Illustrated - Dermatological signs of malignancy

Contributed by Dr Jean Watkins, a retired GP in Hampshire.

Acanthosis Nigricans

In this condition there is hyperpigmentation and hyperkeratotic thickening of the skin in the flexures, and small papillomatous lesions that may also appear on mucous membranes of the mouth, particularly if associated with malignancy. These changes are often related to benign conditions, such as obesity and hyperinsulinaemia, or are induced by drugs, such as steroids. However, if they develop suddenly in middle age, particularly in the absence of obesity, it may indicate underlying malignancy (particularly of the stomach or bowel). These tumours can be aggressive.

Acquired ichthyosis

This condition is characterised by areas of rough, scaly dry skin. There may be areas of hyperkeratosis on palms and soles. In many, this is a congenital problem inherited through an autosomal dominant gene, with symptoms usually starting in the first year of life and continuing into old age.

However, first appearance of such symptoms in adults is usually associated with an underlying problem, such as thyroid disease, or is related to drugs, such as cimetidine. Also consider underlying malignancy. Successful treatment of any underlying problem should improve the ichthyosis.

Inflammatory breast cancer

In this type of breast cancer malignant cells infiltrate the skin and lymphatics causing inflamed, hot and oedematous skin with a patch of reddened, swollen skin that mimics the skin of an orange (peau d'orange). It is easily mistaken for infective cellulitis, and if axillary or cervical lymph nodes are enlarged it is possible that infection could be diagnosed.

Usually there is no palpable lump in the breast itself. This type of breast cancer is more common in older women; referral to a breast clinic is recommended if it does not respond to antibiotics and/or is not improving after a week.

Paget's disease of the nipple

This condition presents with unilateral, apparent eczematous change or ulceration of one nipple and the areola, which is associated with an underlying intraductal or infiltrating carcinoma. The lesion is sharply demarcated and may itch, ooze and bleed. Eventually the nipple is destroyed. The condition usually develops in women aged 50 to 60 years and progresses slowly. Diagnosis should be confirmed by biopsy; a mammogram is required to determine the underlying problem, which may or may not be palpable manually. Referral to a breast clinic is necessary.

Extra-mammary Paget's disease

Similar eczematous changes occasionally occur around the genitalia, affecting the vulva or perianal area, glans penis or genitoscrotal area. This is a rare cutaneous adenocarcinoma, usually starting in the epidermis, but often associated with underlying adnexal carcinoma and internal malignancy.

Perianal Paget's disease is associated with a GI malignancy, while in men there is more likely to be a genitourinary carcinoma. The diagnosis is confirmed by biopsy and wide excision of the area is recommended.

Horner's syndrome

The symptoms of Horner's syndrome develop as the result of involvement of the sympathetic nerve in the neck or brain stem. The patient may have certain specific signs, such as unilateral ptosis, miosis of the pupil or enophthalmos on the affected side with loss of sweating on that side of the face.

A number of different neurological problems, as well as dissection of the carotid artery, can lead to these changes but a carcinoma at the apex, upper lobe of the lung can also be the cause. Chest X-ray is required to exclude this.

Skin secondaries

These may present before there is diagnosis of a primary carcinoma or as in this case of a woman who had undergone a mastectomy for breast cancer years before. Firm, rubbery, skin-coloured/brown/bluish black nodules develop in the skin. Here the nodules had developed in the lie of the scar and were clearly related to the old malignancy.

Where there is no previous history, a thorough search for the primary carcinoma should be made. A clue to its site may come from biopsy of the lesion. Secondaries in breast cancer most commonly occur on the chest, scalp and neck.


Symptoms of this condition include a marked heliotrope rash on sun-exposed areas, such as the face and limbs, including the palms where there is also erythema, thickening and scaling. Other signs include erythema and splinter haemorrhages at the base and sides of the nail plate. Associated myopathy affects the proximal muscles of the limbs.

The cause is unknown but there may be underlying malignancy which should be identified because prognosis can be poor. Other causes include genetic factors and viral infections; treatment involves oral corticosteroids.

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins


Already registered?

Sign in

Just published


GP leaders demand urgent funding to maintain safety in general practice

Underfunding and staff shortages in general practice have put patient safety at risk,...

Labour shadow health secretary Wes Streeting

Labour plans neighbourhood walk-in GP centres open seven days a week

Labour would set up new neighbourhood walk-in GP hubs that could be open seven days...

BMA sign

What questions is the BMA asking GPs to shape its vision for general practice?

GPs are being asked for their views on continuity of care, contracts, safe working...

Scotland's cabinet secretary for health and social care Michael Matheson

Primary care will need bigger share of NHS funding in future, Scottish health secretary says

The share of NHS funding that goes to primary care will have to increase if the health...

Sign pointing to hospital

NHS England seeks to clarify GPs' responsibilities when using advice and guidance

New guidance from NHS England has set out the clinical responsibilities and medicolegal...

Widespread joint pain - red flag symptoms

Presentations and red flag symptoms that may alert you to potentially serious conditions...