Granulomatous Reactions from Tattoos Following BRAF Inhibitor Therapy.

BRAF inhibitors may present several cutaneous adverse effects, including actinic keratosis, squamous cell carcinoma, keratoacanthoma, rashes, increased photosensitivity, panniculitis, palmoplantar and capillary involvement, pruritus and xerosis as well as granulomatous reactions. A 30-year-old patient with multiple tattoos received dabrafenib and trametinib for metastatic melanoma. After 4 months, he developed an induration and thickening strictly limited to several tattoos. Histopathology revealed nonnecrotizing granulomas in the dermis. Topical steroids relieved pruritus but not the granulomatous aspect of the tattoos. As far as we know, this is the first description of granulomatous reactions restricted to preexisting tattoos following BRAF inhibitor therapy.

Pachyderma in Primary Cutaneous NK and T-Cell Lymphoma and Leukemia Cutis.

BACKGROUND: Pachyderma is defined as severely thickened skin with deep folds and is occasionally observed with primary cutaneous NK and T-cell lymphoma (pCNKTCL), primary cutaneous B-cell lymphoma (pCBCL), and leukemia cutis (LC). AIM: To describe the clinical, histological, and therapeutic particularities of a series of pCNKTCL, pCBCL, and LC patients with pachyderma. RESULTS: In a series of pCNKTCL (n = 70), pCBCL (n = 12), and LC (n = 2) patients followed up during 9 years, 6 cases of pachyderma were observed. Pachyderma occurred on the arms (n = 2), thighs (n = 1), forehead (n = 1), and face (n = 2). The mean age of the patients was 69 years (51-82). The stages were erythrodermic (T4) mycosis fungoides (MF) (n = 1), folliculotropic MF (FMF) (n = 2), classic (T2) MF (n = 2), and chronic myeloid leukemia (n = 1). The erythrodermic MF patient with acute pachyderma on the right arm responded rapidly to oral steroids. The other cases were indolent, appeared progressively, and were highly treatment resistant. Histology revealed dense dermal neoplastic infiltration. The immunohistological profile of the pachydermic lesions was similar to common MF and LC. CONCLUSION: Pachyderma is an atypical manifestation of MF and LC and may occur on the face (FMF) or the extremities (MF). The rapidly appearing pachyderma may be transitory and responds readily to oral steroids.

Eruptive Seborrheic Keratoses Restricted to Plaque/Patch-Stage Mycosis Fungoides.

Eruptive seborrheic keratoses (ESK) are rare in dermatology. They are usually inflammatory in nature and may be encountered as Leser-Trélat sign. ESK may also be simultaneously observed with hepatic angiomas, chemotherapy, segmental neurofibromatosis, HIV or erythrodermic pityriasis rubra pilaris, psoriasis, and drug eruption. ESK may be transient and self-healing. Others recede after successful treatment of the underlying disease. In some instances, seborrheic keratoses may follow an isotopic response and remain strictly restricted to sites of previous eczema, photo-exposition or tattoos. A patient with patch/plaque lesions of classic-type mycosis fungoides (MF) presented sudden ESK that were exclusively limited to the MF lesions. In conclusion, this patient combined an isotopic response and ESK.

Melanoma masquerading as nonmelanocytic lesions.

Increased awareness among dermatologists as well as the development of dermoscopy and sequential dermoscopy have contributed significantly toward an increase in the diagnostic accuracy of pigmented melanoma and even of amelanotic melanoma. However, the dermatologist's nightmare is the small group of melanomas that present as common skin diseases, often associated with a significant delay in diagnosis and hence a poor prognosis. The study was carried out to prospectively assess the number of melanomas lacking any clinical suspicion of melanoma and to describe their clinical and histological features over a 6-year observation period in an University Tertiary Skin Cancer Center. Out of 502 cases of newly diagnosed cases of melanoma, seven (1.4%) nonpigmented and nonamelanotic cases of melanoma were identified. The mean age of the patients was 69 years (two females/five males). All cases were discovered by chance on a punch biopsy. The clinical diagnostic suspicions were basal cell carcinoma, fungal intertrigo, keratoacanthoma, lichenoid keratoma, diabetic foot ulcer, eczema, and necrotic pressure ulcer. Dermoscopy, performed after the punch biopsies, was only partially contributive. The mean histological thickness was 2.7 mm, the mean number of mitoses was 7/mm, local micrometastases were present in 5/7 (71%), the mean Ki67 count was 18.9%, and a positive sentinel lymph node was observed in 4/6 (66%) cases. Nonpigmented and nonamelanotic melanomas are rare, are at high risk, and have a poor prognosis because of a delayed diagnosis. Dermoscopy is only of partial diagnostic aid. Treatment resistance or atypical behavior of the above-mentioned lesions should lead to biopsy.

Localized Eruptive Blue Nevi after Herpes Zoster.

A 52-year-old White man presented with a dozen small, well-restricted, punctiform, asymptomatic, blue-gray macules on the left shoulder. A few months earlier, he had been treated with oral acyclovir for herpes zoster (HZ) affecting the left C7-C8 dermatomes. All the blue macules appeared over a short period of time and then remained stable. The patient had not experienced any previous trauma or had tattooing in this anatomical region. The clinical diagnosis suggested blue nevi. Dermatoscopy revealed small, well-limited, dark-blue, compact, homogeneous areas evoking dermal blue nevi. An excisional biopsy was performed and the histological examination confirmed a blue nevus. As far as we are aware of, this is the first report of eruptive blue nevi following HZ, and it should be included in the differential diagnosis of zosteriform dermatoses responding to an isotopic pathway. In addition, a brief review concerning eruptive nevi is presented.

Risk Factors for Skin Infections in Mycosis Fungoides.

BACKGROUND: Mycosis fungoides (MF) is the most frequent type of primary cutaneous natural killer and T-cell lymphoma. MF-required immunosuppressive therapies and MF-related immunosuppressive characteristics render patients with MF more prone to infections. AIM: To describe the clinical features of cutaneous infections observed in MF patients. MATERIALS AND METHODS: A series of 56 MF patients were followed prospectively over 3 years and screened for cutaneous infections. TYPE OF STUDY: Prospective observational study. RESULTS: Four herpes simplex virus type-I (HSV-I), 2 staphylococcal (S. aureus) impetiginizations and 2 Malassezia infections were detected in single isolated plaque/patch stage MF as well as 1 varicella zoster virus infection (herpes zoster, HZ) and 2 cases of cellulitis in 10 patients. All patients presented advanced MF. All the diagnoses were delayed due to atypical clinical presentations. CONCLUSIONS: Patients with advanced MF should be particularly monitored for skin infections, especially by HSV and S. aureus. Unexplained exacerbation or the sudden appearance of oozing or ulcerations in MF lesions should initiate a search for viral or bacterial agents. Cellulitis and HZ can be severer and prolonged in MF patients.

Recurrent in situ melanoma successfully treated with ingenol mebutate.

BACKGROUND: Treatment options for melanoma in situ (MIS) include imiquimod, radiation therapy, cryotherapy, excisional and Mohs surgery. Ingenol mebutate is a new topical treatment option recognized for actinic keratosis. Although in vitro effectiveness has been demonstrated on melanoma cell lines, its therapeutic potential for in vivo melanomas is unknown. CASE REPORT: In 2011, a 91-year-old woman presented a thick melanoma of her cheek. The lateral sections revealed persisting in situ melanoma, which were again excised. She presented for follow-up and a recurrent MIS was evidenced centered on the previous scar. She refused further surgery and ingenol mebutate (0.015% gel) was administered on three consecutive days. One month later, a complete clinical resolution was observed. Histology and immunohistology revealed no residual MIS. CONCLUSION: In this patient, ingenol mebutate was successful and well-tolerated as a topical, alternative therapy for MIS after failure of other treatment options.

Myxofibrosarcoma: a diagnostic pitfall.

Myxofibrosarcoma (MFS) is a variant of the group of malignant fibrous histiocytomas. It is one of the most aggressive types of soft tissue neoplasms. The clinical presentation is not pathognomonic and the histological aspects are highly heterogenous, frequently delaying the diagnosis or leading to misdiagnosis. Complementary histochemical and immunohistochemical stainings are mandatory to achieve the diagnosis of MFS. A 78-year-old male patient is presented illustrating this diagnostic pitfall. Extensive surgery followed by radiotherapy is the first choice treatment.

ADAM metallopeptidase with thrombospondin type 1 motif 2 inactivation reduces the extent and stability of carbon tetrachloride-induced hepatic fibrosis in mice.

UNLABELLED: ADAMTS2 belongs to the "ADAM metallopeptidase with thrombospondin type 1 motif" (ADAMTS) family. Its primary function is to process collagen type I, II, III, and V precursors into mature molecules by excising the aminopropeptide. This process allows the correct assembly of collagen molecules into fibrils and fibers, which confers to connective tissues their architectural structure and mechanical resistance. To evaluate the impact of ADAMTS2 on the pathological accumulation of extracellular matrix proteins, mainly type I and III collagens, we evaluated carbon tetrachloride-induced liver fibrosis in ADAMTS2-deficient (TS2(-/-)) and wild-type (WT) mice. A single carbon tetrachloride injection caused a similar acute liver injury in deficient and WT mice. A chronic treatment induced collagen deposition in fibrous septa that were made of thinner and irregular fibers in TS2(-/-) mice. The rate of collagen deposition was slower in TS2(-/-) mice, and at an equivalent degree of fibrosis, the resorption of fibrous septa was slightly faster. Most of the genes involved in the development and reversion of the fibrosis were similarly regulated in TS2(-/-) and WT mice. CONCLUSION: These data indicate that the extent of fibrosis is reduced in TS2(-/-) mice in comparison with their WT littermates. Inhibiting the maturation of fibrillar collagens may be a beneficial therapeutic approach to interfering with the development of fibrotic lesions.

Emerging therapeutic agents for onychomycosis.

Onychomycosis is a frequent disorder that represents the most prevalent fungal infection, particularly among older individuals. Diverse fungi of the dermatophyte, non-dermatophyte mold and yeast families have been reported to be responsible for onychomycosis. The output from the pharmaceutical industry of new antifungals to treat onychomycosis has been limited over the last decade. Present treatment options include both oral and topical drugs, with oral therapies giving better outcomes. However, neither of these treatment options provides high cure rates that are durable. At present, azoles and allylamines are keeping the pivotal roles. New derivatives with a favorable risk-benefit ratio and new formulations of older azoles seem to be promising. Thus, ongoing drug development activities have focused on novel delivery technologies to facilitate incorporation of existing antifungal drugs inside the nail plate and the discovery of new active antifungals.

Granulomatous cutaneous centrofacial and meningocerebral amebiasis.

A 7-year-old, otherwise healthy Peruvian boy presented with a 3-month history of an indurated centrofacial plaque. Histologic examination revealed a granuloma containing free-living amebae tentatively identified as Balamuthia mandrillaris. The patient failed to respond to tentative treatment. He was admitted to the intensive care unit 7 months later with neurologic manifestations of granulomatous amebic encephalitis, which proved fatal. The difficulty in diagnosing this rare presentation of cutaneous amebiasis, the challenge of treating the condition, and the morbidity and high mortality associated with cerebral involvement are discussed.

Spotlight on nail histomycology.

The misdiagnosis of onychomycosis delays the proper treatment of the nail condition. Nail histomycology refers to the microscopic examination of histologic sections prepared from nail clippings for the purpose of detecting the presence of fungi. This laboratory method is the most sensitive procedure for the diagnosis of onychomycosis. It allows for the visualization of the precise location of the invasive fungus inside the nail apparatus. The method also distinguishes various shapes of the fungal cells, in particular filamentous fungi, yeasts, conidia, and sporodochia. The correct diagnosis provided by histomycology combined with culture not only allows for more efficient expenditure of funds and services but also is important for the timely alleviation of the disorder.

[Revisiting the epidemiology of onychomycoses]. / Un nuevo enfoque sobre la epidemiología de las onicomicosis.

Onychomycoses represent a group of nail affections caused by one or more fungi. Whether aging represents a risk factor for developing onychomycosis, remains a question. In the present work, we studied the variations in frequency and prevalence of onychomycoses and non-mycotic onychodystrophies according to age. Our results show that there is an increase in the frequency and prevalence of onychomycoses and non-mycotic onychodystrophies predominantly in patients over forty years of age.

Immunohistochemical detection of incipient melanoma micrometastases. Relationship with sentinel lymph node involvement.

It is acknowledged that tumour thickness, ulceration and lymph node invasion are the most important prognostic factors for cutaneous melanomas. Other histopathological features may also be informative. The aim of this study was to ascertain whether immunohistochemical methods can improve the detection of satellite micrometastases in primary melanoma patients. In addition, the predictive value of cutaneous satellite micrometastases for sentinel lymph node involvement was evaluated. A total of 265 primary cutaneous melanomas and 68 of the respective sentinel nodes were studied using a panel of seven antibodies directed against melanocyte-related antigens. In 12.4% of the 265 cases, small satellite micrometastases were detected by immunohistochemistry. Sentinel lymph node metastases were found in 14% of the 68 cases. Invasion of the sentinel lymph node correlated with the presence of cutaneous satellite micrometastases. It is concluded that the presence of cutaneous satellite micrometastases may be an indication for the performance of sentinel lymph node biopsy, and this finding calls for a closer follow-up of these patients.

Vascularity and fractal dimension of the dermo-epidermal interface in guttate and plaque-type psoriasis.

BACKGROUND: Histological structures of the skin are often irregular in size and shape. Euclidean geometry and fractal analysis are complementary for assessing distinct aspects of their dimensions. OBJECTIVE: To determine and compare the variations in shape of the dermo-epidermal junction and the size of the superficial vessels in psoriatic lesions. METHOD: The relative microvasculature area and the fractal dimension D of the dermo-epidermal interface were measured inside and outside growth-stunted guttate lesions (n = 22) and expanding plaques (n = 37) in psoriasis of the trunk. RESULTS: The median D values of the dermo-epidermal interface were significantly larger (p < 0.01) in psoriatic plaques (D = 1.15) than in guttate lesions (D = 1.08), and these D values on lesional skin were significantly larger (p < 0.01) than in the uninvolved skin (D = 1.03). The microvasculature was significantly (p < 0.01) more developed in lesional (plaque: 13%, guttate: 8.20%) than in uninvolved skin (3.60 and 3.85%). No correlations were found between the relative microvasculature areas and the D values of the dermo-epidermal interface, both in the uninvolved and lesional skins of each psoriatic type. CONCLUSION: The absence of a relationship between modulations of the dermo-epidermal junction and vascular hyperplasia, both in expanding and stable psoriasis lesions, suggests that these events are regulated by different mechanisms and do not depend on each other.

Immunohistochemical aid at risk stratification of melanocytic neoplasms.

There is increasing awareness of the population about the risk of cutaneous melanoma. In recent years, some improvement was gained in the early recognition of clinical warning signs using dermoscopy. As a result, the number of puzzling cases exhibiting limited classical clues for malignancy are submitted to the dermatopathologist. Thus, the risk of microscopic uncertainty or misdiagnosis may be increasing. The aim of the study was to assess retrospectively the contribution of immunohistochemistry in establishing the histological diagnosis of 520 melanocytic neoplasms. According to the disease evolution and the histological presentation, 6 profiles of phenotypical expressions were distinguished.

Cutaneous psammomatous melanotic schwannoma: non-recurrence with surgical excision.

BACKGROUND: Melanotic schwannoma is a pigmented nerve tumor that may be located in the skin and express local aggressivity. This tumor may occur singly. It may also be part of the Carney complex which consists of various, but specific, tumors. OBJECTIVE: We report two cases of subcutaneous melanotic schwannoma localized on the trunk in two men aged 37 and 45 years. METHODS: Conventional histology and immunohistochemistry were performed. RESULTS: One melanotic schwannoma was associated with a cutaneous atypical myxoma and multiple melanocytic lesions, all being part of the Carney complex. The other case had no associated signs. In both cases, the melanotic schwannoma was completely excised and did not recur. CONCLUSION: Melanotic schwannoma is rare and curable by surgery. It must not be confused with malignant melanoma and other pigmented neoplasms. The Carney complex should be carefully ruled out.

Treatment failures and relapses in onychomycosis: a stubborn clinical problem.

The therapeutic outcome of onychomycoses is uncertain. Comparative short-term efficacy studies on antifungals abound and report contradictory findings. Few unbiased follow-up studies have scrutinized the long-term outcome. Basically, none of the current antifungals can guarantee cure in all instances. In addition, relapses are not rare. The causes of therapeutic failure in onychomycoses are multiple. The most important are the lack of diagnostic accuracy, inadequate antifungal choice or delivery modality, and presence of dormant conidia, sequestrated mycelium pockets or resistant fungal species. The concept of fungicidal drug derived from selected in vitro studies appears irrelevant in clinical practice.