Lichen myxedematosus associated with chronic hepatitis C

A 55‐year‐old woman presented with a 4‐month history of sclerotic and thickened lichen myxedematosus (LM) cutaneous lesions on her face and trunk. She suffered from chronic hepatitis and had been seen by a physician for 8 months. Examination revealed an asymptomatic hard nodular lesion on her nose, multiple flesh‐colored papules grouped on her nape, upper back, and chest, and painful swollen lesions on both of her hands ( Fig. 1 ).

Figure 1 Open in figure viewer PowerPoint Cutaneous lesions of the patient. Multiple flesh‐colored hard papules are grouped on the upper back, nape, and scalp     

A case of adult colloid milium with chronic sun exposure

A 57‐year‐old woman presented with a sudden onset of skin‐colored papules, mainly on the forehead ( Fig. 1 ), around the eyes, and on the dorsum of the hands ( Fig. 2 ). The papules had grown in number and size over 1 month. The papules were discrete, shiny, and dome‐shaped, varying in size between 1 and 5 mm. The patient was a farmer and had commonly been exposed to UV radiation in her work in the fields for a period of more than 45 years. She was fair‐skinned and admitted that she was reluctant to use sun protection during her outdoor work. No lesions were observed on the covered areas of the body. The diagnosis was uncertain and clinical differential diagnoses were those of primary cutaneous amyloidosis, senile sebaceous hyperplasia, adult colloid milium (ACM), and papular mucinosis.

Figure Figure 1  Open in figure viewer PowerPoint Skin‐colored papules on the forehead     

Subcutaneous granuloma annulare following herpes zoster

A 57‐year‐old Korean man developed a papulovesicular eruption on the right chest with unilateral T2 dermatomal distribution; acute herpes zoster (HZ) was diagnosed. The past medical history revealed diabetes mellitus, but was otherwise noncontributory. His pain gradually subsided with treatment in the Pain Clinic of the Anesthesiology Department. Five months later, however, new skin lesions composed of several papules were detected at the site of the HZ scar. There were several discrete, nontender, firm, erythematous papules of about 0.8 cm in diameter on the right chest ( Fig. 1 ). Histologic examination revealed foci of necrobiotic collagen surrounded by a vague palisade of histiocytes in the deep dermis and subcutis ( Fig. 2 ). Mucin deposits were seen within the center of the palisaded granuloma and there were scattered multinucleated giant cells. Gram, Gomeri‐methenamine silver, and acid‐fast stains were negative. Polarizing microscopy did not reveal any material. Subcutaneous granuloma annulare at the HZ scar was diagnosed, and intralesional injections of triamcinolone caused flattening of the papules after 4 weeks of follow‐up.

Figure 1 Open in figure viewer PowerPoint Skin examination revealed several discrete, nontender, firm, erythematous papules of about 0.8 cm in diameter on the right upper chest (T2 dermatome)     

Multiple eccrine hidrocystomas associated with Graves' disease

A 20‐year‐old Korean woman presented in August 1999 with a 3‐month history of multiple, tiny papules on the periorbital and malar areas ( Fig. 1a ). She had noted hyperhidrosis for the preceding 6 months, even at room temperature. She had been well and had received no medication prior to her first visit to our clinic. Physical examination showed yellow colored, translucent, small papules, as well as finger tremor, exophthalmos, and a goiter. Histologic examination demonstrated cystic structures in the dermis lined with two layers of cuboidal epithelial cells ( Fig. 2 ). The epidermis was normal and the rete ridges were partially effaced. Immunohistochemical studies revealed that the epithelial cells of the cyst wall were carcinoembryonic antigen (CEA) positive but S‐100 protein negative.

Figure 1 Open in figure viewer PowerPoint Multiple tiny papules on the periorbital and malar areas before (a) and after (b) treatment for Graves’ disease     

Oral penicilliosis in a patient with human immunodeficiency virus in northern Thailand

A 25‐year‐old Thai woman with human immunodeficiency virus (HIV) infection diagnosed by serology 4 months previously presented to the outpatient clinic with a chief complaint of a sore throat. Three months prior to presentation, she was diagnosed with oral and vaginal candidiasis and bronchitis. The patient was afebrile and other vital signs were normal. Examination of the oral cavity showed patchy erythema and leukoplakia on the buccal mucosa, suggestive of candidiasis. In addition, there were multiple, shiny, translucent papules, 2–4 mm in diameter, especially prominent on the upper palate, suggestive of penicilliosis ( Fig. 1 ). Indeed, a Wright‐stained scraping from a papule revealed numerous inflammatory cells, many containing abundant yeast‐like organisms undergoing binary fission characteristic of penicilliosis ( Fig. 2 ). A slant agar fungal culture of material from an upper palate papule grew Penicillium marneffei, consisting of white, gritty hyphae with underlying deep red coloring as depicted in Fig. 3 , as well as Candida albicans. The oral lesions resolved after 2 weeks of treatment with ketoconazole 200 mg twice daily.

Figure 1 Open in figure viewer PowerPoint Oral cavity with shiny, flesh‐colored papules on the upper palate. Arrow shows area from where material for Wright's stain and culture was obtained     

Wiskott–Aldrich syndrome and molluscum contagiosum: a therapeutic challenge after reaction to cidofovir

A 43‐year‐old white man with molluscum contagiosum and a history of Wiskott–Aldrich syndrome presented to our clinic. He had previously finished six cycles of chemotherapy with R‐CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone), and had achieved complete remission for diffuse large B‐cell lymphoma. The patient had a 1.5‐year history of molluscum contagiosum that had spread to the entire trunk and upper and lower extremities. Past therapies included liquid nitrogen cryotherapy, imiquimod, cantharidin, curettage, topical emollients (Dermasil), salicylic acid (Clear Away and Compound W), and trichloroacetic acid peel. Most recently, topical cidofovir had resulted in severe edema of the left arm. On physical examination, the patient had hundreds of umbilicated, flesh‐colored to erythematous papules over his body( Figs 1 and 2 ). A lesional biopsy of a 5‐mm umbilicated papule from the left axilla showed epidermal cells and infundibular hair follicles with large intracytoplasmic molluscum inclusion bodies.

Figure 1 Open in figure viewer PowerPoint Disseminated molluscum‐lower back     

Treatment of prurigo nodularis with thalidomide: a case report and review of the literature

A 37‐year‐old man was first seen on 20 March 1997 for a 5‐year history of widespread, persistent, and intensely pruritic skin lesions on all the extremities. Two years following the appearance of prurigo nodularis (PN), the patient developed a major depressive disorder for which he was given antidepressant agents (amitriptyline and clonazepam) by the psychiatrist. His past history also revealed hepatitis B virus infection. Examination revealed numerous, excoriated, erythematous papules and nodules on all extremities of variable size (ranging from 1 to 3 cm), accompanied by secondary pigmentary changes and scars ( Fig. 1 ). Investigations revealed normal complete blood count (CBC), urea, creatinine, and liver enzymes. Hepatitis B surface antigen was positive.

Figure 1 Open in figure viewer PowerPoint Lesions prior to treatment. Numerous nodules at different locations in the upper and lower extremities     

Granuloma faciale associated with adenocarcinoma of the prostate

A 65‐year‐old man presented to the Dermatology Outpatient Department complaining of an eruption of 10 years’ duration. He also suffered from hypertension, coronary artery disease, and diabetes mellitus for which he received mononitrate isosorbide, propranolol, nifedipine, aspirin, and glimepinide; he showed well‐controlled hypertension and blood glucose. He had consulted several dermatologists since the appearance of the eruption. A diagnosis of cutaneous leishmaniasis had been made. Although the diagnosis had not been confirmed by histology, the patient had received injections of steroids without any apparent improvement. On clinical examination, the eruption was noticed on the front and anterior area of the scalp ( Fig. 1 ). It consisted of pink‐ to red‐colored papules, which had become confluent and formed large plaques. The lesions had extended with time and were totally asymptomatic.

Figure Figure 1  Open in figure viewer PowerPoint Clinical appearance at initial consultation     

Molluscoid skin lesions in histoid leprosy with pseudo‐isomorphic Koebner phenomenon

A 30‐year‐old Indian man presented with multiple asymptomatic skin lesions on the arms, buttocks, trunk, and knees of 4 months’ duration. These lesions had started over the right arm and gradually increased in number and spread to involve the other sites. There was no history of any skin lesions in the past. Family members were normal. Cutaneous examination showed multiple, skin‐colored, shiny papules abruptly arising over the surrounding normal skin of the arms, buttocks, legs, trunk, and pinnae, varying from 2 to 3 mm in size. Some of the papules over the trunk and arms showed central umbilication resembling molluscum contagiosum, and a few showed superficial erosions and/or crusting ( Fig. 1a,b ). A few similar, erythematous papules over the left buttock showed a linear distribution, suggestive of pseudo‐isomorphic Koebner phenomenon ( Fig. 2a,b ). There was hypoesthesia in the distal part of the arms and legs for thermal, touch, and pain sensation, and the bilateral lateral popliteal and ulnar nerves were thick and mildly tender. The clinical features were suggestive of histoid leprosy. Systemic and eye examination were normal. Routine hematology and liver and kidney function tests were normal, and blood venereal disease research laboratory (VDRL) test and enzyme‐linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) 1 and 2 were negative. Histopathology from a papular lesion showed a thinned out epidermis, flattened rete ridges, a subepidermal Grenz zone, and granulomas of closely packed, spindle‐shaped histiocytes arranged in whorls, with foamy macrophages. In addition to the above histologic findings, the molluscoid lesion also showed an epidermal erosion with acid‐fast bacilli demonstrated by Ziehl–Neelsen stain ( Fig. 3a,b ). Slit skin smear examination from both the ear lobes and umbilicated lesions was highly positive, with a bacillary index (BI) of 6+ (> 1000 bacilli per oil immersion field) and a morphologic index (MI) of 80% ( Fig. 3c ). A diagnosis of histoid leprosy was made. The patient was treated with daily rifampicin and ofloxacin for 2 months, followed by standard multibacillary (MB) multidrug therapy (MDT) with daily dapsone and clofazimine with monthly rifampicin for 2 years. An excellent response to treatment was obtained with regression of all the skin lesions.

Figure 1 Open in figure viewer PowerPoint (a) Umbilicated and shiny papular skin lesions arising abruptly over normal skin. (b) Umbilicated, crusted, and eroded pigmented lesions over the arm     

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     

Giant cutaneous melanoacanthoma

A 45‐year‐old male cook was seen for the evaluation and removal of a “mole on my eye” of steady growth during the previous 6 months. The patient stated that he had had a “brown spot” above his left eye for 17 years prior to its recent enlargement; it was now partly blocking the vision in his left eye. He denied a history or family history of cutaneous tumors, including skin cancer. On examination, a 2.5‐cm × 0.5‐cm × 0.8‐cm, horn‐like, darkly pigmented, cutaneous nodule was evident extending from the left upper eyelid downwards to below the lower eyelid ( Figs 1 and 2 ). He also had scattered, skin‐colored, 2–3‐mm cystic papules on his anterior mid‐chest. A shave excision specimen was obtained from the eyelid nodule.

Figure 1 Open in figure viewer PowerPoint Horn‐like, cutaneous nodule extending from the left upper eyelid downwards to below the lower eyelid     

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)     

Detection of human papillomavirus type 16 in bowenoid papulosis and nonbowenoid tissues

A 58‐year‐old Japanese man visited our clinic in December 2000 with a complaint of an erythematous plaque with reddish papules and pigmentation on the penis shaft and glans. He noticed the lesion 1 month before his visit. He denied any previous homosexual activity. His wife denied any genital skin lesion or gynecologic abnormality. No history of human immunodeficiency virus infection could be obtained. Physical examination of the skin lesion revealed an asymptomatic, flat‐topped, approximately 10‐mm‐sized, reddish‐brown keratotic plaque on the penis shaft. It showed an irregular surface, irregular border, and color variegation. Multiple, small, reddish‐brown papules and plaques were distributed on the surrounding penis shaft and glans ( Fig. 1 ). The patient had no symptomatic signs. No lymphadenopathy was noted in the inguinal area.

Figure Figure 1  Open in figure viewer PowerPoint Clinical features of BP lesions on the penis. A keratotic plaque shows an irregular surface, irregular border, and color variegation, and is surrounded by small, reddish‐brown papules     

Multiple pilomatricoma with perforation

A 22‐year‐old woman presented to our clinic with a complaint of masses on various parts of her body. A mass on her right forearm had appeared 5 years ago and had enlarged during the past 6 months. Two lesions on the back of her neck had a 3‐year history, one lesion on her eyebrow had a 2‐year history, and one lesion on her left forearm had a 1‐year history. The lesion on her left forearm was discharging purulent material. Dermatologic examination revealed a 15 × 16 mm tumor on the right forearm, 11 × 6 mm and 10 × 5 mm tumors on the back of the neck, and a 20 × 20 mm tumor on the eyebrow; they were flesh‐colored, well‐defined, firm tumors. On her left forearm, there was a 12 × 10 mm, well‐defined, firm, blue–red tumor discharging chalky white granules; purulent material was detected ( Fig. 1 ).

Figure 1 Open in figure viewer PowerPoint Firm, blue–red tumor discharging chalky white granules     

Chronic disseminated cutaneous histoplasmosis in an immunocompetent individual--a case report

A 45‐year‐old woman from central India reported to clinic with multiple swellings on the face and neck. She had red patches on her forearms and trunk, but there was a predominance of lesions on the face and neck. On examination, her face showed multiple, succulent, erythematous plaques which were mildly pruritic ( Fig. 1 ). There was no discharge. There were also some scattered erythematous papules and nodules on the face ( Fig. 1 ). Examination of the neck revealed multiple erythematous plaques, many of them with a linear orientation and central ulceration and crusting ( Fig. 2 ). The upper extremities showed multiple erythematous plaques, most of which were ulcerated ( Fig. 3 ). Plaques without ulceration had been present for the past 2 years. The patient had been treated in various centers around her village and in Baroda as a case of reactional leprosy.

Figure 1 Open in figure viewer PowerPoint Multiple, succulent, erythematous plaques, papules, and nodules on the face     

A true molluscum pendulum

A 45-year-old man with epilepsy and mental retardation presented to the dermatology clinic with a “mole” on his nose and a “skin tag” on his scrotum. On examination, the patient had multiple, 2–3-mm, skin-colored, shiny papules in clusters about the perinasal region, and a large, pedunculated, soft, red tumor extending from the inferior aspect of the scrotum ( Fig. 1 ). A shave biopsy from a nasolabial fold lesion and an excision of the pedunculated tumor were performed. The shave biopsy of the nose showed multiple exophytic papules containing blood vessels and fibrous tissue consistent with angiofibroma. The excision biopsy of the groin showed a large skin polyp with a central fibrovascular core. In addition, it revealed papillomatosis of the epidermis and dilated blood vessels, suggesting that the tumor was a molluscum pendulum seen in patients with tuberous sclerosis complex ( Fig. 2 ). A Verhoff van Gieson stain demonstrated a lack of elastin fibers in the tumor ( Fig. 3 ).

Figure 1 Open in figure viewer PowerPoint Pedunculated tumor attached to the scrotum     

Cutaneous Rosai-Dorfman disease preceding inguinal lymphadenopathy

A 33‐year‐old man presented with asymptomatic, gradually progressing, reddish nodules on the thigh of 1 year's duration. Six months later, nodules were noticed on the buttock of the same side. At the same time, the inguinal and femoral lymph nodes increased in size and could be seen as an elevated mass in the groin which, although painless, made the patient limp when walking. On examination, a cluster of pink nodules on an erythematous, oval, indurated area, measuring 10 cm × 5 cm, was seen on the lower medial aspect of the right thigh ( Fig. 1 ). A small, almost circular, cluster of papules was present on the lower part of the right buttock. Some of these lesions, according to the patient, were reducing in size. The right inguinal and femoral lymph nodes were markedly enlarged and firm. The overlying skin was normal. Clinical differential diagnoses of dermatofibrosarcoma and localized, cutaneous T‐cell lymphoma were considered in this patient. Systemic examination revealed no abnormality.

Figure 1 Open in figure viewer PowerPoint Cluster of reddish nodules over the thigh     

Birt-Hogg–Dube Syndrome: an autosomal dominant disorder with predisposition to cancers of the kidney, fibrofolliculomas, and focal cutaneous mucinosis

The proband was evaluated for abdominal pain at age 61 years and found to have bilateral solid renal masses. He underwent a partial left nephrectomy. Two benign renal cysts were present, and two renal cell adenocarcinomas measuring 5.3 cm and 0.7 cm in greatest diameters were found. Histologically, both tumors contained both clear and granular cell types. He had a total right nephrectomy 2 months later. Fourteen or 15 lesions were scattered over the surface of this kidney, so an adrenal‐sparing radical right nephrectomy was performed. On sectioning, the diameter of the largest tumor was 4 cm, and histologically this was described as renal cell carcinoma, clear cell type, Fuhrman grade II. One year later, the patient shows no evidence of recurrent disease. The proband's past medical history was notable for gastroesophageal reflux, degenerative disk disease, hyperlipidemia, and mild hyperglycemia. A genetics consultation was requested because of a family history of renal cancers in three maternal relatives ( Fig. 1 ). On examination, the proband was a nondysmorphic man of normal stature with no unusual findings, except for widespread skin findings ( Fig. 2 ). On his face were innumerable, small, slightly yellowish or flesh‐colored papules on the forehead and especially over the cheeks. No intraoral lesions were seen. Around the neck were innumerable, dome‐shaped, firm, ivory‐colored papules ranging in size from 1 to 10 mm. Very tiny, similar papules were present over the trunk and in the antecubital area. Numerous acrochordons and some cherry angiomas were present. Several biopsies from the neck and upper back were obtained and were thought suggestive of papular mucinosis. The patient's mother had had a skin biopsy of a similar lesion from her face in 1947, interpreted as an adenoma sebaceum. No angiofibromas were evident on our patient's slides nor on physical examination.

Figure 1 Open in figure viewer PowerPoint Pedigree of family with Birt‐Hogg–Dube Syndrome     

An interesting case of colocalization of segmental lichen planus and vitiligo in a 14-year-old boy

A 14‐year‐old boy had segmental vitiligo (L_3?4) on the right thigh and leg for 4 years, and was advised to apply topical clobetasol propionate, 0.05%, in the night, with daily sun exposure for 10 min, as he refused to comply with topical psoralens. As there was no response to therapy even after 3 months, the patient stopped the steroid cream but continued with the sun exposure. Subsequently, the patient noticed gradual‐onset, itchy, violaceous, pigmented, raised lesions superimposed on the vitiligo macules. Cutaneous examination revealed violaceous, polygonal papules, 0.5 × 0.5 cm in size, some of which coalesced to form discrete violaceous plaques, confined to areas of vitiligo, with a clear‐cut demarcation from normal skin ( Fig. 1 ). The scalp, palms, soles, nails, and mucosa were normal. Histopathology of the polygonal papules revealed hyperkeratosis, wedge‐shaped hypergranulosis, irregular acanthosis with saw toothing of the rete ridges, basal cell liquefaction, and a band‐like lymphocytic infiltrate ( Fig. 2 ), consistent with lichen planus. The patient was subsequently prescribed fluticasone propionate (0.05%) ointment once daily for the lesions of lichen planus. There was a marked improvement in the lesions of lichen planus after 1 month.

Figure 1 Open in figure viewer PowerPoint Violaceous papules of lichen planus colocalized on vitiligo macules with associated leukotrichia seen on the right leg     

Erythema multiforme-like lesions associated with lesional infiltration of tumor cells occurring with adult T-cell lymphoma/leukemia

A 66‐year‐old Japanese woman visited our hospital with a complaint of multiple papules on her trunk and extremities. She had a past medical history of appendicitis and blood transfusion 40 years earlier. For the last 10 years, she had noticed multiple, gradually enlarging papulonodular lesions with surrounding erythema on her trunk and extremities. Physical examination revealed multiple, violaceous papules or nodules, less than 10 mm in diameter, with surrounding erythema on her trunk and extremities ( Fig. 1 ). The results of routine laboratory examinations, including blood count, liver function, renal function, serum calcium, and lactate dehydrogenase, were within the normal range. The peripheral blood picture showed a small population of atypical lymphocytes below 1% of the total white blood cells. Human T‐cell lymphotropic virus type I (HTLV‐I) serology was positive. A microscopic examination of a biopsy specimen from a nodule on the abdomen demonstrated diffuse infiltration of large pleomorphic T cells in the upper and middle dermis, although highly atypical lymphocytes, so‐called flower cells, could not be recognized. Infiltrating lymphocytes were positive for CD2, CD3, CD4, CD5, CD7, and CD45, but negative for CD8 and CD20, immunohistologically. Bone marrow biopsy also demonstrated the infiltration of lymphocytes expressing CD2, CD3, CD4, CD5, and CD7, but not CD25. Southern blot analysis of the infiltrating cells in the skin revealed an integration of HTLV‐I proviral DNA in T cells. Clonal T‐cell receptor γ gene rearrangement was detected in skin and bone marrow biopsies. No abnormal mass or bone defect was detected by chest or abdominal computed tomographic scanning, systemic gallium‐67 citrate scintigraphy, or chest radiography. On the basis of these data, the patient was diagnosed with smouldering‐type adult T‐cell lymphoma/leukemia.

Figure 1 Open in figure viewer PowerPoint Clinical features of adult T‐cell lymphoma/leukemia (ATL) skin lesions. Crusted, target‐like, dark‐red plaques on the lower legs