DISCUSSION
The patient’s admittedly dry skin is not his primary problem, and all the moisturizers in the world will not make much difference. The term we use for his problem is dermatoheliosis , literally “sun condition,” which includes predictable indicators of past overexposure to UV sources. Specific lesions include solar lentigines, the tan to orange freckles that are commonly called “age spots” or “liver spots.” (Given enough sun exposure, a 25-year-old can develop solar lentigines, so age is not the cause. Likewise, the liver is not involved at all.)
Chronic overexposure to the sun thins the skin (solar atrophy), making it more susceptible to minor trauma and resultant scarring and also making the tortuous red blood vessels (telangiectasias) visible. Other indications of sun damage include actinic keratoses (flaky white papules), solar elastosis (creamy yellow to white “chicken skin”), and solar purpura. The combination of these superimposed colors (white, red, tan, orange, pink) in the context of dermatoheliosis is sometimes termed poikilodermatous change.
Although dermatoheliosis is a problem in terms of the potential for skin cancer and for cosmetic reasons, it will not be helped much by moisturizers. Sunscreen, too, will have minimal impact so long after the damage has been done. Laser resurfacing could erase most of these skin changes, but it would also knock out all the normal skin pigment, making the area contrast sharply with the rest of the patient’s skin.
A combination of fade cream (4% hydroquinone, applied bid) and sunscreen could reduce the brown discoloration to a degree. Twice-daily application of 5-fluorouracil cream for two weeks would erase much of the redness, but only for a few months. Various other methods have been tried with modest success.
The main outcome of this patient’s visit was to establish the need for periodic examination. His wife’s opinion notwithstanding, the utility of moisturizers is dubious.
TAKE-HOME LEARNING POINTS
• Dermatoheliosis is the collective term for skin changes associated with chronic overexposure to the sun.
• The white, red, pink, and yellow discoloration seen on this kind of sun-damaged skin is known as poikilodermatous change.
• In addition to poikiloderma, patients with advanced dermatoheliosis also have solar atrophy, multiple scars, telangiectasias, actinic keratoses, dry skin, and often solar purpura.
• Moisturizers play a minimal role in treating dermatoheliosis (providing skin-smoothing effects, if anything).
• Such patients need to be examined periodically for skin cancer.
• Younger patients with dermatoheliosis are well advised to use better sun protection.