662 Correspondence 1
(a)
Department of Dermatology and Department of Pediatrics, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan 3 Department of Pathology, Kanazawa Medical University, Kanazawa, Japan E-mail: [email protected] 2
M. MIZAWA1 T. MAKINO1 O. NORISUGI1 H. HARA1 K. SHIMIZU1 K. NOMURA2 H. KANEGANE2 T. NOJIMA3 T. SHIMIZU1
References
(b)
(c)
1 Ewing J. Diffuse endothelioma of bone. Proc NY Pathol Soc 1921; 21:17. 2 Jedlicka P. Ewing Sarcoma, an enigmatic malignancy of likely progenitor cell origin, driven by transcription factor oncogenic fusions. Int J Clin Exp Pathol 2010; 3:338–47. 3 Angervall L, Enzinger FM. Extraskeletal neoplasm resembling Ewing’s sarcoma. Cancer 1975; 36:240–51. 4 Delaplace M, Lhommet C, de Pinieux G et al. Primary cutaneous Ewing sarcoma: a systematic review focused on treatment and outcome. Br J Dermatol 2012; 166:721–6. 5 Esiashvili N, Goodman M, Marcus RB Jr. Changes in incidence and survival of Ewing sarcoma patients over the past 3 decades: Surveillance Epidemiology and End Results data. J Pediatr Hematol Oncol 2008; 30:425–30. 6 Cotterill SJ, Ahrens S, Paulussen M et al. Prognostic factors in Ewing’s tumor of bone: analysis of 975 patients from the European Intergroup Cooperative Ewing’s Sarcoma Study Group. J Clin Oncol 2000; 18:3108–14. 7 Ladenstein R, P€ otschger U, Le Deley MC et al. Primary disseminated multifocal Ewing sarcoma: results of the Euro-EWING 99 trial. J Clin Oncol 2010; 28:3284–91. Funding sources: none. Conflicts of interest: none declared.
Two cases of nicorandil-induced ulceration mimicking skin malignancy DOI: 10.1111/bjd.12978
Fig 2. (a) Positron emission tomography/computed tomography showing high uptake in the bilateral cervical lymph nodes (arrowheads). (b) Coronal T2-weighted short-tau inversion recovery (STIR) magnetic resonance imaging (MRI) findings demonstrating a region with high signal intensity in the left ilium (arrowhead). (c) Coronal T2-weighted STIR MRI findings showing a region with high signal intensity in the right femur (arrowhead).
Generally, we agree with the need to reconsider the therapeutic protocol in the setting of primary cutaneous ES; however, clinicians should also pay attention to the possibility that multiple metastases may develop even in patients with primary cutaneous ES. British Journal of Dermatology (2014) 171, pp657–678
DEAR EDITOR, Cutaneous ulceration caused by nicorandil is well described at perianal, anal, peristomal, oral, vulval and cutaneous sites,1–6 and most recently on the conjunctiva.7 We present the first reported cases of nicorandil-induced ulceration of the temple and the nasal mucosa, which were referred as possible skin malignancies. Patient 1 was an 88-year-old man with a 3-week history of a painful ulcer on his left temple. He had been receiving nicorandil 20 mg twice daily for the previous 2 years. Examination of the left temple revealed a 15-mm discoid, punched-out ulcer with a purulent base and an erythematous rim (Fig. 1). An incisional biopsy from the ulcer edge showed inflammatory © 2014 British Association of Dermatologists
Correspondence 663
change with no evidence of malignancy. Following an unsuccessful trial of topical antibiotic therapy, the entire lesion was removed by curettage. Histology demonstrated mixed suppurative and granulomatous inflammation with no neoplasia. The ulcer completely resolved 4 weeks after stopping nicorandil. Patient 2 was a 57-year-old woman with an 8-month history of an enlarging ulcer on the left columella/nasal septum. The lesion had been bleeding and repeatedly crusting, which led the general practitioner to consider a diagnosis of basal cell carcinoma, despite the fact that it was intensely painful. Examination of the left side of the columella revealed a 20 9 10-mm well-defined ulcer with a raised pearlescent edge extending onto the nasal septum (Fig. 2). A biopsy demonstrated inflammation and the deposition of fibrin, but no malignant change. Further inquiry revealed that she had been taking nicorandil for 2 years, with no recent change in her dosage (20 mg twice daily). Nicorandil was stopped, and within 4 weeks there was a significant improvement in the pain and a reduction in the size of the ulcer. The ulceration was improved by at least 50% at the 3-month follow-up. Nicorandil-induced ulceration has been reported in patients aged 58–89 years, with both sexes equally affected. Ulceration begins between 2 weeks and 4 years after the initiation of therapy, often following an increase in dose. Characteristically, ulcers are painful, localized, extend into deeper tissues and have little granulation tissue at the base. Histological examination reveals the deposition of fibrin and a mixed inflammatory cell infiltrate, with one report of diffuse elastophagocytosis.8 After the discontinuation of medication, there is often significant improvement in pain and size after
Fig 1. A 15-mm discoid, punched-out ulcer with a purulent base and an erythematous rim in an 88-year-old man with a 3-week history of a painful ulcer on his left temple and who had been receiving nicorandil 20 mg twice daily for the previous 2 years.
4 weeks, with complete resolution at 3–6 months. Theories of pathogenesis include direct metabolite toxicity in secretions, vascular steal phenomenon, the accumulation of endogenous nicotinic acid and the interference of neutrophil migration in wound healing. Nasal mucosal and cutaneous scalp ulceration due to nicorandil has not been reported previously. This phenomenon is an important feature to be aware of, as, potentially, it could help in avoiding unnecessary surgical procedures for suspected cutaneous malignancy. Department of Dermatology, Heart of England NHS Trust, Solihull Hospital Lode Lane, Solihull B92 2JL, U.K. E-mail: [email protected]
A. SHARMA S. ORPIN J. GOULDING M. KAUR
References 1 Cooke NS, Tolland JP, Dolan OM. Nicorandil-associated perianal ulceration: a case series of 10 patients. Br J Dermatol 2006; 154:199–200. 2 Toquero L, Briggs CD, Bassuini MM, Rochester JR. Anal ulceration associated with nicorandil: case series and review of the literature. Colorectal Dis 2006; 8:717–20. 3 Ogden S, Mukasa Y, Lyon CC, Coulson IH. Nicorandil-induced peristomal ulcers: is nicorandil also associated with gastrointestinal fistula formation? Br J Dermatol 2007; 156:608–9. 4 Jang H-S, Jo J-H, Kim B-S et al. A case of severe tongue ulceration and laryngeal inflammation induced by low-dose nicorandil therapy. Br J Dermatol 2004; 151:927–52. 5 Claeys A, Weber-Muller F, Trechot P et al. Cutaneous, perivulvar and perianal ulcerations induced by nicorandil. Br J Dermatol 2006; 155:477–500. 6 McKenna DJ, Donnelly J, Armstrong DKB. Nicorandil-induced leg ulceration. Br J Dermatol 2007; 156:394–6. 7 Kamath S, Taylor M, Bhagwandas K. An unusual case of nicorandil-induced conjunctival erosions. Clin Exp Dermatol 2012; 37:681– 2. 8 Wong T, Swain F, Calonge E. Nicorandil-associated perianal ulceration with prominent elasophagocytosis and flexural ulceration. Br J Dermatol 2005; 152:1360–1. Funding sources: none. Conflicts of interest: none declared.
Paronychia-like digital cutaneous metastasis DOI: 10.1111/bjd.13025
Fig 2. A 20 9 10-mm well-defined ulcer with a raised pearlescent edge extending onto the nasal septum in a 57-year-old woman with an 8-month history of an enlarging ulcer on the left columella/nasal septum and who had been taking nicorandil 20 mg twice daily for 2 years. © 2014 British Association of Dermatologists
DEAR EDITOR, Digital metastasis is a rare manifestation that typically signifies a high tumour burden and has a grim prognosis. Metastasis to the hand is considered rare, and has been reported to constitute 01% of all metastatic sites in the body. The most common presentation is a nodular osteolytic lesion.1 Pure digital cutaneous metastasis is extremely rare. We report British Journal of Dermatology (2014) 171, pp657–678
(a)
Department of Dermatology and Department of Pediatrics, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan 3 Department of Pathology, Kanazawa Medical University, Kanazawa, Japan E-mail: [email protected] 2
M. MIZAWA1 T. MAKINO1 O. NORISUGI1 H. HARA1 K. SHIMIZU1 K. NOMURA2 H. KANEGANE2 T. NOJIMA3 T. SHIMIZU1
References
(b)
(c)
1 Ewing J. Diffuse endothelioma of bone. Proc NY Pathol Soc 1921; 21:17. 2 Jedlicka P. Ewing Sarcoma, an enigmatic malignancy of likely progenitor cell origin, driven by transcription factor oncogenic fusions. Int J Clin Exp Pathol 2010; 3:338–47. 3 Angervall L, Enzinger FM. Extraskeletal neoplasm resembling Ewing’s sarcoma. Cancer 1975; 36:240–51. 4 Delaplace M, Lhommet C, de Pinieux G et al. Primary cutaneous Ewing sarcoma: a systematic review focused on treatment and outcome. Br J Dermatol 2012; 166:721–6. 5 Esiashvili N, Goodman M, Marcus RB Jr. Changes in incidence and survival of Ewing sarcoma patients over the past 3 decades: Surveillance Epidemiology and End Results data. J Pediatr Hematol Oncol 2008; 30:425–30. 6 Cotterill SJ, Ahrens S, Paulussen M et al. Prognostic factors in Ewing’s tumor of bone: analysis of 975 patients from the European Intergroup Cooperative Ewing’s Sarcoma Study Group. J Clin Oncol 2000; 18:3108–14. 7 Ladenstein R, P€ otschger U, Le Deley MC et al. Primary disseminated multifocal Ewing sarcoma: results of the Euro-EWING 99 trial. J Clin Oncol 2010; 28:3284–91. Funding sources: none. Conflicts of interest: none declared.
Two cases of nicorandil-induced ulceration mimicking skin malignancy DOI: 10.1111/bjd.12978
Fig 2. (a) Positron emission tomography/computed tomography showing high uptake in the bilateral cervical lymph nodes (arrowheads). (b) Coronal T2-weighted short-tau inversion recovery (STIR) magnetic resonance imaging (MRI) findings demonstrating a region with high signal intensity in the left ilium (arrowhead). (c) Coronal T2-weighted STIR MRI findings showing a region with high signal intensity in the right femur (arrowhead).
Generally, we agree with the need to reconsider the therapeutic protocol in the setting of primary cutaneous ES; however, clinicians should also pay attention to the possibility that multiple metastases may develop even in patients with primary cutaneous ES. British Journal of Dermatology (2014) 171, pp657–678
DEAR EDITOR, Cutaneous ulceration caused by nicorandil is well described at perianal, anal, peristomal, oral, vulval and cutaneous sites,1–6 and most recently on the conjunctiva.7 We present the first reported cases of nicorandil-induced ulceration of the temple and the nasal mucosa, which were referred as possible skin malignancies. Patient 1 was an 88-year-old man with a 3-week history of a painful ulcer on his left temple. He had been receiving nicorandil 20 mg twice daily for the previous 2 years. Examination of the left temple revealed a 15-mm discoid, punched-out ulcer with a purulent base and an erythematous rim (Fig. 1). An incisional biopsy from the ulcer edge showed inflammatory © 2014 British Association of Dermatologists
Correspondence 663
change with no evidence of malignancy. Following an unsuccessful trial of topical antibiotic therapy, the entire lesion was removed by curettage. Histology demonstrated mixed suppurative and granulomatous inflammation with no neoplasia. The ulcer completely resolved 4 weeks after stopping nicorandil. Patient 2 was a 57-year-old woman with an 8-month history of an enlarging ulcer on the left columella/nasal septum. The lesion had been bleeding and repeatedly crusting, which led the general practitioner to consider a diagnosis of basal cell carcinoma, despite the fact that it was intensely painful. Examination of the left side of the columella revealed a 20 9 10-mm well-defined ulcer with a raised pearlescent edge extending onto the nasal septum (Fig. 2). A biopsy demonstrated inflammation and the deposition of fibrin, but no malignant change. Further inquiry revealed that she had been taking nicorandil for 2 years, with no recent change in her dosage (20 mg twice daily). Nicorandil was stopped, and within 4 weeks there was a significant improvement in the pain and a reduction in the size of the ulcer. The ulceration was improved by at least 50% at the 3-month follow-up. Nicorandil-induced ulceration has been reported in patients aged 58–89 years, with both sexes equally affected. Ulceration begins between 2 weeks and 4 years after the initiation of therapy, often following an increase in dose. Characteristically, ulcers are painful, localized, extend into deeper tissues and have little granulation tissue at the base. Histological examination reveals the deposition of fibrin and a mixed inflammatory cell infiltrate, with one report of diffuse elastophagocytosis.8 After the discontinuation of medication, there is often significant improvement in pain and size after
Fig 1. A 15-mm discoid, punched-out ulcer with a purulent base and an erythematous rim in an 88-year-old man with a 3-week history of a painful ulcer on his left temple and who had been receiving nicorandil 20 mg twice daily for the previous 2 years.
4 weeks, with complete resolution at 3–6 months. Theories of pathogenesis include direct metabolite toxicity in secretions, vascular steal phenomenon, the accumulation of endogenous nicotinic acid and the interference of neutrophil migration in wound healing. Nasal mucosal and cutaneous scalp ulceration due to nicorandil has not been reported previously. This phenomenon is an important feature to be aware of, as, potentially, it could help in avoiding unnecessary surgical procedures for suspected cutaneous malignancy. Department of Dermatology, Heart of England NHS Trust, Solihull Hospital Lode Lane, Solihull B92 2JL, U.K. E-mail: [email protected]
A. SHARMA S. ORPIN J. GOULDING M. KAUR
References 1 Cooke NS, Tolland JP, Dolan OM. Nicorandil-associated perianal ulceration: a case series of 10 patients. Br J Dermatol 2006; 154:199–200. 2 Toquero L, Briggs CD, Bassuini MM, Rochester JR. Anal ulceration associated with nicorandil: case series and review of the literature. Colorectal Dis 2006; 8:717–20. 3 Ogden S, Mukasa Y, Lyon CC, Coulson IH. Nicorandil-induced peristomal ulcers: is nicorandil also associated with gastrointestinal fistula formation? Br J Dermatol 2007; 156:608–9. 4 Jang H-S, Jo J-H, Kim B-S et al. A case of severe tongue ulceration and laryngeal inflammation induced by low-dose nicorandil therapy. Br J Dermatol 2004; 151:927–52. 5 Claeys A, Weber-Muller F, Trechot P et al. Cutaneous, perivulvar and perianal ulcerations induced by nicorandil. Br J Dermatol 2006; 155:477–500. 6 McKenna DJ, Donnelly J, Armstrong DKB. Nicorandil-induced leg ulceration. Br J Dermatol 2007; 156:394–6. 7 Kamath S, Taylor M, Bhagwandas K. An unusual case of nicorandil-induced conjunctival erosions. Clin Exp Dermatol 2012; 37:681– 2. 8 Wong T, Swain F, Calonge E. Nicorandil-associated perianal ulceration with prominent elasophagocytosis and flexural ulceration. Br J Dermatol 2005; 152:1360–1. Funding sources: none. Conflicts of interest: none declared.
Paronychia-like digital cutaneous metastasis DOI: 10.1111/bjd.13025
Fig 2. A 20 9 10-mm well-defined ulcer with a raised pearlescent edge extending onto the nasal septum in a 57-year-old woman with an 8-month history of an enlarging ulcer on the left columella/nasal septum and who had been taking nicorandil 20 mg twice daily for 2 years. © 2014 British Association of Dermatologists
DEAR EDITOR, Digital metastasis is a rare manifestation that typically signifies a high tumour burden and has a grim prognosis. Metastasis to the hand is considered rare, and has been reported to constitute 01% of all metastatic sites in the body. The most common presentation is a nodular osteolytic lesion.1 Pure digital cutaneous metastasis is extremely rare. We report British Journal of Dermatology (2014) 171, pp657–678
