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A potent mix noses in on this patient

Joe R. Monroe, PA-C, MPAS

Joe Monroe practices in the dermatology department of the Warren Clinic, Tulsa, Oklahoma, is the department editor for Dermatology Digest, and is the founder and a past president of the Society of Dermatology Physician Assistants. He has indicated no relationships to disclose relating to the content of this article.

CASE

Ultraviolet (UV) light degrades whatever is overexposed to it, whether this is the garden hose left out all summer, the wood lawn furniture, the house, or the owner. Unlike inanimate objects, people are not equally damaged by the same amount of sun exposure. Some people are at higher risk than others. In these high-risk people, overexposure to UV light produces predictable changes in the skin, several of which can be seen on the nose of the 54-year-old man seen in Figure 1.

This patient’s nose shows several examples of the effects of UV overexposure, including at least two skin cancers—a basal cell carcinoma on the anterior portion and a biopsy-confirmed melanoma in situ on the posterior ala. Other benign changes seen on this patient include telangiectasias, which are the narrow, red, tortuous linear blood vessels all over his nose, especially visible on the nostril rim; solar lentigenes, the brownish mottling in multiple locations; widely scattered, multiple actinic keratoses, the white to yellow keratotic papules that are more easily felt than seen in this patient; distinct coarse wrinkling, sometimes called weathering; a flat seborrheic keratosis on the mid-lateral sidewall (not seen in the photo); and a subtle but definite widespread atrophy in the entire area.

A COLLECTIVE TERM FOR THESE CHANGES IS

Dermatoheliosis
Photoaging
Extrinsic aging
Chronic actinic changes

DISCUSSION

The correct answer is all of the above. Technically speaking, extrinsic aging is not caused solely by UV overexposure. Extrinsic aging also can be hastened by chronic exposure to wind, low humidity, and intense cold; the effects of smoking; and chronic alcohol abuse. But overexposure to the sun is, by far, the most significant factor in most patients. So these terms are essentially interchangeable.

COMMENT These changes are so common that most people assume they are the inevitable consequence of aging. For example, most patients call solar lentigines age spots. But if one simply examines skin that is protected from or rarely exposed to the sun, such as on the medial aspects of the arms, virtually none of these changes will be seen.

Fair skin is the most critical risk factor. Fair, in this case, is defined as how a person’s skin tolerates exposure to the sun. But burning is not just the skin turning red, and fair-skinned people are not the only ones who develop skin cancer. The brown color some people develop from sun exposure also is a burn.

Older patients present with examples of intrinsic aging. Intrinsic aging manifests as smooth skin with fine wrinkling but a uniformly pale color. The skin is virtually without blemishes except for an occasional seborrheic keratosis.

TREATMENT This patient was scheduled for surgical removal of the two skin cancers. If desired, he could have electrodesiccation or laser treatment of the telangiectasias and lentigines. Cryotherapy and/or a retinoid prescription are the treatment options for actinic keratoses.

Just as importantly, the patient was educated about his increased risk of developing skin cancers, especially melanoma, elsewhere on his body and the importance of using sun protection. He was also advised to have a yearly examination by a dermatologist.