persistently increased without any signs of inﬂammation or
infection. Although the serum level of G-CSF is an effective bio-
marker in G-CSF-producing tumors,
its measurement is not
widely available. In addition, the acquired resistance of dabrafe-
nib and trametinib was detected by the WBC count earlier than
by the serum level of LDH. In this context, it may be possible to
regard the WBC count as a surrogate marker in the treatment
of G-CSF-producing melanoma.
In conclusion, considering the aggressive nature of this mela-
noma, timely monitoring of the treatment response and resis-
tance is important. The WBC count may be a good marker for
Department of Dermatology, Sapporo Medical University
School of Medicine, Sapporo, Japan
Conﬂicts of interest: None.
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2 Nakamura Y, Ishikawa K, Kai Y, et al. Case of malignant
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Gray-bluish cutaneous pigmentation and ice-pick scars
induced by vandetanib therapy
Drug-induced hyperpigmentation has commonly been
described in association with drugs of frequent use on our
daily clinical practice, such as tetracyclines, amiodarone, and
. The introduction of new targeted antitu-
mor therapies has increased the knowledge about new
adverse events (AEs) involving skin, hair, nails, and mucous
membranes. Dyschromias are infrequently reported AEs
because of their low morbidity, but they represent an impor-
tant alteration of the health-related quality of life (HRQoL) of
the patients that suffer from them. Most of the reported cases
describe hyperpigmentation, repigmentation, or hypopigmenta-
tion. However, changes in pigmentation that include blue/gray
or yellow dyschromias have also implicated imatinib (Bcr-abl
inhibitor), sorafenib (VEGFR inhibitor), and vandetanib (EGFR/
A 33-year-old woman was started on vandetanib therapy for
medullary thyroid carcinoma stage IVC in August 2016. She
was referred to our Dermatology outpatient clinic from the
Oncology Unit due to a facial rash that had developed six
months after initiating the treatment. She had not taken either
minocycline or other tetracycline antibiotic treatment before.
Physical examination revealed ice-pick scars on the medial
aspect of the cheeks. Dark blue-gray little macules on both
cheeks, chin, and forehead could be observed (Fig. 1). Oral
mucosa was not involved.
Blood tests including general biochemistry, autoantibodies,
thyroid hormones, and blood count showed no abnormalities in
comparison with previous results. Histological study of a biopsy
sample showed a granulomatous chronic inﬂammatory reaction
with the presence of giant foreign body multinucleated cells with
abundant hemosiderinic pigment.
Ice-pick scars and dark blue-gray little macules on
both cheeks, chin, and forehead
ª 2018 The International Society of Dermatology International Journal of Dermatology 2018, 57, e30–e43