Alvin R. Solomon

Scarring alopecia: a classification based on microscopic criteria

Scarring alopecias are a heterogeneous group of disorders which restilt in the common eiidpoint of follicular destrucdon. The scarring alopecias have been historically grotiped and categot ized according to clinical criteria. This categorization is not ideal. The term scarring is ctinibeisonie, potentially inaccurate and may have different meaning for the clitiician and pathologist, bttt it is a wellestablished term in the liieratme and in clinical use. For this reason alone, we continue to strnggle with the term and ajjply it as appropriately as possible to the clitiical-palhologic entities discussed in this review. For this review, we have classified these types of permanent alopecia iito two broad categories: primar) scarring alopecia and secondary scarring alopecia. A third type of scarring alopecia exists. This latter group of diseases, which may be termed tiansitiotial scan ing alopecia, is the restill of persistence ol abnormalities of follicular dynamics lestiltitig iu die eventtial drop-otU of affected Follicles, Examples oF this type of scarringalopecia incltide chronic, on-going tracdoti alopecia and trichotillomania, as well as persistent, nonremitting alopecia areata, atidtogenetic alopecia and telogeu effinvium (1). This interesting and clinically impottant pattern of scarring alopecia will not be discussed further in this review since our putpose is to describe the histopathologic changes of the types of alopecia classically defined as scarring.

Proliferating trichilemmal tumors: clinicopathologic evaluation is a guide to biologic behavior.

Background:u2002 Trichilemmal (pilar) cysts are common skin lesions that usually occur on the scalp of elderly women. They differentiate towards the follicular outer root sheath epithelium and show trichilemmal keratinization. Proliferating trichilemmal tumor (PTT) shows features of typical pilar cyst, but additionally shows extensive epithelial proliferation, variable cytologic atypia and mitotic activity. The malignant potential of PTT is controversial, as only a small number of histologically malignant PTTs and a smaller number of clinically malignant PTTs have been reported.

Spindle cell lipoma is strongly CD34 positive. An immunohistochemical study.

Spindle cell lipoma (SCL) is an uncommon soft tissue neoplasm that may provide diagnostic difficulty to the histopathologist. Four retrospectively identified SCLs were evaluated immunohistochemically with a broad panel of antibodies (CD34, factor XIIIa, S‐100, actin and factor VIII). All four SCLs were strongly CD34 positive (95 to 100% of cells) and focally factor XIIIa positive (average 16% of cells). Tumor cells were S‐100, actin and factor VIII negative.

Clinicopathologic variants of cutaneous squamous cell carcinoma.

Cutaneous squamous cell carcinomas (SCC) are one of the most common malignancies, which, with early recognition, may be curable. These tumors represent a broad spectrum of disorders with many significant clinical, morphologic, and etiologic distinctions. The objective of this article is to review the important clinicopathologic features of SCC with particular emphasis on important recent developments, practical application, and their relevance to the practice of pathology. The most pertinent literature of the last 5 years was reviewed and capsulized. Appropriate histologic interpretation and clinical management of patients with cutaneous SCC requires a comprehensive understanding of the latest advances in the broad field of dermatopathology. Squamous cell carcinoma of the skin represents a complex group of disease subtypes, each with its own characteristics, which may influence morphologic diagnosis as well as treatment and clinical management.

Paraganglioma-like dermal melanocytic tumor: A unique entity distinct from cellular blue nevus, clear cell sarcoma, and cutaneous melanoma

We are reporting a previously undescribed primary dermal melanocytic tumor identified by reviewing all dermal melanocytic tumors referred in consultation that did not qualify histologically as a previously described entity. From these cases, 8 were remarkably similar. We termed them paraganglioma-like dermal melanocytic tumor (PDMT) based on their nested growth pattern. This term is used descriptively and does not imply any histogenetic or biologic similarity to true paraganglioma. PDMT is primarily a tumor of the extremities of adult females (18-53 years, mean 35 years; males 2; females 6) which present as a dermal nodule (range, 0.5-4.2 cm; mean, 1.4 cm) composed of nests of clear to amphophilic oval cells separated by delicate fibrous strands. Nuclear atypia was mild and mitotic activity low (1-4 mitoses/10 HPF). Melanin was not obvious on light microscopy. Tumors expressed S-100 protein (8 of 8), Melan-A (4 of 8), HMB-45 (8 of 8), and microphthalmia transcription factor (8 of 8) and lacked pancytokeratin (8 of 8) and smooth muscle actin (8 of 8). FISH analysis of 5 cases revealed an intact EWS gene locus, supporting absence of the clear cell sarcoma 12;22 translocation. Follow-up information in 8 patients (range, 35-92 months; mean, 54 months) indicated that all were alive without disease. PDMT comprises a clinically and pathologically unique subtype of dermal melanocytic tumors. Our study suggests a benign course, although a lesion of low malignant potential cannot be excluded.

Disseminated strongyloidiasis with cutaneous manifestations in an immunocompromised host

Recognition of the characteristic cutaneous eruption of disseminated strongyloidiasis can be crucial for early diagnosis and treatment of this potentially fatal infestation. We describe a corticosteroid-dependent elderly man who had a purpuric eruption. Filariform larvae of Strongyloides stercoralis were found in dermal granulomas and also in the sputum.

The role of calcitonin gene‐related peptide in cutaneous immunosuppression induced by repeated subinflammatory ultraviolet irradiation exposure

Abstract:u2002 Ultraviolet (UV) light is an effective treatment for skin disorders like psoriasis in which the cutaneous neurosensory system may have a pathogenic role. In this study, we examined the possibility that UV modulation of the cutaneous neurosensory system and calcitonin gene‐related peptide (CGRP) may contribute to local immunosuppression mediated by repeated subinflammatory UV irradiation. Our results indicated that exposure of hairless mice to subinflammatory UV three times weekly for 4u2003weeks significantly increased the number of epidermal nerve fibers (ENFs) immunoreactive for CGRP without altering the total number of ENFs. The skin content of CGRP as measured by enzyme‐linked immunosorbent assay was also significantly increased after exposure to this dose of UV. These effects were most apparent 1 day after the last UV exposure and declined 1u2003week after UV. The role of CGRP in UV‐induced immunosuppression of contact hypersensitivity was then examined. Our results indicated that UV suppression of epicutaneous 2,4‐dinitro‐1‐fluorobenzene (DNFB) sensitization could be significantly inhibited by a systemically administered CGRP receptor antagonist. A broad‐spectrum sunscreen applied before UV exposure inhibited increased cutaneous CGRP and blocked immunosuppression. These findings support a role for CGRP in the local immunosuppression caused by chronic, repeated subinflammatory UV exposure.

In Vivo human melanoma cytokine production: Inverse correlation of GM-CSF production with tumor depth

Abstract: Melanomas produce multiple cytokines which may influence their growth in vivo. Experimental evidence suggests that granulocyte macrophage‐colony stimulating factor (GM‐CSF) can induce a potent anti‐melanoma response, whereas interleukin‐8 (IL‐8) may act as a growth factor in human melanoma. Little is currently known regarding the production of these cytokines by human melanoma in vivo. In this study we tested the hypothesis that endogenous production of GM‐CSF and IL‐8 can be correlated with the depth of human malignant melanoma surgical specimens. We examined 45 melanocytic human tissue samples consisting of 27 primary cutaneous melanomas, 9 metastatic melanomas, and 9 dysplastic nevi for in vivo GM‐CSF and IL‐8 production using immunohistochemistry. The majority of thin melanomas (≤0.76 mm) stained highly positive for GM‐CSF with little or no staining for IL‐8 whereas the medium (≤0.76 –≤4.0 mm) and thick (>4.0 mm) melanoma specimens showed little or no staining for GM‐CSF and significant amounts of IL‐8 staining. Metastatic melanoma as well as dysplastic nevi specimens had little or no GM‐CSF and IL‐8 staining. These results support the hypothesis that endogenous melanoma cytokines such as GM‐CSF and IL‐8 with opposing effects on tumor progression play an important role in melanoma growth and regulation.

Cryptococcal cellulitis in a diabetic, kidney transplant patient

The cutaneous manifestations of disseminated cryptococcosis are variable and include papules, plaques, nodules, draining sinuses, acneiform lesions, tumors, abscesses, ulcers, pustules, bullae, molluscum-like lesions, and cellulitis.8-1 0 Cryptococcal cellulitis has only been seen in patients with severe underlying diseases such as leukemiaf myeloma,8.11 systemic lupus erythematosusj chronic active hepatitis,? intestinal lymphangiectasia and congenital lymphedema.P as well as in kidney transplant recipients. 1-7 These patients had received immunosuppressive therapy, which in all cases included prednisone. Only a few cases of cryptococcal cellulitis in kidney transplant patients have been reported. 1-7 Most lesions occurred on an extremity and appeared abruptly as a single, tender, indurated, erythematous plaque that was initially mistaken for bacterial cellulitis and erroneously treated with antibiotics. Ours is only the third reported case of cryptococcal cellulitis with multiple sites of involvement.: 7 Methods of directly diagnosing cryptococcal cellulitis include Grams stain or india ink preparation of tissue aspirates and cultures of skin specimens. Cryptococcal cellulitis may histologically demonstrate a variable lymphohistiocytic infiltrate in the Hugh M. Gloster, Jr., MD, Robert A. Swerlick, MD, and Alvin R. Solomon, MD Atlanta, Georgia

Dysplastic Nevi in Children

Issues surrounding the diagnosis and management of the dysplastic nevus have sparked considerable controversy in the dermatologic literature. Despite the great amount of attention to this subject, little has been written about the prob‐lem as it relates to the pediatric patient. For this reason, we formulated a set of questions that we thought needed to be addressed, and sought answers from several dermatologists. The replies largely reflect personal opinions, as few data are available on which to base a standard approach to these lesions.