Cover image: Unpeeling the layers of harlequin ichthyosis

cine physicians. We report the first case, to our knowledge, of a patient with metastatic melanoma responding to vemurafenib who developed multiple hyperplastic inflammatory oral mucosal lesions after 2 years and 8 months, which have now been followed up for 1 year without malignant transformation. The time course of the oral mucosal lesions and their clinical appearance in our patient is quite different from those described by Vigarios et al. Similarly, Mangold et al. described a patient who developed severely symptomatic gingival hyperplasia 3 months after commencing vemurafenib therapy which resolved only after treatment was discontinued due to disease progression. Although no convincing evidence of dysplasia or invasive carcinoma was noted in our patient’s oral biopsies, oral malignancy associated with BRAF inhibition has been reported. Increased RAS signalling may contribute to the development of hyperplastic oral lesions as is thought to be the case for cutaneous SCCs arising in this context. Reporting of adverse effects in long-term responders may help us to determine the mechanisms underlying these changes. Oral mucosal lesions associated with BRAF inhibitor therapy may be under-reported as a systematic oral examination is not routinely performed. We agree with Vigarios et al. supporting the need for regular oral mucosal examinations in individuals with metastatic melanoma responding to BRAF inhibition, to identify lesions that may predispose to secondary oral malignancy.