Rapid growth and slow involution of Reed nevus in a long-term dermoscopic follow-up.

We describe the rapid growth of a Reed nevus followed by its slow involution and present dermoscopic follow-up images. The child was monitored for 10 years (from age 3 to 13 years) by digital dermoscopy. The Reed nevus completely lost its typical dermoscopic arrangement (starburst pattern) with involution and distinct changes in dermoscopic pattern.

Clinical-Dermoscopic-Histopathological Correlations in Collision Skin Tumours.

Objectives: Collision tumours are rare situations characterised by the coincidence of two different skin neoplasms in the same lesion. Methods: We have analyzed 41 collision skin tumours from one department in the clinical-dermoscopic-histopathologic correlations. Results: We present 41 collisions tumours. The mean age of our patients was 67.9 years, the mean diameter of the lesion was 11.6 mm. The most frequent locations were trunk (27 lesions) and head/neck (11 lesions). The collisions were classified as benign/benign (13 cases), benign/malignant (25 cases) and malignant/malignant (3 cases). The most frequent participants were seborrheic keratosis (24 cases), malignant melanoma (17 cases), melanocytic nevus (14 cases), basal cell carcinoma (12 cases) and heamangioma (10 cases). Thirty cases were of "dominant/minor" type and 11 cases of "half to half" type. Malignant tumours were a part of 28 collisions; these lesions were larger, patients were older and the malignant part was dominant in most cases. More than half of the collisions were unexpected by the initial clinical examination. Six collisions were missed by the initial histopathological examination. Conclusions: Collision tumours can be missed by clinical or even histopathological examination. Dermoscopy is very helpful in the recognizing of difficult cases and cooperating with the histopathologist.

The use of 2940-nm ER:YAG laser for the treatment of lentigo maligna.

OBJECTIVES: Lentigo maligna is a common in situ malignancy in elderly patients, with a low risk of progression to an invasive tumor. Surgical treatment may be complicated or refused. Non-surgical treatment options (such as lasers) may therefore be needed. PATIENTS AND METHODS: We report on 17 patients treated with a 2940-nm Er:YAG (erbium-doped yttrium aluminum) laser for histopathologically confirmed lentigo maligna. The lesions were ablated with a 5 mm margin of adjacent skin under local anesthesia with a 3.5 mm overlapping spot, energy density of 6.5 J/cm2 and a repetition rate of 5 Hz. If clinically visible pigmentation was seen in the ablated area during the following three months, the lesion was re-treated. All patients were followed up for residual or recurrent tumors. RESULTS: We achieved clinical clearance in all 17 patients. There were three recurrences during the follow-up period (9, 30 and 36 months after laser therapy). All patients were satisfied with the treatment course and cosmetic outcome. The mean follow-up duration was 28 months. CONCLUSIONS: Laser ablation is an interesting alternative method for treatment of lentigo maligna. It can be used for selected cases where surgery is contraindicated, complicated or declined by the patient.

IgE-mediated sensitization to malassezia in atopic dermatitis: more common in male patients and in head and neck type.

BACKGROUND: Atopic dermatitis (AD) is a common chronic inflammatory skin disease. Malassezia, the predominant skin microbiota fungus, is considered to exacerbate AD, especially in a subset of patients with head and neck type AD (HNAD). In the present study, the relationship between AD and sensitization to Malassezia antigens was investigated. METHODS: We assessed 173 patients with AD. The severity of eczema was determined with Eczema Area and Severity Index (EASI); the type of AD, namely, head and neck type, was reported as well. The total serum IgE and specific IgE to Malassezia were determined and correlated with clinical picture of AD, sex, age, and the EASI. RESULTS: Total IgE was elevated in 77.7% of patients. Specific IgE to Malassezia was positive (≥0.35 kU/L) in 49.1% of patients. Men were significantly more often sensitized to Malassezia antigen (58% of men vs 42% of women; P value, 0.04). Concurrently, 58% of patients with HNAD versus 42% non-HNAD patients had higher levels of specific IgE to Malassezia, this difference being nearly significant (P value, 0.06). Patients with atopy were also more frequently sensitized to Malassezia. No significant relationship between EASI and the level of total IgE or specific IgE to Malassezia was observed. CONCLUSIONS: In our population, IgE-mediated sensitization was found in up to 49% of all patients with AD, most common in men and in head and neck type.

TSC2/PKD1 contiguous gene syndrome: a report of 2 cases with emphasis on dermatopathologic findings.

The association of tuberous sclerosis complex (TSC) and autosomal dominant polycystic kidney disease (ADPKD), termed TSC2/PKD1 contiguous gene syndrome, is a result of molecular defect demonstrating by deletion disrupting TSC2 and PKD1. Dermatopathology of this syndrome has never been addressed. We report 2 sporadic cases form of TSC2/PKD1 contiguous gene syndrome, with emphasis on dermatopathologic findings. Both patients presented with a typical phenotype of TSC and early-onset renal polycystic requiring kidney transplantation in one of the patients. Of a total of 13 cutaneous lesions studied, there were 7 facial angiofibromas, 2 shagreen patches, 1 periungual fibroma, 1 hypopigmented macule, 1 epidermoid cyst, and 1 intradermal melanocytic nevus. The histological features were basically similar to those occurring in TSC, but some unusual features were identified. In both patients, deletions in the region of TSC2 and PKD1 were revealed performing by multiplex ligation probe amplification test. It is concluded that the histopathological features of skin lesions in this syndrome are similar to those encountered in TSC. Clinical awareness and appropriate molecular investigation of TSC2/PKD1 contiguous gene syndrome is necessary in all patients with a typical phenotype of TSC in infancy, adolescence, or adult age, because of severity of the renal alterations.

Hyperplasia of hair follicles and other adnexal structures in cutaneous lymphoproliferative disorders: a study of 53 cases, including so-called pseudolymphomatous folliculitis and overt lymphomas.

We studied 53 cutaneous lymphoproliferative disorders, all of which manifested hair follicle hyperplasia. There were 42 cases conforming to the description of pseudolymphomatous folliculitis (PLF) and 11 cases of authentic lymphomas including mycosis fungoides, CD30+ anaplastic large cell lymphoma, diffuse large B-cell lymphoma, B-cell small cell lymphoma/leukemia, and peripheral T-cell lymphoma, not otherwise specified. All patients with PLF clinically presented with a solitary nodule preferentially involving the face. Beside hair follicle hyperplasia, the typical features were a dense infiltrate of small well-differentiated lymphocytes, lymphoplasmacytoid cells, plasma cells, and epithelioid histiocytes forming tiny granulomas. Some unusual or worrisome features recognized included eccrine/apocrine duct hyperplasia, subcutis/muscle infiltration, lymphocyte "smudging," single file infiltration, and large atypical cells. Immunohistochemically, T-cell predominant cases dominated in the series. All 34 tested cases revealed a polyclonal pattern of kappa and lambda immunoglobulin (Ig) light chain expression. In 4 cases, scattered CD30+ cells were identified. Monoclonal rearrangements of T-cell receptor (TCR) and IgH genes were detected in 19 and 3 cases respectively, including 1 case with dual T-cell receptor/IgH rearrangement. Three of 30 tested cases proved positive for herpes simplex virus-1, whereas herpes simplex virus-2 always tested negative. Of 31 cases tested for Borrelia burgdorferi, 30 specimens were negative. In 9 cases, fluorescent in situ hybridization for t(11;18) and t(14;18) revealed none of the above translocations. The most common treatment modality was surgical removal. Forty patients with a mean follow-up of 3.7 years included 39 patients with no evidence of disease and 1 individual with local recurrence. The comparison of "clonal cases of PLF" and those with polyclonal population or in which clonality remained undetermined revealed no differences between the 2 groups in the clinical presentation, pathologic, and immunohistochemical features. We conclude that hyperplasia of hair follicles and other adnexa can be seen not only in the condition currently known as PLF, but also in genuine cutaneous lymphomas and may be just a happenstance secondary to a basic pathologic process.

Photodynamic therapy of nonmelanoma skin cancer with topical hypericum perforatum extract--a pilot study.

Hypericin, the photoactive compound of Hypericum perforatum, is probably the most powerful photosensitizer found in nature. This compound has shown high potency in the photodynamic treatment of tumor cells. However, there is only limited knowledge regarding the photodynamic effect of hypericin on nonmelanoma skin cancer cells. The aim of this prospective study was to investigate the efficacy of photodynamic therapy with topical application of an extract of H. perforatum in actinic keratosis, basal cell carcinoma (BCC) and morbus Bowen (carcinoma in situ). The study was carried out on 34 patients--eight with actinic keratoses (AKs), 21 with BCC and five with Bowen's disease. The extract of H. perforatum was applied on the skin lesions under occlusion and that was followed by irradiation with 75 J cm(-2) of red light 2 h later. The treatment was performed weekly for 6 weeks on average. The percentage of complete clinical response was 50% for AKs, 28% in patients with superficial BCC and 40% in patients with Bowen's disease. There was only a partial remission seen in patients with nodular BCCs. A complete disappearance of tumor cells was found in the histologic preparation of 11% of patients with superficial BCCs and 80% in the patients with Bowen's disease. All patients complained of burning and pain sensations during irradiation. Although the results of this first clinical trial could be regarded as disappointing, there are still possibilities for improvement. Better preparation of the lesions, enhancement of hypericin delivery and other types of light exposure procedures could significantly improve the clinical outcomes of this relatively inexpensive treatment modality.

Genital warts treated by photodynamic therapy.

The patient, a 30-year-old man with numerous genital condylomata acuminata (CA), has had unsuccessful treatment with liquid nitrogen, 20% podophyllin, and repeated 0.5% podophyllotoxin solution with 5% imiquimod (Figure 1). Before the appearance of CA, he experienced acute orchiepididimitis and a Candida infection. The patient was immunologically examined, and the lower level of lymphocytes, slightly reduced level of IgM, and C4 complement were revealed. Results from a human immunodeficiency virus examination were negative. After the therapeutic failure mentioned above, photodynamic therapy (PDT) was initiated using 20% aminolevulinic acid (5-ALA) in a gel. The photosensitizer was applied to lesions and 10 mm of surrounding skin in a 1-mm-thick layer under occlusive dressing for 3 hours and then removed with saline and nonwoven gauze. The site was immediately irradiated with noncoherent red light with an emission spectrum of 580 to 680 nm wavelength (Medeikonos PDT-Model 200, Medeikonos AB, Sweden). The total light dose was 50 J/cm(2); light intensity ranged from 70 to 90 mW/cm(2). Because of persistent fluorescence during photodynamic therapy, the treatment was repeated 10 times in 2-week intervals with a follow-up of 1, 3, and 6 months after its completion. After the last PDT treatment, the persistent fluorescence disappeared completely. The absence of fluorescence corresponded with a healed clinical finding without scarring and pigmentation (Figure 2). The period from the initiation of PDT to the consolidation of CA was 22 weeks. During PDT treatment, the patient felt only mild burning, which disappeared after the illumination stopped. Six months after the therapy, there were no signs of recurrent disease.

Coexisting subacute and systemic lupus erythematosus after terbinafine administration: successful treatment with mycophenolate mofetil.

A 39-year-old female patient with systemic lupus erythematosus was treated with terbinafine for onychomycosis. After only 7 days of treatment with 250 mg terbinafine, a widespread severe erythematous eruption developed. The results of clinical, histological and immunofluorescent examinations confirmed the diagnosis of coexisting subacute and systemic lupus erythematosus. The patient was treated with drug withdrawal and administration of cyclosporine and methylprednisolone. One year later, mycophenolate mofetil was successfully used. Exacerbation or induction of lupus erythematosus is an extremely rare cutaneous side-effect of terbinafine. Patients with lupus erythematosus should be advised about the risk of some drugs that might exacerbate their disease.

Dermatoscopic differences between atypical melanocytic naevi and thin malignant melanomas.

Dermatoscopy is used to aid in the differential diagnosis of pigmented skin lesions. The aim of this study was to identify dermatoscopic differences between atypical melanocytic naevi and thin malignant melanomas. A set of 180 difficult cases (60 thin melanomas, 120 clinically atypical benign melanocytic naevi) was analysed. Differences in structure, distribution of pigmentation, presence or absence of important structures, total number of colours and asymmetry of the lesions were identified. The three-structure type, multifocal distribution of pigmentation, eccentric peripheral hyperpigmentation, multiple colours (three or more) and asymmetry of structures/colours in the dermatoscopic image were considerably more frequent in melanomas than in benign lesions (P<0.001, chi-squared test). No single dermatoscopic criterion exists to discriminate between all melanocytic lesions with sufficient confidence. Some criteria are helpful in the differential diagnosis and management of difficult cases.

Cryosurgery in the treatment of earlobe keloids: report of seven cases.

BACKGROUND: Keloids are benign cutaneous lesions that result from excessive collagen synthesis and deposition. Earlobe keloids in particular are seen as a complication of plastic surgery or piercing. Many different treatment modalities have been used, often with unsatisfactory results. METHODS: We have made a retrospective analysis of seven young patients (ages 9 to 22 years) with earlobe keloids. Scarring followed plastic surgery in six cases and piercing in one case. All patients were treated with cryosurgery as the monotherapy. The freeze time and the number of sessions varied depending on the clinical findings, the effect of the treatment, and the patients' tolerance. Cryotherapy was started 6 to 24 months after keloid development. RESULTS: Scar volume was reduced in all cases. Complete flattening in five patients and a pronounced reduction to a maximum of 25% of the previous thickness in one other patient were achieved. One patient discontinued the therapy because of soreness after only partial improvement. The procedure was painful for all patients; no further side effects were noticed. No recurrence was observed within 1 to 4.5 years of follow-up. CONCLUSION: We present an excellent effect of cryosurgery as the monotherapy for the treatment of earlobe keloid scars of young patients.

Mucinous carcinoma of the skin, primary, and secondary: a clinicopathologic study of 63 cases with emphasis on the morphologic spectrum of primary cutaneous forms: homologies with mucinous lesions in the breast.

We present the largest series of mucinous carcinoma involving the skin, describing the histopathologic, immunohistochemical, electron microscopic, and cytogenetic findings. Our aim was fully to characterize the clinicopathologic spectrum and compare it with that seen in the breast. In addition, we wished to reevaluate the differential diagnostic criteria for distinguishing primary mucinous carcinomas from histologically similar neoplasms involving the skin secondarily, and study some aspects of their pathogenesis. We demonstrate that primary cutaneous mucinous carcinomas span a morphologic spectrum compatible to their mammary counterparts. Both pure and mixed types can be delineated morphologically, and some lesions have mucocele-like configurations. Most lesions seem to originate from in situ lesions that may represent, using mammary pathology terminology, ductal hyperplasia, atypical ductal hyperplasia, or ductal carcinoma in situ or a combination of the three. Inverse cell polarity appears to facilitate the progression of the changes similar to lesions in the breast. The presence of an in situ component defines the neoplasm as primary cutaneous, but its absence does not exclude the diagnosis; although for such neoplasms, full clinical assessment is essential. Mammary mucinous carcinoma involving the skin: all patients presented with lesions on chest wall, breast, axilla, and these locations can serve as clue to the breast origin. Microscopically, cutaneous lesions were of both pure and mixed type, and this correlated with the primary in the breast. Dirty necrosis was a constant histologic finding in intestine mucinous carcinomas involving the skin, and this feature may serve as a clue to an intestinal origin.

Disturbed melanin synthesis and chronic oxidative stress in dysplastic naevi.

Dysplastic naevi (DN) are a known risk factor for malignant melanoma. Their occurrence is closely connected with the degree of skin pigmentation. People with a light complexion are more likely to develop DN than dark-skinned individuals. We examined the proposition that DN exhibit altered melanin formation, which may be involved in their malignant transformation. X-ray microanalysis was used to study the composition of melanosomes from DN and to compare the results with those obtained from melanomas, banal (dermal) naevi and normal cutaneous melanocytes. We analysed sulphur (an indicator of phaeomelanin) and two metals, iron and calcium, involved in oxidative stress. FACS analysis of dihydrorhodamine-123-labelled cells was employed to quantify differences in the production of radical oxygen species in DN cells and normal skin melanocytes. A significantly higher sulphur content was found in melanosomes from DN cells and melanoma cells when compared with normal melanocytes and naevus cells from banal naevi. In addition, melanosomes of DN cells and melanoma cells contained higher amounts of iron and calcium. In the case of calcium, this was associated with a significantly elevated cytoplasmic concentration. FACS analysis showed that DN cells exhibited higher concentrations of radical oxygen species than normal skin melanocytes from the same individuals. We propose that increased phaeomelanogenesis in DN cells is connected with oxidative imbalance, which is reflected by increased intracellular concentrations of reactive oxygen species and raised calcium and iron concentrations. We show that the metabolic alterations in DN cells resemble those found in melanoma cells. Our findings provide support for the idea that DN cells are true precursor lesions of melanoma.