Correspondence 663
change with no evidence of malignancy. Following an unsuccessful trial of topical antibiotic therapy, the entire lesion was removed by curettage. Histology demonstrated mixed suppurative and granulomatous inflammation with no neoplasia. The ulcer completely resolved 4 weeks after stopping nicorandil. Patient 2 was a 57-year-old woman with an 8-month history of an enlarging ulcer on the left columella/nasal septum. The lesion had been bleeding and repeatedly crusting, which led the general practitioner to consider a diagnosis of basal cell carcinoma, despite the fact that it was intensely painful. Examination of the left side of the columella revealed a 20 9 10-mm well-defined ulcer with a raised pearlescent edge extending onto the nasal septum (Fig. 2). A biopsy demonstrated inflammation and the deposition of fibrin, but no malignant change. Further inquiry revealed that she had been taking nicorandil for 2 years, with no recent change in her dosage (20 mg twice daily). Nicorandil was stopped, and within 4 weeks there was a significant improvement in the pain and a reduction in the size of the ulcer. The ulceration was improved by at least 50% at the 3-month follow-up. Nicorandil-induced ulceration has been reported in patients aged 58–89 years, with both sexes equally affected. Ulceration begins between 2 weeks and 4 years after the initiation of therapy, often following an increase in dose. Characteristically, ulcers are painful, localized, extend into deeper tissues and have little granulation tissue at the base. Histological examination reveals the deposition of fibrin and a mixed inflammatory cell infiltrate, with one report of diffuse elastophagocytosis.8 After the discontinuation of medication, there is often significant improvement in pain and size after
Fig 1. A 15-mm discoid, punched-out ulcer with a purulent base and an erythematous rim in an 88-year-old man with a 3-week history of a painful ulcer on his left temple and who had been receiving nicorandil 20 mg twice daily for the previous 2 years.
4 weeks, with complete resolution at 3–6 months. Theories of pathogenesis include direct metabolite toxicity in secretions, vascular steal phenomenon, the accumulation of endogenous nicotinic acid and the interference of neutrophil migration in wound healing. Nasal mucosal and cutaneous scalp ulceration due to nicorandil has not been reported previously. This phenomenon is an important feature to be aware of, as, potentially, it could help in avoiding unnecessary surgical procedures for suspected cutaneous malignancy. Department of Dermatology, Heart of England NHS Trust, Solihull Hospital Lode Lane, Solihull B92 2JL, U.K. E-mail: [email protected]
A. SHARMA S. ORPIN J. GOULDING M. KAUR
References 1 Cooke NS, Tolland JP, Dolan OM. Nicorandil-associated perianal ulceration: a case series of 10 patients. Br J Dermatol 2006; 154:199–200. 2 Toquero L, Briggs CD, Bassuini MM, Rochester JR. Anal ulceration associated with nicorandil: case series and review of the literature. Colorectal Dis 2006; 8:717–20. 3 Ogden S, Mukasa Y, Lyon CC, Coulson IH. Nicorandil-induced peristomal ulcers: is nicorandil also associated with gastrointestinal fistula formation? Br J Dermatol 2007; 156:608–9. 4 Jang H-S, Jo J-H, Kim B-S et al. A case of severe tongue ulceration and laryngeal inflammation induced by low-dose nicorandil therapy. Br J Dermatol 2004; 151:927–52. 5 Claeys A, Weber-Muller F, Trechot P et al. Cutaneous, perivulvar and perianal ulcerations induced by nicorandil. Br J Dermatol 2006; 155:477–500. 6 McKenna DJ, Donnelly J, Armstrong DKB. Nicorandil-induced leg ulceration. Br J Dermatol 2007; 156:394–6. 7 Kamath S, Taylor M, Bhagwandas K. An unusual case of nicorandil-induced conjunctival erosions. Clin Exp Dermatol 2012; 37:681– 2. 8 Wong T, Swain F, Calonge E. Nicorandil-associated perianal ulceration with prominent elasophagocytosis and flexural ulceration. Br J Dermatol 2005; 152:1360–1. Funding sources: none. Conflicts of interest: none declared.
Paronychia-like digital cutaneous metastasis DOI: 10.1111/bjd.13025
Fig 2. A 20 9 10-mm well-defined ulcer with a raised pearlescent edge extending onto the nasal septum in a 57-year-old woman with an 8-month history of an enlarging ulcer on the left columella/nasal septum and who had been taking nicorandil 20 mg twice daily for 2 years. © 2014 British Association of Dermatologists
DEAR EDITOR, Digital metastasis is a rare manifestation that typically signifies a high tumour burden and has a grim prognosis. Metastasis to the hand is considered rare, and has been reported to constitute 01% of all metastatic sites in the body. The most common presentation is a nodular osteolytic lesion.1 Pure digital cutaneous metastasis is extremely rare. We report British Journal of Dermatology (2014) 171, pp657–678
664 Correspondence
herein a case of rare manifestation of cutaneous metastasis without bony involvement and with a primary rectal adenocarcinoma origin, which presented as a paronychia-like digital lesion. The patient was an 80-year-old man with a 4-year history of rectal adenocarcinoma. He had received neoadjuvant concurrent chemoradiotherapy with seven courses of oxaliplatin, folinic acid and fluorouracil (FOLFOX4), and radiotherapy at a dose of 5000 cGy in 25 fractions followed by radical proctectomy with coloanal anastomosis. Concurrent lung and liver metastases were observed preoperatively, and the patient had received adjuvant chemotherapy with 12 courses of FOLFOX4 in addition to image-guided radiotherapy. Despite aggressive chemoradiotherapy, the disease progressed. After discussing treatment options with the oncologist, the patient decided to receive palliative therapy. The patient consulted a dermatologist because he had experienced mildly tender swelling in his right thumb for 2 weeks. Physical examination revealed a localized, bluish swelling around the lateral nail fold of his right thumb, with a crust over the edge of the nail, mimicking paronychia (Fig. 1). No history of trauma was discovered throughout the course of the examination. In addition, tenderness was disproportionately mild. The administration of lidocaine and fine-needle aspiration failed to indicate the presence of any blood or pus. Disproportionately mild tenderness, a lack of trauma history and a slow, gradual onset rendered the diagnosis of paronychia or haematoma questionable. An incisional biopsy was performed in order to verify suspected cutaneous metastasis. A myxoid dermal tumour was identified intraoperatively. Pathological examination revealed an adenocarcinoma composed of tumour cells with pseudostratified, hyperchromatic and elongated nuclei arranged in a complex glandular pattern accompanied by necrosis infiltrating the dermis (Fig. 2). Plain film revealed soft tissue swelling without bony destruction. By consulting the clinical history and morphological findings, the patient was diagnosed as having cutaneous digital metastasis with a primary rectal adenocarcinoma origin. Palliative radiotherapy was administered for local disease control, which yielded a partial response. However, the patient died as a result of pulmonary metastatic disease progression 2 months after the diagnosis of digital cutaneous metastasis. Cases of cutaneous metastasis with a primary rectal adenocarcinoma origin are uncommon, and have been reported in < 4% of such patients on whom autopsies have been performed.2 The presence of cutaneous metastasis typically signifies a high tumour burden with poor prognosis. The most frequent clinical presentation of skin metastasis is nodular lesions, which may alert clinicians to the possibility of distal metastasis, although atypical presentations, including inflammatory, cicatricial and bullous lesions, have also been reported.3 Metastasis to the hand is considered rare, and has been reported to constitute 01% of all metastatic sites in the body.1 Its rarity and variable clinical appearance and morphologies often result in delayed or even failed diagnoses. British Journal of Dermatology (2014) 171, pp657–678
Fig 1. Localized bluish swelling around the lateral nail fold with a crust over the edge of the nail, mimicking paronychia.
Fig 2. Histological examination revealed a metastatic adenocarcinoma in the dermis (haematoxylin and eosin, magnification 100 X).
Acrometastasis to the hands reflects the pathology of skeletal tissue, soft tissue and the integumentary system. It can be primarily divided into osseous and cutaneous metastasis. Osseous metastasis constitutes the majority of cases of hand metastasis, which frequently presents with nodular masses or erythematous swollen digits. Therefore, the application of plain film is diagnostically crucial because osteolytic lesions are generally observable.1,4,5 Typically, survival after cutaneous metastasis diagnosis is grim, and treatments emphasize palliative care. The goals of local treatments are pain relief and local disease control. The treatment options are local excision and palliative radiotherapy as needed. The unusual presentation of this case, which masqueraded as paronychia, was a great diagnostic challenge. Conducting © 2014 British Association of Dermatologists
Correspondence 665
meticulous physical examinations and taking a detailed history were essential in considering metastatic disease, which was confirmed by performing a histological examination. We have described an uncommon case of digital cutaneous metastasis, which could easily have been overlooked. We emphasize the importance of maintaining a high index of suspicion of neoplastic processes for lesions associated with cases of atypical clinical histories or morphologies. 1
Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan 2 Department of Radiation Oncology, Wang Fan Hospital, Taipei, Taiwan 3 Department of Radiation Oncology, and 4 Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan Correspondence: K.-H. Wang. E-mail: [email protected]
J.-H. KO1 A. YOUNG2,3 K.-H. WANG1,4
References 1 Sur YJ, Kang YK, Bahk WJ et al. Metastatic malignant tumour in the hand. J Plast Surg Hand Surg 2011; 45:90–5. 2 Gottlieb JA, Schermer DR. Cutaneous metastases from carcinoma of the colon. JAMA 1970; 213:2083. 3 Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients. J Am Acad Dermatol 1993; 29:228–36. 4 Wu CY, Gao HW, Huang WH, Chao CM. Infection-like acral cutaneous metastasis as the presenting sign of an occult breast cancer. Clin Exp Dermatol 2009; 34:e409–10. Reduce sugar intake •
Avoid refined sugar
•
Stop soft drinks and fruit juice
•
Limit sweet cakes, biscuits and lollies
5 Flynn CJ, Danjoux C, Wong J et al. Two cases of acrometastasis to the hands and review of the literature. Curr Oncol 2008; 15:51–8. Funding sources: none. Conflicts of interest: none declared.
Hypertriglyceridaemia with acitretin use: a proposal for its management in the context of overall cardiovascular risk DOI: 10.1111/bjd.13027 DEAR EDITOR, Acitretin is an established treatment for psoriasis, other disorders of keratinization and chemoprevention of skin cancers. Hypertriglyceridaemia, as defined by a fasting triglyceride level of ≥ 17 mmol L 1, is a common adverse effect of acitretin use and is associated with an increased risk of cardiovascular disease.1,2 Limited evidence exists to guide the management of acitretin-induced hypertriglyceridaemia. The British Association of Dermatologists’ guidelines recommend dietary measures for persistently elevated levels, consideration of lipid-modifying drugs if dietary measures are inadequate and referral to a lipidologist when the triglyceride level is > 5 mmol L 1.3 We undertook a retrospective study of all 82 patients in our department who were on acitretin between 2008 and 2011. Twenty-two patients were excluded (six failed to have blood tests and 16 had stopped acitretin prior to their first follow-up
Weight loss (if appropriate) •
and sugars •
Reduce total fat intake •
Replace saturated (animal) fats with monounsaturated or polyunsaturated fats
Reduce energy intake by restricting fat
Increase energy output by undertaking regular physical activity
Avoidance/moderate alcohol intake •
0–2 standard drinks (women)/0–3
in cooking and spreading
standard drinks (men) per day, with two
•
Use spreading fats sparingly
alcohol free days/week
•
Use low fat dairy products, e.g. trim milk,
•
≥ 5·7 mmol L–1
reduced fat yoghurt, cottage cheese •
Aim for 100–150 g of lean meat daily, e.g. chicken, fish and lean red meat
•
Trim all fat from meat
•
Practise low-fat cooking methods, e.g.
Avoid all alcohol if triglyceride
Highly soluble fibre food •
Fruit and vegetables
Physical activity •
Maintain regular physical activity
•
Increase level of physical exercise (if
bake, grill, microwave, boil and steam instead of frying or roasting appropriate)
Fig 1. Suggested lifestyle and dietary modifications to lower triglyceride levels. © 2014 British Association of Dermatologists
British Journal of Dermatology (2014) 171, pp657–678
change with no evidence of malignancy. Following an unsuccessful trial of topical antibiotic therapy, the entire lesion was removed by curettage. Histology demonstrated mixed suppurative and granulomatous inflammation with no neoplasia. The ulcer completely resolved 4 weeks after stopping nicorandil. Patient 2 was a 57-year-old woman with an 8-month history of an enlarging ulcer on the left columella/nasal septum. The lesion had been bleeding and repeatedly crusting, which led the general practitioner to consider a diagnosis of basal cell carcinoma, despite the fact that it was intensely painful. Examination of the left side of the columella revealed a 20 9 10-mm well-defined ulcer with a raised pearlescent edge extending onto the nasal septum (Fig. 2). A biopsy demonstrated inflammation and the deposition of fibrin, but no malignant change. Further inquiry revealed that she had been taking nicorandil for 2 years, with no recent change in her dosage (20 mg twice daily). Nicorandil was stopped, and within 4 weeks there was a significant improvement in the pain and a reduction in the size of the ulcer. The ulceration was improved by at least 50% at the 3-month follow-up. Nicorandil-induced ulceration has been reported in patients aged 58–89 years, with both sexes equally affected. Ulceration begins between 2 weeks and 4 years after the initiation of therapy, often following an increase in dose. Characteristically, ulcers are painful, localized, extend into deeper tissues and have little granulation tissue at the base. Histological examination reveals the deposition of fibrin and a mixed inflammatory cell infiltrate, with one report of diffuse elastophagocytosis.8 After the discontinuation of medication, there is often significant improvement in pain and size after
Fig 1. A 15-mm discoid, punched-out ulcer with a purulent base and an erythematous rim in an 88-year-old man with a 3-week history of a painful ulcer on his left temple and who had been receiving nicorandil 20 mg twice daily for the previous 2 years.
4 weeks, with complete resolution at 3–6 months. Theories of pathogenesis include direct metabolite toxicity in secretions, vascular steal phenomenon, the accumulation of endogenous nicotinic acid and the interference of neutrophil migration in wound healing. Nasal mucosal and cutaneous scalp ulceration due to nicorandil has not been reported previously. This phenomenon is an important feature to be aware of, as, potentially, it could help in avoiding unnecessary surgical procedures for suspected cutaneous malignancy. Department of Dermatology, Heart of England NHS Trust, Solihull Hospital Lode Lane, Solihull B92 2JL, U.K. E-mail: [email protected]
A. SHARMA S. ORPIN J. GOULDING M. KAUR
References 1 Cooke NS, Tolland JP, Dolan OM. Nicorandil-associated perianal ulceration: a case series of 10 patients. Br J Dermatol 2006; 154:199–200. 2 Toquero L, Briggs CD, Bassuini MM, Rochester JR. Anal ulceration associated with nicorandil: case series and review of the literature. Colorectal Dis 2006; 8:717–20. 3 Ogden S, Mukasa Y, Lyon CC, Coulson IH. Nicorandil-induced peristomal ulcers: is nicorandil also associated with gastrointestinal fistula formation? Br J Dermatol 2007; 156:608–9. 4 Jang H-S, Jo J-H, Kim B-S et al. A case of severe tongue ulceration and laryngeal inflammation induced by low-dose nicorandil therapy. Br J Dermatol 2004; 151:927–52. 5 Claeys A, Weber-Muller F, Trechot P et al. Cutaneous, perivulvar and perianal ulcerations induced by nicorandil. Br J Dermatol 2006; 155:477–500. 6 McKenna DJ, Donnelly J, Armstrong DKB. Nicorandil-induced leg ulceration. Br J Dermatol 2007; 156:394–6. 7 Kamath S, Taylor M, Bhagwandas K. An unusual case of nicorandil-induced conjunctival erosions. Clin Exp Dermatol 2012; 37:681– 2. 8 Wong T, Swain F, Calonge E. Nicorandil-associated perianal ulceration with prominent elasophagocytosis and flexural ulceration. Br J Dermatol 2005; 152:1360–1. Funding sources: none. Conflicts of interest: none declared.
Paronychia-like digital cutaneous metastasis DOI: 10.1111/bjd.13025
Fig 2. A 20 9 10-mm well-defined ulcer with a raised pearlescent edge extending onto the nasal septum in a 57-year-old woman with an 8-month history of an enlarging ulcer on the left columella/nasal septum and who had been taking nicorandil 20 mg twice daily for 2 years. © 2014 British Association of Dermatologists
DEAR EDITOR, Digital metastasis is a rare manifestation that typically signifies a high tumour burden and has a grim prognosis. Metastasis to the hand is considered rare, and has been reported to constitute 01% of all metastatic sites in the body. The most common presentation is a nodular osteolytic lesion.1 Pure digital cutaneous metastasis is extremely rare. We report British Journal of Dermatology (2014) 171, pp657–678
664 Correspondence
herein a case of rare manifestation of cutaneous metastasis without bony involvement and with a primary rectal adenocarcinoma origin, which presented as a paronychia-like digital lesion. The patient was an 80-year-old man with a 4-year history of rectal adenocarcinoma. He had received neoadjuvant concurrent chemoradiotherapy with seven courses of oxaliplatin, folinic acid and fluorouracil (FOLFOX4), and radiotherapy at a dose of 5000 cGy in 25 fractions followed by radical proctectomy with coloanal anastomosis. Concurrent lung and liver metastases were observed preoperatively, and the patient had received adjuvant chemotherapy with 12 courses of FOLFOX4 in addition to image-guided radiotherapy. Despite aggressive chemoradiotherapy, the disease progressed. After discussing treatment options with the oncologist, the patient decided to receive palliative therapy. The patient consulted a dermatologist because he had experienced mildly tender swelling in his right thumb for 2 weeks. Physical examination revealed a localized, bluish swelling around the lateral nail fold of his right thumb, with a crust over the edge of the nail, mimicking paronychia (Fig. 1). No history of trauma was discovered throughout the course of the examination. In addition, tenderness was disproportionately mild. The administration of lidocaine and fine-needle aspiration failed to indicate the presence of any blood or pus. Disproportionately mild tenderness, a lack of trauma history and a slow, gradual onset rendered the diagnosis of paronychia or haematoma questionable. An incisional biopsy was performed in order to verify suspected cutaneous metastasis. A myxoid dermal tumour was identified intraoperatively. Pathological examination revealed an adenocarcinoma composed of tumour cells with pseudostratified, hyperchromatic and elongated nuclei arranged in a complex glandular pattern accompanied by necrosis infiltrating the dermis (Fig. 2). Plain film revealed soft tissue swelling without bony destruction. By consulting the clinical history and morphological findings, the patient was diagnosed as having cutaneous digital metastasis with a primary rectal adenocarcinoma origin. Palliative radiotherapy was administered for local disease control, which yielded a partial response. However, the patient died as a result of pulmonary metastatic disease progression 2 months after the diagnosis of digital cutaneous metastasis. Cases of cutaneous metastasis with a primary rectal adenocarcinoma origin are uncommon, and have been reported in < 4% of such patients on whom autopsies have been performed.2 The presence of cutaneous metastasis typically signifies a high tumour burden with poor prognosis. The most frequent clinical presentation of skin metastasis is nodular lesions, which may alert clinicians to the possibility of distal metastasis, although atypical presentations, including inflammatory, cicatricial and bullous lesions, have also been reported.3 Metastasis to the hand is considered rare, and has been reported to constitute 01% of all metastatic sites in the body.1 Its rarity and variable clinical appearance and morphologies often result in delayed or even failed diagnoses. British Journal of Dermatology (2014) 171, pp657–678
Fig 1. Localized bluish swelling around the lateral nail fold with a crust over the edge of the nail, mimicking paronychia.
Fig 2. Histological examination revealed a metastatic adenocarcinoma in the dermis (haematoxylin and eosin, magnification 100 X).
Acrometastasis to the hands reflects the pathology of skeletal tissue, soft tissue and the integumentary system. It can be primarily divided into osseous and cutaneous metastasis. Osseous metastasis constitutes the majority of cases of hand metastasis, which frequently presents with nodular masses or erythematous swollen digits. Therefore, the application of plain film is diagnostically crucial because osteolytic lesions are generally observable.1,4,5 Typically, survival after cutaneous metastasis diagnosis is grim, and treatments emphasize palliative care. The goals of local treatments are pain relief and local disease control. The treatment options are local excision and palliative radiotherapy as needed. The unusual presentation of this case, which masqueraded as paronychia, was a great diagnostic challenge. Conducting © 2014 British Association of Dermatologists
Correspondence 665
meticulous physical examinations and taking a detailed history were essential in considering metastatic disease, which was confirmed by performing a histological examination. We have described an uncommon case of digital cutaneous metastasis, which could easily have been overlooked. We emphasize the importance of maintaining a high index of suspicion of neoplastic processes for lesions associated with cases of atypical clinical histories or morphologies. 1
Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan 2 Department of Radiation Oncology, Wang Fan Hospital, Taipei, Taiwan 3 Department of Radiation Oncology, and 4 Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan Correspondence: K.-H. Wang. E-mail: [email protected]
J.-H. KO1 A. YOUNG2,3 K.-H. WANG1,4
References 1 Sur YJ, Kang YK, Bahk WJ et al. Metastatic malignant tumour in the hand. J Plast Surg Hand Surg 2011; 45:90–5. 2 Gottlieb JA, Schermer DR. Cutaneous metastases from carcinoma of the colon. JAMA 1970; 213:2083. 3 Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients. J Am Acad Dermatol 1993; 29:228–36. 4 Wu CY, Gao HW, Huang WH, Chao CM. Infection-like acral cutaneous metastasis as the presenting sign of an occult breast cancer. Clin Exp Dermatol 2009; 34:e409–10. Reduce sugar intake •
Avoid refined sugar
•
Stop soft drinks and fruit juice
•
Limit sweet cakes, biscuits and lollies
5 Flynn CJ, Danjoux C, Wong J et al. Two cases of acrometastasis to the hands and review of the literature. Curr Oncol 2008; 15:51–8. Funding sources: none. Conflicts of interest: none declared.
Hypertriglyceridaemia with acitretin use: a proposal for its management in the context of overall cardiovascular risk DOI: 10.1111/bjd.13027 DEAR EDITOR, Acitretin is an established treatment for psoriasis, other disorders of keratinization and chemoprevention of skin cancers. Hypertriglyceridaemia, as defined by a fasting triglyceride level of ≥ 17 mmol L 1, is a common adverse effect of acitretin use and is associated with an increased risk of cardiovascular disease.1,2 Limited evidence exists to guide the management of acitretin-induced hypertriglyceridaemia. The British Association of Dermatologists’ guidelines recommend dietary measures for persistently elevated levels, consideration of lipid-modifying drugs if dietary measures are inadequate and referral to a lipidologist when the triglyceride level is > 5 mmol L 1.3 We undertook a retrospective study of all 82 patients in our department who were on acitretin between 2008 and 2011. Twenty-two patients were excluded (six failed to have blood tests and 16 had stopped acitretin prior to their first follow-up
Weight loss (if appropriate) •
and sugars •
Reduce total fat intake •
Replace saturated (animal) fats with monounsaturated or polyunsaturated fats
Reduce energy intake by restricting fat
Increase energy output by undertaking regular physical activity
Avoidance/moderate alcohol intake •
0–2 standard drinks (women)/0–3
in cooking and spreading
standard drinks (men) per day, with two
•
Use spreading fats sparingly
alcohol free days/week
•
Use low fat dairy products, e.g. trim milk,
•
≥ 5·7 mmol L–1
reduced fat yoghurt, cottage cheese •
Aim for 100–150 g of lean meat daily, e.g. chicken, fish and lean red meat
•
Trim all fat from meat
•
Practise low-fat cooking methods, e.g.
Avoid all alcohol if triglyceride
Highly soluble fibre food •
Fruit and vegetables
Physical activity •
Maintain regular physical activity
•
Increase level of physical exercise (if
bake, grill, microwave, boil and steam instead of frying or roasting appropriate)
Fig 1. Suggested lifestyle and dietary modifications to lower triglyceride levels. © 2014 British Association of Dermatologists
British Journal of Dermatology (2014) 171, pp657–678
