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228 Part I Disorders Presenting in the Skin and Mucous Membranes Figure 11-2. Cutaneous horn: hypertrophic actinic keratosis A hornlike projection of keratin on a slightly raised base in the setting of advanced dermatoheliosis on the upper eyelid in an 85-year-old female. Excision showed invasive SCC at the base of the lesion. Arsenical Keratoses ICD-9: 692.4 ° ICD-10: L85.8 ■ Appear decades after chronic arsenic ingestion (medicinal, occupational, or environmental exposure). ■ Arsenical keratoses have the potential to become SCCIS or invasive SCC. These are currently being seen in West Bengal and Bangladesh where drinking water may still contain arsenic. Squamous Cell Carcinoma in Situ ICD-9: 173.0 ° ICD-10: M8070/2 ■ Presents as solitary or multiple macules, papules, or plaques, which may be hyperkeratotic or scaling. ■ SCCIS is most often caused by UVR or HPV infection. ■ Commonly arises in epithelial dysplastic lesions such as solar keratoses or HPV-induced squamous epithelial lesions (SIL) (see Sections 27 and 34). ■ Pink or red, sharply defined scaly plaques on the skin are called Bowen disease; similar but usually non-scaly lesions on the glans and vulva are called erythroplasia (see Section 34). ◐ ■ Two types: punctate, yellow papules on palms and soles (Fig. 11-3A); keratoses indistinguishable from actinic keratoses on the trunk and elsewhere. These are often associated with small SCCIS of the Bowen-type and hypopigmented slightly depressed macules (“raindrops in the dust”) (Fig. 11-3B). ■ Treatment—as for solar keratoses. ◐ ■ Anogenital HPV-induced SCCIS is referred to as Bowenoid papulosis. ■ Untreated SSCIS may progress to invasive SCC. With HPV-induced SCCIS in HIV/AIDS, lesions often resolve completely with successful antiretroviral therapy and immune reconstitution. ■ Treatment is topical 5-fluorouracil, imiquimod, cryosurgery, CO2 laser evaporation, or excision, including Mohs micrographic surgery.
Section 11 Precancerous Lesions and Cutaneous Carcinomas 229 Figure 11-3. Arsenical keratoses (A) Multiple punctate, tightly adherent, and very hard keratoses on the palm. (B) Arsenical keratoses on the back. Multiple lesions are seen here ranging from red to tan, dark brown, and white. The brown lesions are a mix of arsenical keratoses (hard, rough) and small seborrheic keratoses (soft and smooth). The difference can be better felt than seen. The red lesions are small Bowenoid keratoses and Bowen disease (SCCIS, see Fig. 11-4). The white macular areas are slightly depressed and represent superficial atrophic scars from spontaneously shed or treated arsenical keratoses. The entire picture gives the impression of “rain drops in the dust.” A B
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