Fig 1. Extensive ulcerated brown-black nodules and tu-mors deforming the chest and superior abdominal wall.

Fig 1. Massive scrotal edema and inguinal nodules withdraining sinus tracts in patient with chronic hidradenitissuppurativa.

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consistent with HS, including fibrosis, acute andchronic inflammation, and dilated superficial lymph-atics. Stains for fungi, acid-fast bacilli, and bacteriawere negative. In addition, the biopsy specimen didnot reveal any evidence of Kaposi sarcoma, and HIVtesting yielded negative results. Diurnal bloodscreening was performed; there was no eosinophilia,nor was there a filarial ‘‘dance sign’’ noted in thenegative ultrasound examination of lymph nodes.Evaluation by the urology service failed to documentany structural abnormalities; ultrasound demon-strated no evidence of hydronephrosis, bladder emp-tying was unremarkable, and a magnetic resonanceimaging scan revealed only soft tissue edemawithoutidentifying any lymphadenopathy. The diagnosis ofscrotal elephantiasis secondary to HS with multipleepisodes of lymphatic scarring was made, and thepatient was referred to psychiatry for mental healthevaluation and urology to discuss surgical options.

Elephantiasis has been a recognized complicationof inguinal node irradiation, filarial infection, tumorinvolvement, and surgical lymphatic destruction, butit has only been reported in association with HS on afew occasions—and never in the English-languagedermatology literature outside of Alikhan et al’s1

excellent review of the subject.2-4 While rare, webelieve it is important to remember that this grossdeformity, caused by profound scarring of thelymphatics, is a potential consequence of untreated,chronic inguinal HS, because elephantiasis can resultin severe psychological disturbances, social isola-tion, and functional impairment.

Laurie M. Good, MD,a Shayla O. Francis, MD,b andWhitney A. High, MDc

Dermatopathology Research Fellow,a ResidentPhysician,b and Attending Physician,c Depart-ment of Dermatology, University of ColoradoHealth Sciences Center, Denver, Colorado

Funding sources: None.

Conflicts of interest: None declared.

Reprints not available from the authors.

Correspondence to: Whitney A. High, MD, AssociateProfessor, Dermatology and Pathology, Univer-sity of Colorado Health Sciences Center, PO Box6510, Mail Stop F703, Aurora, CO 80045-0510.

E-mail: Whitney.High@ucdenver.edu

REFERENCES

1. Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a

comprehensive review. J Am Acad Dermatol 2009;60:539-61.

2. Chaikin DC, Volz LR, Broderick G. An unusual presentation of

hidradenitis suppurativa: case report and review of the litera-

ture. Urology 1994;44:606-8.

3. Konety BR, Cooper T, Flood HD, Futrell JW. Scrotal elephantiasis

associated with hidradenitis suppurativa. Plast Reconstr Surg

1996;97:1243-5.

4. Baughman SM, Cespedes RD. Unusual presentation of hidrad-

enitis suppurativa with massive enlargement of penis. Urology

2004;64:377, e19-20.

doi:10.1016/j.jaad.2009.08.011

Extensive ulcerated pigmented nodules

To the Editor: Pigmentation of cutaneous metastasesis a rare phenomenon. We report a case of a womanwith breast carcinoma that presented as ulceratedand pigmented metastatic nodules.

Fig 2. A, Neoplastic aggregates between collagen bundles throughout the dermis. B,Neoplastic cells within the dermis and as pigmented nests within the epidermis. C, Intraep-idermal collections of atyipical pigmented epithelial cells simulating nests of atypical melano-cytes. D, Immunohistochemical stain for CK7 decorates epidermotropic metastaticadenocarcinoma of the breast. (A-C, Hematoxylineeosin stain; D, CK7 immunostain; originalmagnifications: A, 320; B, 3100; C, 3400; D, 3200.)

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VOLUME 64, NUMBER 5Letters 995

A 57-year-old African American woman with amedical history significant for diabetes and asthmapresented to the emergency room with worseningchronic lower back pain in March 2007. Uponadmission, she was found to have ‘‘necrotic masses’’involving both breasts and her chest wall. Thepatient attributed the lesions to poorly healing burnsshe had sustained while cooking 2 years earlier. Achest radiograph revealed right-sided pleural thick-ening and effusion and a small opacity overlying theright fourth rib. A computed tomographic scan of herchest revealed extensive right breast scarring, a softtissue mass in the right pole, and right axillary andleft posterior cervical lymphadenopathy. The der-matology department was asked to consult. Thephysical examination revealed extensive ulceratedbrown-black nodules and tumors deforming thechest and superior abdominal wall (Fig 1). A punchbiopsy was performed, showing neoplastic cellularaggregations between collagen bundles throughoutthe dermis and pigmented nests within the epidermis(Fig 2, A-C ). Immunohistochemical stain for CK7was consistent with epidermotropic metastaticadenocarcinoma of the breast (Fig 2, D).

Cutaneous metastases represent a relatively rarephenomenon in patients with internal malignancy,with a reported overall incidence of 0.7% to 9%. Themost common site of origin for epidermotropicmetastases is breast carcinoma in women and lungcarcinoma in men.1 Although cutaneous metastasesoften present during advanced stages of malignan-cies, they occasionally may be the first sign of avisceral carcinoma.

Cutaneous breast metastases may have multipleclinical presentations. Dermal nodules represent themost common clinical presentation, occurring inapproximately 10% of patients. In rare cases, pig-mented metastases have been described—with fewreports since the initial description by Jacoby et al2

nearly 30 years ago. This unusual epidermotropicpigmented clinical subtype makes clinical, derma-scopic,3 and histologic4 differentiation from mela-noma challenging.

Several mechanisms of pigmentation of epidermo-tropic breast metastases have been proposed. In onecase, molecular analysis of tumoral clusters revealedcolonization by melanocytes and high levels of mel-anocyte chemotactic factor. This suggests that secreted

Fig 1. A and B, Patient at presentation, with scalperythema, pustules, and alopecia.

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homingmoleculesmayplay a role in the pathogenesisof pigmentation of cutaneous metastases.5

In addition, metastatic infiltrates within theepidermis may lead to a blockade of the normaltransfer of melanin to keratinocytes. Phagocytosis ofmelanin from melanocytes by the epithelial cells ofthe carcinoma has been shown (most notably inpigmented adenocarcinoma of the rectum).

To our knowledge, we present one of the mostextensive and destructive cases recorded in theliterature of an underlying breast carcinoma present-ing as ulcerated and pigmented metastatic nodules.

Adam Friedman, MD,a Marc Jacobson, MD,a,b andRanon Mann, MDa

Division of Dermatology, Department of Medicinea

and the Department of Pathology,b Albert Ein-stein College of Medicine, Bronx, New York

Funding sources: None.

Conflicts of interest: None declared.

Correspondence to: Adam Friedman, MD, Divisionof Dermatology, Department of Medicine, AlbertEinstein College of Medicine, 3411 Wayne Ave,2nd floor, Bronx, NY 10461

E-mail: ajf0424@yahoo.com

REFERENCES

1. Krathen RA, Orengo IF, Rosen T. Cutaneous metastasis: a meta-

analysis of data. South Med J 2003;96:164-7.

2. Jacoby R, Roses DF, Valensi Q. Carcinoma of the breast

metastatic to the skin and simulating malignant melanoma.

In: Ackerman AB, editor. Pathology of malignant melanoma.

Chicago: Masson; 1981. pp. 263-7.

3. Wyatt AJ, Agero AL, Delgado R, Busam KJ, Marghoob AA.

Cutaneous metastatic breast carcinoma with melanocyte colo-

nization: a clinical and dermoscopic mimic of malignant mel-

anoma. Dermatol Surg 2006;32:949-54.

4. Requena L, S�anchez Yus E, N�u~nez C, White CR Jr, Sangueza OP.

Epidermotropically metastatic breast carcinomas: rare histo-

pathologic variants mimicking melanoma and Paget’s disease.

Am J Dermatopathol 1996;18:385-95.

5. Konomi K, Imayama S, Nagae S, Terasaka R, Chijiiwa K,

Yashima Y. Melanocyte chemotactic factor produced by

skin metastases of a breast carcinoma. J Surg Oncol

1992;50:62-6.

doi:10.1016/j.jaad.2009.08.010

Scarring alopecia associated with theepidermal growth factor receptor inhibitorerlotinib

To the Editor: Erlotinib (Tarceva; Genentech, SouthSan Francisco, CA) is an oral anticancer agent thatblocks the function of the epidermal growth factor

receptor (EGFR) and has been approved by the USFood and Drug Administration for the treatment ofnonesmall cell lung and pancreatic cancers. Therapyis frequently complicated by multiple cutaneousadverse effects ranging from follicular papulopustu-lar (‘‘acneiform’’) eruptions, xerosis, nail changes(including paronychia and pyogenic granulomas inthe lateral nail folds), and hair texture changes.1

Previous reports exist of both nonscarring and scar-ring alopecia with gefitinib (Iressa; AstraZeneca,Wilmington, DE), another EGFR inhibitor; however,to date there are no reports of scarring alopecia witherlotinib.

A 77-year-old white female with metastatic non-small cell lung cancer was referred to our departmentby her oncologist for the evaluation of scalp ery-thema, pustules, and alopecia (Fig 1). The scalperuption started 18 months before the referral andwithin 2 weeks of initiating therapy with erlotinib100 mg daily for progressive metastatic disease. She