The dermatologist and managed care.

Because of the economic concerns of the managed care industry, a study was undertaken to demonstrate the economical treatment of cutaneous tumors by dermatologic specialists. The biopsy reports of 300 consecutive tumors were obtained from a suburban medical center pathology department. The diagnostic accuracy and place of treatment of dermatologists and nondermatologists who treated these tumors were compared. This comparison demonstrates a substantial cost saving to third-party carriers, with clear superiority by dermatologists in dealing with this problem.

Sweet's syndrome with myelofibrosis and leukemia: partial response to interferon.

Sweet's syndrome with malignancy or acute neutrophilic dermatosis (AND) is an unusual cutaneous disorder seen most commonly in association with acute myelogenous leukemia. A large majority of patients with AND and malignancy have neoplasms of hematopoietic, plasma cell or lymphoid nature. The patient reported here had myelofibrosis, chronic myelogenous leukemia and Sweet's syndrome. The individual lesions responded to intralesional interferon-alpha 2, which has not to our knowledge been reported previously. This result, however, was not as great as the response of AND to intralesional steroid injections.

Cutaneous metastases from carcinoma of the ovary.

Cutaneous metastases from ovarian carcinoma are very uncommon. Two cases are presented that demonstrate the typical clinical features of this rare complication of advanced ovarian cancer. Through recognition of the characteristic appearance and distribution of the lesion, the physician may suspect the diagnosis based on clinical examinations.

Controlling malignant melanoma. A focus on pediatricians.

There is evidence that the mortality rate associated with malignant melanoma can be decreased by early identification of the risk factors for melanoma and precursor lesions and by reducing sun exposure in young patients at higher risk. Many of the risk factors for malignant melanoma are seen in the pediatric age group. To determine pediatricians' awareness of risk factors for melanoma and their ability to recognize the precursors of melanoma, we studied three departments of pediatrics--at an urban and a suburban medical center and a medical college. Ninety-six members of the audience, which included full-time faculty, practicing pediatricians, and pediatrics residents, responded to questionnaires before and after a presentation on the risk factors for melanoma. Based on the results of the questionnaires, this group of pediatricians believed that they were not sufficiently knowledgeable about the risk factors for melanoma and did not routinely examine their patients for these risk factors or counsel them on proper sunlight protection. These findings indicate a need for making pediatricians aware of the risk factors for melanoma and of the critical role they play in decreasing the incidence and mortality rate associated with this disease.

Cutaneous clues to renal disease.

The skin is the most visible and easily accessible organ of the body. For an astute clinician, the skin may function as an important diagnostic window to diseases affecting internal organs. This is especially true for the renal system. Chronic renal failure, regardless of its cause, often produces xerosis, pruritus, sallow hyperpigmentation, and nail changes. Half-and-half nails occur frequently in patients with renal failure and are formed of a white proximal nail portion and a normal pink distal end. Uremic frost can occur on the skin in patients with severe renal failure of long duration. This white coating on the skin is caused by an increased concentration of urea in the sweat. However, long before failure is manifested clinically, specific dermatologic abnormalities can provide clues to the cause of renal disease. We review here the hereditary, metabolic, and vascular disorders that affect both the kidney and skin. The dermatologic manifestations are stressed as important guides to the diagnosis of renal disease.

Eruptive syringomas.

We report the case of a seventeen-year-old woman with a rare presentation of a common appendageal tumor, the eruptive syringoma. We treated her with the retinoid isotretinate, which we had hoped would result in prevention or reduction of new tumors and disappearance of pre-existing lesions. The syringomas remained stable throughout our treatment effort and new lesions continued to appear.

Skin clues to medical emergencies.

In a medical emergency, when rapid diagnosis is essential, a thorough examination of the skin often provides clues to the underlying illness. Dermatologic lesions may suggest the etiology of common medical emergencies, such as coma, seizure, shock, chest pain, hemorrhage, respiratory distress, acute abdomen and acute psychosis. Since examination of the skin is rapidly and easily performed, it should be included in the evaluation of a patient with a medical emergency.

Malignant disseminated porokeratosis.

A patient has been observed with a distinct form of disseminated porokeratosis. During the course of his disease, he developed changes in the porokeratosis lesions that included cellular atypia, dysplasia, and invasive squamous cell carcinoma. One of the squamous cell carcinomas produced regional and disseminated metastases, resulting in the death of the patient. Although malignancy has been previously described in the various types of porokeratosis, this is the first report of disseminated metastases and death in any form of this disease.

Septal panniculitis as a manifestation of Lyme disease.

A 22-year-old woman presented with fever, chills, photophobia, and headaches, followed by a centrally clearing erythematous skin eruption, migratory polyarthralgias, conjunctivitis, and subsequently, tender, nodular skin lesions. Antibodies to Borrelia burgdorferi were consistent with acute Lyme disease. Skin biopsy revealed acute septal panniculitis. This dermatologic manifestation has not been previously described in Lyme disease.

Isotretinoin in the treatment of steatocystoma multiplex: a possible adverse reaction.

A patient with steatocystoma multiplex (SM) with severe inflammation was treated with oral isotretinoin. Inflamed cysts markedly improved with treatment. However, after eight weeks of therapy, many pre-existing cysts rapidly enlarged and new cysts occurred. Therapy was then discontinued. Isotretinoin may have exacerbated or worsened this condition.

Osteoma cutis: a case of probable exacerbation following treatment of severe acne with isotretinoin.

A florid case of osteoma cutis was observed following isotretinoin treatment of severe cystic acne in which a few scattered osteomata of the skin were observed prior to the treatment with isotretinoin.

Colonization of nonmelanocytic cutaneous lesions by dendritic melanocytic cells: a simulant of acral-lentiginous (palmar-plantar-subungual-mucosal) melanoma.

Four cases of colonization of nonmelanocytic lesions by dendritic melanocytic cells are reported, one in a verruca vulgaris of the lip, one in a squamous cell carcinoma in situ of mucous membrane overlying a tonsil, one in a lesion of lichen simplex chronicus with a nevocellular nevus of the external ear, and one in a dermatofibrosarcoma protuberans (Bednar tumor). This is an important biological process of melanocytes that must not be confused with the acral-lentiginous (palmar-plantar-subungual-mucosal (P-S-M) melanoma. It is probably much more common than the paucity of published reports would indicate.

Cutaneous signs of dioxin exposure.

Cutaneous stigmata of exposure to the halogenated compounds, including dioxin, may be the most sensitive index of exposure. The most common skin findings include chloracne, hyperpigmentation and hirsutism. Dioxin exposure may occur in a number of ways, in industrial, military and accidental settings. The cutaneous signs of dioxin exposure should prompt a careful evaluation for associated systemic disorders.

Nodal and subcutaneous cellular blue nevi. A pseudometastasizing pseudomelanoma.

A 20-year-old white woman had extensive surgery for "metastatic melanoma" of the dorsum of the right foot and surgical removal of two regional inguinal lymph nodes. Review of the histopathological sections ten years later revealed all three lesions to be cellular blue nevi. Cellular blue nevi may resemble melanoma histologically and, relative to their incidence, are quite frequently found in lymph nodes. Thus they may present a uniquely challenging differential diagnosis with metastatic melanoma.

Trichoepithelioma in a systematized epidermal nevus with acantholytic dyskeratosis. Its occurrence in a black man.

A 2-cm nodular neoplasm in the left parietal region developed in a 52-year-old black man with a 20-year history of a systematized epidermal nevus of the scalp. On biopsy, the epidermal nevus showed both "church spire" papillary changes and multiple foci of acantholytic dyskeratosis. The neoplasm showed quite distinct histopathologic patterns of trichoepithelioma.