Microblading-Induced Granulomatous Reaction: Case Report and Review of the Literature.

ABSTRACT: Microblading is a common cosmetic procedure that can modify the appearance of one's eyebrows. Although generally well-tolerated, the procedure can cause a number of dermatologic issues; on rare occasions, granulomatous reactions can manifest. We use this case to highlight a presentation of a nonsarcoidal granulomatous dermatitis and review the literature on granulomatous reactions secondary to microblading. Of the 21 cases included in our review, approximately half (10/21) were diagnosed with foreign-body granulomas and the other half with sarcoidosis (7 of 21 with systemic sarcoidosis and 4 of 21 with cutaneous sarcoidosis). Although microblading remains a commonplace cosmetic technique, it is not without risk. Much like other types of tattoos, microblading can cause granulomatous reactions for which we must be vigilant, and further workup for sarcoidosis might be considered in select patients.

Eosinophils in Traditionally Noneosinophil-Rich Dermatoses.

ABSTRACT: The presence or absence of tissue eosinophilia has previously aided in the diagnosis of inflammatory skin conditions. However, recent studies have elucidated the presence of eosinophils in traditionally eosinophil-poor inflammatory skin diseases, such as dermatomyositis (DM), psoriasis, and lichen sclerosus (LS). This systematic review of the literature explores previous studies of tissue eosinophilia in skin biopsies of dermatoses that are believed to be classically poor in eosinophil. We identified 26 studies, the majority of which were retrospective reviews. The percent of specimens with increased eosinophils in psoriasis ranged from 18%-73%, pityriasis rubra pilaris (PRP) 22%-63%, LS 29%-53%, DM 15%-44%, morphea 8%-45%, hypertrophic lichen planus (LP) 0%-21%, and oral LP 0%-4%. These reports of tissue eosinophilia in reputed eosinophil-poor dermatologic conditions present a diagnostic pitfall and suggest that tissue eosinophilia itself should not be used to rule out a diagnosis of one of these conditions.

Expanding the Histologic Spectrum of Sudden Conjunctivitis, Lymphopenia, and Rash Combined With Hemodynamic Changes.

ABSTRACT: Sudden conjunctivitis, lymphopenia, and rash combined with hemodynamic changes (SCoRCH) is a recently described hypersensitivity reaction to trimethoprim-sulfamethoxazole. To date, only 1 case of histologic findings in SCoRCH has been reported, revealing a superficial perivascular dermatitis. In this article, we present a 53-year-old woman with a four-day history of a widespread, confluent, erythematous, and dusky rash after exposure to trimethoprim-sulfamethoxazole. Histologic examination revealed a vacuolar interface dermatitis with several apoptotic keratinocytes at multiple levels of the epidermis, similar to an erythema multiforme-like presentation. As described in SCoRCH, our patient's clinical findings rapidly improved within 48 hours of presentation without treatment. This case adds to the current literature by identifying a newly described histopathological presentation of SCoRCH.

Low dose oral minoxidil and the conundrum of cardiovascular complications.

In recent months, the general public has become more cognizant of the potential of oral minoxidil to promote hair growth; this was promulgated, in part, by an article published in the New York Times entitled, "An Old Medicine Grows New Hair for Pennies a Day, Doctors Say." Minoxidil was added to the pharmacologic armamentarium as an antihypertensive nearly 60 years ago and was found to trigger hypertrichosis in many patients, but its use dropped sharply as cardiologists observed a number of adverse cardiovascular events including ischemic heart disease, left ventricular hypertrophy, pleural effusions, and pericardial effusions. Studies in the realm of dermatology have explored the utility and safety of low dose oral minoxidil (LDOM) for management of alopecia. This article highlights potential clinical conundrums posed by these rare but severe cardiovascular complications and the importance of collaboration between cardiologists and dermatologists when employing this agent in patients with cardiorenal or cardiovascular risk factors.

No Recurrence in Primary Invasive Stage 1a and 1b Melanoma and Melanoma in Situ Treated With Serial Disk Staged Excision.

BACKGROUND: Optimal surgical treatment modality for invasive melanoma (IM) and melanoma in situ (MIS) has been debated with proponents for standard wide local excision (WLE), serial disk staged excision, and Mohs micrographic surgery. OBJECTIVE: The purpose of this study is to identify the recurrence rates and surgical margins of invasive stage 1 melanoma and MIS lesions using serial disk staged excision technique with rush permanent processing and "bread loafing" microscopic analysis. MATERIALS AND METHODS: Recurrence rates and surgical margins of 63 IM and 207 MIS at the University of California Dermatology Surgery Unit were retrospectively reviewed. RESULTS: No recurrences were observed with average follow-up of 34 and 36 months for IM and MIS, respectively (range, 10-92 months). Average surgical margins were 19.8 mm (SD 9.7) for IM and 12.1 mm (SD 12.2) for MIS. CONCLUSION: This SSE technique for the treatment of IM and MIS is comparable in efficacy to other SSE techniques, and it offers physicians a simple and accessible alternative to WLE and MMS.

Wells Syndrome-Like Histologic Pattern Caused by a Permanent Tattoo.

ABSTRACT: Tattoo reactions have become more common as tattoos gain visibility and popularity worldwide. A variety of inflammatory patterns have been described in association with tattoos- more commonly fibrosing, granulomatous, lichenoid, pseudolymphomatous, and spongiotic patterns. To date, there has been one case report of a Wells syndrome-like inflammatory pattern associated with a temporary Henna tattoo. Here we present the first case of a permanent tattoo with resulting flame figures, histologically resembling Wells syndrome. We believe this uncommon histologic pattern might be of interest for pathologists to be aware of.

Pseudocarcinomatous Hyperplasia Masquerading as a Well-Differentiated Squamous Cell Carcinoma Associated With Primary Cutaneous Anaplastic Large-Cell Lymphoma.

ABSTRACT: Pseudocarcinomatous hyperplasia (PCH) is a reactive proliferation of the epidermis associated with CD30 + lymphoproliferative disorders. In this article, we report the case of a 42-year-old man who presented with a 10-year history of a solitary erythematous patch on the right thigh that progressed to an ulcerated, crusted plaque. Histologic examination revealed an infiltrate of atypical CD30 + lymphocytes consistent with primary cutaneous anaplastic large-cell lymphoma with overlying well differentiated keratinocyte hyperplasia akin to a well-differentiated invasive squamous cell carcinoma. This case demonstrates the phenomenon of pseudocarcinomatous hyperplasia mimicking features of invasive squamous cell carcinoma. It highlights the necessity of careful clinical correlation when diagnosing squamous cell carcinomas in younger patients on non-sun-exposed areas and the exclusion of accompanying known causes of pseudocarcinomatous hyperplasia.

Preferentially expressed antigen in melanoma expression in nonmelanoma skin cancers and melanocytes in surrounding skin.

BACKGROUND: Immunohistochemistry for preferentially expressed antigen in melanoma (PRAME) has been studied in melanocytic lesions but not nonmelanoma skin cancers (NMSCs). This study evaluated PRAME expression in NMSCs and dermoepidermal junction (DEJ) melanocytes in the surrounding skin. METHODS: Ninety-nine NMSCs were studied: 23 Merkel cell carcinomas (MCCs), 25 well to poorly differentiated squamous cell carcinomas (SCCs), 14 basal cell carcinomas (BCCs), five basosquamous carcinomas, four sebaceous carcinomas, ten atypical fibroxanthomas, 11 dermatofibrosarcoma protuberans, and seven leiomyosarcomas. Staining quality was considered low or high intensity. Staining quantity was reported as negative 0%, 1% to 24%, 25% to 50%, and >50%. DEJ melanocyte PRAME expression was recorded. RESULTS: Forty-eight percent of NMSCs showed PRAME expression, mostly low intensity in fewer than 25% of cells. High-intensity expression was noted in one poorly differentiated SCC, six BCCs, and seven MCCs. Only MCCs showed expression in greater than 25% of tumor cells. Focal DEJ melanocytes expressed high-intensity PRAME in 18% of cases, most commonly SCCs (11/23). CONCLUSIONS: PRAME is negative or expressed with low intensity in a small percentage of NMSCs, with the exception of some MCC showing high-intensity and diffuse staining. Focal DEJ melanocytes showed high-intensity PRAME reactivity in the skin surrounding some NMSCs.

Histopathologic PD-L1 Tumor Expression and Prognostic Significance in Nonmelanoma Skin Cancers: A Systematic Review.

ABSTRACT: PD-L1 and PD-1 inhibitors are being increasingly used to treat a variety of nonmelanoma skin cancers (NMSCs). This systematic review summarizes PD-L1 expression in NMSCs and determines its use for prognosis using targeted immunotherapy. A primary search of peer-reviewed English-language medical literature was conducted for studies on PD-L1 tumor expression in biopsied or excised NMSCs. Fifty-nine articles met criteria for inclusion. PD-L1 expression in advanced NMSCs ranged from 22%-89% for basal cell carcinomas, 42%-50% for Merkel cell carcinomas, and 26%-100% for squamous cell carcinomas. Study limitations included clone heterogeneity across studies, complicating comparison of PD-L1 expression. Differences were also noted in the selection of tumor reactivity threshold. We conclude that there is insufficient evidence to determine the prognostic significance of PD-L1 expression in NMSCs as a whole, but this remains a promising area. More investigation into the role of tumor PD-L1 as a biomarker for predicting clinical response to PD-L1 and PD-1 inhibitors in NMSCs is needed.

Programmed cell death 1 protein and programmed death-ligand 1 inhibitors in the treatment of nonmelanoma skin cancer: A systematic review.

BACKGROUND: Immunotherapy using programmed cell death 1 protein (PD-1) or programmed death-ligand 1 (PD-L1) inhibitors has been increasingly reported in a variety of nonmelanoma skin cancers (NMSCs). OBJECTIVE: To analyze the evidence of PD-1 and PD-L1 inhibitors in the treatment of NMSC. METHODS: A primary literature search was conducted with the PubMed, Cochrane Library, EMBASE, Web of Science, and CINAHL databases through October 28, 2018, to include studies on the use of PD-1 or PD-L1 inhibitors in patients for NMSC. Two reviewers independently performed study selection, data extraction, and critical appraisal. RESULTS: This systematic review included 51 articles. The most robust evidence was in the treatment of Merkel cell carcinoma and cutaneous squamous cell carcinomas, as supported by phase 1 and 2 clinical trials. Treatment of basal cell carcinoma, cutaneous sarcoma, sebaceous carcinoma, and malignant peripheral nerve sheath tumor also showed benefit with PD-1/PD-L1 inhibitors, but data are limited. There does not appear to be efficacy for PD-1/PD-L1 inhibitors in cutaneous lymphomas. LIMITATIONS: More investigation is needed to determine the efficacy, tumor responsiveness, and the safety profile of PD-1 and PD-L1 inhibitors in NMSC. CONCLUSION: PD-1 and PD-L1 inhibitors exhibit treatment efficacy in a variety of NMSCs.

Rare Case of Lipomatous Mixed Tumor With Follicular Differentiation.

Cutaneous mixed tumors are adnexal neoplasms characterized by a mixture of epithelial, myoepithelial, and stromal components of varying proportions. The diagnosis may be of little challenge when chondroid or myxoid components are dominant. However, there are variants of the cutaneous mixed tumor where more uncommon features predominate, making the diagnosis more challenging. Here, we present a case of a rare variant of the cutaneous mixed tumor with extensive adipocytic and follicular differentiation. This is the second case of such a tumor reported to literature to our knowledge.

Keratosis pilaris rubra with mucin deposition.

Keratosis pilaris (KP) is a benign cutaneous disorder characterized by folliculocentric hyperkeratotic papules most often occurring on the proximal extremities. Erythema is usually limited to perifollicular skin, but when keratosis pilaris presents on a background of confluent erythema, the term keratosis pilaris rubra (KPR) is used. The histological findings associated with KP have not been well described in the literature. Herein, we present a case of a 14-year-old male with a 7-year history of erythema and follicular-based papules over his bilateral cheeks, consistent with KPR. Histological examination revealed abundant mucin, keratotic follicular plugging, and periadnexal lymphocytosis. Our novel finding of abundant dermal mucin expands the histopathologic description of KPR.

Intradermal Proliferative Fasciitis Occurring With Chondrodermatitis Nodularis Helicis.

Nodular fasciitis is a benign myofibroblastic tumor. Its uncommon variant, proliferative fasciitis (PF), can present in an even less common intradermal form. We report a case of intradermal PF of the ear in a 45-year-old man who presented with recurrent episodes of pain and swelling of the lesion. Histologic examination showed a dermal, nodular proliferation of ganglion-like basophilic fibroblasts with prominent nuclei and nucleoli, admixed with foamy histiocytes and areas of spindle cells arranged in intersecting fascicles in a fibromyxoid background. Lesional cells stained positive for smooth muscle actin and were negative for AE1/AE3, p63, and Melan-A. CD68 highlighted intervening histiocytes. We postulate that the underlying chondrodermatitis nodularis helicis was a triggering etiology, consistent with the current speculation that intradermal PF results from trauma.

Myoepithelioma of Soft Tissue With Both Squamous and Adipocytic Metaplasia.

Soft tissue, or cutaneous, myoepitheliomas are rare tumors arising solely from a myoepithelial origin. These neoplasms are typically associated with uncertain differentiation and can contain cellular morphologies that include spindle, plasmacytoid, epithelioid, or clear cell forms. Soft tissue myoepitheliomas are commonly found on the lower limbs and in the pelvic girdle but can occur throughout the body. A small minority display heterogenous differentiation, typically osseous or cartilaginous in nature. Squamous and adipocytic cell types are much rarer. We report the case of myoepithelioma of soft tissue with both squamous and adipocytic metaplasia. In the largest myoepithelioma series of 101 soft tissue myoepitheliomas, there were only 2 cases of squamous metaplasia and 1 case of adipocytic metaplasia. Our case displays the unique occurrence of 2 rare histologic findings occurring simultaneously within an already uncommon neoplasm.

Nodular Vasculitis in a Patient With Crohn's Disease on Vedolizumab.

Erythema induratum (EI), or nodular vasculitis (NV), is a type of panniculitis that is often associated with vasculitis affecting various-sized veins, venules, and arteries in reaction to various causative factors. Historically, EI was highly linked to tuberculosis, but in 1946, Montgomery first proposed the term NV to describe cases of EI not associated with tuberculosis. Only 2 reports of NV associated with inflammatory bowel disease have been reported in the literature. The authors report a 60-year-old woman with Crohn's disease presenting with exacerbation of NV in the setting of vedolizumab therapy.