As you get older, you may begin to notice rough, scaly spots appearing on your hands, arms, or face. Then youd apply it again, using it every night for 2 weeks. Those who have had a lot of sun exposure in their youth are at a high risk as well. Gibson LE (expert opinion). Erythroderma is not a clinical feature . People who have skin thats been badly damaged by ultraviolet (UV) light develop AKs and have a higher risk of getting skin cancer. They typically feel like sandpaper. Under freezing conditions, ice crystals form inside the tiny lumps and tear them apart. It is best to perform the exam in a well-lit area after a shower or bath. The lesion seemly came off all at once, save for that teensy part of it. The skin protrusions are remarkably thick and the base of the horn could be flat or nodular. Some actinic keratoses can turn into squamous cell skin cancer. Sun exposure can cause rough lesions on your skin. adminsos 25th January 2012. Such individuals often complain of sunburns and tans. AK is primarily caused by long-term exposure to sunlight. The photosensitizing medication gets activated and releases an oxygen molecule, which directly destroy the lesions. There might be itching or burning in the affected area. This image displays a bald scalp with areas of sun damage and actinic keratoses. What are my treatment options and the pros and cons of each? 11 Because most patients have more than one actinic keratosis, another study . People with light skin who sunburn easily; have trouble tanning; have blue, green, or hazel eyes; and red or blond hair are most at risk for developing actinic keratoses. This image displays two actinic keratoses and thinning and wrinkling of the skin, which suggests severe, chronic sun damage. 2. The lesions can be: Benign (not cancerous). If you have darker skin, your spots may closely resemble age spots, with a brown, black, or gray hue. They are caused by ultraviolet (UV) damage to the skin. The 2020 study mentioned listed how frequently AKs appear on each area of the face: Meanwhile, facial acne will most often erupt in your T-zone, which includes your chin, nose, and forehead. Whats the Difference Between Seborrheic Keratosis and Actinic Keratosis? In some cases when you call to set up an appointment, you may be referred directly to a specialist in skin diseases (dermatologist). Most patients with AKs need 2 PDT treatments, with the second treatment given 3 weeks after the first. Using this approach can reduce your risk of developing new AKs and possibly skin cancer. Healthline Media does not provide medical advice, diagnosis, or treatment. McGraw Hill; 2019. https://accessmedicine.mhmedical.com. Gavish has begun his career as a health and medical writer for daily newspapers. IE 11 is not supported. Actinic keratosis. Fitzpatricks Dermatology in General Medicine (seventh edition). An actinic keratosis is a precancerous skin lesion. RF 2CBAP9F . It is atopical medication that functions as an immune stimulator and fights against the viral agents. Steeb T, et al. Find her on Twitter and LinkedIn. Heres whats involved with each treatment. The patches are not usually serious. You can also develop keratoses along the rim of your ear. It's hard to tell which actinic keratoses will develop into skin cancer, so they're usually removed as a precaution. Your time with your health care provider is limited, so preparing a list of questions will help you make the most of your appointment. The growths may be gray, pink, red, or the same color as your skin. Your healthcare provider might remove the area of skin to have it checked under a microscope. These lesions most commonly appear on the:. It may be red and swollen for a brief time. Your doctor may recommend one or a combination, depending on factors like: Your doctor may recommend surgical treatment if you have only one or two isolated lesions. Males get more affected than females. Have a look at some of the pictures of Actinic Keratosis for a better understanding. Keep every appointment. During the first part of treatment, a solution that makes your skin extremely sensitive to light is applied to the area with AKs. In: Fitzpatrick's Dermatology. Some manufacturers make specialty clothing with a high sun protection factor (SPF) rating, or you can purchase a special ingredient to be added to your washer that can wash SPF into your clothing. Actinic keratosis Causes. The condition is more obvious when simple blemishes on the skin transform into painful lesions, having high potential for malignancy. These may grow up to 3-10 mm or several centimeters, resembling warts. Seborrheic keratosis vs. actinic keratosis. Mayo Clinic; 2020. Some actinic keratoses can turn into squamous cell skin cancer, so it is important to perform self-examinations often and catch them early. Actinic keratoses localized superficial tumors with the biological potential to develop into invasive skin cancer.Although the chance of an individual actinic keratosis progressing into an invasive squamous cell carcinoma is less than 1%, patients with many of these lesions (very common) who continue to expose their skin to carcinogenic ultraviolet sunlight are likely to develop invasive skin . Some AKs look and feel inflamed. Depending on the size of the incision, stitches may or may not be needed. Sometimes people will say, I just have this dry skin that wont get better, Ferris said. They are usually start off light tan, and then may darken to dark brown or nearly black. Youll sit in the office with this on your skin for about 60 to 90 minutes. Stick to your clothing, causing discomfort. Even after treatment for actinic keratosis, your health care provider might suggest that you have your skin checked at least once a year for signs of skin cancer. The following are some of the natural treatments you can try for actinic keratosis: 1. With a chemical peel, your dermatologist will apply a caustic chemical to your skin to peel back the outer skin layer. During the test, examiners usually detect these lesions on sun-exposed areas of the skin like bare scalp, face and hands. The image depicts actinic keratosis, which is the most common precursor of cutaneous invasive squamous cell carcinoma. Actinic keratosis usually appears as a patch of dry, scaly skin. They are commonly found on areas of the skin exposed to sunlight over long periods of time, such as the hands, forearms, shoulders, ears, lips, neck, and scalp. Should you have an AK, an accurate diagnosis and treatment can: Reduce your risk of developing skin cancer, Get rid of an AK, replacing it with new, healthy-looking skin, Help ease symptoms, such as itch, pain, or tenderness. Apple Cider Vinegar. These can include the face, ears, bald scalp, neck, backs of hands and forearms, and lips. Should that change be an AK, you have a greater risk of developing skin cancer. It can be caused by conditions that range from mild, Learn all about dark circles under your eyes. Actinic keratosis (AK), sometimes called solar keratosis or senile keratosis, is a pre-cancerous area of thick, scaly, or crusty skin. https://www.uptodate.com/contents/search. After treatment, the skin will feel raw and sore. Actinic keratosis. Discover symptoms, risk factors, signs to see a doctor, and more. Seborrheic keratosis is a type of harmless skin growth that can resemble melanoma. Accessed Nov. 12, 2020. When you see a board-certified dermatologist about AKs, your dermatologist will: Ask questions about your health, medications, and symptoms. All rights reserved. You have a higher risk of developing this condition if you: Actinic keratoses start out as thick, scaly, crusty skin patches. Its not always necessary, but its usually a good idea to treat actinic keratosis. Many methods are used to remove actinic keratosis, including: You're likely to start by seeing your primary care provider. (2021). Your dermatologist can tell you the best way to protect your skin. However, medical experts are still unaware of the mechanism by which these lethal virus triggers tumor growth. Dermatology, pp.1676-1693. Photodynamic therapy: This may be recommended for a patient who continues to get new AKs or has AKs that return after treatment. Actinic keratoses on your mouth can resemble chapped lips that never seem to heal. An actinic keratosis (also known as a solar keratosis) is the most common skin condition caused by sun damage. Guorgis G, et al. A topical medication called 5-fluorouracil may also be used to treat actinic keratoses. People with fair skin are more likely to develop actinic keratoses on sun-exposed areas like the face, arms, hands, back of the neck, and upper chest. Therefore, the skin papules appear bright red in color. 9th ed. They often have a white or yellow crusty scale on top. Even when the medication causes a skin reaction, which indicates that its working, youll need to keep applying the medication. In cauterization, the lesion is burned with an electric current. Inspect the tops and bottoms of your feet, the area between your toes, and toenails. Topical pharmacotherapy for skin cancer: part I. Pharmacology. J Am Acad Dermatol. Arsenical keratosis is a precancerous dermatosis seen in patients with chronic arsenic toxicity (CAT). Sometimes it looks scabby or wart-like. Anyone can develop these lesions, but youre more likely to develop them if youve had a lot of unprotected sun exposure. Micali G, Lacarrubba F, et al. If your clothing tears off the top layer of skin, the lesion may bleed. Prevention is very important. In severely chronically sun-damaged individuals, they may also be found on the upper trunk, upper and . Thisparticular version of keratosis is characterized by circumscribed, firm, scaling plaques with rich supply of inflammatory cells beneath the skin. With this condition, you develop scaly, discolored spots called actinic keratoses. Actinic keratoses are common, especially in older people, many of . Masks are required inside all of our care facilities. This can be treated with cryosurgery or certain ointments. Actinic keratosis (Solar Keratosis) Pictures, Cradle Cap Symptoms, Causes, Pictures, Treatment and Home Remedies, How long does nicotine stay in your system, Suppressed immune system, due to regular intake of immunosuppressive drugs after an organ transplant, Psoriasis, treated with PUVA a therapeutic procedure involving administration of oral drugs called psoralens followed by exposure to UVA light, Bowens disease/Bowenoid actinic keratosis, Restrict outdoor activities, especially from 10:00 am to 3:00 pm, Avoid using artificial tanning beds or lamps, Apply an appropriate sunscreen or other skincare products on solar damage-prone areas before going out in the sun, Eat a healthy diet rich in vitamin D and other supplements, Wear long sleeves, pants, hat/cap and sunglasses to protect against the damaging UV rays. Here are some pictures of SCC and what changes to look out for. Physical observation of the skin cannot help locate the lesion, owing to the minute size of the papules. It can help treat skin cancer, prostate cancer, and more. These dermatologists' tips tell you how to protect your skin. Actinic keratosis develops over a number of years. Carbon dioxide or Er:YAG lasers can repair the sun damaged skin in a short span of time. This image displays actinic keratosis of the legs. AKs are often more easily felt than seen. With photodynamic therapy, your dermatologist will spread a chemical agent across the actinic keratoses on your face. Actinic keratosis is often referred to as a pre-cancer, and when left untreated, these skin lesions can develop into skin cancer. This image displays actinic keratoses hidden by facial hair. Make a donation. Spread it evenly over the skin that your dermatologist says to treat. Actinic keratosis is a precancerous skin condition that causes patches of rough, patchy lesions. The medications that dermatologists prescribe include the following, which have all been approved by the US. Actinic keratoses are lesions in the outer skin layer caused by too much exposure to the ultraviolet rays of sunlight. To be effective, you need to apply the medication as often as your dermatologist recommends. 18 common and not so common bumps, rashes and growths, A discoloration that looks like an age spot, A change in color where the lips start to match the color of the face, Have a weakened immune system or certain health conditions, such as, How many you have, where they are and what they look like. If you have many AKs, its a good idea to be under a dermatologists care. This type of keratosis appears only in areas that are sun-exposed especially the face and neck. What is actinic keratosis? A single lesion generally doesnt pose a major cause for concern, but theres a small chance that an actinic keratosis can become cancerous. (2006). Treatment for an actinic keratosis may include: Cryotherapy. It tends to lie flat against the skin of the head and neck, but appears as a bump on arms and hands. Cutaneous horns are much more likely to become cancerous than other types of actinic keratosis, so if you have one of these on your face, a dermatologist should examine it right away. This image displays a frequent site for actinic keratoses, the rim of the ear. Symptom checkers like Aysa can help narrow down possible skin conditions by analyzing a skin photo. Actinic keratoses occur most frequently in fair-skinned people. It tends to lie flat against the skin of the head and neck, but appears as a bump on arms and hands. However, they can progress to squamous cell carcinoma (SCC), though the likelihood is low. Your body can heal some of the damage from the suns rays, but the effects of radiation accumulate with every exposure. These are precancerous skin cancers that look like scaly patches on your skin, and they can turn into cancer in the future. These tend to appear symmetrically across a person's back, arms, legs, and shoulders. (2020). Over 58 million Americans have actinic keratosis, a skin condition caused by damage from the suns ultraviolet (UV) rays. American sunscreen may also be less great at sun and skin protection than brands from other countries. Sensitivity to UV light is an inherited condition in fair-skinned or blonde patients. The cancer is capable of spreading to other regions of the skin. In the very early stages, squamous cell skin cancer can look like actinic keratosis. This natural product is known to cure different types of skin ailments. This image displays a very large, scaly actinic keratosis. The surface of the ear is a typical location of actinic keratoses. Our website services, content, and products are for informational purposes only. Clinical Information and Differential Diagnosis of Actinic Keratosis (Solar Keratosis), Mild one or two spots, not thick or hard, Severe numerous or thick, hard, or bleeding spots. 6th ed, pp. The scale or crustmay behorny, dry, and rough. You might also notice your lips lose color, with the edges fading into the same hue as the rest of your face. Avoid going outside at midday, when the sun is brightest. In many cases, its not easy to tell which lesions will become cancerous and which will stay benign. This is performed in order to inspect the current stage of precancerous keratosis and rule out the presence of cancer. This disease is most common in infants and children, but adults may be, Genital human papillomavirus (HPV) infection is a common sexually transmitted infection (STI) caused by human papillomavirus. Image 1: J Am Acad Dermatol. This treatment freezes the lesion. If you want to diminish a noticeable scar, know these 10 things before having laser treatment. Urticaria pigmentosa is a skin condition that causes lesions and itchy skin. At Another Johns Hopkins Member Hospital: Masks are required inside all of our care facilities, COVID-19 testing locations on Maryland.gov, Bloomberg-Kimmel Institute for Cancer Immunotherapy, Squamous Cell Skin Cancer of the Head and Neck. Padilla RS. When she's not writing, look for her out walking her dog or riding her bike in Pennsylvania's Lehigh Valley. Often, a person will have more than one actinic keratosis lesion. If you have one or more AKs, your dermatologist will talk with you about whether to treat these precancerous skin growths. Actinic keratoses are considered precancers . Seborrheic keratosis and actinic keratosis both cause skin growths, but actinic keratosis may become cancerous. This image displays a thin white scale typical of actinic keratosis. This procedure is a bit time-consuming because it consists of 2 parts. Untreated, they can turn into a type of skin cancer called squamous cell carcinoma. Prolonged and intense sun exposure acts as a contributing factor in causing the condition. Actinic keratosis growths can also be tan, pink, red or any combination of these colors. Gavish is an award-winning freelance medical and health writer and editor with 15 years of experience. While treating actinic keratosis, never try to calm your treated skin by applying hydrocortisone or another corticosteroid medication. American Academy of Dermatology. Read on to know all about this disorder, including its causes, symptoms, diagnosis and treatment. Your dermatologist will tell you how often to return for check-ups. Your dermatologist can do this during an office visit while you remain awake. Cover up with tightly woven clothing. Use these professionally produced online infographics, posters, and videos to help others find and prevent skin cancer. https://www.aad.org/dermatology-a-to-z/diseases-and-treatments/a---d/actinic-keratosis. Excision involves cutting the lesion from the skin. These can include the face, ears, bald scalp, neck, backs of hands and forearms, and lips. Spots usually appear in those who are older (over 50), but they can start appearing in younger adults who have had a lot of sun exposure. Duncan KO, Geisse JK, et al. In rare cases they may come back. Your dermatologist can watch for signs of new AKs and skin cancer. Epithelial precancerous lesions. In: Wolff K, Goldsmith LA, et al. have a tendency to . The advantage of using a medication to treat your AKs is that the medication can treat many AKs, including the ones you cannot see yet. Rarely, it can spread to the dorsa of the . These patches or plaques often form in clusters. 5 facts you should know about precancerous skin growths. Tanning beds can also cause actinic keratosis since they emit UV radiation. 16. It can smooth out deep wrinkles and lines, but the results arent permanent. After a medical-grade chemical peel, the treated skin will be red, swollen, and sore. Estoy en riesgo de desarrollar melanoma? Using a hair dryer can help you examine any areas of skin covered by hair, such as your scalp. SCC is relatively easy to diagnose and treat in its early stages. Eventually, it will cause visible changes to your skin. If 12 to 16 weeks is too long, you may be able to use the medication a bit differently. This image displays an actinic keratosis in the center as well as prominent blood vessels, which suggest chronic sun damage. In . In some cases, there is no demarcation between the tiny bumps and the surrounding skin. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Apply generously 30 minutes before going outdoors and reapply every 2 hours or after swimming or sweating a lot. Using one of these will prevent your AK treatment from working. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). They . Our website services, content, and products are for informational purposes only. Later, they may become hard and wart-like or gritty and . Actinic keratoses are rough , scaly spots that form on sun-damaged skin. People with fair skin are more likely to develop actinic keratoses on sun-exposed areas like the face, arms, hands, back of the neck, and upper chest. Thousands of new, high-quality pictures added every day. An actinic keratosis sometimes disappears on its own but might return after more sun exposure. When it heals in 1 or 2 weeks, you see new, healthier skin. If you dont already have a dermatologist, you can browse doctors in your area through the Healthline FindCare tool. While the rough, gritty scale of actinic keratoses is sometimes easier to feel than see, it can also be very obvious to the naked eye as with this lesion on the forehead. Wear a hat with a brim of at . It most likely appears onareas of skin often exposed to the sun. A baseball hat does not give much protection. Heres what you need to know. This is normal and expected. There are certain herbalremedies like green tea and milk thistle that help in alleviating the painful symptoms of this condition. We see them more frequently on chronically sun-exposed areas like the face, forearms and the backs of the hands, said Dr. Laura Ferris, associate professor and director of clinical trials in the dermatology department at the University of Pittsburgh Medical Center and a member of the American Academy of Dermatology. Cryotherapy uses extreme cold to remove tissue such as tumors. It most likely appears on areas of skin often exposed to the sun. Use sunscreen on all exposed skin areas, including the lips, before going outdoors. Sometimes it looks like small bubbles or cysts within the growth. Healthline Media does not provide medical advice, diagnosis, or treatment. Preventing these lesions becomes especially important if you have risk factors like pale skin or immunodeficiency. Local destruction with freezing (cryosurgery), scraping (curettage), burning (electrocautery), dermabrasion, or a laser, Creams with either tretinoin, adapalene, fluorouracil, diclofenac, or imiquimod. To be effective, treatment must destroy the AKs. What will the treatments cost? It's also common to have harmless brown spots or . the tops and undersides of your arms and hands. Actinic keratoses, also known as solar keratoses, are small rough or scaly areas of skin due to damage from sun exposure. This content does not have an English version. All rights reserved. Martin G, Swanson N. Clinical findings using ingenol mebutate gel to treat actinic keratoses. J Am Acad Dermatol 2013;68:S39-48. In rare instances, they may bleed or develop a persistent sore, also known as an ulceration. However, real age spots are smooth, not scaly. Ferris added that though Black patients are at lower risk of actinic keratosis, the lesions "appear the same when they occur. [1] It is characterized by corn-like, yellowish, hyperkeratotic papules and plaques, primarily affecting the palms and soles. Accessed Sept. 30, 2020. This is known as a skin biopsy. Estimates on the risk vary widely by source, but the Skin Cancer Foundation estimates that 5%10% of actinic keratosis lesions become cancerous. A prospective, longitudinal study found the risk of progression to be 0.24 percent per year for each actinic keratosis. An actinic keratosis can develop after ultraviolet light from the sun or from indoor tanning damages cells in the skin called keratinocytes, according to the AAD. Treatment for AKs can get rid of AKs as well as reduce signs of aging on Actinic keratosis is a fairly common skin condition. Similarly, color variations range from light to dark with variations throughout the patches. Accessed Sept. 30, 2020. Types of surgery include: If you have multiple lesions on your face, your doctor may prescribe a topical cream or gel you can apply at home. Everyone's at risk for skin cancer. He has been writing for Prime Health Channel more than 750 high quality and informative based medical / health articles for both consumer and professional readers. All rights reserved. Use a full-length mirror with the added assistance of a hand mirror, when necessary. Watch TODAY All Day! ", If you suspect you might have actinic keratosis, see your dermatologist. But unlike dry skin they dont go away with moisturizers.. Actinic keratosis lesions can appear on any part of your body regularly exposed to sun, but they frequently appear on the face. How to spot a precancerous growth on your skin. You have a higher risk of developing this condition if you: are over age 60. have light-colored skin and blue eyes. During a skin biopsy, a small sample of skin is taken for analysis in a lab. Although the epidermis appears thick, there is a loss of granular layer with wide gaps between the cells. Sometimes, it takes on a red color. Its best to use a sunscreen with a sun protection factor (SPF) rating of at least 30. . Find out how a board-certified dermatologist helped Natalie see clear skin before her wedding. Chemical peel: This is a medical-grade chemical peel used to destroy the top layers of skin. An actinic keratosis can develop after ultraviolet light from the sun or from indoor tanning damages cells in the skin called keratinocytes, according to the AAD. It may take several years or even decades for the skin to undergo keratosis. If you have a weakened immune system or a rare condition that greatly increases your risk of developing AKs and skin cancer, you may need to see your dermatologist every 8 to 12 weeks. These products might cause inflamed skin, scaling or a burning sensation for a few weeks. Your doctor may choose to remove extra tissue around or under the lesion if there are concerns about skin cancer. Post-application, the skin appears smooth and lesion-free. The base of an actinic keratosis may be light or dark . This image displays numerous areas of sun damage and actinic keratoses. Food and Drug Administration (FDA) to treat AKs: 5-fluorouracil (5-FU) cream: You apply this once or twice a day for 2 to 4 weeks. If you have an actinic keratosis, commonly called an age spot, your dermatologist may prescribe medication to treat this condition at home. Actinic keratosis: How to differentiate the good from the bad ones? 2013;68(1):98-102. As the epidermal cells begin to deteriorate, there is a modification in the texture and color of the skin. But sometimes an actinic keratosis can be hard to tell apart from skin cancer. Learn how to identify skin cancer types and how to prevent and treat them. To prevent actinic keratosis, it's important to: Avoid exposure to sunlight during peak sunlight hours (10 a.m. to 2 p.m.). If you have severe changes or have a spot that is growing or bleeding, see the doctor. 2005-2023 Healthline Media a Red Ventures Company. Youll find the self-care that dermatologists recommend at, Actinic keratosis: Self-care. These patches are usually about the size of a small pencil eraser. AskMayoExpert. Color variations, including pink, red or brown. Skin lesions are skin growths or patches that don't look like the skin around them. These herbal formulations also protect the skin from the damaging effects of UV rays. Such individuals often complain of sunburns and tans. It is a chemotherapeutic cream that causes reddening and inflammation of the affected skin areaprior to falling off of the lesions. This kills the affected skin cells. your skin. Find Seborrheic Keratosis stock images in HD and millions of other royalty-free stock photos, illustrations and vectors in the Shutterstock collection. Most actinic keratoses can be treated and cured. This cream is laden with a non-steroidal anti-inflammatory drug, analogous to ibuprofen. Then, theyll expose your skin to blue light, which activates the chemical agent to remove the lesions. Seborrheic keratoses may appear as if they are stuck on to the skin. The skin becomes tender when multiple lesions develop within a single area, causing more discomfort and agony. Most patients with AKs need 2 PDT treatments, with the second treatment given 3 weeks after the first. Some people develop a few AKs, which can often be cleared with treatment. New York: Mosby, 2003. This site complies with the HONcode standard for trustworthy health information: verify here. In the course of time, the skin lesions grow bigger in size. Certain topical treatments such as 5-fluorouracil (Carac, Efudex, Fluoroplex, Tolak) cause inflammation and destruction of the lesions. In pictures of actinic keratosis, you'll see they are typically pink, scaly, and flat. Actinic keratosis can sometimes turn cancerous, so its important to monitor and treat these spots when you find them. AKs result from long-term exposure to ultraviolet (UV) radiation. This is called Bowen's disease, a very early squamous cell skin cancer that is only in the epidermis. Image Source: 2007 Interactive Medical Media LLC. Actinic keratosis overview: A common precancer. Other areas include: The condition initially manifests as small crusty spotsmeasuring between 2-6 millimeters in diameter that cannot be easily spotted. (2022). They typically feel like sandpaper. This will also help minimize your risk of skin cancer. As your skin heals, the damaged cells slough off, allowing new skin to appear. When actinic keratoses are visible, they can show up in various ways, according to the AAD. As the treated skin heals, youll see new, healthier skin. The skin changes begin as flat and scaly areas. This image displays a close-up of actinic keratoses. Those with a weak immune system due to chemotherapy, HIV, or an organ transplant are at higher risk. The fluorescent lamps used in these indoor tanning equipments radiate UV rays, which could be detrimental to the skin. What suspicious changes in my skin should I look for? A few basic tips to prevent actinic keratosis include: Buy quality sunscreen: Look for sunscreen with broad-spectrum UV protection and an SPF of 30 or higher. https://www.aad.org/media/stats/prevention-and-care/sunscreen-faqs. However, fair-skinned patients who are into regular outdoor activities or occupations involving extended periods of sun exposure are prone to the disease. In most cases, people who develop actinic keratosis are in their 40s or older. The more lesions you have, the higher your cancer risk becomes. When did you first notice the patches or spots?