Skin Neoplasias in Older Adults
Skin neoplasias are more commonly seen in older patients. These skin diseases can frequently be more severe, particularly in long-term care residents. Common nonmelanoma skin cancers seen in these individuals include actinic keratoses, squamous cell carcinomas, and basal cell carcinomas. Benign neoplasias that are seen in older patients include seborrheic keratoses, skin tags, and classical Kaposi’s sarcoma. Treatment for neoplasias in the older adult are often not as aggressive as in younger patients.
Key words: actinic keratosis, squamous cell carcinoma, basal cell carcinoma, seborrheic keratosis, skin tag, classical Kaposi’s sarcoma.
Introduction
Primary neoplastic disease of the skin is common in older patients and can be severe, particularly among residents of long-term care. Early recognition and therapy can prevent potentially fatal complications of nonmelanoma skin cancers from developing. A number of such lesions, particularly actinic keratoses, seborrheic keratoses, and skin tags can be treated in the primary care setting, whereas malignant and extensive lesions are likely to require referral to a specialist.
Actinic Keratosis
Actinic keratosis (AK), also known as solar keratosis, is a consequence of skin damage caused by the sun and is considered a premalignant neoplasm. They are more common in men than women and tend to occur in individuals with fair skin, light hair and eyes, a poor ability to tan, and who burn easily. AK is found in a high proportion of pale-skinned individuals around the world and its incidence increases with age.1
AK lesions are often small, discrete, yellow-brown, scaling pink, round/oval areas less than 1 cm in diameter. These scaly patches are frequently found on a background of sun-damaged skin (bearing pigmentary changes and elastosis) and may feel like sandpaper on palpation. AK may also take the form of cutaneous horns.
AK lesions are found on areas of maximum sun exposure: forehead, bald scalp, ears, temples, nose, cheeks, lips, neck, forearms, hands, and shins. The differential diagnosis includes seborrheic keratosis, viral warts, Bowen’s disease (squamous cell carcinoma in situ), superficial basal cell carcinoma (BCC), and chronic cutaneous lupus erythematosus.
Many lesions are easily identified and treated without further investigation. A biopsy can be performed to confirm diagnosis or exclude malignancy. This is particularly important for lesions not responding to conventional therapy, suggesting squamous cell carcinoma (SCC). If ever the diagnosis is in question, or if the lesion may be malignant, patients should be referred to a dermatologist.
Prompt treatment of lesions is very important even though some lesions regress spontaneously. One percent of AK lesions per year transform into malignancies (mainly SCC) and there may be occult foci of SCC within clinically benign-appearing lesions (especially in the hyperkeratotic variety).2,3 Avoiding UVR exposure is the key to any AK treatment regime. Advise patients to avoid sunlight and wear appropriate sunscreen.
Field therapy is perhaps the most promising approach for treating AKs, as this approach treats lesions that are not clinically apparent. Topical fluorouracil or 5-FU is for more serious cases and is especially useful if there are large numbers of lesions on the face. Normally, a 5% 5-FU cream is applied to lesions once daily for 2-4 weeks.4
Topical imiquimod is another field therapy for treating AKs.5 Imiquimod acts by stimulating Toll-like receptors found on antigen presenting cells, stimulating