Leser-Trélat sign
Sign of Leser-Trélat; eruptive seborrhoeic keratoses
The Leser-Trélat sign describes the abrupt eruption of multiple new seborrhoeic keratoses (often pruritic, often on the trunk). It is a rare and debated paraneoplastic association, reported most often with gastrointestinal adenocarcinoma but also in case reports with lymphoma, breast, lung and prostate cancer. Its clinical validity is debated because seborrhoeic keratoses are extremely common in older adults and the apparent association may be confounded by age. Suspicion is higher when the eruption is truly abrupt, the patient is younger than expected, or there are co-existing red flags such as malignant acanthosis nigricans, tripe palms, weight loss or unexplained systemic symptoms; in that setting, targeted workup for occult malignancy is reasonable.
Clinical features
- Sudden eruption (weeks to months) of multiple new seborrhoeic keratoses, often on the trunk and back.
- Lesions are often pruritic and may be inflamed.
- Frequently associated with malignant acanthosis nigricans and tripe palms (palmar keratoderma with prominent dermatoglyphics) — the "triple paraneoplastic" pattern.
- Constitutional symptoms — weight loss, fatigue, dyspepsia — should be specifically sought.
- Median age 60+; both sexes.
Reported tumour associations
- Gastrointestinal adenocarcinoma — gastric (commonest), colon, oesophagus, pancreas.
- Lymphoproliferative — non-Hodgkin lymphoma, leukaemia.
- Breast, lung, prostate, hepatocellular carcinoma.
- Melanoma and other skin malignancies reported in case series.
- Association is reported but not consistently demonstrated in case-control studies — interpret with appropriate scepticism.
The controversy
- Seborrhoeic keratoses are extremely common — most older adults develop new SKs continuously over time.
- Case-control studies have variably failed to show a statistically significant association between eruptive SKs and malignancy after age adjustment.
- However, individual case series and clinical experience document patients in whom paraneoplastic regression of new SKs follows successful cancer treatment — supporting the entity at least in selected cases.
- Pragmatic approach — investigate the highly atypical clinical picture (truly abrupt eruption, marked pruritus, accompanying paraneoplastic signs) while not over-investigating expected age-related SK accumulation.
Workup
- Detailed history — change tempo, constitutional symptoms, weight, GI symptoms, lymphadenopathy.
- Examination — abdominal mass, lymphadenopathy, weight, pallor, mucosal acanthosis nigricans.
- Initial investigations — FBC, U&E, LFT, FBG, CRP, ferritin, faecal occult blood, urinalysis, chest X-ray.
- Targeted onward investigation — upper / lower GI endoscopy (gastric / colonic adenocarcinoma the strongest historical association), CT NCAP, age-appropriate screening (mammogram, cervical screening, PSA), depending on clinical context.
- Co-existing paraneoplastic signs (AN, tripe palms) substantially raise the index of suspicion.
Management
- Treat the underlying malignancy where identified — SKs may regress after successful therapy.
- Symptomatic treatment of pruritic SKs — emollients, mild topical steroid, antihistamines.
- Curettage / cryotherapy / electrodesiccation of bothersome lesions — see SK.
- If no malignancy identified after appropriate workup, reassure and monitor; many patients remain disease-free at long-term follow-up.
References
- Heaphy MR Jr, Millns JL, Schroeter AL. The sign of Leser-Trélat in a case of adenocarcinoma of the lung. J Am Acad Dermatol; 2000.
- Husain Z et al. Sign of Leser-Trélat — clinical review of the controversy. Cutis; 2013.
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