This document discusses various cutaneous manifestations that can be associated with internal malignancies. It describes how cutaneous metastases can directly involve the skin through tumor extension or metastases. It also discusses indirect involvement through paraneoplastic dermatoses where skin findings are caused by substances secreted by the tumor. Common cutaneous findings are described for different malignancies as well as criteria for diagnosing paraneoplastic dermatoses. Cutaneous manifestations are grouped into categories including proliferative/inflammatory dermatoses, genodermatoses, immunodeficiency syndromes, and hormone-secreting tumors. Specific examples of associations between cutaneous findings and internal cancers are provided.

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2. • There may be direct or indirect involvement
of skin in various visceral malignancies.
• Direct involvement indicates the presence of
tumor cells in the skin due to direct tumor
extension or metastases.
• Cutaneous metastases from cancers of the
lung , large intestine, and kidney are most
prevalent in men.

3. • Cancers of breast, and large intestine are most
prevalent in women.
• In case of indirect involvement, there is absence of
neoplastic cells in the skin, and this is considered as
a dermatological paraneoplstic syndrome.
• Indirect involvement caused by a variety of factors
(inflammatory,proliferative,metabolic
factors)related to the neoplasia, such as
polypeptides, hormones, cytokines,growth factors
that act as a mediators, interfering with cell
communication, and consequently, with its activity.
• Helen Ollendorff Curth proposed criteria for
diagnosis of a paraneoplastic dermatosis .

4. • 1.The cutaneous manifestation and internal malignancy
may be diagnosed simultaneously or with in a short
interval.
• 2.Both the conditions can run a parallel course,the
dermatoses may clear on treatment of malignancy and
relapse if the malignancy recurs.
• 3.Specific type of neoplasms and the para neoplastic
conditions occur the skin manifestation is not very
common in general population .
• 4. A statistically significant association is reported
between the cutaneous manifestation and the internal
malignancy.
• 5.A genetic association exists between the internal
maignancy and specific cutaneous disease

5. Cutaneous manifestations of internal
malignancies are grouped into 4 categories:
• 1.Proliferative and inflammatory dermatoses
associated with internal malignancies.
• 2.Genodermatoses with cutaneous tumors
and internal malignancies.
• 3.Inherited immunodeficiency syndromes and
internal malignancies.
• 4.Hormone secreting tumor with cutaneous
manifestations.

7. • Velvety, verrucous,hyper pigmented plaques on
flexures and neck.
• Papillomatous changes in the oral cavity .
Associated malignancy:
• Adenocarcinoma of the stomach.

8. Cutaneous manifestation:
• Hyperkeratosis in a wrinkled or ridged
pattern on the palms(honey comb
appearance) and the dorsal surface of
the large joints.
Associated malignancy:
• Squamous cell carcinoma of the lung.

9. Cutaneous manifestations :
• Sudden appearance and/or rapid
increase in size of multiple
seborrheic keratoses often
pruritic.
Associated malignancy:
• carcinoma of the gastrointestinal
tract.
• Tumors of the female
reproductive system.
• lympho proliferative disorders.

10. Cutaneous manifestations:
• Symmetrical, psoriasiform and erythematous to
violaceous plaques on nose, ears, and distal
extremities.
• Dystrophic nails are pruritic.
• The malignancy and cutaneous findings are
concurrent.
Associated malignancy:
• carcinoma of the upper respiratory, and
digestive tracks.

12. Cutaneous manifestation:
• Howel evans syndrome-{focal palmo
plantar keratoderma,keratosis pilaris,oral
hyper keratosis.}
• Triple palms.
• Punctate arsenical keratoses.
Associated malignancy:
• Esopageal carcinoma,adenocarcinoma of
the gut, lung cancer, basal and squamous
cell cancers, squamous cell cancers of
upper aero digestive tract and urinary
carcinomas.

13. :
• Cutaneous manifestation--genaralised xerosis and
ichthyotic scaling.
• Associated malignancy--hodgkins lymphoma,lympho
proliferative disorders.
:
• Cutaneous manifestation--Symmetrical circular scaly
lesions on the trunk described in japanese.
• Associated malignancy--hepato cellular cancer,cancers
of gut ,prostate, myeloproliferative disorders.
:
• Cutaneous manifestation--genaralised erythema and
scaling.
• Associated malignancy--cutaneous T- cell
lymphoma(sezary syndrome),lympho reticular
malignancies.

14. Cutaneous manifestation:
• extensive, silky nonpigmented
lanugo hair on the face, neck,
trunk, and on the
extremities.(previously seen hair
less by the patient).
• Painful glossitis,angular
cheilitis,and swollen red
fungiform papillae on the anterior
half of the tongue.
• Hyper trichosis usually antedates
the malignancy.
Associated malignancy:
• Adeno carcinoma of the gastro
intestinal tract,lung cancer.

15. Cutaneous manifestation:
• Adult onset,
• - classical heliotrope rash(purplish-red
rash occurs on the face),
-gottrons papules(Small erythematous or violaceous,
flat papules occur over the knuckles, on the dorsa of
the finger joints and around the nail folds) .
-proximal myopathy.
• The risk of underlying malignancy is highest with in the
first year, after the diagnosis of either condition and
then declines.
Associated malignancy:
• ovarian and breast cancers in females .
• Lung and prostate cancers in males.

17. Cutaneous manifestation:
• Infiltrated and violaceous papules and
nodular lesions on the
hands,knees,shoulders,wrists,hips,elbows
ankles ,feet,and spine,associated commonly
with arthritis mutilans and the classic opera
glass hand.
Associated malignancy:
• Pancreatic adenocarcinoma,squamous cell
cancer of the lung,and metastatic
melanoma.

18. Cutaneous manifestation:
• Acute onset of erythematous,tender
papules,plaques,or nodules on the face,
extremities and upper trunk with
vesiculation or pustules on the surface.
Associated malignancy:
• Myeloproliferative disorders
commmonly acute myelogenous
leukemia.

19. Cutaneous manifestation:
• large spreading purulent ulcers,with
cyanotic over hanging borders .
• Cutaneous disease and malignancy
often present concurrently and run
a parallel course
Associated malignancy:
• Hematological malignancy,
• Monoclonal gammmopathies,
• Myeloma solid tumors,Non
hodgkins lymphoma,

20. Cutaneous manifestation:
• palpable purpura
Associated malignancy:
• Myelo proliferative disorders.

21. Figurate erythema:
Cutaneous manifestation:
• Erythema gyratum
repens(multiple wavy urticarial
bands with fine scales,migratory
with wood grain like pattern
),,erythema annulare
centrifugam.
Associated malignancy:
lung, esophageal,brest,cancers

22. Cutaneous manifestation:
Extensive areas of purpura,which may
figurate,linear ,or diffuse,typically non palpable,may
be associated with disseminated intravascular
coagulation.
• Trousseau syndrome:migratory superficial
thrombophlebitis,and multiple deep venous
thrombosis,on the neck ,chest abdominal wall,and
limbs.
Associated malignacy:
• Hematological malignancies,tumors arising in the
pancreas,lung, prostate,or hematopoietic system.

23. Cutaneous manifestation:
• Paraneoplstic pemphigus,
• Cicatricial pemphigoid,
• Dermatitis herpetiformis,
• Epidermolysis acquisita.
Associated malignacy:
• Catleman tumor,
• Non hodgkins lymphoma,thymoma,
• Follicular dendritc cell sarcoma and chronic lymphocytic
leukemia,
• Adenocarcinomas,intestinal lymphomas,lympho reticular
tumors.

24. PIGMENTORY DISORDERS
Cutaneous manifestation:
• Diffuse hyper pigmentation in hemochromatosis
and metastatic melanoma,
• Diffuse cutaneous and mucosal hyper pigmentation
can occur in the Cronkhite -Canada syndrome.
• Vitiliginous depigmentation may be seen with
melanoma.
Associated malignancy:
• liver cancer,melanomas.

25. METABOLIC DISORDERS
:
Cutaneous manifestation:
• Genaralised waxy papules,nodules,
purpura,macroglossia,
Associated malignancy:
• Myelomas

26. Cutaneous manifestation:
• Linear waxy,lichenoid papules,pseudo
scleroderma,
Associated malignancy:
• Myelomas, plasma cell dyscrasias.

27. cutaneous manifestation:
• Erythematous plaques at site other than the
breast ,most often on the axillary ,inguinal
fold,vulva,or scrotum.
Associated malignancy:
• Adenocarcinoma of the rectum or anal
canal,underlying sweat gland ,sebaceous and
apocrine carcinomas.

28. Cutaneous manifestation:
• Hypertrophic osteoarthropathy a manifestation of
sub periosteal new bone formation occurs along the
shaft of the phalanges.
Pachydermoperiostosis:
• clubbing associated with acromegaloid features.
Associated malignancy:
• Lung cancer and metastatic tumors to the lung.
• Pitutory tumor in case of Acromegaly

29. cutaneous manifestation:
• Yellow discoloration of nails,thickened nails with
slow growth,some times nails present with loss of
cuticle and erythema and edema of the proximal
nail folds.
Associated malignancy:
• Mycosis fungoides,laryngeal carcinoma,
• Gall bladder carcinoma,bronchial carcinoma,brest
cancer,
• Non hodgkin lymphoma,and endometrial cancer.

30. .

31. • Cutaneous features:
Facial trichilemmomas.(-
proliferation of the external root
sheath of the hair follicle results
in small, non-specific papules on
facial skin).
• Acral keratoses.
• Lipomas .
• Angiomas.
Associated malignancy:
• Breast cancer ,
• Thyroid cancer,
• Endometrial cancer, malignant
transformation of gastro
intestinal polyps.

32. Cutaneous features:
• Fibro(tricho)folliculomas(a small, skin-
coloured papule on the face, usually
present from birth)
• Trichodiscomas(-hamartoma of The
Harscheibe a slowly reacting
mechanoreceptor associated with the hair
follicle.
• multiple, discrete, flat-topped papules 2–
3 mm in diameter,they occur mainly in
the central area of the face).
• achrochordans,
Associated malignancy:
• Renal cancers

33. Cutaneous features:
• Sebaceous adenomas,
• keratoacanthomas. (firm, rounded, flesh-
coloured or reddish papule--central part of the
face,the dorsum of the hand,wrist and
forearm commonly affected.)
Associated malignancy:
• Colorectal, genito urinary cancers.

34. GARDNER SYNDROME
Cutaneous features:
• Epidermoid cysts,osteomas,
Associated malignancy:
• Colorectal,thyroid,duodenal,pancreatic
cancers,hepatoblastoma,medulloblastoma(tur
cot syndrome:gardners syndrome with CNS
tumors)

35. Cutaneous features:
• CALMS, axillary freckling,neurofibromas.
Associated malignancy:
• Malignant peripheral nerve sheeth
tumor,leukemias,breast cancers.
Cutaneous features:
• Schwanomas,neurofibromas.
Associated malignancy:
• occasional malignant transformation of
ocoustic neuromas,meningiomas

36. cutaneous features :
• Adenoma sebaceum consist of hyperplastic blood
vessels and sebaceous glands of immature hair follicles.
• shagreen patch(, an irregularly thickened, soft,slightly
elevated, skin-coloured plaque on the lumbo sacral
region.)
• ash leaf macule(multiple, scattered and have a shape
of the leaflet of the mountain ash )
• confetti macules.
• koenens tumors(smooth, firm, flesh-coloured
excrescences emerging from the nail folds.)
• oral fibromas.
Associated malignancy:
• Renal cancers,CNS tumors(usually benign)

38. Cutaneous features:
• Multiple basalcell carcinomas.
• Acralpits,epidermalcysts milia.
Associated malignancy:
• Medulloblastomas
cutaneous features:
• Freckles,lentigenes,
• Poikiloderma,
• Basalcell carcinomas,squamous cell carcinomas,melanomas.
Associated malignancy:
• leukemia,cancersofbreast,lung,pancreas,stomach,testes.

39. Cutaneous features:
• Multiple melanomas, Atypical melanocytic naevi.
Associated malignancy:
• Pancreatic cancer.
Cutaneous features:
• Leiomyomas
Associated malignancy:
• Renal cancers

41. Blooms syndrome
Cutaneous features:
• Malar rash,
• Telangiectasias.
Associated malignancy:
• Leukemia,lymphoma,and adenocarcinoma of
the gastro intestinal tract.

42. (poikiloderma congenitale)
Cutaneous features:
• Erythema ,telangiectasia,dyspigmentation,and
atrophy on the face, extensor extremities,and
buttocks.
• Alopacia,and dystrophic nails.
Associated malignacy:
• Osteo sarcoma,fibrosrcoma,gastric
carcinoma,and cutaneous squamous cell
carcinoma.

43. Cutaneous features:
• Telangiectasias initially on the bulbar conjunctiva, other sites
include cheeks, corners of the eyes and the ears.
Associated malignancy:-
• Leukemia,
• Lymphoma.
cutaneous features:
• Purpura,eczema,secondary infectious complications.
Associated malignancy:
• Lymphoreticular malignancy,
• Usually non hodgkins lymphoma.

45. • Cutaneous manifestation:
• Necrolytic migatory erythema
• Associated malignancy:
• Neoplastic proliferation of the glucagon
secreting alpha cells of the pancreas.

46. Necrolytic migratory erythema
• Characterised by a widespread, eruption with
uneven patches of intense erythema,
• Superficial flaccid vesicles,and bullae these
rupture and form extensive erosions and crusted
plaques.
• Confluent ,annular,pruritic,and painful plaques
develop.
• Course:
• typically waxing and waning in cycles of 10-14
days

48. Sites of involvement:
Perineum,
abdomen,
groin,
buttocks and lower extremities.(sites of pressure
and trauma).
Muco cutaneous findings :
cheilitis,
Atrophic glossitis,
alopacia.

49. • Differential diagnosis:
acrodermatitis enteropathica,
Essential fatty acid deficiency,
Annular lupus erythematosus,
Drug reactions,
Contact dermatitis,
Deficiencies of vitamins-
niacin,riboflavin,pyridoxine.

50. Treatment:
• Complete resection of underlying tumor.
• NME is also seen in celiac disease, ulcerative
colitis,chrons disease,hepatic cirrhosis,hepato
cellular carcinoma,lung cancer, tumors that
secrete - insulin like growth factor.

51. Cutaneous manifestations:
• Flushing,Permanent facial cyanotic flush and
telangiectasia,resembling rosacea.
• Leonine facies due to persistant facial erythema and
edema,
• Pellagroid rash.
Associated malignancy:
• Carcinoid tumors are most often found in the
appendix or small intestine.
• Extra intestinal carcinoids may arise in the bile
ducts, pancreas, stomach, ovaries, or bronchi.

53. MEN
Cutaneous manifestation:
• Carcinoid like syndrome in MEN 2A,
• Mucocutaneous lesions occur only in MEN 2B
• (multiple mucosal neuromas syndrome).
Associated malignancy:
• Medullary thyroid cancers

54. Ectopic ACTH
Cutaneous manifestations:
• Intense hyper pigmentation.systemic feature are
common—hypokalemic metabolic
alkalosis,hypertension,glucose intolerence,or frank
diabetes ,weight loss, myasthenia gravis like syndrome
manifested as profound proximal muscle weakness.
• Associated malignancy:
• Small cell carcinoma of the lung,
• carcinoid tumors,
• pancreatic islet cell tumors,pheochromocytoma.

56. • Cutaneous manifestations of metastases occur
in the form of flesh colored to violaceous
nodules,commonly located close to the
primary neoplasm.
• Cutaneous involvement frequently seen in the
malignancies that spread through the
lymphatics, such as cancers of the
breast,oropharynx,and urinary bladder.

57. Types of
cutaneous
manifestation
Sailent features
nodular Most common clinical presentation,usually asymptomatic,solitary,multiple
Carcinoma
erysipeloides
Erythematous,warm, tender patches or plaques with raised ,well defined
margins,resembling erysipelas affecting the breast and the surrounding
skin may progress to carcinoma en cuirasse due to lymphoedema
Carcinoma en
cuirasse
Erythematous plaque with induration and infiltration of the chest wall
,localised lymphedema gives a peau d orange appearance to the skin.
telangiectactic Purpuric nodule,papules or plaques on the chest wall,may be continuous
with a surgical scar.
zosteriform Dermatomal dissemination of metastases in various clinical patterns
nodular,papulo vesicular, or vesiculo bullous.
Alopacia
neoplastica
Area of hair loss as a result of a primitive tumor that has metastasized to
the scalp- may appear as single or multiple areas of cictrial alopacia.

59. LE
• 1.Umbilical subcutaneous nodule caused by a
metastases from an intra abdominal
malignancy.
• 2.Malignancies associated:
• Gastric adeno carcinoma,
• Cancers of the colon,pancreas,and ovary.