Sarcoidal tattoo granuloma

A 41-year-old man presented for evaluation of a widespread eruption. The eruption started six months beforehand as bumps within pre-existing black tattoos over his trunk and arms. One month later, the patient developed eye pain and the diagnosis of a uveitis was made. A different eruption soon followed, which the patient described as patches of rough skin. Finally, the patient developed discrete patches of hair thinning. The clinical examination, history, skin biopsy findings, and elevated angiotensin-1 converting enzyme and immunoglobulin levels supported the diagnosis of systemic sarcoidosis, which manifested as a sarcoidal tattoo granuloma, perifollicular cutaneous sarcoidosis, and uveitis.     

Follicular and epidermal alterations in patients treated with ZD1839 (Iressa), an inhibitor of the epidermal growth factor receptor

We report the cutaneous side-effects of ZD1839 (Iressa), a new anticancer agent that acts by inhibiting epidermal growth factor (EGF) receptor signal transduction. Three patients receiving ZD1839 developed an eruption consisting of follicular papules and pustules in an acneiform distribution as well as diffuse fine scaling of the skin. Additionally, hair growth abnormalities were noted in two patients. Histologically, a superficial purulent folliculitis and disordered differentiation with focal parakeratosis were seen. The follicular eruption appeared to respond favourably to treatment with tretinoin cream and minocycline. The cutaneous adverse effects of ZD1839 are similar to those of other EGF receptor-targeted agents and result from direct interference with the functions of EGF receptor signalling in the skin.     

Paracetamol-induced fixed drug eruption with positive immunofluorescence findings

A 93-year-old woman with an 8-year history of episodes of fixed drug eruption due to paracetamol is described. The rash was characterized by bullae, crusted lesions, hyperpigmented and erythematous patches as well as lesions resembling toxic epidermal necrolysis. Direct immunofluorescence revealed deposition of IgG and C3 in the epidermal intercellular cement substance of lesional skin only; the pathogenetic significance of this finding is discussed.     

Photodermatitis with minimal inflammatory infiltrate: clinical inflammatory conditions with discordant histologic findings

Dermatoses associated with cutaneous photosensitivity are a group of photodistributed skin eruptions caused or exacerbated by light. Multiple clinical variants of photosensitive dermatoses have been characterized including polymorphous light eruption, chronic actinic dermatitis, solar urticaria, phototoxic and photoallergic dermatitis, reticular erythematous mucinosis, acute cutaneous lupus erythematosus, and dermatomyositis. As there may be significant overlap among the clinical presentation of these conditions, the specific diagnosis of individual photodermatosis relies heavily on characteristic histopathologic features. We present here 5 cases of photodistributed eruptions with virtual absence of histologic epidermal changes and dermal inflammation, yet all were described clinically as being "inflammatory" and erythematous. All cases of this "pauci-inflammatory photodermatitis" presented with photodistributed bright red macular erythema or slightly indurated plaques that developed over a period of weeks to months and clinically resembled photoallergic or phototoxic drug reactions or polymorphous light eruption. Microscopically, however, only very sparse dermal lymphocytic infiltrate was noted with no or minimal epidermal changes. To our knowledge, the observation of clinically evident photodistributed dermatoses that demonstrate such minimal histopathologic findings has not been reported. Clinicians and histologists should be aware of the disparity that may be encountered in this setting, as the clinical features are usually far more impressive than those seen histologically.     

The glucagonoma syndrome. A distinctive cutaneous marker of systemic disease.

The glucagonoma syndrome is a rare clinical condition characterized by a distinctive cutaneous eruption associated with a glucagon-secreting islet cell neoplasm of the pancreas. A 19-year-old woman manifested typical features of this condition: a polymorphous skin eruption with characteristic distribution of lesions in perioral and paragenital regions; lesions in sites of cutaneous trauma; a skin biopsy that showed epidermal cleavage; glossitis; weight loss; mild anemia; abnormal glucose tolerance test results. Plasma glucagon levels, determined by radioimmunoassay, were approximately five times normal. Angiography indicated a pancreatic tumor with liver metastases. Islet cell origin was confirmed histologically. It is hoped that wider recognition of the distinctive clinical features of this syndrome will result in earlier detection and possible surgical cure of the underlying malignancy.     

电针围刺治疗斑块型银屑病疗效观察

目的通过皮损的临床症状改变及检测表皮厚度、乳头密度、血管直径的变化,观察电针围刺对银屑病局限性斑块型皮损的临床疗效。方法分为空白对照组和电针围刺治疗组,通过临床疗效及CLSM（皮肤CT）检测局部皮损治疗前后表皮厚度、乳头密度、血管直径的变化,探讨治疗斑块型银屑病的机制。结果临床观察电针围刺治疗第1、2疗程后,较治疗前硬厚斑块分解、皮损颜色变淡、鳞屑变薄;CLSM检测局部皮损,电针围刺组治疗第1、2疗程后各项数值均明显低于空白对照组,差异有统计学意义（P〈0．05）。结论经电针围刺治疗后斑块型银屑病皮损明显改善,表皮厚度、乳头密度、血管直径有明显改善。电针围刺是治疗银屑病的有效方法。     

Lymphoma- and leukemia-associated cutaneous atypical CD30+ T-cell reactions

Cutaneous CD30+ lymphoid infiltrates appear cytologically atypical and occasionally may be misinterpreted as recurrent disease when they occur in patients treated for other primary hematologic malignancies. We recently encountered two such cases and present our findings. One patient with B-cell lymphoma and another with myeloid leukemia developed cutaneous eruptions after chemotherapy displaying highly atypical perivascular lymphoid cells on histology that mimicked recurrent disease. In both cases, the lymphocytes were CD30+ T cells by immunohistochemistry. The skin lesions spontaneously resolved and have not recurred. Because one case was initially misinterpreted as recurrent leukemia, we conclude that close clinical correlation and immunophenotypic confirmation should be done for atypical cutaneous lymphoid infiltrates in patients with primary hematologic malignancies. We discuss the differential diagnosis of atypical CD30+ infiltrates in this setting, which include recurrent lymphoma or myeloid leukemia, primary cutaneous anaplastic large cell lymphoma (ALCL), lymphomatoid papulosis (LyP), carbamazepine-induced CD30+ pseudolymphoma, viral infection and an atypical eruption of lymphocyte recovery.     

Neonatal lupus erythematosus mimicking langerhans cell histiocytosis

Neonatal lupus erythematosus (NLE) is an autoimmune disease characterized primarily by transient skin lesions and/or permanent congenital heart block. Other clinical findings include self-limited cytopenias and liver disease. The syndrome results from the passive transfer of maternal anti-SSA, anti-SSB, or anti-U1RNP autoantibodies to the fetus across the placenta. The cutaneous manifestations are generally analogous to those of subacute cutaneous lupus erythematosus (SCLE) and consist of small, erythematous macules that progress to annular plaques with delicate scaling. The skin lesions usually resolve within the first 6 months of life as maternal autoantibodies are cleared from the infant's circulation. We describe a patient with cutaneous NLE with hepatic and hematologic manifestations. The clinical presentation was atypical, with splenomegaly and petechiae at birth followed by a crusting, papulosquamous skin eruption of the scalp and face mimicking Langerhans cell histiocytosis (LCH).     

Bullous subacute cutaneous lupus erythematosus

We describe a 59-year-old woman, with a history of autoimmune disease and disseminated uterine leiomyosarcoma, who developed a photoaggravated, blistering skin eruption. An initial rash, at the outset of treatment with chemo- and radiotherapy, resembled erythema multiforme. Review of the original skin biopsy showed it to be subacute cutaneous lupus erythematosus. There were no systemic symptoms or signs to suggest systemic lupus erythematosus. The much later photoaggravated rash consisted mainly of bullae and eventual epidermal denuding which resembled toxic epidermal necrolysis. We propose that the clinical and histological diagnosis is one of bullous subacute cutaneous lupus erythematosus in a patient with no other features of systemic lupus erythematosus.     

A Case of Congenital Leukemia Cutis

Congenital leukemia is a rare condition diagnosed at birth to 6 weeks of life with an estimated incidence of 4.7 per million live births. In a review, about 25~30% of cases were well documented as leukemia cutis. We report a case of a 3-month-old infant presented with asymptomatic multiple erythematous to bluish patches and nodules, which had developed about two months ago. Biopsy of the cutaneous lesions revealed immature cells which are overall monotonous with large kidney shaped nucleus, prominent nucleoli and moderate cytoplasm. These atypical cells stained positive for leukocyte common antigen, lysozyme and CD68. With this result, a congenital leukemia cutis was diagnosed. Six months later, she underwent cord blood stem cell transplantation. Seven months after the cord blood stem cell transplantation, the bone marrow examination revealed a normal result. Leukemia can be presented in the skin, the eruption may be nonspecific and it may precede systemic involvement. The recognition is important because early diagnosis can lead to appropriate treatment, followed by better prognosis.     

Dapsone hypersensitivity syndrome with circulating 190‐kDa and 230‐kDa autoantibodies

Dapsone has potent anti‐inflammatory effects, and is used in the treatment of leprosy, cutaneous vasculitis, neutrophilic dermatoses, and dermatitis herpetiformis and other blistering disorders. However, it may cause severe adverse reactions such as hypersensitivity syndrome, which is characterized by fever, skin rash, hepatitis and lymphadenopathy. We report a 44‐year‐old female Korean patient with dapsone hypersensitivity syndrome (DHS) that presented as a bullous skin eruption. The patient had a 1‐year history of urticarial vasculitis, treated with antihistamines, prednisolone and dapsone. Although the skin lesions improved, she reported fever, nausea, abdominal pain, jaundice, fatigue and skin rashes. On physical examination, there were generalized erythematous macules and purpura with facial oedema that developed into vesicles on the upper limbs. Histological examination of a skin biopsy of a vesicular lesion found subepidermal oedema with a mixed inflammatory cell infiltrate, including eosinophils in the dermis. Indirect immunofluorescence testing using normal foreskin as substrate revealed IgG deposits in the basement membrane zone. Circulating autoantibodies against antigens of 190 and 230 kDa were found by immunoblotting analysis using epidermal extracts. This case illustrates DHS with the formation of circulating autoantibodies.     

Congenital cutaneous candidiasis: a rare and unpredictable disease

Congenital cutaneous candidiasis (CCC) is an extremely rare disorder that presents within the first 6 days of life. The manifestations ranges from diffuse skin eruption without any systemic symptoms to respiratory distress, hepatosplenomegaly, sepsis, and death. We report a neonate who presented with generalized skin eruptions at birth, characterized by erythematous macules and papules. The eruption involved head, face, neck, trunk, and extremities. Candida albicans was demonstrated on direct KOH smear, skin biopsy. The disease implies a congenital intrauterine infection and is different from neonatal candidiasis, which manifests as thrush or diaper dermatitis. The infection is acquired from the maternal genital tract in an ascending fashion. Clinical features, direct smear examination of specimen, and appropriate cultures are useful in differentiating the lesions from other more common dermatoses of the neonatal period. Topical antifungal therapy is sufficient unless systemic candidiasis is present. Prognosis for congenital cutaneous candidiasis is good.     

Histologic patterns of polyethylene glycol-liposomal doxorubicin-related cutaneous eruptions

Polyethylene glycol (PEG)-liposomal doxorubicin (Stealth R, Doxil) is a formulation of doxorubicin, which is encapsulated in liposomes formulated with PEG. It is favored in the palliative setting over doxorubicin because of its generally favorable side effect profile. Adverse reactions are predominantly skin eruptions. We report 3 cases of women with breast cancer undergoing treatment with liposomal doxorubicin who developed palmar-plantar erythrodysesthesia and diffuse morbilliform eruptions. Biopsies in the 2 cases demonstrated vacuolar interface dermatitis with epidermal dysmaturation and the third case suggested a drug eruption. Additionally, we report a woman with metastatic breast cancer who developed a similar morbilliform eruption soon after completing a regimen of liposomal doxorubicin. The biopsy revealed an atypical squamous proliferation showing epidermal dysmaturation with focal evidence of interface damage. Both clinician and pathologist alike should be cognizant of this cutaneous eruption, as well as the histologic patterns.     

Bullous eruption of SLE—a case report and investigation of the relationship of anti-basement-membrane-zone antibodies to blistering

We describe the clinical and immunopathological findings in a patient with a bullous eruption and systemic lupus erythematosus (SLE). The bullous eruption preceded a dramatic flare of the SLE with a rise in anticardiolipin antibodies and life-threatening cardiac vasculitis. The clinical and histological findings were similar to those described in the classic bullous eruption of SLE but, unlike previous cases, IgG anti-basement-membrane-zone (anti-BMZ) antibodies were detected on the epidermal as well as the dermal side of the split in chemically separated human skin. We screened the sera of another eight patients with SLE and 10 patients with chronic cutaneous lupus erythematosus (CCLE) without evidence of systemic involvement for the presence of anti-BMZ antibodies and demonstrated that these were present in a low titre in a further two SLE patients neither of whom had a history of blistering. Once more there was binding to both sides of the split. We conclude that although there may be low titres of antibodies to several BMZ antigens in patients with SLE, these are not always associated with blistering and their role in the initiation or perpetuation of cutaneous disease is uncertain.     

Epidermal cell-derived thymocyte activating factor (ETAF) is a potent T-cell chemoattractant

The epidermis, in particular epidermal cytokines, have been shown to modulate a number of inflammatory and cellular immune responses. In this study we have demonstrated that the partially purified epidermal cytokine, epidermal thymocyte activating factor (ETAF), a polypeptide released by keratinocytes, is a potent T-cell chemoattractant. Compared to its ability to augment lectin-stimulated thymocyte proliferation, ETAF is much more active as a T-cell chemoattractant. The results of this study give further support to the role of local epidermal factors in immune reactivity. This finding may have particular relevance to pathologic states characterized by T-cell infiltration in the skin, such as cutaneous T-cell lymphoma.     

Epidermal necrolysis as the presenting manifestation of pediatric lupus

Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) represents the spectrum of skin lesions characterized by rashes, exfoliation, and sloughing usually following drug intake. Occasionally, TEN-like cutaneous manifestations have also been described with systemic lupus erythematosus. Recognition of lupus in a child presenting with TEN-like skin changes is clinically challenging and requires a high degree of suspicion. We describe the case of a child who had epidermal necrolysis as the presenting feature of lupus and had severe neurological complications. TEN-like skin changes in association with severe neurological complications in pediatric lupus are uncommon. Lupus must be considered in the differential diagnosis of a child presenting with epidermal necrolysis with no provocative risk factors such as a history of exposure to medications.     

Emerging dermatologic issues in the oncology patient

The spectrum of skin diseases that occurs in the oncology patient differs somewhat from that seen in other immunosuppressed populations. We review the cutaneous manifestations of invasive mold infections in the leukemia/lymphoma population. Aspergillus mold infections are now the leading infectious cause of death in this population. We also review the pustular eruption caused by a new class of chemotherapy for solid malignancies. An update on cutaneous graft-versus-host disease appears elsewhere in this journal. Cutaneous squamous cell carcinomas and basal cell carcinomas occur more frequently in the chronic lymphocytic leukemia and non-Hodgkin's lymphoma population; this is discussed, as is the more aggressive clinical course of these tumors.     

Death from mast cell leukemia: a young patient with longstanding cutaneous mastocytosis evolving into fatal mast cell leukemia

Mastocytosis is a broad term used for a group of disorders characterized by accumulation of mast cells in the skin with or without extracutaneous involvement. The clinical spectrum of the disease varies from only cutaneous lesions to highly aggressive systemic involvement such as mast cell leukemia. Mastocytosis can present from birth to adulthood. In children, mastocytosis is usually benign, and there is a good chance of spontaneous regression at puberty, unlike adult-onset disease, which is generally systemic and more severe. Moreover, individuals with systemic mastocytosis may be at risk of developing hematologic malignancies. We describe a girl who presented to us with a solitary mastocytoma at age 5 and later developed maculopapular cutaneous mastocytosis. At age 23, after an episode of anaphylactic shock, a bone marrow examination revealed mast cell leukemia. She ultimately died despite aggressive chemotherapy and bone marrow transplantation.     

Cutaneous effects of the most commonly used antidepressant medication, the selective serotonin reuptake inhibitors

Selective seritonin reuptake inhibitors (SSRIs) are widely used antidepressants that are often safer than alternatives, but may produce a variety of cutaneous reactions including spontaneous bruising, pruritus, urticaria, angioedema, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema nodosum, alopecia, hypertrichosis, leukocytoclastic vasculitis, and an acneiform eruption. We review this category of medications and its side effects. Many cutaneous alterations seen in association with SSRIs can be serious, some even life threatening. Because there appears to be cross-reactions between SSRIs, even though they have different chemical structures, it is advisable to use another family of antidepressants if an SSRI is linked with a serious skin eruption.     

A case of ochronosis successfully treated with the picosecond laser

Exogenous ochronosis is a cutaneous condition characterized by blue‐black pigmentation resulting as a complication of long‐term application of skin‐lightening creams containing hydroquinone and other substances such as quinine, phenol and mercury derivatives. We report a case of a 55‐year‐old woman who developed exogenous ochronosis as a result of prolonged use of topical hydroquinone for 5 years, characterized by greyish hyperpigmented patches on the nose and cheeks. The diagnosis was confirmed histologically. Treatment with picosecond laser resulted in marked clinical improvement together with improvement in overall texture and quality of the skin.