A 65-year-old woman comes to the office for evaluation of a rash. The rash started nearly 3 years ago as a single lesion on her back, followed by multiple additional lesions in the same area and elsewhere on her trunk. There is no associated pruritus. The patient has a history of hypertension and gastroesophageal reflux disease. Her medications include hydrochlorothiazide and omeprazole. She has no history of tobacco or alcohol use. Vital signs are within normal limits. Skin examination findings are shown in the image below. There is no warmth or tenderness around the lesions. The remainder of her physical examination is normal. Which of the following is the best next step in management of this patient?

Question

A 65-year-old woman comes to the office for evaluation of a rash.  The rash started nearly 3 years ago as a single lesion on her back, followed by multiple additional lesions in the same area and elsewhere on her trunk.  There is no associated pruritus.  The patient has a history of hypertension and gastroesophageal reflux disease.  Her medications include hydrochlorothiazide and omeprazole.  She has no history of tobacco or alcohol use.  Vital signs are within normal limits.  Skin examination findings are shown in the image below.  There is no warmth or tenderness around the lesions.  The remainder of her physical examination is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient's rash is consistent with seborrheic keratosis (SK), a benign epidermal tumor due to proliferation of immature keratinocytes. SKs typically present after age 50 and are more common in fair-skinned individuals. The pathogenesis is not well understood. Patients can develop single or multiple lesions that are well-demarcated, pigmented, round or oval, and have a dull or verrucous surface with a "stuck-on" appearance. Typical locations include the face, upper extremities, and trunk. SKs can be asymptomatic or cause pruritus, pain, or bleeding (especially with friction against clothing or jewelry). Explosive onset of multiple pruritic SKs (Leser-Trélat sign) has been associated with malignancies (especially lung and gastrointestinal tumors). Diagnosis is based on the lesions' clinical appearance but sometimes may require biopsy in uncertain cases. Because they are slow growing and benign, SKs usually do not require any treatment. However, symptomatic or cosmetically disfiguring lesions can be treated with cryotherapy or removed by curettage/shave excision or electrodessication (Choice A). (Choices B and C) Excisional or intralesional biopsy would be required if this patient had atypical-appearing lesions or if there was a concern for malignancy (eg, melanoma). However, she is asymptomatic and her rash has the characteristic appearance of SK. (Choice E) Salicylic acid is used for treating cutaneous warts, which typically present as multiple flesh-colored, hyperkeratotic papules. However, cutaneous warts are usually not as pigmented as SKs. cutaneous warts Educational objective: Seborrheic keratosis is a benign epidermal tumor that can occur on the face, upper extremities, and trunk. Lesions are well-demarcated, pigmented, round or oval, and have a dull or verrucous surface with a "stuck-on" appearance. Treatment is not necessary unless the lesions are symptomatic or cause cosmetic problems. References: Seborrheic keratosis. (http://www.ncbi.nlm.nih.gov/pubmed/18801147) Management of benign skin lesions commonly affecting the face: actinic keratosis, seborrheic keratosis, and rosacea. (http://www.ncbi.nlm.nih.gov/pubmed/19465852)

A 65-Year-Old Woman Comes to the Office for Evaluation of a Rash