Cranial fasciitis of childhood

A 2‐month‐old boy was seen at our pediatric dermatology department with a history of a tumoral lesion of the scalp since his birth. On examination he had a single, ovoid, firm, 2 × 1.8‐cm painless subcutaneous mass on the temporal left calvarium, covered by normal skin ( Fig. 1 ). It had experienced explosive growth in the preceding 2 weeks. There was no history of previous trauma in the area. The remainder of the examination was normal. Roentgenographic studies of the skull revealed a soft‐tissue mass without involvement of the underlying bone. Ultrasonography of the lesion showed it to be an echolucid tumor. With the presumed diagnosis of dermoid cyst we sent the patient for surgical removal. At surgery, the lesion did not have the typical surgical appearance of a cyst. The histopathologic exam of the specimen was interpreted as cranial fasciitis of childhood ( Fig. 2 ). Immunohistochemistry showed diffuse positivity for vimentin and muscle actin. After 1 year the patient is free of lesions.

Figure 1 Open in figure viewer PowerPoint Lesion at the temporal left calvarium     

Chronic telogen effluvium or early androgenetic alopecia?

A 16‐year‐old girl presented with a 12‐month history of generalized hair shedding from the scalp. The onset of shedding coincided with the development of Hashimoto's thyroiditis and iron deficiency. At the time of initial presentation, the Hashimoto's thyroiditis had been treated with Neo‐Mercazole and she was euthyroid. Her iron stores were low, with a ferritin level of 13 µg/L. As she was vegetarian, oral iron replacement therapy was commenced without further investigation. On follow‐up 6 months later, her iron stores were normal (ferritin, 36 µg/L), but the hair shedding had continued. On examination, there was a positive hair pull test from both the vertex of the scalp and the occipital scalp. There was mild bitemporal recession, but no widening of the central part, and she appeared to have a full, thick head of hair ( Fig. 1 ). Additional investigations at that time revealed normal thyroid function and negative antinuclear antibody (ANA) and syphilis serology. She was on no medication other than Neo‐Mercazole. Serum testosterone, dihydroepiandosterone sulphate (DHEAS) and sex hormone binding globulin (SHBG) were normal. Two 4‐mm punch biopsies were taken from the vertex of the scalp; one was sectioned horizontally and the other vertically. The vertical section was unremarkable. On the horizontal section, there were 32 hair follicles in total, 30 of which were terminal hairs and two of which were vellus hairs. One hair was in telogen. The ratio of terminal to vellus hairs was 15 : 1.

Figure 1 Open in figure viewer PowerPoint Initial presentation     

Pyoderma gangrenosum of the scalp treated with cyclosporine A

A 56‐year‐old woman presented with an ulcer, with a depth of 9 mm, on the vertex and frontal parietal regions of the scalp. The lesion had a round shape (diameter, 7 cm), with clear‐cut margins and vertical borders sinking vertically to a bottom that was entirely covered with purulent fibrinous yellowish matter and greenish colored necrotic tissue. Other numerous small roundish ulcers were present next to the large ulcer. These had irregular margins with a yellowish fibrinous bottom ( Fig. 1 ). The patient reported the appearance of two small ulcers on the left and on the right frontal parietal regions about 1 year earlier. These had been treated locally with antimicrobials and antiseptics with no result. During the 2 months prior to our evaluation, a few small round‐shaped ulcers had appeared on the scalp. These had progressively increased in size and number.

Figure Figure 1  Open in figure viewer PowerPoint Large ulcer with clear‐cut margins, covered by purulent fibrinous matter, and other small roundish ulcers     

Superficial cutaneous Trichosporon asahii infection in an immunocompetent host

A 16‐year‐old schoolgirl presented with a complaint of enlarging erythematous and mildly pruritic patches located on the buttocks of 2 years’ duration. She had been treated with a potent topical corticosteroid for many months without apparent benefit. She was in otherwise good health. She denied a history of hair infection, previous eruptions, asthma, or hay fever. No one in her family or friends had similar lesions. She had no pets in her house. Examination revealed the presence of two erythematous and slightly indurated plaques measuring approximately 16 cm × 9 cm and 6 cm × 11 cm in diameter on her right and left buttocks, respectively ( Fig. 1 ). Similar progressively enlarging lesions were present on the dorsum of her right hand, extending to the extensor aspect of the forearm and to the lateral, inner, palmar, and extensor aspects of the second, third, and fourth fingers, and on the dorsum of her left hand up to the flexor aspect of the wrist. A few erythematous papules clustering around these plaques in a satellite fashion were also detectable. Her scalp, pubic, axillary, eyebrow, and eyelash hair appeared normal with no concretions or soft, lightly pigmented, white to light‐brown, loosely attached, irregularly spaced nodules. There was no regional or generalized lymphadenopathy or hepatosplenomegaly. Routine laboratory investigations, human immunodeficiency virus (HIV) testing, and standard patch tests were negative.

Figure 1 Open in figure viewer PowerPoint Erythematous and slightly indurated plaques on the right and left buttocks     

Linear-agminated juvenile xanthogranulomas

An 8‐month‐old girl presented with an asymptomatic skin lesion on the right popliteal fossa, which had been present for approximately 6 months. The child had a past medical history of a urinary tract infection at the age of 1 month and had been on daily cotrimoxazole since. There was no history of trauma to the site. Examination revealed a solitary, well‐demarcated, plaque‐like lesion on the right popliteal fossa, with multiple agminated papules in an almost linear distribution ( Fig. 1a ). The lesion did not follow Blaschko's lines, but was vertical to them. The plaque was slightly indurated, measuring approximately 4 × 1.5 cm, fixed to the overlying skin but movable over the deeper tissue. The papules were yellowish in color and firm to palpation, showing a positive Darier's sign ( Fig. 1b,c ). There was no regional adenopathy and no other skin lesions were observed. The physical examination and laboratory investigations were otherwise unremarkable. There was no hepatosplenomegaly, and an ocular examination and chest X‐ray were normal.

Figure 1 Open in figure viewer PowerPoint Juvenile xanthogranuloma: agminated nodulopapular lesions on the right popliteal fossa (a) showing positive Darier's sign (b and c; arrows)     

Atypical clinical form of cutaneous leishmaniasis: erysipeloid form

A 60‐year‐old woman was admitted to our clinic with a gradually enlarging red papule on her face. Her history revealed that, 9 months previously, a painless, red papule of 1–2 cm in diameter had occurred in the middle of her face and, with time, had enlarged to cover her nose, both cheeks, and eyelids. It was diagnosed as a superficial skin infection, and topical and systemic antibiotics were prescribed; however, no response was obtained. In the last 2 months, a sore had formed in the middle of her nose. The patient lives in the east of Eastern Anatolia, where no case of cutaneous leishmaniasis has been reported in the last 20 years. On dermatologic examination of the patient, an erythematous, indurated, slightly squamous, 10 cm × 5 cm, butterfly‐shaped plaque with sharply defined borders was seen on both cheeks, lower eyelids, and the whole nose ( Fig. 1 ). In smears taken from the lesion, a number of amastigotes belonging to Leishmania were determined in the intracellular and extracellular area ( Fig. 2 ). Histopathologic examination of the cutaneous lesion showed scattered infiltration composed of mononuclear cells, histiocytes, plasma cells, and small epithelioid granulomas. Gram smear and anaerobe–aerobe culture prepared from the lesion were negative. The total blood count and sedimentation rate of the patient were within normal limits. Routine biochemical tests, urine analysis, chest radiography, and intradermal purified protein derivative (PPD) skin test were all normal. Antinuclear antibody and antistreptolysin antibody examinations were negative.

Figure 1 Open in figure viewer PowerPoint Butterfly‐shaped infiltrated erythematous plaque on the face     

Lichen planopilaris [cicatricial (scarring) alopecia] in a child.

A mother of a 12‐year‐old boy, 2 years ago, noticed that he showed patchy loss of hair on the vertex of the scalp. It was asymptomatic and progressive. Subsequently, similar patches appeared elsewhere on the scalp. Some of these patches joined to form a large bald patch. This was accompanied by dusky blue eruptions over the left upper lip and eyebrows. Later, there was localized loss of hair. A family history of a similar ailment was absent. Examination of the scalp revealed plaques of alopecia with mild to moderate erythema. The skin was smooth, shiny, and atrophic ( Fig. 1 ). Atrophy was apparent by the presence of wrinkles in places, and by holding the skin between the thumb and the index finger. The periphery of the lesions was well demarcated and was occupied by erythematous, scaly, follicular papules. Lesions were also located on the patches of alopecia. In addition, flat‐topped, dusky blue, papules/plaques were present over the upper lip.

Figure 1 Open in figure viewer PowerPoint Lichen planopilaris: plaques of alopecia showing smooth, shiny, atrophic skin with erythema     

Intravascular large cell lymphoma

A 19‐year‐old female presented at our hospital with a 1‐year history of a 5‐cm indurated nontender lesion on the left shoulder. Two months later, a similar lesion appeared in the left mammary region, accompanied by necrosis and fever. At admission to our department, she presented disseminated lesions in the left submandibular region, the sternal area and the posterior part of the upper and lower extremities. The lesions were indurated erythematous‐violaceous plaques affecting the adipose tissue, some with ulcerations and necrotic crusting ( Fig. 1 ). The first histopathological report was thrombosis of the capillary vessels and focal vasculitis ( Fig. 2 ).

Figure 1 Open in figure viewer PowerPoint Ulceration and necrotic crusting lesion in the left mammary region     

Giant annular dermatomyofibroma

A 74-year-old lady presented with a painful giant annular abdominal plaque for a duration of 2 years. The plaque developed from a cholecystectomy scar and extended peripherally around it. The patient had had a cholecystectomy for gallstones 10 years previously. She was a diabetic on oral hypoglycaemic agents and had no history of radiotherapy. Physical examination showed a tender well-demarcated annular erythematous keloid-like plaque, measuring 13 cm × 15 cm, surrounding a cholecystectomy scar. Another smaller oval plaque, measuring 3 cm × 2 cm, was found on the left side of the abdomen ( Fig. 1 ). The initial clinical diagnosis was dermatofibrosarcoma protuberan (DFSP). A deep incisional biopsy including subcutaneous fat was performed under local anesthesia for pathological examination. Histologically, there was a plaque-like lesion involving the upper reticular dermis but not extending to the subcutaneous fat. The lesion showed proliferation of spindle-shaped cells arranged in intersecting fascicles and appeared parallel to the skin surface. Only a vague storiform pattern was seen at the edges. The cells had relatively uniform elongated nuclei and mitosis was not seen. The overlying epidermis showed mild hyperplasia with pigmentation of the basal layer ( Fig. 2 ). Smooth muscle actin was positive ( Fig. 3 ), desmin was negative and CD34 was negative. The final diagnosis was dermatomyofibroma (DMF). Extra-abdominal fibromatosis was unlikely because broad elongated fascicles among collagenous stroma were not evident, while intersecting fascicles parallel to the skin surface were typical of DMF. The smaller plaque on her left abdomen was excised and gave similar histological and staining results. The giant annular plaque was not excised as the patient refused further surgery. She has since been closely monitored.

Figure 1 Open in figure viewer PowerPoint A well-demarcated annular erythematous keloid-like 11 cm × 13 cm plaque surrounding a cholecystectomy scar; a smaller oval plaque measuring 3 cm × 2 cm was found on the left side of the abdomen     

The papulokeratotic type of solitary benign lichenoid keratosis

A 67‐year‐old housewife was referred to us for a papulonodular keratotic lesion on the left side of the left eyebrow ( Fig. 1 ). The lesion had started to develop 6 months earlier and had gradually reached a size of 2 cm in diameter. It was firm, nonitching, and painless on pressure.

Figure 1 Open in figure viewer PowerPoint Papulokeratotic lesion on the left eyebrow     

Syringoid eccrine carcinoma with apparently aggressive transformation: case report and review of the literature

A 65‐year‐old man presented with a 20‐year history of a lesion on his lower abdomen. The lesion had started as an indolent papule that slowly developed to form an extensive plaque. Physical examination revealed a flat‐topped, elevated, well‐demarcated, erythematous plaque measuring 7 cm × 5 cm in diameter ( Fig. 1 ). The lesion had an elastic, hard induration beneath the plaque and was fixed to the underlying tissue. Inguinal lymphadenopathy was present. Hematologic and biochemical investigations were all within the normal ranges. The patient underwent incision biopsy.

Figure 1 Open in figure viewer PowerPoint Clinical appearance of the lesion. An indurated plaque can be seen on the lower abdomen     

Faun tail: a rare cutaneous stigma of spinal dysraphism

A 13‐year‐old girl was referred to our dermatology outpatient clinic for the treatment of a congenital, circumscribed, hypertrichotic area on the lumbosacral region because it was cosmetically embarrassing. Dermatologic examination revealed a 25 × 15 cm circumscribed hypertrichotic area on the lumbosacral region. Coarse, dark, terminal hairs were observed, but the underlying skin was normal ( Fig. 1 ). The lesion had been present since birth. Her history also revealed back pain, which developed by 3 years of age, and a long history of urinary incontinence. On neurologic examination, no motor weakness or sensory changes were observed. On orthopedic examination, minimal atrophy and 2 cm shortening of the right leg were detected, and the right foot was smaller than the left. There was an accentuation of lumbar lordosis. There was no history of a similar lesion in the family. There was no consanguinity in the relatives.

Figure 1 Open in figure viewer PowerPoint Clinical appearance of the patient 6 months after operation     

Angiolymphoid hyperplasia with eosinophilia induced by trauma

A 48‐year‐old Hispanic man presented to our clinic with multiple, bright red, firm nodules limited to the right side of the scalp ( Fig. 1 ). The patient had first noted a lesion 6 months previously, and complained of mild associated pruritus and ease of bleeding. The first lesion developed at the exact site at which the patient had accidentally hit his head against a filing cabinet 2 years previously. The trauma had been associated with significant bleeding, which required more sutures than expected. In a magnetic resonance image, the initial nodule was visualized and, because of its firm consistency, the diagnosis of a lipoma was made. Surgical excision of the tumor was attempted, but was complicated by significant bleeding, which required extensive electrocoagulation. Shortly thereafter, multiple new lesions slowly began to develop around the original nodule. In addition, the patient complained of new‐onset migraine headaches.

Figure 1 Open in figure viewer PowerPoint Linear arrangement of erythematous nodules on the scalp     

Cutaneous phaeohyphomycosis caused by Veronaea botryosa observed as sclerotic cells in tissue

A 65‐year‐old Japanese female farmer had an erythematous, slightly scaly, indurated plaque on the dorsum of the left wrist of more than 3 years’ duration. She had a history of hepatitis C. Her medical history and family history were otherwise unremarkable. The lesion had begun as a small region of erythema on the dorsum of the left wrist 3 years previously and had gradually enlarged. The patient had seen a local physician and had been treated with topical steroids, topical antifungals, and topical vitamin D3 agents without improvement. Initial laboratory studies revealed slightly decreased numbers of white blood cells and thrombocytes, decreased albumin levels, and elevated liver enzymes, reflecting chronic hepatitis C. Clinical examination of the lesion revealed a well‐demarcated, erythematous, slightly scaly, indurated plaque of 22 mm × 28 mm in size on the dorsum of the left wrist ( Fig. 1 ). Superficial lymph nodes were nonpalpable. Direct microscopy revealed aggregates of thick‐walled spores, considered to be sclerotic cells, from which budding brown hyphae emanated ( Fig. 2a ).

Figure 1 Open in figure viewer PowerPoint A well‐demarcated, erythematous, slightly scaly, indurated plaque of 22 mm × 28 mm in size on the dorsum of the left wrist     

Eccrine poroma of the heel

A 67‐year‐old African–American woman had a tender red nodule on the posterior aspect of her left heel of 20 years' duration. The lesion had initially grown quickly to its present size, but subsequently remained unchanged through the years. No previous history of trauma to the area could be elicited. The lesion was not tender or painful, although the patient related some recent discomfort when wearing shoes with high heel counters. Examination revealed a soft, multilobulated, skin‐colored nodule, measuring approximately 1.1 cm at its greatest diameter ( Fig. 1 ), with a rim space or moat ( Fig. 2 ) surrounding the lesion. Biopsy of the lesion demonstrated a uniform proliferation of basaloid cells exhibiting a sharp demarcation between the adjacent normal epidermis ( Fig. 3 ). No horn cysts were present. The papillary dermis demonstrated multiple ectatic blood vessels ( Fig. 4 ) which may be responsible for its reddish appearance.

Figure 1 Multilobulated, Open in figure viewer PowerPoint red, granulating lesion on the posterior heel     

Treatment of cutaneous T-cell lymphoma with alitretinoin gel

A 62‐year‐old man with a 5‐year history of tumor stage cutaneous T‐cell lymphoma (CTCL) used alitretinoin gel, 0.1% twice daily on a right sole tumor. The treatment at the time of topical therapy included acitretin, 35 mg daily, and psoralen with ultraviolet A radiation (PUVA) twice weekly. Previous therapy included topical mechlorethamine, etretinate, and topical glucocorticoids. After 6 weeks, he discontinued alitretinoin gel upon noting that the treated tumor site had turned black. Two weeks later (2 months after the initiation of therapy) he presented with a 6‐cm keratotic plaque on the treated area with a 1‐cm eschar. No lymphadenopathy, peripheral erythema, or tenderness was noted. He started amoxicillin/clavulanate, 875 mg twice daily, and 2% mupirocin ointment. One month later, the foot lesion had completely eroded into a 6‐cm plaque ( Fig. 1 ). There were no changes in the tumors on his trunk, face, and extremities.

Figure 1 Open in figure viewer PowerPoint Foot lesion eroded into a 6‐cm plaque.     

A case of simultaneously occurring lichen sclerosus and segmental vitiligo: connecting the underlying autoimmune pathogenesis

A 41‐year‐old African‐American woman reported a 6‐month history of asymptomatic white macules and patches that started on her left foot, and then spread proximally up her leg to her thigh, and then to her buttocks. She also noted that several of her pubic hairs had turned white, but only on the left side of the midline. She also complained of concomitant severe burning and itching in the vaginal area and that her vaginal skin had turned whitish pink. The patient denied contact with industrial or hazardous chemicals, and her medical history included childhood iron deficiency anemia only. On examination, the patient had linear guttate hypo‐ and depigmented macules on the left dorsal foot, extending up the medial calf, the medial and posterior thigh, and coalescing into scalloped patches across her left medial buttock ( Fig. 1 ). There was sharp midline demarcation in the suprapubic region. Her pubic hairs on the left side were predominantly depigmented. Examination of the genital area revealed areas of atrophy, together with slightly hyperkeratotic pink and hypopigmented plaques covering the entire perineal area, with a slightly irregular rim of gray–brown hyperpigmentation almost encircling the introitus. The lichen sclerosus of the labia minora extended directly into the perianal region ( Fig. 2 ). The vulvar area was tender to the touch.

Figure 1 Open in figure viewer PowerPoint Hypo‐ and depigmented macules and patches on the medial left calf, thigh, and pubic area     

Florid eruption of seborrheic keratoses associated with elevated insulin-like growth factor, hypoglycemia, and solitary fibrous tumor of the pleura

A 66‐year‐old man with a past medical history of hypertension and arthritis was hospitalized and treated for bacterial pneumonia. Chest X‐ray revealed a left‐sided chest mass. Computed tomography (CT) scan of the chest demonstrated a large heterogeneously enhancing mass occupying most of the left lower lobe and extending to the inferior aspect of the hilum. It measured 16.6 × 12 cm and caused a mild shift of the mediastinum to the right. The patient declined further work‐up or surgical resection of the mass. Dermatologic examination was unremarkable at that time. Over the next 5 months, numerous skin lesions erupted on the patient's trunk. He then experienced several syncopal episodes, at which time he was found to be profoundly hypoglycemic. It was suspected that the chest tumor was producing high serum levels of insulin‐like growth factor (IGF) resulting in hypoglycemia and syncope. Serum laboratory investigations were significant for glucose of 20 mg/dL (normal, 60–120 mg/dL), IGF‐1 of 39 ng/mL (normal, 152–494 ng/mL), IGF‐2 of 927 ng/mL (normal, 210–750 ng/mL), and insulin of < 5.0 microunits (MCU)/mL (normal, 0–30 MCU/mL). Surgical extirpation of the chest tumor was recommended. The dermatology service was consulted to evaluate whether the numerous skin lesions in the area of planned surgery would pose an increased risk of infection. Cutaneous examination revealed a dense aggregation of pigmented hyperkeratotic plaques with a “stuck‐on” appearance, predominantly localized on the trunk. Many were unusually large or darkly pigmented. A particularly dense distribution was apparent on the left side of the chest ( Fig. 1a ). Numerous large acrochordons were evident on the lower eyelids and in the axillary vaults. Acanthosis nigricans was not present. A biopsy specimen from a hyperkeratotic lesion on the left upper back revealed an acanthotic, hyperpigmented epidermis with a lamellar horn, anastomosing rete, and pseudohorn cysts ( Fig. 1b ).

Figure 1 Open in figure viewer PowerPoint (a) Dense aggregation of pigmented hyperkeratotic papules and plaques with a “stuck‐on” appearance predominantly localized on the left side of the trunk. Many are unusually large or darkly pigmented. (b) Photomicrograph of a biopsy specimen from a hyperkeratotic lesion on the left upper back. An acanthotic, hyperpigmented epidermis with a lamellar horn, anastomosing rete, and pseudohorn cysts is demonstrated (hematoxylin and eosin stain; original magnification, × 4)     

Bowen's disease: an uncommon presentation

A 60‐year‐old man presented with a lesion over the abdomen of 12–13 years’ duration. The lesion had been gradually progressing over the years and was asymptomatic. It had been treated by application of 5‐fluorouracil in 1993, which had resulted in partial regression; however, it started to grow again. A similar lesion had occurred over the left thigh, 2 years after the abdominal lesion appeared, and was excised. Past personal and family history was noncontributory. General and systemic examination revealed no abnormality. Dermatologic examination revealed a plaque, 18 cm × 15 cm in size, over the abdomen. It was well defined and erythematous. In places, hyperpigmented, verrucous, firm papules of various sizes were seen at the periphery and center of the lesion. There was no atrophy, ulceration, bleeding, and lymphadenopathy ( Fig. 1 ). A differential diagnosis of hyperkeratotic lupus vulgaris, Bowen's disease, pagetoid type of basal cell carcinoma, squamous cell carcinoma, and superficial spreading melanoma was considered.

Figure 1 Open in figure viewer PowerPoint Clinical photograph of lesion over the abdomen     

Pachydermoperiostosis with cutaneous squamous cell carcinomas

A 46-year-old man visited our department with masses on the face and a skin problem. Approximately 15 years ago, he had noticed marked thickening of the skin on the face and scalp, which had exaggerated progressively to produce deep wrinklings with seborrhea ( Fig. 1 ). He had profuse perspiration of the face, hands, feet, and the upper aspects of the trunk.

Figure 1 Open in figure viewer PowerPoint Clinical features of pachydermoperiostosis, consisting of thickened skin folds and deep wrinkles on the forehead and scalp. A large ulcerative tumor on the nasal dorsum and a nodular one on the glabellar area (arrow) can be seen.