Follicularly-based papules on the thigh of a young woman.

Varicella zoster virus (VZV) is an uncommon cause of folliculitis. We present a case of a 29-year-old woman who presented with an atypical follicularly-based eruption localized to her inner thigh with an associated pain in her lower back and inner thigh prior to the papular eruption. She was successfully treated with valacyclovir 1,000 mg three times daily with no complications.

Vulvar dermatoses: a histopathologic review and classification of 183 cases.

BACKGROUND: Vulvar dermatoses are often difficult to classify due to histopathologic overlap. We aimed to report our experience at a single institution. METHODS: A total of 183 non-neoplastic, non-infectious vulvar biopsies were reviewed. Associations between histopathologic features and specific diagnoses were analyzed by Chi-squared tests. RESULTS: Twenty-two biopsies (12.0%) showed two concurrent processes. A limited differential rather than a definitive diagnosis was rendered in 15 cases (8.2%). The final diagnoses included lichen sclerosus (LS) (38.8%), lichen simplex chronicus (LSC) (29.0%), eczematous dermatitis (23.0%), Zoon vulvitis (8.2%), non-specific/resolved dermatitis (5.5%), hidradenitis suppurativa (2.7%), Behçet disease (2.2%), lichen planus (1.6%), ruptured cyst (1.6%), ulcer not-otherwise-specified (1.6%), psoriasis (1.1%), radiation dermatitis (1.1%), sebopsoriasis (1.1%), seborrheic dermatitis (1.1%), epidermolytic hyperkeratosis (0.5%) and granular parakeratosis (0.5%). Early LS and Zoon vulvitis were commonly included as part of a differential diagnosis. LS was associated with wiry collagen with lymphocyte entrapment (p = 0.0188). LSC was associated with zones of pale epithelium (p = 0.0084), and often displayed prominent fibroblasts (p = 0.0555). Zoon vulvitis was frequently misdiagnosed, and was associated with basal keratinocytic crowding (p < 0.0001). CONCLUSIONS: Our study has determined the relative frequencies of a wide variety of vulvar dermatoses, and identified new diagnostic clues for early LS, LSC and Zoon vulvitis.

Churg-Strauss syndrome presenting as scar reactivation: histopathologic features and an illustration of 'locus minoris resistentiae'.

We report a 33-year-old female with cutaneous involvement by Churg-Strauss syndrome confined to surgical scars that were obtained 13 years before. She presented to the emergency department with 2-day history of fever, night sweats, right-sided weakness, hoarseness and worsening asthma symptoms. She was found to have an eosinophilia and two sub-5-mm pulmonary nodules. The patient also reported that the scars on her right thumb, inner wrist and back had been swollen, red and painful for 2 days. Examination revealed tender, erythematous, well-healed edematous scars studded with small skin colored papules. She had no clinical findings that were classic for cutaneous vasculitis. A skin biopsy of a scar revealed perivascular and palisading granulomatous inflammation consisting of histiocytes and neutrophils with leukocytoclasia. Focal vascular injury was identified. Scattered tissue eosinophils were seen. Special stains were negative for infection. Thereafter, she was started on intravenous steroids, at which point the fever, pulmonary and cutaneous symptoms subsided. Although scar sarcoidosis is a well-described phenomenon, granulomatous inflammation and vasculitis seen in Churg-Strauss syndrome exclusively manifesting in well-healed surgical scars highlights the unique features seen in this case and draws attention to the concept of locus minoris resistentiae. This case also highlights how a skin biopsy in the setting of suspected systemic vasculitis can confirm the presence of vasculitis and/or granulomatous inflammation and obviate the need for more invasive, higher risk procedures such as lung biopsy.

Epidermal panfolliculoma: A report of 2 cases.

There are a variety of known lesions displaying differentiation toward various portions of the hair follicle. However, there is no established term given to an intraepidermal entity showing differentiation toward both upper and lower portions of the follicle. We report 2 cases of a histologically distinct variant of panfolliculoma that, unlike the traditionally described panfolliculoma, is located intraepidermally. The lesions were taken from the medial thigh of an 81-year-old man and the lateral thigh of a 61-year-old woman, clinically suspected to be an inflamed seborrheic keratosis and a squamous cell carcinoma, respectively. Each case appeared as a demarcated plaque-like lesion with mild epidermal hyperplasia and prominent differentiation toward the upper and lower segments of the hair follicle. The specific histologic features included focal differentiation toward the infundibulum and isthmus (infundibular cystic structures and pilar epithelium), inner root sheath (trichohyalin granules), the matrix/hair shaft (matrical cells, ghost cells and refractile keratinization), and follicular germ/papilla (papillary mesenchymal bodies). This varied histology is similar to that of the previously described panfolliculoma, differing in that it emanates largely from the epidermis rather than being predominantly dermally located. We propose the term "epidermal panfolliculoma" for these lesions.

Lupus erythematosus-like reaction in imiquimod-treated skin: a report of 2 cases.

Imiquimod (Aldara) is a topical immune response modifier effective against a variety of cutaneous tumors. Post therapy histologic reaction patterns have not been well characterized. Here, we present 2 patients treated with imiquimod, whose biopsies showed interface dermatitis of the epidermis and the adnexae with prominent periadnexal and perivascular lymphocytic inflammation. Without the clinical history, these histologic findings may be misinterpreted as lupus erythematosus. This report describes a new finding in imiquimod-treated skin and supports the diversity of reaction patterns that may be seen in association with imiquimod treatment.

Beyond the Superficial: Disseminated Trichophyton rubrum Infection in a Kidney Transplant Recipient.

Superficial dermatophyte infections are common in the general population and are readily treated with topical antifungals. Deeper invasion is rare, and dissemination to visceral organs is extremely uncommon. We describe a 66-year-old renal transplant recipient who developed disseminated Trichophyton rubrum infection while undergoing treatment for acute humoral rejection. The infection presented as a facial rash with subsequent dissemination to the lungs and chest wall. All sites of infection improved with combination administration of oral posaconazole and terbinafine. In this work, we review the available literature regarding management of disseminated Trichophyton infection and discuss therapeutic interventions for disseminated dermatophytosis in immunosuppressed hosts.

Metastatic peritoneal mesothelioma in the setting of recurrent ascites: a case report.

Malignant peritoneal mesothelioma is uncommon but rapidly fatal with a median survival of less than 1 year. The diagnosis of this entity is often delayed because of the nonspecific presenting symptoms and nonspecific cytological features of the mesothelial cells in the peritoneal fluids. A 72-year-old man who had no known history of exposure to asbestos and had longstanding refractory ascites thought to be secondary to alcoholic cirrhosis was found to have widespread metastatic malignant mesothelioma involving the lung, liver, pancreas, peritoneal, and pelvic wall, skin and subcutaneous tissue.