DISCUSSION
This patient’s condition is poikiloderma of Civatte (PC), an increase in surface vasculature etched into the skin by chronic overexposure to the sun. PC usually follows a very predictable pattern, mirroring the patient’s usual attire. This made the asymmetry in this patient’s case striking and puzzling. Speculation included uneven sunscreen application or use of clothing such as overalls, which tend to shift during wearing, but the cause remained a mystery—that is, until the patient got dressed.
After putting his shirt back on, he placed his large, heavy cell phone in the left pocket, effectively pulling his shirt down and to the left. This exposed more skin on that side, covering up the right side of the chest. He confirmed that he carried the cell phone in his shirt pocket constantly during his waking hours, at home and on the job.
This conundrum needed to be solved in order to rule out other possible conditions. There’s no rule that prevents a person from having two adjacent diagnoses at the same time, such as PC and Bowen disease (a superficial form of squamous cell carcinoma). In this case, the patient’s skin changes were all consistent with one diagnosis.
TAKE-HOME LEARNING POINTS
• Poikiloderma of Civatte (PC) is the term given to a particular pattern of chronic overexposure to UV rays, typically affecting the neck and upper chest.
• PC is often caused by occupational sun exposure.
• Unless treated with a laser, PC changes are permanent but harmless. They do, however, identify the patient as being at risk for sun-caused skin cancer.
• Atypical presentations of what appear to be common problems may need a bit of investigation to rule out other items in the differential.