Dermatology

Poikiloderma, Telangiectasia, Seborrheic Keratosis

S:  Mr. S is a 47-year-old new patient to Dermatology Clinic, referred for a complete skin exam.  Complains of gradual photo damage, particularly on the lateral neck sides and forehead.  He has treated this with Retin-A 0.1 percent Micro gel, without irritation for four months.  He is careful about sun exposure and uses sunscreen on a regular basis.  He has no other complaints.

The patient had multiple skin tags on the neck, which he states resolved with use of Retin-A Micro gel.  He has no other medical problems.  Medications include Retin-A.  He has no known drug allergies.  There is no family history of skin cancer.  The patient works designing car interior as an engineer.  He hikes regularly, particularly in the mountains.

O:  Physical exam shows a well-appearing, 47-year-old gentleman.  There are prominent telangiectasia, hyperpigmentation, hypopigmentation, and atrophy on the lateral neck sides, as well as the left more than right cheek.  There is a background erythema to the face with punctate telangiectasia on the forehead, helical rims, less so on the chin and nose.  There is similar change on the upper anterior chest wall.  Complete skin exam shows an 8 x 8 mm well demarcated, slightly hyperkeratotic papule on the mid-back.  Dermoscopy shows milia-like openings and horned pseudocysts, consistent with a seborrheic keratosis.  Otherwise, complete skin exam of the scalp, face, neck, ears, chest, back, abdomen, four extremities, fingers and toes, as well as buttocks and groins was unremarkable.

ASSESSMENT AND PLAN:

1.  Seborrheic keratosis, mid-back:  Reassured.

2.  Poikiloderma, and telangiectasia, lightly firm, chronic sun exposure.  We have referred the patient for laser, V-Beam therapy, aiming to target the neck sides where the telangiectasia is more localized.  Because of the hyperpigmentation here, we have prescribed 4 percent hydroquinone cream to use b.i.d. to the area as well as the Retin-A Micro gel.  Patient will call with any changes, but otherwise return to clinic for V-Beam.

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