April 9, 2005
Common Causes of Skin Atrophy
There are many non-malignant changes in the skin that are caused by ultraviolet light, for example mottling, wrinkling, coarseness, telangiectasia and atrophy of the skin in later life. This woman had dry, mottled atrophie skin with multiple solar keratoses on her legs and feet having spent many years living in the Far East and Florida. She was advised to avoid further sun exposure, to apply plenty of emollients and to try 5-fluorouracil cream for the solar keratoses.
Basal cell and squamous carcinomata respond well to radiotherapy but the irradiated skin will develop signs of atrophy afterwards. The skin shown here is scarred, atrophie and has developed telangiectasia over it. In the long term, the area may also develop further basal cell carcinomas at the site. It is therefore advisable to restrict the use of radiotherapy for these lesions to patients who are very elderly and nervous, for large lesions, and for those that may have recurred after surgery.
Lichen sclerosis et atrophicus
The cause of lichen sclerosis et atrophicus is unknown. It may occur at any age. The lesions are shiny, white, smooth-surfaced papules that coalesce symmetrically and become atrophie with telangiectasia and purpuric changes. These skin changes frequently occur around the vulva and anus where patients complain of itching and burning. In men, the foreskin and glans penis may be involved. These problems may lead to shrinkage of the vulval tissue and balanitis xerotica obliterans. Similar skin changes do occur elsewhere on the body as in this patient, who has a typical 'cigarette paper'-like area on the forearm.
Chronic cutaneous lupus erythematosus
Chronic cutaneous lupus erythematosus or discoid LE presents with a rash that is precipitated by sunlight and appears mainly on the light exposed areas of the face, scalp and limbs. Discoid LE is more common in women. Its cause is unknown. The patient presents with raised red or purpuric plaques with scaling, follicular plugging and hyperkeratosis. Healing starts centrally leaving atrophie scars. Hair follicles on the scalp are destroyed, causing permanent alopecia that cannot be treated. The diagnosis of discoid LE can be confirmed by skin biopsy.
Striae often cause embarrassment and distress to the patient. It is only occasionally that they may tear or ulcerate. They are particularly common on the breasts and abdomen in pregnant women, as in this case. They are also frequently seen in adolescents during their growth spurt and may also occur in patients on prolonged systemic or potent topical steroids. In Cushing's disease the striae tend to be wider, deeper and have a greater intensity of colour. Some patients have been helped with topical tretinoin (not to be used in pregnancy), 15-20 per cent trichloracetic peels, and pulsed dye laser treatment.
Disseminated superficial actinic porokeratosis
Disseminated superficial actinic porokeratosis usually develops in patients aged 30-50 years and in those that have enjoyed much exposure to ultraviolet light. It is more common in women and presents with multiple, light-brown, atrophie patches on the extensor surfaces of the limbs and sometimes the face. Occasionally they may itch but are often asymptomatic. There is a risk of developing basal and squamous cell carcinoma. The patient should avoid further sun exposure and protect themselves, and be alert to the signs of any possible malignant change. Topical 5-fluorouracil may induce remission.
Necrobiosis lipoidica occurs in 0.3 per cent of diabetics. It presents most commonly in women in their thirties but may occur at any age. Asymptomatic, shiny red-brown patches gradually increase in size and become yellow and atrophie. They may be multiple and bilateral. Trauma may encourage the development of ulcers that are painful and which, if they heal, leave scars. It usually occurs on the pretibial area but may also be seen on the face, scalp, trunk and upper limbs. Topical or intralesional steroids may reduce the inflammation of early, active borders of lesions but may in the long run induce further atrophy. Aspirin and dipyridamole can be tried.
Morphoeic basal cell carcinoma
Morphoeic basal cell carcinoma can be difficult to diagnose. This sclerosing basal cell carcinoma may look like a patch of atrophie skin or an old scar. However, it does slowly increase in size and when stretched, the edges of the lesion can be made to stand out. In fact, the lesion is usually much biggerthan it appears at first sight. The lesion is best excised. It is obviously important to remove the whole of the lesion and a wide margin should be allowed if a recurrence is to be avoided.
Copyright Haymarket Business Publications Ltd. Mar 11, 2005