Photo Quiz

Red, Raised Papule on the Chest


Am Fam Physician. 2021 Aug ;104(2):199-200.

A 54-year-old patient presented with a new lesion on the upper chest that had been present for three months. The lesion was solitary and slightly pruritic.

The patient had no trauma to the involved area and no family history of melanoma. The patient had a history of skin lesions that were biopsied but determined to be benign. The patient reported multiple severe sunburns over several years and had spent numerous summers playing outside as a child. The patient used sunscreen regularly.

Physical examination revealed a red, slightly raised papule on the anterior chest wall, near the left breast (Figure 1).




Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

  • A. Actinic keratosis.

  • B. Basal cell carcinoma.

  • C. Bowen disease.

  • D. Lichenoid keratosis.

  • E. Seborrheic keratosis.


The answer is D: lichenoid keratosis. Lichenoid keratosis normally occurs in middle-aged and older patients and is more common in those with frequent sun exposure and sun-damaged skin. Lichenoid keratosis typically presents as a solitary asymptomatic lesion on the skin, ranging from 5 to 20 mm in diameter.1 It is a slightly hardened, plaque-like lesion that is normally erythematous but can be brown or sometimes violaceous.1

Because of the wide-ranging clinical appearance, lichenoid keratosis is often misdiagnosed.1 The condition is benign and does not have the histologic characteristics of basal cell carcinoma.2 Because the presentation of lichenoid keratosis is similar to that of basal cell carcinoma, a biopsy may be required to confirm the correct diagnosis. If desired or for cosmetic reasons, lichenoid keratosis can be removed through cryotherapy or excision.

Actinic keratosis is a distinct, hyperkeratotic lesion on the skin due to confined proliferation of keratinocytes at the dermoepidermal junction. This proliferation causes a disturbance in the differentiation of the epidermis, which commonly presents as a rough, scaly patch of skin.3

Basal cell carcinoma generally presents on sun-exposed skin, most notably on the head and neck. It presents as a pearly papule or nodule with overlying telangiectasia and a translucent rolled border.4

Bowen disease, the in situ form of squamous cell carcinoma, presents as a nonpigmented, slowly growing, erythematous, well-demarcated plaque with a scaly or crusty surface that may be eroded or ulcerated.5 Bowen disease is common on the lower extremities of older patients with sun-damaged skin.

Address correspondence to Julia Carroll, BSC, MD, FRCPC, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Gori A, Oranges T, Janowska A, et al. Clinical and dermoscopic features of lichenoid keratosis: a retrospective case study. J Cutan Med Surg. 2018;22(6):561–566....

2. Goette DK. Benign lichenoid keratosis. Arch Dermatol. 1980;116(7):780–782.

3. Hashim PW, Chen T, Rigel D, et al. Actinic keratosis: current therapies and insights into new treatments. J Drugs Dermatol. 2019;18(5):s161–s166.

4. Sobanko JF, Lynm C, Rosenbach M. Basal cell carcinoma. JAMA Dermatol. 2013;149(6):766.

5. Mohandas P, Lowden M, Varma S. Bowen's disease. BMJ. 2020;368:m813.

6. Higgins JC, Maher MH, Douglas MS. Diagnosing common benign skin tumors. Am Fam Physician. 2015;92(7):601–607. Accessed May 14, 2021.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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