boards’ fodder Skin Signs of Internal Malignancy By Amandeep Sandhu, MD, Caroline Perez, MD, and Sharon E. Jacob, MD Dermatologic manifestation Description Associated malignancy or syndrome (or malignancies) Acanthosis nigricans (Malignant Hyperpigmented velvety plaques, com- GI adenocarcinoma acanthosis nigricans) monly of the neck, axilla, and groin. Acquired hypertrichosis Growth of lanugo hairs. Distribution can be Various internal malignancies, most often lanuginosa specific to the face or generalized. Hairs lung, colon or breast carcinoma. can become coarser with time. Acquired ichthyosis Clinically similar to ichthyosis vulgaris, with Hodgkin lymphoma, non-Hodgkin lympho- symmetrical fine, rough scale, typically ma, multiple myeloma, mycosis fungoides, more pronounced on lower extremities. carcinomatosis. Adenopathy and extensive skin Red-brown, violaceous patch or plaque. Plasmacytoma patch overlying a plamacytoma Biopsy: dermal vascular hyperplasia with (AESOP) syndrome increased surrounding dermal mucin. Alopecia neoplastica Solitary or multiple patches or plaques Breast most common, also GI, lung, renal, of cicatricial hair loss OR non-scarring gastric, and pancreatic. resembling alopecia areata. Bazex syndrome Violaceous erythema and scaling of the Primarily squamous cell carcinoma of upper (Acrokeratosis paraneoplastica) fingers, toes, nose and aural helices. May respiratory or GI tract. see nail dystrophy or palmoplantar kera- toderma. Bullous pemphigoid Tense, fluid-filled, subepidermal bullae. Renal cell carcinoma, lung carcinoma. Aman Sandhu, MD, is PG-4 and chief Carcinoid syndrome Flushing and erythema of head and neck. GI with liver metastases. Bronchial carcinoid dermatology resident In later disease, may see sclerodermoid tumors. changes and pellagra-like dermatitis. at Loma Linda University Medical Carcinoma en cuirasse/ Means “encasement of armor;” indurated, Breast cancer most common, also stomach, sclerodermoid fibrotic, scar-like plaques to the trunk, kidneys, or lungs. Center sometimes with a peau d’orange appear- ance; due to malignancy infiltrating col- lagen in the skin. Carcinoma erysipeloides Sharply demarcated red patch due to local Breast and lung cancer. spread of primary cancer that blocks lym- phatic blood vessels in adjacent skin. Cryoglobulinemia Variable; may include retiform purpura, Multiple myeloma, other hematologic malig- ischemic necrosis, acral cyanosis, livedo nancy. reticularis, and Raynaud’s. Cushing syndrome Rounded facies, “buffalo hump,” global Oat cell carcinoma skin atrophy, striae, prolonged wound healing. Caroline Perez, MD, is Dermatomyositis Heliotrope rash, Gottron’s papules, pho- Ovarian, breast cancer in women; gastric a PGY-1 at University todistributed poikiloderma (shawl and hol- cancer, lymphoma in men. of Missouri ster signs), nailfold telangiectasias. Eosinophilic fasciitis Induration of the skin and subcutaneous Polycythemia vera, metastatic colorectal car- tissue with dry riverbed sign following the cinoma, and multiple myeloma. course of underlying vessels. Epidermolysis bullosa acquisita Classic: tense vesicles, bullae, erosions on Multiple myeloma, lymphoma. trauma prone areas, heals with scarring; also generalized and mucosal variants. Erythema annulare centrifugum Annular or polycyclic erythematous Lymphoma, leukemia, malignant histiocy- plaques with trailing scale. tosis. Erythema gyratum repens “Wood grain” concentric figurate ery- Lung most commonly, many other malignan- thema, mild scaling; rapid migration; often cies. severe pruritus. Sharon Jacob, MD, is Generalized hyperpigmentation Hyperpigmentation due to ectopic ACTH Most commonly small cell lung cancer. associate professor production. of dermatology at Loma Linda University Generalized pruritus Diffuse pruritus, not preceded by rash. Lymphoma, leukemia, internal organ cancer. Medical Center Leser-Trélat sign Acute onset of multiple pruritic seborrheic General internal malignancy, GI adenocarci- keratoses. Commonly occurs with malig- noma most common. nant acanthosis nigricans. irinections D Residency p. 1 • Winter 2016 boards’ fodder Skin Signs of Internal Malignancy (cont.) By Amandeep Sandhu, MD, Caroline Perez, MD, and Sharon E. Jacob, MD Dermatologic manifestation Description Associated malignancy or syndrome (or malignancies) Migratory thrombophlebitis Painful indurated and erythematous Pancreatic cancer “cords,” typically linear or branching in configuration. Necrolytic migratory erythema Erythematous, eroded, crusted plaques, Glucagonoma (pancreatic α-cell tumor) (Glucagonoma syndrome) commonly in groin, anogenital, buttocks, most common; may also see with inflamma- lower legs, or perioral locations. May also tory bowel disease, diabetes, small cell lung see angular cheilitis and glossitis. cancer, or hepatocellular carcinoma. Palmoplantar keratoderma/ kerato- Excessive formation of keratin Keratoderma climactericum, arsenical sis palmaris et plantaris / tylosis on the palms and soles, characterized by keratoses, porokeratosis plantaris discreta, thickened plaques of scale. porokeratotic eccrine ostial and dermal duct nevus, glucan-induced keratoderma in acquired immunodeficiency syndrome (AIDS) Paraneoplastic pemphigus Severe erosive stomatitis, may involve Non-Hodgkin’s lymphoma (most common entire oropharynx; cutaneous lesions vari- in adults), Castleman’s (most common in able, includes erythematous macules, flac- kids, benign), chronic lymphocytic leukemia, cid and tense bullae, erythema multiforme- Waldenstrom macroglobulinemia, sarcoma, like, lichenoid, and/or pemphigus-like thymoma (benign). erosions. Pityriasis rotunda Round, discrete, scaly patches; typically Lymphoma, leukemia, esophageal or stom- seen in darker-skinned individuals. ach carcinoma, hepatocellular carcinoma. Plane xanthoma Yellow-tan to orange macules or rarely Often myeloma and biliary cirrhosis (non- thin plaques; palmar crease involvement malig); also monoclonal gammopathy, characteristic of familial dysbetalipopro- lymphoma, leukemia, adult T-cell lymphoma/ teinemia III; may also spread and become leukemia due to human lymphotropic virus generalized. (HTLV)-1; non-malignant: high-density lipo- protein (HDL) deficiency, acquired C1 ester- ase inhibitor deficiency. Polyneuropathy, organomegaly, Associated skin findings include glo- Osteosclerotic myeloma, Castleman’s, plas- endocrinopathy, M-protein, skin meruloid hemangioma, cherry angiomas, macytoma. changes (POEMS) hyperpigmentation, hypertrichosis, sclero- dermatous thickening, hyperhidrosis, digi- tal clubbing, plethora, acrocyanosis, and leukonychia. Pyoderma Gangrenosum Classically an inflammatory pustule with Leukemia, IgA gammopathy, polycycthemia surrounding halo that enlarges and ulcer- vera; non-malignant: inflammatory bowel ates with sharply marginated, overhanging disease, HIV, PAPA syndrome (Pyogenic blue to purple borders. Arthritis, Pyoderma Gangrenosum, Acne). Sister Mary Joseph nodule Umbilical metastatic nodule, color/appear- Most common GI (stomach, colon, pancre- ance varies. as); also gynecological (ovary, uterus). Sweet’s syndrome Well-defined, tender/burning/painful, AML most common, also other hematologic (Acute febrile neutrophilic derma- erythematous to violaceous, indurated to malignancies and GI, GU, and breast can- tosis) edematous plaques or nodules; non-prurit- cers. ic; face, neck, extremities most common. Systemic amyloidosis Petechiae, purpura (“pinch purpura”), Multiple myeloma ecchymoses;” also waxy, firm, flat-topped papules, nodules, and plaques; glossitis with macroglossia. Tripe palms Ridged, velvety lesions on palms. Lung (palms only), gastric (palms + AN) . (Acanthosis palmaris) References 1. James WD, Berger TG, Elston DM. Genodermatoses and Congenital Anomalies. In: James WD, Berger TG, Elston DM. Andrews’ Disease of the Skin. 11th ed. Atlanta, GA: Elsevier; 2011. 2. James WD, Berger TG, Elston DM. Dermal and Subcutaneous Tumors. In: James WD, Berger TG, Elston DM. Andrews’ Disease of the Skin. 11th ed. Atlanta, GA: Elsevier; 2011. 3. Schwarzenberger K, Callen JP. Dermatologic Manifestations in Patients with Systemic Disease. In: Bolognia JL, Jorizzo JL, Schaffer JV. Dermatology. 3rd ed. Atlanta, GA: Elsevier; 2012. irinections D Residency p. 2 • Winter 2016.