Dermatologists and other health care practitioners are often visited by a patient with a

hand rash-sometimes accompanied by a foot rash also.

                                And,specialists like dermatologists often immmediately think of eczema,psoriasis,contact

dermatitis and, perhaps,even  a fungal infection.

                              As for myself,,in addition to taking a histoery of the rash  which includes how long he or she

has been aware of it,I also list any treatments already tried and I always ask the patient what he or she thinks

may have caused it.

                             In addition,I would immediately look at the patient's fingernails and elbows,looking for signs

of psoriasis which can be manifested by a red scaley plaque like surface on the elbows and ragged fingernails.

And,often I can make the diagnosis by the simple history and physical exam described above,especially if the

feet are also involved.

                           Also, a simple test for fungus not only includes taking a skin scraping for examination under

the microscope and /or a culture to try to grow it. In addition,a fungal rash is more likely to involve 2 hands

and 1 foot or 2 feet and 1 hand-thus,adding up to 3 rather than 2 hands and/or  2 feet .

                          However, the main thrust of this narrative is to impress upon the reader that there are many

more serious causes of hand and foot rashes than the above.

                         To begin with, Woringer Kolopp disease which is a cutaneous form of an internal cancer

called lymphoma is manifested by psoriasis like thickened plaques on the hands and also the feet. It is

a type of mycoses fungoides lymphoma which can be treated by surgical excision and radiation therapy

and could easily be mistaken clinically for psoriasis.

                        Another serious disease that can appear as a rash on the hands and feet is palmoplantar

syphilis which  could be misdiagnosed as palmoplantar psoriasis. In fact, secondary syphilis has often been

called one of the great  masqueraders in dermatology since it can mimic many types of skin didease and

is often missed when it can frequently diagnosed with a simple blood test.

                       Basex syndrome is a paraneoplastic(a set of signs and symptoms that is a consequence of

cancer in the body but is not due to the local presence of cancer cells)syndrome characterized by thickened

skin on the hands or feet(ie,acral areas) as well as on the ears and nose . It is associated with malignancies

of the upper aero digestive tract such as cancer of the esophagus.

                     And, I would not want to leave this topic by not discussing the entity known as "mechanic's

hands." Mechanics hands refers to a non-itching, thickened skin eruption accompanied by scaling,fissuring and

hyperpigmentation giving one the  appearance of the calloused hands of a manual laborer.

                   In my opinion,mechanics hands could be easily misdiagnosed as hand eczema. However,

over the years mechanics hands have become recognized as a clinical marker  for pulmonary disease

as well as occurring in a condition called Dermatomyositis . People with the latter have not only skin

rashes but a 20 % incidence of internal cancer.

                  Dermatomyositis is also characterized by muscle weakness,various other skin findings as

well as a marked sensitivity to the sun.,

                 In summary, I would urge patients with  dry thickened  skin on their hands(and feet) that has

not responded to topical and (sometimes)internal steroids  or  antifungals  to see their healthcare

provder  for a detailed history and physical exam of the entire body looking for telltale signs of internal

malignancy.

                    Coming soon.

                        As a young hospital pharmacist I often dispensed nitroglycerin tablets to relieve angina

(chest pain)  caused by coronary artery disease. Later,as a physician internist I prescribed it both

while working in the emergency room and on the hospital floors.

                        Now,as a physician dermatologist, I am amazed at the many uses of this valuable

medication even when  used topically(ie,not taken internally but applied to various parts of the outside

of the body.)

                      Nitroglycerin can be applied as an ointment to the skin where it again -as in the heart-

dilates or widens small blood vessels which have been vasoconstricted by various factors including

cold temperatures,emotions,hormones and even certain medications.In addition, autoimmune

diseases  such as systemic lupus erythematosus and systemic sclerosis can also cause this

condition.

                    This vasosparm or constriction of the blood supply to body parts such as the fingers

and toes is called Raynaud's phenomenon. And,if your fingers or toes have ever been exposed to

freezing cold temperatures even for a short time,you know how discomforting it is and how fast

you have tried to rewarm them.

                    Pernio,also called chilblains,is an inflammatory response to cold on the hands and

feet and is characterized by itching,red patches and swelling and blistering.

                   Also,topical nitroglycerin ointment has been used in dermatology to  treat small

tender nodules usually found on the outer rim of the ears (ie,the helix of the ear) which are

exquisitely sensive to pressure-especially when the patient lays on them in bed at night.

This condition is called chondrodermatitis nodularis helicis (literally inflamation of the ear

cartilage)

                   In addition,topical nitroglycerin ointment is also used to relieve the severe

pain caused by long term tears in the lining of the anal cavity,called anal fissures, by

reducing the pressure on them.

                  Two of the most common side effects of topical nitroglycerin include headaches 

and dizziness,although this is even less likely with the 1 % formulation than with the

2 % product.

                  In summary, topical nitroglycerin may be a safe,inexpensive and effective

therapy wherever increased cutaneous blood flow is needed.

                    Did you know that the new onset of dry skin-called ichthyosis or "fish scale skin" in adult life

and which does not respond to lubricating creams may be related to a type of internal cancer,especially a

type of malignancy  called Hodgkins disease which is a type of lymphoma although the use of some

medications and some benign conditions such as hypothyroidism and sarcoidosis as well as malnutrition

may be the cause.

                   Acquired ichthyosis (or dry skin) has also been related to other internal cancers including

reticulolymphosarcoma,T-cell lymphoma,multiple myeloma, and lung,breast and cervical cancers.

                 In addition,this dry skin of adulthood not responding to lubricating creams can also occur in

people suffering from leprosy,AIDS,tuberculosis,and typhoid fever.

                Also, carcinomas originating in many internal body areas have a very high frequency to

metastasize(ie,spread) to the skin. In one large reported study of internal cancers there was a 5 % spread

to the skin and in 0.8 % the skin metastasis was the first sign of the internal malignancy.

               These skin metastases often present as erythematous( red) ,painless,and rapidly growing

solitary or multiple skin nodules(a small rouded lump) on the skin  or under the skin .

             Usually, the location correlates with the underlying carcinoma,ie,breast cancers most commonly

spread to the anterior(ie,front ) chest wall.

             Again,the teaching point is to get an exam by your healthcare provider for any change in

color,shape,texture or size of your skin.

                    As we age many of us (depending on our genetic composition) notice the growth of pigmented

or tan,waxy,rough skin growths which appear to be mostly on the surface of the skin or almost "stuck on."

These skin growths or lesions are called seborrheic keratoses.

                  In my practice I have seen patients with just one or two of these growths and patients with

literally dozens of them. And,when they ask me where they have come from,my answer is almost always:

"Momie and Daddie."

                And,research indicates that only about 1 % of this "benign" type undergoes malignant

transformation to a form of skin cancer-especially,the squamous cell carcinoma.

              However,the abrupt or sudden eruption of multiple seborrheic keratoses that rapidly increase

in size and number,often itchy, can be caused by an associated internal cancer-mostly a gastrointestinal

adenocarcinoma. This is called the sign of Leser-Trelat and is called a paraneoplastic syndrome

since  the skin manifestations of the multiple seborrheic keratoses is thought to be mediated by

hormones secreted by the internal cancer or by the body's immune response against the tumor.

              Although,some question that this abrupt or sudden onset of seborrheic keratoses is a sign of

internal cancer since seborrheic keratoses and cancer are common findings in the elderly anyway.

            In addition,it is encumbent on any clinician ,especially when examining a patient with

multiple seborrheic keratoses,not to do a cursory exam since a malignant  melanoma skin cancer(which can

look very much like a seborrheic keratosis) could be easily missed in such a patient.

          Again,the bottom line is to see your clinician for regular skin exams and especially if

you notice any change in size,color,shape or behavior of any skin lesion.

                         We are on the threshold of expanded use of onycolytic viruses for a number of 

malignancies including malignant melanoma. An oncolytic virus is a virus that preferentially

infects and kills tumor cells.

                        The drug Talimogene laherparepvec (TVEC) is a type one herpes simplex virus

(HSB) genetically modified to preferentially replicate in the tumor cells of malignant melanoma.

                        As the infected cancer cells are destroyed by the virus,,the virus releases new

infectious virus particles called virions to help destroy the remaining tumor.

                       Oncolytic viruses are thought not only to cause direct destruction of the tumor

cells,but also to stimulate host antitumor immune responses.

                      In addition,researchers are now using a modified poliovirus to unleash the

body's ability to fight cancer.

                     Also,these cancer killing viruses may be utilized for a number of malignancies 

including a type of brain cancer called glioblastoma,a blood cancer called multiple myeloma,

a cancer of the lining of the lung cavity called mesothelioma,and carcinomas of the breast,

lung,prostate,kidney,liver,pancreas,bladder,ovary and head and neck.

                  Only time and additional research will tell if these oncolytic viruses will

increase cancer patient survival  time or cure rates.