Acneiform lesions in Becker's nevus and breast hypoplasia

An 18‐year‐old woman was referred for the evaluation of a dull gray macule on the left breast. From the age of 13 years, the patient noted breast asymmetry beginning with the development of the left breast and the presence of a pigmented stain on its border. Physical exploration revealed hypoplasia of the left breast and a homogeneous, light brown macule on the side of the breast ( Fig. 1 ) without infiltration. Papules and pustules were located mainly around the Becker's nevus on the left anterior chest wall. Biopsy specimens with Fontana's stain disclosed a hyperpigmented acanthotic epidermis. A diagnosis of Becker's nevus, acne, and hypoplasia of the breast was made.

Figure 1 Open in figure viewer PowerPoint Hypoplasia of the left breast and a homogeneous light brown macule with acneiform lesions     

A case of basal cell carcinoma arising in epidermal nevus

A 24‐year‐old man was admitted to our outpatient clinic with lesions in a linear configuration. On dermatologic examination, widespread, dark brown, warty papules and plaques over an erythematous base, following Blaschko"s lines, extended from the middle of the chest to the right arm. These lesions had been present on the chest since birth and had gradually extended during childhood. Recently, a nodular lesion had appeared in the pre‐existing epidermal nevus in the middle part of the chest ( Fig. 1 ). The nodular lesion was totally excised by a plastic surgeon.

Figure 1 Open in figure viewer PowerPoint Basal cell carcinoma (white arrow) appearing on the epidermal nevus in the middle part of the chest     

Temporary henna tattoo reactions in children.

Case 1 A 9‐year‐old girl applied a temporary henna tattoo to her right arm and 1 week later repeated the same process. In the following 2 days, erythema and papulovesicular eruptions developed at the application site ( Fig. 1 ). Patch tests were performed with the European Standard Series, specific hairdressing agents, and commercial and natural henna. The patient showed a 3+ reaction to both natural henna and ‘‘para‐phenylenediamine (PPD)’' 1% and a 3+ reaction to nickel sulfate 5% at 48, 72, and 96 h ( Fig. 2 ). She was treated with topical steroid cream (beclomethasone dipropionate), applied twice daily. A slight postinflammatory hypopigmentation was observed at the time of the patch test. The hypopigmentation has gradually decreased in severity over time ( Fig. 3 ).

Figure 1 Open in figure viewer PowerPoint Case 1: temporary henna tattoo reaction with papulovesicular eruptions     

Alopecia: a rare manifestation of lupus vulgaris

A 14‐year‐old girl presented with a 2‐year history of gradually developing, asymptomatic, reddish, raised lesions over the scalp, face, arms and trunk. The family history was significant for tuberculosis. Her grandmother was found to have pulmonary tuberculosis. Clinical examination revealed reddish‐brown, soft papules forming two large plaques by coalescence over the scalp and back ( Figs 1 and 2 ).

Figure 1 Open in figure viewer PowerPoint Lupus vulgaris, plaque form manifesting as alopecia     

Localized linear IgA disease responding to colchicine

A 64‐year‐old white woman presented to our clinic with a 3‐month history of multiple blisters on her right breast which had been unresponsive to acyclovir, amoxicillin/clavulanate and fluconazole. She denied taking any antibiotics prior to the eruption. Physical examination revealed grouped vesicles on an erythematous base and shallow ulcerations in an annular pattern localized to the right breast, without areolar involvement ( Fig. 1 ). There were no oral or mucosal lesions. Past medical history was significant only for a distant history of uterine carcinoma which had been successfully treated with hysterectomy/oophorectomy. No history of liver or autoimmune disease was present. Further examination failed to reveal any history of unusual contact allergens. There was no family history of similar eruptions.

Figure 1 Open in figure viewer PowerPoint Shallow ulcerations and blisters on erythematous bases in an annular pattern     

Psoriasis and side-effects of mesotherapy.

A 67‐year‐old woman was referred to our Department in January 1997 with an isomorphic Koebner response due to mesotherapy. The patient has been affected by psoriasis for 10 years and underwent treatment with Cyclosporine A (4–2 mg/kg/day for 12 weeks) 2 years earlier. Since the previous year plaques were treated only with topical preparations, with mild worsening over the autumn. In December 1996 a single mesotherapy was erroneously performed with a cocktail of aminophilline, xantinol nicotinate and lidocaine to treat a left neuralgic sciatica. Two weeks later typical circular psoriatic lesions appeared on the left thigh in the injection's sites ( Fig. 1 ). At the same time, psoriasis worsened on the scalp, trunk, and limbs, while pustular lesions appeared on the palms and soles. The patient was admitted to our Department and underwent treatment with Cyclosporine A with a rapid response (4 mg/kg/day in divided doses for 3 weeks reduced gradually to 2 mg/kg/day and stopped after 14 weeks). Clinical and laboratory examinations excluded further trigger factors for psoriasis.

Figure 1 Open in figure viewer PowerPoint Isomorphic Koebner response where mesotherapy was performed.     

A clonal cutaneous CD30+ lymphoproliferative eruption in a patient with evidence of past exposure to hepatitis E

The patient was a 52‐year‐old white man who had worked in remote areas of the world during the past 2 years, including an extended period in rural areas of Central Africa and in Central and South America. He had no acute illnesses during the 2‐year period except for rare, mild, upper respiratory tract infections. For approximately 1 year, however, he had developed recurrent, papular‐vesicular, slightly painful lesions on the fingers and palms, that spontaneously healed over weeks to months ( Fig. 1 ). The patient had no other concurrent illnesses and no abnormal laboratory findings, except for positive enzyme‐linked immunoabsorbent assay (ELISA) for immunoglobulin G (IgG) antibodies for hepatitis E virus (HEV) using a recombinant expressed HEV antigen (Genelabs Technologies, Inc., San Antonio). Prolonged treatment with minocycline did not appear to moderate the lesions. At approximately 2.5 years after the development of his first cutaneous lesion, however, the patient reported that he had had no new lesions for over 3 months.

Figure 1 Open in figure viewer PowerPoint Vesicular lesion on the finger which regressed over a period of weeks     

Eruptive lesions in a patient with bone marrow transplantation

A 41‐year‐old man with a diagnosis of chronic myeloid leukemia presented with several elevated, small, soft, yellow papules, disseminated over the face and upper trunk. The cutaneous lesions had developed 5 years after transplantation ( Fig. 1 ).

Figure 1 Open in figure viewer PowerPoint Sebaceous hyperplasia on the upper trunk presenting as yellowish, dome‐shaped, asymptomatic papules, 1–2 mm in diameter. The lesion is umbilicated, with individual lobules growing out from the center; lesions may occur individually or in groups     

Extensive xanthelasma associated with anaplastic large cell lymphoma and hyperimmunoglobulin E syndrome

A 57‐year‐old woman presented with a 6‐month history of an extensively spreading, yellowish patch on the periorbital areas and cheeks. A diagnosis of hyperimmunoglobulin E syndrome had been made at the age of 22 years on the basis of an eczematous eruption, recurrent furunculosis, and a persistently elevated immunoglobulin E (IgE) level. Her past medical history revealed that she had suffered from numerous recurrent bouts of chronic sinusitis, otitis media, oral candidiasis, orbital cellulitis, acne rosacea, and pneumonia caused by cytomegalovirus since her twenties. In addition, 1 year ago, anaplastic large cell lymphoma of the cervical lymph node (stage IIIb) developed, and she received six cycles of cyclophosphamide–doxorubicin–vincristine–prednisolone (CHOP) chemotherapy with partial remission. None of her family had any of these problems. Cutaneous examination showed extensive, symmetric, noninfiltrated macular areas of distinct yellow discoloration around the eyes and on both cheeks ( Fig. 1 ). There were also erythematous papulonodular eruptions on the nose and both cheeks, which were thought to be acne rosacea. Laboratory findings were normal, except for an elevated IgE level (8157 IU/mL). Serum concentrations of IgG, IgA, and IgM were normal. Serum complement levels were normal, as evidenced by normal C₃, C₄, and CH₅₀. Although she had a previous history of a decreased level (12%) of nitroblue tetrazolium (NBT) test (control, 53%), NBT test at our institute was normal. Neutrophil function tests, including neutrophil chemotaxis, neutrophil phagocytosis, neutrophil respiratory burst, and neutrophil microbial killing test, by flow cytometry, showed normal results. The serum lipid levels, including total cholesterol, triglyceride, low‐density lipoprotein‐cholesterol, and high‐density lipoprotein‐cholesterol, were normal. Serum lipoprotein electrophoresis was normal. A biopsy specimen revealed scattered foamy cells throughout the dermis. The larger clusters of foamy cells tended to group around the blood vessels of the dermis ( Fig. 2 ).

Figure 1 Open in figure viewer PowerPoint Extensively distributed, yellowish, flat xanthelasma on the face     

Folliculo-sebaceous cystic hamartoma.

Case 1 A 6‐month‐old boy presented to our clinic with a scalp lesion dating since birth ( Fig. 1 ). The lesion was in the form of an erythematous, dome‐shaped nodule, measuring around 1.5 cm in diameter and having a slightly irregular surface. The lesion was nonitchy, nontender, and showed limited mobility. Our clinical differential diagnosis included: meningocele, hemangioma, dermoid cyst, and apocrine nevus. A computed tomography (CT) scan was performed to exclude possible intracranial connection, and the lesion was surgically excised.

Figure 1 Open in figure viewer PowerPoint Case 1: erythematous nodule on the occipital area of a 6‐month‐old boy. The lesion was clinically suggestive of apocrine nevus, dermoid cyst, or meningocele     

Wells’ syndrome triggered by centipede bite

A 68-year-old African–American woman was awoken from her sleep by a centipede bite on the dorsum of her left hand. Several days later, the patient presented to the emergency room complaining of fevers, severe itching, swelling, and blistering ( Fig. 1 ) of both hands. The past history was unremarkable. There was no history of asthma or use of medications. Physical examination at that time was consistent with a bullous cellulitis of the hands. Laboratory investigations revealed: white blood cell count (WBC), 10.3 (normal, 4 1 , 2 , 3 - 9 , 10 .5); differential: 54 neutrophils, 15 lymphocytes, and 31 eosinophils. The platelet count was 225,000/mm³. A blood chemistry profile was within normal limits. Blood cultures and stool examination for ova and parasites were negative. The patient was treated with oral cephalexin and diphenhydramine.

Figure 1 Open in figure viewer PowerPoint Left hand reveals a bulla and several vesicles at the site of the centipede bite     

Multiple lesions of granuloma annulare following BCG vaccination: case report and review of the literature.

A 12‐year‐old Japanese boy presented with asymptomatic, multiple annular, erythematous, infiltrated lesions on his left upper arm and right knee as well as the lateral side of the right ankle joint. He had noted these erythematous lesions five days after bacille Calmette‐Guerin (BCG) vaccination. The lesions gradually enlarged and increased in number. Topical corticosteroid therapy for several weeks failed to improve the lesions. There was no familial history of pulmonary tuberculosis. Physical examination revealed extensively disseminated, round, erythematous plaques and papules. Some plaques showed an annular configuration, varying in diameter from 5 to 45 mm, on his left upper arm, right knee and the lateral side of the right ankle joint ( Fig. 1 ). One month after BCG vaccination, reddish‐brown, infiltrated erythema with crusts was observed at the BCG vaccination site ( Fig. 2 ). Tuberculin test showed an erythema with induration measuring 2.5 cm in diameter at 48 h. Routine laboratory tests including complete blood cell count, erythrocyte sedimentation rate and biochemical analysis were within normal limits. Serum glucose level and GhbA_1c were also normal.

Figure 1 Open in figure viewer PowerPoint Annular erythematous lesion on left lateral malleolus     

Purpuric pityriasis rosea

A 17‐year‐old young man presented with a 2‐week history of an asymptomatic widespread eruption affecting the trunk and arms. On physical examination we observed multiple, oval purpuric macules and papules, 1–3 cm in diameter, distributed in a “christmas tree” pattern on the trunk and arms ( Figs 1 and 2 ). There was no sign of a herald patch and mucosal examination was normal.

Figure 1 Open in figure viewer PowerPoint Lesions distributed in christmas tree pattern on the trunk     

Malignant melanoma on the sole showing prominent neural differentiation and perineural infiltration

A 56‐year‐old Japanese woman presented with a 15 × 6 mm, ill‐demarcated, irregularly bordered, brownish macule on the distal portion of her left sole ( Fig. 1a ). She had first noticed the macule 3 years earlier. The color was variegated from tan to grayish blue, and no nodules or induration were detected within the lesion. A biopsy revealed malignant melanoma with neural differentiation showing prominent infiltration around vessels and peripheral nerves. There was no lymphadenopathy in the left inguinal area and whole body examinations with echography and computed tomography scan showed no evidence of metastases. She underwent a wide local excision with amputation of the fourth and fifth toes and dissection of the inguinal lymph nodes. The patient received adjuvant chemobiotherapy using dacarbazine, nimustine hydrochloride, and vincristine sulfate, together with local injection of interferon β around the operation scar. No signs of recurrence have been detected for 6 years since the operation.

Figure 1 Open in figure viewer PowerPoint (a) Ill‐demarcated, irregularly bordered, brownish and partially dark bluish‐gray macule on the peripheral part of the left sole. No nodules or induration were detected. (b) Asymmetric, poorly circumscribed growth of neoplastic cells in the epidermis and the dermis. Diffuse infiltration of spindle cells was seen in the superficial dermis. Perivascular and perineural infiltration was detected in the deeper dermis. Slight perivascular lymphocytic infiltration was seen without desmoplastic change     

Cutaneous diphtheria in a child.

A 2-year-old, nonimmunized, lower socioeconomic stratum girl from the rural outskirts of Bangalore, southern India, was brought to the hospital with complaints of nonhealing “kissing ulcers” over the right thigh and inguinal region and fever of 1 month. The lesions started as small pustules. There was no history of respiratory illness or contact with tuberculosis. On physical examination, the child weighed 10 kg, was afebrile, and had mild anemia. The inguinal lymph nodes were enlarged. Systemic examination was essentially normal. Local examination revealed punched out ulcers with grayish slough over the ulcer measuring 3 cm × 4 cm ( Fig. 1 ). The differential diagnosis of cutaneous tuberculosis, ecthyma, tropical ulcer, and mycotic ulcer were considered.

Figure 1 Open in figure viewer PowerPoint Two “kissing ulcers” with adherent slough     

Erythema nodosum associated with sporotrichosis

Case 1 A 34‐year‐old woman had ulcerated lesion 2 cm in diameter on the right leg of 2 months’ evolution. She also presented painful erythematous nodules on lower limbs accompanied by arthralgia appearing 1 month after the initial lesion ( Figure 1a ). The patient reported having been scratched on the right leg by a cat with sporotrichosis 15 days before the initial symptoms. Examination of the ulcerated lesion showed growth of Sporothrix schenckii, and histological investigation of one nodule showed a mononuclear inflammatory infiltrate in the hypodermis with a predominantly septal distribution, negative upon culture for fungi ( Figure 1b ). Radiographic examination of left ankle showed increased soft tissue, while other ancillary tests were normal. The patient was treated with itraconazole 100 mg/day for 4 months, with regression of Erythema nodosum (EN) on day 20.

Figure Figure 1  Open in figure viewer PowerPoint (a) Ulcerated lesions on right calf and erythematous nodules on lower limbs. (b) Histopathology of one lower limbs nodule, displaying small granuloma in the subcutaneous cellular tissue (HE, 4 ×)     

Nevus lipomatosus cutaneous superficialis with angiokeratoma

A 35‐year‐old woman presented with a nodular growth on her right buttock. She had more than a 20‐year history of multiple, asymptomatic, smooth, skin‐colored papules involving her right buttock. The lesions had increased in number over time and had become yellowish or pale red with coalescing nodules exhibiting irregular surfaces. There was no general malaise. Ten years earlier, a diagnosis of connective tissue nevus was made on the basis of a biopsy obtained at a local hospital, but the patient declined treatment at that time. During the past 10 years, the lesions had continued to develop. The medical and social history was otherwise unremarkable, and a general physical examination was negative except for the skin lesions. Cutaneous examination showed soft, yellowish or pale red to violaceous papules and nodules of various sizes with wrinkled surfaces, coalescing into plaques. The lesions were aggregated on her right buttock and extended onto the thigh. The biggest nodule, with a coarse and dry surface, was 40 mm in diameter ( Fig. 1 ). Histopathologic examination of the largest nodule revealed hyperkeratosis and epidermal hyperplasia with elongated rete ridges. There were thin‐walled, ectatic papillary dermal vessels engorged with red blood cells and masses of mature adipose cells throughout the dermis ( Fig. 2 ) (Tianwen G, Jianfang S. Non‐epidermal related. In: Tianwen G, Jianfang S, eds. Current Dermatopathology. Beijing: People's Medical Publishing House, 2001: 349–410). A diagnosis of nevus lipomatosus cutaneous superficialis with angiokeratoma was made. The patient declined excision.

Figure 1 Open in figure viewer PowerPoint Soft, yellowish or pale red to violaceous coalescing papules and nodules of various sizes, involving the right buttock and extending onto the thigh; the largest nodule has a coarse, dry surface     

Poikilodermatous mycosis fungoides

A 60‐year‐old woman presented with a 10‐year history of pruritic patch lesions that had originated on her breast and progressed over the years to involve the lower part of the abdomen. Different cutaneous biopsies were obtained during this period revealing a superficial chronic dermatitis. She had been treated previously with intermittent cycles of medium‐strength topical steroids. This regimen was of only temporary benefit and progression of the skin lesions had occurred over the last year. The patient's medical history was otherwise unremarkable. Physical examination revealed atrophic red–brown skin with telangiectasia predominantly located on the breast ( Fig. 1 ). Clinical examination also revealed various red‐to‐brown scaly plaques affecting the lower part of the abdomen.

Figure 1 Open in figure viewer PowerPoint Representative clinical appearance with reticulate pigmentation, atrophy, scaling, and telangiectasia     

Infraorbital eyelid edema as the presenting sign of bronchogenic carcinoma

A 59‐year‐old man presented at our department with a 4‐week history of persisting and therapy‐refractory infraorbital edema ( Fig. 1 ). There was no previous history of eyelid edema, allergic reactions, autoimmune diseases, or new medications. Earlier therapy with corticosteroids and antihistamines was ineffective.

Figure 1 Open in figure viewer PowerPoint Persistent swelling of both infraorbital folds     

Rosacea fulminans (pyoderma faciale): successful treatment of a 3-year-old girl with oral isotretinoin.

A 3‐year‐old girl presented with several erythematous papules, pustules, cysts, and purulent discharging sinuses on the face. The lesions suddenly appeared on the cheeks 3 months previously and then rapidly extended to other areas of the face. She had been treated with a variety of topical and systemic antimicrobials (including erythromycin, cephalexin, dicloxacillin, and suIfamethoxazole‐trimethoprim) and topical corticosteroids with no effect. Examination revealed deep red erythema of facial skin with several papules, pustules, cysts, and draining sinuses on the cheeks, chin, perioral, and paranasal areas ( Fig. 1 ). No comedones or signs of hidradenitis suppurativa were observed. The child was otherwise in good health. She did not have a family history of severe acne vulgaris.

Figure 1 Open in figure viewer PowerPoint Patient before treatment