Speckled pigmentation and palmoplantar keratoses leading to the mass detection of chronic arsenic poisoning

Arsenic is a known human carcinogen and skin manifestations are the earliest and most specific markers of chronic arsenic poisoning. A 43-year-old man from Luzon presented at the Section of Dermatology with a one-year history of hyperkeratotic papules and plaques on the palms and soles. Numerous round hypopigmented macules were scattered on the upper back. Initial 24-hour urine arsenic level was elevated at 288mcg/liter. The patient underwent successful chelation with N-acetylpenicillamine and the palmoplantar keratoses were treated with cryotherapy and topical 20% salicylic acid in white petrolatum. In cooperation with the Department of Health, a comprehensive health and environmental assessment was conducted in the affected communities. This case highlights the role of dermatologists in the diagnosis and management of this public health problem.

Cutaneous paraneoplasia in a woman with occult hepatic carcinoma

Tripe palms, sign of Leser-Trélat, and florid cutaneous papillomatosis are paraneoplastic entities most commonly associated with aggressive tumors. Recognition of cutaneous paraneoplasia in this case led to the detection of an occult liver malignancy in a 54-year-old woman who presented with a six-month history of diffuse thickening of palmar skin and an eruption of intensely pruritic hyperpigmented papules and plaques on her neck, abdomen, and extremities. Biopsy from the palm, thigh, and axillary lesions were consistent with tripe palms, seborrheic keratosis, and florid cutaneous papillomatosis, respectively. This patient was asymptomatic for involvement of the gastrointestinal system but had elevated serum CEA and CA 19-9 and was positive for anti-Hbs and anti-HBc. Triple-contrast triphasic scan of the abdomen revealed multiple hepatic masses and persistent sigmoid wall thickening and narrowing. Liver biopsy was positive for carcinoma cells. Therefore, an exhaustive search for the underlying neoplasia should be undertaken even in asymptomatic cases as paraneoplastic entities can be the initial and only physical clues to an underlying malignancy and early detection can be lifesaving.