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Dermatomyositis and cancer: East and West
Letters 699
J AM ACAD DERMATOL VOLUME 42, NUMBER 4
2. McManus C. Pruritus. Lancet 1995;345:1584. 3. Bernhard JD. Pruritus. Lancet 1995;345:1584. 16/8/104128 doi:10.1067/mjd.2000.104128
Editor’s reply As a serious student of this subject, I thank Professor Teufelsdröckh for his careful reading of The Blue Journal and hasten to add that we will redouble our efforts to correctly spell the other word for “itch.” Jeffrey D. Bernhard, MD 16/8/104130 doi:10.1067/mjd.2000.104130
Mucocutaneous reactions to chemotherapy To the Editor: We read with great interest the CME article entitled “Mucocutaneous Reactions to Chemotherapy” by Wendy S. Susser, MD, Diane L. Whitaker-Worth, MD, and Jane M. Grant-Kels, MD, in the March 1999 issue of the Journal (1999;40:36798). However, there are two statements made by the authors that we would like to comment on. First, the authors state in their discussion of eccrine squamous syringometaplasia (ESS): “The clinical presentation is similar to that of NEH [neutrophilic eccrine hidradenitis] with erythematous macules, papules, plaques, or vesicles that may be localized or generalized” (page 386), and they cite two of our articles.1,2 Although we agree that ESS and NEH may be observed in similar clinical lesions, the special interest of our patients was the peculiar distribution of the eruption. In fact, we described a distinctive eruption in 10 patients with ESS, which was characterized by a predominant involvement of the axillae, groins, and/or palms and soles.2 The article comprises the largest series of cases of chemotherapy-induced ESS and reports a clinicopathologic correlation between the histologic finding of ESS and the cutaneous lesions in sites, which contain high numbers of eccrine glands and/or represent natural sites of occlusion of sweat. This observation highlights the connection between the concentration of chemotherapy in eccrine sweat and subsequent clinical and histologic changes in skin.3 Second, the authors state in their discussion of the pathogenesis of acral erythema that “…microscopic damage to the eccrine glands or ducts has never been detected.” (page 377) However, in 1991 Rongioletti et al4 described a patient who had typical
acral erythema with histopathologic ESS. In addition, in our series of 10 patients with ESS cited above,2 5 patients also exhibited acral erythema. Finally, Santa Cruz et al5 observed ESS in a palmar and plantar eruption after high-dose chemotherapy and/or radiotherapy, which they named “epidermal dystrophy.” The reason that many reports of acral erythema fail to describe alterations of the eccrine glands or ducts is partly explained by inadequately performed histologic studies. Most of the cited reports lack any reference of the eccrine glands or ducts in their histopathologic descriptions or simply do not include a histologic examination at all. Another factor may be the inadequate size and depth of the biopsy specimens obtained in some studies without sufficient dermal tissue to evaluate the eccrine glands or ducts. Most reports did not describe the size of the biopsy specimen or show the eccrine glands in the photomicrographs. Nevertheless, the lack of damage to the eccrine glands or ducts in reports in which an adequate biopsy specimen was obtained suggests the existence of alternative or additional pathophysiologic mechanisms in acral erythema. It may also reflect an individual or drug-related response of the eccrine glands or ducts. Ruud Valks, MD Amaro García-Díez, MD Jesús Fernández-Herrera, MD Department of Dermatology Hospital Universitario de la Princesa Diego de León 62, 28006 Madrid, Spain REFERENCES 1. Valks R, Buezo GF, Dauden E, Fraga J, García-Díez A. Eccrine squamous syringometaplasia in intertriginous areas. Br J Dermatol 1996;134:984-6. 2. Valks R, Fraga J, Porras-Luque J, Figuera A, García-Díez A, Fernández-Herrera J. Chemotherapy-induced eccrine squamous syringometaplasia. Arch Dermatol 1997;133:873-8. 3. Horn TD. Antineoplastic chemotherapy, sweat, and the skin. Arch Dermatol 1997;133:905-6. 4. Rongioletti F, Ballestrero A, Bogliolo F, Rebora A. Necrotizing eccrine squamous syringometaplasia presenting as acral erythema. J Cutan Pathol 1991;18:453-6. 5. Santa Cruz DJ, Samuels LE, Bauer EA, Phillips GL, Herzig GP. Epidermal dystrophy: clinicopathologic study of chemotherapeutic agent toxicity in ten patients. Lab Invest 1982; 46:72. 16/8/103186 doi:10.1067/mjd.2000.103186
Dermatomyositis and cancer: East and West To the Editor: I read with interest the CME article entitled “Dermatomyositis” by Kovacs and Kovacs in
700 Letters
J AM ACAD DERMATOL APRIL 2000
the December 1998 issue (J Am Acad Dermatol 1998;39:899-920). As stated in the review, the population-based, albeit retrospective, study by Airio, Pukkala, and Isomaki1 from Finland demonstrated a 6.5-fold risk of malignancy in patients with dermatomyositis but no increased risk with patients with polymyositis. The highly associated internal malignancies were ovarian, stomach, and lung (with standardized incidence ratios between observed and expected numbers of cancer cases of 32, 14, and 10, respectively). There is no mention of nasopharyngeal carcinoma as an associated malignancy. In the Far East the most common cancer, by far, associated with adult dermatomyositis is nasopharyngeal carcinoma.2-4 We strongly suggest that an ear-nose-throat evaluation should constitute an essential part of the examination in this group of patients.
H. L. Chan, MB, FRCP Department of Medicine (Division of Dermatology) National University Hospital Singapore 119074 REFERENCES 1. Airio A, Pukkala E, Isomaki A. Elevated cancer incidence in patient with dermatomyositis: a population-based study. J Rheumatol 1995;22:1300-3. 2. Wong KO. Dermatomyositis: a clinical investigation of 23 cases in Hong Kong. Br J Dermatol 1969;81:544-7. 3. Goh CL, Rajan VS. Dermatomyositis in a skin clinic. Ann Acad Med 1983;12:6-12. 4. Chan HL. Dermatomyositis and cancer in Singapore. Int J Dermatol 1985;24:447-50. 16/8/103267 doi:10.1067/mjd.2000.103267
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J AM ACAD DERMATOL VOLUME 42, NUMBER 4
2. McManus C. Pruritus. Lancet 1995;345:1584. 3. Bernhard JD. Pruritus. Lancet 1995;345:1584. 16/8/104128 doi:10.1067/mjd.2000.104128
Editor’s reply As a serious student of this subject, I thank Professor Teufelsdröckh for his careful reading of The Blue Journal and hasten to add that we will redouble our efforts to correctly spell the other word for “itch.” Jeffrey D. Bernhard, MD 16/8/104130 doi:10.1067/mjd.2000.104130
Mucocutaneous reactions to chemotherapy To the Editor: We read with great interest the CME article entitled “Mucocutaneous Reactions to Chemotherapy” by Wendy S. Susser, MD, Diane L. Whitaker-Worth, MD, and Jane M. Grant-Kels, MD, in the March 1999 issue of the Journal (1999;40:36798). However, there are two statements made by the authors that we would like to comment on. First, the authors state in their discussion of eccrine squamous syringometaplasia (ESS): “The clinical presentation is similar to that of NEH [neutrophilic eccrine hidradenitis] with erythematous macules, papules, plaques, or vesicles that may be localized or generalized” (page 386), and they cite two of our articles.1,2 Although we agree that ESS and NEH may be observed in similar clinical lesions, the special interest of our patients was the peculiar distribution of the eruption. In fact, we described a distinctive eruption in 10 patients with ESS, which was characterized by a predominant involvement of the axillae, groins, and/or palms and soles.2 The article comprises the largest series of cases of chemotherapy-induced ESS and reports a clinicopathologic correlation between the histologic finding of ESS and the cutaneous lesions in sites, which contain high numbers of eccrine glands and/or represent natural sites of occlusion of sweat. This observation highlights the connection between the concentration of chemotherapy in eccrine sweat and subsequent clinical and histologic changes in skin.3 Second, the authors state in their discussion of the pathogenesis of acral erythema that “…microscopic damage to the eccrine glands or ducts has never been detected.” (page 377) However, in 1991 Rongioletti et al4 described a patient who had typical
acral erythema with histopathologic ESS. In addition, in our series of 10 patients with ESS cited above,2 5 patients also exhibited acral erythema. Finally, Santa Cruz et al5 observed ESS in a palmar and plantar eruption after high-dose chemotherapy and/or radiotherapy, which they named “epidermal dystrophy.” The reason that many reports of acral erythema fail to describe alterations of the eccrine glands or ducts is partly explained by inadequately performed histologic studies. Most of the cited reports lack any reference of the eccrine glands or ducts in their histopathologic descriptions or simply do not include a histologic examination at all. Another factor may be the inadequate size and depth of the biopsy specimens obtained in some studies without sufficient dermal tissue to evaluate the eccrine glands or ducts. Most reports did not describe the size of the biopsy specimen or show the eccrine glands in the photomicrographs. Nevertheless, the lack of damage to the eccrine glands or ducts in reports in which an adequate biopsy specimen was obtained suggests the existence of alternative or additional pathophysiologic mechanisms in acral erythema. It may also reflect an individual or drug-related response of the eccrine glands or ducts. Ruud Valks, MD Amaro García-Díez, MD Jesús Fernández-Herrera, MD Department of Dermatology Hospital Universitario de la Princesa Diego de León 62, 28006 Madrid, Spain REFERENCES 1. Valks R, Buezo GF, Dauden E, Fraga J, García-Díez A. Eccrine squamous syringometaplasia in intertriginous areas. Br J Dermatol 1996;134:984-6. 2. Valks R, Fraga J, Porras-Luque J, Figuera A, García-Díez A, Fernández-Herrera J. Chemotherapy-induced eccrine squamous syringometaplasia. Arch Dermatol 1997;133:873-8. 3. Horn TD. Antineoplastic chemotherapy, sweat, and the skin. Arch Dermatol 1997;133:905-6. 4. Rongioletti F, Ballestrero A, Bogliolo F, Rebora A. Necrotizing eccrine squamous syringometaplasia presenting as acral erythema. J Cutan Pathol 1991;18:453-6. 5. Santa Cruz DJ, Samuels LE, Bauer EA, Phillips GL, Herzig GP. Epidermal dystrophy: clinicopathologic study of chemotherapeutic agent toxicity in ten patients. Lab Invest 1982; 46:72. 16/8/103186 doi:10.1067/mjd.2000.103186
Dermatomyositis and cancer: East and West To the Editor: I read with interest the CME article entitled “Dermatomyositis” by Kovacs and Kovacs in
700 Letters
J AM ACAD DERMATOL APRIL 2000
the December 1998 issue (J Am Acad Dermatol 1998;39:899-920). As stated in the review, the population-based, albeit retrospective, study by Airio, Pukkala, and Isomaki1 from Finland demonstrated a 6.5-fold risk of malignancy in patients with dermatomyositis but no increased risk with patients with polymyositis. The highly associated internal malignancies were ovarian, stomach, and lung (with standardized incidence ratios between observed and expected numbers of cancer cases of 32, 14, and 10, respectively). There is no mention of nasopharyngeal carcinoma as an associated malignancy. In the Far East the most common cancer, by far, associated with adult dermatomyositis is nasopharyngeal carcinoma.2-4 We strongly suggest that an ear-nose-throat evaluation should constitute an essential part of the examination in this group of patients.
H. L. Chan, MB, FRCP Department of Medicine (Division of Dermatology) National University Hospital Singapore 119074 REFERENCES 1. Airio A, Pukkala E, Isomaki A. Elevated cancer incidence in patient with dermatomyositis: a population-based study. J Rheumatol 1995;22:1300-3. 2. Wong KO. Dermatomyositis: a clinical investigation of 23 cases in Hong Kong. Br J Dermatol 1969;81:544-7. 3. Goh CL, Rajan VS. Dermatomyositis in a skin clinic. Ann Acad Med 1983;12:6-12. 4. Chan HL. Dermatomyositis and cancer in Singapore. Int J Dermatol 1985;24:447-50. 16/8/103267 doi:10.1067/mjd.2000.103267
RECEIVE TABLES OF CONTENTS BY E-MAIL To receive the tables of contents by e-mail, sign up through our Web site at: http://www.mosby.com/jaad Choose E-mail Notification. Simply type your e-mail address in the box and click the Subscribe button. Alternatively, you may send an e-mail message to [email protected]. Leave the subject line blank and type the following as the body of your message: subscribe jaad_toc You will receive an e-mail to confirm that you have been added to the mailing list. Note that table of contents e-mails will be sent out when a new issue is posted to the Web site.