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Stasis Dermatitis May Present As Single Lesion 22 Cutaneous Oncology S KIN & ALLERGY N EWS • December 2008 Stasis Dermatitis May Present as Single Lesion BY SHERRY BOSCHERT cases, clinical diagnoses mistook 11 cases tinic keratosis, Kaposi’s sarcoma, nevus, or solitary-lesion cases occurred in the usual San Francisco Bureau for squamous cell carcinoma and 8 cases for a neoplasm, not otherwise specified. setting for stasis dermatitis—on the low- basal cell carcinoma, Dr. Joshua Weaver and “We have revealed that there is an ear- er extremities of older adults (the cohort’s S AN F RANCISCO — It is not uncom- his associates reported in a poster presen- ly form of stasis dermatitis presenting as average age was 66 years) and in more fe- mon for stasis dermatitis to present as a tation at the annual meeting of the Amer- a solitary lesion that clinically can look like males than males. solitary lesion with no history of venous ican Society of Dermatopathology. a neoplasm,” said Dr. Weaver of the Cleve- Detailed clinical descriptions in a subset insufficiency, but it is uncommon for Physicians also believed that three cases land Clinic. “It’s important to diagnose sta- of 25 cases reported a single erythematous physicians to correctly diagnose it. were consistent with granuloma annulare, sis dermatitis early so that you can begin plaque on the lower portion of the leg as Thirty-three (7%) of 483 cases of stasis and another three were deemed consistent treatment as early as possible” to prevent the most common presentation, affecting dermatitis diagnosed from a skin biopsy be- with irritated seborrheic keratosis. Other leg ulcers and an increased risk for devel- either leg in equal frequency. The lesions tween 1992 and 2008 at the Cleveland Clin- differential diagnoses offered by physicians oping squamous cell carcinoma. averaged 1.6 cm in size. ic presented as a solitary lesion. Of these 33 were scars, pyoderma gangrenosum, ac- The retrospective study found that the Out of 21 cases that physicians de- IMPORTANT SAFETY INFORMATION Risk of Serious Infections Neurologic Events Infections, including serious infections leading to TNF inhibitors, including ENBREL, have been associated hospitalization or death, have been observed in patients with rare cases of new onset or exacerbation of CNS treated with ENBREL. Infections have included demyelinating disorders (some presenting with mental bacterial sepsis and tuberculosis. Patients should be status changes and some associated with permanent educated about the symptoms of infection and closely disability). Transverse myelitis, optic neuritis, multiple monitored for signs and symptoms of infection during sclerosis, and cases of new onset or exacerbation and after treatment with ENBREL. Patients who develop of seizure disorders have been observed in association an infection should be evaluated for appropriate with ENBREL therapy. The causal relationship to antimicrobial treatment and, in patients who develop ENBREL therapy remains unclear. Exercise caution when a serious infection, ENBREL should be discontinued. considering ENBREL for patients with these disorders. Tuberculosis (frequently disseminated or Hematologic Events extrapulmonary at clinical presentation) has been Rare cases of pancytopenia, including aplastic anemia, observed in patients receiving TNF-blocking agents, some fatal, have been reported. The causal relationship including ENBREL. Tuberculosis may be due to to ENBREL therapy is unclear. Exercise caution in patients reactivation of latent tuberculosis infection or to new who have a previous history of significant hematologic infection. Data from clinical trials and preclinical abnormalities. Advise patients to seek immediate medical studies suggest that the risk of reactivation of latent attention if they develop signs or symptoms of blood tuberculosis infection is lower with ENBREL than with dyscrasias or infection. Consider discontinuing ENBREL TNF-blocking monoclonal antibodies. Nonetheless, if significant hematologic abnormalities are confirmed. postmarketing cases of tuberculosis reactivation have been reported for TNF blockers, including ENBREL. Malignancies Patients should be evaluated for tuberculosis risk In clinical trials of all TNF inhibitors, more cases of factors and be tested for latent tuberculosis infection lymphoma were seen compared to control patients. The prior to initiating ENBREL and during treatment. risk of lymphoma may be up to several-fold higher in RA Treatment of latent tuberculosis infection should be and psoriasis patients; the role of TNF inhibitors in the initiated prior to therapy with ENBREL. Treatment of development of malignancies is unknown. In clinical trials, latent tuberculosis in patients with a reactive the incidence of malignancies other than lymphoma has tuberculin test reduces the risk of tuberculosis not increased with exposure to ENBREL and is similar reactivation in patients receiving TNF blockers. Some to what would be expected in the general population. patients who tested negative for latent tuberculosis Hepatitis B Reactivation prior to receiving ENBREL have developed active TNF inhibitors, including ENBREL, have been associated tuberculosis. Physicians should monitor patients with reactivation of hepatitis B virus (HBV) in chronic receiving ENBREL for signs and symptoms of active carriers of this virus. The majority of these reports tuberculosis, including patients who tested negative occurred in patients on concomitant immunosuppressive for latent tuberculosis infection. agents, which may also contribute to HBV reactivation. Many of these serious infections occurred in patients Prescribers should exercise caution in prescribing predisposed to infection because of concomitant TNF blockers for patients identified as carriers of HBV. immunosuppressive therapy and/or their underlying Adverse Events disease. Do not start ENBREL in the presence of sepsis, The most commonly reported adverse events in RA active infections (including chronic or localized), clinical trials were injection site reaction, infection, or allergy to ENBREL or its components. Use caution and headache. In clinical trials of all other adult in patients predisposed to infection, such as those indications, adverse events were similar to those with advanced or poorly controlled diabetes. reported in RA clinical trials. Please see brief summary of Prescribing Information on adjacent pages. December 2008 • www.skinandallergynews.com Cutaneous Oncology 23 scribed, 12 were called plaques, 5 were said (58%) of cases, which correlated approxi- siderophages. All had dermal fibrosis, but tive for hemosiderin with macrophages. to be papules, 3 were described as patch- mately half the time with the clinical im- in variable proportions, he said. Stasis dermatitis is a cutaneous mani- es, and 1 was called a nodule. Physicians pression of a scale. Additional biop- festation and marker of increased venous noted some erythema in 12 cases, scaling Only five cases All of the single- sies performed at pressure of the lower extremities. It usu- in 8, and erosion in 5. (15%) had a serum lesion cases the time of the orig- ally presents in middle-aged to elderly All cases demonstrated the classical crust, Dr. Weaver demonstrated the inal diagnosis in six people as erythematous with slightly yel- morphologic picture of stasis dermati- reported. classical cases produced his- low-to-brown pigmented patches over the tis—variable acanthosis, mild spongiosis of All biopsies morphologic tologic findings bilateral lower legs with or without con- the epidermis, and underlying prolifera- showed the charac- picture of stasis similar to the origi- spicuous varicose veins. tion of thick-walled blood vessels in the teristic lobular pro- dermatitis. nal slides under Most cases of stasis dermatitis are caused papillary dermis with deposition of he- liferation of thick- hematoxylin and by insufficient deep venous system valves mosiderin and extravasation of red blood walled blood vessels DR. WEAVER eosin stain. Special preventing proper return of blood to the cells. In 27 (82%) of the 33 cases, spongi- in the papillary der- stains for microor- central circulation through the muscular otic change in the epidermis was mild or mis. Nearly all cases showed evidence of ganisms performed in nine cases found no pumping action of the lower legs. Prior absent and no spongiotic vesicles were hemorrhage, including extravasated ery- fungal or bacterial organisms. An iron stain thrombophlebitis or congenital fragility seen. Parakeratosis was present in 19 throcytes, hemosiderin deposition, and was performed in one case and was posi- can cause venous valvular insufficiency. ■ Enbrel® (etanercept) Brief Summary Hematologic Events without known preexisting cardiovascular disease. Some of these SEE PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION Rare reports of pancytopenia including aplastic anemia, some with a patients have been under 50 years of age. Physicians should exercise fatal outcome, have been reported in patients treated with ENBREL®. caution when using ENBREL® in patients who also have heart failure, INDICATIONS AND USAGE The causal relationship to ENBREL® therapy remains unclear. Although and monitor patients carefully. ENBREL® is indicated for reducing signs and symptoms, inducing major no high risk group has been identified, caution should be exercised in ® Immunosuppression clinical response, inhibiting the progression of structural damage, and patients being treated with ENBREL who have a previous history of Anti-TNF therapies, including
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