A 72-year-old man comes to the office because of a skin lesion on his hand that first appeared 6 months ago. The lesion does not itch or cause pain. The patient has had similar lesions on his face; some spontaneously resolved, and some were successfully treated with topical liquid nitrogen therapy. Skin examination reveals a 1.3-cm lesion, as shown in the exhibit;it is nontender. Which of the following is the most appropriate next step in management of this patient?

Question

A 72-year-old man comes to the office because of a skin lesion on his hand that first appeared 6 months ago.  The lesion does not itch or cause pain.  The patient has had similar lesions on his face; some spontaneously resolved, and some were successfully treated with topical liquid nitrogen therapy.  Skin examination reveals a 1.3-cm lesion, as shown in the exhibit;it is nontender.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be6e_41d9_8f63_630dc3c3cf0e_MD0005_00 This patient has an erythematous, hyperkeratotic plaque on the dorsal hand. Although it is most likely actinic keratosis (AK), squamous cell carcinoma (SCC) cannot be excluded. AK most commonly presents as erythematous, scaly papules with a sandpaper texture in fair-skinned individuals. Because they are related to chronic sun exposure, lesions often appear on skin with other signs of actinic damage (eg, dyspigmentation, atrophy, telangiectasia). Some lesions can spontaneously resolve, others can persist as AKs, and the remainder (1%-20%) can transform to SCC. The diagnosis of AK is typically apparent based on appearance; however, due to similarities in appearance between a large, hyperkeratotic AK and SCC, biopsy for definitive diagnosis is indicated for lesions ?1 cm. Other signs of malignant transformation that warrant biopsy include tenderness or induration and rapid growth of the lesion. Typical lesions that do not respond to treatment (eg, liquid nitrogen cryotherapy, topical fluorouracil or imiquimod) also should be biopsied. (Choices B, C, and D) Because of the risk for transformation to SCC, the treatment of AK should not be delayed. However, lesions ?1 cm, as in this patient, have a higher likelihood of being SCC, so biopsy should be performed as soon as possible to guide treatment. (Choice E) Topical retinoids are typically used to treat comedonal acne. Although a few studies have shown that they can reduce the number of AKs, more data are needed to establish their role in routine management. comedonal acne Educational objective: Actinic keratosis typically presents as scaly, erythematous papules on sun-exposed skin. Lesions that are ?1 cm, are tender/indurated, exhibit rapid growth, or fail to respond treatment should be biopsied to rule out squamous cell carcinoma. References: Current perspective on actinic keratosis: a review. (http://www.ncbi.nlm.nih.gov/pubmed/27500794)

A 72-Year-Old Man Comes to the Office Because of a Skin