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The incidence of melanoma continues to increase. In the absence of a defined and preventable etiology, early recognition and proper management offer the best hope for prolonged survival and cure. Clinically suspect lesions must be biopsied for diagnostic confirmation and histologic information. Reliable prognostic information can be gained from histologic and clinical parameters, which are described.

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Extramammary Paget's disease is a rare cutaneous adenocarcinoma, usually of epidermal origin and glandular differentiation and frequently associated with an underlying adnexal carcinoma and perhaps with underlying internal malignancy. One hundred ninety-seven cases of extramammary Paget's disease (196 cases reported in the English literature from 1962 to 1982 and one case of my own) are reviewed. It remains a rare cutaneous malignancy that occurs primarily in elderly people. It is seen more frequently in women than in men and occurs predominantly in vulvar and perianal locations. Twenty-six percent of patients with this disease will ultimately die of it or an associated internal malignancy. Twenty-four percent of patients with the disease have an associated underlying cutaneous adnexal adenocarcinoma. These patients have a higher mortality rate--46%--than patients with extramammary Paget's disease without underlying cutaneous adnexal adenocarcinoma. Twelve percent of patients with extramammary Paget's disease have an associated concurrent underlying internal malignancy. The location of the underlying internal malignancy appears to be closely related to the location of the extramammary Paget's disease--i.e., a perianal location is associated with adenocarcinoma of the digestive system, a penile-scrotal-groin location with genitourinary malignancy, etc. A directed internal malignancy search may be of benefit in patients who are diagnosed as having extramammary Paget's disease.

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Bacteria belonging to the Rhodochrous complex are of uncertain taxonomic status. Currently excluded from the genus Mycobacterium, these organisms are more closely allied to Nocardia. Organisms of the Rhodochrous complex have only rarely been implicated as human pathogens. An 81-year-old man had a plaquelike cutaneous granuloma from which Rhodochrous was both cultured and demonstrated in tissue section. A pathogenic role for Rhodochrous causing a primary cutaneous infection is suggested. Specific antimicrobial treatment with doxycycline hydrochloride was successful and there has been no recurrence of the infection after three years.

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Scleromyxedema (also known as lichen myxedematosus or papular mucinosis) is a rare cutaneous disorder characterized by lichenoid waxy papules, sclerosis, and a characteristic paraproteinemia. Rarely, if ever, is there systemic involvement. The cause and pathogenesis remain a mystery, however, a recent report has linked a serum factor with fibroblast proliferation in the skin. Treatment is often ineffective, although systemic melphalan may lead to improvement in 50 to 60 percent of patients. Morbidity and mortality due to melphalan used in the treatment of scleromyxedema have been reported, therefore, this therapy should be reserved for only the most extreme cases, if at all.

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The efficacy and safety of intravenously administered miconazole nitrate was examined in eight patients with the following infections: cutaneous North American blastomycosis (one), extensive dermatophytosis(one), and chronic mucocutaneous candidiasis (six). Mycologic assessment included direct examination for fungal elements, fungal culture, and histopathology. Laboratory evaluations were performed before and at regular intervals during the study. The total miconazole nitrate dosage, which was administered over a seven- to 32-day period, ranged from 4.0 to 46.8 g. Follow-up examinations extended from two to 15 months. Excellent results were obtained in five patients and fair results in three. No renal, cardiac, hepatic, or hematopoietic toxicity was observed. Other side effects, however, necessitated premature cessation of therapy in four patients. Overall, intravenously administered miconazole is an effective antifungal agent for these cutaneous infections.

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Malignant melanoma (MM) is an important cutaneous neoplasm. In classic cases, histologic levels of tumor invasion have been used as indicators of prognosis. Recent research suggests that vertical tumor thickness may be an equally valuable guide to prognosis and also to therapy. The standard surgical approach of wide excision and regional lymph node dissection may not be mandatory for all patients with MM. Regional perfusion of accessible primary tumors as an adjunct to surgery has yielded encouraging results. Immunotherapy of MM alone and in combination with chemotherapy may improve the poor outlook for disseminated MM.

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Dermatitis herpetiformis has been associated with a variety of thyroid abnormalties. A case of thyrotoxicosis in a patient with pre-existing dermatitis herpetiformis is reported. Thyroid antibodies were present in the serum. This may suggest an immunologic relationship between dermatitis herpetiformis and thyroid disorders, that may be more than fortuitous.

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The recently described syndrome of diffuse fasciitis with eosinophilia consists of scleroderma-like cutaneous changes in the absence of Raynaud's phenomenon and without visceral involvement. Peripheral blood eosinophilia and hypergammaglobulinemia occur in the majority of patients. The biopsy specimen is characteristic and shows a diffusely thickened fascia with a noticeable inflammatory infiltrate. The etiology and pathogenesis of the entity are unknown. The majority of the cases have been reported to respond to corticosteroids. Pulmonary function abnormalities and rheumatoid factor elevation in one of our patients suggests that this syndrome may be a variant scleroderma or may have previously unrecognized systemic manifestations. The patients' objective responses to corticosteroids were minimal.

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Cutaneous manifestations of histoplasmosis may be divided into primary and secondary lesions. Primary cutaneous histoplasmosis is rare; to our knowledge, there are only three reported cases in the literature. Secondary cutaneous histoplasmosis develops during the course of disseminated disease. An isolated nodule of the hand was the initially appearing sign of recurrent disseminated disease in our patient. Because of the extreme rarity of primary cutaneous histoplasmosis, cutaneous lesions that are proven to be due to histoplasmosis should alert the physician to the presence of disseminated disease.

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Sarcoidosis is a disease of unknown etiology with protean manifestations. Its history is revealed in its many eponymic syndromes. The histologic features are nonspecific, as are most of the clinical manifestations. The diagnosis is made by exclusion. The immunologic abnormalities are fascinating, with features of both hyperactivity and depression. Therapy is nonspecific and generally symptomatic.

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Sclerotic changes in the skin are most frequently caused by scleroderma. In those cases in which scleroderma is not implicated, careful historical, physical, histologic, and laboratory evaluation will allow an appropriate diagnosis to be made. In this way, appropriate therapy and prognostication can be given.

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The fact that malignant melanoma occurs on a readily observable organ, the skin, and behaves in a predictable biological pattern in many cases suggests that its rate of cure should be high. Yet, despite advances in recognition and management, a significant percentage of patients still succumb to their disease. More sensitive methods of early detection and more effective therapies are required to improve survival.

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Erythema multiforme (EM) is clinically characterized by a "minor" form and a "major" form. The latter is known as the Stevens-Johnson syndrome. Infections (particularly herpes simplex and Mycoplasma pneumoniae) and drugs seem to predispose toward the development of EM. The pathogenesis is poorly understood. The treatment is supportive. Prognosis varies with the severity of the eruption. Recurrences are commonly seen.

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