JAM ACAD DERMATOL Letters 163 VOLUME 55, NUMBER 1

Memorial Sloan-Kettering Cancer Centerc factor; an erythrocyte sedimentation rate of 100 Dermatology Service millimeters per hour; normal complements levels; New York, New York and no anemia. A bone scan revealed increased uptake in the bilateral patellae and proximal tibias The authors have no conflicts of interest to disclose. likely caused by degenerative changes and, less Correspondence to: likely, by osteomyelitis. There were multiple foci of Ralph P. Braun, MD increased uptake in the right costal cartilage. There Department of Dermatology was increased uptake in both patellas and proximal University Hospital Geneva tibias because of degenerative changes or osteomy- 24, rue Micheli-du-Crest elitis. There was an increased uptake in the mid- CH-1211 Geneva 14, Switzerland thoracic spine and sternum. Diagnoses entertained for this patient included E-mail: [email protected] the SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis [or osteomyelitis]) syndrome or the REFERENCES follicular occlusion triad with associated arthritise 1. Miyazaki A, Saida T, Koga H, Oguchi S, Suzuki T, Tsuchida T. Anatomical and histopathological correlates of the dermo- disease entities likely on a continuum rather than scopic patterns seen in melanocytic nevi on the sole: wholly distinct. The later seemed more likely be- a retrospective study. J Am Acad Dermatol 2005;53:230-6. cause hidradenitis was his most significant and 2. Braun RP, Krischer J, Saurat JH. The ‘‘wobble sign’’ in epilumi- protracted cutaneous symptom and his radiographic nescence microscopy as a novel clue to the differential diag- finding did not clearly show osteomyelitis. The nosis of pigmented skin lesions. Arch Dermatol 2000;136:940-2. 3. Saida T, Oguchi S, Miyazaki A. Dermoscopic findings in pig- former diagnosis, however, could not be ruled out. mented lesions on glabrous skin. In: Malvehy J, Puig S, editors. The patient stopped taking methotrexate, plaque- Principles of Dermoscopy. 1st ed. 2002. pp. 243-56. nil, and isotretinoin and began taking adalimumab 4. Marghoob AA, Braun RP, Kopf AW. Atlas Of Dermoscopy. 40 mg every other week, and after 2 months noted London & New York: Taylor And Francis Group; 2005. improved ambulation and decreased axillary floccu- lence of the axillary nodules. One month later, the doi:10.1016/j.jaad.2005.12.032 patient stated that his condition was worsening, so the adalimumab was increased to 40 mg weekly. Treatment of coincident seronegative arthritis Over the following months, pain and edema de- and hidradentis supprativa with adalimumab creased. When an insurance issue prevented adali- To the Editor: Fifteen reported cases link acne mumab use, pain and swelling returned; when conglobata with hidradenitis suppurativa (diseases adalimumab was re-administered, symptoms abated. part of the follicular occlusion triad) and arthritis, Because adalimumab, a human monoclonal tumor in which nonsteroidal anti-inflammatory drugs, sys- necrosis factor alpha (TNFa) antibody is approved temic steroids, penicillamine, methotrexate, sulpha- therapy for rheumatoid and psoriatic arthritis, adali- salazine, and infliximab have been noted effective.1 mumab’s use for the treatment of arthritis with In this case, a 41-year-old morbidly obese African etiologically consistent and coincident inflammatory American male with arthritis, hidradentitis suprativa, dermatosis has a therapeutic basis. Infliximab has and a history of cystic acne with keloid formation was been effective against combinations of hidradentitis treated with adalimumab. The patient had developed and arthritis (eg, the SAPHO syndrome2,3) and etaner- hidradentitis 15 years before presentation and arthritis cept has been used to treat hidradenitis.4 In numerous 8 years before presentation. He had a history of anectodal reports in the literature, adalimumab has nodules and ulcers on his legs clinically diagnosed as been used off-label to effectively treat a variety of pyoderma gangrenosum. He complained of frequent disorders including Crohn’s disease, sarcoidosis, se- bowel movements that did not, upon investigation, vere, recalcitrant, major aphthous stomatitis, recalci- relate to infection or inflammatory bowel disease. For trant acrodermatitis continua of Hallopeau, adult-onset the 6 months leading up to his consultation, he had Still’s disease, psoriasis, Takayasu’s arteritis, subcorneal been treated with 600 mg of hydroxychloroquine, pustular dermatosis, ulcerative colitis, ankylosing isotretinoin 40 mg trice daily (120 mg/d), and 10 mg spondylitis, orbital myositis, pyoderma gangrenosum, of methotrexate dosed every 12 hours in 3 doses and psoriatic onycho-pachydermoperiostitis.5 weekly (30 mg/wk) without effect. This report constitutes a case involving the off- Physical examination revealed flocculent axillary label use of adalibumab. In any case, adalimumab nodules and knee effusions. Laboratory examination seemed to help treat this patient’s disease and is a demonstrated a white blood cell count of 13,000/cc; therapy that could aid patients with dermatoses of a total protein of 9.9 mg/cc; a normal rheumatoid the follicular occlusion triad associated with arthritis. 164 Letters JAM ACAD DERMATOL JULY 2006

Noah Scheinfeld, MD Department of Dermatology St Lukes Roosevelt Hospital New York, New York The author has no conflicts of interest to disclose. Address correspondence to: Noah Scheinfeld, MD Department of Dermatology St Lukes Roosevelt Hospital 1090 Amsterdam Ave New York, NY 10025 E-mail: [email protected]

REFERENCES 1. Thein M, Hogarth MB, Acland K. Seronegative arthritis asso- ciated with the follicular occlusion triad. Clin Exp Dermatol 2004;29:550-2. 2. Iqbal M, Kolodney MS. Acne fulminans with synovitis-acne- pustulosis-hyperostosis-osteitis (SAPHO) syndrome treated with infliximab. J Am Acad Dermatol 2005;52(5 Suppl 1):S118-20. Fig 1. Heliotrope rash and shawl sign. 3. Gupta AK, Skinner AR. A review of the use of infliximab to manage cutaneous dermatoses. J Cutan Med Surg 2004;8:77-89. 4. Walsh N. TNF Inhibitor Puts the Brakes On Refractory Hidrad- enitis. Skin & Allergy News 2005;36:22. 5. www.pubmed.gov search term ‘‘adalimumab.’’ Accessed Novem- ber 12, 2005.

doi:10.1016/j.jaad.2006.01.024

Hypomyopathic dermatomyositis associated with lentigo maligna melanoma To the Editor: Dermatomyositis is an idiopathic inflammatory myopathy with characteristic cutane- ous findings. On average, 25% of adult patients have Fig 2. Gottron’s sign. an associated occult malignancy, most commonly ovarian, breast, lung, and gastrointestinal carcino- mas. Rare association has been made with mela- noma, particularly metastatic disease. We report a case of lentigo maligna melanoma in association with hypomyopathic dermatomyositis that spontaneously resolved after wide local excision of the tumor. An 88-year-old woman presented with scalp ery- thema, scale, and pruritus as well as a complaint of ‘‘bruising’’ below the eyes of 11 months’ duration. Review of systems did not yield any history of muscle weakness or pain or respiratory, gastrointestinal, or constitutional symptoms. Physical examination revealed diffuse scalp erythema and scale without Fig 3. Irregularly pigmented dark brown macule. alopecia as well as periorbital violaceous patches with erythematous patches on the cheeks and V area of the chest (Fig 1). There were also erythematous Additionally, on the left shoulder we noted a 0.8- 3 macules over the metacarpophalangeal, proximal 0.9-cm, irregularly bordered, dark brown macule interphalangeal, and distal interphalangeal joints (Fig 3). The duration of this lesion was unknown. and erythematous, scaly plaques on both elbows No lymphadenopathy or hepatosplenomegaly was (Fig 2). Proximal muscle strength was intact. noted.