There Have Been Several Recent Reports of the Apparently Successful

CORRESPONDENCE

1. Bohm M, Frieling U, Luger TA, Bonsmann G. Successful treatment of anogenital lichen sclerosus with topical tacrolimus. Arch Dermatol. 2003;139: COMMENTS AND OPINIONS 922-924. 2. Kunstfeld R, Kirnbauer R, Stingl G, Karlhofer FM. Successful treatment of vulvar lichen sclerosus with topical tacrolimus. Arch Dermatol. 2003;139:850- 852. Topical Tacrolimus, Genital Lichen 3. Assmann T, Becker-Wegerich P, Grewe M, Megahed M, Ruzicka T. Tacroli- mus ointment for the treatment of vulvar lichen sclerosus. J Am Acad Derma- Sclerosus, and Risk of Squamous tol. 2003;48:935-937. Cell Carcinoma 4. Pandher BS, Rustin MH, Kaisary AV. Treatment of balanitis xerotica obliter- ans with topical tacrolimus. J Urol. 2003;170:923. 5. Neill SM, Ridley CM. Management of anogenital lichen sclerosus. Clin Exp Dermatol. 2001;26:637-643. here have been several recent reports of the 6. Bunker CB. Topics in penile dermatology. Clin Exp Dermatol. 2001;26:469- apparently successful use of topical tacrolimus 479. 7. Neill SM, Tatnall FM, Cox NH; British Association of Dermatologists. Guide- in the treatment of genital lichen sclerosus lines for the management of lichen sclerosus. Br J Dermatol. 2002;147:640- T1-4 (LSc), 2 of which have appeared in the Archives of 649. Dermatology.1,2 Genital squamous cell carcinoma is an established risk in the context of a chronic inflammatory scarring der- Clonal Seborrheic Keratosis: 5,6 matosis such as LSc. All too frequently in situ and in- A Dermoscopic Pitfall vasive carcinoma is unsuspected, misdiagnosed, or di- agnosed late, with dire consequences. Several factors e congratulate Hirata and coworkers1 for their contribute to this, including a low index of suspicion and report on the dermoscopic features of 2 cases a failure to recognize significant signs, often less florid of clonal seborrheic keratosis. We would like than the features of the precursor dermatosis such as LSc, W to add some comments based on our observation of a pig- that are indicative of neoplastic change. mented clonal seborrheic keratosis on the leg of a 72- It is therefore disconcerting that not one of the ar- year-old woman. ticles advocating the use of topical tacrolimus in LSc con- As in Hirata et al’s cases, dermoscopic examination siders the possibility that this topical immunosuppres- revealed large areas of a bluish pigmentation composed sant might create an increased risk of squamous cell of multiple, variously sized and irregularly distributed, carcinoma: This theoretical concern already exists for the blue-gray roundish structures, also aggregated to form use of topical ultrapotent steroids in genital LSc al- short lines (Figure 1). In our case, the blue-gray struc- though it does not seem to have been borne out in prac- tures were similar to the so-called blue-gray ovoid nests, tice, as topical clobetasol proprionate has been used in which are a dermoscopic hallmark of pigmented basal our clinics since 1986 without a rise in the incidence of cell carcinoma.2,3 The clinical features and the addi- squamous cell carcinoma in genital LSc. However, the tional dermoscopic observation of comedolike open- risk needs to be considered very carefully for a newer agent that has not stood the test of time and that may be used on skin or mucosae that have already been extensively treated with topical steroid. We urge that a topical ultrapotent steroid, which is very effective in the majority of cases of genital LSc, should remain the first line of medical treatment (alongside possible surgical intervention, eg, circumci- sion, in the male)6,7 and that topical tacrolimus should be used with caution.

C. B. Bunker, MD, FRCP S. Neill, MB, FRCP R. C. D. Staughton, MB, FRCP

The authors have no relevant financial interest in this Figure 1. Pigmented clonal seborrheic keratosis. Dermoscopically, multiple, letter. variously sized and irregularly distributed, blue-gray roundish structures Correspondence: Dr Bunker, Department of Derma- (square), also aggregated to form short lines, are seen along with multiple tology, Chelsea & Westminster Hospital, 369 Fulham Rd, brown to black comedolike openings. Jelly sign (left border of the lesion) and few milialike cysts (circle) are also present. The central brown to black London SW10 9NH, England ([email protected] area corresponds to erosion covered by a scale crust (inset, clinical view; .co.uk). original magnification ϫ10).

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©2004 American Medical Association. All rights reserved. Downloaded From: http://archderm.jamanetwork.com/ by a UQ Library User on 11/12/2015 lesions: results of a consensus meeting via the Internet. J Am Acad Dermatol. 2003;48:679-693. 4. Braun RP, Rabinovitz HS, Kriescher J, et al. Dermoscopy of pigmented seborrheic keratosis: a morphological study. Arch Dermatol. 2002;138:1556-1560.

VIGNETTES

Leukemia Cutis Presenting as a Sister Mary Joseph Nodule

he term Sister Mary Joseph (SMJ) nodule refers to a rare metastatic malignant neoplasm of the T periumbilical region. The eponym, which first appeared in Sir Hamilton Bailey’s book on physical signs, honors Dr William Mayo’s first assistant, Sister Mary Jo- Figure 2. Histopathologic features of clonal seborrheic keratosis: note the large, heavily pigmented nest of basaloid cells within the hyperplastic seph, who observed that patients with advanced abdomi- epidermis (circle). Some smaller, nonpigmented intraepidermal nests are nal cancer often had umbilical nodules. Metastatic tu- discernible as well (hematoxylin-eosin, original magnification ϫ100). mors of the umbilicus are usually adenocarcinomas of gastrointestinal origin.1 ings, few milialike cysts, and the jelly sign were all in fa- Acute promyelocytic leukemia (APL), which is a dis- vor of the diagnosis of seborrheic keratosis.3,4 However, tinct form of acute myelogenous leukemia, is character- the presence of blue-gray ovoid nests raised the need for ized by an abundant number of abnormal progranulo- a histopathologic examination, which revealed a clonal cytes and a distinct chromosomal abnormality and is often seborrheic keratosis. As reported by Hirata et al, the blue- associated with a severe coagulopathy. Skin lesions in APL gray ovoid nests corresponded histopathologically to mul- are rarer than in other forms of leukemia.2,3 Herein, we tiple nests of pigmented basaloid cells within the epider- present the first description of a patient with leukemia mis (Figure 2). cutis that presented as an SMJ nodule. We agree with Hirata et al that, in their first case, the presence of irregular globulelike structures together Report of a Case. A 53-year-old African American man with the absence of any dermoscopic features of sebor- with a history of APL, which was in remission, pre- rheic keratosis are in favor of the diagnosis of mela- sented to his primary care physician with a 1-month his- noma. However, in their second case, the differential di- tory of a pruritic and malodorous umbilical lesion. The agnosis of pigmented basal cell carcinoma should be also lesion was resistant to antifungal, antibacterial, and anti- considered for the presence of aggregated blue-gray struc- inflammatory therapies. A new 3- to 4-mm translucent tures resembling large blue-gray ovoid nests and leaf- papule with telangiectasias was observed over the fol- like areas. Therefore, we would suggest including pig- lowing 4 weeks (Figure 1). A biopsy specimen from the mented basal cell carcinoma in the dermoscopic differential diagnosis of clonal seborrheic keratosis. In agreement with Hirata et al, we conclude that dermoscopy does not reach 100% diagnostic accuracy and clonal seborrheic keratosis may represent a dermoscopic pitfall, being difficult to differentiate from mela- noma and basal cell carcinoma. Histopathologic examination should always be performed in cases in which dermoscopy reveals confounding features that do not al- low an accurate diagnosis.

Iris Zalaudek, MD Gerardo Ferrara, MD Giuseppe Argenziano, MD

The authors have no relevant financial interest in this letter. Correspondence: Dr Argenziano, Department of Der- matology, Second University of Naples, Via S Pansini 5, I-80131 Naples, Italy ([email protected]).

1. Hirata SH, Almeida FA, Tomimori-Yamashita J, et al. “Globulelike” dermoscopic structures in pigmented seborrheic keratosis. Arch Dermatol. 2004; 140:128-129. 2. Menzies SW, Westerhoff K, Rabinovitz HS, et al. Surface microscopy of pigmented basal cell carcinoma. Arch Dermatol. 2000;136:1012-1016. Figure 1. Umbilicus showing a 3- to 4-mm translucent papule (arrow) 3. Argenziano G, Soyer HP, Chimenti S, et al. Dermoscopy of pigmented skin surrounded by a diffuse yellow crust.

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