Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android

Isolated scaly patches may represent actinic (solar) keratoses, nonpigmented seborrheic keratoses, or Bowen or Paget disease.


Actinic keratoses are small (0.2–0.6 cm) macules or papules—flesh-colored, pink, or slightly hyperpigmented—that feel like sandpaper and are tender to palpation. They occur on sun-exposed parts of the body in persons of fair complexion. Actinic keratoses are considered premalignant, but 1:1000 lesions per year progress to squamous cell carcinoma.

Application of liquid nitrogen provides rapid eradication of lesions, which crust and disappear in 10–14 days. “Field treatment” with a topical agent to an anatomic area where the actinic keratoses are most prevalent (eg, forehead, dorsal hands, etc) can be considered in patients with multiple lesions in one region. Fluorouracil cream is the most effective topical agent used for field treatment; imiquimod and ingenol mebutate are also effective, as is photodynamic therapy. Combination therapy may be clinically beneficial. Any lesions that persist should be evaluated for possible biopsy.

Jansen  MHE  et al. Randomized trial of four treatment approaches for actinic keratosis. N Engl J Med. 2019;380:935.
[PubMed: 30855743]  
Heppt  MV  et al. Cryosurgery combined with topical interventions for actinic keratosis: a systematic review and meta-analysis. Br J Dermatol. 2019;180:740.
[PubMed: 30447074]  
Heppt  MV  et al. Efficacy of photodynamic therapy combined with topical interventions for the treatment of actinic keratosis: a meta-analysis. J Eur Acad Dermatol Venereol. 2019;33:863.
[PubMed: 30710390]  


Bowen disease (intraepidermal squamous cell carcinoma) can develop on sun-exposed and non–sun-exposed skin. The lesion is usually a small (0.5–3 cm), well-demarcated, slightly raised, pink to red, scaly plaque and may resemble psoriasis or a large actinic keratosis (eFigure 6–49). Lesions may progress to invasive squamous cell carcinoma. Excision or other definitive treatment such as topical treatment (fluorouracil or imiquimod) or photodynamic therapy is indicated.

eFigure 6–49.

This isolated, scaly patch on a patient's arm turned out to be Bowen disease (intraepidermal squamous cell carcinoma) on biopsy. (Used, with permission, from S Goldstein, MD.)

Extramammary Paget disease, a manifestation of intraepidermal carcinoma or underlying genitourinary or gastrointestinal cancer, resembles chronic eczema and usually involves apocrine areas such as the genitalia. Mammary Paget disease of the nipple, a unilateral or rarely bilateral red scaling plaque that may ooze, is associated with an underlying intraductal mammary carcinoma (see Figure 17–3). While these lesions appear as red patches and plaques in fair-skinned persons, in darker-skinned individuals, hyperpigmentation may be prominent.

Edey  KA  et al. Interventions for the treatment of Paget’s disease of the vulva. Cochrane Database Syst Rev. 2019;6:CD009245.
[PubMed: 31167037]  
Matsumoto  AJ  et al. Factors influencing squamous cell carcinoma in situ recurrence and ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.