Correspondence
exocytosis was seen in the epidermis. Keratinocytes in the lesional areas were larger than those in the nonlesional area, and exhibited slightly pale-staining cytoplasm (Fig. 2). Periodic-acid–Schiff (PAS) staining revealed the presence of glycogen in the pale cells. The patient was diagnosed with CCA, and the tumour was completely removed with a carbon dioxide laser. No recurrence was noted during a follow-up of 5 months. CCA has been described as a clinical hybrid exhibiting the ‘stuck-on’ appearance of seborrhoeic keratosis, the vascular appearance of pyogenic granuloma, and peripheral scaling and exudation consistent with an eczematous process.1 CCA often develops on the legs of elderly patients. More unusual locations include the scalp, vermilion, ear, palm, nipple, buttock, scrotum and toe.1 Ours is the first case of CCA occurring in the axilla. The most diagnostic histopathological feature of CCA is psoriasiform epidermal hyperplasia involving glycogenrich clear cells.2 The clear keratinocytes stain strongly with PAS, and contain multiple glycogen-rich and phosphorylase-deficient cytoplasmic vacuoles.2,3 The epidermis is frequently infiltrated by abundant numbers of neutrophils, and dilated vessels may be seen in the upper dermis.2 The differential diagnosies of CCA depend on the clinical presentation, and include seborrhoeic keratosis, haemangioma, viral or flat wart, pyogenic granuloma, basal or squamous cell carcinoma, eccrine poroma, clear cell hidradenoma, and metastatic cancer.2,3 Dermoscopy may aid in the diagnosis of CCA. The characteristic finding is the presence of dilated pinpoint capillary loops; reticular and linear dermoscopic patterns have also been reported.4 The natural course of CCA is to persist.3 Reported treatments for CCA include excision, curettage, cryotherapy and electrofulguration.1 CO2 laser therapy has also been performed with success.5 In this case, CCA developed in the axilla, a very unusual site, and was successfully treated with CO2 laser. We suggest that the axilla should be added to the list of unusual locations of CCA. This case confirms that CO2 laser is effective in the treatment of CCA without relapse, as in the previous report.5 I. J. Kang, N. I. Kim and M. K. Shin Department of Dermatology, College of Medicine, Kyung Hee University, No. 1 Hoegi-Dong, Dongdaemun-gu, 130-702, Seoul, Korea E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 1 July 2014
References 1 Wang SH, Chi CC. Clear cell acanthoma occurring on the hallux: the first case report. J Eur Acad Dermatol Venereol 2006; 20: 1144–6.
ª 2014 British Association of Dermatologists
2 Portal C, Fang F, Kanner W, Wilson B. Clear cell acanthoma. Cutis 2013; 92: 62, 77–9. 3 Tempark T, Shwayder T. Clear cell acanthoma. Clin Exp Dermatol 2012; 37: 831–7. 4 Zalaudek I, Hofmann-Wellenhof R, Argenziano G. Dermoscopy of clear-cell acanthoma differs from dermoscopy of psoriasis. Dermatology 2003; 207: 428. 5 Chi CC, Wang SH, Huang HS. Clear cell acanthoma successfully treated with a carbon dioxide laser. Dermatol Surg 2005; 31: 1355–8.
Metastatic melanoma of the transverse colon heralded by vitiligo-like depigmentation: two rare conditions occurring in the same patient doi: 10.1111/ced.12532 We read with interest the paper by Wang et al. reporting an association between metastatic melanoma and vitiligolike depigmentation.1 In their case, the metastatic melanoma involved the left inguinal and iliac nodes, and the hypopigmentation manifested 4 months prior to lymphnode enlargement. We present another atypical example of this clinically important correlation. A 72-year-old man with facial vitiligo (Fig. 1a) presented with the clinical impression of bowel obstruction. Contrast-enhanced, whole-body computed tomography revealed a solid mass, 150 9 90 mm in size, inside the patient’s transverse colon, associated with occasional swollen (to about 10 mm) regional lymph nodes (Fig. 1b). Laparotomic resection of the involved colon was performed along with lymphadenectomy. Histologically, the tumour was confirmed to be a metastasis from epithelioid cell-type melanoma, and two lymph nodes also showed metastases (Fig. 2). The patient confirmed that he had undergone excision of a skin melanoma from his chest 16 years previously, and a 3-year course of treatment (believed to be interferon-a) following excision. He also stated it had been 3 years since vitiligo became evident and stable on his face. The patient remains under follow-up. A mediastinal lymph-node metastasis was detected at the 3-month follow-up, and a cerebral metastasis was found at the 6-month follow-up. The patient underwent excision of both, and is now scheduled for adjuvant-whole brain radiotherapy. Melanoma metastasis involving the transverse colon represents a medical rarity, as does vitiligo-like depigmentation occurring in patients with melanoma; their coexistence in the same patient is unprecedented. Cutaneous melanoma metastasizes more frequently to the small intestine than to the large bowel: postmortem identification is 58% for the former and 22% for the latter. Antemortem detection is even rarer (1–5%) because such
Clinical and Experimental Dermatology (2015) 40, pp441–456
453
Correspondence
(a)
(b)
Figure 2 The transverse colon, containing the melanoma
metastasis, was resected.
Figure 1 (a) Patches of vitiligo-like depigmentation on patient’s
face (red arrows); (b) contrast-enhanced computed tomography showed a solid mass, 150 9 90 mm in size, obstructing the transverse colon.
metastases are often clinically silent; when they are symptomatic, bowel obstruction or a palpable mass are the most common presentations. After a thorough search through the pertinent literature and excluding rectal involvement, we found only 77 cases of colonic metastases from skin melanoma; these data came from a few case reports and small case series, where declaration of patient sex, age, localization of the primary tumour and metastatic colonic segment, and description of the metastatic lesions as solitary or multiple was omitted in 60–90% of cases, thus hampering the correct analysis of the clinicopathological features of this condition. Melanoma metastasis to the transverse colon was documented only in two cases: both patients were elderly men (75 and 85 years), experiencing changes in bowel habits or marked weight loss, and presenting multiple extraperitoneal metastatic foci at diagnosis, although
454
Clinical and Experimental Dermatology (2015) 40, pp441–456
there was no identification of the primary tumour.2,3 Our patient shared the same characteristics, except for the known site of the primary melanoma and the development of vitiligo-like depigmentation. The occurrence of this leucoderma in patients with melanoma was reported for the first time in 1967 by Goldman and colleagues. Since then, this association has been described in 2.8% of patients with melanoma (affected by primary skin or uveal melanoma, or as an early sign of metastatic melanoma) and a higher incidence of up to 23–43% has been registered in patients with metastais following immunotherapeutic strategies.4 The significance of vitiligo development in patients with melanoma remains controversial; however, mounting evidence supports an improved prognosis in the advanced stages (for which it is considered an independent prognostic factor) and after immunotherapy.4,5 To our knowledge, this is the first case in which vitiligo portended a colonic metastasis of a previously resected skin melanoma. In addition, the long disease-free survival recorded before relapse (16 years) suggests that extensive follow-up of patients with melanoma is needed. E. Virgilio, R. Sandomenico, P. Fransvea and G. Balducci Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology Sapienza, St. Andrea Hospital, via di Grottarossa 1035-39, Rome 00189, Italy E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 4 June 2014
ª 2014 British Association of Dermatologists
Correspondence
Erythema multiforme-like drug reaction with eosinophilia and systemic symptoms (DRESS)
References 1 Wang JR, Yu KJ, Juan WH et al. Metastatic malignant melanoma associated with vitiligo-like depigmentation. Clin Exp Dermatol 2009; 34: 209–11. 2 Ozuner G. Colonoscopic detection of a malignant melanoma metastatic to a tubular adenoma of the colon. Dis Colon Rectum 2002; 45: 1681–4. 3 Tak AM. Metastatic melanoma: a case of unknown site of primary origin. IJGE 2006; 4: 987. 4 Quaglino P, Marenco F, Osella-Abate S et al. Vitiligo is an indipendent favourable prognostic factor in stage III and IV metastatic melanoma patients: results from a singleinstitution hospital-based observational cohort study. Ann Oncol 2010; 21: 409–14. 5 Gogas H, Ioannovich J, Dafni U et al. Prognostic significance of autoimmunity during treatment of melanoma with interferon. N Engl J Med 2006; 354: 709–18.
doi: 10.1111/ced.12541 Drug reaction with eosinophilia and systemic symptoms (DRESS) is recognized as a distinct disease entity of delayed-onset severe drug eruptions.1 Although diagnostic criteria have been established,2 they do not include details of skin manifestations. We describe a case of DRESS showing erythema multiforme (EM)-like eruptions. A 38-year-old woman with schizophrenia was admitted to our hospital with a 1-week history of worsening fever, malaise and itchy eruptions. Physical examination revealed scattered target-like lesions on the patient’s body (Fig. 1a), and cervical lymph-node swelling. No mucous membrane lesions were identified.
(a)
(b)
(c)
(d)
Figure 1 (a) Erythema multiforme (EM)-like erythema scattered on the trunk. The skin biopsy site can be seen in the lower right corner
(marked eruption). (b) Perivascular infiltration in the upper dermis, with no signs of pidermal necrosis/apoptosis and (c) marked perivascular eosinophil infiltration (arrowhead). Haematoxylin and eosin, original magnification (b) 9 40; (c) 9 200. (d) Alopecia areata on the top of the head during the disease course.
ª 2014 British Association of Dermatologists
Clinical and Experimental Dermatology (2015) 40, pp441–456
455
exocytosis was seen in the epidermis. Keratinocytes in the lesional areas were larger than those in the nonlesional area, and exhibited slightly pale-staining cytoplasm (Fig. 2). Periodic-acid–Schiff (PAS) staining revealed the presence of glycogen in the pale cells. The patient was diagnosed with CCA, and the tumour was completely removed with a carbon dioxide laser. No recurrence was noted during a follow-up of 5 months. CCA has been described as a clinical hybrid exhibiting the ‘stuck-on’ appearance of seborrhoeic keratosis, the vascular appearance of pyogenic granuloma, and peripheral scaling and exudation consistent with an eczematous process.1 CCA often develops on the legs of elderly patients. More unusual locations include the scalp, vermilion, ear, palm, nipple, buttock, scrotum and toe.1 Ours is the first case of CCA occurring in the axilla. The most diagnostic histopathological feature of CCA is psoriasiform epidermal hyperplasia involving glycogenrich clear cells.2 The clear keratinocytes stain strongly with PAS, and contain multiple glycogen-rich and phosphorylase-deficient cytoplasmic vacuoles.2,3 The epidermis is frequently infiltrated by abundant numbers of neutrophils, and dilated vessels may be seen in the upper dermis.2 The differential diagnosies of CCA depend on the clinical presentation, and include seborrhoeic keratosis, haemangioma, viral or flat wart, pyogenic granuloma, basal or squamous cell carcinoma, eccrine poroma, clear cell hidradenoma, and metastatic cancer.2,3 Dermoscopy may aid in the diagnosis of CCA. The characteristic finding is the presence of dilated pinpoint capillary loops; reticular and linear dermoscopic patterns have also been reported.4 The natural course of CCA is to persist.3 Reported treatments for CCA include excision, curettage, cryotherapy and electrofulguration.1 CO2 laser therapy has also been performed with success.5 In this case, CCA developed in the axilla, a very unusual site, and was successfully treated with CO2 laser. We suggest that the axilla should be added to the list of unusual locations of CCA. This case confirms that CO2 laser is effective in the treatment of CCA without relapse, as in the previous report.5 I. J. Kang, N. I. Kim and M. K. Shin Department of Dermatology, College of Medicine, Kyung Hee University, No. 1 Hoegi-Dong, Dongdaemun-gu, 130-702, Seoul, Korea E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 1 July 2014
References 1 Wang SH, Chi CC. Clear cell acanthoma occurring on the hallux: the first case report. J Eur Acad Dermatol Venereol 2006; 20: 1144–6.
ª 2014 British Association of Dermatologists
2 Portal C, Fang F, Kanner W, Wilson B. Clear cell acanthoma. Cutis 2013; 92: 62, 77–9. 3 Tempark T, Shwayder T. Clear cell acanthoma. Clin Exp Dermatol 2012; 37: 831–7. 4 Zalaudek I, Hofmann-Wellenhof R, Argenziano G. Dermoscopy of clear-cell acanthoma differs from dermoscopy of psoriasis. Dermatology 2003; 207: 428. 5 Chi CC, Wang SH, Huang HS. Clear cell acanthoma successfully treated with a carbon dioxide laser. Dermatol Surg 2005; 31: 1355–8.
Metastatic melanoma of the transverse colon heralded by vitiligo-like depigmentation: two rare conditions occurring in the same patient doi: 10.1111/ced.12532 We read with interest the paper by Wang et al. reporting an association between metastatic melanoma and vitiligolike depigmentation.1 In their case, the metastatic melanoma involved the left inguinal and iliac nodes, and the hypopigmentation manifested 4 months prior to lymphnode enlargement. We present another atypical example of this clinically important correlation. A 72-year-old man with facial vitiligo (Fig. 1a) presented with the clinical impression of bowel obstruction. Contrast-enhanced, whole-body computed tomography revealed a solid mass, 150 9 90 mm in size, inside the patient’s transverse colon, associated with occasional swollen (to about 10 mm) regional lymph nodes (Fig. 1b). Laparotomic resection of the involved colon was performed along with lymphadenectomy. Histologically, the tumour was confirmed to be a metastasis from epithelioid cell-type melanoma, and two lymph nodes also showed metastases (Fig. 2). The patient confirmed that he had undergone excision of a skin melanoma from his chest 16 years previously, and a 3-year course of treatment (believed to be interferon-a) following excision. He also stated it had been 3 years since vitiligo became evident and stable on his face. The patient remains under follow-up. A mediastinal lymph-node metastasis was detected at the 3-month follow-up, and a cerebral metastasis was found at the 6-month follow-up. The patient underwent excision of both, and is now scheduled for adjuvant-whole brain radiotherapy. Melanoma metastasis involving the transverse colon represents a medical rarity, as does vitiligo-like depigmentation occurring in patients with melanoma; their coexistence in the same patient is unprecedented. Cutaneous melanoma metastasizes more frequently to the small intestine than to the large bowel: postmortem identification is 58% for the former and 22% for the latter. Antemortem detection is even rarer (1–5%) because such
Clinical and Experimental Dermatology (2015) 40, pp441–456
453
Correspondence
(a)
(b)
Figure 2 The transverse colon, containing the melanoma
metastasis, was resected.
Figure 1 (a) Patches of vitiligo-like depigmentation on patient’s
face (red arrows); (b) contrast-enhanced computed tomography showed a solid mass, 150 9 90 mm in size, obstructing the transverse colon.
metastases are often clinically silent; when they are symptomatic, bowel obstruction or a palpable mass are the most common presentations. After a thorough search through the pertinent literature and excluding rectal involvement, we found only 77 cases of colonic metastases from skin melanoma; these data came from a few case reports and small case series, where declaration of patient sex, age, localization of the primary tumour and metastatic colonic segment, and description of the metastatic lesions as solitary or multiple was omitted in 60–90% of cases, thus hampering the correct analysis of the clinicopathological features of this condition. Melanoma metastasis to the transverse colon was documented only in two cases: both patients were elderly men (75 and 85 years), experiencing changes in bowel habits or marked weight loss, and presenting multiple extraperitoneal metastatic foci at diagnosis, although
454
Clinical and Experimental Dermatology (2015) 40, pp441–456
there was no identification of the primary tumour.2,3 Our patient shared the same characteristics, except for the known site of the primary melanoma and the development of vitiligo-like depigmentation. The occurrence of this leucoderma in patients with melanoma was reported for the first time in 1967 by Goldman and colleagues. Since then, this association has been described in 2.8% of patients with melanoma (affected by primary skin or uveal melanoma, or as an early sign of metastatic melanoma) and a higher incidence of up to 23–43% has been registered in patients with metastais following immunotherapeutic strategies.4 The significance of vitiligo development in patients with melanoma remains controversial; however, mounting evidence supports an improved prognosis in the advanced stages (for which it is considered an independent prognostic factor) and after immunotherapy.4,5 To our knowledge, this is the first case in which vitiligo portended a colonic metastasis of a previously resected skin melanoma. In addition, the long disease-free survival recorded before relapse (16 years) suggests that extensive follow-up of patients with melanoma is needed. E. Virgilio, R. Sandomenico, P. Fransvea and G. Balducci Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology Sapienza, St. Andrea Hospital, via di Grottarossa 1035-39, Rome 00189, Italy E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 4 June 2014
ª 2014 British Association of Dermatologists
Correspondence
Erythema multiforme-like drug reaction with eosinophilia and systemic symptoms (DRESS)
References 1 Wang JR, Yu KJ, Juan WH et al. Metastatic malignant melanoma associated with vitiligo-like depigmentation. Clin Exp Dermatol 2009; 34: 209–11. 2 Ozuner G. Colonoscopic detection of a malignant melanoma metastatic to a tubular adenoma of the colon. Dis Colon Rectum 2002; 45: 1681–4. 3 Tak AM. Metastatic melanoma: a case of unknown site of primary origin. IJGE 2006; 4: 987. 4 Quaglino P, Marenco F, Osella-Abate S et al. Vitiligo is an indipendent favourable prognostic factor in stage III and IV metastatic melanoma patients: results from a singleinstitution hospital-based observational cohort study. Ann Oncol 2010; 21: 409–14. 5 Gogas H, Ioannovich J, Dafni U et al. Prognostic significance of autoimmunity during treatment of melanoma with interferon. N Engl J Med 2006; 354: 709–18.
doi: 10.1111/ced.12541 Drug reaction with eosinophilia and systemic symptoms (DRESS) is recognized as a distinct disease entity of delayed-onset severe drug eruptions.1 Although diagnostic criteria have been established,2 they do not include details of skin manifestations. We describe a case of DRESS showing erythema multiforme (EM)-like eruptions. A 38-year-old woman with schizophrenia was admitted to our hospital with a 1-week history of worsening fever, malaise and itchy eruptions. Physical examination revealed scattered target-like lesions on the patient’s body (Fig. 1a), and cervical lymph-node swelling. No mucous membrane lesions were identified.
(a)
(b)
(c)
(d)
Figure 1 (a) Erythema multiforme (EM)-like erythema scattered on the trunk. The skin biopsy site can be seen in the lower right corner
(marked eruption). (b) Perivascular infiltration in the upper dermis, with no signs of pidermal necrosis/apoptosis and (c) marked perivascular eosinophil infiltration (arrowhead). Haematoxylin and eosin, original magnification (b) 9 40; (c) 9 200. (d) Alopecia areata on the top of the head during the disease course.
ª 2014 British Association of Dermatologists
Clinical and Experimental Dermatology (2015) 40, pp441–456
455
