A case of herpes simplex virus reactivation after fractional ablative carbon dioxide laser to treat a burn scar.

Fractional photothermolysis was initially introduced by Manstein in 2004 .Fractional CO2 laser technology introduced has allowed physicians to obtain good cosmetic results with a lower rate of complications than non-fractionated ablative laser treatment. However, adverse effects may still occur.Reported cases of HSV infection after fractional photothermolysis are rare. A 48-year-old woman with Fitzpatrick skin type III presented with a scar in her perioral area desiring esthetic improvement of her burn scar. She didn't have a history of recurrent herpes simplex virus (HSV) infection periorally. A fractionated resurfacing laser Quadralase (Candela) was used to treat her perioral burn scar. Two sessions were performed with a month interval. Five days after the second session of laser therapy even after she took antiviral prophylaxis based on valacyclovir 500mg twice daily 24 hours before the laser session and 3 days after, she presented with a rash on the perioral area preceded by pain. Correlation of the history and the clinical presentation was consistent with HSV reactivation. Treatment was initiated with acyclovir 10mg/kg/8h administered intravenously for 10 days with a clearing of her vesicular eruption. Fractional CO2 laser is a very safe procedure when used with accepted parameters. Early recognition, close monitoring and careful wound care will prevent long term sequelae when complications occur.

Association of khellin and 308-nm excimer lamp in the treatment of severe alopecia areata in a child.

Alopecia areata (AA) is an autoimmune inflammatory disorder of hair, characterized by non-scarring hair loss. A 308-nm excimer lamp (EL) has been reported as one effective modality in the treatment of AA. Khellin is a furanochromone photosensitizer whose chemical structure is close to psoralens and has previously proven its efficacy in vitiligo in association with ultraviolet A. We evaluated the efficacy and safety of a combination of topical khellin and 308-nm EL in the treatment of a refractory ophiasic AA, of 1-year evolution, in a 5-year-old boy. Treatment consisted in topical application of khellin 45 mn before irradiation with EL (starting dose 50 mJ/cm2) twice a week for 3 months. The result was a complete regrowth of hair with no recurrence 1 year later. Further studies should be carried out to confirm this promising result and to propose khellin-excimer as a new alternative treatment for resistant cases of AA in children.

Multicentric Anogenital Bowen's Disease Treated with Imiquimod and CO2 Laser.

A 53-year-old white woman presented to our clinic with skin lesions in the anogenital region that had persisted for 1 year. She had a past medical history of total vulvectomy for a vulvar localization of Bowen's disease. She was otherwise in good health, with no evidence of illness or immunosuppression. Physical examination revealed multiple erythematous papular lesions located in the anogenital region (Figure 1). Dermatoscopy of the anogenital papules revealed glomerular vessels on an erythematous background typical of Bowen's disease (Figure 2A). There were no palpable inguinal lymph nodes. Rectosigmoidoscopy was normal. The biopsy specimen showed full thickness keratinocyte atypia with loss of normal stratification and was conclusive for Bowen's disease (Figure 2B).

Pemphigus Vegetans Confined to the Face and Scalp.

A 58-year-old man presented to our department with multiple chronic vegetant plaques on the face and scalp that had been present for 4 months. The plaques were well-defined hypertrophic areas, measuring between 3 cm × 3 cm and 3 cm × 4 cm, that were located mainly on the face symmetrically and on the forehead (Figure 1). The patient did not report itching or pain. There were also dry, crusty, well-defined plaques on the scalp. No other lesions were present on the skin or mucous membranes.

Melanoma of the Nasal Cavity.

78-year-old man presented with complaints of progressive nasal blockage and epistaxis over the previous 2 months. Clinical examination revealed a nodular, polypoid, ulcerated nonpigmented tumor filling the right nasal cavity (Figure 1). A punch biopsy was taken from the mass for histopathologic examination, which revealed many melanocytes in the submucosa. The stroma contained large numbers of spindle-shaped cells with hyperchromatic spindleoid nuclei (Figure 2), confirming the diagnosis of malignant melanoma. The tumor cells stained positive for melan-A (Figure 3) and HMB-45.

Bullous Fixed Drug Eruption Caused by Doxycycline.

A 50-year-old woman presented to our dermatology clinic with pruritic lesions on her hands that had appeared 24 hours earlier. The clinical manifestations had started 24 hours after taking 100 mg of doxycycline for acute bronchitis. She had no history of allergic disease or allergic reactions to drugs. The dermatologic examination revealed multiple erythematous, purplish annular patches with overlying bullae with hemorrhagic content on both palms (Figure 1). The patient had no fever, and the rest of the physical examination did not reveal any abnormalities. Results of laboratory tests were within normal limits. A skin biopsy was performed, showing hydrophic degenerations of the basal membrane, a superficial perivascular infiltrate consisting of lymphocytes and eosinophils, and red blood cells in the dermis (Figure 2). A pharmacovigilance investigation was conducted, and doxycycline was confirmed as the agent responsible for the bullous fixed drug eruption (FDE) in our patient.

Multiple Eccrine Spiradenomas in a Zosteriform Distribution.

A 52-year-old man was referred to our department with a 28-year history of painful nodular lesions located on his left buttock and left inguinal region that had recently increased in size and number. The lesions had developed progressively over many years. Cutaneous examination revealed multiple, well-circumscribed, subcutaneous, blue-gray nodules in a zosteriform distribution across the left inguinal region and the left buttock. Some of the painful nodules were large and ulcerated (Figure 1). Computed tomography showed multiple cutaneous nodules but no bone metastases or subcutaneous invasion. Histologic examination of a nodule demonstrated sharply delineated dermal nodules comprising basaloid cells arranged in a trabecular pattern surrounded by eosinophilic fibrous strands (Figure 2). No evidence of malignant transformation was noted. A diagnosis of multiple eccrine spiradenomas was made, and the patient underwent surgical excision of the painful and ulcerated nodules. He was regularly followed up in our department for 12 years.

Significant alleviation of Darier's disease with fractional CO2 laser.

Darier's disease (DD) is a dominantly inherited genodermatosis with highly variable expression. It is characterized by symmetrical hyperkeratotic papules affecting seborrheic areas and extremities. The existence of unsightly lesions could lead to discomfort and social handicap. Conventional treatment consists of topical and systemic steroids and/or retinoids alleviating DD. Ablative lasers also have been used to treat these conditions with variable results and side effects. To the best of our knowledge, fractional CO2 laser has never been used to treat DD. We present a case of a 36-year-old woman with verrucous and hyperkeratotic plaques of the forehead significantly improved after two sessions of fractional CO2 laser treatment. Neither scars nor pigmentary disorders were noted.

A case of linear atrophoderma of Moulin successfully treated with methotrexate.

Linear atrophoderma of Moulin is an acquired rare and self-limited skin condition. It is characterized by atrophic bandlike skin lesions that often show hyperpigmentation and always follow the lines of Blaschko. Usually it begins in childhood or adolescence and there is no evidence of any long term progression. We describe a case of a 21-year-old woman with clinical and histological features of linear atrophoderma of Moulin. The patient was successfully treated with methotrexate 20 mg/week during 6 months with an improvement of skin pigmentation and atrophy. Approximately, 30 cases of linear atrophoderma of Moulin were described in the literature. There is not a proven effective treatment of this dermatosis. High dose penicillin, topical corticosteroids, heparin, and oral potassium aminobenzoate have been used but found to be uneffective. To our knowledge, this is the first case of extensive linear atrophoderma of Moulin treated with methotrexate.

Unilateral Onychodystrophy and Puffy Fingers: Think about Carpal Tunnel Syndrome.

An 87-year-old man was referred to our department for evaluation of his dystrophic left fingernails that developed progressively for the past 2 years. His past medical history included hemodialysis for 10 years for chronic renal failure. Examination of his nails revealed xanthonychia, onycholysis, Beau's lines, and marked hyperkeratosis of the nail plate involving all of his left fingernails. However, his right fingernails were not affected (Figure 1). He also had edema of the left hand associated with puffy fingers but without trophic disorders (Figure 2). Mycologic exam-ination with direct microscopy and culture of his affected nails were negative. Antinuclear antibodies (ANAs), Scl-70 (anti-topoisomerase) antibodies, anti-centromere antibodies, and anti-RNA polymerase III antibodies were all negative. Capillaroscopy showed no abnormalities. An X-ray of his left hand showed no bony abnormalities. For the past 5 years, the patient had suffered from paresthesia and numbness on the left hand in the area of the median nerve. Paresthesia, pain, burning, and tingling involved mainly the thumb, plus the index and middle fingers, but not the little finger. Carpal tunnel syndrome (CTS) was suspected. Neurologic examination and electromyography (EMG) confirmed the diagnosis of CTS of the left hand explaining his unilateral onychodystrophy. The patient was then referred to a hand surgeon for his CTS.

Nail involvement in connective tissue diseases: an epidemiological, clinical, and dermoscopic study.

BACKGROUND: The assessment of nail changes in connective tissue diseases (CTD) has been rarely explored in previous studies. The use of dermoscopy to study vascular changes in nailfolds is an interesting diagnostic technique. The aim of the study was to describe the epidemiological, clinical, and dermoscopic features of nail lesions in CTD. METHODS: A prospective study was performed at the Dermatology Department of Habib Thameur Hospital (Tunis, Tunisia) in collaboration with the Internal Medicine Department over a period of 15 months, from July 2020 to September 2021, including patients diagnosed with systemic sclerosis (SS), systemic lupus erythematosus (SLE) and dermatomyositis (DM). RESULTS: Our study included 48 patients. Nail involvement was found in 44 cases. Dermoscopic nailfold abnormalities were identified in 37 cases. The most common clinical features were ragged cuticle, nailfold erythema, and onycholysis. Additionally, splinter hemorrhage, longitudinal ridging, lunula abnormalities, melanonychia, trachyonychia, leukonychia, increase in transverse curvature, parrot beak nail, half and half nails, and onychorrhexis were described. Nailfold dermoscopy showed a normal pattern in 10 cases, a nonspecific pattern in nine cases (SLE), and a scleroderma pattern in 29 cases (SS and DM). The scleroderma pattern was further categorized into an early pattern (6), an active pattern (14), and a late pattern (9). Normal pattern was observed solely in patients in remission. The late scleroderma pattern was associated with disease duration and systemic involvement. In SLE, disease activity correlated with onycholysis, nailfold erythema, and pathologic pattern in dermoscopy. However, patients with DM displayed a positive correlation between pulmonary involvement and scleroderma pattern. CONCLUSION: Nail involvement in CTD includes a diverse range of abnormalities. Despite being nonspecific, it can provide crucial clues for establishing a diagnosis. Nailfold dermoscopy serves as a mirror for microangiopathy, enabling the detection of changes at an initial stage, and thus, it becomes a diagnostic and prognostic tool.

Subcutaneous Nodules of the Vulva.

A 32-year-old patient complained of three slow-growing subcutaneous nodules on her right labius majus, present for 3 years. Her past medical history was unremarkable. Cutaneous examination revealed three subcutaneous nodules of 1 cm diameter firmly adherent to the underlying tissues, located on her right labium majorum (Figure 1). Regional lymph nodes were not enlarged. She underwent an excision biopsy of a subcuta-neous nodule under local anesthesia. The gross specimen was firm, white and fleshy in appearance. A skin biopsy was performed, and histological findings revealed a non-encapsulated dermal nodule composed of clusters of polygonal cells with small central nuclei and abundant eosinophilic cytoplasm (Figure 2a). The tumor cells formed sheets and nests irregularly infiltrating between collagen bundles. There was no significant cyto-logic atypia and mitotic features. There were no necrosis and hemorrhage. The cells were positive for S-100 immunostain (Figure 2b). Hence, the diagnosis of benign vulvar granular cell tumor was assessed. The patient underwent surgical excision of the subcutaneous nodules with no recurrence at 2 years.

Cutaneous Metastases: Clinicopathologic Study of 30 Patients.

Cutaneous metastases (CMs) of internal malignancies are uncommon. The breast in women and the lung in men represent the two elective sites of internal malignancies metastasizing to the skin. The aim of this study was to determine the epidemiologic, clinical, and pathologic features of CMs. A retrospective study of the patients diagnosed with CMs over 30 years was conducted. Thirty cases of CMs were enrolled in our study. In 16 cases (53%), the skin metastasis revealed the internal malignancy. The mean age was 66.4 years with sex ratio men/women of 2. CMs were solitary in 18 cases and multiple in 14 cases. The most frequent location was the chest (12 cases), followed by the abdomen (eight cases), the scalp (seven cases), and the arms (six cases). The common sites of primary malignancy were the lungs in men (nine cases) and the breast in women (three cases). Nine out of 30 patients died with an average of 33 months after diagnosis. In our study, the most frequent primary malignancy in men was lung cancer and in women breast cancer. The onset of CMs during the course of internal malignancy worsens the prognosis of the disease.

Comorbidity of bathing suit ichthyosis and limb-girdle muscular dystrophy type 2 A in a Tunisian patient revealed by Whole Exome Sequencing.

Elevated rates of consanguinity and inbreeding are responsible for the high prevalence of recessively inherited diseases among inbred populations including Tunisia. In addition, the co-occurrence of two of these conditions, called also comorbidity, within the same individual or in members of the same family are often described in Tunisia which is challenging for diagnosis. The high throughput sequencing has improved the diagnosis of inherited diseases. We report here on a 32-year-old woman born to consanguineous parents. She presented with congenital ichthyosis and muscular dystrophy. She was primarily suspected as suffering from Chanarin-Dorfman syndrome (CDS) with unusual form. Screening of founder mutations allowed only the elucidation of the molecular etiology of Ichthyosis. As the result was inconclusive, Whole Exome Sequencing (WES) was conducted. WES data analysis led to the identification of a mutation in the CAPN3 gene underlying limb-girdle muscular dystrophy type 2A (LGMD2A). Sanger sequencing confirmed the familial segregation of mutations. This work presents the first case worldwide of individual comorbidity of bathing suit ichthyosis and LGMD2A. The co-occurrence of two diseases should be systematically considered when establishing a diagnosis especially in consanguineous populations. WES is a powerful tool for molecular diagnosis in particular for revealing comorbidities and rectifying the diagnosis.