Recalcitrant psoriasiform dermatosis of the face: Is it related to pityriasis rubra pilaris?

BACKGROUND: There are patients with recalcitrant psoriasiform plaques that do not fit into conventional categories of facial dermatoses. Our study aims to describe the clinicopathological characteristics of several patients with a unique presentation of persistent psoriasiform facial rashes. METHODS: This retrospective cross-sectional study analyzed clinical and histological data of known cases of recalcitrant psoriasiform dermatosis of the face diagnosed at National Skin Centre, Singapore, over 10 years. RESULTS: There were 8 Chinese patients with mean age at onset of 29 years. Majority had pink to pink-orange well-defined plaques with dry scale (n = 6, 75%), distributed mostly on the cheeks (100%) and chin (n = 7, 88%). Hyperkeratosis, parakeratosis, preserved granular layer and psoriasiform hyperplasia were showed in all biopsies. Other common findings included subtle subcorneal acantholysis, "checkerboard" alternating ortho-/parakeratosis, vacuolated keratinocytes and follicular plugging. All patients showed little treatment response. One patient eventually developed features of type II pityriasis rubra pilaris (PRP). Our study was limited by its small sample size and lack of a pre-existing diagnostic code. CONCLUSIONS: This recalcitrant psoriasiform facial dermatosis seems to be a distinct entity, with consistent and reproducible clinical features and a PRP-like histology, bearing some resemblance to the recently described condition-facial discoid dermatosis.

Cutaneous Plasmacytosis: A Clinicopathologic Study of a Series of Cases and Their Treatment Outcomes.

INTRODUCTION: Cutaneous plasmacytosis (CP) is a rare skin disorder characterized by multiple reddish brown nodules with polyclonal plasma cell proliferation. It has most often been reported to affect the trunk but is also known to affect the face and extremities in adults and is predominantly seen in Asians. The etiology is poorly understood, and there is no consensus on treatment methods. METHODS: Five cases diagnosed to have CP were collated from our institution. Their clinicopathologic features and treatment outcomes were reviewed. RESULTS: Four of the 5 patients presented with lesions that affected multiple sites of the body including the trunk, axillae, face, and limbs. The remaining patient had lesions localized to his axillae. The lesions were generally asymptomatic. All patients had hypergammaglobulinaemia but only one had a faint monoclonal band detected on immunofixation. Common findings in the biopsy results for all patients were perivascular plasma cell infiltrates without light chain restriction on kappa/lambda staining, as well as mast cell infiltrates. Partial remission of cutaneous lesions was observed in 3 of the patients, with 2 of them responding well to psoralen and ultraviolet A radiation therapy. CONCLUSION: CP presents with distinctive clinical features and characteristic histological features including polyclonal perivascular plasma cell infiltrates. The axilla seems to be a frequent and characteristic site of involvement and may be a useful clinical clue to the condition. In the management of patients with CP, it is important to exclude secondary causes of plasmacytic infiltrates. While there are no clearly established treatment modalities for CP, psoralen and ultraviolet A radiation therapy may be a viable option in view of the clinical improvement observed in our patients who received it.

Severely Crusted Cheilitis as an Initial Presentation of Systemic Lupus Erythematosus.

Lupus erythematosus (LE) is an autoimmune disease which may initially present solely with lip lesions. Due to a wide spectrum of presentation, these features may initially be misdiagnosed as other oral diseases such as lichen planus, erythema multiforme (EM), and actinic cheilitis, leading to a delay in diagnosis and treatment. We discuss a case of severely crusted cheilitis which was initially diagnosed as EM, with subsequent development of subacute cutaneous LE, and progression to systemic LE. We will discuss the clinical and histological features of lupus cheilitis.

A case series of imatinib-induced generalized hypopigmentation and progression of existing acquired dermal melanocytosis.

Imatinib mesylate is a tyrosine kinase inhibitor used in the treatment of oncological conditions, including chronic myeloid leukemia and gastrointestinal stromal tumors. The most frequent dermatological side effect reported is pigmentary abnormalities. We report a case series of three Asian Chinese females with preexisting acquired dermal melanocytosis that progressed after initiation of imatinib treatment, and concurrently developed generalized hypopigmentation of the skin. All three patients had similar histological findings on skin biopsy. It is postulated that the KIT/SCF pathway has a central role in the pathogenetic mechanism. Therefore, it is important for physicians to be aware of this potential side effect of paradoxical pigmentation in patients treated with imatinib.

Reflectance confocal microscopy is a useful non-invasive tool in the in vivo diagnosis of pigmented basal cell carcinoma in Asians.

BACKGROUND: The clinical differentiation between pigmented basal cell carcinoma (BCC) and other benign pigmented skin lesions can be challenging even with an additional dermoscopic evaluation, especially if the lesion is small. In vivo reflectance confocal microscopy (RCM) is an emerging, non-invasive imaging tool that allows near-microscopic evaluation of skin lesions. The features of RCM for pigmented BCC and seborrhoeic keratosis have previously been described. However, the use of RCM to differentiate between these clinically and dermoscopically challenging pigmented skin lesions among Asians has not yet been demonstrated. OBJECTIVES: We aimed to evaluate the usefulness of non-invasive RCM to differentiate between clinically and dermoscopically challenging pigmented skin lesions among Asians in a series of 11 lesions. METHODS: Nine patients with 11 clinically and dermoscopically difficult to distinguish pigmented skin lesions were evaluated by RCM to differentiate between pigmented BCC and benign lesions. In all cases, a histological confirmation of the RCM diagnosis was obtained. RESULTS: The clinical or dermoscopical characteristics were non-specific in all 10 cases. RCM detected features of pigmented BCC in nine patients and seborrhoeic keratosis in one patient. These were all confirmed by histological examination. CONCLUSIONS: This case series shows the value of non-invasive in vivo RCM imaging in the differentiation of malignant and benign pigmented lesions. Early diagnosis of small, pigmented BCC allows earlier excision with better prognosis. Future biopsies of benign lesions in cosmetic areas could also be avoided.

Terra Firma-Forme Dermatosis in Singaporean Patients: The "Alcohol Wipe" Sign.

The term terra firma-forme dermatosis arises from the Latin phrase terra firma, meaning dry land (dirt), thus implying dirt-like dermatosis. The authors highlight five cases of patients with terra firma-forme dermatosis presenting to our dermatology center between 2012 and 2013. All patients presented to the dermatologist for persistent reticulated brown patches on the skin. These patients ranged in age from 6 to 22 years. All patients had tried various cleansing soaps and agents but were unable to remove the patches. The condition was cosmetically unacceptable to the patients and parents. Clinically, these patients had reticulated brown patches. Rubbing 70% isopropyl alcohol wipes on the affected areas demonstrated clearance of the brown pigmented patches in all cases. The diagnosis of terra firma-forme dermatosis (TFFD) was confirmed by forceful rubbing with a gauze pad immersed in 70% isopropyl alcohol or ethyl alcohol. Patients should be reassured about the benign nature of TFFD and educated about the cleaning procedure. Recognition of this condition can assist physicians in making a diagnosis and therapy with a simple alcohol wipe, preventing further unnecessary tests for patients.

A prospective study on the use of teledermatology in psychiatric patients with chronic skin diseases.

BACKGROUND: To compare the use of live interactive teledermatology versus conventional face-to-face consultation in long-term, institutionalised psychiatric patients with chronic skin diseases. METHODS: All institutionalised psychiatric patients at the Institute of Mental Health with follow-up appointments at the National Skin Centre were assessed for eligibility and invited to participate. Recruited patients were first seen by a dermatologist via videoconferencing, and then by another dermatologist in person, within 1 week. Clinical outcome measures were then assessed by a third independent dermatologist. The following outcome measures were assessed for each paired patient visit: inter-physician clinical assessment, diagnosis, management plan, adverse events and total patient turnaround time (PTAT) for each consultation. RESULTS: There were a total of 13 patients (mean age, 64.6 years; range 44-80) with 27 patient visits. All were male patients with chronic schizophrenia. The predominant skin condition was chronic eczema and its variants (62%), followed by cutaneous amyloidosis (23%) and psoriasis (15%). The level of complete and partial agreement between the teledermatology and face-to-face consultation was 100% for history-taking and physical examination and 96% for the investigations, diagnosis, management plan and the treatment prescribed. The PTAT for teledermatology was 23 min, compared to 240 min for face-to-face consultations. No adverse events were reported. CONCLUSION: Teledermatology was as effective as face-to-face consultation and reduced the PTAT by 90%, resulting in increased patient convenience, operational efficiency and reduced manpower need. Our study supports the safe and cost-effective use of teledermatology for the follow-up of chronic skin conditions in psychiatric patients.

Benign Eccrine Tumors Presenting on the Penis: Common Tumors at an Uncommon Site.

Case 1 A 60-year-old Chinese man presented to the dermatology clinic with an asymptomatic, 0.5 × 0.5-cm erythematous papule on the penile shaft for a 2-year duration (Figure 1a). His medical problems consisted only of well-controlled hypothyroidism and hypertension. The initial clinical diagnoses considered were pyogenic granuloma or condyloma accuminatum. The excisional biopsy revealed a polypoidal lesion entirely covered by epidermis, with a proliferation of cuboidal, basaloid cells, consistent with an eccrine poroma (Figure 1b). Case 2 A 28-year-old Chinese man presented with an asymptomatic fusiform, 1.4 × 0.4-cm nodule over the ventral aspect of the prepuce, for a 10-year duration (Figure 2a). His medical history was otherwise unremarkable. Lymphangioma was the initial clinical diagnosis but biopsy results revealed large collapsed cystic spaces within the superficial dermis lined by a double layer of epithelial cells with eosinophilic cytoplasm, without evidence of decapitation secretion, consistent with an eccrine hidrocystoma (Figure 2b).

Cutaneous angiosarcoma of the scalp mimicking a keratoacanthoma.

Cutaneous angiosarcoma (CA) has a wide range of clinical presentations. In this case report, we discuss a 78-year-old gentleman, who presented with a keratoacanthoma-like scalp lesion that turned out histologically to be a cutaneous angiosarcoma. A brief overview of CA, including its etiology, prognostic factors, clinical manifestations, and treatment options will also be discussed.

Congenital combined melanocytic nevus of the scalp with associated alopecia areata.

We report a case of a 20-year-old Chinese man with an alopecic congenital combined compound and blue melanocytic nevus of the scalp, associated with alopecia areata. The diagnosis of a combined melanocytic nevus was confirmed by histopathological examination and immunohistochemical stains, with exclusion of neurocristic hamartoma, which can have a similar clinical and histopathological appearance but different prognosis. In addition, we explore the association of this large melanocytic lesion with alopecia areata.

Extensive hyperpigmented plaques in a chinese singaporean woman: a case of cutaneous plasmacytosis.

Cutaneous plasmacytosis is a rare disease entity presenting with multiple extensive red-brown plaques, histopathology showing marked hyperplasia of mature polyclonal plasma cells, and polyclonal hypergammaglobulinemia on serum protein electrophoresis, in the absence of an underlying secondary cause. We report in this article the first case of cutaneous plasmacytosis from Singapore. A 33-year-old Chinese woman presented with mildly pruritic reddish brown papules and plaques over her trunk and arms for 2 years. Physical examination, laboratory investigations, and radiographic examination were negative for systemic involvement and lymphadenopathy. Serum immunoelectrophoresis showed polyclonal hypergammaglobulinemia with immunoglobulin G and immunoglobulin A. Two sets of skin biopsies performed 2 years apart essentially showed similar histopathological findings of a superficial and deep perivascular infiltrate with numerous mature plasma cells and small typical lymphocytes. There were lymphoid follicles with well-formed germinal centers and mantle zones, surrounded by mature lymphocytes. No light chain restriction was present on immunohistochemistry, and polymerase chain reaction for heavy chain gene rearrangement was negative for monoclonality. Despite potent topical corticosteroids and 8 months of phototherapy with narrow band ultraviolet light, there was no improvement. Intralesional triamcinolone injections to a few lesions afforded temporary relief of itch and flattening of lesions.

Contact dermatitis: a common adverse reaction to topical traditional Chinese medicine.

BACKGROUND: Over the past decade, there has been an increase in the use of topical traditional Chinese medicine (TTCM). The most common adverse event seen in the use of TTCM is contact dermatitis. This retrospective study was designed to determine the types of commonly used TTCM in Singapore causing contact dermatitis. METHODS: We retrospectively reviewed the case notes of 10 patients seen at the National Skin Centre over a 4-month period with a diagnosis of adverse cutaneous reactions to TTCMs. RESULTS: A total of 10 patients were diagnosed with contact dermatitis to TTCM at our institution over a 4-month period. The clinical manifestation ranged from eczematous lesions to urticarial plaques and blisters. Five of these patients were patch-tested to our standard series, our in-house TTCM series, as well as to the TTCM they had used. The other five patients declined patch testing. The results of patch testing confirmed the diagnosis of allergic contact dermatitis in three of the tested patients. Negative patch testing results inferred the diagnosis of irritant contact dermatitis to TTCM in the other two patients. Two of the patients with positive patch tests also had a positive reaction to balsam of peru and fragrance mix. The three positive patch tests were all caused by medicated oils. CONCLUSIONS: These results suggest it is likely that essential oils present as constituents of the medicated oils could be the possible allergen. The study also confirms that contact dermatitis is a common adverse event associated with the use of TTCM.

Prominent Degos-like skin lesions in a patient with chronic cutaneous lupus erythematosus.

Malignant atrophic papulosis, commonly known as Degos disease, is a rare vasculopathy encompassing both benign, cutaneous and lethal systemic variants. We report a case of chronic cutaneous lupus erythematosus in a 41-year-old male presenting with prominent Degos-like skin lesions. Multiple atrophic, porcelain-white, scar-like papules and plaques with dusky, erythematous borders, suggestive of malignant atrophic papulosis, were noted on the patient's back. Additional cutaneous findings included photo-distributed facial erythema and discoid lupus-like plaques on the face, shoulders, and arms. Clinicopathological correlation supported a diagnosis of chronic cutaneous lupus erythematosus; hydroxychloroquine was initiated with good clinical response. No new or active lesions were observed at the sixteen-month follow-up. This case highlights a rare skin finding associated with chronic cutaneous lupus erythematosus and underscores the importance of ruling out primary autoimmune disease, particularly lupus, before a diagnosis of malignant atrophic papulosis can be made.

A rare connexin 26 mutation in a patient with a forme fruste of keratitis-ichthyosis-deafness (KID) syndrome.

BACKGROUND: Keratitis-ichthyosis-deafness (KID) syndrome is a rare ectodermal dysplasia characterized by generalized erythrokeratotic plaques, sensorineural hearing loss, and vascularizing keratitis. Cutaneous changes and hearing loss typically present in early childhood, whereas ocular symptoms present later. Mutations in the connexin (Cx) 26 gene, GJB2, are now established to underlie many of the affected cases, with the majority of patients harboring the p.D50N mutation. METHODS: A rare patient demonstrating features of incomplete KID syndrome associated with an uncommon Cx26 gene mutation is described. RESULTS: The patient presented late in adolescence with partial features of KID syndrome. There was limited cutaneous involvement and the rare association of cystic acne. Both hearing impairment and ophthalmic involvement were mild in severity. Genetic mutation analysis revealed a previously described, rare mutation in GJB2, resulting in a glycine to arginine change at codon 12 (p.G12R). CONCLUSIONS: This report describes a patient exhibiting characteristics suggestive of a late-onset, incomplete form of KID syndrome with the GJB2 mutation (p.G12R). The p.G12R mutation has only been described in one other patient with KID syndrome, whose clinical presentation was not characterized.