When Multiple Lesions Fail To Resolve On The Lower Extremities

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By Gary “Dock” Dockery, DPM, FACFAS

What To Consider In The Differential Diagnosis

      Stucco keratosis is far more common, drier and more papular than flat warts. They are easy to remove and do not bleed when one scrapes them off. They affect a much older patient population than warts do.       Seborrheic keratoses are usually less dry, firm, more pigmented and are more difficult to scrape off than stucco keratoses. Actinic keratoses are relatively uncommon on the lower legs and feet, and are not as dry and warty as stucco keratoses.       Xerosis (dry skin) is much more uniform in nature and does not typically have distinct areas of raised, dry, papular lesions. Dermatofibroma is an incorrect diagnosis because these lesions are by nature firm, pigmented, compact and intradermal rather than epidermal. They are also much more likely to be solitary than stucco keratoses.       One would make the diagnosis of acrokeratosis verruciformis or epidermodysplasia verruciformis via biopsy and they are easy to distinguish from stucco keratosis through the dermatopathology findings.

Essential Keys To Prevention And Treatment

      Prevention of stucco keratosis is one of vigilance with hygiene, regular bathing and using moisturizers immediately after bathing. Protection from excessive solar exposure is also considered to be a preventative measure.       In regard to problematic stucco keratosis, one could consider treatment with cryotherapy, curettage, topical urea, topical lactic acid or topical imiquimod 5% cream (Aldara, 3M). In many cases, no treatment is necessary.       Cryotherapy is a very acceptable method of removing stucco keratoses but it may be a somewhat arduous process when numerous lesions are present. I prefer to use the CryoProbe unit (CryoSurgical Concepts) for benign skin lesions and this treatment is painless for most patients. Depending upon the thickness of the lesion, two freeze cycles of 10 seconds are usually required. The lesions may blister and then fall off in a few days. If any lesions remain, one may repeat the process. Clinicians may also use liquid nitrogen, either a spray or dipstick method, but it is much more painful. It is also common to see residual pigmentary changes following the removal of stucco keratoses with liquid nitrogen. The discoloration may remain for many months following treatment.       Podiatrists may also remove stucco keratoses by curettage and one can gently scrape off the lesions. After removing the lesions, one can apply a topical antibiotic until the area heals. Many patients complain that the curettage process is very uncomfortable and are less agreeable to this type of treatment as compared to cryotherapy.       One method of treatment is the use of bathing with a loofah sponge to remove much of the superficial stucco lesions. Then patients can follow this with daily application of lotion containing urea (Keralac® 35% lotion, Doak Dermatologics) or lotion with lactic acid (Lactinol® 10%, Pedinol).       Imiquimod 5% cream is reportedly useful in removing multiple lesions of stucco keratosis. One would apply the cream sparingly to each lesion three times a week for eight to 12 weeks. No cover is applied during treatment. This form of treatment is relatively expensive when compared to the other treatments, and may not have any benefits in the long run.

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