Ulcerated Kaposi's Sarcoma

May Leveriza-Oh, MD; Lynne J. Goldberg, MD; Tania J. Phillips, MD, FRCPC

Wounds. 2004;16(7)

Presentation

A 78-year-old Caucasian man of Italian descent previously diagnosed with Kaposi's sarcoma (KS) presented with an ulcerated lesion on the third digit of his right foot. The patient was diagnosed with classic type KS 10 years ago and since then intermittently develops several violaceous papules on the hands and feet. He underwent multiple treatments with liquid nitrogen, and one year ago was started on topical five-percent imiquimod cream applied nightly on his lesions with good results. Lesions clear after several weeks of treatment; however, new ones evolve.

One week prior to consult, the patient noted ulceration of a violaceous papule, which had been present on the distal portion of his toe for 4 to 6 weeks. The lesion was moderately painful and the toe was swollen and red. The patient did not recall any specific traumatic event to the affected area although the lesion was located at a site of frequent contact with the adjacent toe. He continued to apply imiquimod cream on the ulcerated area and cover it with a plaster dressing.

The patient had no other systemic illnesses, and had a cousin also diagnosed with Kaposi's sarcoma.

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Table 1. Types and descriptions of Kaposi's sarcoma
Types	Classic Sporadic	African Endemic	KS in Immunosuppressed Patients	HIV-Associated Epidemic KS
Subpopulation affected	Ashkenazic Jews or people of Mediterranean/Eastern European descent	Black Africans	Organ-transplant recipients, patients with cancer, autoimmune diseases or on immunosuppressive therapy	HIV-infected persons: Homo- or bisexual men and their female partners; rare in IV drug users, hemophiliacs, blood transfusion recipients, children born to HIV-positive mothers
Male:female ratio	15:1-3:1	Adults: 10:1-18:1	3:1 to 7:1	20:1
Male:female ratio	15:1-3:1	Children: 3:1	3:1 to 7:1	20:1
Age of onset	>50 (Mean age: 65)	Males: 48	Clinical course similar to classic type	Early lesions: small pink macules resembling insect-bites or dermatofibroma-like small tense, brownish papules
		Females: 36
		More fulminant course in children
Clinical features	Slowly growing blue-red macules on distal lower extremities that may form plaques, nodules, or tumors and spead cetripetally	Clinico-pathologic subtypes: nodular -- resembles classic type; florid; infiltrative; lymphadenopathic	May resolve upon withdrawal of or reduction of immunosuppressive therapy	Lesions predominantly on face and trunk following cleavage lines, may appear on extremities; frequent involvement of oral mucosa
Extracutaneous manifestations	May develop on mucous membranes, especially oral cavity and gastro-intestinal tract	Gastrointestinal involvement in 90%		May affect pharynx, larynx, GI tract, lymph nodes, and lungs
Median survival	Years to decades	Months to years	Months to years	Weeks to months

Table 2. Treatment options for African-endemic, KS in immunosuppressed, and HIV-associated epidemic KS types
	African-Endemic	KS in immunosuppressed	HIV-associated epidemic KS
Local therapies
Radiotherapy
Chemotherapy	^[19]	^[20]	^[21]
Highly active antiretroviral therapy (HAART)	X	X	^[22,23]
Reduction/modification of immunosuppressive drugs	X	^[24]	X
Systemic interferon alpha (high dose)	X	X	^[25,26]
Systemic interferon in combination with anti-retroviral therapy (zidovudine)	X	X	^[27,28]

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