Under the midnight sun: A case of actinic keratoses in an avid Inuit fisherman

Abstract

We report the case of a 74-year-old Inuit man from Kangiqsualujjuaq, Quebec, with a 10-year history of persistent facial skin changes, reported as “dry skin.” Examination revealed violaceous scaly papules on sun-exposed areas that had sandpaper texture on palpation. The patient, with no significant medical history, spends extensive time outdoors in a subarctic environment. A diagnosis of actinic keratoses was made. This case highlights the need to recognize atypical presentations of actinic keratoses in patients with darker skin phototypes and high environmental ultraviolet exposure. Topical 5% fluorouracil was initiated.

Introduction

Actinic keratosis (AK) is a common precancerous lesion caused by chronic ultraviolet (UV) exposure, most often diagnosed in fair-skinned individuals (Fitzpatrick I–III). However, it can also occur in those with darker skin phototypes (Fitzpatrick ⩾ IV), where it may be underdiagnosed due to subtle features. In northern Inuit Indigenous communities, prolonged daylight, minimal shade, and high albedo (surface reflectivity from snow, ice, and water) increase cumulative UV exposure. This case emphasizes the need for clinical awareness of AKs in patients with darker skin living in high-latitude environments.

Case presentation

We report the case of a 74-year-old Inuit man from Kangiqsualujjuaq, Quebec, presenting with a 10-year history of “dry skin” on the face. Examination revealed numerous subtle violaceous, scaly papules, predominantly on the right side of the face in sun-exposed areas (Figure 1). The patient, with no significant past medical history, reported being an avid hunter and fisherman who regularly uses a Ski-Doo and spends extensive time outdoors in a subarctic environment. The lesions were nonpruritic and had a sandpaper-like texture on palpation. A diagnosis of multiple, predominantly unilateral AKs was made, and treatment with topical fluorouracil (5-FU) was recommended. ¹

Figure 1.

Multiple violaceous, scaly papules (arrows) on right face indicative of extensive actinic damage.

Discussion

While AKs are common in Caucasian (Fitzpatrick I–III) individuals living closer to the equator, darker skin phototypes (Fitzpatrick ⩾ IV) due to higher melanin content are less susceptible to actinic damage. A defining characteristic of the northern Canadian region (Inuit Nunangat) is its sparse or absent canopy cover, resulting in minimal natural shade. This, combined with high surface albedo, which refers to the reflection of UV radiation off persistent snow, ice, and water, particularly during fishing and hunting activities, significantly increases UV exposure. Additionally, communities located above the 65th parallel experience nearly continuous daylight during the summer solstice. These environmental factors collectively heighten residents’ cumulative UV exposure and increase the risk of skin cancers.^2,3 This case highlights the potential for substantial actinic damage in individuals with darker skin phototypes due to intense environmental UV exposure, recreational and occupational outdoor activity, and the amplifying effects of climate change and Arctic warming. Lesions may be more difficult to identify, as erythema is less prominent and may appear violaceous in Indigenous patients. Hence, it is important for physicians treating Indigenous patients presenting with “dry skin spots” on the face to maintain a high index of suspicion for AKs and in situ cutaneous squamous cell carcinomas (Bowen’s disease).