Patient Care Hematology & Oncology - October 2007 - (Page 25)

Dermatology Case Challenge I acromegaly, Cushing’s disease), familial lipodystrophies, congenital syndromes (eg, Bloom syndrome), and autoimmune diseases (eg, systemic lupus erythematosus, scleroderma). Acral AN occurs predominantly in dark-skinned patients who are in otherwise good health and manifests itself as hyperkeratotic velvety lesions over the dorsal aspects of the hands and feet. Unilateral AN is believed to be inherited as an autosomal dominant trait and can present at any age with lesions enlarging gradually before stabilizing or regressing. Familial AN is a rare, likely autosomal dominant genodermatosis that typically begins during early childhood and progresses until puberty, when it stabilizes or regresses. Drug-induced AN, although uncommon, may be caused by several medications, including nicotinic acid, systemic corticosteroids, methyltestosterone, and diethylstilbestrol (no longer available). The lesions of AN may regress following the discontinuation of the offending medication. Malignant AN has been reported with many kinds of cancer, but by far the most common underlying malignancy is an adenocarcinoma of GI origin, usually a gastric adenocarcinoma. Of associated tumors, 75% are abdominal adenocarcinomas, of which 60% arise in the stomach. Less commonly, lung, pituitary, and liver malignancies have caused AN. In 25% to 50% of cases of malignant AN, the oral cavity is involved. The tongue and lips are most commonly affected, with elongation of the filiform papillae on the dorsal and lateral surfaces of the tongue and multiple papillary lesions appearing on the commissures of the lips. Although malignant AN is clinically indistinguishable from the benign forms, one must be more suspicious if the lesions arise rapidly or if they are more extensive, symptomatic, or in atypical locations (eg, oral, palmoplantar). Regression of AN has been seen with treatment of the underlying malignancy, and reappearance may suggest recurrence or metastasis of the primary tumor. For patients with adult-onset AN, perform a basic workup for underlying malignancy. The physical examination should evaluate obesity, masculinization, lymphadenopathy, and visceromegaly. A screen for diabetes with a fasting blood glucose, A1c level, or glucose tolerance test should be performed. A good screening test for insulin resistance is a plasma insulin level, which will be high in those with insulin resistance. Depending on the history, screen for thyroid and ovarian disease with thyroid-stimulating hormone/T4 and luteinizing hormone/follicle-stimulating hormone tests. If malignant AN is suspected, a CBC, stool screen for occult blood, chest and abdominal x-rays, and GI endoscopic procedures are warranted. Treatment of the lesions of AN is for cosmetic reasons only. Correction of hyperinsulinemia and weight reduction in obesity-associated AN may result in resolution of the dermatosis. Treatment of endocrinopathies (eg, hypothyroidism) can result in improvement or resolution of AN. There is no treatment of choice, and therapies are anecdotal, including topical options such as tretinoin, calcipotriol, hydroquinone, corticosteroids, and keratolytics. Dermabrasion, oral isotretinoin and oral contraceptives, and carbon dioxide laser are other more aggressive and less commonly employed options. In the very hypertrophic types of AN, especially on the neck, carbon dioxide laser ablation has provided some improvement in appearance, but it may only be temporary in nature. The patient was treated with a modified Kligman’s formulation (topical corticosteroid, retinoid, and hydroquinone) with a 25% improvement after 3 months, according to the patient. The endocrinologist warned the patient that, in light of his weight and family history of heart disease, he needs to focus on a healthier, portion-controlled diet and on exercise. His fasting glucose was slightly elevated, and he is being followed by the endocrinologist. OCTOBER 2007 PATIENT CARE HEMATOLOGY & ONCOLOGY 25

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Patient Care - Hematology & Oncology - October 2007 Research Digest Contents Information for Authors Medicine in the News Strategies for Bridge Anticoagulation Therapy How to Integrate the New Cervical Cancer Guidelines into Practice Dermatology Case Challenge Clinical Clips Classified Advertising

Patient Care Hematology & Oncology - October 2007

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