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Facial Erythema in an Elderly Man

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A man in his 80s with a pacemaker; a history of congestive heart failure, coronary artery disease, atrial fibrillation, transient ischemic attack, and Parkinson disease; and dependence in all activities of daily living presented to the dermatology department with a 4-month history of new-onset persistent facial eruption. He denied a history of facial flushing. The patient was initially treated for rosacea at an outside hospital with topical 1% metronidazole cream for 1 month without improvement and developed acute facial purpura after 1 day of treatment with oral doxycycline, which was discontinued. Because of the eruption’s rapid onset and violaceous appearance, as well as empirical treatment failure, the patient was referred for further evaluation. On examination, the patient had asymmetric, centrofacial, erythematous-violaceous indurated telangiectatic and ecchymotic plaques over a phymatous background (Figure, A). A series of punch biopsies were performed (Figure, B-D).

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C. Rosacea-like angiosarcoma

Microscopic examination findings revealed a dissecting vascular proliferation through the entire dermis. Ectatic vascular channels were lined by atypical plump endothelial cells (Figure, B and C). Immunohistochemistry staining results were negative for Human herpesvirus 8 (Figure, D). These findings were diagnostic of cutaneous angiosarcoma (CA).

Results of a positron emission tomography/computed tomography scan revealed only mildly avid malar subcutaneous thickening consistent with CA (American Joint Committee on Cancer tumor-node-metastasis staging T2aN0M0G2, stage IIB). When feasible, standard treatment entails surgery with or without radiation; however, owing to this patient’s comorbidities, poor performance status, and disease extent, reduced-dose intravenous paclitaxel (60 mg/m2) was initiated as palliative therapy. After completing 6 months of 120-mg paclitaxel weekly treatment, a partial response was obtained. Because of worsening overall health, no additional treatments were added. He was transitioned to home hospice.

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Article Information

Corresponding Author: Alina Markova, MD, Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 545 E 73rd St, New York, NY 10021 (markovaa@mskcc.org).

Published Online: March 25, 2020. doi:10.1001/jamadermatol.2020.0123

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient and his executor for granting permission to publish this information. From the Memorial Sloan Kettering Cancer Center, New York, NY, thanks to Arlyn Apollo, MD (Medical Oncology Service), Cristopher Barker, MD (Radiation Oncology Service), and Ciara Kelly, MD (Department of Medical Oncology), for their invaluable help with patient care and for reviewing an earlier version of the article. They were not compensated.

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