Linear lichen planus pigmentosus of the face with histological findings of lichen planopilaris - an uncommon variant of lichen planus.

Lichen planus pigmentosus and lichen planopilaris are two clinically and histologically distinct forms of lichen planus. Lichen planus pigmentosus presents with sudden onset hyperpigmented macules and patches, predominantly in darker skin phototypes. On the other hand, lichen planopilaris is a scarring follicular variant of lichen planus that presents with progressive, permanent patches of alopecia. It is not uncommon for different variants of lichen planus to clinically coexist with each other. However, to our knowledge, there has been no previous reporting of linear lichen planus pigmentosus of the face with histological features of lichen planopilaris. We herein present a hybrid case of these two entities.

Fibro-osseous pseudotumor on the hyponychium of the great toe.

Fibro-osseous pseudotumor of the toe is a benign soft tissue tumor that is predominant in the young adult population. Although the etiology is unknown, a history of trauma has been reported to precede tumor development. The differential diagnosis includes myositis ossificans, extraskeletal osteosarcoma, and pyogenic granuloma. Once removed, the tumor typically has no recurrence. Surgical excision is the treatment of choice. We present a patient with fibro-osseous pseudotumor of the great toe, which had no recurrence following excision.

Apocrine adenocarcinoma of the eyelid: case report and literature review on management.

Apocrine adenocarcinoma of the eyelid is a rare sweat gland cancer. It is predominant in older adults and has increased prevalence in males. Management is based on recommendations from reported cases and their outcomes. Surgical excision is considered effective in apocrine adenocarcinoma of the eyelid. We report the case of a 58-year-old woman with apocrine adenocarcinoma located on her left upper eyelid. Excisional biopsy demonstrated focal apocrine secretion in a basaloid nest proliferation. The patient had no recurrence at four months. Our case provides insight into the workup and management of eyelid apocrine adenocarcinoma. Furthermore, we discuss key management recommendations according to previous authors' experiences with eyelid apocrine adenocarcinoma.

Atrophic dermatofibroma in an elderly male - a rarely described variant of a common lesion.

Dermatofibroma frequently presents as a red-brown nodule on the extremities of the middle aged. Atrophic dermatofibroma is a rare variant that has been most commonly described as an atrophic depressed, erythematous lesion in females. The correct diagnosis of atrophic dermatofibroma is often hindered by its infrequent presentation. It has a female preponderance with an occurrence ratio of 10:1. We describe a case of an atrophic dermatofibroma on the back of an elderly man. Skin biopsy demonstrated a spindle cell proliferation in a storiform pattern, loss of elastic fibers, and substantial atrophy of both the underlying dermis and subcutaneous tissue. An aggregation of elastic fibers was found in the periphery of the tumor. These histologic features supported the diagnosis of atrophic dermatofibroma. The dermal and adipocyte atrophy was likely responsible for the retracted appearance of the lesion.

The routine use of iron stain for biopsies of dermatoses of the legs.

BACKGROUND: Our goal was to study the utility of the routine use of the Gomori iron stain in the evaluation of leg biopsies of inflammatory lesions. METHODS: One hundred consecutive skin biopsies from the legs were evaluated with hematoxylin and eosin and Gomori iron stains. Iron positivity was semi-quantitatively graded from trace to 4+. RESULTS: Forty-two (42) cases were positive with the Gomori iron stain as follows: stasis dermatitis (14), Schamberg's disease (7), folliculitis (2), psoriasis (2), trauma (2), arthropod bite (2), allergic contact dermatitis (2), lichen simplex chronicus (1), senile purpura (1), vascular ectasia (1), lobular capillary hemangioma (1), scar (1), pretibial pigmented patches (1), tinea (1), lentigo maligna (1), traumatic fat necrosis (1), lichen planus (1) and fixed drug eruption (1). Twelve of 14 cases of stasis dermatitis had 2+ or greater iron staining; 8 cases were 3+ or 4+. All other diagnoses had trace or 1+ staining for iron except for one scar (2+). One of 19 samples (5.3%) of 'normal' leg skin controls showed iron stain positivity, and was graded as trace. CONCLUSIONS: After correcting for iron staining in 5.3% of normal leg skin controls, we observed Gomori iron positivity in 36.7% of 100 consecutive leg biopsies. We suggest that routine application of an iron stain on biopsies of dermatoses from the legs is useful. Stasis dermatitis and Schamberg's disease are the most frequent iron positive diagnoses, and the diagnosis is aided by the pattern of hemosiderin deposition. Negative iron stain is also useful in suggesting the presence of melanin pigment in macrophages in lichenoid and other dermatoses. To confirm a truly negative iron stain, study of the section at ×400 rather than ×100 is recommended.

Choriocarcinoma-like squamous cell carcinoma: a new variant expressing human chorionic gonadotropin.

Cutaneous squamous cell carcinoma (SCC) has been classified into a large number of subtypes, which have been grouped according to malignant potential. We describe a new morphological variant containing areas of intermingled cytotrophoblast-like and syncytiotrophoblast-like cells and designate it "choriocarcinoma-like SCC." Furthermore, the neoplasm exhibits expression of human chorionic gonadotropin predominantly in the syncytiotrophoblast-like foci, mimicking the germ cell tumor. Human chorionic gonadotropin expression has been described in SCC from other organs, but not by cutaneous SCC, to our knowledge. This new variant could be misinterpreted as metastatic choriocarcinoma, especially in small punch biopsies. The frequency of this neoplasm and its malignant potential are undetermined.

Blastic plasmacytoid dendritic cell neoplasm: evolving insights in an aggressive hematopoietic malignancy with a predilection of skin involvement.

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) derived from precursors of plasmacytoid dendritic cells is a very rare, unique, and highly aggressive immature hematopoietic malignancy, more frequently occurring among healthy elderly adults. BPDCN can be characterized by a striking predilection for cutaneous involvement, which is often detected incidentally by dermatologists and is difficult to clinically distinguish it from other primary skin lesions and histologically from leukemia/lymphoma cutis. Thus, histological diagnosis of cutaneous biopsies is crucial to correctly classify this entity. Most patients eventually progress to acute myeloid leukemia and are generally not curable. Here, we present 2 cases of classic BPDCN and discuss the origin of tumor and literature-based characteristic clinical and morphological features, evolving immunomarkers, and molecular genetic aspects of this neoplasm.

Radiation-associated atypical vascular lesions: vascular lesions with endothelial cell atypia presenting in the radiation port of breast cancer patients.

Atypical vascular lesions are an uncommon adverse sequela to the radiotherapy of tumors. Many characteristics are shared between atypical vascular lesions caused by radiation port and well-differentiated radiation-induced angiosarcomas. The authors retrospectively reviewed the medical literature using PubMed, searching the terms acquired, atypical, benign, lymphangioma, lymphangioendothelioma, lymphangiomatous, lesion, papules, progressive, and vascular. Patient reports and previous reviews of the subject were critically assessed and the salient features are presented. Atypical vascular lesions associated with the radiation port present as clinically innocuous flesh-colored to erythematous papules or plaques. The condition presents within the radiation field, approximately 3 years after initial treatment. While the exact me chanism remains to be elucidated, growing evidence supports an association between radiation-associated atypical vascular lesions and radiation-induced angiosarcomas. Atypical vascular lesions within a radiation port are suggested to be in a state of morphologic continuum, which may progress into the more aggressive, malignant angiosarcoma. The authors recommend consideration for biopsy of new skin lesions within or adjacent to radiation. While it is clear that atypical vascular lesions caused by radiation are not equivalent to angiosarcoma, growing evidence supports that radiation-associated atypical vascular lesions may progress to angiosarcoma in some patients; therefore, the authors recommend excision of the lesion with margins depending on clinical judgment and the lesion encountered.

Intratumoral heterogeneity of chromosome 9 loss and CDKN2A (p16) protein expression in a morphologically challenging spitzoid melanoma.

In young adults and children, spitzoid melanoma carries striking resemblance to spitz nevus clinically and histopathologically. Many have attempted to differentiate between these 2 entities by searching for immunohistochemical and molecular diagnostic differences. Here, the authors report a spitzoid melanoma in a young adult, which was morphologically similar to a spitzoid nevus and carried a loss of chromosome 9 detected by an array-based comparative genomic hybridization. However, the expression of cyclin-dependent kinase inhibitor 2A (p16) protein, encoded on chromosome 9p21, detected by the immunohistochemical study was heterogeneous among tumor cells. This case demonstrates the presence of clonal heterogeneity of losses of chromosome 9 and p16 protein expression within a single spitzoid melanoma, challenging a robust application of p16 expression detected only by immunohistochemical staining in determining the diagnosis of spitzoid melanoma.

Molluscum contagiosum of the areola and nipple: case report and literature review.

Molluscum contagiosum is a common cutaneous infection caused by a double-stranded DNA poxvirus. Skin lesions classically present as small, flesh-colored papules with central umbilication. Lesions are frequently seen on the face, trunk, and extremities of children, or on the genitals of young adults as a sexually transmitted infection. Molluscum contagiosum on the nipple or areola has only been previously described in 4 women. We describe a woman with molluscum contagiosum on the left areola and review the clinical characteristics and histological findings of patients who developed molluscum contagiosum of the nipple or areola.

Cutaneous Coccidioidomycosis and Basal Cell Carcinoma: Case Report on a Diagnostic Dilemma.

In the world of medical diagnoses, a particularly intriguing scenario unfolds, wherein the cutaneous manifestation of a systemic fungal infection disguises itself as a Basal Cell Carcinoma (BCC), a skin cancer. Coccidioidomycosis is an endemic fungal infection caused by inhaling spores of the fungus Coccidioides immitis. It is primarily a pneumonic illness which, in a few cases, has the potential to cause severe systemic disease. In this article, we report a case of a 60-year-old female with a known history of infiltrating ductal carcinoma of left breast status post lumpectomy and adjunct chemotherapy presented with complaints of cough, fever, and easy fatigability that seemed to be attributable to her immunocompromised state. She also had a pseudo-vesicular plaque on her left upper arm for two years. As we delve into the case, it becomes clear that Coccidioidomycosis and other opportunistic infections are commonplace among immunocompromised patients. Prior awareness of this condition and a cautious yet open-minded approach prevented gross misdiagnosis in our case. Physicians should be vigilant in diagnosing Coccidioidomycosis, especially in immunocompromised patients presenting with mild constitutional symptoms in endemic regions. Early detection and management are crucial to prevent severe complications and increase patient survival rates.

Plantar molluscum contagiosum: a case report of molluscum contagiosum occurring on the sole of the foot and a review of the world literature.

Molluscum contagiosum (MC) is a skin infection caused by the double-stranded DNA virus of the family Poxviridae that typically presents as flesh-colored asymptomatic umbilicated papules. Plantar MC is uncommon. We describe a 23-year-old man who presented with multiple plantar MC. We also summarize the epidemiologic features of the 34 previously reported patients with plantar MC and discuss the clinical characteristics, differential diagnosis, and treatment of plantar MC. The patients were immunocompetent and the median age at diagnosis was 21 years. Although the plantar MC were asymptomatic in some individuals, a common presenting symptom was pain while walking. Patients had 1 lesion (23/35), 2 lesions (5/35), 3 lesions (4/35), or more than 5 lesions (3/35). Giant MC (>or=1 cm in diameter) was observed in more than 75% (a minimum of 27/35) of patients. At the initial patient evaluation, plantar verruca often was suspected; subsequently, light and/or electron microscopy of the plantar lesion confirmed the diagnosis of plantar MC. Removal or destruction of the lesion resulted in definitive treatment of the plantar MC.

Cladosporium scalp infection.

An 11-year-old healthy red-haired girl presented with a 3-year history of hair loss and mild pruritus of her scalp. She had previously been diagnosed with trichotillomania. Cutaneous examination showed scant hair loss with neither crusting nor scaly lesions. The scalp hair was diffusely thin, dry, and brittle on the frontal, mid-parietal, and anterior occipital scalp (Figure 1A). A pull test was negative, and a significant number of hair shafts were not detached on repeated traction. Closer examination using a dermatoscope showed follicles with broken hair shafts. The dermatoscopic evaluation also showed frequent pinpoint black dots scattered among the terminal hair shafts at their bases. No scale, scar, or inflammatory changes were seen in the involved areas (Figure 1B). A 20% potassium hydroxide (KOH) preparation of material obtained after gentle scrapping of the black dots on the scalp provided fragments of hair fibers containing aggregates of pigmented yeast forms (Figure 2A) and brown septate hyphae (Figure 2B). Two samples were sent for fungal culture and both showed dark brown colonies on the surface and black coloration when viewed from the reverse side (Figure 3A). Lactophenol cotton blue preparation of the fungal colonies revealed long and septate hyphae with laterally branching conidiophores ending in round-shaped conidia (Figure 3B). The microorganism was identified by the reference laboratory as Cladosporium species. The conidia were usually noted to be single-celled with a distinct dark hilum. They also exhibited prominent attachment scars that caused the cells to appear "shield-shaped." These features were considered to be diagnostic for Cladosporium; however, the reference laboratory could not identify the organism to the species level. The girl's Cladosporium scalp infection was treated with itraconazole at an oral daily dose of 200 mg for 2 months. Upon re-evaluation, she showed significant improvement with not only discontinuation of her alopecia and new hair growth (Figure 4A), but also an absence of broken hair shafts and the dark pigmentation found initially at their base when her scalp was examined using a dermatoscope (Figure 4B). In addition, a new KOH preparation did not reveal the presence of conidia.

Delayed diagnosis of adult-onset mastocytosis.

Urticaria pigmentosa is most frequently observed in children. The associated symptomatology in mastocytosis is vague and not always diagnostic, and Darier's sign is often negative, making the diagnosis challenging. We describe a case of a 61-year-old man with extensive brown papules and macules in different locations of the body that slowly progressed in the last 10 years with a previous anaphylactic reaction after an ant bite. This suggests that urticaria pigmentosa in an adult should be furthered assessed for the possibility of systemic involvement for a correct diagnosis and treatment.

Early-stage mycosis fungoides variants: case-based review.

Mycosis fungoides (MF) is the most common type of cutaneous T-cell lymphoma. The diagnosis of classic MF is based on a combination of clinical presentation, histopathology, and T-cell monoclonality detected by molecular studies. However, the diagnosis can be difficult in cases of early MF because of the subtle nature of histologic findings and, in cases of variants of MF, because of the unusual clinical and/or pathologic features. In this review, we presented the most frequent variants of MF at early stage including hypopigmented, folliculotropic, pagetoid reticulosis, unilesional, granulomatous, and ichthyosis forms. This case-based clinicopathologic review provides the notion that a comprehensive clinicopathologic correlation is of substantial importance to render the diagnosis of MF. In addition, we discuss the role of molecular studies, which are highly sensitive and recently more applicable to routinely processed skin biopsy specimens in the diagnosis of MF.

Fluoroscopy-induced chronic radiation dermatitis: a report of three cases.

We report these cases to emphasize the importance of recognizing fluoroscopy as a cause of radiation dermatitis. The diagnosis of fluoroscopy-induced chronic radiation dermatitis should be raised when patients present with morpheaform, telangiectatic, or ulcerative skin findings in the characteristic locations.

Follicular Mucinosis: A Case Report.

Follicular mucinosis (FM) is a rare disorder of the skin characterized by follicular degeneration due to the accumulation of mucin within the pilosebaceous unit, with associated inflammatory changes. We report a case of an 11-year-old female with widespread lesions showing distinct clinical and histological features of FM with a brief review of the literature.

Pulse granuloma in a rectocutaneous fistula.

Pulse granulomas are rare foreign body reactions to vegetable material characterized by hyaline rings or starch granules. Pulse granulomas have mainly been reported in association with lung aspirations, the oral cavity with a history of oral procedures and less frequently in intestinal fistulae, colonic diverticulae or stomach ulcers. Only one case involving the skin has been reported in a patient with jejunocutaneous and ileocutaneous fistulae. We report the second cutaneous pulse granuloma in a patient with a rectocutaneous fistula.