ATYPICAL PRESENTATION OF DISSEMINATED ACTINIC KERATOSES IN AN IMMUNOCOMPETENT PATIENT

Alexandra-Irina Butacu, George-Sorin Tiplica, Ioana Mitoseriu-Bonteanu, Carmen Maria Salavastru

Abstract


Introduction: Actinic keratoses are frequent precancerous lesions, caused by cumulative UV radiation, especially UVB, which involve sun-exposed areas such as the face, ears or dorsum of hands in fair-skinned people. The risk of malignant transformation into squamous cell carcinoma is 10%.

Material and methods: A 66 years old female, with Fitzpatrick photo type II skin, with no significant personal history, presented for consultation with multiple, disseminated, more than 20 erythemato-squamous, hyperkeratotic, well-circumscribed lesions, localized on the ears, chest, dorsum of the upper limbs and lower legs, that spared the face, in evolution for 10 years. In the inferior region of the right leg, a well circumscribed ulcer, 3 centimeters in diameter, was present for 2 years. The lesions were asymptomatic and topically treated for psoriasis vulgaris for several years with emollients and topical corticoids, with no improvement. Results: All laboratory investigations for immunosuppression and an aggressive evolution of these precancerous lesions, such as HIV-infection, neoplasia and autoimmune diseases, were negative. The pathology investigations (3 punch biopsies) showed actinic keratosis KIN II-III andKIN III. The biopsy from the leg ulcer revealed an ulcerated squamous cell carcinoma. A multidisciplinary approach of the patient had been chosen in order to evaluate the medical status.

Discussions: Actinic keratoses, as precancerous lesions, require a strict follow-up and a histopathological examination of any lesion suspectedof having a neoplastic transformation. An accurate and prompt diagnosis is essential. Close monitoring with the analysis of different diagnostics is necessary in chronic skin diseases in order to adapt a long-term treatment. In this case, the psoriasis vulgaris treatment was maintained by the patient despite the poor outcome.

Conclusions: This patient typically illustrates the necessity of sun protective measures for all exposed skin, not only for the face (patient with photo type II skin, blue eyes and lesions that involve sun-exposed areas such as dorsum of hands, ears and chest, but sparing the face).

The diagnosis of skin lesions in older persons should consider not
only common diseases such as vascular leg ulcer due to chronic
venous insufficiency, but also ulcerated skin carcinomas and not every erythemato-squamous lesion should be considered psoriasis vulgaris. Patients with actinic keratoses require a strict clinical follow-up. It is extremely important that the patient understands the necessity of reporting any changes in the preexisting lesions as soon as possible.


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