Generalized early inflammatory morphea mimicking interstitial T-cell lymphoma: A diagnostic pitfall.

Early generalized morphea can clinically mimic mycosis fungoides. The microscopic features of early inflammatory morphea may show variable degrees of infiltration and do not have the characteristic dermal collagen sclerosis. We report the case of a 63-year-old female patient who presented with a 2-month history of an asymptomatic skin rash. Physical examination revealed multiple erythematous to dusky patches on the trunk and thighs, resembling the patch stage of mycosis fungoides. Two skin biopsies were performed, both of which showed prominent interstitial lymphoid infiltration in the reticular dermis without dermal sclerosis. Small lymphocyte exocytosis and lining along the dermal-epidermal junction were observed focally in the epidermis. Small clusters of plasma cells and eosinophils were observed in perivascular areas. Although no predominant clonality was found for CD4 and CD8 stains, 50% loss of CD5 antigen and 90% loss of CD7 antigen expression were apparent in immunohistochemical studies. Subsequent blood tests showed a normal blood cell count and positive human T-lymphotropic virus Type 1 antibodies. The overall findings suggested interstitial mycosis fungoides or early adult T-cell lymphoma-leukemia. The patient refused aggressive treatment, and 3 months later, she presented with indurated plaques from the previous rash. A repeat biopsy revealed the typical features of morphea. This report discussed the pitfalls in the clinical and histopathological diagnosis of early generalized inflammatory morphea that both clinicians and pathologists should consider.

A retrospective study on the direct immunofluorescence findings in pigmented purpuric dermatosis.

BACKGROUND: Pigmented purpuric dermatosis (PPD) is characterized by grouped petechiae, purpuric macules, and pigmentation in the bilateral lower extremities. It runs a chronic and relapsing course. Pathophysiology is poorly understood, but it has been proposed to be an immune-complex disease or capillaritis. This study aimed to determine the incidence and patterns of positive direct immunofluorescence (DIF) findings in patients with clinically and histopathologically confirmed PPD. The association between DIF deposition type and clinical profile was also analyzed. METHODS: Patients with a clinical and histopathologic PPD diagnosis who had undergone DIF studies at a tertiary medical center with attached dermatopathology and immunofluorescence diagnostic centers between January 2002 and December 2021 were included in this study. Data on age, sex, disease duration, comorbidities, and drug intake were collected from medical records. RESULTS: There were 65 patients who satisfied the inclusion criteria. Among them, 58 (89%) had at least one positive finding and 53 (82%) were vascular deposition of immunoglobulin (Ig), complement, or fibrinogen. The most common vascular deposition was fibrinogen (71%) followed by C3 (62%), IgM (18%), IgA (6%), and IgG (3%). Fibrinogen deposition was associated with hypertension (p < 0.03). There was no association between vascular DIF deposition of IgG, IgA, and C3, with age, sex, comorbidities, disease duration, and drug history. CONCLUSION: The most common DIF findings in PPD were vascular deposition of fibrinogen and C3, with or without Ig presence. DIF findings supported a vascular origin in PPD but not an immune complex-mediated disease. Hypertension was associated with fibrinogen deposition and may play a role in its pathophysiology.

Should antituberculosis treatment be prescribed in erythema induratum? A case-control and incidence correlation study in Taiwan, 2001-2020.

BACKGROUND: Erythema induratum (EI) is a tuberculid associated with Mycobacterium tuberculosis infection. Using polymerase chain reaction (PCR), M. tuberculosis has been identified in Taiwan with a high percentage of EI. However, this pathogen is now rarely detected in Taiwan. OBJECTIVES: To explore the association between EI, the annual incidence of tuberculosis (TB) in Taiwan and treatment outcomes over the last two decades. METHODS: Patients diagnosed with EI between 2001 and 2020 were enrolled based on histopathology, tissue culture and positive M. tuberculosis PCR tests. Other cases of panniculitis with positive M. tuberculosis PCR results were used as controls. The clinical information of participants was obtained. The results were correlated with the annual incidence of TB and compared between groups. RESULTS: Fifty-five biopsy specimens from patients with EI met the inclusion criteria; three (5%) had positive M. tuberculosis PCR results. One patient diagnosed with erythema nodosum in the control group had a positive M. tuberculosis PCR (n = 1/27; 4%). There was no significant relationship between M. tuberculosis and EI (odds ratio 1.5, 95% confidence interval -0.964 to 3.964). The correlation between the incidence of M. tuberculosis and the number of EI cases was not statistically significant (r = -0.185, P = 0.45). Only four patients received anti-TB treatment; they all showed clinical improvement without recurrence. One patient with M. tuberculosis PCR-positive EI was not treated with anti-TB therapy; however, the skin lesion improved after 3 months. No other patients in the EI group were diagnosed with M. tuberculosis infection over a follow-up period of 508 person-years. CONCLUSIONS: Most cases of EI in Taiwan are nodular vasculitis and not tuberculid, owing to well-controlled TB. This condition can be alleviated without anti-TB treatment.

Adaptability of melanocytes post ultraviolet stimulation in patients with melasma.

BACKGROUND: Dynamic in vivo changes in melanin in melasma lesions after exposure to ultraviolet (UV) irradiation have not been described. OBJECTIVES: To determine whether melasma lesions and nearby perilesions demonstrated different adaptive responses to UV irradiation and whether the tanning responses were different among different locations on face. METHODS: We collected sequential images from real-time cellular resolution full-field optical coherence tomography (CRFF-OCT) at melasma lesions and perilesions among 20 Asian patients. Quantitative and layer distribution analyses for melanin were performed using a computer-aided detection (CADe) system that utilizes spatial compounding-based denoising convolutional neural networks. RESULTS: The detected melanin (D) is melanin with a diameter >0.5 µm, among which confetti melanin (C) has a diameter of >3.3 µm and corresponds to a melanosome-rich package. The calculated C/D ratio is proportional to active melanin transportation. Before UV exposure, melasma lesions had more detected melanin (p = 0.0271), confetti melanin (p = 0.0163), and increased C/D ratio (p = 0.0152) in the basal layer compared to those of perilesions. After exposure to UV irradiation, perilesions have both increased confetti melanin (p = 0.0452) and the C/D ratio (p = 0.0369) in basal layer, and this effect was most prominent in right cheek (p = 0.030). There were however no significant differences in the detected, confetti, or granular melanin areas before and after exposure to UV irradiation in melasma lesions in all the skin layers. CONCLUSIONS: Hyperactive melanocytes with a higher baseline C/D ratio were noted in the melasma lesions. They were "fixed" on the plateau and were not responsive to UV irradiation regardless of the location on face. Perilesions retained adaptability with a dynamic response to UV irradiation, in which more confetti melanin was shed, mainly in the basal layer. Therefore, aggravating effect of UV on melasma was mainly due to UV-responsive perilesions rather than lesions.

Blastomycosis-like pyoderma: A pitfall for the misdiagnosis of squamous cell carcinoma.

Blastomycosis-like pyoderma is a rare cutaneous disease presenting as solitary or multiple verrucous or ulcerated plaques and nodules in a susceptible patient. The diagnostic criteria include characteristic verrucous plaques with pustules and elevated borders, histopathologic findings of pseudoepitheliomatous hyperplasia with abscesses, growth of at least one bacterium in tissue culture, and exclusion of other infectious sources. This report describes a case of a 62-year-old man with poorly controlled type 2 diabetes mellitus who presented with plaques, nodules, and ulcers in both groins and the right ankle. The patient was initially misdiagnosed with multiple squamous cell carcinomas and underwent several operations. A review of the pathology slides revealed pseudoepitheliomatous hyperplasia with multiple dermal abscesses, while repeated wound and tissue cultures were positive for coagulase-negative Staphylococcus. Blastomycosis-like pyoderma was diagnosed. The patient was subsequently treated with culture-guided prolonged antibiotic therapy followed by intralesional steroid injection, which led to gradual resolution of the lesions.

Application of Cellular Resolution Full-Field Optical Coherence Tomography in vivo for the Diagnosis of Skin Tumours and Inflammatory Skin Diseases: A Pilot Study.

BACKGROUND: Optical coherence tomography (OCT) has been shown to provide non-invasive diagnosis of common skin neoplasms, especially basal cell carcinoma. OCT produces a cross-sectional view of the tissue, similar to a traditionally sectioned histopathological view, but the resolution of conventional OCT is low and thus limits clinical application. OBJECTIVES: This study aimed to investigate the application ability of a full-field (FF)OCT system which was newly developed to scan the skin at the cellular level. METHODS: Patients with skin tumours or inflammatory lesions warranting biopsy were consecutively enrolled. All lesions underwent clinical, dermoscopic, and OCT assessment, followed by routine biopsy. The adjacent normal skin was scanned for comparison. OCT images were interpreted (blinded to the biopsy results) and then compared with the histopathological diagnosis. RESULTS: A total of 111 patients with 115 lesions completed the protocol, including 80 skin tumours, 28 inflammatory diseases, and 7 other diseases. Of the OCT images, 43.5% were of good quality and show expected features. Identifiable features of actinic keratosis, Bowen's disease, basal cell carcinoma, extramammary Paget's disease, seborrheic keratosis, large cell acanthoma, bullous pemphigoid, interface dermatitis, lichenoid tissue reaction, and psoriasis were demonstrated. Lesions are located deeply, and so some features were out of the field of view, accounting for 40.0% (46/115). CONCLUSIONS: This study expanded the ability of FFOCT for the clinical diagnosis of various skin conditions. This new optical technique can clearly visualise skin lesions located in the epidermis and upper dermis. It provided an effective way to perform digital skin biopsy in superficial skin diseases.

A Case Series With Acquired Dermal Melanocytosis: A Retrospective Study From 2001 to 2018.

ABSTRACT: Acquired dermal melanocytosis (ADM) is a pigmented lesion caused by melanocytes in the dermis, and it is most often observed on the face of young and middle-aged Asian women. ADM development may be associated with melanin synthesis alterations, but little evidence of its molecular and histological alteration has yet been reported. This study aimed to evaluate ADM in different body locations using different immunohistochemical and chemical staining techniques. This retrospective case series includes consecutive patients confirmed as ADM by biopsy between 2001 and 2018. Patient data and archival images were used to determine the pattern and duration of skin lesions, as confirmed by data analysis of immunohistopathological staining of skin biopsy specimens. A total of 22 ADM patients were included with mean age at diagnosis of 47 years, and 63.6% were female. The most common site was limbs (36.4%), followed by face (27.3%), trunk (22.7%), and scalp (13.6%). Melanin levels were highest in the face and upper extremities and lowest in the trunk. All participants had perivascular distribution of dermal melanocytes, particularly on the face and limbs. The perineural distribution of dermal melanocytes was observed in the lower limbs, with prominent inflammation and fibrosis on the scalp. Dermal melanocytes expressed most markers recognizing melanocytes except for CD117. Analysis of this ADM case series has confirmed that melanin is activated by dermal melanocytes that may aggregate along blood vessels. CD117 may be a useful biomarker by which to identify the migration of epidermal melanocytes.

Pathological and Immunohistochemical Characteristics of Granuloma and Lymphatics in Cheilitis Granulomatosa.

ABSTRACT: Cheilitis granulomatosa (CG) is an idiopathic, rare, and chronic granulomatous disorder involving the lips. We characterized the pathological and immunohistopathological findings of these granulomas and their relationship with the lymphatic vessels. Pathologically confirmed cases of primary CG from 2001 to 2016 were collected. Cases of inflammatory cheilitis without the presence of granuloma were included in the control group. Demographic data, clinical presentation, response to therapy, and pathological differences were compared. Periodic acid-Schiff and acid-fast stains excluded patients having infections. CD68, CD163, and D2-40 stains demonstrated features of granuloma, macrophage polarization, and the relationship between granuloma and lymphatic vessels. Thirteen patients diagnosed with CG were enrolled. Thirteen people were enrolled in the control group. The granulomas were either mononuclear or sarcoidal. They were predominantly positive for CD68 but negative for CD163. Perilymphatic granulomas were found in all patients. Intralymphatic histiocytosis and lymphatic dilatation were more commonly observed in patients diagnosed with CG than those in controls (54% vs. 15%, P = 0.03 and 92% vs. 23%, P < 0.01). TH1 immune response due to CD68+ M1 macrophages results in CG. Perilymphatic aggregation of macrophages and intralymphatic histiocytosis were important pathological clues for diagnosis.

Factors facilitating clinical application of and adherence to evidence-based healthcare among medical professionals attending national competitions in Taiwan: a study based on the decomposed theory of planned behaviour.

BACKGROUND: Implementing evidence-based healthcare (EBHC) to improve the quality of patient care is a key issue for physicians and nurses. One of the most effective activities for achieving this is the annual topic-oriented clinical application national competition in Taiwan. Hundreds of clinical issues have been presented in this competition. By using the decomposed theory of planned behaviour (DTPB), this study explored physicians' and nurses' behaviour and adherence to the clinical application of EBHC after participating in the competitions. METHODS: We conducted a 3-month cross-sectional online survey using a structured questionnaire adapted from the original study of the DTPB to collect behavioural and intention-related data. We also used a model of seven action stages (from aware of to adhered to) to assess target behaviours. We targeted contestants of the EBHC competitions between 1999 and 2017 as study participants. Of 631 teams, 321 teams completed the questionnaire, representing a 49.5% response rate. We applied structural equation modelling to test model fit. Moreover, we executed multivariate logistic regression to identify potential predictors. RESULTS: Of the respondents, 33.3% reportedly reached the final adhered to stage. The DTPB model exhibited a good fit to the observed data. All constructs (usefulness, compatibility, peer influence, superior influence, self-efficacy, resource facilitating conditions, attitude, subjective norms, behavioural control, and intentions) were positively associated with the target behaviours, except for ease of use and technology facilitating conditions. Furthermore, the study model explained the variance in the target behaviours (37.0%). Having managerial duties (odds ratio [OR] =2.03, 95% confidence interval [CI] =1.10-3.77), resource facilitating conditions (OR = 1.06, 95% CI = 1.01-1.11), behavioural control (OR = 2.21, 95% CI = 1.47-3.32), and intentions (OR = 1.96, 95% CI = 1.40-2.73) were significant predictors of the achievement of the adhered to stage. CONCLUSIONS: The study demonstrated the association between determinants of behaviour and clinical applications and factors influencing adherence to EBHC among competition participants. The adherence rate was not high after the competitions, and this may be improved by promoting certain factors associated with the target behaviours.

Photoaging and Sequential Function Reversal with Cellular-Resolution Optical Coherence Tomography in a Nude Mice Model.

Although nude mice are an ideal photoaging research model, skin biopsies result in inflammation and are rarely performed at baseline. Meanwhile, studies on antiphotoaging antioxidants or rejuvenation techniques often neglect the spontaneous reversal capacity. Full-field optical coherence tomography (FFOCT) can acquire cellular details noninvasively. This study aimed to establish a photoaging and sequential function reversal nude mice model assisted by an in vivo cellular resolution FFOCT system. We investigated whether a picosecond alexandrite laser (PAL) with a diffractive lens array (DLA) accelerated the reversal. In the sequential noninvasive assessment using FFOCT, a spectrophotometer, and DermaLab Combo®, the photodamage percentage recovery plot demonstrated the spontaneous recovery capacity of the affected skin by UVB-induced transepidermal water loss and UVA-induced epidermis thickening. A PAL with DLA not only accelerated skin barrier regeneration with epidermal polarity, but also increased dermal neocollagenesis, whereas the nonlasered group still had >60% collagen intensity loss and 40% erythema from photodamage. Our study demonstrated that FFOCT images accurately resemble the living tissue. The photoaging and sequential function reversal model provides a reference to assess the spontaneous recovery capacity of nude mice from photodamage. This model can be utilized to evaluate the sequential noninvasive photodamage and reversal effects after other interventions.

Loss of GPNMB Causes Autosomal-Recessive Amyloidosis Cutis Dyschromica in Humans.

Amyloidosis cutis dyschromica (ACD) is a distinct form of primary cutaneous amyloidosis characterized by generalized hyperpigmentation mottled with small hypopigmented macules on the trunks and limbs. Affected families and sporadic case subjects have been reported predominantly in East and Southeast Asian ethnicities; however, the genetic cause has not been elucidated. We report here that the compound heterozygosity or homozygosity of GPNMB truncating alleles is the cause of autosomal-recessive ACD. Six nonsense or frameshift mutations were identified in nine individuals diagnosed with ACD. Immunofluorescence analysis of skin biopsies showed that GPNMB is expressed in all epidermal cells, with the highest staining observed in melanocytes. GPNMB staining is significantly reduced in the lesional skin of affected individuals. Hyperpigmented lesions exhibited significantly increased amounts of DNA/keratin-positive amyloid deposits in the papillary dermis and infiltrating macrophages compared with hypo- or depigmented macules. Depigmentation of the lesions was attributable to loss of melanocytes. Intracytoplasmic fibrillary aggregates were observed in keratinocytes scattered in the lesional epidermis. Thus, our analysis indicates that loss of GPNMB, which has been implicated in melanosome formation, autophagy, phagocytosis, tissue repair, and negative regulation of inflammation, underlies autosomal-recessive ACD and provides insights into the etiology of amyloidosis and pigment dyschromia.

Isotopic response of labetalol-associated lichen planus pemphigoides on an old radiation site: A case report.

Over the years, the occurrences of different types of skin disorders arising from radiation sites have been observed and studied. Examples include autoimmune blistering diseases such as pemphigus, pemphigoid, and interface or inflammatory reaction patterns such as lichen planus, lupus erythematosus, and Stevens-Johnson syndrome. The phenomenon whereby a new skin disorder arises from a previously healed or irradiated site is called an isotopic response, described as a type of Koebner phenomenon. Ionizing radiation itself can profoundly affect the skin. Both early and late changes can present, which typify the progression of changes following irradiation of the skin. Herein, we report a rare case of labetalol-associated lichen planus pemphigoides that occurred at the site treated with radiation for a soft tissue malignancy after 19 years as a result of an isotopic response. The rash was well-controlled after therapy and kept a 4-year remission. The same skin reaction recurred after the reintroduction of labetalol 4 years later.

Plaque-Type Variant of Acquired Rhabdomyomatous Mesenchymal Hamartoma on the Chin: A Case Series.

ABSTRACT: Rhabdomyomatous mesenchymal hamartoma (RMH) is a rare benign tumor composed of skeletal muscle fibers and other mesenchymal-derived cells. The lesions are generally solitary sessile papules or skin tag lesions that occur during childhood. We retrospectively reviewed patients diagnosed with RMH pathologically between January 2001 and June 2020 at a tertiary medical center. A literature review was conducted. Seven plaque-type RMHs on the chin were found, including 6 in adults and one in a 14-year-old boy. The average age was 45.7 years. The onset of the RMH appearance was between several months and years. Pathologically, all patients showed a scattered haphazard arrangement of skeletal muscle bundles in the dermis and/or subcutis. Subcutis replaced by fibrous tissue and skeletal muscle bundles was present in 2 cases. Some skeletal muscles had a periadnexal distribution. This case series demonstrated a distinct clinical presentation of acquired RMH specifically located on the chin.

Cutaneous Pseudolymphoma With Langerhans Cell Hyperplasia-A Rare Case With Clinical Presentation Mimicking Malignancy and Potential Diagnostic Pitfall.

ABSTRACT: We describe a rare case of cutaneous pseudolymphoma with Langerhans cell hyperplasia. An 84-year-old female patient presented with erythematous and pernicious-looking plaques on her scalp that had been present for months. Histologically, lymphoid follicles consisting of mixed-type lymphocytes and Langerhans cells were aggregated focally. The diagnosis was verified by several immunohistochemical stains and by clinical evaluation. Skin lesions were steadily resolved with low-dose corticosteroid and hydroxychloroquine.

Spongiform pemphigoid: A case series of an uncommon histopathologic pattern.

INTRODUCTION: Bullous pemphigoid is an autoimmune bullous disease characterized by subepidermal separation. We encountered cases of bullous pemphigoid confirmed by direct immunofluorescence study but demonstrating spongiotic dermatitis without subepidermal clefting. Many of them occurred in volar sites, mimicking dyshidrotic dermatitis. METHODS: We retrospectively collected patients who were pathologically and/or immunopathologically diagnosed with bullous pemphigoid from 2002 to 2017. Patients who presented with prominent spongiosis without subepidermal clefting were included and compared with patients who were diagnosed with dyshidrotic dermatitis. RESULTS: A total of nine cases of spongiform pemphigoid out of 385 bullous pemphigoid patients (2.3%) were identified and compared with 15 patients with dyshidrotic dermatitis. Average age of spongiform pemphigoid patients (76 years) was much older than that of the control group (34 years). Microvesicles in the mid- to lower epidermis (P < 0.001), eosinophils exocytosis (P < 0.001), and eosinophils microabscess (P < 0.001) in both the epidermis and papillary dermis were more common in spongiform pemphigoid. CONCLUSION: Spongiform pemphigoid mimics spongiotic dermatitis may result in a pathological diagnostic pitfall. The presence of eosinophil microabscess and exocytosis in the epidermis and papillary dermis were important clues. Immunofluorescence studies should be conducted to confirm the diagnosis of bullous pemphigoid.

Basaloid tumors arising from seborrheic keratosis: Malignant basal cell carcinoma or benign basaloid follicular hamartomatous proliferation?

BACKGROUND: Basaloid tumors arising from seborrheic keratosis (SK) that resembled basal cell carcinoma (BCC) were infrequently observed in our patients. They also exhibited morphologic features similar to those of trichoblastoma or basaloid follicular hamartoma. METHODS: We retrospectively collected cases of SK with basaloid tumors from 2001 to 2017. Ten cases of BCC, five of nevus sebaceus with trichoblastoma, five of trichoblastoma, and five of trichoepithelioma were included as controls. Tumor-associated antigens Bcl-2, CD10, PHLDA1, and CK20 were tested. Antigenic markers CD34 and CD10 were used to analyze peritumoral stroma features and Ki-67 and pHH3 to measure the mitotic activity. RESULTS: Ten cases of SK with basaloid tumors were found and all located in non-sun-exposed areas, including five men and five women, with a mean age of 61 years. A distinct PHLDA1 staining was not observed. The staining patterns of basaloid tumor lobules associated with SK were similar to the benign control group. Bcl-2 staining in the tumor lobules was mostly negative. Peritumoral CD10 stain and CK20-positive Merkel cells in the lobules were observed and the mitotic counts were low. CONCLUSION: Basaloid tumors arising from SK are not always BCC. They were all benign follicular hamartomatous proliferation in this case series.

Ex vivo full-field cellular-resolution optical coherence tomography of basal cell carcinomas: A pilot study of quality and feasibility of images and diagnostic accuracy in subtypes.

BACKGROUND: Studies have reported the application of conventional optical coherence tomography (OCT) in the diagnosis of basal cell carcinoma (BCC). The new OCT provides cellular details similar to those in pathology slides and may reduce user learning time. This study aimed to demonstrate the quality of ex vivo full-field cellular-resolution OCT images and compare the diagnostic accuracy between physicians with varying pathology experience. MATERIALS AND METHODS: Sixty histologically confirmed BCCs were selected. Tissue samples were sectioned and scanned using OCT, and their features were compared with those of hematoxylin and eosin (H&E)-stained sections. Thirty images were selected for the test administered to dermatology residents, dermatopathology fellows, and board-certified general pathologists without any OCT experience. The pretest learning included a 3-min instruction and 10-min self-study of four BCC variants. RESULTS: Histopathological BCC and normal histological features were clearly recognizable on the OCT images. The pathological BCC features observed in the OCT images correlated with those found in the H&E-stained sections. Seven participants completed the test. The correct answer rates of the residents, fellows, and pathologists were 71%, 68%, and 83% for BCC and 44%, 57%, and 57% for the BCC subtypes, respectively. CONCLUSION: All the participants identified BCC in >70% cases with a learning time of only 13 minutes. The results indicated that cellular-resolution OCT provided high-quality images similar to the conventional pathology slides. Pathology experience did reflect the diagnostic accuracy. However, a longer training time is still needed at all levels to recognize the BCC subtypes correctly.

Lucio phenomenon mimicking antiphospholipid syndrome: The occurrence of antiphospholipid antibodies in a leprosy patient.

Lucio phenomenon is an atypical reaction of leprosy, characterized by vasculitic lesions that can mimic antiphospholipid syndrome (APS) clinically. Distinguishing the two can be difficult as antiphospholipid autoantibodies may be present in patients with leprosy. We report on a 32-year-old female patient presenting with a sudden onset of fever, hemorrhagic bullae, and skin necrosis on her lower legs. She was treated for APS due to the presence of antiphospholipid antibodies but had an inadequate response. A skin biopsy revealed thrombotic vasculopathy and necrotizing vasculitis associated with aggregation of foam cells in the perivascular area and subcutis, with acid-fast bacilli in the histiocytes and blood vessel walls. Direct immunofluorescence showed IgM, C3, and fibrinogen deposition in the superficial and deep dermal blood vessels. The pathology confirmed the diagnosis of Lucio phenomenon, and appropriate therapy was given. It is essential to evaluate the patient comprehensively, including clinical, serological, and pathological aspects, to obtain the correct diagnosis.

Tinea folliculorum complicating tinea of the glabrous skin: an important yet neglected entity.

Dermatophytes are capable of infecting the skin and its appendages such as nails and hairs producing a variety of clinical conditions. Hair invasion by dermatophytes is a key feature of tinea capitis and tinea barbae but not of tinea of glabrous skin. In this project, we studied the clinico-mycological aspects of follicular involvement in patients with dermatophytosis of the glabrous skin. In total, 16 patients, eight males and eight females, were included in the study. All were adults except for one girl. The disease durations ranged from one month to more than ten years. Fourteen (78.5%) had multiple lesions, and most of them had undergone treatment with antifungals, antibiotics, or steroids. Dermoscopic examination showed infected hairs in the form of broken stubs, coily, curly, or as black dots on the surface of the lesions. Pathogens were either anthropophilic (seven cases of Trichophyton rubrum) or zoophilic (six cases Microsporum canis, three cases of the T. mentagrophytes). Patients responded well to oral griseofulvin or terbinafine, and topical antifungals. No antifungal resistance developed during the treatment course. Follicular involvement of glabrous skin is not as rare as previously thought and should be considered for systemic antifungal treatments.