The hyperkeratotic variant of disseminated superficial actinic porokeratosis (DSAP)

A 78-year-old South Korean man was referred to us from the Medical Intensiv e Care Unit (MICU) for an opinion. He was comatose and was on ventilatory c are due to aspiration pneumonia. Multiple tiny papules had developed in yea rs previously and since then the number and size had been increasing gradua lly, He had been diabetic for the past 4 years, and had Parkinson's disease diagnosed 1 year previously, Laboratory examinations revealed an elevated revel of white blood cells (WBCs) (25,000/mu L) and decreased hemoglobin (8 .8 g/dL), Other laboratory results were negative or within normal limits. Skin examination showed multiple, discrete, crust-like, brownish papules ov er the erythematous base on the face, upper extremities. and lower extremit ies (Fig, 1). With the clinical impressions of irritated verruca vulgaris, seborrheic keratosis, or cutaneous fungal infection, a skin biopsy was take n from a papule on the left shin, and histopathologic examination revealed several pronounced hyperkeratotic and parakeratotic columns, and characteri stic cornoid lamellae in the stratum corneum (Fig. 2), Beneath the cornoid lamellae, the granular layer was decreased, A number of round or oval, dysk eratotic, homogenized eosinophilic cells with pyknotic nuclei were scattere d in the prickle cell layer below the cornoid lamellae (Fig. 3). A mild lym phohistiocytic infiltrate was observed in the papillary dermis and around t he blood vessels in the upper dermis. Also, actinic degeneration was presen t in the upper dermis.