Cutaneous metastases from head and neck cancer are an unusual problem. We review risk factors, management strategies, and clinical outcome in patients with cutaneous metastases from epidermoid cancer of the head and neck. From 1980 to 1994 a total of 12 patients with pathologically documented cutaneous metastases from epidermoid cancer of the head and neck were identified at Yale University School of Medicine. Patient records were reviewed and cases were evaluated for risk factors, therapeutic techniques, and clinical outcome as it relates to local control and survival. Median follow-up was 6 months. There were 11 males and 1 female in t h i s series. Primary tumor sites included tonsillar fossa, anterior tonsillar pillar, base of tongue, pyriform sinus, buccal mucosa (2 patients), auricle, larynx, and unknown primary (4 patients). Predominant tumor histology was squamous cell carcinoma, seen in 10 of 12 patients. Treatment modalities for primary and recurrent disease prior to development of cutaneous metastases included surgery, external beam radiotherapy (EBRT), intraoperative brachytherapy (IOBT), and/or chemotherapy. Management of cutaneous metastases included observation, chemotherapy, electron beam radiotherapy (EB), wide excision of involved skin (WE) with IOBT and reconstruction, and definitive brachytherapy implantation of cutaneous nodules. Local control of cutaneous metastases was achieved in 6 patients, all treated with WE and IOBT or WE and EB. Median survival after cutaneous metastases was 6 months. Three patients remain alive, 2 with progressive disease and 1 without evidence of disease. Since patients in this series were clinically heterogeneous and treated with one or more modalities for primary and recurrent disease, it is difficult to draw conclusions as to which modality or clinical presentation may put patients at highest risk for cutaneous metastases. Those patients requiring extensive neck surgery, high dose EBRT, and/or IOBT, all of which may interrupt both deep and dermal lymphatics, may put patients at greatest risk rather than any single modality alone. Those patients that do develop dermal metastases may be effectively managed with a combined modality approach including WE and IOBT with or without EB. This approach appears to offer the best chance of local control, palliation, and perhaps even curative potential. Dermal metastases, however, are a harbinger of progressive disease with most patients ultimately succumbing to their disease.