Congenital Dermal Melanocytosis on the Foot: A Case Report and Review of the Literature

Dermal melanocytosis is a common pigmented skin disease, characterized by an increased number of ectopic melanocytes in the dermis. Rare variants of dermal melanocytosis that do not belong to these four typical groups–nevus of Ota, nevus of Ito, blue nevus, and Mongolian spots–are called dermal melanocyte hamartoma, or congenital dermal melanocytosis (CDM) as it mostly appears from birth. We report a case of CDM on the foot of a young woman with a literature review of previously reported cases of CDM.     

Associations between anti‐melanoma differentiation‐associated gene 5 antibody and demographics,clinical characteristics and laboratory results of patients with dermatomyositis: A systematic meta‐analysis

Anti‐melanoma differentiation‐associated gene 5 (MDA5) antibody is a specific biomarker in patients with dermatomyositis (DM). Results from several studies that examined the relationship between anti‐MDA5 antibody and the demographics, clinical characteristics and laboratory results of DM patients have been conflicting. The purpose of this study was to identify the relationship, if any, of anti‐MDA5 antibody with demographics, clinical characteristics and laboratory results of DM patients. PubMed, Web of Science, Embase and the Cochrane Library databases were searched for studies without language restrictions conducted before 16 March 2017. Stata version 12.0 software was used to calculate pooled odds ratios or weighted mean differences and corresponding 95% confidence intervals to determine the relationship between anti‐MDA5 antibody and patient characteristics. Twenty studies comprising 1500 cases were included in this meta‐analysis. Anti‐MDA5 antibody was strongly associated with clinically amyopathic DM (CADM) and rapidly progressive interstitial lung disease (RPILD). Anti‐MDA5 antibody also increased the risk of developing eight characteristics comprising Gottron's sign or papules, mechanic's hand, V rash, skin ulcers, panniculitis, alopecia, arthritis/arthralgia and pneumomediastinum, but reduced the risk of muscle weakness, classic DM (CDM) and elevated creatine kinase (CK). Our meta‐analysis indicated that anti‐MDA5 antibody is related to muscle weakness, Gottron's sign or papules, mechanic's hand, V rash, skin ulcers, panniculitis, alopecia, arthritis/arthralgia, pneumomediastinum, RPILD, CDM, CADM and elevated CK in patients with DM.     

EMA positivity in epithelioid fibrous histiocytoma: a potential diagnostic pitfall

Background: Epithelioid fibrous histiocytoma (EFH) represents a morphologic variant of cutaneous fibrous histiocytoma (FH) but can lack many characteristic features. The presence of epithelioid cytomorphology may mimic other dermal neoplasms. Our anecdotal experience of epithelial membrane antigen (EMA) expression in some examples of EFH has caused diagnostic difficulty. Our aim was to examine the immunohistochemical profile and incidence of EMA expression in EFH. Methods: Forty‐four cases of EFH were retrieved from consultation files. Clinicopathologic and immunohistochemical features were evaluated. Results: Membranous EMA positivity was found in tumor cells in 27/42 cases (64%). Focal positivity for factor XIIIa was found in 10/14 (71%) and D2‐40 in 14/27 (52%). Scattered smooth muscle actin (SMA)‐positive tumor cells were seen in 11/43 (25%). Focal positivity for claudin‐1 was found in 3/42 (7%). CD163 staining highlighted stromal macrophages; however, in five cases it was difficult to exclude focal staining of tumor cells. Tumor cells were consistently negative for pan‐keratin, AE1/AE3, S100, CD31, CD34, CD68, desmin, p63, GFAP and CD45/LCA. Conclusion: Frequent EMA expression in EFH represents an unexpected finding and constitutes a potential diagnostic pitfall. Although of uncertain significance, this finding, when combined with established morphologic differences, raises the possibility that EFH is unrelated to classic FH. Doyle LA, Fletcher CDM. EMA positivity in epithelioid fibrous histiocytoma: a potential diagnostic pitfall.     

Treatment of COVID‐19 with pentoxifylline: Could it be a potential adjuvant therapy?

The world is facing a viral pandemic of a new coronavirus called COVID‐19. Pentoxifylline is a methyl‐xanthine derivative and it inhibits the phosphodiesterase IV (PDE IV). This drug is known for its unique features as an immunomodulatory and anti‐inflammatory agent, also it could have antiviral affects. This is a scoping review, in which all related articles on COVID‐19 and the probable benefits of Pentoxifylline against COVID‐19 pathogenesis, in Medline, Scopus, Web of Sciences, and Google Scholar up to 20 March 2020 with proper keywords including: pentoxifylline, Pentoxil, COVID‐19, coronavirus, treatment, anti‐inflammatory, immunomodulatory, antifibrosis, oxygenation, circulation, bronchodilator, ARDS, and organ failure. We found many confirmatory data on proper efficacy of pentoxifylline on controlling COVID‐19 and its consequences. The antiviral, anti‐inflammatory, anti‐oxidative, immune‐modulatory, bronchodilator and respiratory supportive effects and protective roles in organ failures of PTX, along with its main functions means better circulation‐oxygenation properties, low price and safety, make it a promising drug to be considered for COVID‐19 treatment, especially as an adjuvant therapy in combination with other drugs.     

Bilastine: a new H1‐antihistamine with an optimal profile for updosing in urticaria

This review set out to examine published papers detailing the efficacy of bilastine in skin models and urticaria to assess whether it meets the optimal profile for updosing in urticaria, that is, strong clinical efficacy and freedom from unwanted side effects, particularly sedation. Bilastine is a highly effective H₁‐antihistamine even when used at the basic dose of 20 mg daily. Its facilitated uptake after oral dosage gives it a rapid onset and long duration of action. In both wheal and flare studies and in urticaria updosing fourfold showed increased effectiveness. With respect to somnolence, bilastine is a substrate for P‐glycoprotein, a membrane pump which prevents it crossing the blood–brain barrier. Consequently, bilastine is a practically ‘non‐sedating’ H₁‐antihistamine. In conclusion, the excellent profile of bilastine in both efficacy and safety make it the ideal H₁‐antihistamine for updosing the daily dose fourfold in difficult‐to‐treat urticaria as recommended by the EAACI/GA²LEN/EDF/WAO guideline for the management of urticaria.     

E‐FABP induces differentiation in normal human keratinocytes and modulates the differentiation process in psoriatic keratinocytes in vitro

Epidermal fatty acid‐binding protein (E‐FABP) is a lipid carrier, originally discovered in human epidermis. We show that E‐FABP is almost exclusively expressed in postmitotic (PM) keratinocytes, corresponding to its localization in the highest suprabasal layers, while it is barely expressed in keratinocyte stem cells (KSC) and transit amplifying (TA) keratinocytes. Transfection of normal human keratinocytes with recombinant (r) E‐FABP induces overexpression of K10 and involucrin. On the other hand, E‐FABP inhibition by siRNA downregulates K10 and involucrin expression in normal keratinocytes through NF‐κB and JNK signalling pathways. E‐FABP is highly expressed in psoriatic epidermis, and it is mainly localized in stratum spinosum. Psoriatic PM keratinocytes overexpress E‐FABP as compared to the same population in normal epidermis. E‐FABP inhibition in psoriatic keratinocytes markedly reduces differentiation, while it upregulates psoriatic markers such as survivin and K16. However, under high‐calcium conditions, E‐FABP silencing downregulates K10 and involucrin, while survivin and K16 expression is completely abolished. These data strongly indicate that E‐FABP plays an important role in keratinocyte differentiation. Moreover, E‐FABP modulates differentiation in psoriatic keratinocytes.     

Cutaneous polyarteritis nodosa: a comprehensive review

Cutaneous polyarteritis nodosa is a rare form of vasculitis relating to small‐to‐medium‐sized arteries. Its etiology is unknown. Clinical manifestations include tender subcutaneous nodules, livedo reticularis, cutaneous ulcers and necrosis. Although it is distinct from systemic polyarteritris nodosa in that it lacks significant internal organ involvement, extra‐cutaneous manifestations may be evident. Commonly encountered symptoms include fever, malaise, myalgias, arthralgias, and paresthesias. Exclusion of systemic polyarteritis nodosa is essential in diagnosis. The clinical course is chronic with remissions, relapses, and a favorable prognosis. Mild cases may resolve with nonsteroidal anti‐inflammatory drugs. If more severe, treatment with systemic corticosteroids generally achieves adequate response; however, adjunctive therapy is often necessary to allow reduction in steroid dosage.     

Vogt‐Koyanagi‐Harada Disease in an Adolescent Boy

Vogt‐Koyanagi‐Harada (VKH) disease is a rare multiorgan disorder that affects the melanocytes of the eyes, skin, inner ear, and meninges. It is more common in women and in patients 30 to 50 years of age; it is rarely seen in children. We report a 14‐year‐old boy who meets the criteria for complete VKH disease.     

Acne infantum as presenting symptom of congenital adrenal hyperplasia due to 11‐beta‐hydroxylase deficiency

Infantile acne is a rare condition which usually begins after the third month of life and appears mainly on the cheeks. Spontaneous healing typically occurs within 2 years. A 2‐year‐old boy developed acne infantum during the first days after birth; it failed to respond to topical treatment. Detailed physical examination and endocrinologic evaluation confirmed the presumed diagnosis of congenital adrenal hyperplasia (CAH), and showed it was caused by 11‐beta‐hydroxylase deficiency. CAH comprises a group of autosomal‐recessively inherited disorders. These hereditary enzyme defects in steroid biosynthesis cause glucocorticoid deficiency and an overproduction of biosynthetic precursor steroids. Adrenal androgen biosynthesis is not impaired but shows a massive reactive overproduction due to the increased ACTH secretion within the up‐regulated hypothalamo‐pituitary‐adrenal system. The characteristic features of CAH in male infants are demonstrated on the basis of this case report.     

Methicillin resistant Staphylococcus aureus (MRSA): Diagnostic,clinical relevance and therapy

In the last decades, increasing numbers of patients with problematic bacteria such as methicillin‐resistant Staphylococcus aureus (MRSA) have been reported. Beside the common problem of MRSA variants in hospitals, recently community‐based MRSA (cMRSA) has become a growing problem even in patients without typical risk factors. cMRSA often carries the virulence factor Panton‐Valentine‐leukocidin (PVL) causing dermatologic diseases like therapy‐refractory furunculosis in young adults. Thus, it is both a medical and health economic issue to identify MRSA as quickly as possible and then eradiate it completely. We review the practical consequences and in particular, the therapy options which are reasonable once MRSA is identified.     

Keratoacanthoma with perineural invasion: An indicator for aggressive behavior?

Neurotropic invasion of keratoacanthoma (KA) is rare and can easily be missed histologically. A 36‐year‐old woman developed a KA on the upper lip four weeks after CO₂ laser skin resurfacing; it showed microscopic evidence of perineural invasion. Despite repeated treatment with intralesional methotrexate, the KA recurred after 6 months. She was then treated with ionizing radiation (56 Gy) and has been tumor‐free for more than 3 years. Immunohistochemistry showed decreased expression of desmoglein 1 as it is seen in squamous cell carcinomas. In most cases not much importance is attached to perineural invasion which is frequently seen in KA because of the high rate of spontaneous regression. Our case suggests that perineural invasion may be an indicator for aggressive growth of head‐and‐neck KAs so that histologically‐controlled excision is recommended.     

Clinical and histological evaluation of 1% nadifloxacin cream in the treatment of acne vulgaris in Korean patients

Objectives Nadifloxacin is a fluoroquinolone with broad‐spectrum antibacterial activity. Although it is used as an acne treatment in some European countries, it has not been used to treat Korean acne patients. We aimed to evaluate the clinical efficacy and safety of 1% nadifloxacin cream and the histological changes it incurs when used to treat mild to moderate facial acne in Korean patients. Methods An eight‐week, randomized, prospective, split‐face, double‐blind, vehicle‐controlled trial was performed. All participants were treated with 1% nadifloxacin cream on one‐half of the face and vehicle cream on the other, twice per day for eight weeks. Results At final visits, inflammatory acne lesions were reduced by 70% on nadifloxacin‐treated skin and increased by 13.5% on vehicle‐treated skin; non‐inflammatory acne lesions showed reductions of 48.1 and 10.1%, respectively. A significant difference was observed between the two treatments at four weeks. Histopathological examinations of the acne lesions showed decreased inflammation and interleukin‐8 expression but no change in transforming growth factor‐β expression in nadifloxacin‐treated skin compared with vehicle‐treated skin after eight weeks of treatment. Conclusions Nadifloxacin 1% cream is an effective, safe, and well‐tolerated topical treatment for Korean patients with mild to moderate acne vulgaris. Histopathological changes after nadifloxacin treatment were well correlated with clinical outcomes. Therefore, nadifloxacin can be used as an effective and safe treatment option in the management of mild to moderate acne in Asian subjects.     

Surgical subcision as a cost-effective and minimally invasive treatment for axillary osmidrosis

Background Axillary osmidrosis, characterized by unpleasant odor and occasional staining of clothing, is a personal discomfort and social impairment for people who suffer from it. Various types of surgical procedures involving instrumented‐assisted tools (lasers, ultrasonic, endoscope, and others) have shown relatively positive results; however, for patients in developing countries, especially in China, these treatments are inconvenient and cost‐ineffective. Objective To introduce a minimal incision surgical procedure with skin flap treatment that removes the apocrine sweat glands in the subcutaneous tissue through a 1‐cm‐long incision without instrument‐assisted tools. Method From July 2005 to October of 2007, 108 patients (68 women and 40 men) were treated with the minimal incision and cost‐effective surgical treatment by manual excision. A 1‐cm‐long incision is made in the axillary crease. Subcutaneous tissue and glands were removed with scissors through this incision. This procedure is repeated throughout the entire axilla until the axilla has essentially become a super‐thin flap. Result Malodor elimination was good in 206 out of 215 axillae (95.8%) treated, fair in nine (4.2%), and poor in zero (0%). The resulting scar is small and virtually invisible because it is only 1‐cm long and located in the axillary crease. Conclusion Treatment of axillary osmidrosis by manual excision through a 1‐cm incision is a convenient, efficient, cost‐effective, and relatively safe technique that results in high patient satisfaction and benefits patients and surgeons in developing countries. Axillary osmidrosis, a non‐life‐threatening condition characterized by unpleasant odor and occasional staining of clothing, is an annoying problem, particularly in Asian societies. For many people who suffer from this problem, this condition is a personal discomfort, a social impairment, and discourages patients from enjoying social or personal activities, especially young women. They are usually embarrassed by the smell during their daily activities and communication with other people.     

Novel coronavirus disease 2019 (COVID‐19) and neurodegenerative disorders

During the last few months, the whole humanity is experiencing largest and most severe sudden influx of COVID‐19 outbreak caused by the novel coronavirus (CoV) originated from Wuhan, China. According to the WHO reports, total 3 862 676 positive cases and 265 961 deaths have been recorded worldwide due to COVID‐19 infection as of May 9, 2020. CoVs are a large family of viruses (enveloped, single‐stranded RNA viruses), which includes severe acute respiratory syndrome coronavirus (SARS‐CoV) and Middle East respiratory syndrome‐related coronavirus (MERS‐CoV). New SARS CoV2 is the members of Betacoronavirus genus. These viruses cause infections in bats, camels and humans, and a few other associated species. Despite many neurologic complications associated with SARS‐CoV‐2 infection, it is still unclear whether these symptoms results from direct neural injury or due to some other reason. Currently, it appears that most of the neurological symptoms of COVID‐19 are nonspecific and secondary to the systemic illness. A single case of acute hemorrhagic necrotizing encephalopathy has been reported. SARS‐CoV‐2 associated Guillain‐Barré syndrome is an atypical case. Till today, no convincing evidence is available to confirm that the SARS‐CoV‐2 virus directly affects nerves system in humans. However, postinfection surveillance will be necessary to identify the possible post‐COVID‐19 neurologic syndromes.     

Image Gallery: Pyoderma gangrenosum of the penis

Hidradenitis suppurativa (HS) is a serious skin disease. The cause of HS not known, but it is thought that a disturbance in the immune system's response plays an important role. Studies have found elevated levels of small proteins called cytokines in HS skin. Cytokines are signalling molecules that cells of the immune system use to communicate with each other. Some cytokines cause more inflammation in the skin and others reduce it. IL‐17A is one of the cytokines that cause inflammation, and it was found to be elevated in HS skin. If you remove IL‐17A from the skin tissue, inflammation is reduced and may even disappear. Secukinumab is an antibody that binds and destroys IL‐17A. Because there is a lot of IL‐17A in the skin of HS patients, we have tried this new treatment in a patient with severe disease. Our patient is a 47‐year‐old man, with severe HS. He has been treated for many years and only had temporary benefit from several other treatments that have been tried. We carefully recorded the patient's experience of the treatment, comparing the results at the start of treatment with those after 12 weeks of treatment. After treatment with secukinumab the patient reported fewer boils (going from 23 to 7); less pain (going from 5 to 3 on a ten point scale) and less pain/utility loss/handicap (going from 7 to 4 on a ten point scale). The results may be taken to imply that medications targeting IL‐17A could provide a possible treatment approach for HS in the future.     

Pseudogranulomatous Spitz nevus: a variant of Spitz nevus with heavy inflammatory infiltrate mimicking a granulomatous dermatitis

Spitz nevus is a benign melanocytic proliferation that shows relatively characteristic clinicopathologic features. Despite this, Spitz nevus is clinically confused with many other lesions, and histopathologically it is sometimes difficult to distinguish it from melanoma. However, Spitz nevus rarely causes differential diagnostic problems with granulomatous dermatitis. This article describes an 8‐year‐old girl who presented with a nodule on her right arm, a clinical appearance of a pyogenic granuloma. Histopathologically, there was a dermal lesion composed of aggregates of large epithelioid cells surrounded by a heavy inflammatory infiltrate, mimicking a sarcoid‐like granulomatous dermatitis. Immunohistochemistry showed epithelioid cells with strong nuclear and cytoplasmic staining with S‐100 protein, thus establishing the diagnosis of a melanocytic tumor. The heavy T‐cell lymphocytic infiltrate that accompanies the large epithelioid cells caused its granulomatous appearance. Molecular assessment showed H27H mutation in the HRAS gene. We suggest the term ‘pseudogranulomatous’ for this variant of Spitz nevus because it indicates that the lesion is not authentically granulomatous and simply mimics a granulomatous dermatitis.     

Nodular colloid milium mimicking keloid

Colloid milium is a rare cutaneous deposit disease that usually presents clinically by the development of yellowish translucent or flesh‐colored papules or plaques on sun‐exposed skin. Histologically, it is characterized by the presence of colloid in the dermal papillae. In this case report, we present a 52‐year‐old man who presented with a nodule on his upper lip that mistakenly was diagnosed and treated as keloid.     

Erythema multiforme: Differences between HSV‐1 and HSV‐2 and management of the disease—A case report and mini review

Erythema multiforme (EM) is an immune‐mediated reaction characterized by target lesions and with possible mucosal involvement. Its most frequent cause is HSV, with HSV‐1 more common than ?2. It is usually self‐limited but it can show recurrences. We report a peculiar case of recurrent herpes‐associated erythema multiforme (HAEM) in a 35‐year‐old man. The patient was affected by both herpes labialis and genitalis, but the typical target lesions were only associated with recurrent herpes labialis. Here, we hypothesize about the pathogenic differences between HSV‐1 and HSV‐2, and discuss the therapeutic management of HAEM.