A 73‐year‐old woman with multiple crusted lesions

Abstract

A 73-year-old woman was attended for multiple crusted lesions on her head and hands for more than 1 year. These lesions had appeared 1 year ago as red patches with adherent scales without accompanying itch or pain. The patches gradually enlarged and proliferated with thick scales and an ulcer on the left side of her face. The patient suffered from polycythemia vera and had been treated with hydroxyurea (HU), 500 mg daily for 6 years. There was no personal history of local radiotherapy or heavy sun exposure and no family history of malignancy. On examination, several large infiltrated plaques with irregular borders were seen on the eyebrows, cheeks, jaw, nose and hands. The largest one was located on the left cheek (6 × 3 cm2) (Figure 1a,b). A thick scale covered all lesions. In addition, there were smaller red plaques with fine scaling in sun-exposed areas (Figure 1a,b). Lab analyses including blood cell counts and serum chemistry were normal. A skin biopsy from the lesion on her left cheek was done (Figure 1b). Histologic findings of the skin biopsy showed an invasive, moderately differentiated, keratinizing squamous cell carcinoma (SCC). A positron emission tomography scan and ultrasound revealed enlarged lymph nodes on the left side of the neck, but a lymph node biopsy was negative. The lesion on the left cheek was widely excised with complete grafting, and the other lesions were treated with 5% imiquimod cream since the patient declined surgical excision. HU was discontinued and imatinib was started. After 12 months of follow-up, her polycythemia vera was well controlled, no new SCC lesions had developed, and the previous lesions had not progressed. HU is very frequently used as a first-line treatment of polycythemia vera.1-3 HU also has a role in selected skin conditions.4 HU may also play a role in reducing the mortality of coronavirus disease 2019.5 HU selectively acts on the most actively dividing cells such as basal layer keratinocytes. Hence, cutaneous adverse effects have been described, including xerosis, hyperpigmentation and skin atrophy and, less frequently, nonmelanoma skin cancers.3, 6 SCCs associated with HU therapy are seen in patients who used HU for long periods of time. Most patients present multiple SCC lesions.7, 8 The SCCs are usually located in photodistributed areas, which suggests that ultraviolet plays an important adjuvant role in HU-associated SCCs.7-9 Strict photoprotection is thus mandatory in patients on long-term HU therapy. In patients with HU-associated SCCs, HU treatment must be discontinued. Patients should be evaluated basally and then on a regular basis, especially for older patients and those with a propensity to skin cancer.3 As an aggressive and metastatic tumour, the SCCs must be widely excised, and metastases promptly identified and adequately treated.7 So far, no study has compared outcomes in HU-associated SCCs with regular SCCs. Patients on long-term HU therapy must undergo dermatological examination at baseline and regularly thereafter. If a cutaneous malignancy is suspected, a biopsy is mandatory. If malignancy is confirmed, discontinuation of HU must be considered. Ronghui Zhu collected the clinical data and tissue specimens. Shangshang Wang was responsible for the study design and drafted the manuscript. All authors read and approved the final manuscript. This work was supported by grants from the National Natural Science Foundation of China (82003357). The authors declare no conflict of interest. The study was approved by the Institutional Review Board of Huashan Hospital, Shanghai, China, and the patient provided written informed consent. The authors confirm that the data supporting the findings of this case report are available within the article. Raw data that support the findings are available from the corresponding author upon request.