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Know Cutaneous Signs of Internal Malignancies.

SEA ISLAND, GA. -- Manyofthe7%15% of patients with internal malignancy who develop cutaneous paraneoplasias will seek care for these dermatologic conditions first, so family physicians should be alert to their significance for early diagnosis, Dr. Toni L. McCullough said at the annual meeting of the Georgia Society of Dermatologists.

Cutaneous paraneoplastic syndromes sometimes are apparent several months prior to diagnosis of the malignancy responsible, noted Dr. McCullough, a dermatologist in private practice in Savannah, Ga.

She outlined the following characteristics of several dermatologic conditions that can be associated with cancer:

* Bazex's Syndrome. Psoriasiform eruptions on the nose and ears are characteristic of this paraneoplastic syndrome, which is most often associated with upper respiratory cancers, said Dr. McCullough, who is also of the department of internal medicine and chief of the dermatology curriculum at Memorial Health University Medical Center in Macon, Ga.

She described a patient who had these signs as well as a palmoplantar keratoderma with central sparing, an eruption that was moving up the leg, and extensive nail dystrophy.

There also was red scaling on the nose and ears. The patient was diagnosed with esophageal cancer.

Most of the cancers that are associated with Bazex's syndrome are squamous cell carcinomas.

This syndrome appears an average of 11 months prior to cancer diagnosis, and the skin symptoms are usually resistant to therapy

* Acanthosis Nigricans. This involves a hyperpigmented velvety appearance of some portions of the skin and the thickening of some areas of the skin, Dr McCullough said.

Signs that this condition is paraneoplastic, rather than a drug eruption or sign of some other condition such as diabetes, include onset after age 40, sudden and rapid onset, mucosal involvement, and thickened and exaggerated skin margins on the hands.

When this condition is associated with malignancy, the malignancies tend to be gastric, and they tend to be very aggressive, said Dr. McCullough, also of the Medical College of Georgia in Augusta.

* Erythema Gyratum Repens. This eruption, consisting of flat to slightly palpable erythematous bands arranged in patterns described as wood grain, can move rapidly, up to 1 cm/day Dr. McCullough said.

This condition is very specific for underlying cancer--usually adenocarcinoma and lung cancer.

It appears an average of 9 months prior to cancer diagnosis.

* Glucagonoma Syndrome. This syndrome, specific for certain pancreatic tumors, is usually misdiagnosed until the rumors have metastasized.

This is unfortunate, because many clues are present prior to metastasis, Dr. McCullough said.

For example, perianal and perioral eruptions, with spread to adjacent areas in the groin, are common.

Mucocutaneous involvement also is common. The rashes are usually resistant to treatment, and if they do respond, they - will usually recur.

Diabetes is present in 90% of patients, and weight loss, diarrhea, depression, anemia, and venous thrombosis are also common.

Glucagon levels are well above the normal range, she added.

* Acquired Ichthyosis. Extremely dry, scaly skin is a characteristic feature of this condition.

It is very similar to ichthyosis vulgaris, but unlike the genetic forms, acquired ichthyosis tends to spare the palms of the hands and soles of the feet.

The condition can be associated with chronic diseases, malnutrition, drugs, AIDS, thyroid disorders, and chronic renal failure, but it also can be a sign of malignancy especially Hodgkin's lymphoma and other lymphoreticular carcinomas, Dr McCullough said.

* Paraneoplastic Pemphigus. Painful erosions of the vermilion border and mucosal involvement are characteristic of this paraneoplasia.

It is most often associated with non-Hodgkin's lymphoma but has been reported with other types of cancers. Clinical and histologic features have features of both pemphigus vulgaris and erythema multiforme.

The condition is very resistant to treatment.

* Tripe Palms. This very rare paraneoplasia has been reported in fewer than 100 patients in the literature, and most have underlying gastrointestinal or pulmonary malignancies.

One patient who presented with this condition--characterized by a honey-comblike thickening of the palms--also had extensive telangiectasias, hair loss, a 1year history of diarrhea, a recent 50-pound weight loss, and night fevers, Dr. McCullough said.

In patients who have acanthosis nigricans in addition to tripe palms, gastric cancers are the most common finding. In those with tripe palms alone, pulmonary cancers are most common.

* Pityriasis Rotunda. This extremely rare condition involves perfectly round, scaly hyperpigmented areas on the skin.

On biopsy it looks like ichthyosis vulgaris, and it is believed to be a unique localized form of acquired ichthyosis, Dr. McCullough said.

However, it requires a genetic predisposition. The condition has been reported in patients of Japanese origin as well as patients from South Africa, the West Indies, and the Americas. It can be associated with hepatocellular carcinoma.
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Publication:Family Practice News
Article Type:Brief Article
Geographic Code:1USA
Date:Sep 15, 1999
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