Silicone breast implant rupture presenting as bilateral leg nodules

Gross migration of silicone gel from ruptured breast implants is a rare event. It is associated with extravasation of gel into the breast parenchyma, and to distant locations such as the abdominal wall and inguinal areas. This silicone deposits present as subcutaneous nodules and cause a local reaction known as siliconoma. We evaluated a 56-year-old woman who presented with a 2-year history of painful, firm and ill-defined subcutaneous nodules on the medial aspect of the shins and ankles. Her medical history was notable for bilateral breast augmentation with silicone implants 30 years before presentation. Although there were no signs or symptoms on breast examination, ultrasonography and magnetic resonance imaging confirmed that both implants had ruptured. Histological examination of a punch biopsy from a nodule on the shin found lobular granulomatous panniculitis. An excisional biopsy of the lesion was analysed by scanning electron microscopy and was found to contain silicone. This is a rare case of gross migration of silicone to the shins, originating from ruptured breast implants. To our knowledge, there is no previous report of silicone migration to such a distant location. We discuss the common presentation of silicone migration and highlight the importance of awareness among dermatologists and plastic surgeons about this unusual occurrence.     

Reactions at silicone-injected sites on the face associated with silicone breast implant "inflammation" or "rejection"

Although complications in various parts of the body have been suggested as being produced when silicone mammary implants are "rejected" or produce inflammation, there have apparently been no reports describing "flares" at previous sites of facial silicone injections as complications of mammary silicone implants. Such reactions appear to be comparable to so-called "systemic contact dermatitis." However, in the absence of results of skin testing, the mechanism of such "ectopic" flares remains in doubt.     

Cutaneous defects of focal dermal hypoplasia: an ectomesodermal dysplasia syndrome

The 5 major cutaneous defects of development found in focal dermal hypoplasia, an ectomesodermal dysplasia syndrome, are: aplasia cutis congenita, multiform atrophy-like areas, striate, papillomatous, and lipomatous lesions of skin. Subepidermal lipomatosis, present in some lesions, has been reported to be due to absence of dermis or a striking underdevelopment of connective tissue with replacement by adipose tissue from herniation of subcutaneous fat through multiple areas of hypoplasia. We believe this theory to be a major error in interpretation of the microscopic findings. We have had the unique experience of studying 2 patients periodically for 27-30 years and 2 additional patients for a shorter time. Biopsy specimens were removed at intervals for analysis from the same or similar lesions (43 specimens) from these 4 individuals. Our evidence strongly supports the concept that the cutaneous defects of development involving fat cells represent heterotopic fat i.e. a fat nevus resulting from dysplasia, not hypoplasia followed by herniation of subcutaneous fat.     

Histopathological evidence of small-vessel vasculitis within the skin and lungs associated with interstitial pneumonia in an adult patient with dermatomyositis

Dermatomyositis (DM) often has a poor prognosis, due to complications associated with malignancy or interstitial pneumonia (IP). It is uncommon to find histopathological small-vessel vasculitis within cutaneous lesions and pulmonary capillaritis in patients with DM. A 64-year-old woman was diagnosed with DM based on the presence of quadriparesis, typical heliotropic rash, Gottron's papules, increased serum levels of muscle enzymes and typical muscle biopsy findings. She also had associated IP, which subsequently developed into a rapidly progressive condition. We found a high titre of Krebs von den Lunge (KL)-6 in her serum. Measurement of serum KL-6 level is widely accepted as a diagnostic test to monitor the activity of interstitial lung diseases. Histopathological examinations of the cutaneous and lung-associated features showed small-vessel vasculitis. We suggest that investigation of KL-6 levels in patients with DM and associated conditions should be carried out to determine if raised KL-6 levels are useful at predicting outcome or severity of various features.     

Flexural erythematous eruption following autologous peripheral blood stem cell transplantation: a study of four cases

Autologous bone marrow transplantation and autologous peripheral blood stem cell transplantation (APBSCT) are alternative therapeutic options in the treatment of various malignancies. We describe four patients undergoing APBSCT for malignancies; they developed a cutaneous eruption characterized by confluent erythematous and hyperpigmented patches within the flexural areas during the first month after transplantation. The lesions were poorly circumscribed without epidermal changes such as scaling, xerosis, erosions or atrophy. The skin patches were treated with topical corticosteroids and resolved within a few days with discoloration. Histopathological findings were characterized by focal vacuolar degeneration of the basal layer with epidermal dysmaturation. We believe that these cutaneous eruptions are consistent with an interplay of high-dose chemotherapy and local factors such as friction, local skin temperature and eccrine gland distribution, which could explain the constant location of this eruption in the axillae and genital area.     

Prevention and early diagnosis of melanoma: a regional experience in Italy

Background Over the 1980s several education campaigns for prevention and early diagnosis of cutaneous melanoma have been reported from various parts of the world. Aim To improve incidence and prognosis of cutaneous melanoma in 1985 we started, in our area, an information and health education campaign aimed at identifying precursors of melanoma (congenital melanocytic nevi), suspicious lesions (changing moles) and subjects with increased risk of melanoma. Method Precursors and suspicious lesions were promptly removed, and high-risk persons entered the follow-up program. Result As a general effect of these activities the percentage of thin melanomas diagnosed in our division after 1985 increased from 25 to 37. Conclusion We believe that education campaigns and screening of a targeted population, particularly of subjects presenting increased risk of melanoma, may be helpful in the early diagnosis of melanoma.     

Histologic features of cutaneous sinus histiocytosis (Rosai-Dorfman disease): study of cases both with and without systemic involvement

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) is a systemic proliferation of cells that resemble the sinus histiocytes of lymph nodes. Whereas initial reports highlighted the often striking cervical adenopathy, more than 40% of patients have extranodal involvement. Cutaneous lesions are the most common form of extranodal disease, but cases that present as cutaneous disease without lymph node involvement are rare. We examined biopsies from three patients with cutaneous lesions of sinus histiocytosis, none of whom had detectable systemic involvement, and compared them to those of two patients whose lymph nodes were involved by the disease. The histology of skin lesions in all five cases showed dense nodular or diffuse infiltrates of "histiocytes," emperipolesis of lymphocytes, neutrophils, and plasma cells. "Histiocytes" were present in lumens of dilated lymphatics. At the peripheries of the lesions were lymphoid aggregates and thick-walled vessels surrounded by plasma cells. Staining with anti-S-100 protein antibody showed marked cytoplasmic positivity in the "histiocytes" in each case. The only features that differed among the two groups were the presence of pseudoepitheliomatous hyperplasia and infiltrates of eosinophils in one case in which the disease was limited to the skin. We believe that cutaneous sinus histiocytosis can be specifically diagnosed by skin biopsy. Because cutaneous sinus histiocytosis may be unfamiliar to general pathologists, dermatopathologists, and dermatologists, cases limited to the skin may be under-recognized.     

Skin diseases in Turkish renal transplant recipients

BACKGROUND: Organ transplant recipients are predisposed to a variety of cutaneous complications due to immunosuppressive therapy. We aimed to determine the prevalence and the clinical spectrum of skin diseases in renal transplant recipients (RTRs). METHODS: One hundred and eleven RTRs were examined at the Renal Transplantation Center in Ege University Hospital between October 1999 and October 2001. The effects of age, gender and duration time after transplantation on cutaneous manifestations were evaluated and the dermatologic manifestations in RTRs were compared with findings in a control group consisting of 100 patients. The t-test, chi2 test and Fisher's exact test were used for statistical analysis. RESULTS: Seventy-five patients (66.4%) had an infection of the skin, 66 patients (58.4%) had drug-related manifestations, and 11 patients (9.7%) had premalignant or malignant skin lesions. Human papilloma virus (HPV) infections were the most common skin lesions. There was no significant relation between age and gender and the incidence of skin diseases in RTRs. The incidence of HPV infections, tinea versicolor and premalignant and malignant lesions increased with the duration of immunosuppression. The incidence of infectious skin diseases, especially HPV infections and tinea versicolor, was higher in the study group than in the control group. CONCLUSIONS: In this study, we observed that cutaneous lesions, especially those caused by infectious diseases, had a higher frequency in RTRs. The findings emphasize the importance of regular dermatological screening in these patients, which can provide early diagnosis and a better quality of life for RTRs.     

Cutaneous oncocytoma - a report of three cases and review of the literature

The oncocyte is a cell characterized by capacious, eosinophilic, finely granular cytoplasm, and lesions composed primarily of oncocytes are termed oncocytomas. Whereas oncocytic metaplasia has been reported in various cutaneous neoplasms, oncocytomas typically occur in the kidneys, thyroid and salivary glands and are uncommon in the dermatopathology literature. We present three cases of cutaneous oncocytoma so that dermatopathologists are cognizant of this uncommon entity. Although some believe that oncocytomas are locally aggressive lesions, our cases indicate that their clinical course is perhaps as banal as their histology.     

Multiple xanthogranulomas in an adult

Xanthogranulomas develop in adults as well as in children; however, adult cases with multiple lesions are very rare. We report an adult who developed both multiple cutaneous lesions on the face and trunk and lesions on the conjunctiva, oral mucosa and genitalia. We believe that this is the first such case described.     

Cutaneous granulomas associated with adult T-cell leukemia/lymphoma

A 59-year-old Japanese woman showed recurrent violaceous, indurated erythemas and papules on the buttocks and extremities for a period of 7 years. The lesions showed histologically epithelioid cell granulomas associated with lymphocytes. After 7 years, the patient developed adult T-cell leukemia (ATL), of the acute type, the course of which was fatal. Immunohistochemical staining of the skin sections of granulomatous lesions showed prominent infiltration of CD25-positive cells. Human T-lymphotropic virus type I proviral DNA and monoclonal T-cell receptor beta gene rearrangement were detected in the skin samples by a retrospectively performed gene analysis. We believe that the patient initially had an unusual cutaneous type of ATL in which granulomas occurred as a host-protective response against ATL progression.     

Self-Healing Infantile Familial Cutaneous Mucinosis

Abstract: Childhood cutaneous mucinoses have been rarely reported and are difficult to classify. We describe two brothers who developed multiple, extensive cutaneous lesions during the first few months of life Histologically the lesions were composed of mucin deposits in the dermis. In the first patient, the lesions spontaneously disappeared over the years. We believe that familial self-healing cutaneous mucinosis represents a unique entity not previously reported.     

Liquid injectable silicone for soft tissue augmentation

Liquid injectable silicone is a unique soft tissue augmenting agent that may be effectively utilized for the correction of specific cutaneous and subcutaneous atrophies. Although historical complications have occurred, resulting likely from the presence of adulterants and impurities, modern purified silicone products approved by the Food and Drug Administration for injection into the human body may be employed with minimal complications when strict protocol is followed. In this article the present authors review the history and controversy regarding silicone as well as describe the appropriate indications, patient selection, instrumentation, treatment protocol, and anticipated complications involved with the use of liquid injectable silicone for soft tissue augmentation. Although its use is controversial, the present authors maintain that liquid injectable silicone is an important and effective augmenting agent for the long-term correction of scars and facial contour defects such as HIV facial lipoatrophy. Furthermore, it is a treatment modality deserving of continued investigation.     

Local treatment of mycosis fungoides with dichlorodiethyl sulfide in combination with phototherapy

9 patients suffering from mycosis fungoides in various stages were topically treated with dichlorodiethyl sulfide solution associated with photochemotherapy. Topical application of dichlorodiethyl sulfide is indicated in the stages 1 to 3. In more advanced stages, the cutaneous lesions showed good response to therapy, but systemic lesions could not be influenced. Only one patient developed sensitization to topical dichlorodiethyl sulfide. The low incidence of allergic complications may be due to the combined therapy of dichlorodiethyl sulfide and photochemotherapy.     

Rowell's syndrome

Rowell's syndrome is the name given to a distinct group of patients with lupus erythematosus who develop erythema multiforme-like lesions and have a characteristic serological picture. We report a case of a 29-year-old woman of Afro-Caribbean origin who presented with an erythema multiforme-like eruption on the hands. Subsequently she developed painful erythematous swellings on the feet and scaly plaques on the forearm and thigh consistent with subacute cutaneous lupus. She developed a positive antinuclear factor and had positive anti-Ro and anti-La antibodies and a positive rheumatoid factor. All of these features are consistent with Rowell's syndrome which we believe is a rare but distinct variant of cutaneous lupus erythematosus.     

Schwere Komplikationen nach glutealer Silikoninjektion

Silicone has a broad range of medical applications and plays an important role, for example, in plastic reconstruction. The use of silicone, however, may result in unpredictable consequences for the patient. These range from swelling and erythema at the site of injection and regional lymphadenopathy to the development of disseminated granulomas distant from the administration site. We report a woman who developed extensive distally-spreading ulcerations in both buttocks several years after gluteal silicone injection. Potential systemic reactions of silicone include intrapulmonary granulomas, embolism and related pneumonitis. Moreover, an association with the development of autoimmune diseases and neoplasias has been discussed. Therapeutic options include surgically removing the silicone and topical or systemic anti-inflammatory drug therapy. However, due to the diffuse dissemination of silicone, the former is often not completely possible and for the latter empirical data are limited and follow-up studies are missing. Liquid silicone is no longer authorized in Europe or in the U.S.A. When silicone implants are used, the decision should be weighed carefully and the patient adequately counseled. In addition, follow-up care on a regular basis is mandatory for both those with implants and those who obtained injections of liquid silicone in the past.     

Herpes gestationis: clinical and histologic features of twenty-eight cases

We have studied 28 patients with well-documented herpes gestationis (HG) to determine the frequency of complications and to review the histopathology, immunopathology, and clinical parameters of disease. The frequency of miscarriages and other maternal complications in our series was not extraordinary. Fetal complications were similarly limited. Less than 5% of infants had cutaneous lesions, and no other untoward fetal complications were apparent. Although the clinical features of our patients largely paralleled those typically reported for patients with HG, several variants of disease were noted. We report one woman with immunofluorescence-confirmed HG who had no clinical disease during a subsequent pregnancy. We also identified cases in which the characteristic vesiculobullous lesions of HG never developed. Instead, four women had urticarial papules or plaques throughout their clinical courses. HG was verified in these four women by typical immunofluorescent findings and by recurrent, classical disease during subsequent pregnancies in two. In addition, two women were identified with recurrent HG during pregnancies by different husbands.     

Foreign bodies in sarcoidosis

Sarcoidosis is a multisystem disease of unknown etiology. The demonstration of polarizable foreign bodies in cutaneous granulomas is generally thought to exclude a diagnosis of sarcoidosis. Nevertheless. some investigators have reported systemic sarcoidosis with cutaneous manifestations in which polarizable particles were associated with granuloma formation in the skin. We searched the biopsy specimens of granulomatous lesions from 50 patients with cutaneous sarcoidosis using polarization microscopy to estimate the frequency of polarizable foreign bodies in cutaneous lesions of sarcoidosis. Using electron probe microanalysis, we sought to determine what elements compose these foreign bodies. Polarizable foreign bodies were found in the granulomatous skin lesions of 12 of 50 patients with cutaneous sarcoidosis. All 12 patients also had at least one other granulomatous systemic lesion, and 4 had biopsy specimens of a systemic lesion available for review. Polarizable foreign bodies were found in two cases. The elements identified were calcium, phosphorus, silicon, and aluminum. Polarizable foreign bodies were found in cutaneous sarcoidosis far more often than expected. Foreign bodies were also found in granulomatous systemic lesions. The foreign body may serve as an inciting stimulus for granuloma formation in selected cases of sarcoidosis.     

Colchicine in the treatment of the cutaneous manifestations of Behçet's disease

Five patients with Behçet's disease were satisfactorily treated with colchicine. Oral aphthosis, erythema nodosum-like lesions and genital erosions improved greatly within a month as did laboratory findings. We believe colchicine to be the first choice in the management of the cutaneous and ocular lesions of Behçet's disease.     

A double-blind controlled clinical trial assessing the effect of topical gels on striae distensae (stretch marks): a non-invasive imaging, morphological and immunohistochemical study

Striae distensae (SD) are cutaneous lesions often presenting post-pregnancy with atrophy and flattening of the epidermis. SD is poorly understood and treatment remains ill-defined. Our aim was to assess the effect of topical application of silicone gel compared with placebo on SD using non-invasive devices and by immunohistochemical analysis of sequential tissue biopsies in a double-blind controlled trial. Twenty volunteers massaged silicone and placebo gels into separate sides of the abdomen, daily for 6 weeks. Objective non-invasive imaging plus subjective self-assessment of SD were performed on days 0, 21, 42, 90, in addition to tissue biopsies on days 0 and 42. Non-invasive imaging demonstrated an increase in melanin and a decrease in haemoglobin, collagen and pliability over the 6-week period on both sides. Additionally, collagen levels in SD were significantly higher (p value = 0.001) and melanin levels lower (p value = 0.048) with silicone gel compared with placebo. Histological analysis revealed epidermal flattening with a reduction of rete ridges in SD on both sides. Vascular count significantly decreased with placebo gel (p = 0.002). Corroborating the clinical results, melanin levels increased, whilst collagen type 1 and elastin decreased on both sides. Non-invasive techniques showed that the application of silicone gel increased collagen levels and reduced pigmentation compared with placebo. However, both clinical and histological data revealed that melanin increased whilst collagen, elastin and pliability decreased over the 6-week period with both gels. Furthermore, vascularity significantly decreased with placebo gel. These findings provide preliminary evidence of the utility of topical gels in the clinical management of SD.