Novel Presentation of Fibroepithelioma of Pinkus on the Ear of a Patient Treated on a Panamanian Humanitarian Mission.

Fibroepithelioma of Pinkus (FEP) is traditionally classified as an unusual variant of basal cell carcinoma. It has non-specific clinical findings yet distinct histologic features. The diagnosis can be challenging for clinicians because it often mimics benign entities such as intradermal nevi. FEP typically occurs on the trunk, but many body sites can be involved including the head, neck, and genitalia. According to a PubMed search of articles indexed in MEDLINE using "Fibroepithelioma of Pinkus" and "ear" or "auricle," there are no reports of FEP specifically occurring on the ear. We describe the first case of FEP on the ear of a heavily sun-damaged male treated while on a military humanitarian mission to Panama. This case helps support the classification of FEP as a basal cell carcinoma variant and raises awareness for this entity as it may be encountered both on military humanitarian missions and in military clinics.

Traumatic ulcerative granuloma with stromal eosinophilia: a malignant-appearing benign lesion.

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is an underreported diagnosis in dermatologic literature. Rapid expansion with an ulcerative clinical appearance often provokes fear of malignancy despite its benign nature. Traumatic ulcerative granuloma with stromal eosinophilia is thought to be a reactive tissue response to trauma, but CD30+ mononuclear cells within a TUGSE lesion suggests the possibility of an underlying lymphoproliferative disorder. This case highlights the clinical and histological features of TUGSE and provides a brief review of the literature addressing this debate. Knowledge of this condition, which uncommonly presents to the practicing dermatologist, is important in providing appropriate patient care and counseling. When correctly identified, unnecessary therapies and emotional stress can be avoided.

Sebaceous carcinoma on the arm of a 10-year-old girl.

We report a case of a 10 year-old girl diagnosed with sebaceous carcinoma of the posterior left arm. The presented case reviews the histopathological and immunohistochemical characteristics of this malignancy, including a review of the literature in pediatric patients regarding prognosis and treatment. Sebaceous carcinoma is a malignant neoplasm with sebaceous differentiation, typically occurring in the sixth-to-seventh decades of life. It most commonly arises in the periocular region. It is extremely rare in the pediatric population.

Histopathology of bilateral lower extremity inflammatory lymphedema in military basic trainees: A leukocytoclastic vasculitis of the deep vascular plexus.

Bilateral lower extremity inflammatory lymphedema (BLEIL) is a recently described condition that presents with exquisite tenderness, erythema and edema of the lower leg, ankle and dorsal foot resembling an acute cellulitis. It was first reported in healthy, young adult military basic trainees with a normal body mass index during the first 72 hours of arrival to basic training. It occurs while standing at attention for many hours, and shows rapid resolution with elevation and rest. We report an additional case of BLEIL and describe the histopathology of this case and 2 of the previously reported cases. All 3 biopsies showed a deep perivascular infiltrate of neutrophils with karyorrhectic debris and prominent red blood cell extravasation. One of the 3 cases was positive for complement by direct immunofluorescence. We postulate this condition represents a deep leukocytoclastic vascultis with secondary reactive lymphedematous changes.

Diffuse Urticarial Reaction Associated with Titanium Dioxide Following Laser Tattoo Removal Treatments.

IMPORTANCE: Local and generalized allergic reactions following laser tattoo removal have been documented, but are rare. To our knowledge, this is the fourth documented case of widespread urticarial eruptions following laser tattoo removal treatment. Unlike previously documented cases, this patient's reaction was found to be associated with titanium dioxide within the tattoo and her symptoms were recalcitrant to medical therapy. OBSERVATIONS: A 46-year-old female experienced diffuse urticarial plaques, erythema, and pruritis following multiple laser tattoo removal treatments with an Nd:YAG laser. The systemic allergic reaction was recalcitrant to increasing doses of antihistamines and corticosteroids. The tattoo was finally surgically excised. The excised tissue was analyzed by scanning electron microscopy and energy-dispersive X-ray analysis and contained high levels of titanium dioxide. Two weeks following the excision, and without the use of medical therapy, the patient had complete resolution of her generalized urticaria. CONCLUSIONS: Ours is the first documented case of a diffuse urticarial reaction following laser tattoo removal treatments that shows a strong association to titanium dioxide within the tattoo pigment. Herein, we describe a novel surgical approach to treat recalcitrant generalized allergic reaction to tattoo pigment.

Use of the frozen section 'jelly-roll' technique to aid in the diagnosis of bullous congenital ichthyosiform erythroderma (epidermolytic hyperkeratosis).

Frozen section is a valuable tool that is often underutilized in the setting of in-patient dermatology. Traditionally, frozen section has been used in dermatology to diagnose toxic epidermal necrolysis, with some additional utility in staphylococcal scalded skin syndrome in the new born period. We report a newborn female with ruptured bullae on the face, chest, back and extremities with a clinical differential diagnosis that included staphylococcal scalded skin, bullous congenital ichthyosiform erythroderma/epidermolytic hyperkeratosis and epidermolysis bullosa. A thin detached skin sample ('jelly-roll') taken from a ruptured bulla on the abdomen was prepared for frozen section analysis. Characteristic findings of epidermolytic hyperkeratosis were seen which included hyperkeratosis with granular layer degeneration, vacuolization and eosinophilic globules. The 'jelly-roll' technique can be used for quick diagnosis with minimal trauma to the patient. Epidermolytic hyperkeratosis was subsequently confirmed by a biopsy fixed in formalin and by genetic testing. A novel missense mutation in KRT1 (I479N) was identified. Herein, we discuss the use of the frozen section 'jelly roll' technique for rapid diagnosis in a case of bullous congenital ichthyosis erythroderma/epidermolytic hyperkeratosis.

Fibroelastolytic papulosis: histopathologic confirmation of disease spectrum variants in a single case.

Fibroelastolytic papulosis is a rare, acquired fibroelastolytic disorder that presents clinically as white-to-yellow papules and plaques most commonly occurring on the neck of elderly patients. The term fibroelastolytic papulosis encompasses two closely related conditions previously described as pseudoxanthoma elasticum-like papillary dermal elastolysis (PDE) and white fibrous papulosis of the neck (WFPN). Here we present a case of a 78-year-old white female with a several-year history of numerous, asymptomatic 2-3 mm yellowish, non-follicular papules distributed symmetrically over the posterior neck, axillae, arm and antecubital fossae. Histopathologic examination revealed thickened and clumped elastotic fibers admixed with thick, sclerotic appearing collagen bundles in the mid and deep reticular dermis. Rare melanophages, loss of vertically oriented elastic fibers and scattered elastotic globes were noted in the papillary dermis. Based on the shared clinicopathologic features showed in this case, strong consideration should be made for the additional inclusion of papillary dermal elastosis as existing along the disease continuum of fibroelastolytic papulosis. This occurrence of fibroelastolytic papulosis shows unique histopathologic findings of pseudoxanthoma elasticum-like PDE, papillary dermal elastosis and WFPN, further supporting the theory that these entities exist as variants along the fibroelastolytic papulosis spectrum.

Linear trichoepithelioma on the neck of a 15-year-old girl.

Trichoepitheliomas are trichogenic tumors that can have various clinical morphologies. These tumors are benign and differentiate toward the outer root sheath of the hair follicle. Solitary trichoepitheliomas arise sporadically, in contrast to multiple trichoepitheliomas, which are usually inherited as an autosomal dominant trait or as part of various genetic syndromes. We report a case of an adolescent female with a linear array of trichoepitheliomas on her left neck.

Dyschromatosis Universalis Hereditaria with Oral Leukokeratosis--A Case of Mistaken Identity and Review of the Literature.

Dyschromatosis universalis hereditaria (DUH) is a rare pigmentary genodermatosis characterized by reticulated hyper- and hypopigmented macules distributed over the trunk and extremities in otherwise healthy patients. DUH presents in a fashion similar to that of a variety of reticulate and pigmentary dermatoses, some of which are associated with precancerous entities and other comorbidities. It is therefore imperative that the clinician recognize and differentiate these disorders so that appropriate screening and counseling can be offered to the patient. We report a case of DUH in a 13-year-old boy presenting with oral leukokeratosis, with a review of the literature exploring the differential diagnoses.

Localized chrysiasis, aluminum salt deposition and dystrophic calcification a decade after gold injections.

Localized chrysiasis is rare and can occur in two settings: after localized or traumatic implantation of elemental gold or gold salts or after localized laser or light therapy in someone who has been previously exposed to systemic gold therapy. We report a unique case of localized chrysiasis with associated aluminum salt deposition and sclerosing lipogranulomas because of previous injections of aurothioglucose (Solganal®). The unique histopathologic findings seen in this case have not been previously reported.

Diagnosis and treatment of leprosy type 1 (reversal) reaction.

Leprosy is a chronic granulomatous infection caused by the organism Mycobacterium leprae that primarily affects the skin and peripheral nerves. Leprosy has several distinct clinical presentations ranging from moderate to severe, with the extent of disease generally depending on the host's immune response to the infection. Treatment typically involves antimicrobials (eg, clofazimine, dapsone, rifampin). Once treatment is started, an important aspect of patient care is the recognition of possible reversal reactions. We report the case of a 44-year-old man who repeatedly developed physical findings consistent with a type 1 (reversal) reaction after undergoing multiple treatments for leprosy. A discussion of leprosy along with its clinical manifestations, treatment methods, and management of reversal reactions also is provided.

Dermatitis medicamentosa: severe rebound erythema secondary to topical brimonidine in rosacea.

BACKGROUND: Rebound erythema secondary to use of topical brimonidine in the setting of rosacea is an important, possibly significantly distressing potential side effect that may be under-reported; there is little photo-documentation in the literature to date. This article documents such a case. OBSERVATIONS: A 28-year-old woman (Fitzpatrick II) with a long-standing history of untreated rosacea presented for initiation of treatment of what was noted to be primarily erythematotelangiectatic rosacea and was offered Mirvaso for daily use. Initial improvement was followed by progressive worsening of baseline erythema several hours following treatment, only improved with subsequent applications of additional Mirvaso. The patient's symptoms were improved upon discontinuing use of Mirvaso. CONCLUSIONS: There are few cases documented of rebound erythema secondary to use of Mirvaso to date. Further reporting might prompt further long term investigation for this topical medication for further delineation of its role in treatment of rosacea. What is proposed is a phenomenon similar to that of rhinitis medicamentosa with upregulation of alph-adrenergic receptors, suggesting the name "dermatitis medicamentosa" for this phenomenon.

Bilateral lower extremity inflammatory lymphedema in Air Force basic trainees: clinical and epidemiologic study of a new disease entity.

IMPORTANCE: This observational study characterizes a new clinical condition identified in 55 military trainees. OBJECTIVE: To determine the incidence and underlying cause of bilateral lower extremity inflammatory lymphedema in Air Force basic trainees. DESIGN, SETTING, AND PARTICIPANTS: An observational study was conducted at Lackland Air Force Base in San Antonio, Texas. Participants included 14 243 Air Force basic trainees who entered training between September 2011 and January 2012 and the 55 trainees (0.4%) who developed bilateral lower extremity inflammatory lymphedema that occurred during the 8½-week basic training course. Two modifiable risk factors were evaluated: vaccine reaction and newly issued military footwear (combat boots and boot socks). INTERVENTIONS: During November 2011, all new trainees wore only white socks and running shoes rather than the issued military footwear. During December 2011 and January 2012, the scheduled administration of tetanus/diphtheria/acellular pertussis and meningococcal vaccines, respectively, was delayed by 1 week for all new trainees. A full medical record review was conducted for every confirmed case of bilateral lower extremity inflammatory lymphedema. MAIN OUTCOMES AND MEASURES: Identification of incident cases, symptom onset, antimicrobial treatment, immunization reaction, laboratory studies, specialty referral, and biopsy. RESULTS: Fifty-four of the 55 incident cases (98%) of bilateral lower extremity inflammatory lymphedema occurred during the first 120 hours of training. Alterations in the timing of the military footwear used and selected vaccine administration had no effect on the incidence of new cases. Two participants (4%) experienced symptom onset before receipt of the vaccines. Oral antimicrobial medications were not found to speed symptom resolution compared with conservative treatment measures (P = .34). One incident case was diagnosed as leukocytoclastic vasculitis by tissue examination. CONCLUSIONS AND RELEVANCE: Multiple training-related risk factors were ruled out as sources of bilateral lower extremity inflammatory lymphedema. Cases are likely secondary to prolonged standing with resultant gravity-dependent venous congestion and inflammatory vasculitis. The potential roles of undiagnosed venous reflux disease and the military physical training environment in these cases remain to be elucidated.