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Can you identify the cause of the hyperpigmented umbilicated lesions seen bilaterally on the patient's extremities and on her back?

Hyperbilirubinemia and Diffuse Skin Lesions in a Woman with Diabetes, CVD

 uptake among US adults aged 45 to 49 years, aligning with updated guidelines recommending earlier screening to combat rising CRC incidence in this age group.

Between 2019 (before the American Cancer Society and US Preventive Services Task Force [USPSTF] lowered the recommended starting age) and 2023, the share of US adults aged 45 to 49 who were up-to-date with CRC screening jumped from 20.8% to 33.7%, according to a cross-sectional analysis of National Health Interview Survey (NHIS) data. 

 remained the dominant modality (27.7%) in 2023, but the absolute increase was largest for stool-based testing, which more than quintupled to 7.1% over the study period, according to first author Jessica Star, MA, MPH, of the American Cancer Society, and colleagues. 

"From 2019 to 2023, CRC screening increased among US adults aged 45 to 49 years, consistent with a previous report among certain commercially insured adults aged 45 to 49 years in late 2021-2022," Star and colleagues wrote. "This trend is encouraging because screening reduces CRC mortality, mostly through the detection and removal of potentially precancerous lesions."

 prevalence in 2019, 2021, and 2023 NHIS waves. The nationally representative household survey achieved response rates of 59.1%, 50.9%, and 47%, respectively. Logistic regression adjusted for age, sex, race and ethnicity, education, and region to generate adjusted prevalence ratios (APRs). 

Researchers found colonoscopy prevalence among adults aged 45-49 increased from 19.5% in 2019 and 17.8% in 2021 to 27.7% in 2023 (APR 1.43, 95% CI 1.26–1.62). Similarly, stool-based testing rose from 1.3% in 2019 and 2.7% in 2021 to 7.1% in 2023, corresponding to an APR of 5.37 (95% CI, 3.36–8.57).

Screening for adults aged 50 to 75 years remained largely stable, suggesting no reduced access for older individuals. Yet the possible lack of progress among lower-educated and uninsured individuals may foreshadow widening disparities," Star and colleagues concluded. "Strategies to improve screening include mailed fecal immunochemical testing interventions, timely referrals by primary care physicians, and delegation of select average-risk screening referrals to nonphysicians."

Star J, Siegel RL, Smith RA, et al. Trends in colorectal cancer screening in US adults aged 45-49 years. 

. Published online August 4, 2025. doi:10.1001/jama.2025.10618

New data show up-to-date CRC screening rose from 20.8% in 2019 to 33.7% in 2023, with gains driven by stool testing and colonoscopy.

Clinical Topics

One-Third of US Adults Aged 45-49 Were Up-to-Date on Colorectal Cancer Screening in 2023

A 9-year-old boy presented with a 1-week history of pruritus and rash on his elbows, knees, back, and legs. Several areas of excoriation were noted. He had recently run through a field of tall grass but denied any other exposure history.

A 9-year-old boy presented with a 1-week history of pruritus and rash on his elbows, knees, back, and legs. He had recently run through a field of tall grass but denied any other exposure history. Your Dx?

What Cause of This Itchy Rash?

Nearly half (46.7%) of US adults have hypertension, defined as blood pressure equal to or greater than 130/80 mm Hg and documented as the leading preventable risk factor for cardiovascular disease (CVD). Hypertension is also a major contributor to kidney disease, complications of pregnancy and childbirth, cognitive decline, and dementia, emphasized authors of a new joint guideline from the American Heart Association (AHA) and the American College of Cardiology (ACC).

The “2025 AHA/ACC Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults,” published August 14 in 

, revises and updates the 2017 iteration,  incorporating updated evidence for use of newer therapies (eg, GLP-1 receptor agonists); discussion of the role of early hypertension treatment to reduce the risk of cognitive decline; and use of the AHA’s PREVENT (

“High blood pressure is the most common and most modifiable risk factor for heart disease,” Daniel W. Jones, MD, chair of the writing committee and dean and professor emeritus at the University of Mississippi School of Medicine, said in an AHA statement. “By addressing individual risks earlier and offering more tailored strategies across the lifespan, the 2025 guideline aims to aid clinicians in helping more people manage their blood pressure and reduce the toll of heart disease, kidney disease, type 2 diabetes and dementia.”

To mitigate the many downstream outcomes associated with elevated blood pressure, the updated AHA/ACC guideline emphasizes the need for earlier treatment to reduce risk, with a focus on lifestyle modification, pharmacotherapy as necessary but for all levels of hypertension, and use of appropriate therapies for concomitant disease.

Clinicians should use the PREVENT calculator to estimate 10- and 30-year CVD risk in adults aged 30 to 79 years. The tool integrates cardiovascular, kidney, and metabolic health indicators, and includes zip code as a proxy for social drivers of health.

Early intervention to preserve cognition:

 Initiate treatment for adults with high blood pressure to target systolic blood pressure <130 mm Hg to reduce risk of cognitive decline and dementia.

 Start antihypertensive therapy during pregnancy when blood pressure reaches ≥140/90 mm Hg. Consider low-dose aspirin (81 mg/day) to lower preeclampsia risk in women with chronic hypertension. Continue close monitoring postpartum and measure blood pressure annually in those with pregnancy-related hypertension.

 Perform urine albumin-to-creatinine ratio testing in all adults with hypertension. Broaden screening for primary aldosteronism, including in patients with obstructive sleep apnea and those with stage 2 hypertension.

The guideline continues to recommend the AHA's 

 behaviors as first-line care for all adults:

 sodium to <2,300 mg/day, aiming for 1,500 mg/day.

 alcohol to ≤2 drinks/day for men and ≤1 drink/day for women.

 or achieve a healthy weight; target ≥5% loss in adults with overweight or obesity.

a heart-healthy eating pattern, such as DASH.

 75–150 minutes/week of aerobic and/or resistance activity.

 stress through exercise, meditation, breathing techniques, or yoga.

 monitoring to confirm diagnosis and guide treatment.

The recommended guidance for initiating therapy remains unchanged from the 2017 guideline: For individuals with BP of 140/90 mm Hg or higher (stage 2 hypertension), treatment should begin with 2 medications, ideally in a single combination pill. First-line agents include ACE inhibitors, ARBs, long-acting dihydropyridine calcium channel blockers, and thiazide-type diuretics. Individualizing therapy for patients with comorbidities could include consideration of adding GLP-1 medications in select individuals with hypertension and overweight or obesity.

“This updated guideline is designed to support health care professionals—from primary care teams to specialists—with the diagnosis and care of people with high blood pressure,” Jones said. “It also empowers patients with practical tools that can support their individual health needs as they manage their blood pressure, whether through lifestyle changes, medications or both.”

According to the CDC, just two-thirds (68.3%) of adults on treatment for hypertension have their blood pressure controlled to less than 140/90 mm Hg. Fewer than 1 in 4 (22.5%) have reached the guideline recommended target of less than 130/80 mm Hg.

 The disease is more prevalent among men (50.8%) than among women (44.6%) and, regardless of sex, prevalence increases with age, reaching a rate of 71.6% among adults aged 60 years and older.

Eleven other professional societies, including the American Academy of Physician Associates, the American Association of Nurse Practitioners, the American College of Clinical Pharmacy, the American College of Preventive Medicine, the American Geriatrics Society, the American Medical Association, the American Society of Preventive Cardiology, have co-endorsed the updated guideline.

Jones D, Ferdinand K, Taler S. et al. 2025  AHA/ACC/AANP/AAPA/ABC /ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. 

https://doi.org/10.1016/j.jacc.2025.05.007

New high blood pressure guideline emphasizes prevention, early treatment to reduce CVD risk. News release. American Heart Association. August 14, 2025. Accessed August 15, 2025. https://newsroom.heart.org/news/new-high-blood-pressure-guideline-emphasizes-prevention-early-treatment-to-reduce-cvd-risk

Fryar DC, Kit B, Carroll MD, Afful J. Hypertension prevalence, awareness, treatment, and control among adults age 18 and older: United States, August 2021–August 2023. NCHS data brief, No. 511. Hyattsville, MD: National Center for Health Statistics. 2024. https://www.cdc.gov/nchs/products/databriefs/db511.htm

Updates to the 2017 guideline focus on new monitoring strategies, earlier intervention to reduce cognitive decline, improved perinatal care, and refined risk assessment.   

AHA/ACC Release Revised Hypertension Clinical Practice Guidelines to Reduce CVD Risk

A 56-year-old woman presents with pruritic skin lesions on the arms and legs.

D. Subacute cutaneous lupus erythematosus

A 56-year-old woman presents with pruritic skin lesions on the arms and legs. What does this pattern suggest? 

Jason Green, DO

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