Erythroderma secondary to esophageal carcinoma

Volume 13 Number 2, Part I August, 1985

Tomich, M.D., and Donald J. Grande, M.D., brings back to mind vivid memories of my interest in this sad subject. The bibliography cites an article written by me in 1965. A later and much more important article, euphemistically entitled "Evaluation of Electrolysis: A Questionable Procedure," was published in Dermatology Digest in October 1972 (pp. 39-43). F. L. Karp's article is cited. I remember her as an elegant refugee dermatologist at the old Skin and Cancer Hospital in New York City where she was one of my instructors. At that time, the McKee (fonner head of the Skin & Cancer unit) needle, as stiff and thick as a crowbar, was a popular electrolysis needle. I have a letter from M. G. Mahoney, also cited, in which she agrees with my opinion that electrolysis is pretty much a useless, expensive, and scarring procedure. Years ago, housewives jumped at the opportunity offered to make big bucks, just with the purchase of a small machine, and this often included a course in its use. I visited M. H. Marton, who first wrote about and patented an electrolysis needle with a bare tip and an insulated shaft. He applied an enamel paint as an insulating coating. This was not successful. About that time I practiced in Plainfield, NJ, close to home of the Comell-Dubilier Corp., specialists in electrical devices. Silicone had just been developed and 1 thought this might have better insulating qualities than paint enamels. This, also, did not work. Having been educated to memorize and recite and not ask questions or use my imagination, I missed the great opportunity to initiate the use of silicone in dermatologic preparations! Epoxy resins also failed to have satisfactory dielectric insulating properties. My article in 1972 mentioned two experimental methods to evaluate the effectiveness of the electrolysis procedure. The first in vivo method was to place the needle between a piece of grounded steak and a glass slide to see its effectiveness. The second in vitro method was to use India ink on an electrolysis needle and trace its path in the hair follicle with the use of biopsy examination. Two pathologists, Dr. Mehregan of Detroit and Dr. Bong Hek Hyun of Plainfield, NJ, generously helped me in these experimental studies. My conclusion at that time was that electrolysis with any existing method was valueless and produced considerable scarring. I believe that the situation, unfortunately, remains unchanged. Equally disconcerting is the generally accepted feeling that electrolysis is indeed a good treatment modality in "good hands."

Harry C. Goldberg, M.D. 1717 North Flagler Dr., West Palm Beach, FL 33407

Correspondence

311

Reply To the Editor: Work that was pUblished subsequent to the preparation of our manuscript is of interest. Kligman and Peters compared theTI1101ysis with the use of uninsulated standard straight needles to thennolysis using flexible, insulated, bulbous-tipped probes. I Although thermolysis usually did not immediately destroy the papilla and hair matrix, this thermal injury initiated inflammation that eventually destroyed the hair bulb. They found that the insulated probe produced relatively greater damage to the lower portion of the hair follicle. Montagna also supported the view that severe damage to the papilla results in the destruction of the follicle. * He argued that the phenomenon of regrowth is an illusion that can be explained by the activation of adjacent telogen follicles or the change of nearby veUus hair follicles into teTI11inal hair follicles. In this review the words anode and cathode were reversed. The caption for Fig. 1 (page 443) should read, "Mechanisms of electrolysis: A direct current is passed into a saline solution, which results in formation of hydroxyl ions and hydrogen gas at the cathode and chlorine gas at the anode." On page 444 the second sentence under the heading of "Electrolysis" should read, "In electrolysis, electrons are removed from chloride ions at the anode, resulting in the fonnation of chlorine gas (Fig. 1). At the cathode, electrons are added to water to form hydroxyl ions and hydrogen gas. " Richard F. Wagner, Jr., M.D. JohnM. Tomich, M.D., and Donald J. Grande, M.D. New England Medical Center Hospitals 171 Harrison Ave., Boston, MA 02111 *Montagna W: Electrolysis and the problem of hair "regrowth." J Appl Cosmetol 2:6-17, 1984.

REFERENCE I. Kligman AM, Peters L: Histologic changes of human hair follicles after electrolysis: A comparison of two methods. Cutis 34:169-176, 1984.

Erythroderma secondary to esophageal carcinoma* To the Editor: ErythrodeTI11a is a relatively uncommon skin reaction of numerous etiologies, described in a series of re*The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Anny or the Department of Defense.

312

Correspondence

ports. {-5 Undetermined etiologies account for 9.5%1 to 47%,3 preexisting dermatoses account for 25%4 to 48%,2 drug-related problems, 14%3 to 42%,4 and underlying malignancies, 4%5 to 24.6%. I We report a case of erythroderma associated with an esophageal carcinoma. To our knowledge, such an association has not been recorded previously. Case report. A 72-year-old white man had slow onset of erythema during a period of approxImately 2 years. The dennatitis was associated with severe scaling and pruritus. Results of two separate evaluations obtai~ed at another facility (one in March 1983 involving a banum enema, upper gastrointestinal series, intravenous pyelogram, chest x-ray examination, and liver-spleen scan and another in September 1983 that included a bone marrow biopsy and abdominal computerized axial tomography (CAT) scan) were nonnal. At that time laboratory investigations showed nonnal values for the following tests: complete blood count (CBC) with differential, chemistry profile, antinuclear antibody (ANA), rheumatoid factor, and urinalysis. The only abnonnal finding was an erythrocyte sedimentation rate (ESR) of 37 mm/hr. A skin biopsy showed a nonspecific chronic dermatitis with moderate acanthosis, mild hyperparakeratosis, and rare foci of mild spongiosis, with a few normal lymphocytes in their vicinity. In the papillary dermis a mild perivascular round cell infiltrate was observed, along with a moderate amount of edema. No atypical ceIls were noted. Topical therapy with 0.1 % triamcinolone cream and emollients was unsuccessful and the patient was referred to us. He had no previous history of dermatoses and had used no systemic or topical medications prior to disease onset. On admission to our hospital in January 1984, the patient had an exfoliative erythrodenna covering approximately 90% of the skin surface, palmoplantar keratodenna, onychauxis of all nails, and small islands of normal skin, primarily on the extremities. Three additional skin biopsies again showed a nonspecific chronic dermatitis as described above. Direct immunofluorescence studies were negative. Laboratory findings consisting of CBC with differential, urinalysis, chemistry proflle, ANA, VDRL, and a blood smear for Sezary cells were negative. A more detailed examination was not performed because of the extensive evaluation done earlier. A presumptive diagnosis of psoriasis versus pityriasis rubra pilaris was made and confirmed during a case presentation at the San Francisco Dermatological Society meeting in January ~rogressively spreading

1984.

Trials of oral and intramuscular steroids provided only temporary relief. The patient's desire for more effective treatment prompted us to use methotrexate, 15 mg araBy in onceweekly doses, after obtaining a normal liver biopsy specimen. A moderate decrease in exfoliation occurred, but the erythema and induration-lichenification remained relatively unchanged. In the year preceding his January 1984 admission the patient had noted a gradual weight loss of 0.5 to I kg/m~nth, which he attributed to the eyrthroderma. Following 4 months of methotrexate therapy, 15 to 25 mg weekly, in one dose by

Journal of the American Academy of Dermatology

mouth, the patient began to have some shortness of breath mild anorexia, and increasing weight loss of approximatel; 2.2 kg/month. Chest x-ray examination showed bilateral pulmonaI}' interstitial infiltrates and a diagnosis of chronic obstnIctive pulmonary disease was made. Theophylline therapy was begun and methotrexate dosage was decreased. Because of deterioration of his general condition the patient was readmitted in August 1984 for further evaluation. A barium swallow revealed a large esophageal mass that was confirmed histologically to be a squamous cell carcinoma of the lower part of the esophagus, with extension into the lung, as evidenced by bronchoscopy. A CAT scan was interpreted as esophageal carcinoma with local spread. The gastroenterologist believed that, because of the size of the carcinoma, it had been present for at least 1, possibly 2 years. The pulmonologist suggested from his examination the possiblity of a second primary squamous cell carcinoma in the bronchus. Histopathologic examination of the esophageal biopsy showed a moderately well-differentiated squamous cell carcinoma definitely arising from the esophageal mucosa. The bronchial specimen showed a submucosal squamous cell carcinoma without overlying epithelial change. This was believed to be most consistent with esophageal carcinoma with local extension. While the findings are most consistent with esophageal carcinoma with local spread, the remote possibility of two entirely separate primaries cannot be totally excluded. The carcinoma was determined to be inoperable. Radiation therapy of 5,000 rads over a 6-week period, in fractional doses to the anterior and posterior mediastinum, was begun. Within 3 weeks, a noticeable decrease in the erythema and exfoliation had occurred. By the end of radiation therapy the erythroderma had essentially cleared with slight residual lichenification. Reevaluation of the patient 4 weeks after the cessation of his radiation therapy showed complete resolution of his erythroderma, with no residual skin or nail changes. . The patient died from the widespread malignancy approxImately 2 months later.

Comments. Erythroderma of undeterminable etiology continues to present a diagnostic and therapeutic challenge to the dermatologist. In reviewing the literature, we found no other cases of erythroderma secondary to esophageal carcinoma. Documented cases of lung carcinoma associated with erythrOderma are rare. 4 •6 Although the majority of erythroderma-associated malignancies are of a lymphoproliferative nature, the possibility of an occult carcinoma must not be overlooked, since repeated studies over many months may uncover a latent malignancy.

Timothy A. Deffer, M.D., Captain, MC, USA** PatriciaP. Overton-Keary, M.D., Captain,MC, USA*** Detle! K. Goette, M.D., Colonel, MC, USA** Dermatology Service** and Internal Medicine Service, ***Department of Medicine Letterman Army Medical Center Presidio of San Francisco, CA 94129-6700

Volume 13 Number 2, Part I August, 1985

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REFERENCES 1. Montgomery H: Exfoliative dermatitis and malignam erythroderma. Arch Dermatol Syph 27:253-273, 1933. 2. Wilson HTH: Exfoliative dermatitis: Its etiology and prognosis. Arch Dermatol Syph 69:577-589, 1954. 3. Abrahams 1, McCarthy JT, Sanders SL: 101 cases of exfoliative dermatitis. Arch Dermatol 87:96-101, 1963. 4. Nicolis GD, Helwig EB: Exfoliative dermatitis: A clinicopathologic study of 135 cases. Arch Dermatol108:788797, 1973. 5. Hasan T, Jansen CT: Erythroderma: A follow-up of fifty cases. J AM ACAD DERMATOL 8:836-840, 1983. 6. McGaw B, McGovern VJ: Exfoliative dermatitis associated with carcinoma of the lung. Australas J Dermatol 3:115-119, 1956.

Cimetidine and recurrent genital herpes To the Editor: Anecdotal reports appearing in the literature have suggested that cimetidine reduces the severity and frequency of various herpetic infections, possibly due to some antiviral or immunostimulatory effect. 1-4 Most of these observations have involved patients with herpes zoster. Studies have not heretofore been extended to patients with genital herpes. We conducted an open, uncontrolled trial of daily oral cimetidine in otherwise healthy adults with frequently recurring genital herpes to attempt to establish its potential value in this infection. Seven adults (5 males, 2 females) from 26 to 54 years of age with culture-confirmed genital herpes simplex virus were studied. These patients reported at least

one herpetic eruption every 4 ta 6 weeks far I or more years prior ta treatment. No patient had a clinical recurrence at the time of enrollment or in the prior 2 weeks. Infonned consent was obtained, and an oral dose of 400 mg of cimetidine daily was prescribed for 60 days. At presentation and at each 2-week follow-up visit, a clinical examination was performed and a questionnaire administered regarding the frequency and severity of recurrences, the development of prodromal symptoms, and compliance with medication. Suspected recurrences were evaluated within 48 hours after onset. Only lesions that first appeared or were progressive on or after day 7 of treatment were considered indicative of suppressive-treatment failure and were recorded. At the end of the medication period, patients were followed with routine monthly visits, and examinations during recurrences, for an additional 2 months. All enrolled patients completed the study without adverse effects. Results are presented in Table 1. During the medication period, the majority of patients (five) did not show any change in their pretreatment recurrence rate, with one patient (Patient 4) showing a reduction and one (Patient 2) showing an increase in recurrence. Lesion duration, symptom duration (pain), and subsequent recurrence rate were also not significantly altered by therapy. Results of this study indicate that oral treatment with cimetidine does not appreciably diminish the severity or frequency of recurrent genital herpes simplex infections. Whether a higher dosage would yield better results is speculative, but our data, as well as a recent unfavorable reportS of the drug in herpes zoster, suggest

Table I. Treatment of recurrent genital herpes with oral cimetidine Patient

Age/Sex

Recurrences Before treatment (2 mo) During treatment (2 rna) After treatment (2 rna) Mean duration of lesions (days) Before treatment (2 mo) During treatment (2 mo) After treatment (2 rna) Mean duration of pain (days) Before treatment (2 mo) During treatment (2 mo) After treatment (2 mo)

1

2

3

4

5

6

7

26 yr/F

32 yr/M

33 yr/M

34 yr/M

28 yr/M

30 yr/F

54 yr/M

3 5

5 5 5

3 0

9

3 3 3

4

6 6 6

6.8 7.8

10 8.2 9.6

7

3 3 3

2 1.6 1.8

4

2 2

2

1

7

4

4 4 3

2 2 2

2 2 2

8.2

7.5 8 8

7 7 7

3 3 3

1

1

7.7 8

I

1

I 1