Linear IgA bullous disease presenting as toxic epidermal necrolysis: a case report and review of the literature.

A 91-year-old female presented with widespread skin sloughing and bullae clinically mimicking toxic epidermal necrolysis (TEN). The patient was on multiple antibiotics, including vancomycin and piperacillin/tazobactam. Histopathology and direct immunofluorescence were consistent with a diagnosis of linear IgA bullous disease (LABD). In a PubMed review of the literature from 1975 to the present, there have been 15 cases of LABD presenting as TEN clinically and with characteristic linear IgA deposits on direct immunofluorescence studies. Vancomycin and phenytoin were the most commonly implicated medications. Twelve patients saw a resolution or healing of skin lesions after discontinuation of the implicated medication. There were, however, 5 patients who died of complications related to their comorbidities. It is important to include LABD in the differential diagnosis when evaluating patients who clinically present with TEN.

The histologic spectrum of epithelial neoplasms induced by sorafenib.

Sorafenib is a multikinase inhibitor newly approved for the treatment of renal cell carcinoma and hepatocellular carcinoma. Multiple cutaneous adverse effects of sorafenib have been described. We present a 68-year-old patient with renal cell carcinoma who developed multiple tender hyperkeratotic papules within weeks of starting sorafenib. The degree of symptoms and size of lesions corresponded directly with his sorafenib dosing. Four biopsy specimens of representative lesions were taken. Three lesions showed keratin-filled endophytic epithelial-lined invaginations, one with a coexistent actinic keratosis. The fourth biopsy specimen revealed an invasive squamous cell carcinoma with keratoacanthoma-like features. To our knowledge, diffuse eruptions of epidermal invaginations, ectatic follicular infundibula, and follicular infundibular cysts have not been reported previously with sorafenib, although they are well known to occur with epidermal growth factor receptor inhibitor therapy. Keratoacanthoma and squamous cell carcinoma as a result of sorafenib use are only beginning to be reported in the literature. At the time of acceptance of our manuscript, sorafenib-induced keratoacanthoma was noted only once in the literature, and deeply invasive squamous cell carcinoma has been reported once in the setting of sorafenib and tipifarnib combination therapy. We review the spectrum of dermatologic side effects of sorafenib to facilitate their recognition.

The inadequacy of punch-excised melanocytic lesions: sampling through the block for the determination of "margins".

BACKGROUND: Dermatopathologists often are asked by clinicians to report margins on punch excisions of melanocytic lesions. OBJECTIVE: We sought to determine the adequacy of surgical margins on melanocytic lesions submitted with intention of complete excision using punch removal technique. METHODS: We conducted prospective analysis of surgical margins on 266 consecutive patients who underwent attempted complete removal of 405 melanocytic nevi submitted as punch and fusiform excisions. RESULTS: Of 206 nonbisected punch excisions, 127 (62%) had final positive margins. Of 159 bisected punch excisions, 76 (48%) had final positive margins. Of 40 elliptical excisions, two (5%) had final positive margins. LIMITATIONS: Information on the perilesional rim of nonpigmented skin included in the excision was not available. CONCLUSIONS: Of punch excisions, 56% had positive margins. Importantly, 30% of these punch excised specimens were negative on initial levels but had positive margins after extensive sectioning, affirming that fusiform excisions are the preferred method to evaluate margins in melanocytic lesions.

Familial ichthyosiform keratoderma in newly out-of-pouch Bennett's wallabies (Macropus rufogriseus) and report of two cases.

Primary inherited disorders of cornification in veterinary medicine are uncommon and rarely reported. Herein described is a unique syndrome associated with keratoderma that occurred in two Bennett's wallaby siblings (Macropus rufogriseus), and was characterized by profound thickening of the pad skin of all feet, generalized scaling of haired skin, and death within 7 weeks of out-of-pouch experience. The male also had depressed serum zinc levels. In addition, the male had, on electron microscopic exam of his skin, the presence of abnormal lipid deposits within the stratum corneum and stratum granulosum. The combination of clinical features and electron microscopic findings strongly suggests a syndrome analogous to harlequin ichthyosis or lamellar ichthyosis in humans.

Lipidized dermatofibromas and their relationship to serum lipids.

BACKGROUND: Lipidized dermatofibromas represent a rare variant of dermatofibroma that has been regarded as an incidental finding with no particular clinical significance. OBJECTIVE: The goal of this study was to investigate the relationship between lipidized dermatofibromas and patient age, anatomic location, and serum total cholesterol. METHODS: A retrospective case control format was used with an experimental group containing patients with biopsy-proven lipidized dermatofibromas and a control group containing patients with nonlipidized dermatofibromas. RESULTS: Ages in the experimental group ranged from 35 to 75 years with a mean value of 53 years whereas ages in the control group ranged from 27 to 72 years with a mean value of 48 years. A comparison between the mean of the ages between the two groups using the t test method showed no statistically significant difference (P = .09). Lesion location on the body was grouped into 4 sites: leg, thigh, trunk, and upper extremity. Of the 23 patients in the experimental group, 10 had lesions on the legs, 5 had lesions on the thighs, 2 had lesions on the trunk, and 5 had lesions on the upper extremities. Of the 41 patients in the control group, 15 had lesions on the legs, 7 had lesions on the thighs, 9 had lesions on the trunk, and 10 had lesions on the upper extremities. A comparison between the two groups showed no statistically significant difference (P = .60). In all, 16 of the 23 patients in the experimental group and 24 of the 41 patients in the control group were considered to have high cholesterol. A comparison showed no statistically significant difference between the cholesterol levels of the two groups (P = .38). LIMITATIONS: Limitations that we encountered during the study included the relative infrequency of lipidized dermatofibromas, limiting the number of patients in the study. In addition, medication histories and lipid levels on patients were not always available. In addition, we formed a control group from people who had their cholesterol checked often, which may cause them to have a higher average cholesterol than that of the general population. CONCLUSIONS: Our data show that lipidized dermatofibromas do not differ clinically from nonlipidized dermatofibromas in age distribution of patients, tumor location, or underlying serum lipid levels.

Impact of thorough block sampling in the histologic evaluation of melanomas.

OBJECTIVE: To determine if changes in histologic parameters obtained from intermittent sampling of the entire block correlated with differences in prognosis and management. DESIGN: Prospective analysis of skin biopsy specimens. SETTING: Skin pathology laboratory. Patients One hundred consecutive patients with an unequivocal diagnosis of melanoma. Interventions Two initial slides were prepared from serial sections of 5-mum thickness. When evaluation of the initial slide revealed melanoma, 5 additional slides were obtained by sectioning at levels through the entire block. Breslow depth, Clark level, ulceration, tumor infiltrating lymphocytes, vascular invasion, regression, presence of a precursor lesion, and histologic type of melanoma for the first slide and the additional 6 slides were analyzed and compared. RESULTS: Review of the additional 6 slides from level sectioning revealed a greater maximum tumor thickness than was evident from the original slide in 43% of the cases. In 10 of these cases, the new maximum tumor thickness measurements changed the surgical management of the patients. Ulceration was observed in 6% of cases on the initial slides, and an additional 3% of lesions were found to have ulceration on levels. The level of invasion was deeper than originally found in 10% of the cases. CONCLUSIONS: Level sectioning through an entire block of a melanoma specimen provides additional information in the classification and management of melanomas. Extensive block sampling will result in more accurate information regarding histologic parameters of melanoma, but the yield must be balanced with the extra cost of materials, time, labor, and the potential disadvantage of not retaining tissue for future use.

Benign lymphangiomatous papules of the skin.

Benign lymphangiomatous papules of the skin are benign lymphatic proliferations that may arise in the skin after operation or radiation therapy. We report a case of benign lymphangiomatous papules of the skin that occurred in a patient 4 years after undergoing radiation therapy to the chest for adenocarcinoma of the breast.

Subtle intracorneal findings in inflammatory disorders: hyphae or not?

BACKGROUND: Spongiotic and lichenoid dermatitides are frequently stained with periodic acid-Schiff (PAS) stains to check for the presence of dermatophytes. PAS+ structures without a septate morphology are often seen with lichenoid dermatitides, however, their nature has not been previously characterized. METHODS: Fifteen consecutive biopsies of lichenoid and five spongiotic dermatitides were stained with hematoxylin and eosin (H&E), PAS, and antibodies to CD1a. RESULTS: Twelve of 15 lichenoid and none of the five spongiotic dermatitis showed PAS+ structures in the stratum corneum. Distinct septation or branching was not identified in these PAS+ structures. Eleven of 15 from the lichenoid group, but none from the spongiotic group, showed CD1a+ structures in the stratum corneum. This staining pattern suggests that the intracorneal structures represent the dendritic processes of Langerhans' cells (LCs) within the stratum corneum. CONCLUSIONS: PAS+ and CD1a+ structures are present in the stratum corneum of lichenoid, but not in spongiotic, dermatitis. This study morphologically confirms extension of LC dendrites into the stratum corneum in lichenoid but not in spongiotic dermatitides.

Interstitial granulomatous dermatitis secondary to soy.

A healthy 58-year-old woman developed an asymptomatic papular eruption of the neck, cheek, abdomen, arms, and flexures. There was an 8-year history of the lesions, which had erupted when the patient started a strict vegetarian diet. Lesions lasted 3 to 5 days, cleared without scarring, and were associated with burning and increased tearing of the eyes. The biopsy specimen showed an interstitial granulomatous dermatitis without vascular injury, collagen alteration, or mononuclear atypia. The eruption cleared when the patient omitted soy products from her diet. It subsequently recurred with intake of even minimal amounts of soy. Interstitial granulomatous dermatitis is a histologic pattern of inflammation that generates a broad differential diagnosis. No previous reports of interstitial granulomatous dermatitis related to soy products are available in the literature.

Topical methotrexate for lymphomatoid papulosis.

Lymphomatoid papulosis is a lymphoproliferative disease characterized by recurrent papules, nodules, or plaques that spontaneously involute within several weeks. Despite having a histologically malignant-appearing infiltrate, patients with lymphomatoid papulosis have a clinically benign course. Several treatment options have been described for the management of lymphomatoid papulosis. We describe a patient who had complete resolution of lesions with the use of topical methotrexate.

Superficial morphea.

The superficial variant of morphea is a recently described entity that differs in its clinical and histologic presentation from classic morphea. The condition has been reported only in females to date and is characterized by minimal to no induration and hypopigmented or hyperpigmented patches without associated symptoms, systemic involvement, contractures, or atrophy. We present the unique clinical and histopathologic findings in a 77-year-old woman.

Benign cephalic histiocytosis: a case report and review.

Benign cephalic histiocytosis is a rare non-Langerhans histiocytosis characterized by a self-healing eruption of papules and macules on the head and neck that occurs during infancy or childhood. Histologic and ultrastructural evaluations show a dermal proliferation of histiocytes with intracytoplasmic comma-shaped bodies, coated vesicles, and desmosome-like structures with an absence of Birbeck granules. We report a case of benign cephalic histiocytosis in a 9-month-old boy who presented with tan papules on his face that spread to his lower extremity and subsequently began to regress at 30 months of age. We review the features of this rare entity through a literature review and discuss the differential diagnosis.

Granular parakeratosis in a child.

Granular parakeratosis has only recently been described and typically occurs in adults. We report the first instance of this condition affecting a child.