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Erysipelas melanomatosum – Melanoma Skin Metastasis

Erysipelas melanomatosum is a rare form of cutaneous metastasis of malignant melanoma, in which tumor cells infiltrate skin lymphatics, mimicking the appearance of bacterial erysipelas.

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Things worth knowing about "Erysipelas melanomatosum"

Erysipelas melanomatosum is a rare form of cutaneous metastasis of malignant melanoma, in which tumor cells infiltrate skin lymphatics, mimicking the appearance of bacterial erysipelas.

Definition

Erysipelas melanomatosum is a rare and clinically significant form of cutaneous metastasis arising from malignant melanoma. In this condition, melanoma cells infiltrate the lymphatic vessels and connective tissue of the skin, producing a spreading, red, and slightly raised skin lesion that closely resembles erysipelas (bacterial skin infection also known as St. Anthony's Fire). The term combines the Latin erysipelas (referring to the bacterial skin infection) and melanomatosum (relating to melanoma).

Causes and Pathogenesis

The condition arises from the lymphangitic spread of melanoma cells within the skin. Tumor cells invade the dermal and subdermal lymphatic capillaries, causing lymphatic obstruction and an inflammatory-like tissue reaction that clinically mimics a bacterial infection.

Primary malignant melanoma as the underlying source
Lymphangitic infiltration of dermal lymphatics by tumor cells
Local inflammatory-like tissue reaction due to tumor infiltration
Often occurs near the site of the primary tumor or previous surgical scars

Symptoms

The clinical presentation of erysipelas melanomatosum is characteristic and can be diagnostically misleading:

Spreading, well-demarcated erythema (redness) of the skin
Warmth and mild swelling of the affected area
Occasional sensation of tightness or mild discomfort
Absence or minimal systemic signs of infection (no high fever, no significant elevation of infection markers)
Lack of response to antibiotic treatment

Diagnosis

Diagnosis requires a high degree of clinical suspicion, particularly in patients with a known history of malignant melanoma.

Clinical Examination

Inspection reveals an erythematous, slightly indurated skin area. The key diagnostic clue is the absence of improvement with antibiotics and the context of a prior melanoma diagnosis.

Histopathology

Skin biopsy is the gold standard for diagnosis. Histological examination reveals melanoma cells within lymphatic vessels and the dermal interstitium. Immunohistochemical staining markers such as S-100, HMB-45, and Melan-A confirm the diagnosis.

Imaging

To assess the full extent of metastatic spread, imaging modalities such as PET-CT or MRI are employed.

Differential Diagnoses

Due to its clinical resemblance to other conditions, the following must be excluded:

Erysipelas (bacterial skin infection caused by streptococci)
Inflammatory breast cancer (carcinoma erysipelatoides)
Contact dermatitis
Cellulitis
Other forms of cutaneous metastasis

Treatment

Treatment of erysipelas melanomatosum is guided by the overall stage of the malignant melanoma and includes both systemic and local approaches:

Systemic Therapy

Immunotherapy: Checkpoint inhibitors such as PD-1 antibodies (e.g., pembrolizumab, nivolumab) represent the preferred first-line treatment for metastatic melanoma.
Targeted Therapy: In cases with a BRAF V600 mutation, BRAF and MEK inhibitors (e.g., dabrafenib and trametinib) are used.
Chemotherapy: Reserved for selected cases, typically as a later-line option.

Local and Palliative Measures

Radiation therapy for local tumor control
Electrochemotherapy for localized cutaneous metastases
Intralesional therapies (e.g., talimogene laherparepvec / T-VEC)

Prognosis

The development of erysipelas melanomatosum indicates advanced metastatic disease and is associated with a serious prognosis. However, modern systemic therapies have substantially improved survival outcomes for patients with metastatic melanoma in recent years.

References

Garbe C. et al. - Melanoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology, 2022.
Elder D.E. et al. (eds.) - Lever's Histopathology of the Skin, 11th edition, Wolters Kluwer, 2015.
National Comprehensive Cancer Network (NCCN) - Clinical Practice Guidelines in Oncology: Melanoma: Cutaneous, Version 2.2023. NCCN.org.

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