A 65-year-old man comes to the office due to multiple hand lesions. Pink, white, and gray spots have been present on his hands for several years and are slowly increasing in number and size. The lesions do not itch or hurt. Medical and family histories are unremarkable. The patient takes no medications. BMI is 27 kg/m². Skin examination of the right hand is shown in the exhibit, and the left hand has similar lesions. This patient is at greatest risk of developing which of the following? A)Cutaneous basal cell carcinoma B)Cutaneous squamous cell carcinoma C)Inflammatory arthritis D)Pulmonary hypertension E)Visceral malignancy

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Explanation: 11ec2b69_c128_0aee_8f63_ede371e2b564_MD0005_00 This patient has multiple scaly papules on the dorsal hands, concerning for actinic keratosis (AK). AK is a premalignant condition caused by UV radiation exposure that most commonly occurs in sun-exposed areas (eg, face, scalp, dorsal hands). It presents as chronic, erythematous, scaly papules, sometimes with a background of chronically photodamaged skin. In particular, dyspigmentation, rough texture, atrophy, and telangiectasia indicate cellular carcinogenic changes; this diffuse surface involvement is termed field cancerization. presents AK can transform to squamous cell carcinoma (SCC), and the majority of SCCs develop from preexisting AK; therefore, patients should be treated without delay. Isolated lesions can be treated effectively with liquid nitrogen cryotherapy. However, diffuse or numerous lesions should be treated with topical therapy (eg, 5-fluoruracil, tirbanibulin), which can cover a large area. (Choice A) Unlike SCC, basal cell carcinoma does not have a precursor lesion; it typically presents with pearly, skin-colored papules with telangiectasia. skin-colored papules (Choice C) Inflammatory arthritis is associated with psoriasis, which typically presents with erythematous plaques with diffuse silvery scales, predominantly at extensor surfaces (eg, knees). Scaly papules at the dorsal hands are more suggestive of AK. erythematous plaques (Choice D) Pulmonary hypertension is associated with scleroderma, which manifests with skin thickening and tightening, features absent in this patient; scaly papules are not characteristic. tightening (Choice E) Dermatomyositis is often seen as a paraneoplastic manifestation of visceral malignancy. On the hands, dermatomyositis can present with Gottron papules, violaceous lesions over the dorsal interphalangeal and metacarpophalangeal joints. Gottron papules Educational objective: Actinic keratosis can present as diffuse scaly papules, often in a background of photodamaged skin (eg, dyspigmentation, telangiectasia, atrophy) that has undergone carcinogenic changes. Treatment with topical therapy (eg, 5-fluoruracil) is indicated to prevent progression to squamous cell carcinoma. 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 Multiple