Primary and isolated cutaneous precursor B-lymphoblastic lymphoma in an infant.

Cutaneous lesions may represent the initial sign of various neoplasms in children, including histiocytosis, neuroblastomas, and lymphomas. Primary cutaneous lymphoblastic lymphomas are rare and involve mostly the B-cell phenotype. Herein, we report a case of isolated, primary B-lymphoblastic lymphoma in a 7-month-old infant and emphasize the importance of early diagnosis.

A case of herpes simplex virus reactivation after fractional ablative carbon dioxide laser to treat a burn scar.

Fractional photothermolysis was initially introduced by Manstein in 2004 .Fractional CO2 laser technology introduced has allowed physicians to obtain good cosmetic results with a lower rate of complications than non-fractionated ablative laser treatment. However, adverse effects may still occur.Reported cases of HSV infection after fractional photothermolysis are rare. A 48-year-old woman with Fitzpatrick skin type III presented with a scar in her perioral area desiring esthetic improvement of her burn scar. She didn't have a history of recurrent herpes simplex virus (HSV) infection periorally. A fractionated resurfacing laser Quadralase (Candela) was used to treat her perioral burn scar. Two sessions were performed with a month interval. Five days after the second session of laser therapy even after she took antiviral prophylaxis based on valacyclovir 500mg twice daily 24 hours before the laser session and 3 days after, she presented with a rash on the perioral area preceded by pain. Correlation of the history and the clinical presentation was consistent with HSV reactivation. Treatment was initiated with acyclovir 10mg/kg/8h administered intravenously for 10 days with a clearing of her vesicular eruption. Fractional CO2 laser is a very safe procedure when used with accepted parameters. Early recognition, close monitoring and careful wound care will prevent long term sequelae when complications occur.

Association of khellin and 308-nm excimer lamp in the treatment of severe alopecia areata in a child.

Alopecia areata (AA) is an autoimmune inflammatory disorder of hair, characterized by non-scarring hair loss. A 308-nm excimer lamp (EL) has been reported as one effective modality in the treatment of AA. Khellin is a furanochromone photosensitizer whose chemical structure is close to psoralens and has previously proven its efficacy in vitiligo in association with ultraviolet A. We evaluated the efficacy and safety of a combination of topical khellin and 308-nm EL in the treatment of a refractory ophiasic AA, of 1-year evolution, in a 5-year-old boy. Treatment consisted in topical application of khellin 45 mn before irradiation with EL (starting dose 50 mJ/cm2) twice a week for 3 months. The result was a complete regrowth of hair with no recurrence 1 year later. Further studies should be carried out to confirm this promising result and to propose khellin-excimer as a new alternative treatment for resistant cases of AA in children.

Pemphigus Vegetans Confined to the Face and Scalp.

A 58-year-old man presented to our department with multiple chronic vegetant plaques on the face and scalp that had been present for 4 months. The plaques were well-defined hypertrophic areas, measuring between 3 cm × 3 cm and 3 cm × 4 cm, that were located mainly on the face symmetrically and on the forehead (Figure 1). The patient did not report itching or pain. There were also dry, crusty, well-defined plaques on the scalp. No other lesions were present on the skin or mucous membranes.

Multicentric Anogenital Bowen's Disease Treated with Imiquimod and CO2 Laser.

A 53-year-old white woman presented to our clinic with skin lesions in the anogenital region that had persisted for 1 year. She had a past medical history of total vulvectomy for a vulvar localization of Bowen's disease. She was otherwise in good health, with no evidence of illness or immunosuppression. Physical examination revealed multiple erythematous papular lesions located in the anogenital region (Figure 1). Dermatoscopy of the anogenital papules revealed glomerular vessels on an erythematous background typical of Bowen's disease (Figure 2A). There were no palpable inguinal lymph nodes. Rectosigmoidoscopy was normal. The biopsy specimen showed full thickness keratinocyte atypia with loss of normal stratification and was conclusive for Bowen's disease (Figure 2B).

Melanoma of the Nasal Cavity.

78-year-old man presented with complaints of progressive nasal blockage and epistaxis over the previous 2 months. Clinical examination revealed a nodular, polypoid, ulcerated nonpigmented tumor filling the right nasal cavity (Figure 1). A punch biopsy was taken from the mass for histopathologic examination, which revealed many melanocytes in the submucosa. The stroma contained large numbers of spindle-shaped cells with hyperchromatic spindleoid nuclei (Figure 2), confirming the diagnosis of malignant melanoma. The tumor cells stained positive for melan-A (Figure 3) and HMB-45.

Bullous Fixed Drug Eruption Caused by Doxycycline.

A 50-year-old woman presented to our dermatology clinic with pruritic lesions on her hands that had appeared 24 hours earlier. The clinical manifestations had started 24 hours after taking 100 mg of doxycycline for acute bronchitis. She had no history of allergic disease or allergic reactions to drugs. The dermatologic examination revealed multiple erythematous, purplish annular patches with overlying bullae with hemorrhagic content on both palms (Figure 1). The patient had no fever, and the rest of the physical examination did not reveal any abnormalities. Results of laboratory tests were within normal limits. A skin biopsy was performed, showing hydrophic degenerations of the basal membrane, a superficial perivascular infiltrate consisting of lymphocytes and eosinophils, and red blood cells in the dermis (Figure 2). A pharmacovigilance investigation was conducted, and doxycycline was confirmed as the agent responsible for the bullous fixed drug eruption (FDE) in our patient.

Multiple Eccrine Spiradenomas in a Zosteriform Distribution.

A 52-year-old man was referred to our department with a 28-year history of painful nodular lesions located on his left buttock and left inguinal region that had recently increased in size and number. The lesions had developed progressively over many years. Cutaneous examination revealed multiple, well-circumscribed, subcutaneous, blue-gray nodules in a zosteriform distribution across the left inguinal region and the left buttock. Some of the painful nodules were large and ulcerated (Figure 1). Computed tomography showed multiple cutaneous nodules but no bone metastases or subcutaneous invasion. Histologic examination of a nodule demonstrated sharply delineated dermal nodules comprising basaloid cells arranged in a trabecular pattern surrounded by eosinophilic fibrous strands (Figure 2). No evidence of malignant transformation was noted. A diagnosis of multiple eccrine spiradenomas was made, and the patient underwent surgical excision of the painful and ulcerated nodules. He was regularly followed up in our department for 12 years.

Comparative clinical trial: fluconazole alone or associated with topical ketoconazole in the treatment of pityriasis versicolor.

BACKGROUND: The efficacy of ketoconazole and fluconazole in pityriasis versicolor had been proved. AIM: To compare the efficacy and the safety of two doses of fluconazole given 1 week apart alone or associated to ketoconazole shampoo. METHODS: Our study included all patients with pityriasis versicolor who attended in dermatology department of Habib Thameur Hospital, Tunis (over a 21-month period). During the considered period, patients were randomly assigned in two study groups: G1 receiving fluconazole two doses 300mg given 1 week apart with G2 taken an association of fluconazole (two doses 300mg given 1 week apart) and ketoconazole shampoo the first day. RESULTS: Seventy one patients were enrolled in our study: 35 in the fluconazole group and 36 in the fluconazole associated to ketoconazole shampoo comparator group. The mean age was 29.1 years [16-70 years].  Concerning the clinical form, 27% had macular lesions, 24% had plaques and 49% had mixed form. Lesions werehyperchromic52%; hypochromic 15% and erythematous 6%. As for main location, 67% had lesions on the neck; 66% on the trunk, 60% on the shoulders. At the end of the study, there was no significant difference in clinical presentation and in improvement rate of pityriasis versicolor between fluconazole and association of fluconazole and ketoconazole shampoo ((p=0.13 at day 14, p=0.57 at day 28 and p=0.2 at day56). CONCLUSION: In this study, we have shown that the improvement rate of PV treated with two doses of 300 mg of fluconazole with one week interval was similar to those of an association of one application of ketoconazole shampoo and the same dose of fluconazole.

Significant alleviation of Darier's disease with fractional CO2 laser.

Darier's disease (DD) is a dominantly inherited genodermatosis with highly variable expression. It is characterized by symmetrical hyperkeratotic papules affecting seborrheic areas and extremities. The existence of unsightly lesions could lead to discomfort and social handicap. Conventional treatment consists of topical and systemic steroids and/or retinoids alleviating DD. Ablative lasers also have been used to treat these conditions with variable results and side effects. To the best of our knowledge, fractional CO2 laser has never been used to treat DD. We present a case of a 36-year-old woman with verrucous and hyperkeratotic plaques of the forehead significantly improved after two sessions of fractional CO2 laser treatment. Neither scars nor pigmentary disorders were noted.

Unilateral Onychodystrophy and Puffy Fingers: Think about Carpal Tunnel Syndrome.

An 87-year-old man was referred to our department for evaluation of his dystrophic left fingernails that developed progressively for the past 2 years. His past medical history included hemodialysis for 10 years for chronic renal failure. Examination of his nails revealed xanthonychia, onycholysis, Beau's lines, and marked hyperkeratosis of the nail plate involving all of his left fingernails. However, his right fingernails were not affected (Figure 1). He also had edema of the left hand associated with puffy fingers but without trophic disorders (Figure 2). Mycologic exam-ination with direct microscopy and culture of his affected nails were negative. Antinuclear antibodies (ANAs), Scl-70 (anti-topoisomerase) antibodies, anti-centromere antibodies, and anti-RNA polymerase III antibodies were all negative. Capillaroscopy showed no abnormalities. An X-ray of his left hand showed no bony abnormalities. For the past 5 years, the patient had suffered from paresthesia and numbness on the left hand in the area of the median nerve. Paresthesia, pain, burning, and tingling involved mainly the thumb, plus the index and middle fingers, but not the little finger. Carpal tunnel syndrome (CTS) was suspected. Neurologic examination and electromyography (EMG) confirmed the diagnosis of CTS of the left hand explaining his unilateral onychodystrophy. The patient was then referred to a hand surgeon for his CTS.

Nail involvement in connective tissue diseases: an epidemiological, clinical, and dermoscopic study.

BACKGROUND: The assessment of nail changes in connective tissue diseases (CTD) has been rarely explored in previous studies. The use of dermoscopy to study vascular changes in nailfolds is an interesting diagnostic technique. The aim of the study was to describe the epidemiological, clinical, and dermoscopic features of nail lesions in CTD. METHODS: A prospective study was performed at the Dermatology Department of Habib Thameur Hospital (Tunis, Tunisia) in collaboration with the Internal Medicine Department over a period of 15 months, from July 2020 to September 2021, including patients diagnosed with systemic sclerosis (SS), systemic lupus erythematosus (SLE) and dermatomyositis (DM). RESULTS: Our study included 48 patients. Nail involvement was found in 44 cases. Dermoscopic nailfold abnormalities were identified in 37 cases. The most common clinical features were ragged cuticle, nailfold erythema, and onycholysis. Additionally, splinter hemorrhage, longitudinal ridging, lunula abnormalities, melanonychia, trachyonychia, leukonychia, increase in transverse curvature, parrot beak nail, half and half nails, and onychorrhexis were described. Nailfold dermoscopy showed a normal pattern in 10 cases, a nonspecific pattern in nine cases (SLE), and a scleroderma pattern in 29 cases (SS and DM). The scleroderma pattern was further categorized into an early pattern (6), an active pattern (14), and a late pattern (9). Normal pattern was observed solely in patients in remission. The late scleroderma pattern was associated with disease duration and systemic involvement. In SLE, disease activity correlated with onycholysis, nailfold erythema, and pathologic pattern in dermoscopy. However, patients with DM displayed a positive correlation between pulmonary involvement and scleroderma pattern. CONCLUSION: Nail involvement in CTD includes a diverse range of abnormalities. Despite being nonspecific, it can provide crucial clues for establishing a diagnosis. Nailfold dermoscopy serves as a mirror for microangiopathy, enabling the detection of changes at an initial stage, and thus, it becomes a diagnostic and prognostic tool.

Subcutaneous Nodules of the Vulva.

A 32-year-old patient complained of three slow-growing subcutaneous nodules on her right labius majus, present for 3 years. Her past medical history was unremarkable. Cutaneous examination revealed three subcutaneous nodules of 1 cm diameter firmly adherent to the underlying tissues, located on her right labium majorum (Figure 1). Regional lymph nodes were not enlarged. She underwent an excision biopsy of a subcuta-neous nodule under local anesthesia. The gross specimen was firm, white and fleshy in appearance. A skin biopsy was performed, and histological findings revealed a non-encapsulated dermal nodule composed of clusters of polygonal cells with small central nuclei and abundant eosinophilic cytoplasm (Figure 2a). The tumor cells formed sheets and nests irregularly infiltrating between collagen bundles. There was no significant cyto-logic atypia and mitotic features. There were no necrosis and hemorrhage. The cells were positive for S-100 immunostain (Figure 2b). Hence, the diagnosis of benign vulvar granular cell tumor was assessed. The patient underwent surgical excision of the subcutaneous nodules with no recurrence at 2 years.

Alopecia patterns and trichoscopic findings in patients with autosomal recessive congenital ichthyosis.

Background: Autosomal recessive congenital ichthyosis (ARCI) is a rare genodermatosis categorized among nonsyndromic ichthyoses. While ARCI patients often manifest hair abnormalities, their impact on the quality of life remains underreported in the literature. Objective: This study aims to comprehensively characterize the clinical and trichoscopic findings of alopecia in ARCI patients. Methods: A prospective study spanning from January 2019 to December 2021 (3 years) was conducted at the Dermatology Department of Habib Thameur Hospital, Tunis, Tunisia. Clinical and trichoscopic examinations were performed on the hair of the participants, with molecular studies conducted on 15 patients. Results: The study included 30 patients, predominantly female (male/female = 0.58), with a mean age of 20 years. Twenty-eight patients were born from consanguineous marriages. Lamellar ichthyosis was observed in 22 cases, while congenital ichthyosiform erythroderma and bathing suit ichthyosis were each present in 4 cases. The ARCI severity score, assessed using the Visual Index For Ichthyosis Severity scale, had a mean value of 15 (4-28). Alopecia emerged as a prominent finding in 11 patients, presenting as hairline recession (13%), multiple patchy alopecia (27%), and alopecia of the eyebrows (13%). Trichoscopic findings included interfollicular and perifollicular scaling, perifollicular lamellar hyperkeratosis, peripilar casts, interfollicular erythema, loss of hair openings, predominance of single hair follicles, broken hair, vellus hair, anisotrichosis, pili torti, dystrophic hair, and comma hair. Several trichoscopic findings showed statistically significant associations with the severity of ARCI. Limitations: In our study, we only included 30 patients due to the rarity of this genodermatosis. Conclusion: Contrary to previous perceptions, alopecia is a notable finding in ARCI, particularly in patients with a severe form. This study provides a detailed characterization of alopecia in ARCI, shedding light on its prevalence and associated trichoscopic features, thereby enhancing our understanding of this dermatological condition.