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REFERENCES 1. Mensing H. Gibt es eine Indikation Ilir Cyclosporin A in der Derrnatologie? Hautarzt 1986;37:421-3. 2. Brown MD, Ellis C, Voorhees JJ. Cyclosporin A: a review of its derrnatologic applications. Semin Derrnatol 1987;6: 2-9. 3. van Joost T, Bos JD, Heule F, et aI. Low-dose cyclosporin A in severe psoriasis. A double-blind study. Br J Dermatol 1988;118:183-90. 4. Ellis CN. Cyclosporine improves psoriasis in a double-blind study. JAMA 1986;256:3110-6. 5. Gupta AK, Matteson EL, Ellis CN. Cyclosporine in the treatment of psoriatic arthritis. Arch Derrnatol 1989; 125:507-10. 6. Meinardi MMHM, Westerhof W, Bos JD. Generalized pustular psoriasis (von Zumbusch) responding to Sandimmun (SIM): a case report. Br J Dermatol1987; 116;269-70. 7. Braun-Falco 0, Plewig G, Wolff HH. Dermatologie und Venerologie. Berlin: Springer, 1984. 8. Furue~, Gaspari AA, Katz SI. The effect of cyclosporin A on epidermal cells. II. Cyclosporin A inhibits proliferation of normal and transformed keratinocytes. J Invest Dermatol 1988;90:796-9. 9. Zachariae H, Thestrup-Pedersen K. Cielosporin A in acrodermatitis continua. Dermatologica 1987;175:29-32. 10. Mihatsch MJ, Bach JF, Coovadia HM, et a!. Cyclosporinassociated nephrotoxicity in patients with autoimmune diseases. Klin Wochenschr 1988;66:43-7.

Prevalence of the early warning signs of melanoma among participants in the 1989 Rhode Island skin cancer screening

Fig. 2. A, Pustular psoriasis of the palms after 2 weeks of low-dose therapy with cyclosporine. B, Detail of A shows complete disappearance of pustular eruption. onychodystrophy (Fig. 2). No clinical or laboratory signs of drug toxicity occurred during the treatment period.

Discussion. The mechanism of action of cyclosporine is unknown. Inhibition of keratinocyte proliferation" and synthesis and/or release of cytokines from inflammatory cells3 have been demonstrated. Both effects may be important for cyclosporine's beneficial action in psoriasis. This case demonstrates the efficacy of cyclosporine in pustular psoriasis of the palms, a disease characterized by its chronic, recalcitrant course. Thus far, one patient has been reported whose disease responded to cyclosporine (14 rug/kg/day)." We believe that our observation of the therapeutic efficacy of the drug at daily doses as low as 4.8 to 2.1 mg/kg is important, particularly because long-term maintenance therapy may be necessary. Recent investigations have shown the relative safety of low-dose cyclesporine regimens. In 29 patients studied by renal biopsy, no signs of nephrotoxicity were observed at doses less than 7.5 rug/kg/day, whereas in five of nine patients taking higher daily doses, nephrotoxicity occurred.l?

Martin A. Weinstock, MD, PhD Providence, Rhode Island A major focus of efforts to reduce the mortality rate associated with melanoma has been the screening examinations offered to the general public, most notably the nationwide effort coordinated by the American Academy of Dermatology (AAD). The AAD campaigns have many beneficial effects for both the public and dermatologists. From the public health point of view, thousands of suspected skin cancers are examined each year, and those that are confirmed are presumably treated earlier with better results than otherwise would have been the case. Additional benefit may derive from the detection and treatment of precursor lesions. Furthermore, the publicity of these efforts has undoubtedly contributed to increased public awareness of early warning signs and hence to early diagnosis and amelioration of morbidity and mortality. The increased public awareness of skin From the Departmentof Medicine (Dermatology), Veterans Administration Medical Center, Roger Williams General Hospital, and Brown University. Reprint requests: Martin A. Weinstock, MD, PhD, Medical Service 650-111, Veterans Administration Medical Center Davis Park Providence, Rl 02908. "

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Table I. Prevalence of self-reported melanoma warning signs or risk factors % Yes (No. of respondenrss)

Question

Changing moles Do you have any new moles that were not present last year at this time? Do you have any moles that have changed recently? Are any of your moles changing color? Are any of your moles changing shape? Are any of your moles growing larger? Large moles (coded 'yes" if one or more) How many moles do you have that are at least as big as the head of a pencil eraser? How many moles do you have that are at least as big as a dime? Other warning signs Do you have any sores that you had 1 month ago and that still have not healed? Have any of your moles been itchy for a month or more? Do you have a single mole on your skin that stands out from all the rest as being dark, large, unusual, or ugly? Other risk factors Has a doctor ever told you that you have (or had) a "dysplastic" or "atypical" mole? Were you born with a mole?] Have you ever had skin cancer?:j: Has anyone in your family ever had a melanoma?

28 (163) 28 (159) 17 (161) 23 (161) 31 (163) 65 (125) 16 (128) 24 (170) 16 (166) 48 (168) 6 (155) 13 (158) 15 (164) 15 (159)

·Excludes "don't know" and "unsure." [The possible answers were: "Yes, r know 1 was born with a mole because my parents told me they noticed at least one of my moles before I was 1 month old" (counted as a "yes"); "1 have had at least one of my moles as long as I can remember, but my parents never told me whether 1 was actually born with it." (counted as "no"); and "No, 1 had no moles at birth." :j:Twopercent reported a history of melanoma; 4% reported squamous cell carcinoma; 2%, basal cell carcinoma; and 6%, skin cancer of uncertain type.

cancer is also a factor in the increased use of sunscreens and in efforts to halt the deterioration of the ozone layer. In 1988,435 suspected cases of melanoma were noted among 67,124 persons screened (AAD, unpublished data). This article reports the prevalenceof persons who perceivethemselves to have one or more of the warning signs or major risk factors for melanoma among those who attend the skincancer screeningsand provides an estimate of the increase in yield that might be expected if only these persons were to be screened. Methods. Freeskin cancer screening clinics were conducted byRhode Island dermatologists at theVeterans Administration Medical Center andRoger Williams General Hospital inProvidence. Rhode Island, with theassistance oftheAmerican CancerSociety and the AAD in May 1989. In addition to theconsent form, each of the 175 persons screened was asked to complete a questionnaire that included inquiries about possible warning signs for melanoma andmelanoma risk factors. 1 These inquiries were added tothequestionnaire used inMassachusetts for evaluation ofskin cancer screening efforts (H. K. Koh, unpublished data).No one refused tocomplete thequestionnaire. Information about warning signs was included in some of the publicity about the screening. Results. The questionsusedand the proportionwhoresponded affirmatively are listed in Table 1. A new or changing mole was reported by 84 (48 %) of the persons screened.An additional 23 (13%) reported a soreof more

than 1 month's duration that had not healed or an itchy mole. Twenty-six additional participants had a single, particularly prominent mole or a mole "at least as big as the head of a pencil eraser" (6 mm). An additional eight persons (5%) had a history of congenital or dysplasticnevusor melanoma,or a family historyof melanoma. Hence 141 persons (81%) had one or more warning signs or major risk factorsfor melanoma. If only persons with one or more of these risk factors were screened, the expected yield of melanomas detected would increase by 24%. Discussion. Many scientific issues that surround skin cancer screening are unresolved.? The present investigation addresses the appropriateness of the population beingscreened byexamining the self-reported prevalenceof certain warningsigns and risk factors among the persons screened. The screenee's perception that a warning sign was present may be inaccurate. For example, those who indicated that they had a changing mole may have had a changingseborrheickeratosis,or they may not accurately recall the previous appearance of the mole. More specific questions might produce a lower prevalence of positive responses but wouldrun the risk of inadequate sensitivity, that is, negative responses in persons with melanoma. The experience in Rhode Island suggests that restricting screening efforts to those who believe they have the warning signsor risk factors evaluated herein is unlikely

518 Brief communications to have a dramatic effect on the yield of screening. Most persons who attended the free skin cancer screening clinics had reason to believe that they may have had a skin cancer, particularly melanoma. REFERENCES

1. Rhodes AR, Weinstock MA, Fitzpatrick TB, et al. Risk factors for cutaneous melanoma: a practical method of recognizing predisposed individuals. lAMA 1987;258: 3146-54. 2. Koh HK, Lew RA, Prout MN. Screening for melanoma/ skin cancer: theoretic and practical considerations. J AM ACAD DERMATOL 1989;20:159-72.

Primary oral Kaposi's sarcoma of the hard palate Gordon E. Searles, OD, MD,a Saul Markman, MD, FRCPC,b and Hosein M. Yazdi, MD, FRCPCc

Edmonton, Alberta, and Ottawa, Ontario, Canada Kaposi's sarcoma (KS), or multiple idiopathic hemorrhagic sarcoma, is an uncommon vascular tumor of endothelial origin that most commonly arises in the skin. Pharyngeal involvement occurs in only 10% of cases of classic KS. Almost all cases have skin, lymph node, and/ or gastrointestinal involvement. 1 In fact, any organ except the brain can be affected.? Abramson and Simonsreported that 84% of their cases of KS of the head and

From the Division of Dermatologyand Cutaneous Sciences, University of Alberta,' and the Departments of Medicine'' and Pathology," Ottawa CivicHospital, University of Ottawa. Reprint requests: G. E. Searles, MD, Division of Dermatologyand Cutaneous Sciences, 260 Clinical Research Wing, Heritage Medical ResearchBldg., Universityof Alberta, Edmonton,Alberta, T6G 2S2, Canada.

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Fig. 1. Monomorphic spindle cell component of welldeveloped Kaposi's sarcoma. Note presence of slitlike vascular spaces. (Hematoxylin-phloxine-saffron stain;

X460.)

Journal of the American Academy of Dermatology

neck had associated granulomatous skin involvement. In KS associated with the acquired immunodeficiency syndrome (AIDS) or iatrogenic immunosuppression, up to 50% of patients present with oral or gastrointestinal lesions.' and all have preceding cutaneous lesions. The incidence of the oral mucosa being the primary site of KS is rare; only three patients with primary oral KS have been described. Each had an associated condition that caused immunodeficiency. We report a case of primary oral KS in a woman with intact immune function. Case report. An 86-year-old white woman had a small painless lesion on the hard palate for 1 year. There was no history of antecedent trauma. She had no constitutional symptoms, and except for mild hypertension, she was well. She was a lifelong nonsmoker and never drank alcoholic beverages. Physical examination revealed a 1 X 2 em, flat, purplish plaque on the left aspect of the hard palate. Results of routine laboratory tests were normal. Serologic testing for human immunodeficiency virus was negative. A biopsy specimen of the lesion showed a relatively monomorphous neoplasm composed of fascicles of spindle cells blending with an angiomatous component. (Figs. 1 and 2). The tumor consisted predominantly of spindle cells, with minimal pleomorphism, that were interrupted by slitlike vascular spaces (Fig. 1) and well-formed capillaries lined by recognizable endothelium. Occasional, ectactic, slightly irregular vessels were also seen (Fig. 2). Sea ttered mitotic figures (one or two per 10 high-power field) were present. The striking features were the presence ofan extensive extravasation of red blood cells and hemosiderin pigment deposition. These features are typical of a well-developed stage of KS. The patient was treated with radiation. To date, no further lesions have appeared after almost 1 year of observation.

Discussion. Primary oral KS is rare. Farman and U ys4 uncovered only eight cases. Unfortunately, a full cutaneous examination was not done to confirm the absence of cutaneous lesions. In only three cases were the results of a cutaneous examination described. Farman and U ys4 reported a male kidney transplant recipient in whom sev-

Fig. 2. Kaposi's sarcoma, with irregular ectactic vessels. (Hematoxylin-phloxine-saffron stain; X460.)