An Unusual Form of Skin Tuberculosis Following B.C.G. Vaccination

A 25-year-old female has had brown to erythematous telangiectatic patches and grouped papules on her face, neck, arm, and trunk since childhood following B.C.G. vaccination. Histopathologically, the lesions consisted of hyperkeratosis, slight acanthosis, tuberculoid granulomas with some Langerhans type giant cells in the mid-dermis. Although various forms of cutaneous tuberculosis after B.C.G. vaccination have been reported, it was difficult for us to assign the patient's skin lesion to any specific disease entity. Remission of her cutaneous lesions occurred clinically and histopathologically after treatment with isoniazid and rifampin.     

Immunoperoxidase examination of cutaneous infiltrates of mycosis fungoides and large-plaque atrophic parapsoriasis with OKT10

A monoclonal antibody (OKT10), which was developed recently, reacts with pro-thymocytes, T cell acute lymphoblastic leukemia (ALL) cells, cells in normal bone marrow (including plasma cells), and activated T cells. Tissues from patients with cutaneous T cell lymphoma were studied for the presence of OKT10-reactive cells with the use of an indirect immunoperoxidase technic. OKT10-reactive cells were identified in three of eight cases of mycosis fungoides, one of two cases of Sézary syndrome, with an equivocal reaction in one of ten cases of large-plaque parapsoriasis and in one of seven positive patch tests (allergic contact dermatitis). The biologic and possible clinical implications are discussed.     

L.E.A.P.ing into the cosmetic consult

Establishing good rapport with patients is important during the initial consult, especially in aesthetic medicine. While experienced physicians develop expertise in cultivating a positive patient experience, younger physicians may benefit from some guidance. We describe the L.E.A.P (Listen, Educate and Empower, Align, Perform) method which may help guide young physicians through a successful cosmetic consult. In addition we will review the B.L.A.S.T (Believe, Listen, Apologize, Satisfy, Thank) method for dealing with unhappy patients.     

The edema of fiddler's neck.

Fiddler's neck is a dermatosis of violinists and violists. It characteristically presents as focal lichenification and pigmentation on the left side of the neck. Edema may also occur in the same area and lead to cosmetic concern or fear of malignancy. The edema apparently results from pressure on the patient's neck by the base of the violin or viola and is worsened by holding the instrument in a drooping position.     

Alarm reaction of pilosebaceous apparatus.

A series of histologic changes involving the pilosebaceous structures are described under the term "alarm reaction." The follicular manifestation of this phenomenon is characterized by regression of hair matrix, forming a well-defined nest of small basaloid cells found in various parts of the follicular canal. The sebaceous glands either become undifferentiated, forming a solid mass of stratified squamous epithelium, or the sebaceous lobules are taken into the follicular canal and into the surface keratin layer.     

Histologic changes associated with ultraviolet A-induced erythema in normal human skin

We have examined the effects of a standardized, moderately erythemogenic dose of long-wave ultraviolet (UVA) radiation on normal human skin, with the use of an appropriately filtered solar simulator and sequential biopsy specimens processed as 1-μm Epon-embedded sections. Histologic changes were present immediately after irradiation and evolved slowly during the 48-hour study. The epidermis manifested slight intracellular and intercellular edema and progressive loss of Langerhans cells to approximately one-fifth control values. A dermal infiltrate of neutrophilic polymorphonuclear leukocytes was present in all postirradiation specimens and peaked at 3 hours. A perivascular lymphocytic infiltrate, moderate endothelial cell enlargement, mast cell hypogranulation, occasional massive venular dilation, and sparse red blood cell extravasation were also noted. Overall, our findings expand and quantify earlier impressions that, compared to UVB, UVA has a relatively greater histologic effect on the dermis than on the epidermis, depletes epidermal Langerhans cells, and recruits neutrophils into irradiated human skin.     

Eccrine syringofibroadenoma (Mascaro). Report of two cases

We report two cases of eccrine syringofibroadenoma. Both patients had a large, solitary hyperkeratotic nodular lesion over the extremities. Histologic sections showed spongelike masses of small cuboidal acrosyringeal cells. Fibrovascular connective tissue stroma resembling premalignant fibroepithelial tumor of Pinkus filled the spaces between the masses.     

Malignant melanoma and dermatofibrosarcoma in a 60-year-old patient with lifelong acrodermatitis enteropathica

The life course of acrodermatitis enteropathica is recorded in a 62-year-old white man. Initially saved in infancy by breast-feeding and good medical care, later in his twenties he responded well to diiodohydroxyquinoline (Diodoquin) therapy, his only residua being dermatitis, hoarseness, and short stature. Subsequently untreated, this patient years later developed not only a dermatofibrosarcoma but also a large amelanotic malignant melanoma. Both were successfully excised. Subsequently, oral zinc therapy initiated for the first time cleared his acrodermatitis, which had been present for 60 years. It is suggested that this patient's malignancies developed as a result of an immune deficiency state typically found in acrodermatitis enteropathica. On this basis, acrodermatitis enteropathica may be viewed as having a malignant potential over the long term. The zinc-dependent nature of the immune deficit, however, suggests that lifelong daily zinc supplementation is an appropriate prophylactic measure.     

Therapy in psychosomatic dermatology

In dealing with the subject of therapy in psychosomatic dermatology, it is necessary to set forth premises examining certain aspects which are determinant in establishing treatments. The first, ever held to be of fundamental importance precisely in light of the correct statement of medicine as claimed by psychosomatic theories, is the doctor/patient relationship.     

Diagnosis in psychosomatic dermatology

Franz Alexander¹ proposed that the term “psychosomatic” should be used only to indicate an investigative method for diagnosis and therapy with simultaneous and coordinated application of somatic (ie, physiologic, anatomic, pharmacologic, surgical, and dietetic) and psychological concepts and methods. Correct diagnostic methodology in psychosomatic dermatology could not, therefore, avoid subverting some of the procedures habitually used in medicine. In fact, in a traditional somatic approach the fundamental points are the progressive evaluation of the data resulting from the anamnesis, objective clinical examination of the patient, and the laboratory findings, from which diagnosis is deduced, by exclusion.² Dermatology—the science of evidence—has not subtracted itself from this interest aimed, above all, at “the apparent,” sometimes with scarce propensity for “what lies underneath,” what is not immediately in the foreground, what is not concretely evaluable.     

Eosinophilic histiocytosis: A variant form of lymphomatoid papulosis or a disease sui generis?

Five patients are reported on whose clinical skin disease consisted of polymorphous papulonodular lesions healing with a depigmented scar. Although all cases had been termed lymphomatoid papulosis after clinical or histologic examination, the lesions consisted principally of masses of histiocytes and eosinophils. Individual lesions healed spontaneously or with minimal treatment, but the chronic course of disease was not altered by any therapy used. Follow-up 3 to 17 years later indicated persistent or recurrent disease, and one patient died of histiocytic malignancy. Eosinophilic histiocytosis is the microscopic picture of an unusual group of patients with chronic papulonodular necrotic skin disease that may deserve to be considered a disease pattern per se.     

Nodular lymphoid disease of the head and neck: lymphocytoma cutis, benign lymphocytic infiltrate of Jessner, and their distinction from malignant lymphoma

Skin biopsy specimens from six patients with nodular lymphoid disease of the head and neck were studied by routine histology, direct immunofluorescence microscopy, and leukocyte monoclonal antibodies to T and B cell subsets and monocytes. Initially, these lesions were clinically considered to be benign lymphocytic infiltrates of Jessner, lymphocytoma, or lymphoma. Direct immunofluorescence was negative or showed nonspecific staining in all four patients in whom it was performed. Leukocyte monoclonal antibody stains revealed two distinct patterns of lymphocytes. Lymphocytoma was represented by nodular masses of B lymphocytes with peripheral and intervening zones of T cells. The second pattern consisted of solid nodular masses of T lymphocytes occupying the dermis and subcutaneous tissue. In the specimens interpreted as benign lymphocytic infiltration, the T cells were composed equally of helper and suppressor cells.