A 19 year old albino with a skin lesion

A 19 year old lady from Blantyre, Malawi, attends with a scaly lesion which has been present on her right cheek for 3 months.

  1. Can you describe what you see?
  2. What is the diagnosis?
  3. What is your management?

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This is an albino woman with a small (approx 1 cm) superficial looking red scaly lesion on her right lateral cheek.  She has some lentigines (the brown marks) and coarse wrinkled neck skin.  If palpated the skin over the red lesion feels rough.

This is an actinic keratosis (actinic/solar – sunlight (UV) induced, keratosis – scaly/horny growth).  Considered to be pre-malignant, actinic keratoses are most often seen in exposed skin in fair skinned individuals who have had excessive UV light.

An actinic keratosis may follow 1 of 3 paths: it may regress, it may persist unchanged, or it may progress to invasive squamous cell carcinoma. The actual percentage that progress to invasive squamous cell carcinoma remains unknown, and estimates have varied from as low as 0.1% to as high as 10%.  Generally, thicker lesions are more likely to progress.

She should be advised to avoid further damaging sun exposure by wearing a wide-brimmed hat, clothing which covers the skin and a high factor sunscreen on exposed sites.  The actinic keratosis can be treated in several ways including medical management with creams and surgical management.  As she has several further actinic keratoses on her neck and other cheek (not seen in the photo above) and as other treatment modalities are not available in the clinic she is treated with imiquimod.  This is an expensive treatment, but had been donated to the clinic from an overseas organisation.

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