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The spread of thyroid cancer to the skin rarely occurs. Of seven reported cases, three were identified as papillary cancers, or tumors consisting of papillae, which are nipple-like growths. A case is described of a 59-year-old man with papillary cancer of the thyroid gland. His thyroid was removed and he received radiation treatment to eliminate any residual cancer cells. The cancer recurred a year later and the patient was treated with a higher dose of radioactive iodine. The cancer recurred a second time on the right side of the neck and spread (metastasized) to the left thigh and right side of the chest. Despite further radiation treatment, the cancer cells continued to spread to the lungs and recurred on the left thigh and neck. Three years after the initial diagnosis of thyroid cancer, a red-brown node-like skin lesion was detected on the left side of his scalp, and was removed. The tumor tissue had similar microscopic features to that of other glandular tumors. The tumor secreted mucin, a carbohydrate and protein compound found in mucus, which is released by epithelial cells of the outer skin layer. The detection of epithelial mucin may be useful in differentiating this type of cancer from others. Thyroglobulin, an iodine-containing protein released by the thyroid gland, confirmed the diagnosis of papillary carcinoma of the thyroid gland. (Consumer Summary produced by Reliance Medical Information, Inc.)

Pyoderma gangrenosum is a skin disease that is characterized by the presence of ulcers (areas where the surface of the skin has come off and the underlying tissue is exposed). The disease is idiopathic (of unknown cause) and may occur in conjunction with other diseases. Pyoderma gangrenosum generally is treated with corticosteroids taken systemically or by injection. A previous article reported that a patient with pyoderma gangrenosum was treated successfully with cyclosporine. Therefore, the effectiveness of cyclosporine in healing skin ulcers in patients with pyoderma gangrenosum was evaluated. The seven patients in the study group had been treated previously with corticosteroids, but the ulcers did not heal. Cyclosporine therapy was started, on a daily oral dose of 8 to 10 milligrams of cyclosporine per kilogram of body weight. Out of the seven patients, three were healed, three were partially healed, and one had no response to the therapy. The duration of treatment ranged from three to seven months. The side effects of cyclosporine treatment included headache and nausea, reported by three patients, and altered liver function in three patients. Previous studies have shown that cyclosporine is toxic to the liver and can cause severe side effects including seizures and central nervous system disorders. Cyclosporine also suppresses the immune system, and may increase the risk of developing infections. It is concluded that cyclosporine is useful in the treatment of pyoderma gangrenosum when other treatments fail. Since cyclosporine suppresses the immune system, these results also suggest that the immune system may be involved in the development of pyoderma gangrenosum. (Consumer Summary produced by Reliance Medical Information, Inc.)

Squamoid eccrine ductal carcinoma (SEDC) is a rare cutaneous neoplasm that often manifests as a plaque or nodule in sun-exposed areas of older patients. Herein, the authors report the first case of SEDC in the eyelid. A 76-year-old man presented with a 2.5 × 1.5 mm area of left upper eyelid erythema, thickening, ulceration, and scaling with madarosis superotemporally just above the lash line. Full-thickness wedge biopsy demonstrated irregular epithelial tubules with nuclear atypia and focal squamous differentiation, consistent with SEDC. The patient underwent Mohs resection and has had no recurrence approximately 27 months after surgical removal. The authors present this case to raise awareness of SEDC to ophthalmologists as all previous cases have been described in the nonophthalmic literature. A full-thickness biopsy is recommended to avoid misdiagnosing SEDC as squamous cell carcinoma (SCC), a less aggressive tumor. With greater awareness, there may be increased recognition of this likely underreported, more malignant entity.The first reported case of squamoid eccrine ductal carcinoma in the eyelid highlights the importance of full-thickness biopsies of such lesions to avoid misdiagnosing them as squamous cell carcinoma.

First described in 1992, onychomatricoma is a rare, benign, fibroepithelial tumor of the nail matrix with few reported cases in the literature. The tumor predominately affects the fingers of Caucasian women during the 5th decade of life and is typically slow growing and painless. The authors present a unique clinical presentation of a giant onychomatricoma in a darker-skinned 60-year-old South Asian individual who presented with a large dome-shaped nail that was smooth, shiny, and green.

IMPORTANCE Mutations driving melanoma growth have diagnostic, prognostic, and therapeutic implications. Traditional classification systems do not correlate optimally with underlying melanoma growth–promoting mutations. Our objective was to determine whether unique dermoscopic growth patterns directly correlate with driving mutations. OBSERVATIONS We evaluated common driving mutations in 4 different dermoscopic patterns (rhomboidal, negative pigmented network, polygonal, and dark homogeneous streaks) of primary cutaneous melanomas; 3 melanomas per pattern were tested. Three of the 4 patterns lacked common mutations in BRAF, NRAS, KIT, GNAQ, and HRAS. One pattern, the dark homogeneous streaks pattern, had unique KIT mutations in the second catalytic domain of KIT in exon 17 for all 3 samples tested. Two tumors with the dark homogeneous streaks pattern turned out to be different primary melanomas from the same patient and had different sequence mutations but had an impact on the same KIT domain. CONCLUSIONS AND RELEVANCE While future study is required, these results have multiple implications. (1) The underlying melanoma-driving mutations may give rise to specific dermoscopic growth patterns, (2) BRAF/NRAS mutations in early melanomas may not be as common as previously thought, and (3) patients may be predisposed to developing specific driving mutations giving rise to melanomas or nevi of similar growth patterns.

BACKGROUND Human growth hormone (HGH) and insulin-like growth factor-1 (IGF-1) have been shown to play a role in the malignant transformation and progression of a variety of cancers. HGH is also known to upregulate molecular signaling pathways implicated in the pathogenesis of melanoma. Although HGH has previously been implicated in promoting the clinical growth of both benign and malignant melanocytic neoplasms, to our knowledge there are no conclusive studies demonstrating an increased risk of melanoma following HGH therapy. Nevertheless, there are reports of melanoma developing subsequent to HGH coadministered with either other hormones or following irradiation. OBSERVATION A 49-year-old white man presented with a new pigmented papule that was diagnosed as melanoma. The patient reported using HGH for 3 months prior to the diagnosis. His 51-year-old wife, who also was white, had also been using exogenous HGH for 3 months and had been diagnosed as having a melanoma 2 weeks prior. CONCLUSIONS Given the unlikelihood of 2 unrelated people developing melanoma within a short time span, it is reasonable to assume that a common environmental component (HGH or other shared exposure) contributed to the development of both melanomas. Because of the increased use of exogenous HGH as an antiaging agent, it is important to be aware of the growth-promoting effects of this hormone. Until better data are available that determines the true risk of exogenous HGH, its use as an antiaging agent merits increased surveillance.

Small and medium congenital melanocytic nevi are relatively common but present a small but significant risk of malignant transformation. Because prophylactic excision of all nevi is impractical, dermoscopic evaluation has a role in the clinical decision-making process. Dermoscopy of benign congenital nevi reveals a globular or homogenous pattern, black or brown dots and globules, small milia-like cysts within the globules, and terminal hairs. Dermoscopic criteria of melanoma are outlined here, with discussion of common scoring methods, the seven-point checklist, the ABCD rule, pattern analysis, and the Menzies criteria. Serial examination of congenital nevi with dermoscopy and excision of those lesions with malignant criteria are useful in the management of congenital melanocytic nevi.

Background:Chlorambucil is an alkylating agent that preferentially affects B cells over T cells and has been shown to be effective in the treatment of bullous pemphigoid. Objective:Our purpose was to determine whether chlorambucil is effective in the treatment of pemphigus. Methods:We retrospectively reviewed the medical records of 9 patients with pemphigus (7 with pemphigus vulgaris and 2 with pemphigus foliaceus) in whom therapy with other immunosuppressive regimens failed and who were subsequently treated with chlorambucil and prednisone. Results:There was clinical improvement in 6 of 9 patients and a decrease in indirect immunofluoresent antibody titers in 3 of the 5 patients who had titers drawn before and after treatment with chlorambucil. Three of the 9 patients failed treatment with chlorambucil, as evidenced by lack of improvement of lesions. Conclusion:Chlorambucil may be a potential adjuvant therapeutic approach with steroid-sparing effects in patients with pemphigus who have failed treatment with other immunosuppressive regimens. (J Am Acad Dermatol 2000;42:85-8.)

Cutaneous reactions to stinging insects are common and potentially serious conditions which may be presented to the dermatologist or primary care physician. Appropriate examination and history taking are critical to the evaluation of the patient. Principles of diagnosis of these events are discussed, and appropriate therapy is considered.

This department of AJDC is reserved for comment, criticism, observation, and discussion of "issues of current concern and importance for children's health." The Editor encourages our readers to express themselves on a variety of topics and issues. Further, we encourage the submission of unique and brief clinical and scientific observations that do not fulfill the criteria for original articles.Sir.—The occurrence of a rash, usually described as truncal, is one of the major criteria for the diagnosis of Kawasaki disease.1 The exanthem may appear morbilliform or scarlatiniform or may be composed of erythematous plaques or papules, thereby simulating urticaria or erythema multiforme.1,2 Less frequently, vesicles, pustules, or petechiae may be observed.1 Recently, three groups of investigators have described patients with Kawasaki disease in whom the exanthem either began or was most prominent in the diaper area.2-4 We report a 21-month-old child with Kawasaki disease whose

In Reply.—We appreciate the thoughtful comments of Drs Aschner and Aschner regarding the possible relationship of mercury exposure and the development of Kawasaki disease. As they note, a number of less obvious or frankly occult exposures to mercury exist, including that resulting from the use of certain diaper rinses. The patient described by us,1 however, wore disposable diapers, almost exclusively of the Ultrapampers variety. To our knowledge, mercury is not used in the manufacture of these products, thus obviating diapers as a source of potential exposure.Acrodynia is appropriately included in the differential diagnosis of the cutaneous and systemic manifestations of Kawasaki disease. While Kawasaki disease and acrodynia share certain similarities of presentation, these processes may be distinguished by their unique clinical manifestations.2,3 Kawasaki disease has a sudden onset and a self-limited course, with the majority of overt clinical findings resolving within 1 month. In contrast, acrodynia manifests an