Ecthyma gangrenosum.

Case 1. An 18-year-old white man with AML-M3 received allogeneic bone marrow transplantation (BMT) in August 1997. On the seventh day of BMT, he developed chills, fever (39.1 °C), anorexia, and perirectal pain. On physical examination, a hemorrhagic bulla and “punched out” ulceration were observed on the perirectal region. Subsequently, the ulcer was surrounded by a red, swollen, tender, cellulitic plaque ( Fig. 1 ).

Figure 1 Open in figure viewer PowerPoint The ulceration on the perianal region of the first patient     

Lyme disease presenting with multiple erythema migrans lesions: an illustrative case

A 39‐year‐old, previously healthy male park ranger presented to the emergency room with a 24‐h history of a rapidly progressive, widespread, painful skin eruption associated with severe viral illness‐like symptoms of fever as high as 40 °C, generalized migratory arthralgias, exhaustion, and malaise with prostration. On physical examination, confluent urticarial plaques, many with dusky and bruise‐like central discoloration, were observed involving approximately 90% of the skin, sparing the scalp, palms, and soles ( Fig. 1 ). He was febrile with a temperature of 39 °C, and had signs of dehydration with orthostatic hypotension. Physical examination, including cardiovascular and neurologic examination, was otherwise normal. There was no evidence of lymphadenopathy.

Figure 1 Open in figure viewer PowerPoint Confluent urticarial plaques     

Amyopathic dermatomyositis

A 54‐year‐old female patient with edema and erythema on both eyelids, hands, and neck was admitted to our clinic in December 1997. The lesions on the eyelids and neck appeared in September 1996, while the lesions on the hands appeared about 1 year later. The patient was using Simvastatyn 10 mg/day (Zocor) for the hyper‐lipidemia and she had also diet‐regulated diabetes mellitus. Systemic examination findings were normal. Chest X‐ray was normal. Laboratory findings were as follows: erythrocyte sedimentation rate 7 mm/h, ASO 200 IU/mL, C‐reactive protein (negative), RF (negative), CBC, urine analysis, liver, kidney functions, blood sugar and electrolytes were normal. Blood lipids were slightly increased. Antinuclear antibodies, anti‐dsDNA, and VDRL were negative. Muscle enzyme values were normal (CPK, lactic dehydrogenase, SGOT). On dermatologic examination, edema and violaceous erythema around the eyelids and V of neck were present. There were erythema, squam, and violet‐colored plane papules 0.5–1 cm in diameter on the metacarpals and extensor surfaces of metacarpophalangeal joints. ( Figs 1 and 2 ) Gottron's papule diagnosis was made on the histopathologic examination of the biopsy of one of the papules.

Figure 1 Open in figure viewer PowerPoint Erythema and edema of the eyelids and erythema on the V of the neck     

Lichen planus pemphigoides presenting with a strikingly unilateral distribution

A 44-year-old Pakistani woman presented with a unilateral eruption of 2 months’ duration. She was in her usual state of health when she awoke one morning with an acute blistering eruption in the right axilla. At that time she also began to experience “rough spots” on the buccal mucosa. Approximately 4 days later, lesions, including small blisters, appeared at multiple other sites, all in a right-sided distribution. The patient had an 8-year history of hypothyroidism and was treated with levothyroxine. Physical examination revealed a widely distributed and strikingly right-sided eruption. Dark brown macules and patches measuring 0.1–1.2 cm, some of which were confluent, were located in the right axillary area at the site of previous blister formation ( Fig. 1a ). Close inspection revealed that some of these lesions had a glistening and violaceous appearance at their periphery. Discrete, small, flat-topped papules with similar qualities were also present at this location. Lichenoid lesions were evident in multiple other

Figure 1 Open in figure viewer PowerPoint (a) Hyperpigmented macules and patches in the right axillary region. Some of these lesions had a glistening, violaceous, and raised quality at the periphery (white arrow) suggesting post-inflammatory hyperpigmentation secondary to lichen planus. (b) Lichenoid lesions in the intergluteal area and the right buttock     

Pigmented vulvar macules as a presenting feature of the Carney complex.

A 27‐year‐old woman was referred by her gynecologist for asymptomatic pigmented vulvar lesions first noted 2 years previously. Medical history was significant for a personal history of atrial myxoma, diagnosed due to a systolic murmur, along with a family (maternal) history of atrial myxoma. The patient also reported irregular menses, increasing and darkening of body and facial hair, and an increase in shoe size. Physical examination revealed multiple 2‐5 mm dark brown to black macules on the labia majora and minora. ( Fig. 1 ) Faint scattered light brown macules were noted on the chest and face. A 2‐mm brown scleral macule was present adjacent to the iris, and scattered small pigmented macules were present on the vermilion border of the lips. A 4‐mm blue‐black papule was found on the upper back, and several firm, 2 mm flesh‐colored papules were found on the abdomen and thigh. Hypertrichosis of both forearms was present, and enlargement of the jaw and hands was noted.

Figure 1 Open in figure viewer PowerPoint Multiple dark brown to black macules on the labia majora and minora     

Barraquer-Simons syndrome with benign infundibulocystic proliferation

A white man attended our outpatient clinic because of soft papules on the second finger of the left hand. They were livid red‐colored, warty surfaced cysts, 1–2 cm in diameter, arranged in an annular configuration ( Fig. 1 ). The patient showed prominent zygomatic bones and symmetric loss of buccal fat pads (Bichat's fats), leading to sunken cheeks ( Fig. 2 ). The history of the patient could not be taken because of his debility.

Figure 1 Open in figure viewer PowerPoint Soft papules on the second finger of the left hand     

Alopecia: a rare manifestation of lupus vulgaris

A 14‐year‐old girl presented with a 2‐year history of gradually developing, asymptomatic, reddish, raised lesions over the scalp, face, arms and trunk. The family history was significant for tuberculosis. Her grandmother was found to have pulmonary tuberculosis. Clinical examination revealed reddish‐brown, soft papules forming two large plaques by coalescence over the scalp and back ( Figs 1 and 2 ).

Figure 1 Open in figure viewer PowerPoint Lupus vulgaris, plaque form manifesting as alopecia     

Late-onset neurofibromatosis in a liver transplant recipient

A 44‐year‐old Caucasian man was admitted in December 1995 for the treatment of generalized skin pruritus. The patient had a history of cirrhosis felt to be caused by chronic ethanol abuse and renal insufficiency. He had undergone orthotopic liver transplantation in January 1991. Physical examination revealed numerous, fleshy, nontender nodules protruding from the face ( Fig. 1 ), trunk, and extremities, as well as axillary freckling. The patient was certain that the lesions had appeared 2–‐3 months after his liver transplant. Wood's lamp examination revealed several café‐au‐lait macules. Ophthalmic examination was remarkable for Lisch nodules ( Fig. 2 ).

Figure 1 Open in figure viewer PowerPoint A representative clinical lesion as a fleshy, non‐tender nodule on the neck. Also a few very small lesions are barely visible on the mandible line     

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     

Prolidase deficiency

A 32‐year‐old mentally retarded woman was admitted to hospital with recurrent ulcers on her legs, which appeared for the first time at 8 years of age. Apart from recurrent lower respiratory tract infections and chronic otitis media, her personal history was unremarkable. Her parents were second‐degree relatives. The family history showed no similar disease or mental retardation. Physical examination revealed that the patient had an unusual facial appearance, with a high‐arched palate; she had multiple tooth caries ( Fig. 1 ).

Figure Figure 1  Open in figure viewer PowerPoint Facial appearance of the patient     

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)     

Cutaneous sinus tract of dental origin.

A 47‐year‐old woman presented with a nodular lesion on her face that had been discharging pus intermittently for 7 months. She could not recall any previous trauma to the site. Dermatologic examination revealed a nontender, erythematous, nodular, draining lesion on the patient's chin ( Fig. 1 ). Dental examination showed poor oral hygiene and severe chronic periodontitis, but no acute infection. Radiography demonstrated diffuse periapical radiolucency associated with the right central mandibular incisor ( Fig. 2 ). The patient was diagnosed with chronic apical periodontitis. Because it was too late for her oral condition to be corrected with endodontic treatment, the tooth was extracted and the scar on her chin was revised later.

Figure 1 Open in figure viewer PowerPoint A cutaneous draining sinus of dental origin presenting as an erythematous nodule on the patient's chin     

Wells’ syndrome triggered by centipede bite

A 68-year-old African–American woman was awoken from her sleep by a centipede bite on the dorsum of her left hand. Several days later, the patient presented to the emergency room complaining of fevers, severe itching, swelling, and blistering ( Fig. 1 ) of both hands. The past history was unremarkable. There was no history of asthma or use of medications. Physical examination at that time was consistent with a bullous cellulitis of the hands. Laboratory investigations revealed: white blood cell count (WBC), 10.3 (normal, 4 1 , 2 , 3 - 9 , 10 .5); differential: 54 neutrophils, 15 lymphocytes, and 31 eosinophils. The platelet count was 225,000/mm³. A blood chemistry profile was within normal limits. Blood cultures and stool examination for ova and parasites were negative. The patient was treated with oral cephalexin and diphenhydramine.

Figure 1 Open in figure viewer PowerPoint Left hand reveals a bulla and several vesicles at the site of the centipede bite     

Xeroderma pigmentosum with limited involvement of the UV-exposed areas: a case report

A 21‐year‐old woman with skin type IV, who had developed photophobia and brown, spotty, hyperpigmented lesions on her face from early childhood, presented to our center for treatment of her facial lesions. Examination on admission revealed numerous, freckle‐like, hyperpigmented macules and actinic keratoses over the central part of the face, with sparing of the forehead, chin, and peripheral area ( Fig. 1 ). The area involved was approximated to be around 2% of the total body surface. The dorsal parts of the hands showed no lesions ( Fig. 2 ), but guttate hypomelanotic lesions were apparent on both forearms.

Figure 1 Open in figure viewer PowerPoint Limitation of xeroderma pigmentosum lesions to the center of the face     

Metastatic gastric cancer presenting as a solitary axillary cutaneous nodule

An 84‐year‐old man, with a medical history of dilated cardiomyopathy, was admitted to our hospital with a nodular lesion in his right axilla of 6 weeks’ duration. There was no history of weight loss, nausea, or vomiting. Physical examination revealed a red–violet axillary nodule, 7 cm in diameter and 3 cm thick, with an ulcerated surface ( Fig. 1 ). A palpable right adenopathy was also found. The rest of the physical examination was normal.

Figure 1 Open in figure viewer PowerPoint Cutaneous nodule located on the right axilla     

Purpuric pityriasis rosea

A 17‐year‐old young man presented with a 2‐week history of an asymptomatic widespread eruption affecting the trunk and arms. On physical examination we observed multiple, oval purpuric macules and papules, 1–3 cm in diameter, distributed in a “christmas tree” pattern on the trunk and arms ( Figs 1 and 2 ). There was no sign of a herald patch and mucosal examination was normal.

Figure 1 Open in figure viewer PowerPoint Lesions distributed in christmas tree pattern on the trunk     

Acneiform lesions in Becker's nevus and breast hypoplasia

An 18‐year‐old woman was referred for the evaluation of a dull gray macule on the left breast. From the age of 13 years, the patient noted breast asymmetry beginning with the development of the left breast and the presence of a pigmented stain on its border. Physical exploration revealed hypoplasia of the left breast and a homogeneous, light brown macule on the side of the breast ( Fig. 1 ) without infiltration. Papules and pustules were located mainly around the Becker's nevus on the left anterior chest wall. Biopsy specimens with Fontana's stain disclosed a hyperpigmented acanthotic epidermis. A diagnosis of Becker's nevus, acne, and hypoplasia of the breast was made.

Figure 1 Open in figure viewer PowerPoint Hypoplasia of the left breast and a homogeneous light brown macule with acneiform lesions     

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     

Cutaneous metastases from hepatocellular carcinoma

A 52‐year‐old South‐east Asian came in with complaints of an ulcerated, profusely bleeding, painful, 7‐cm cutaneous mass over his left scapula. This actively bleeding mass had a dusky vascular appearance and a boggy central core ( Fig. 1 ). The patient first noticed the mass 6 months before seeking medical attention. At that time it was a centimeter in diameter.

Figure 1 Open in figure viewer PowerPoint Appearance of the 7‐cm scapular mass showing signs of bleeding and ulceration     

Three cases of cutaneous sparganosis.

Case 1 A 64‐year‐old man visited our clinic complaining of an asymptomatic nodule on his right thigh, detected 10 days previously. Physical examination revealed a solitary subcutaneous nodule, 1.5 cm in diameter on his right thigh. Twenty years previously the patient had undergone surgery to remove a ‘‘worm’' from his leg. The patient stated that he enjoyed eating raw snakes. On performing excisional biopsy of the lesion, the white, flat, shiny sparganum was detected and removed ( Fig. la ). The histopathological study of the biopsy specimen showed several encapsulated, mummified sparganum pieces and dense lymphohistiocytic infiltration along with neutrophils and eosinophils ( Fig. lb) .

Figure 1 Open in figure viewer PowerPoint (a) A flat, band‐like, white glistening sparganum being removed from the right thigh of case 1. (b) An encapsulated, mummified sparganum piece showing degenerated internal organs (hematoxylin and eosin × 40)