A 56-year-old man is worried about a number of slowly growing facial bumps. There are several under each eye and one on each side of the nose. He is convinced that these are skin cancers.
Key point: Without being overwhelmed by the expanse of pathology, the macular, scaly erythema covering his cheek and extending down to the neck, below the ear, is quite characteristic for actinic keratoses. An exceptionally large superficial basal cell carcinoma or unusually extensive squamous cell carcinoma in situ (Bowen disease) could also be considered. Several small biopsies done from various portions of the cheek and neck disclosed only actinic keratoses.
Treatment: The patient was treated with topical pulse therapy, with 3.75% imiquimod cream (daily for 2 weeks, 2 weeks off, second course of 2 weeks of daily treatment). Although the patient experienced considerable inflammation during active treatment intervals, he ultimately healed with total lesion resolution and an excellent cosmetic result.
Note: Proliferating actinic keratoses is the name given to this diffuse form of actinic keratosis. Cryotherapy with liquid nitrogen is rarely sufficient, and topical field therapy is indicated.