Florid Cutaneous Papillomatosis

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Florid cutaneous papillomatosis (FCP) is a disorder consisting of the rapid onset of numerous warty papules on the trunk and the extremities that are clinically indistinguishable from viral warts. [1, 2, 3, 4] Florid cutaneous papillomatosis was first described and the name florid cutaneous papillomatosis was coined in 1978 by Schwartz and Burgess. [5]

Florid cutaneous papillomatosis usually occurs in association with malignant acanthosis nigricans and an internal malignancy (see Acanthosis Nigricans). In fact, florid cutaneous papillomatosis is believed to be an obligatory paraneoplastic syndrome in that it has always been associated with an internal malignancy (see Paraneoplastic Diseases and Paraneoplastic Syndromes). The cancer, which is usually intra-abdominal and most often gastric in origin, tends to evolve in parallel with florid cutaneous papillomatosis. The onset of florid cutaneous papillomatosis often becomes evident before or concurrent with the diagnosis of the internal tumor.

In a review of 46 patients, Stieler and Plewig [6] noted that each patient had an underlying cancer. The most common type was gastric adenocarcinoma, which occurred in more than half the patients. One patient had a gastric adenocarcinoma and a second malignancy, namely, breast adenocarcinoma. Other neoplasms that are reported to occur with florid cutaneous papillomatosis include other intra-abdominal tumors, such as cancer of the urinary bladder, biliary ducts, ovaries, and uterus; breast adenocarcinoma; squamous cell carcinoma of the lungs; and non-Hodgkin lymphoma.

Florid cutaneous papillomatosis occurs with signs of internal cancer. Although acanthosis nigricans and the sign of Leser-Trélat (ie, eruptive seborrheic keratoses) are most frequently linked to florid cutaneous papillomatosis, other signs, such as hypertrichosis lanuginosa acquisita, can be present. [7] See Sign of Leser-Trelat for more information on this topic.

The etiology of florid cutaneous papillomatosis is not known, as is the cause of the other 2 eruptive paraneoplastic syndromes that occur with florid cutaneous papillomatosis: malignant acanthosis nigricans and the sign of Leser-Trélat. These 3 paraneoplastic syndromes are probably directly induced by their underlying neoplasms, most likely by means of a tumor-secreted growth factor. [1]

In 1976, Millard and Gould [8] found high levels of immunoreactive human growth hormone in 2 patients with tylosis, one of whom had the sign of Leser-Trélat. In another report, a patient was described as having a small cutaneous melanoma, acanthosis nigricans, the sign of Leser-Trélat, and multiple acrochordons. In this patient, the lesions of the cutaneous paraneoplastic syndrome were stimulated by the epidermal growth factor receptor. [9] Increased epidermal staining for the epidermal growth factor receptor was initially noted in skin specimens of acanthosis nigricans, seborrheic keratoses, and cutaneous papillomas. Both the staining and the urine level of alpha-transforming growth factor markedly decreased after the primary nonmetastatic melanoma was removed. Alpha-transforming growth factor is structurally related to epidermal growth factor but antigenically distinct from it.

Florid cutaneous papillomatosis, malignant acanthosis nigricans, and the sign of Leser-Trélat should be viewed as part of a continuum. These conditions develop by means of a common or similar pathogenic pathway due to an underlying malignancy that produces a factor possibly similar to human epidermal growth factor.

The cause of florid cutaneous papillomatosis is not known. Florid cutaneous papillomatosis may be due to a tumor-secreted growth factor, although, to the author’s knowledge, none has been identified (see Pathophysiology in Overview). Its association with acanthosis nigricans and the sign of Leser-Trélat suggests a common pathogenic mechanism. [10]

Florid cutaneous papillomatosis is a rare disease. So far, only about 25 patients have been reported.

From the limited number of patients described to date, florid cutaneous papillomatosis is almost twice as common in men than in women.

Florid cutaneous papillomatosis is usually diagnosed in individuals aged 53-72 years (mean patient age, 58.5 y).

Florid cutaneous papillomatosis is an obligate paraneoplastic syndrome, the underlying case is most commonly of gastric origin as documented in the 9 patients described since 2000. [2]

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Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for MOHS Surgery, Association of Military Dermatologists, Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Society for Investigative Dermatology, Association of Professors of Dermatology, North American Hair Research Society

Disclosure: Nothing to disclose.

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Takeji Nishikawa, MD Emeritus Professor, Department of Dermatology, Keio University School of Medicine; Director, Samoncho Dermatology Clinic; Managing Director, The Waksman Foundation of Japan Inc

Disclosure: Nothing to disclose.

The assistance of Edmund Janniger is greatly appreciated.

Florid Cutaneous Papillomatosis

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