A new nonhydrophilic agarose gel as subdermal filler for facial rejuvenation: Aesthetic results and patient satisfaction.

BACKGROUND: A wide range of fillers are already available for facial rejuvenation. Most of them are based on the use of reticulated or nonreticulated hyaluronic acid. AIMS: The main objective of this study is to present the advantages, efficacy, and safety profile of a new agarose gel filler without reticulating agents, for different facial areas. PATIENT/METHODS: A total of 41 patients were treated with different concentrations of the agarose gel filler (1%; 1,5%; 2,5% and 3,5%). Mean age of the participants was 44.62 years. 67.7% (31/41) of the patients were female. Typically, each anatomic area was injected with half of the syringe volume (0.7 + 0.1 mL of lidocaine 2%) per side. One week after one-session treatment, Global Aesthetic Improvement Scale (GAIS) was obtained and satisfaction surveys were filled by patients. RESULTS: Clinical improvement was noted immediately, with no progressive volume gain over following days. In the GAIS, 90% of the cases scored as "significant or great improvement." Patient satisfaction was very high with 83% of them evaluating the results as 8 or higher in a scale 1-10. Only one late-onset nodule was observed some weeks after injection, that resolved completely with corticosteroid injection. CONCLUSIONS: This new agarose gel filler represents an effective and safe alternative for facial rejuvenation with fillers. Among its advantages, it can be highlighted the absence of reticulating agents and its nonhydrophilic nature.

Anti-NXP2-Positive Paraneoplastic Dermatomyositis With Histopathologic Changes Confined to the Acrosyringia.

BACKGROUND: Paraneoplastic syndromes consist of a group of disorders that are not related to the extension of the primary tumor or its metastases and that might be the first manifestation of a hidden neoplasm. It is a well-known association between dermatomyositis (DM) and cancer, especially gynecological tumors in women and lung cancer in men. METHODS: We describe the case of a 67-year-old male who developed muscular weakness and pruritic skin lesions. Skin biopsies were performed and histologic findings were consistent with DM. RESULTS: Skin biopsy showed interface dermatitis with vacuolar degeneration of the basal layer, dermal mucin deposits, and necrotic keratinocytes in the acrosyringia, a finding that has been previously reported in lupus erythematous but not in DM. Autoimmunity tests showed positivity for antinuclear antibodies and anti-NXP2, a recently described antibody associated with juvenile DM and, more rarely, with paraneoplastic DM. CONCLUSION: We present the first case in the literature with histopathologic changes of DM affecting the acrosyringia. Besides, our patient autoimmunity results support the utility of the new myositis-specific autoantibodies and its relation with a clinical phenotype.

Primary Signet-Ring Cell/Histiocytoid Carcinoma of the Eyelid: A "Binocle" Presentation of the "Monocle Tumor".

Primary cutaneous signet-ring cell carcinoma is a rare and aggressive neoplasm which diffusely involves dermis and subcutis of the eyelid or axillae. Neoplastic cells show a signet-ring cell or histiocytoid morphology in variable number, and can be found intermingled among collagen bundles, sparing the epidermis. This neoplasm typically appears in the eyelids of elderly men, in the form of a painless infiltration and swelling but with no other specific clinical feature, and frequently causes diagnostic retardation and worse prognosis. Frequent involvement of both eyelids of the same eye has given it the name of monocle tumor. Only 29 cases have been described in English literature to date, of which 7 developed metastases, mainly on regional lymph nodes. The authors present a case of involvement of contralateral eyelid, which has only been described previously in 2 cases. The immunohistochemical profile of the involvement in the contralateral eye, and the absence of other metastasis, suggest that it is locally spread from the initial lesion. However the possibility of being a second primary tumor or metastasis cannot be readily ruled out.

Primitive follicular induction in molluscum contagiosum.

BACKGROUND: Molluscum contagiosum (MC) is the commonest human poxvirus infection. Follicular induction has rarely been observed in the epidermis surrounding lesions of MC. A virus-induced localized proliferation of germinative/stem cells of the folliculosebaceous-apocrine unit has been suggested as the underlying cause, however few reports of this peculiar phenomenon exist in the literature and the mechanisms involved in this proliferation require further study. METHODS: We prospectively collected MC cases showing multifocal areas of primitive follicular induction involving the adjacent undersurface epidermis. Immunohistochemical expression of BerEP4, PHLDA1 and cytokeratin 20 (CK20) was evaluated in the basaloid germs surrounding the lesions. For PHLDA1, we used epidermal melanocytes as a positive internal control. For BerEP4, we employed a basal cell carcinoma (BCC) and for CK20, colon as positive external controls. An incubation without the primary antibody functioned as an external negative control. RESULTS: All the cases studied showed an intense positive staining of the basaloid buds with BerEP4 and weaker stain for PHLDA1. CK20 showed the presence of scattered Merkel cells within the induced epidermal basaloid proliferations favoring their reactive origin. DISCUSSION: The pathogenetic mechanisms behind the development of these microscopic features and the link between follicular induction and poxvirus infection are explored. Awareness of this unusual phenomenon by dermatopathologists will be helpful in avoiding a misdiagnosis of a superficial BCC in such cases. CONCLUSIONS: BerEP4 and PHLDA1 were consistently expressed in the areas of primitive follicular induction surrounding lesions of MC. CK 20 stained the Merkel cells present in the basaloid buds. All these findings support the reactive origin of this phenomenon, which we believe is most probably viral-induced.

Nodular amyloidosis at the sites of insulin injections.

Amyloid is characterized by its fibrillary ultrastructure, and more than 20 proteins have been described to date as possible precursors. Among them, insulin and enfuvirtide represent the only medications described as amyloidogenic substances. We describe two diabetic patients, who were undergoing long-standing subcutaneous insulin treatment, who developed subcutaneous nodules at the sites of insulin injections. Histopathologic examination showed the presence of eosinophilic and amorphous masses in deep dermis, which stained positive with Congo red, amyloid P substance and anti-human insulin antibody. Whether the type of injected insulin played a role or not in the pathogenesis of the process is still uncertain, because all described patients used both fast-acting and slow-acting insulins at the same injection sites. Our second case showed nodular insulin-derived amyloid tumors only at the sites where exclusively fast-acting insulin was injected, which supports the notion that fast-acting insulin may also be the cause of this disorder. Insulin-derived nodular amyloidosis is probably underdiagnosed because of the small body of literature in comparison with the prevalence of insulin dependent diabetic patients. This underdiagnosis probably is because of its clinical similarity with the lesions of lipohypertrophy at the sites of insulin injections, which is rarely biopsied.

Dermatofibrosarcoma Protuberans of the Vulva With Myoid Differentiation.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft-tissue tumor characterized by a relatively high risk for local recurrence and low risk for metastasis. Many histopathologic variants of DFSP have been described, including the fibrosarcomatous and myoid variants, which may obscure the diagnosis in some cases, especially when arising in unusual locations. Of all the variants described so far, the only one with prognostic relevance is the FS-DFSP variant, which implies tumor progression and a higher possibility for metastasis. The authors report a case of a giant DFSP, located on the vulvar area, which histopathologically showed areas of fibrosarcomatous and myoid differentiation, and discuss the importance of the myoid variant in regards of the debated histogenesis of DFSP.

Merkel cell carcinoma arising within a poroma: report of two cases.

Merkel cell carcinoma (MCC) has been reported in association with other types of cutaneous neoplasms within the same lesion, including squamous cell carcinoma, Bowen's disease, actinic keratosis, follicular cysts, trichoblastoma and lentigo maligna, among others. However, the association of MCC and sweat gland tumors has never been described in the literature. We report two unique cases of MCC that developed within cutaneous poromas. A 56-year-old male (Patient 1) and an 81-year-old female (Patient 2) presented with nodules on the upper arm and lower back, respectively. Histopathologic study of both cases revealed a tumor in the dermis composed of poroid and cuticular cells intermingled with a proliferation of small round cells that showed characteristic histopathological and immunohistochemical features of MCC. In both cases, the two neoplasms were tightly admixed and distinct, suggesting that the MCC could have developed within a previously existing poroma. No morphological features of transition between the two tumors were seen. Neoplastic cells of MCC expressed immunoreactivity for chromogranin, synaptophysin, neuron-specific enolase, CAM 5.2 and cytokeratin 20, the last two markers showing the characteristic paranuclear dot-like pattern. In contrast, the poroma cells only expressed cytokeratin MNF116. Metastatic deposits were not identified in the regional lymph nodes or distantly.

Cutaneous lupus erythematosus with histopathologic changes restricted to the acrosyringia.

Cutaneous lupus erythematosus may present as an isolated condition or as part of a systemic disease, being acute cutaneous lupus erythematosus, the skin manifestation, more closely related to systemic involvement. The histopathologic findings may show a wide variety of features, which show overlap among different clinical presentations. The exclusive involvement of the eccrine units, including eccrine coils, dermal ducts, and acrosyringia is extremely uncommon. We present the second case of systemic lupus erythematosus (SLE) with histopathologic involvement mostly located in the acrosyringia. The patient was a 37-year-old male with multiorgan failure who, in the context of flare-up of SLE, presented cutaneous lesions consisting of erythematous and edematous macules and plaques on the face, arms, and anterior chest. Histopathologic examination demonstrated necrotic keratinocytes confined to the acrosyringia as the main finding. It was associated with sparse inflammatory infiltrate in the superficial dermis, mostly composed of lymphocytes. The epidermis between the acrosyringia was spared. Our case was clinically almost identical to the one previously described, being a patient with a severe SLE and widespread cutaneous involvement and receiving treatment in the intensive care unit. The main differential diagnosis, both clinically and histopathologically was drug-related erythema multiforme. Clinicopathologic correlation is necessary to establish a correct diagnosis. SLE with histopathologic involvement mostly of the acrosyringia is a rare histopathologic variant of the disorder.