Cutaneous Hydrophilic Polymer Embolism: An Important and Overlooked Clinical Entity.

ABSTRACT: Hydrophilic polymer embolism from vascular medical devices is an underrecognized clinical entity that can cause deleterious end-organ ischemia and culminate in mortality. This is concerning as we are in the era where minimally invasive procedures are commonplace. Diagnosis is often made retrospectively after obtaining histopathological tissue samples showing endoluminal, cerebriform, amorphous, anucleate, basophilic, nonrefractile, nonpolarizable foreign body material. We detail 2 more cases of cutaneous hydrophilic polymer embolism to underscore its salient clinicopathological features and increase awareness of this important iatrogenic entity.

Dermatopathologic features of cutaneous squamous cell carcinoma and actinic keratosis: Consensus criteria and proposed reporting guidelines.

BACKGROUND: There is considerable variation in the literature regarding the dermatopathologic diagnostic features of and reporting guidelines for actinic keratosis (AK) and cutaneous squamous cell carcinoma (cSCC). OBJECTIVE: To develop consensus recommendations regarding diagnostic criteria, nomenclature, and reporting of AK and cSCC. METHODS: Literature review and cross-sectional multiround Delphi process including an international group of expert dermatopathologists followed by a consensus meeting. RESULTS: Consensus was achieved regarding the key dermatopathologic features necessary for diagnosing cSCC, AK, and associated variants; grading of degree of cellular differentiation in cSCC; utility of immunohistochemistry for diagnosis of cSCC; and pathologic features that should be reported for cSCC and AK. LIMITATIONS: Consensus was not achieved on all questions considered. CONCLUSION: Despite the lack of clarity in the literature, there is consensus among expert dermatopathologists regarding diagnostic criteria and appropriate reporting of AK and cSCC. Widespread implementation of these consensus recommendations may improve communication between dermatopathologists and clinicians, facilitating appropriate treatment of AK and cSCC.

Acute iododerma presenting as cryptococcoid neutrophilic dermatosis: A clinicopathological pitfall and interesting findings gleaned from a review of the literature.

Iododerma is an uncommon dermatosis caused by excessive iodine exposure and is associated with significant morbidity and mortality. Because of its heterogenous clinical presentation and variable histopathological findings, which depend on the time the skin biopsy is performed, the diagnosis of iododerma is often delayed. We report a rare case of acute iododerma in a woman with end-stage diabetic nephropathy with antecedent radioiodine contrast exposure, presenting histopathologically as cryptococcoid neutrophilic dermatosis (CND). We underscore important clinicopathological pitfalls to avoid misdiagnosis with similar overlapping entities such as Sweet syndrome, review all published cases of CND and draw novel insights into its associated entities.

Miliarial gout: Clinical case and a brief review.

Miliarial gout is a rare clinical variant of chronic tophaceous gout characterised by tiny milia-like papules containing chalky tophaceous material. In this report, we present a case of miliarial gout in a patient with known history of gouty arthritis and review the reported cases of miliarial gout in the literature to discuss its characteristics, diagnosis and treatment.

Cryocrystalglobulinemia-An Uncommon Cutaneous Presentation of Multiple Myeloma and Novel Finding of Transepidermal Elimination of Crystals.

ABSTRACT: Cryocrystalglobulinemia (CCG) is a rare subset of type 1 cryoglobulinemia that is classically associated with an underlying paraproteinemia. The cryocrystalglobulins are characterized by extracellular crystals, which are eosinophilic, periodic acid-Schiff positive, and exhibit nonbirefringence under polarized light. This archetypal appearance renders CCG readily diagnosable histologically. Unlike in mixed cryoglobulinemias (types II and III cryoglobulinemia) where there is complement-mediated inflammation amounting to vasculitis, the deposition of crystallized paraproteins within vessels in CCG result in an occlusive vasculopathy and culminate in severe systemic involvement. Aside from cutaneous lesions, the resultant ischemic hypoperfusion manifest frequently with fulminant acute kidney failure, polyarthralgia, peripheral neuropathy, or gastrointestinal ulceration, conferring a poor prognosis. We present an unusual case of a patient diagnosed with immunoglobulin G kappa multiple myeloma that first presented with cutaneous necrosis as a result of CCG and did not have any renal impairment or fatal outcome. We highlight this uncommon entity to underscore the clinical importance of early diagnosis to avoid significant morbidity and mortality. In addition, we also discuss a novel feature of transepidermal elimination of crystalline precipitates demonstrated on his skin biopsy.

Fibroblastic Rheumatism Versus Variant Disease of Multinucleate Cell Angiohistiocytoma.

We report an unusual case of a 49-year-old woman who presented with persistent papulonodules over bilateral fingers and inframammary region in conjunction with features of connective tissue disease including symmetrical polyarthritis and Raynaud phenomenon. Skin biopsy showed an upper-to-mid dermal proliferation of bland spindled cells with thickened collagen bundles and occasional multinucleated giant cells. Dermal blood vessels were only marginally increased. On immunohistochemistry, both the spindled cells and multinucleated giant cells stained negatively for smooth muscle actin. Some of the spindled cells stained positively with CD68 and CD163, whereas the multinucleated giant cells stained negatively for both stains. Elastic fibers were absent on elastic Van Gieson. The clinical and histopathologic features raise a diagnostic dilemma between fibroblastic rheumatism and multinucleate cell angiohistiocytoma. The patient responded well to cyclosporine and methotrexate therapy, with gradual improvement of the finger nodules.

Lichen nitidus presenting with nail changes--case report and review of the literature.

Lichen nitidus of the nail is rare and can precede the onset of skin lesions. Delayed diagnosis is common. We present an unusual case of lichen nitidus-associated nail changes that preceded the onset of skin lesions in a 4-year-old Indian girl. We also conduct a review of six other cases of lichen nitidus with nail involvement from the English-language literature. Clues to the diagnosis of lichen nitidus include violaceous or pigmentary changes of the nail fold and subtle lichenoid papules on the affected digits. Lichen nitidus of the nails appears to be less severe than nail changes of lichen planus and is generally self-limiting. Understanding the natural history of lichen nitidus of the nails will help physicians better counsel patients and their families.

A rare combination of sebaceoma with carcinomatous change (sebaceous carcinoma), trichoblastoma, and poroma arising from a nevus sebaceus.

We report a case of a 48-year-old Malay female who presented with multiple tumors arising from a large nevus sebaceus on her right parieto-temporal scalp. Histologically, the tumors corresponded to a sebaceoma with carcinomatous change, a poroma and a trichoblastoma. Immunohistochemical staining of the sebaceous tumor with p53 showed strong within the areas of carcinomatous change, while there was negative to weak staining within the sebaceoma-like areas. A discussion on the potential secondary neoplasms from a nevus sebaceus ensues, with a review of this literature on multiple tumors from a nevus sebaceus.

Congenital combined melanocytic nevus of the scalp with associated alopecia areata.

We report a case of a 20-year-old Chinese man with an alopecic congenital combined compound and blue melanocytic nevus of the scalp, associated with alopecia areata. The diagnosis of a combined melanocytic nevus was confirmed by histopathological examination and immunohistochemical stains, with exclusion of neurocristic hamartoma, which can have a similar clinical and histopathological appearance but different prognosis. In addition, we explore the association of this large melanocytic lesion with alopecia areata.

Systematized epidermal nevus with epidermolytic hyperkeratosis improving with topical calcipotriol/betametasone dipropionate combination ointment.

We present the case of a 5-year-old boy who presented with systematized epidermal nevus with evidence of epidermolytic hyperkeratosis on skin biopsy. He was otherwise well, with normal growth and development and no evidence of other organ system involvement. He had experienced only mild improvement with potent topical corticosteroids. He reported more-marked improvement after 2 months of topical calcipotriol/betamethasone dipropionate combination ointment once a day to the lesions. Extensive epidermal nevi can lead to severe cosmetic disfigurement. We recommend a trial of topical calcipotriol/betamethasone dipropionate ointment for patients with extensive epidermal nevus not amenable to surgical treatment.

Acroangiodermatitis of Mali in protein C deficiency due to a novel PROC gene mutation.

Acroangiodermatitis of Mali is a dermatologic condition of kaposiform skin lesions that has been associated with chronic venous insufficiency. Here we report a case of a 28-year-old Chinese man with acroangiodermatitis which co-existed with chronic lower limb deep vein thrombosis. Investigations revealed protein C deficiency and a frame shift mutation, c246_247dupCT, of the PROC gene. Our report lengthens the list of male acroangiodermatitis of Mali cases with a Chinese patient harboring a novel PROC mutation with manifest protein C deficiency.

Effectiveness of Paint Psoralen and Ultraviolet-A in Alopecia Areata - Our Experience in the National Skin Center.

BACKGROUND: Alopecia areata (AA) is usually a benign cause of patchy hair loss that often resolves within a few weeks to months. Most treatment modalities are ineffective in the treatment of severe AA. The use of paint psoralen and ultraviolet-A (PUVA) in the treatment of patients with severe forms of AA has been reported in the literature. AIMS AND OBJECTIVE: The aim of this study was to evaluate the effectiveness of paint PUVA therapy in the treatment of AA in Singapore. MATERIALS AND METHODS: We performed a 10-year retrospective analysis of patients who underwent paint PUVA for AA. We evaluated patient demographics and treatment outcomes in the form of percentage change in baseline severity of alopecia tool score and final amount of hair regrowth and relapse rate. RESULTS: Ten patients were included in this study. With paint PUVA therapy, significant hair regrowth was seen in six patients. Paint PUVA therapy in our study showed minimal side effects. CONCLUSION: PUVA gives fair response in AA in a reasonable time as per our center's experience in Singapore.

Acquired Diffuse Trichomalacia Associated With Prolonged Use of a Detangling Hairbrush.

This case series reports on cases of diffuse alopecia with trichomalacia after use of a detangling hairbrush.

Prolonged urticaria with purpura: the spectrum of clinical and histopathologic features in a prospective series of 22 patients exhibiting the clinical features of urticarial vasculitis.

BACKGROUND: Biopsy specimens of lesions with clinical features of urticarial vasculitis often show a predominantly lymphocytic infiltrate with eosinophils and red blood cell extravasation. Only occasionally is a leukocytoclastic vasculitis encountered, confirming a diagnosis of urticarial vasculitis. OBJECTIVE: The aim of this study was to assess the clinical presentation and histologic features of patients who meet the clinical criteria for urticarial vasculitis. METHODS: Patients were recruited who had persistent urticarial lesions individually lasting longer than 24 hours, associated with at least 2 of 3 of the following: pain or tenderness; purpura or dusky changes; and resolution with hyperpigmentation. Patients were interviewed based on a standard questionnaire with regard to their symptoms. Blood tests and chest radiographs were performed to exclude systemic involvement and hypocomplementemia. Skin biopsy specimens were sent for histology and direct immunofluorescence. RESULTS: Of 22 patients recruited, 19 (86.4%) showed a predominantly lymphocytic infiltrate on histology. Three cases (13.6%) had a neutrophil-predominant infiltrate associated with a leukocytoclastic vasculitis. Twenty (90.9%) had a superficial perivascular infiltrate, and two (9.1%) had a superficial and deep perivascular infiltrate. In all, 21 biopsy specimens (95.5%) showed inflammatory cells within dermal blood vessel walls, obscuring the vessel outline in some. Endothelial cell swelling was seen in 20 biopsy specimens (90.9%), erythrocyte extravasation in 17 (77.3%), nuclear dust in 5 (22.7%), and fibrin extravasation in 2 (9.1%). Multivariate analysis revealed the following features to be independently associated with neutrophil predominance: fulfillment of all 3 minor criteria for urticarial vasculitis-like lesions (P = .007); presence of fibrin on histology (P < .001); presence of nuclear dust on histology (P = .001); hypocomplementemia (P = .001); and anemia (P = .015). There was a trend toward lesions not clearing as readily in the neutrophil-predominant group (P = .071), even with two-modality treatment (P = .089). LIMITATIONS: Serum immunoelectrophoresis was not done to exclude Schnitzler's syndrome. Electronmicroscopy and cytokine profiling were not performed. CONCLUSION: Biopsy specimens of lesions with clinical features of urticarial vasculitis reveal that only a minority of patients has leukocytoclastic vasculitis. The majority has a lymphocyte-predominant histology, associated with varying numbers of eosinophils. We favor a lymphocytic vasculitis as a causative explanation in the lymphocyte-predominant group.