Seventeen Rough Spots on a Balding Scalp: Treating a Field of Actinic Keratoses in a 76-Year-Old Retired Roofer, and Why Fluorouracil Cream Came First
[Student Name]
University of Phoenix
NRP/556: Adult and Geriatric Management II
Week 5 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Mr. H., a 76-year-old retired roofer who worked outdoors for 40 years, comes for a routine visit. On his balding scalp, forehead and cheeks, I count 17 rough, scaly, pink to tan patches, some easier to feel than to see. He says they come and go and sometimes bleed when he scratches. He had a squamous cell carcinoma removed from his ear six years ago. This paper describes my assessment and treatment plan.
What Actinic Keratoses Are
Actinic keratoses are intraepidermal proliferations of atypical keratinocytes caused by cumulative ultraviolet exposure. They appear as rough, scaly macules or papules on chronically sun-exposed skin, especially in older adults with fair skin. The presence of many keratoses marks field cancerization, a wide area of sun-damaged skin with genetic changes, in which new keratoses and skin cancers can arise.
How Risky They Are
Criscione et al. (2009), following 7,784 actinic keratoses on the face and ears of 169 veterans in a chemoprevention trial, found that the risk of an individual keratosis progressing to squamous cell carcinoma was 0.60% at one year and 2.57% at four years. About 65% of the squamous cell carcinomas in the cohort arose in lesions previously diagnosed as actinic keratoses. Many keratoses also regressed: 55% were gone at one year. The risk for any single lesion is small, but with 17 lesions and a field of damage, Mr. H.'s cumulative risk is substantial, and his prior skin cancer adds to it.
Each spot is unlikely to become cancer; seventeen of them on a man who has already had one are a different calculation.
Examination and Differential
Most lesions are typical: rough, scaly, 3 to 8 mm, on a background of freckling and wrinkling. One lesion on his left temple is thicker, tender and has grown over two months. Thick, tender, rapidly growing, bleeding or ulcerated lesions, or those with induration at the base, raise concern for squamous cell carcinoma rather than a simple keratosis. I biopsy the temple lesion. Other lesions in the differential include seborrheic keratoses, which are waxy and stuck-on, and superficial basal cell carcinoma.
Choosing a Treatment
The American Academy of Dermatology guideline recommends treatment of actinic keratoses and lists options including cryosurgery for individual lesions and field-directed therapies such as topical 5-fluorouracil, imiquimod and photodynamic therapy (Eisen et al., 2021). For multiple lesions over an area, field treatment addresses both visible and subclinical damage.
The Evidence Between Field Treatments
A randomized trial of 624 patients with multiple actinic keratoses on the head compared four field treatments. At 12 months after treatment, the probability of remaining free from treatment failure was 74.7% with 5% fluorouracil cream, 53.9% with imiquimod, 37.7% with photodynamic therapy using methyl aminolevulinate and 28.9% with ingenol mebutate (Jansen et al., 2019). Fluorouracil was the most effective of the four and is inexpensive. On this evidence, I choose 5% fluorouracil cream.
The Regimen
Mr. H. will apply 5% fluorouracil cream twice daily to the scalp and forehead for four weeks, then treat his cheeks separately afterward, so that the reaction is manageable. He should wash his hands after application and avoid the eyes and lips.
Preparing Him for the Reaction
The treated skin will become red, crusted, sore and sometimes weepy, usually peaking in the second to third week, before healing over two to four weeks after stopping. This inflammation is expected and means the medicine is working on damaged cells. I show him photographs of typical reactions so that he is not alarmed, give him a bland emollient for after treatment and explain when to call: signs of infection, severe pain or reactions spreading beyond treated areas.
Timing
He plans to start in early winter, when he spends less time outdoors and can stay out of the sun during treatment.
Why Not Freeze All Seventeen
Cryotherapy with liquid nitrogen is quick and effective for single lesions, and many patients expect it. For 17 lesions in a sun-damaged field, freezing each one would treat only what is visible, leave subclinical keratoses untreated and cause 17 blisters and possible white scars. Field treatment addresses the whole area at once, which is why the guideline supports field-directed therapy for patients with multiple keratoses (Eisen et al., 2021).
Why Fluorouracil Over the Others
In the four-arm trial, fluorouracil not only had the highest rate of sustained clearance but was also among the least expensive options, and patients applied it at home (Jansen et al., 2019). Imiquimod was the second most effective, and photodynamic therapy requires clinic visits and specialized equipment. For a man on a fixed income who lives an hour from a dermatologist, fluorouracil is practical as well as effective.
The Biopsy Result
The temple lesion's biopsy shows a well-differentiated squamous cell carcinoma, confirming the concern. It will be excised by dermatology before he begins field treatment on that area. This finding reinforces the importance of separating atypical lesions from routine keratoses before treating a field.
Explaining Field Cancerization
Mr. H. asked why so many spots appeared now. I explained that decades of sun exposure on the roof damaged the skin cells over his whole scalp and face, and that the spots are the visible part of that damage. Treating the field is like treating the whole roof rather than patching each leak.
Cryotherapy for Stragglers
Any lesions that persist after field treatment can be treated with cryotherapy at follow-up. Combining field and lesion-directed treatment is common.
Sun Protection
Sunscreen every morning, a hat with a brim all the way around and shade during the middle of the day slow the appearance of new keratoses. As a roofer, he never used sunscreen; I explain that protection still helps at his age.
His Other Medications
Mr. H. takes hydrochlorothiazide for blood pressure, which increases sensitivity to sunlight and some studies link long-term use to more nonmelanoma skin cancer. I discuss with him whether another blood pressure medicine would be as effective, and plan to change it at his next visit if his readings allow.
Follow-Up Visit
I will see him two weeks into treatment to check the reaction and again four weeks after finishing to assess clearance.
Skin Surveillance
Given his prior squamous cell carcinoma and field damage, he needs full skin examinations every six to twelve months. I review the biopsy result with him at a follow-up visit and refer to dermatology if it shows carcinoma.
Conclusion
Mr. H.'s 17 actinic keratoses and prior skin cancer mark a field of sun damage with meaningful cancer risk, and one atypical lesion was biopsied. Following the AAD guideline and a randomized trial showing 5% fluorouracil cream to be the most effective field treatment, he will treat his scalp and face in stages, prepared for the expected skin reaction, and continue with sun protection and regular skin examinations.
References
Criscione, V. D., Weinstock, M. A., Naylor, M. F., Luque, C., Eide, M. J., Bingham, S. F., & Department of Veteran Affairs Topical Tretinoin Chemoprevention Trial Group. (2009). Actinic keratoses: Natural history and risk of malignant transformation in the Veterans Affairs Topical Tretinoin Chemoprevention Trial. Cancer, 115(11), 2523-2530. https://doi.org/10.1002/cncr.24284
Eisen, D. B., Asgari, M. M., Bennett, D. D., Connolly, S. M., Dellavalle, R. P., Freeman, E. E., Goldenberg, G., Leffell, D. J., Peschin, S., Sligh, J. E., Wu, P. A., Frazer-Green, L., Malik, S., & Schlesinger, T. E. (2021). Guidelines of care for the management of actinic keratosis. Journal of the American Academy of Dermatology, 85(4), e209-e233. https://doi.org/10.1016/j.jaad.2021.02.082
Jansen, M. H. E., Kessels, J. P. H. M., Nelemans, P. J., Kouloubis, N., Arits, A. H. M. M., van Pelt, H. P. A., Quaedvlieg, P. J. F., Essers, B. A. B., Steijlen, P. M., Kelleners-Smeets, N. W. J., & Mosterd, K. (2019). Randomized trial of four treatment approaches for actinic keratosis. New England Journal of Medicine, 380(10), 935-946. https://doi.org/10.1056/NEJMoa1811850
How this NRP 556 Week 5 example is structured
The NRP/556 Week 5 work usually addresses dermatologic conditions in primary care. This paper moves from recognizing a lesion to judging its risk, choosing among treatments with trial evidence and preparing the patient for a treatment whose side effects are the sign it is working. Students search this week as NRP 556 Week 5, NRP556 Wk 5 or NRP/556 Wk 5; all three are the same assignment.
NRP/556 Week 5 questions, answered
What does NRP/556 Week 5 usually ask for?
Many sections present a skin condition seen in primary care and ask for diagnosis, differential, treatment and follow-up.
What are actinic keratoses?
Rough, scaly patches on sun-damaged skin, caused by ultraviolet damage to keratinocytes, that can occasionally progress to squamous cell carcinoma.
What is field treatment?
Treatment applied to a whole area of sun-damaged skin, such as the scalp or face, rather than to single lesions, to treat visible and subclinical keratoses together.
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