1. What essential question does one still need to ask to help make the diagnosis?
2. What is the tentative diagnosis?
3. Can you list at least three differential diagnoses?
4. What features of this condition differentiate it from other conditions in your differential?
5. What is the suitable treatment of this condition?
When Multiple Lesions Fail To Resolve On The Lower Extremities
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.
In summary, stucco keratoses are benign lesions, similar to seborrheic keratoses, which may be mistaken for warts on the lower extremities. Clinicians can remove them via cryotherapy, curettage or appropriate skin hygiene techniques. While these lesions are benign, clinicians should encourage patients to have a periodic skin examination in order to prevent missing other, more serious skin conditions that may occur concomitantly in the same areas.
Dr. Dockery is a Fellow of the American College of Foot and Ankle Surgeons, and a Fellow of the American Society of Podiatric Dermatology. He is
board certified in foot and ankle surgery. He is the Chairman of the Board and Director of Scientific Affairs for Northwest Podiatric Foundation for Education and Research.
Dr. Dockery is the author of Cutaneous Disorders of the Lower Extremity (Saunders, 1997) and Lower Extremity Soft Tissue & Cutaneous Plastic Surgery (Elsevier Science, 2006).