Late-onset eccrine angiomatous hamartoma on the forehead

A 71-year-old Korean man presented with a solitary erythematous plaque on his forehead (Fig. 1). It was first noticed by the patient 1 year previously and had slowly increased in size over that time. Physical examination revealed a slightly elevated, 1.5 cm x 1.5 cm erythematous plaque on the upper midline of the forehead. Sweating was not evoked by physical work or emotional stress. There was no pain or tenderness associated with the lesion. The patient had no history of trauma to the forehead. Histopathologic examination of the lesion showed increased numbers of eccrine glands, as well as dilated vascular channels in the deep dermis and subcutaneous tissue (Fig. 2). An immunohistochemical study showed that these eccrine glands stained positively for S-100 and carcinoembryonic antigen (CEA), and the vascular channels for the antifactor VIII-related antigens. These findings are consistent with eccrine angiomatous hamartoma. There was no change in the lesion during the 1-year follow-up period.     

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     

Eccrine angiomatous hamartoma: a rare skin lesion with diverse histological features

Eccrine angiomatous hamartoma (EAH) is an exceedingly rare benign tumor-like lesion prevalent in childhood which may produce pain and marked sweating. The histological features include proliferation of eccrine sweat glands and angiomatous capillary channels. We report an 8-year-old girl who had a single lesion on her left lower leg. Physical examination revealed a slightly elevated, 4×7 cm erythematous plaque on the lateral aspect of left leg. Sweating in the lesion was evoked by physical work or emotional stress. There was no pain or tenderness associated with the lesion. The patient had no history of trauma to the site. These lesions were clinically angiomatous, and we obtained the diagnosis by histopathological examination. Histopathological examination of the lesion showed increased numbers of eccrine glands, as well as dilated vascular channels in the deep dermis and subcutaneous tissue. These findings are consistent with EAH.     

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)     

Atypical acral persistent papular mucinosis.

A 70-year-old woman presented with a 10-year history of cutaneous lesions on her calves that worsened with solar exposure. Her past medical history was irrelevant. Physical examination revealed 10–15 erythematous, firm nodules with a diameter of 2–5 mm, which were slightly painful on palpation. The lesions were located on both calves, although some elements extended to the posterior side of the thighs ( Fig. 1 ). General physical examination did not show any abnormalities. A biopsy specimen from one of the elements showed a normal epidermis and, in the upper dermis, a slight inflammatory infiltrate of mononuclear cells, with the presence of splits between collagen fibers ( Fig. 2 ). Alcian blue stain at pH 2.5 revealed the existence of mucinous material in these spaces ( Fig. 3 ). An electron microscopic study did not show any abnormalities.

Figure 1 Open in figure viewer PowerPoint Clinical appearance of the lesions     

Primary squamous syringometaplasia with no underlying malignancy.

A 26-year-old Thai man was first seen in our department for the evaluation of an intermittent, pruritic, papular eruption that had appeared over the previous 2 months. He noticed that the lesions usually arose following exposure to heat or excessive sweating. The patient was otherwise in good health and did not take any medication. His family history did not reveal any similar disease. On examination, there were multiple 2–3 mm, clustered, erythematous papules widely distributed on the chest, abdomen, buttock, and thighs ( Fig. 1 ). They were purpuric and blanched slightly when palpated. All lesions appeared to be at the same stage of development. Some papules had coalesced to give edematous plaques with satellite margins. Healing lesions showed striking reticulated hyperpigmentation. The clinical differential diagnosis included allergic contact dermatitis and herpes simplex. Histology of a punch biopsy from the back revealed squamous metaplasia of the eccrine ductal epithelium of the epidermis and the upper dermis. The metaplastic ducts were lined by large polygonal epithelial cells. Focal necrosis of the ductal epithelium, obliteration of the lumen, and parakeratosis were also observed. A slight perivascular infiltrate of lymphocytes with some neutrophils and eosinophils was noted in the upper dermis. The coils in the deeper dermis were not involved. A diagnosis of primary squamous syringometaplasia was made. Routine laboratory tests were normal.

Figure 1 Open in figure viewer PowerPoint Multiple groups of 2–3 mm erythematous papules on the trunk and abdomen. Some lesions are confluent     

Atypical clinical form of cutaneous leishmaniasis: erysipeloid form

A 60‐year‐old woman was admitted to our clinic with a gradually enlarging red papule on her face. Her history revealed that, 9 months previously, a painless, red papule of 1–2 cm in diameter had occurred in the middle of her face and, with time, had enlarged to cover her nose, both cheeks, and eyelids. It was diagnosed as a superficial skin infection, and topical and systemic antibiotics were prescribed; however, no response was obtained. In the last 2 months, a sore had formed in the middle of her nose. The patient lives in the east of Eastern Anatolia, where no case of cutaneous leishmaniasis has been reported in the last 20 years. On dermatologic examination of the patient, an erythematous, indurated, slightly squamous, 10 cm × 5 cm, butterfly‐shaped plaque with sharply defined borders was seen on both cheeks, lower eyelids, and the whole nose ( Fig. 1 ). In smears taken from the lesion, a number of amastigotes belonging to Leishmania were determined in the intracellular and extracellular area ( Fig. 2 ). Histopathologic examination of the cutaneous lesion showed scattered infiltration composed of mononuclear cells, histiocytes, plasma cells, and small epithelioid granulomas. Gram smear and anaerobe–aerobe culture prepared from the lesion were negative. The total blood count and sedimentation rate of the patient were within normal limits. Routine biochemical tests, urine analysis, chest radiography, and intradermal purified protein derivative (PPD) skin test were all normal. Antinuclear antibody and antistreptolysin antibody examinations were negative.

Figure 1 Open in figure viewer PowerPoint Butterfly‐shaped infiltrated erythematous plaque on the face     

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     

Pustular psoriasis of pregnancy in a patient whose dermatosis showed features of acute generalized exanthematous pustulosis

A 23‐year‐old pregnant woman at 38 weeks of gestation presented with a 2‐day history of a red eruption on her abdomen and upper thighs. The patient had applied baby oil to her abdomen a few days earlier, but she denied using any other topical products. Her only medications were prenatal vitamins and iron, which she had been taking since the beginning of her pregnancy. The clinical impression was contact dermatitis, and she was started on topical Sarna lotion (containing 0.5% camphor and 0.5% menthol) after she declined topical steroids. Three days later, she presented to the dermatology clinic with worsening pruritus, mild diarrhea, and subjective chills. On physical examination, there were diffuse erythematous plaques studded with 1–2‐mm pustules on the upper extremities, chest, back, abdomen, and upper thighs ( Fig. 1a–c ). The pustules were distributed diffusely throughout the plaques with no obvious circinate pattern.

Figure 1 Open in figure viewer PowerPoint (a) Diffuse erythematous plaques on the abdomen and proximal upper thighs. (b) Abdomen showing coalescing pustules. (c) Proximal upper thigh showing clustered 1–2‐mm pustules on an erythematous plaque     

Prurigo pigmentosa

Case 1 A 28-year-old woman with skin type 2 was first seen in May 1997 with a 10-year history of a recurrent pruritic eruption in the intermammary area. Her medical history was not significant regarding a systemic disease or a triggering factor that could have been related to her eruption. Results of laboratory investigations, including peripheral blood cell counts, liver and renal function tests, blood glucose levels, and urinalysis, were within normal limits. Physical examination revealed erythematous papules and reticulated hyperpigmentation in the intermammary area. Histopathologic examination from an erythematous papule showed parakeratosis, mild acanthosis, spongiosis, dyskeratotic keratinocytes, and focal vacuolar degeneration of basal keratinocytes within the epidermis; and perivascular lymphocytic infiltrate and pigment incontinence within the upper dermis ( Fig. 1 ). Following an initial treatment with topical corticosteroid for 2 weeks with a partial response, doxycycline was started in 200 mg daily doses for 3 weeks. The eruption resolved leaving marked residual hyperpigmentation within 3 weeks. No recurrence has been observed over the past 6 months.

Figure 1 Open in figure viewer PowerPoint Biopsy of an erythematous papule revealed parakeratosis, mild acanthosis, spongiosis, necrotic keratinocytes (double arrows), and focal vacuolar alteration of the basal layer (single arrows) (hematoxylin and eosin stain; original magnification, × 100)     

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     

Nevus comedonicus syndrome: a case associated with multiple basal cell carcinomas and a rudimentary toe

A 28-year-old man presented to our clinic for the evaluation of widespread black spots and cysts, in which recurrent infections could not be controlled by topical and systemic antimicrobials. He was first noted at birth to have a rudimentary toe on the right foot. By the age of 8 years, he had developed pitting on the neck and sole, many of which contained black dots. Over subsequent years, pigmented papules representing pigmented basal cell carcinomas (BCCs) also began to appear on the neck and chest. The patient gave a history of recurrent abscesses and cysts developing on the lesions after the age of 14 years. His personal history was negative for epileptiform attacks and congenital cataract. There was no parental consanguinity and no family history of any similar skin condition. Dermatologic examination revealed aggregated, linear, discrete, dilated, follicular orifices plugged with keratinous material on both sides of the neck, extending down to the upper chest. In some areas, these comedo-like pits were associated with erythematous papules, nodules, cysts, and scars. Some follicules had a rudimentary hair, and others no hair at all. In addition, there were multiple, small, black, glistening papules, characteristic of pigmented BCCs ( Fig. 1 ). Interfollicular hypopigmentation was also observed. On the medial edge and sole of the right foot, there was a linear patch of pitting. There was also a skin-colored, soft, 2 cm pedunculated nodule arising from the medial aspect of the great toe, which was diagnosed as a rudimentary toe ( Fig. 2 ). The rest of the physical examination was normal. The patient's general health was good.

Figure 1 Open in figure viewer PowerPoint Multiple, small, black, glistening papules on the upper chest typical of pigmented basal cell carcinoma     

Microcystic adnexal carcinoma induced by multiple radiation therapy

We present an 84‐year‐old Caucasian man (Fitzpatrick classification: skin type II) with microcystic adnexal carcinoma (MAC) on his left cheek and a 15‐year history of recurrent squamous cell carcinoma (SCC) of the head, treated with numerous surgical interventions and multiple palliative 60‐Gy radiation therapy. In 1996, the patient developed a nontender, indurated, irregularly marked, erythematous lesion on his left cheek (1.5 × 1 cm). Furthermore, the patient suffered from radiodermatitis due to previous radiotherapy ( Fig. 1 ). Punch biopsy and a subsequent wedge excision showed features of both SCC and eccrine carcinoma. Histopathologic and immunohistochemical tests of the tumor revealed a diagnosis of MAC. The patient underwent Mohs' micrographically controlled surgery to obtain tumor‐free peripheral soft tissue margins. There was no evidence of any lymphatic invasion or distant metastasis in the physical and laboratory examination. So far, the patient has not developed any recurrences.

Figure 1 Open in figure viewer PowerPoint Clinical picture of MAC showing features of radiodermatitis     

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     

Nodular morphea in a linear pattern.

A 9-year-old black girl presented with papules and nodules in a linear distribution on her right inner arm, right axilla, and right chest ( Fig. 1 ). The lesions were hyperpigmented, indurated, and had been present for 3 years. She was otherwise healthy. A biopsy of one of the lesions revealed a sparse superficial and deep perivascular infiltrate of lymphocytes, compactly arranged collagen bundles in the upper part of the dermis, and abundant mucin throughout the reticular dermis, which was consistent with morphea with dermal mucinosis ( Fig. 2 ). Biopsy of another lesion revealed classic histologic features of morphea: thickened bundles of collagen crowded in the reticular dermis aligned parallel to the skin surface.

Figure 1 Open in figure viewer PowerPoint Discrete nodules in a linear distribution on the right arm     

Vegetative pyoderma gangrenosum: an unusual presentation

A 44-year-old woman presented with a 6-month history of subcutaneous nodules involving her face and shins. Her past history revealed myomatous uterus with menometrorrhagia, resulting in an iron deficiency anemia, treated by ferrum sulfate tablets. She also had diabetes mellitus type II treated by glibenclamide and metformin tablets. There was no evidence of bromide or iodide ingestion. On initial examination, several firm, tender, erythematous subcutaneous nodules, 2–4 cm in diameter, were present on the face ( Fig. 1 ) and shins ( Fig. 2 ), two with normal overlying skin. Within a few weeks, the nodule on the left shin enlarged and several superficial ulcers appeared, surrounded by purplish borders, secreting sinuses, and a vegetative exophytic surface ( Fig. 3 ). Physical examination was normal. Incisional biopsies from the ulcer margins showed pseudoepitheliomatous hyperplasia, diffuse neutrophilic infiltration with microabscess formation (Fig. .4), and the presence of a dense infiltrate composed of epithelioid cells, giant cells, and a few lymphocytes forming non-necrotizing granulomas within the dermis and subcutaneous lobules ( Fig. 5 ). Leukocytoclastic vasculitis was also present in the lower dermis. Routine blood tests and urine analysis were normal, except for a high erythrocyte sedimentation rate (120/h) and anemia with a hemoglobin level of 10 g%. The results of the following laboratory tests were found to be within normal limits: rheumatoid factor; antinuclear antibody; C3; C4; serum immunoglobulins; serum protein electrophoresis; stool for parasites and occult blood; X-ray of the chest, left shin, hands, and facial bones; isotopic bone scanning; abdominal ultrasonography; chest and

Figure 1 Open in figure viewer PowerPoint Erythematous nodule on the chin     

Kikuchi disease associated with Still disease

A 32-year-old white man with no previous medical past was admitted to our department with an 8-month intermittent history of acute spiking fever with axillary, inguinal, and neck lymphadenopathy, arthritis, and cutaneous eruption. Cutaneous examination showed nonpruriginous, indurated erythematous papules affecting the face, ears, and trunk, suggestive of subacute lupus erythematosus ( Fig. 1a,b ). On general physical examination, no abnormalities were observed except for arthritis of the right ankle and, a few months later, arthritis of the left knee. Biological investigations revealed a raised erythrocyte sedimentation rate with a serum ferritin level at 800 ng/mL (normal < 200 ng/mL), a white blood cell count of 12,500/mm³ (with 80% neutrophils, 16% lymphocytes, and 4% monocytes), a hematocrit of 40%, and a hemoglobin level of 13.1 g/dL. Electrolytes and liver function tests were normal. Antinuclear antibodies and antibodies to deoxyribonucleic acid (DNA) were negative. Rheumatoid factor was absent. No evidence of the following infections/organisms was found on serologic screening: syphilis, Streptococcus, Toxoplasma, Mycoplasma, Brucella, Borrelia burgdorgferi, spotted fever, leptospirosis, hepatitis B and C virus, parvovirus, human immunodeficiency virus (HIV) 1 and 2, human T-cell lymphotropic virus (HTLV) 1, Epstein–Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus (HSV) 6. Immunoglobulin M (IgM) HSV(1+2) by enzyme-linked immunosorbent assay (ELISA) analysis with 1 year follow-up was still detected. The articular synovial fluid of the involved ankle and knee was inflammatory but sterile. A bone marrow biopsy specimen revealed no lymphomatous involvement. Abdominal and chest scans were normal. Skin biopsy of a facial nodule showed, in the dermis and in the subcutaneous fat tissue, a dense perivascular and periadnexal infiltrate composed of numerous plasmacytoid histiocytes and large- or medium-sized lymphocytes ( Fig. 2a,b ). No epidermal changes, edema in the papillary dermis, or vasculitis were found. Immunofluorescence staining of frozen tissue sections of a facial nodule showed granular deposits of C3. Inguinal lymph node biopsy revealed, in the paracortical area, focal necrosis with a proliferation of transformed lymphocytes, histiocytes, and numerous nuclear debris typical of histiocytic necrotizing lymphadenitis ( Fig. 3a,b ). On immunohistochemical staining examination, CD68 was positive in pathologic paracortical areas. Few mononuclear cells were positive for CD3, CD8, and L-26 ( Fig. 4 ). Polymerase chain reaction (PCR) amplification did not show human herpes simplex viruses in the skin biopsy specimen, and culture was also negative.

Figure 1 Open in figure viewer PowerPoint (a) Clinical aspect: erythematous papulonodules on the face. (b) Clinical aspect: erythematous papulonodules of the upper part of the trunk     

Acute febrile neutrophilic dermatosis (Sweet's syndrome) with nodular episcleritis and polyneuropathy

A 56‐year‐old Japanese housewife presented with multiple erythematous lesions in association with ocular hyperemia and pain in the right upper and lower extremities, including the hands and feet. These symptoms were preceded by a sore throat with persistent fever higher than 38.5 °C for about 1 week. Dermatologic examination showed tender, dull‐red, erythematous lesions, measuring 1–2 cm in diameter, located predominantly on the forehead, cheeks, auricular region, neck, forearm, hands, and feet. A biopsy specimen obtained from an erythematous lesion on the right forearm revealed prominent edema in the papillary dermis and remarkable inflammatory cell infiltration throughout the entire dermis ( Fig. 1 ). The infiltrate predominantly consisted of neutrophils and nuclear dust without signs of vasculitis. In routine examination, the leukocyte count was 15,000/mL (normal range, 4000–8000/mL) with severe neutrophilia (80%). The C‐reactive protein (CRP) level was 17.65 mg/dL (normal range, < 0.5 mg/dL) and the anti‐streptolysin (ASLO) level was 611 IU/mL (normal range, < 166 IU/mL). In human leukocyte antigen (HLA) testing, HLA‐A2, ‐B39, ‐B35, ‐Cw2, and ‐Cw7 were positive, and HLA‐B51, ‐B54, and ‐Cw1 were negative.

Figure Figure 1  Open in figure viewer PowerPoint Histologic picture showing a dermal infiltrate of neutrophils     

Giant annular dermatomyofibroma

A 74-year-old lady presented with a painful giant annular abdominal plaque for a duration of 2 years. The plaque developed from a cholecystectomy scar and extended peripherally around it. The patient had had a cholecystectomy for gallstones 10 years previously. She was a diabetic on oral hypoglycaemic agents and had no history of radiotherapy. Physical examination showed a tender well-demarcated annular erythematous keloid-like plaque, measuring 13 cm × 15 cm, surrounding a cholecystectomy scar. Another smaller oval plaque, measuring 3 cm × 2 cm, was found on the left side of the abdomen ( Fig. 1 ). The initial clinical diagnosis was dermatofibrosarcoma protuberan (DFSP). A deep incisional biopsy including subcutaneous fat was performed under local anesthesia for pathological examination. Histologically, there was a plaque-like lesion involving the upper reticular dermis but not extending to the subcutaneous fat. The lesion showed proliferation of spindle-shaped cells arranged in intersecting fascicles and appeared parallel to the skin surface. Only a vague storiform pattern was seen at the edges. The cells had relatively uniform elongated nuclei and mitosis was not seen. The overlying epidermis showed mild hyperplasia with pigmentation of the basal layer ( Fig. 2 ). Smooth muscle actin was positive ( Fig. 3 ), desmin was negative and CD34 was negative. The final diagnosis was dermatomyofibroma (DMF). Extra-abdominal fibromatosis was unlikely because broad elongated fascicles among collagenous stroma were not evident, while intersecting fascicles parallel to the skin surface were typical of DMF. The smaller plaque on her left abdomen was excised and gave similar histological and staining results. The giant annular plaque was not excised as the patient refused further surgery. She has since been closely monitored.

Figure 1 Open in figure viewer PowerPoint A well-demarcated annular erythematous keloid-like 11 cm × 13 cm plaque surrounding a cholecystectomy scar; a smaller oval plaque measuring 3 cm × 2 cm was found on the left side of the abdomen     

Cutaneous protothecosis

A 63‐year‐old Korean woman presented with erythematous plaques on her right forearm. The lesion had developed 4 months previously as pruritic papules and scaly patches, and grew slowly coalescing to eczematous plaques. Examination showed thick scaly erythematous plaques with multiple erosions and minute pustules over the right forearm ( Fig. 1 ). Her past history included hypertension and chronic arthritis of her knees requiring intermittent corticosteroid therapy over a period of 15 years. Routine laboratory evaluations (complete blood count, erythrocyte sedimentation rate (ESR), urinalysis, renal and liver function) and chest X‐ray studies were negative or within normal limits. The biopsy specimens of the plaque revealed mild acanthosis and mixed inflammatory infiltrates with some round spores in the dermis, which showed multiple morula‐like sporangia containing many endospores on periodic acid‐Schiff (PAS) and Gomori's methenamine silver (GMS) staining ( Fig. 2 ). Scraping of the lesion with potassium hydroxyde examination showed no specific findings, but the tissue culture revealed creamy yeast‐like colonies on Sabouraud dextrose agar (SDA) in room temperature within 48 h, and the colonies showed characteristic sporangia with morula‐like appearance on lactophenol cotton blue staining. The biochemical evaluation using a Yeast biochemical card (Vitec®, bioMérieux, France) identified the organisms as Prototheca wickerhamii, which assimilated galactose, trehalose, glycerol and glucose on the kit. Oral itraconazole (200 mg/day) for 8 weeks resulted in complete healing with remaining mild pigmentation, and there was no evidence of recurrence over the following 12 months.

Figure 1 Open in figure viewer PowerPoint Scaly erythematous and eczematous plaque on the right forearm