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.

            Merkel cell carcinoma (MCC) is a very aggressive skin cancer(please see my two previous blogs:

"Merkel Cell Carcinoma,"and Merkel cell carcinoma-a blood test to predict spread" posted on 04/13/2014.

           The incidence of MCC has increased markedly by 95 % during the past decade as compared to

malignant melanoma (57 %) and all solid tumors (15 %).

          Current estimates are for about 2500 new cases in the USA yearly and increase to 3250 cases

annually by 2025. Much of this increase is attributed to an older population,especially the aging of the

Baby Boomers.

          MCC is not only very prone to spread internally(ie,metastasize) but can be very difficult to diagnose

even by astute clinicians since it can appear simply as a firm red,purple or even skin-colored lump or

bump which could easily be mistaken for a cyst or blocked pore or hair follicle.

          Merkel cell carcinoma is caused in part by exposure to the sun and is found on the head or

neck in about 50 % of cases and on the extremities in about 40 % of patients.

         And, merkel cell carcinoma is aggressive and has a strong tendency to recur,to spread

to regional lymph nodes  and to metastasize.

           So,early detection is vital since when caught early the chance of cure increases dramatically

and is better than 90 %.

           An exciting new development in the treatment of metastatic MCC is the first FDA approved

treatment for adults and pediatric patients 12 years of age and older,including those who have not

yet received chemotherapy. 

           The medication called Avelumab is another advance in cancer treatments called biologics

or. monoclonal antibodies which help the body's immune system to fight the cancer.