Lichenoid photodermatitis associated with nimesulide

An 81‐year‐old‐female patient presented with a 2 week history of erythematous to violaceous lichenoid papules and plaques exhibiting a reticulated pattern on the ‘‘V’' area of the chest and dorsal hands. Fine, whitish reticulated networks were present over the surface of many well developed papules. The lesions were sharply demarcated and moderately pruritic ( Fig. 1 ).

Figure 1 Open in figure viewer PowerPoint Violaceous lichenoid papules with reticular pattern located on the ‘‘V’' area of the chest     

Subcutaneous phycomycosis mimicking synovial sarcoma

A 6-year-old girl presented to the pediatric surgery department with swelling of the right hand of 4 months’ duration. According to the patient’s parents, it started as a small nodule over the dorsum of the right hand which gradually increased in size covering nearly the whole of the hand. There was no history of preceding trauma or insect bite. She had no constitutional symptoms; however, she had limitation of movement of the fingers of the affected hand. The surgeon made a clinical diagnosis of synovial sarcoma. A biopsy specimen from the border of the lesion was obtained for histologic examination. Microscopic examination of the histologic section was not suggestive of this condition. Hence, she was referred to a dermatologist for expert opinion. On cutaneous examination, the right hand showed a single, large, well-defined, indurated mass involving the dorsal and ventral aspects, encircling the proximal portions of the fingers and thumb ( Figs 1, 2 ). The skin over the swelling was nodular, shiny, and intact. On palpation, the mass was nontender, lying between the skin and the superficial fascia, and the examining fingers could be inserted under the smooth, well-defined upper edge. The patient’s general condition was good and regional lymph nodes were not enlarged.

Figure 1 Open in figure viewer PowerPoint Indurated swelling over the dorsum of the right hand     

Treatment of localized epidermodysplasia verruciformis with tacalcitol ointment

A 69‐year‐old Japanese woman presented with multiple, erythematous, keratotic plaques distributed on her right breast, right shoulder, and left cubital fossa. The lesions varied in size from 5 mm to 6 cm. The patient had first noticed a small area of primary erythema on her left cubital fossa at the age of 18 years. The number and size of the lesions had increased for 50 years. A black nodule appeared on the plaque on the right breast 3 years ago and enlarged to 5 cm in diameter ( Fig. 1A ).

Figure 1 Open in figure viewer PowerPoint (a) Erythematous plaques varying in size distributed on both breasts. The biggest plaque contained hyperkeratotic tumor. The black nodule appeared on the plaque of the right breast. (b) Six months after black tumor removal, hypertrophic change was noted on the scar. Topical application of vitamin D3 analog caused regression in size and elevation of the largest keratotic plaque, and a decrease in hyperkeratosis of the other eruptions     

Bockhart's impetigo: complication of waterbed use

A 30-year-old black man with no relevant past medical history presented with a 2-day history of a mildly pruritic eruption that began on his legs and spread to his trunk. He stated that he awoke with the eruption on his legs after he had slept on a waterbed. He had experienced profuse sweating because of the plastic bedcover. He denied any medical problems. Specifically, he had no fever or chills. He also denied taking any medications or applying any topical agents to his skin. On physical examination, the patient appeared to be a healthy black man who had hundreds of 1-mm, white-to-yellow pustules on his back ( Fig. 1 ) and proximal, posterior extremities ( Fig. 2 ). His face, scalp, mucous membranes, palms, and soles were spared. The pustules had no surrounding erythema ( Fig. 3 ).

Figure 1 Open in figure viewer PowerPoint Multiple 1–2-mm pustules on the back     

Cutaneous T-cell lymphoma presenting as disseminated, pigmented, purpura-like eruption

A 48‐year‐old man with a history of psoriasis, who had received no oral pharmacologic treatment, presented in March 2000 with a progressive, cutaneous, pruritic eruption that began on his arms and legs, and became generalized. Examination revealed discrete, purpuric elements disseminated over the entire cutaneous surface, and in some areas confluent, large, erythematous, purpuric patches ( Figs 1 and 2 ). The palmoplantar surfaces and mucous membranes were spared. No lesions suggesting parapsoriasis or the usual presentation of cutaneous T‐cell lymphoma (CTCL) were present.

Figure 1 Open in figure viewer PowerPoint Confluent, large, erythematopurpuric patches with sharply pointed purpuric elements on the buttocks     

Cutaneous extramedullary hematopoiesis in idiopathic myelofibrosis

A 67‐year‐old German woman presented with a 2‐month history of indolent erythematous macules and livid papulonodules of 0.5–1.5 cm in diameter scattered on her abdomen ( Fig. 1 ). On physical examination, the patient was alert, the liver was palpable 3 cm below the right costal margin, and the spleen was enlarged 3 cm below the left costal margin. There was no lymphadenopathy.

Figure 1 Open in figure viewer PowerPoint Clinical lesions with extramedullary hematopoiesis on the abdomen     

T-cell chronic lymphocytic leukemia mimicking dermatomyositis

A 57‐year‐old man was diagnosed with chronic lymphocytic leukemia (CLL) during routine hematologic evaluation. Two months later, the patient developed a mildly pruritic periorbital eruption and erythematous plaques in a photosensitive distribution. A skin biopsy at an outside institution showed nonspecific histopathologic changes. The patient was diagnosed with amyopathic dermatomyositis and treated with prednisone 1 mg/kg/day with no improvement. The patient was subsequently admitted to our institution for CLL chemotherapy. Physical examination on admission revealed bilateral, violaceous, nonblanching periorbital plaques ( Fig. 1A )and symmetric erythematous plaques with mottled hypo‐ and hyperpigmentation on the shoulders, proximal arms ( Fig. 1B ), and upper chest ( Fig. 1C ). Periungual erythema was noted. Muscle strength was normal. Laboratory examination was significant for a white cell count of 33,700/mm³ with 78% lymphocytes, a hematocrit of 25.8%, and a platelet count of 25,000/mm^3. The lymphocytes were almost exclusively CD4 T cells expressing CD2, CD3, CD5, and CD7. Electrolytes, liver function tests, creatine kinase, aldolase, antinuclear antibodies, and anti‐Jo antibodies were normal or negative. Several biopsies of the plaques on the arms were obtained. Histopathology revealed leukemic infiltration of the skin with monoclonal T lymphocytes positive for CD2, CD3, CD4, CD5, and CD7 ( Fig. 2 ). Steroids were discontinued. The patient died a week later from toxic epidermal necrolysis secondary to allopurinol.

Figure 1 Open in figure viewer PowerPoint Clinical findings included periorbital violaceous plaques mimicking a heliotrope eruption (a) and poikilodermatous‐appearing plaques on the lateral arms (b) and upper chest (c)     

Waardenburg syndrome: case report

A 15-year-old Arab boy presented with congenital deafness, heterochromia iridis (right, brown; left, blue), poliosis (white forelock), with an area of leukoderma beneath the forelock, broad nasal root, and lateral displacement of the medial canthi ( Fig. 1 ). Further investigation revealed that one of his siblings was similarly affected. The child was diagnosed with Waardenburg syndrome.

Figure 1 Open in figure viewer PowerPoint Waardenburg syndrome: white forelock, heterochromia iridis, broad nasal root, leukoderma and hypertrichosis of medial eyebrows     

Recurrent primary cutaneous adenoid cystic carcinoma of the scrotum

A 60‐year‐old man had asymptomatic erythematous nodule on the right inguinal area, which had progressively grown for 2 years. Excision was performed at the Department of Urology of our hospital. Two months later, there was local recurrence on the excision site, and it extended locally to make several tender erythematous nodules on the right inguinal area and firm plaque on the scrotum ( Fig. 1 ). Histopathologic examination of the excision specimen revealed large cell masses with tubular or cribriform pattern and many small, solid epithelial islands unattached to the overlying epidermis. The tumor was confined to the dermis and subcutaneous tissue. Round spaces formed by malignant epithelial cells and containing amorphophilic basement membrane‐like material occured inside the tumor masses. The tumor cells were basaloid cells with scanty cytoplasm and deeply stained round‐to‐oval nucleus ( Fig. 2 ). There was clear perineural involvement by the tumor cells. A substance in the pseudoglandular spaces, cystic spaces and the stroma was stained strongly with periodic acid‐Schiff (PAS) and alcian blue (pH 2.5). A PAS‐positive substance was digested by diastase pretreatment. These findings suggested the substance to be a neutral mucopolysaccharide. Immunoperoxidase staining for S‐100 protein and cytokeratin were strongly positive with the tumor cells but not with carcinoembryonic antigen. A histopathologic diagnosis of ACC was made. Salivary glands, bronchi, esophagus, and other organs were examined, but there was no evidence of neoplasm in other organs. A diagnosis of primary cutaneous adenoid cystic carcinoma was made but the patient refused all the treatment, including surgery.

Figure 1 Open in figure viewer PowerPoint Several erythematous nodules on the right inguinal area and indurated plaque on the adjacent scrotum     

Acne in Becker''s nevus

An 18‐year‐old man presented with a progressively enlarging, asymptomatic, well‐demarcated, irregular, hyperpigmented patch, 13 cm × 11 cm, on the anterior aspect of the chest below the left clavicular region, with a few small macules at the periphery, of 2 years duration. After 18 months, multiple, discrete, erythematous papules and comedones developed over the patch ( Fig. 1 ). A few melanocytic nevi were present in and around the patch. A clinical diagnosis of Becker's nevus with acne vulgaris was made. A skin biopsy from the patch showed acanthosis, elongated rete ridges, increased pigmentation in the basal layer, and a mild perivascular lymphocytic infiltrate in the upper and lower dermis with few melanophages in the dermis. Histopathology of the comedone revealed slight acanthosis, irregular elongation of the rete ridges, and hyperpigmentation of the basal layer of the epidermis. Multiple melanophages were seen in the upper dermis. In the mid‐dermis, a ruptured closed comedone was seen. The follicular lumen contained a plug of loosely arranged keratinized cells, sebaceous material, and bacterial colonies. Aggregates of neutrophils were found at the site of rupture of the follicular wall. There was a mild perivascular lymphocytic infiltrate in the upper and lower dermis ( Fig. 2 ). These features confirmed the diagnosis of Becker's nevus with acne vulgaris. The acne was treated with 0.05% tretinoin and 2% erythromycin creams. After 2 months of treatment, all the acne lesions subsided. On further follow‐up, the patient had relapse of the acne lesions over the patch with the discontinuation of treatment. A few new lesions also appeared on the face. The treatment was restarted, but the patient was lost to follow‐up.

Figure 1 Open in figure viewer PowerPoint Multiple, discrete, erythematous papules and comedones over Becker's nevus with a few melanocytic nevi in and around the lesion     

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     

Lichenoid secondary syphilis

Argentina Case 1 A married, heterosexual, promiscuous, 29-year-old white man had experienced an asymptomatic eruption on the trunk and left palm for the last 3 months. After 2 months, the trunk involvement disappeared, but 2 weeks later lip and tongue lesions developed. No history of genital ulcer was found. The physical examination revealed asymptomatic, violaceous, erythematous, flat-topped papules in an annular pattern, 5–10 mm in size, on the left palm ( Fig. 1 ). Painful vesicular lesions surrounded by a red halo, with erosions on the labial mucosa and defined areas of depapillation on the posterior aspect of the tongue, were observed. The genitalia and soles were free of lesions. The clinical findings suggested lichen planus or secondary syphilis.

Figure 1 Open in figure viewer PowerPoint Flat-topped papules on the palm     

Carcinoma erysipeloides as a presenting feature of breast carcinoma.

Drug name tamoxifen: Nolvadex An 80-year-old caucasian woman was seen in November 1997 for an asymptomatic raised lesion on the left side of the neck extending to the infraclavicular area of 7 months’ duration. She had been treated with topical steroids by her general practitioner with no relief. On examination, there was a large, irregular, ill-defined, indurated, erythematous plaque, 7 × 4 cm, over the left side of the neck extending to the infraclavicular area ( Fig. 1 ). The diagnoses entertained included tinea incognito, cutaneous mucinoses, and carcinoma erysipeloides.

Figure 1 Open in figure viewer PowerPoint Infiltrated plaque of carcinoma erysipeloides on the left side of the neck     

Treatment with chemotherapy of scleredema associated with Ig A myeloma.

A 70‐year‐old woman was referred to the dermatology outpatient clinic in January 1999. During the previous 12 months she had developed a progressive induration and stiffness of the skin of her face, neck, shoulders, and upper aspect of her arms. There was no history of a preceding infection or of diabetes mellitus. An examination revealed that the skin of her face, back, shoulders, arms and chest was shiny, erythematous, and diffusely indurated, with a wooden consistency and decreased range of motion. Consistent firm pressure demonstrated a brawny edema. The face lacked expression, with minimal wrinkling ( Fig. 1 ). Lymphadenopathies were not found in any location.

Figure 1 Open in figure viewer PowerPoint Woody face with minimal wrinkling     

Sympathectomy-induced ichthyosis-like eruption

An 80‐year‐old African–American man, with a past medical history of childhood rheumatic fever, hypertension, coronary artery disease, unstable angina, and asbestosis, underwent cardiac catheterization 37 years ago for unstable angina. The postcatheterization course was complicated by a right brachial arterial thrombosis. A venous brachial bypass graft was placed, with vascular supply to the affected arm restored. Postbypass, the patient recovered full use of the arm, but suffered from persistent arm pain. Surgical sympathectomy was performed 1 year later. The patient has been pain‐free since, but noted soon after sympathectomy, unilateral scaly dry skin, unilateral hypohidrosis of the axilla, and increased temperature sensitivity on the affected limb. In the 37 subsequent years, despite application of emollients, he reported no significant improvements or changes in the skin findings. The patient denied that other family members suffered from similar skin problems. He denied ever having atopy or other skin problems prior to the current episode. On physical examination, dry plate‐like scales were seen on the dorsum of the right hand ( Fig. 1A,B ), right shoulder, and upper back, extending to the midline ( Fig. 1C ), in an area of distribution supplied by the injured nerves. Mild follicular prominence of the affected extensor arm was also seen as compared with the uninvolved arm (not shown).

Figure 1 Open in figure viewer PowerPoint Patient with fish‐like fine scales on the right hand (a) which are absent on the left hand. (b) Close‐up view of the fish‐like scales on the affected hand. (c) Posterior trunk and shoulder demonstrating ichthyosiform change extending to the midline     

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     

Re-infection (secondary) inoculation cutaneous tuberculosis.

Case 1 A 24‐year‐old crockery merchant reported on July 1, 1999 with a symptomatic, progressive, recalcitrant, reddish, noduloulcerative eruption on the left cheek. The patient was apparently well 3 months prior to reporting, when he suddenly experienced a mildly itchy raised eruption, probably following a (mosquito) bite. After scratching with the nail, he broke the continuity of the skin at the site. Since then the eruptions had increased in size, despite the use of antimicrobials (unknown). There was no recent history of cough/expectoration/evening rise in temperature or weight loss. Examination of the lesion was striking and was characterized by a noduloulcerative lesion (size, 2 × 2 cm). It was located on an erythematous brick‐red base. Marked induration was present ( Fig. 1a ). Apple‐jelly nodules were demonstrated on diascopy. A bacillus Calmette‐Guérin (BCG) vaccination scar was identified on the left deltoid. There was no regional lymphadenopathy, nor any systemic abnormality. A Mantoux test, with the intradermal injection of 0.1 mL SPAN's tuberculin (PPD/5 TU/0.1 mL), was negative after 72 h. Investigations, including total and differential leukocyte count, erythrocyte sedimentation rate, serum biochemistry, and renal and liver function tests, were normal, as was a chest X‐ray. Tuberculosis (TB) enzyme‐linked immunoabsorbent assay (ELISA) immunoglobulin M (IgM) antibodies (Ab): Mycobacterium tuberculosis IgM Ab titer was 0.5 (< 0.8: negative).

Figure 1 Open in figure viewer PowerPoint (a) A noduloulcerative lesion located on an erythematous brick‐red base. (b) Regression of the lesion after antitubercular therapy     

Sweet's syndrome in an infant--report of a rare case

A 35‐day‐old baby girl presented with a history of sudden onset of skin lesions of 4 days’ duration. The skin lesions initially appeared on the cheeks, but progressed to involve the trunk and limbss within 4 days. There was a history of upper respiratory tract infection 10 days prior to the onset of the skin lesions. The skin lesions were associated with fever. There was no history or symptoms suggestive of systemic involvement. The child was not on any drugs prior to the onset of the skin lesions. On examination, the child was febrile with a temperature of 100 °F and a pulse rate of 120 beats/min, and weighed 3.8 kg. Cutaneous examination revealed multiple, erythematous, nodular lesions on the face ( Fig. 1 ). A few large bullous lesions were present on the thighs and gluteal region. Multiple tender nodules and a few annular lesions with well‐defined discrete papules at the margins and central erythema were also seen on the trunk and limbs. There was no involvement of the mucous membranes. Systemic examination was within normal limits.

Figure Figure 1  Open in figure viewer PowerPoint Face showing erythematous nodular lesions     

Bullous variant of Sweet's syndrome

A 69-year-old woman presented to our clinic as an emergency with erythematous, well-circumscribed plaques, which were partly vesicular, on her extremities and in her armpits, and additionally hemorrhagic blisters on both her palms and her fingers ( Fig. 1a ), which had developed 2 days after the first appearance of the skin lesions. The rapid onset of the lesions (within a few hours) and the pain associated with them were extremely troublesome to the patient. On admission she complained of fever, tiredness and being easily fatigued. Because of a urinary tract infection 1 month prior to admission, trospiumchloride was given. On clinical examination, body temperature was found to be above 38 °C and infraclavicular lymph nodes were enlarged but not tender.

Figure 1 Open in figure viewer PowerPoint (a) Bullae on the patient's right hand. (b) Multiple partly confluent vesicles with neutrophilic granulocytes intraepidermally and a dense interstitial perivascular infiltration of neutrophilic granulocytes and lymphomononuclear cells (H&E, ×200)     

Retiform hemangioendothelioma

A 32‐year‐old white woman presented with a 2‐year history of a gradually enlarging, asymptomatic, cutaneous and subcutaneous, 3 Ï 5‐cm plaque with a nodular surface on the left upper thigh ( Fig. 1 ). There were no other complaints or physical signs. The clinical differential diagnosis included: cutaneous lymphoma, metastatic adenocarcinoma, and dermatofibrosarcoma protuberans.

Figure 1 Open in figure viewer PowerPoint Retiform hemangioendothelioma: clinical presentation is in the form of an exophytic plaque with an irregular surface