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Joe R. Monroe, PA-C, MPAS, DEPARTMENT EDITOR

A 63-year-old woman reports new changes in a long-standing “rash”

Joe R. Monroe, PA-C, MPAS

The author practices in the dermatology department of the Springer Clinic, Tulsa, Okla, and is the founder and President-elect of the Society of Dermatology Physician Assistants. He has indicated no relationships to disclose relating to the content of this article.

A 63-year-old woman presents with recent changes in a “rash” on her upper chest and neck that has been present for many years. The rash has become progressively redder and focally irritated. A lesion was “removed” from this area when the patient was a child, and the rash has been there ever since. The patient denies having any other significant health concerns or having other problems with her skin. She has never consulted another health care provider for this skin problem.

Examination shows a 20-cm area of profound skin changes, including atrophy, telangiectasias, erythema, and focal stellate scarring (see Figure 1). There is no ulceration or palpable regional nodes.

Based on the scant clinical information and the problems with the skin itself, you decide to refer the patient.

The patient should be examined by

A plastic surgeon
A general surgeon
A dermatologist
An endocrinologist

Discussion

The correct answer is an endocrinologist, to check the patient’s thyroid function. More than likely, the changes seen in this patient’s skin represent those we would expect to see after radiation therapy—which, until the 1960s, was commonly used to treat conditions such as acne, warts, and even benign lesions (a benign lesion is probably what this patient had removed in childhood). Such radiation damage to skin can be acute or chronic; the chronic changes are identical to those seen in this patient and are called radiodermatitis. The larger issue, however, is that such exposure to radiation can produce malignant transformation, either in the skin or in adjacent organs—especially the thyroid glands, which are particularly susceptible and therefore should be examined regularly.

Skin surgery will play no part in the patient’s care, so the choices of plastic surgeon and general surgeon are incorrect. Referral to a dermatologist is a reasonable step, though without focal changes in the skin requiring biopsy, not much will be gained from this approach. No definitive treatment of the radiodermatitis is possible in such cases.

Given the patient’s history and the appearance of the affected area, there are no other conditions in the differential diagnosis—though it should perhaps be noted that old thermal burn sites can take on a similar look.