A lifelong rancher, now 58, considers himself to be in “decent” health—except for a persistent rash on the back of his neck. Over the years, he’s tried a variety of moisturizers, antifungal creams, topical antibiotics, and a course of oral cephalexin. His wife even removed the tags from his shirts, assuming they were irritating the affected patch of skin. Nothing has helped. But aside from a little itching, the lesion is asymptomatic. It is purely the persistent nature that troubles the patient.

The problem spot is a 3-cm, ill-defined, pink scaly patch located over the C7 area of the upper back/neck. Closer inspection reveals moderated atrophy, faint scale, and multiple fine telangiectasias coursing over the surface of the lesion. No induration is felt on palpation, and no nodes are appreciated on palpation of local nodal locations.

Around the lesion, and elsewhere on the patient’s sun-exposed skin, is abundant evidence of overexposure to the sun, including multiple solar lentigines, actinic keratosis (on the arms and face), and solar elastosis. He has type II skin, blue eyes, and reddish brown hair.

Thorough examination reveals no additional lesions of note.