Do You Recognize These Sun-Related Lesions?

January 1, 2007

A 56-year-old African American man presents with a painful “raw” lip that hasgradually developed during the summer. Physical examination reveals a geographic,superficial erosion; notably, the erosion is surrounded by hypopigmentedand, most distally, hyperpigmented rings. The patient believes that exposureto sunlight has aggravated the condition.

Case 1:


A 56-year-old African American man presents with a painful "raw" lip that hasgradually developed during the summer. Physical examination reveals a geographic,superficial erosion; notably, the erosion is surrounded by hypopigmentedand, most distally, hyperpigmented rings. The patient believes that exposureto sunlight has aggravated the condition.What is your clinical impression?

Case 1:

Biopsy results revealed the classic histologic featuresof lupus erythematosus, which confirmed the clinicalimpression of mucosal

discoid lupus erythematosus

(DLE). Patients with DLE may present with lesions onthe lip. The key clinical feature is the band-like arrangementof erosion surrounded by dyschromia. Both hypopigmentationand hyperpigmentation may be encountered.The most important long-term complication of untreated,long-standing DLE involving the lip is squamouscell carcinoma.This patient was advised to avoid sunlight exposure.Oral antimalarial therapy (hydroxychloroquine, 200 mgtwice daily) and once-daily application of an ultrapotentcorticosteroid cream (clobetasol, 0.05%) were prescribed.Therapy is ongoing.

Case 2:


A "sunburn" that has failed to resolve prompts this 28-year-old man to seekmedical attention. Erythema, edema, and papules are evident on his chin,upper cheeks, and glabella.Do you attribute these lesions solely to sun exposure--or is somethingelse going on here?

Case 2:

Erythema, papules, pustules, and telangiectases are typically observedin patients with

rosacea,

although not all affected persons have all ofthese characteristics. The cause of rosacea is unknown; however, it is associatedwith an increase in the population of the hair follicle mite,

Demodex folliculorum.

Alcohol, sun exposure, and hot drinks (such as coffee) may accentuatethe erythema, but they do not cause rosacea.Often resembling acne, rosacea predominantly affects the forehead,cheeks, nose, and occasionally the eyelids. It typically occurs after age 30 yearsin persons with fair skin.Oral treatment includes tetracycline, minocycline, doxycycline, erythromycin,metronidazole, and isotretinoin. Maintenance therapy includes topicalagents, such as metronidazole, clindamycin, and sulfacetamide/sulfur, whichare usually used in conjunction with oral therapy, except in mild cases.Rosacea typically lasts for years with intermittent quiescent periods of variablelength.This patient was treated with oral tetracycline and metronidazole cream,and the condition resolved over several weeks.

Case 3:


For several years, an 80-year-oldwoman has had a slowly enlarging,"glassy," telangiectatic lesion on herleft lower eyelid margin. The lesion isnow 2.2 *1 cm and slightly impingeson her vision. She has not sustainedan injury to the area, and the lesionis not painful. Her facial skin exhibitsadvanced dermatoheliosis, resultingfrom chronic overexposure to thesun. The patient also has a history ofhypertension.What will you include in the differentialdiagnosis, and how will youidentify this lesion?

Case 3:

The differential diagnosis ofa planar plaque-like lesion near thelid margin includes basal cell carcinoma,squamous cell carcinoma, seborrheickeratosis, and sebaceous carcinoma.These entities have a similarmorphologic/clinical appearance andcan develop at this site. Therefore,biopsy is essential; it is the only wayto effectively rule out the other conditionsin the differential, includingsebaceous carcinoma, which in thislocation is especially dangerous.Shave biopsy of the lesion revealed

basal cell carcinoma.

In this case, biopsy was indicatednot only because of the lesion's size, location, and appearancebut also because of the patient's age and deeplysun-damaged skin.Basal cell carcinomas are distinguished by their clinicalappearance. The nodular (or nodulo-ulcerative)lesions--the most common type--typically have asmooth shiny surface with translucent or raised borders;telangiectasia is often present. Although basal cell carcinomasrarely metastasize, they are locally invasive andcan result in widespread tissue destruction.Given the size and location of this patient's lesion,surgical removal with microscopically controlled marginswas performed. Recovery was uneventful.

Case 4:


For 1 year, a 62-year-old man has hadan asymptomatic, nickel-sized, spotty,pigmented lesion with sharp borderson his right temple. The lesion hasnot enlarged recently, but it has becomemore deeply pigmented. Thepatient, who worked in the Gulf ofMexico on an oil field supply boatmost of his life, wishes to have it removed.He is given a local anesthetic,and the lesion is excised withoutcomplications.Is it likely that this lesion ismalignant?

Case 4:

Histopathologic examination of the excised lesionconfirmed the diagnosis of

actinic keratosis

with incontinenceof pigment and chronic inflammation; there was noevidence of carcinoma. Actinic keratoses arise after yearsof sun damage to the skin; they are considered squamouscell carcinomas confined to the epidermis. The incidenceincreases with age. When they extend more deeply, theyare true squamous cell carcinomas.Immunosuppression is a risk factor; squamous cellcarcinoma is 65 times more frequent in patients who havereceived transplants.

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Single or multiple lesions may appearon sun-exposed surfaces. Inflammation, induration,and oozing herald the development of a true malignancy.Clinical variants include cutaneous horns, pigmented actinickeratoses, and actinic cheilitis. About 60% of squamouscell carcinomas develop from actinic keratoses; therate of transformation is 10.2% over 10 years.

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Biopsy isalways needed for a definitive diagnosis. Histologically,abnormal epithelial cells are confined to the epidermis.Treatment options include surgical excision, cryotherapy,and topical medications (such as 5-fluorouracil,imiquimod, and diclofenac gel). Applying sunscreen onthe lesion may prevent it from developing into a true squamouscell carcinoma. This patient was treated withcryotherapy.

References:

REFERENCE:


1.

Habif TP.

Clinical Dermatology: A Color Guide to Diagnosis and Therapy.

4th ed.Philadelphia: Mosby; 2004:736-743.