- Email: [email protected]
Palmoplantar hyperkeratosis in mycosis fungoides
Volume 13 Number 5, Part 2 November, 1985
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Pyoderma gangrenosum and hepatitis
servations in five cases occurring in adults. Arch Dermatol Syphilol 22:655-680, 1930. Johnson RB, Lazarus GS: Pulse therapy: Therapeutic efficacy in the treatment of pyoderrna gangrenosa. Arch Dermatol 118:76-84, 1982. Fragola LA: Pyoderma gangrenosum. Cutis 7:593-597, 1971. Newell LM, Malkinson FD: Commentary: Pyoderma gangrenosum. Arch Dermatol 118:769-773, 1982. Hickman JG, Lazarus GT: Pyoderma gangrenosum: New concepts in etiology and treatment? Dermatology update. New York, 1979, Holland, Inc., pp. 225-342. Callen JP, Taylor WB: Pyoderma gangrenosum: A literature review. Cutis 21:61-64, 1978. Newell LM, Malkinson FD. Commentary: Pyoderma gangrenosum. Arch Dermatol 118:769-773, 1982. Hickman JG, Lazarus GS: Pyoderma gangrenosum: A reappraisal of associated systemic diseases. Br J Dermatol 102:235-237, 1980. Cohen S, Soloway RD: Classification of chronic hepatitis. Chronic active liver disease. New York, 1983, Churchill Livingstone, Inc., pp. 2-13. Boyer JL: Chronic hepatitis: A perspective on classification and determinants of prognosis. Gastroenterology 70:1161-1171, 1976. Burns DA, Sarkany I: Active chronic hepatitis and pyoderma gangrenosum. Report of a case. Clin Exp Dermatol 4:465-469, 1979, Byme JP, Hewitt M, Summerly R: Pyoderma gangrenosum associated with active chronic hepatitis. Arch Dermatol 112:1297-1301, 1976. Sherlock S: Diseases of the liver and biliary system, ed.
I
I IIII II
14. 15. 16. 17.
18. 19.
20. 21. 22.
6. Oxford, 1981, Blackwell Scientific Publications, Ltd., pp. 276-277. McElgunn PSJ: Dermatologic manifestations of hepatitis B virus infection. J AM ACAD DERMATOL 8:539-548, 1983. Lazarus GS, Goldsmith LA, Rocklin RE, et al: Pyoderma gangrenosum: Altered delayed hypersensitivity and polyarthritis. Arch Derrnatol 105:46-51, 1972. Delescluse J, deBast CL, Achten G: Pyoderma gangrenosum with altered cellular immunity and dermonecrotic factor. Br J Dermatol 87:529-532, 1972. Miller ME, Dooley R: Deficient random mobility, normal chemotaxis and impaired phagocytosis: A new abnormality of neutrophil function (abst). Pediatr Res 7:365, 1973. Jacobs JL, Goetzl EJ: "Streaking leukocyte factor," arthritis, and pyoderma gangrenosum. Pediatrics 56:570578, 1975. Holt PJA, Davies MG, Saunders KC, Nuki G: Pyoderma gangrenosum: Clinical and laboratory findings in 15 patients with special reference to polyarthritis. Medicine (Baltimore) 59:114-133, 1980. Jennings JL: Pyoderma gangrenosum: Successful treatment with intralesional steroids. J AM ACAD DERMATOL 9:575-580, 1983. Moschella SL: Pyoderma gangrenosum: A patient successfully treated with intralesional injections of steroids. Arch Dermatol 95:121-123, 1967. Gardner LW, Archer DW: Triamcinolone and pyoderma gangrenosum (letter). Arch Dermatol 106:599600, 1972.
I
I
III IIIII
III
Ill
II
Palmoplantar hyperkeratosis in mycosis fungoides H o m a y o u n A r a m , M . D . , and Moshe Zeidenbaum, M . D .
Jerusalem, Israel
The association of palmoplantar hyperkeratosis and mycosis fungoides (MF) has been described less frequently in the dermatologic literature. We present a patient with MF who developed hyperkeratosis of the palms and soles. Histologic examination of a specimen from the left palm showed microscopic changes of MF. (J AM ACAD DERMATOL13:897-899, 1985.)
CASE REPORT A 56-year-old man was hospitalized in July, 1983, with multiple pruritic lesions of 4 years' duration. His From the Departmentof Dermatology,HadassahUniversityHospital. Reprint requests to: Dr. H. Aram, SeniorDermatologist,DepartmeBt of Dermatology, Hadassah UniversityHospital, Ein Kerem, P.O. Box 12116, Jerusalem 91120, Israel/(02)446366.
previous hospitalization had been in October, 1982, for plaques of mycosis fungoides (MF) involving the trunk and extremities. He had been treated successfully with total body application of nitrogen mustard, with resolution of most of the lesions. Physical examination disclosed normal vital signs and mobile, nontender axillary and inguinal lymphadenopathy, The skin showed multiple erythematous, in-
897
898
Journal of the American Academyof Dermatology
Aram and ZeMenbaum
Fig. 1. Hyperkeratotic plaques with sharp borders involving palms. Tumors of MF are present on wrists. filtrated plaques predominantly on the extremities and several ulcerated tumors on the wrists. Hyperpigmented areas from previous lesions were present on the trunk. Erythematous, markedly hyperkeratotic psoriasiform pIaques with sharp borders were also noted on the palms (Fig. 1) and soles. These lesions were a significant source of discomfort and were resistant to a variety of topical treatments. Results of laboratory investigations, including a chemistry profile, erythrocyte sedimentation rate, platelet count, hemoglobin and hematocrit determinations, and urinalysis, were all normal. White blood cell count was 4,900/mm 3, with 50% neutrophils, 26% lymphocytes, and 10% eosinophils. Findings from a further search for lymphatic and systemic involvement, including chest roentgenogram, upper and lower gastrointestinal x-ray films, intravenous pyelogram, and liverspleen scans, were negative or normal. The results of the liver and bone marrow biopsies were also normal. Multiple biopsy specimens taken from different lesions showed microscopic evidence of plaque and tumor stages of MF. A biopsy specimen taken from the left palm revealed marked hyperkeratosis, acanthosis, and a diffuse infiltrate in the dermis. The dermal infiltrate was composed of lymphocytes, histiocytes, eosinophils, plasma cells, and cells with hyperchromatic, irregularly shaped nuclei (mycosis cells). A few Pautrier microabscesses were also present in the epidermis. Lymph node biopsies from the left groin and right elbow revealed dermatopathic lymphadenitis. The lesions were treated with daily topical application of nitrogen mustard (10 mg/60 ml of tap water).
Within 4 days the patient developed severe dermatitis of the treated areas. Therapy was stopped, and a corticosteroid ointment was substituted. During this time an episode of coagulase-positive Staphylococcus aureus infection of the skin was treated with oral cloxacillin, 2 gm/day for 10 days. In addition, he was given hydroxyzine, 75 rag/day, for his itching. The patient was referred in August, 1983, to another hospital for x-ray treatment of the tumors and generalized electron beam therapy. COMMENT Although hyperkeratotic verrucous lesions of the palms and soles are not uncommon in MF, only a few such cases have been reported in the literature. Credit for describing the association of palmoplantar hyperkeratosis and MF is attributed to Hallopeau and Bureau. t Milian and Perin 2 reported a patient with hyperkeratotic and verrucous lesions of the legs and of the dorsa of the hands and feet. In 1926 three additional cases were described by Jeanselme and Burnier 3 as " l a forme verruqueuse et hyperkeratosique de mycosis fungoides." Their patients exhibited hyperkeratotic verrucous lesions predominantly on the distal parts of the extremities. Price et al 4 reported a patient with hyperkeratotic lesions that were confined to the dorsal and plantar aspects of the right foot for 24 years. More recently, Tomsick 5 described a 57year-old woman with MF who showed diffuse pal-
Volume 13 Number 5, Part 2 November, 1985
mar hyperkeratosis, irregular hyperkeratosis of the soles, and patchy scaling over the trunk and extremities. Most major dermatology textbooks do not describe the occurrence of palmoplantar hyperkeratosis in MF patients. However, Costello and Gibbs, 6 in their book The Pabns and Soles in Medicine, mention the association of palmar hyperkeratosis and MF. Fromer, 7 in Moschella's Dermatology, states that diffuse or patchy hyperkeratosis (psoriasiform dermatitis) of the palms and soles develops in 5% to 7% of patients with plaque-stage MF. Palmoplantar hyperkeratosis in our case was reminiscent of S6zary syndrome. In this syndrome the palms and soles are diffusely hyperkeratotic, whereas in our patient the lesions were hyperkeratotic plaques with sharp borders. Furthermore, the key features of S6zary syndrome, such as generalized erythroderma and atypical monocytic cells
Palmoplantar hyperkeratosis in mycosis fimgoides
in the peripheral blood, were lacking in our patient. REFERENCES 1. Hallopeau H, Bureau G.: Sur un 6rythrodermie mycosique avec hyperk6ratose plantaire et palmaire et peut-6tre n6o-
plasic initial. Bull Soc Fr Dermatol Syph 7:222, 1896. 2. Milian G, Perin L: Mycosis fungoide avec 6rythrodermie psoriasiforme et hyperk6ratose v6g6tante. Bull Soc Fr Dermatol Syph 30:394-398, 1923. 3. Jeanselme E, Burnier L: La forme verruqueuse et hyperk6ratosique du mycosis fungoi'de. Ann Dermatol Syphiligr 7:65-73, 1926. 4. Price NM, Fuks ZY, Hoffman TE: t-Iyperkeratotic and verrucous features of mycosis fungoides. Arch Dermatol 113:57-60, 1977. 5. Tomsiek RS: Hyperkeratosis in mycosis fungoides. Cutis 29:621-623, 1982. 6. Costello MJ, Gibbs RC: The palms and soles in medicine. Springfield, IL, 1967, Charles C Thomas, Publisher, p. 552. 7. Fromer JL: Lymphoma cutis, multiple myeloma, leukemia cutis, and mycosis fungoides, in Moschella SL, Pillsbury DM, Hurley HJ Jr, editors: Dermatology, vol. 2. Philadelphia, 1975, W. B. Saunders Co., p. 1427.
Punch biopsy of melanoma E. P. van der Esch, M.D.,* and F. H. J. Rampen, M.D.**
Amsterdam, The Netherlands A 46-year-old albino woman is described with a melanoma on the leg from which a punch biopsy specimen was inadvertently taken. In the reexcision specimen, two biopsy wounds were recognized that were filled with tumor. The initial level iii lesion had to be subsequently reported as a deep level IV amelanotic melanoma with an increased thickness. It is emphasized that in places where the subcutaneous fat is absent, punch or incision biopsy may thwart proper secondary excision. (J AM ACADDERMATOI.13:899-902, 1985.)
The hazards of incisional and punch biopsy of cutaneous melanoma remain a controversial isFrom the Department of Pathology, Antoni van Leeuwenhoekhuis (The Netherlands Cancer Institute),* and the Departmentof Dermatology, Academic Medical Center.** Reprint requests to: Dr. Eric P. van der Esch, Departmentof Pathology, Nederlands Kankerinstituut,Plesmanlaan121, 1066 CX Amsterdam, The Netherlands.
sue, 1-4An adverse effect on the patient's survival
could be caused by contamination of the surrounding skin or subcutaneous structures with melanoma ceils that are dislodged by the procedure. This has never been substantiated in a prospective study, nor can testimony of such an event be found in the literature. However, we have recently treated an albino woman with a melanoma on the leg, 899
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Pyoderma gangrenosum and hepatitis
servations in five cases occurring in adults. Arch Dermatol Syphilol 22:655-680, 1930. Johnson RB, Lazarus GS: Pulse therapy: Therapeutic efficacy in the treatment of pyoderrna gangrenosa. Arch Dermatol 118:76-84, 1982. Fragola LA: Pyoderma gangrenosum. Cutis 7:593-597, 1971. Newell LM, Malkinson FD: Commentary: Pyoderma gangrenosum. Arch Dermatol 118:769-773, 1982. Hickman JG, Lazarus GT: Pyoderma gangrenosum: New concepts in etiology and treatment? Dermatology update. New York, 1979, Holland, Inc., pp. 225-342. Callen JP, Taylor WB: Pyoderma gangrenosum: A literature review. Cutis 21:61-64, 1978. Newell LM, Malkinson FD. Commentary: Pyoderma gangrenosum. Arch Dermatol 118:769-773, 1982. Hickman JG, Lazarus GS: Pyoderma gangrenosum: A reappraisal of associated systemic diseases. Br J Dermatol 102:235-237, 1980. Cohen S, Soloway RD: Classification of chronic hepatitis. Chronic active liver disease. New York, 1983, Churchill Livingstone, Inc., pp. 2-13. Boyer JL: Chronic hepatitis: A perspective on classification and determinants of prognosis. Gastroenterology 70:1161-1171, 1976. Burns DA, Sarkany I: Active chronic hepatitis and pyoderma gangrenosum. Report of a case. Clin Exp Dermatol 4:465-469, 1979, Byme JP, Hewitt M, Summerly R: Pyoderma gangrenosum associated with active chronic hepatitis. Arch Dermatol 112:1297-1301, 1976. Sherlock S: Diseases of the liver and biliary system, ed.
I
I IIII II
14. 15. 16. 17.
18. 19.
20. 21. 22.
6. Oxford, 1981, Blackwell Scientific Publications, Ltd., pp. 276-277. McElgunn PSJ: Dermatologic manifestations of hepatitis B virus infection. J AM ACAD DERMATOL 8:539-548, 1983. Lazarus GS, Goldsmith LA, Rocklin RE, et al: Pyoderma gangrenosum: Altered delayed hypersensitivity and polyarthritis. Arch Derrnatol 105:46-51, 1972. Delescluse J, deBast CL, Achten G: Pyoderma gangrenosum with altered cellular immunity and dermonecrotic factor. Br J Dermatol 87:529-532, 1972. Miller ME, Dooley R: Deficient random mobility, normal chemotaxis and impaired phagocytosis: A new abnormality of neutrophil function (abst). Pediatr Res 7:365, 1973. Jacobs JL, Goetzl EJ: "Streaking leukocyte factor," arthritis, and pyoderma gangrenosum. Pediatrics 56:570578, 1975. Holt PJA, Davies MG, Saunders KC, Nuki G: Pyoderma gangrenosum: Clinical and laboratory findings in 15 patients with special reference to polyarthritis. Medicine (Baltimore) 59:114-133, 1980. Jennings JL: Pyoderma gangrenosum: Successful treatment with intralesional steroids. J AM ACAD DERMATOL 9:575-580, 1983. Moschella SL: Pyoderma gangrenosum: A patient successfully treated with intralesional injections of steroids. Arch Dermatol 95:121-123, 1967. Gardner LW, Archer DW: Triamcinolone and pyoderma gangrenosum (letter). Arch Dermatol 106:599600, 1972.
I
I
III IIIII
III
Ill
II
Palmoplantar hyperkeratosis in mycosis fungoides H o m a y o u n A r a m , M . D . , and Moshe Zeidenbaum, M . D .
Jerusalem, Israel
The association of palmoplantar hyperkeratosis and mycosis fungoides (MF) has been described less frequently in the dermatologic literature. We present a patient with MF who developed hyperkeratosis of the palms and soles. Histologic examination of a specimen from the left palm showed microscopic changes of MF. (J AM ACAD DERMATOL13:897-899, 1985.)
CASE REPORT A 56-year-old man was hospitalized in July, 1983, with multiple pruritic lesions of 4 years' duration. His From the Departmentof Dermatology,HadassahUniversityHospital. Reprint requests to: Dr. H. Aram, SeniorDermatologist,DepartmeBt of Dermatology, Hadassah UniversityHospital, Ein Kerem, P.O. Box 12116, Jerusalem 91120, Israel/(02)446366.
previous hospitalization had been in October, 1982, for plaques of mycosis fungoides (MF) involving the trunk and extremities. He had been treated successfully with total body application of nitrogen mustard, with resolution of most of the lesions. Physical examination disclosed normal vital signs and mobile, nontender axillary and inguinal lymphadenopathy, The skin showed multiple erythematous, in-
897
898
Journal of the American Academyof Dermatology
Aram and ZeMenbaum
Fig. 1. Hyperkeratotic plaques with sharp borders involving palms. Tumors of MF are present on wrists. filtrated plaques predominantly on the extremities and several ulcerated tumors on the wrists. Hyperpigmented areas from previous lesions were present on the trunk. Erythematous, markedly hyperkeratotic psoriasiform pIaques with sharp borders were also noted on the palms (Fig. 1) and soles. These lesions were a significant source of discomfort and were resistant to a variety of topical treatments. Results of laboratory investigations, including a chemistry profile, erythrocyte sedimentation rate, platelet count, hemoglobin and hematocrit determinations, and urinalysis, were all normal. White blood cell count was 4,900/mm 3, with 50% neutrophils, 26% lymphocytes, and 10% eosinophils. Findings from a further search for lymphatic and systemic involvement, including chest roentgenogram, upper and lower gastrointestinal x-ray films, intravenous pyelogram, and liverspleen scans, were negative or normal. The results of the liver and bone marrow biopsies were also normal. Multiple biopsy specimens taken from different lesions showed microscopic evidence of plaque and tumor stages of MF. A biopsy specimen taken from the left palm revealed marked hyperkeratosis, acanthosis, and a diffuse infiltrate in the dermis. The dermal infiltrate was composed of lymphocytes, histiocytes, eosinophils, plasma cells, and cells with hyperchromatic, irregularly shaped nuclei (mycosis cells). A few Pautrier microabscesses were also present in the epidermis. Lymph node biopsies from the left groin and right elbow revealed dermatopathic lymphadenitis. The lesions were treated with daily topical application of nitrogen mustard (10 mg/60 ml of tap water).
Within 4 days the patient developed severe dermatitis of the treated areas. Therapy was stopped, and a corticosteroid ointment was substituted. During this time an episode of coagulase-positive Staphylococcus aureus infection of the skin was treated with oral cloxacillin, 2 gm/day for 10 days. In addition, he was given hydroxyzine, 75 rag/day, for his itching. The patient was referred in August, 1983, to another hospital for x-ray treatment of the tumors and generalized electron beam therapy. COMMENT Although hyperkeratotic verrucous lesions of the palms and soles are not uncommon in MF, only a few such cases have been reported in the literature. Credit for describing the association of palmoplantar hyperkeratosis and MF is attributed to Hallopeau and Bureau. t Milian and Perin 2 reported a patient with hyperkeratotic and verrucous lesions of the legs and of the dorsa of the hands and feet. In 1926 three additional cases were described by Jeanselme and Burnier 3 as " l a forme verruqueuse et hyperkeratosique de mycosis fungoides." Their patients exhibited hyperkeratotic verrucous lesions predominantly on the distal parts of the extremities. Price et al 4 reported a patient with hyperkeratotic lesions that were confined to the dorsal and plantar aspects of the right foot for 24 years. More recently, Tomsick 5 described a 57year-old woman with MF who showed diffuse pal-
Volume 13 Number 5, Part 2 November, 1985
mar hyperkeratosis, irregular hyperkeratosis of the soles, and patchy scaling over the trunk and extremities. Most major dermatology textbooks do not describe the occurrence of palmoplantar hyperkeratosis in MF patients. However, Costello and Gibbs, 6 in their book The Pabns and Soles in Medicine, mention the association of palmar hyperkeratosis and MF. Fromer, 7 in Moschella's Dermatology, states that diffuse or patchy hyperkeratosis (psoriasiform dermatitis) of the palms and soles develops in 5% to 7% of patients with plaque-stage MF. Palmoplantar hyperkeratosis in our case was reminiscent of S6zary syndrome. In this syndrome the palms and soles are diffusely hyperkeratotic, whereas in our patient the lesions were hyperkeratotic plaques with sharp borders. Furthermore, the key features of S6zary syndrome, such as generalized erythroderma and atypical monocytic cells
Palmoplantar hyperkeratosis in mycosis fimgoides
in the peripheral blood, were lacking in our patient. REFERENCES 1. Hallopeau H, Bureau G.: Sur un 6rythrodermie mycosique avec hyperk6ratose plantaire et palmaire et peut-6tre n6o-
plasic initial. Bull Soc Fr Dermatol Syph 7:222, 1896. 2. Milian G, Perin L: Mycosis fungoide avec 6rythrodermie psoriasiforme et hyperk6ratose v6g6tante. Bull Soc Fr Dermatol Syph 30:394-398, 1923. 3. Jeanselme E, Burnier L: La forme verruqueuse et hyperk6ratosique du mycosis fungoi'de. Ann Dermatol Syphiligr 7:65-73, 1926. 4. Price NM, Fuks ZY, Hoffman TE: t-Iyperkeratotic and verrucous features of mycosis fungoides. Arch Dermatol 113:57-60, 1977. 5. Tomsiek RS: Hyperkeratosis in mycosis fungoides. Cutis 29:621-623, 1982. 6. Costello MJ, Gibbs RC: The palms and soles in medicine. Springfield, IL, 1967, Charles C Thomas, Publisher, p. 552. 7. Fromer JL: Lymphoma cutis, multiple myeloma, leukemia cutis, and mycosis fungoides, in Moschella SL, Pillsbury DM, Hurley HJ Jr, editors: Dermatology, vol. 2. Philadelphia, 1975, W. B. Saunders Co., p. 1427.
Punch biopsy of melanoma E. P. van der Esch, M.D.,* and F. H. J. Rampen, M.D.**
Amsterdam, The Netherlands A 46-year-old albino woman is described with a melanoma on the leg from which a punch biopsy specimen was inadvertently taken. In the reexcision specimen, two biopsy wounds were recognized that were filled with tumor. The initial level iii lesion had to be subsequently reported as a deep level IV amelanotic melanoma with an increased thickness. It is emphasized that in places where the subcutaneous fat is absent, punch or incision biopsy may thwart proper secondary excision. (J AM ACADDERMATOI.13:899-902, 1985.)
The hazards of incisional and punch biopsy of cutaneous melanoma remain a controversial isFrom the Department of Pathology, Antoni van Leeuwenhoekhuis (The Netherlands Cancer Institute),* and the Departmentof Dermatology, Academic Medical Center.** Reprint requests to: Dr. Eric P. van der Esch, Departmentof Pathology, Nederlands Kankerinstituut,Plesmanlaan121, 1066 CX Amsterdam, The Netherlands.
sue, 1-4An adverse effect on the patient's survival
could be caused by contamination of the surrounding skin or subcutaneous structures with melanoma ceils that are dislodged by the procedure. This has never been substantiated in a prospective study, nor can testimony of such an event be found in the literature. However, we have recently treated an albino woman with a melanoma on the leg, 899