A 65-year-old man comes to the office due to a rough lesion on the left cheek for the past 6 months. The lesion has not changed and is painless and nonpruritic. Medical history includes type 2 diabetes mellitus. The patient lived most of his life in Florida and has a history of several sunburns. Household pets include a dog and a cat. Skin examination findings are shown in the exhibit. Which of the following is the most appropriate treatment for this patient's skin condition?
A)Reassurance and no additional therapy
B)Topical clotrimazole
C)Topical lactic acid
D)Topical liquid nitrogen
E)Topical triamcinolone

Question

A 65-year-old man comes to the office due to a rough lesion on the left cheek for the past 6 months.  The lesion has not changed and is painless and nonpruritic.  Medical history includes type 2 diabetes mellitus.  The patient lived most of his life in Florida and has a history of several sunburns.  Household pets include a dog and a cat.  Skin examination findings are shown in the exhibit.  Which of the following is the most appropriate treatment for this patient's skin condition?
A)Reassurance and no additional therapy 
B)Topical clotrimazole 
C)Topical lactic acid 
D)Topical liquid nitrogen 
E)Topical triamcinolone

Quizplus · Accepted Answer

Explanation: 11ec2b69_c123_c529_8f63_6f7b053f67fa_MD0005_00 This patient's rough, asymptomatic facial lesion is most likely actinic keratosis (AK), a precursor to squamous cell carcinoma. AK presents as chronic, scaly papules or plaques and is most common in fair-skinned patients. Lesions are located primarily in sun-damaged areas (eg, face, dorsal hands). Although the papules are typically erythematous, nonerythematous lesions are easily distinguished from dry skin by the characteristic sandpaper-like texture. Other clinical variants of AK include the following: Hypertrophic AK, which presents with thick scales on a red base Atrophic AK, which presents with soft, red macules that lack scales AK associated with a cutaneous horn, which presents as a cone of keratin (straight or curved), typically with AK or SCC at its base The diagnosis is based on clinical examination; hypertrophic AK and cutaneous horns typically require biopsy to rule out SCC. Isolated AKs can be treated effectively with liquid nitrogen cryotherapy. In contrast, numerous or diffuse lesions should be treated with topical therapy (eg, 5-fluorouracil, tirbanibulin), which can cover a large area. Treatment should not be delayed because of the risk for progression to SCC (Choice A). (Choice B) Topical clotrimazole is used to treat tinea facialis, which presents as an erythematous, scaly, annular patch or plaque that spreads without treatment. tinea facialis (Choice C) Topical lactic acid is a keratolytic used to treat ichthyosis, which presents with diffuse, rough, dry skin with fish-like scales usually on the extensor extremities and trunk. An isolated scaly lesion is not characteristic. ichthyosis (Choice E) Topical triamcinolone is used to treat a variety of inflammatory skin lesions (eg, contact dermatitis, atopic dermatitis); most of these disorders are associated with significant pruritus and other inflammatory features (eg, erythema, papule/vesicle formation). This patient's scaly, nonerythematous, nonpruritic lesion is more characteristic of AK, which does not respond to topical corticosteroids. Educational objective: Actinic keratosis typically presents as chronic, scaly papules or plaques with a sandpaper-like texture in sun-damaged areas. Isolated lesions can be effectively managed with liquid nitrogen cryotherapy. References: Actinic keratoses: review of clinical, dermoscopic, and therapeutic aspects (http://www.ncbi.nlm.nih.gov/pubmed/31789244)

A 65-Year-Old Man Comes to the Office Due to a Rough