough-textured papules. Which of the following is the most appropriate next step in the management of this patient?

Question

A 62-year-old man comes to the physician for a preventive visit.  He is being treated for mild hypertension and has no other known medical problems.  He drinks alcohol occasionally but does not use tobacco.  He works as a rancher.  The patient has some lesions on his head, which are pictured below:  Palpation of these lesions reveals small, rough-textured papules.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has numerous actinic keratosis (AK) lesions; this is likely due to chronic sun exposure during his lifetime spent outdoors as a rancher. AK most commonly occurs in areas of heavy sunlight exposure such as the face, scalp, ears, upper chest, and dorsal hands and forearms. AK lesions are characterized by small, rough, erythematous, and keratotic papules that are often easier to feel than they are to see. The skin upon which they occur often shows signs of chronic photodamage such as dyspigmentation, wrinkling, thinning, and telangiectasia. Untreated AK has up to a 20% risk of progression to squamous cell carcinoma. For this reason, any AK lesions that are detected should be removed or destroyed (Choice C). There are numerous acceptable therapies for AK. Individual lesions can be destroyed with liquid nitrogen cryosurgery or by surgical excision or curettage. However, treatment of individual lesions is impractical when numerous small lesions are present; field therapy(an entire region of the body is treated at once) is employed instead. The most commonly used field treatment is 5-fluorouracil cream; it is applied to the entire affected area for a period of 3-6 weeks. Other options include imiquimod cream, topical diclofenac, and photodynamic therapy. (Choice A) An antinuclear antibody assay is a useful test to screen for systemic lupus erythematosus (SLE) or related connective tissue diseases. SLE is associated with a rash in sun-exposed areas that is characterized by erythema and edema in a "butterfly" distribution on the cheeks and bridge of the nose. rash (Choice B) Oral doxycycline is an appropriate therapy for acne rosacea. Rosacea typically presents with facial erythema and edema, often with telangiectasias, papules, pustules, and localized tissue hyperplasia. Rosacea (Choice E) Severe skin inflammation associated with subclinical AK may be seen in patients undergoing systemic chemotherapy for malignancy. Such cases may respond to topical glucocorticoids, but otherwise, glucocorticoids are not recommended for AK treatment. Educational objective: Actinic keratosis is usually treated with excision or destruction of lesions, often with cryotherapy. However, for patients with numerous or widespread lesions, destruction of individual lesions may be impractical and field therapy is recommended. Topical 5-flurouracil cream is the most commonly employed form of field therapy. References: Pharmacotherapy of actinic keratosis. (http://www.ncbi.nlm.nih.gov/pubmed/19925043)

A 62-Year-Old Man Comes to the Physician for a Preventive