Ana María Molina-Ruiz

Frontal fibrosing alopecia: A multicenter review of 355 patients

BACKGROUND To our knowledge, there are no large multicenter studies concerning frontal fibrosing alopecia (FFA) that could give clues about its pathogenesis and best treatment. OBJECTIVE We sought to describe the epidemiology, comorbidities, clinical presentation, diagnostic findings, and therapeutic choices in a large series of patients with FFA. METHODS This retrospective multicenter study included patients given the diagnosis of FFA. Clinical severity was classified based on the recession of the frontotemporal hairline. RESULTS In all, 355 patients (343 women [49 premenopausal] and 12 men) with a mean age of 61 years (range 23-86) were included. Early menopause was detected in 49 patients (14%), whereas 46 (13%) had undergone hysterectomy. Severe FFA was observed in 131 patients (37%). Independent factors associated with severe FFA after multivariate analysis were: eyelash loss, facial papules, and body hair involvement. Eyebrow loss as the initial clinical presentation was associated with mild forms. Antiandrogens such as finasteride and dutasteride were used in 111 patients (31%), with improvement in 52 (47%) and stabilization in 59 (53%). LIMITATIONS The retrospective design is a limitation. CONCLUSIONS Eyelash loss, facial papules, and body hair involvement were associated with severe FFA. Antiandrogens were the most useful treatment.

Histopatología de las alopecias. Parte I: alopecias no cicatriciales

The diagnosis of disorders of the hair and scalp can generally be made on clinical grounds, but clinical signs are not always diagnostic and in some cases more invasive techniques, such as a biopsy, may be necessary. This 2-part article is a detailed review of the histologic features of the main types of alopecia based on the traditional classification of these disorders into 2 major groups: scarring and nonscarring alopecias. Scarring alopecias are disorders in which the hair follicle is replaced by fibrous scar tissue, a process that leads to permanent hair loss. In nonscarring alopecias, the follicles are preserved and hair growth can resume when the cause of the problem is eliminated. In the first part of this review, we describe the histologic features of the main forms of nonscarring alopecia. Since a close clinical-pathological correlation is essential for making a correct histologic diagnosis of alopecia, we also include a brief description of the clinical features of the principal forms of this disorder.

Foreign Body Granulomas

A large list of foreign substances may penetrate the skin and induce a foreign body granulomatous reaction. These particles can enter the skin by voluntary reasons or be caused by accidental inclusion of external substances secondary to cutaneous trauma. In these cases, foreign body granulomas are formed around such disparate substances as starch, cactus bristles, wood splinters, suture material, pencil lead, artificial hair, or insect mouthparts. The purpose of this article is to update dermatologists, pathologists, and other physicians on the most recent etiopathogenesis, clinical presentations, systemic associations, evaluation, and evidence-based management concerning foreign body granulomatous reactions of skin.

Metastatic Melanoma in Association With a Giant Congenital Melanocytic Nevus in an Adult: Controversial CGH Findings

Giant congenital melanocytic nevi (GCMNs) represent a distress to patients for 2 reasons: one is disfigurement, and the other is the increased risk of developing secondary melanocytic tumors, such as benign proliferative nodules (BPNs) and malignant melanoma (MM). BPN present as a rapid growth nodule arising within a congenital melanocytic nevus (CMN) that often ulcerates, occurs in children younger than 2 years of age. BPNs arising within a CMN are exceedingly rare after childhood, and very few cases have been described in adults. Despite the worrisome clinical and histologic findings of BPN, most laboratory investigations seem to support their benignity. The distinction between MM and BPN is extremely important, but the histopathology of BPN of GCMN can be a challenge to differentiate from MM. In the recent years, molecular tests that investigate DNA copy number alterations such as fluorescence in situ hybridization and comparative genomic hybridization have shown promise to help guide the diagnosis of ambiguous melanocytic proliferations arising within CMNs. We report the case of a 22-year-old woman with a nodule arising in a GCMN and with an axillary mass suggesting a nodal metastasis of melanoma, and discuss the unusual clinical, histopathologic, and molecular findings that make this case particularly interesting.

Immunohistochemistry in the diagnosis of cutaneous viral infections--part I. Cutaneous viral infections by herpesviruses and papillomaviruses.

Background:Cutaneous viral infections are of increasing clinical importance, particularly in patients who are immunocompromised. Objective:The use of immunohistochemistry (IHC) in the diagnosis of cutaneous infections provides a rapid morphological diagnosis and can be applied to confirm the diagnosis of specific viral infections that may be difficult to diagnose with certainty using routine microscopy alone, thus facilitating clinical decisions in patient care. Methods:Several immunostains for specific viruses that have been useful in dermatopathology are reviewed. Emphasis is placed on new stains and novel uses of existing stains. Results:This article is an up-to-date overview of the potential uses and limitations of IHC in the histopathologic diagnosis of cutaneous viral infections by herpesviruses and papillomaviruses. Limitations:Whereas specific monoclonal antibodies effectively distinguish infections by herpes simplex virus-1, herpes simplex virus-2, varicella zoster virus, Epstein–Barr virus, and cytomegalovirus, IHC does not distinguish between the 120 antigenically distinct strains of human papillomavirus. Conclusions:IHC may assist dermatopathologists to appropriately diagnose viral infections caused by herpesviruses and papillomaviruses.

Merkel cell carcinoma arising within a poroma: report of two cases.

Merkel cell carcinoma (MCC) has been reported in association with other types of cutaneous neoplasms within the same lesion, including squamous cell carcinoma, Bowens disease, actinic keratosis, follicular cysts, trichoblastoma and lentigo maligna, among others. However, the association of MCC and sweat gland tumors has never been described in the literature. We report two unique cases of MCC that developed within cutaneous poromas. A 56‐year‐old male (Patient 1) and an 81‐year‐old female (Patient 2) presented with nodules on the upper arm and lower back, respectively. Histopathologic study of both cases revealed a tumor in the dermis composed of poroid and cuticular cells intermingled with a proliferation of small round cells that showed characteristic histopathological and immunohistochemical features of MCC. In both cases, the two neoplasms were tightly admixed and distinct, suggesting that the MCC could have developed within a previously existing poroma. No morphological features of transition between the two tumors were seen. Neoplastic cells of MCC expressed immunoreactivity for chromogranin, synaptophysin, neuron‐specific enolase, CAM 5.2 and cytokeratin 20, the last two markers showing the characteristic paranuclear dot‐like pattern. In contrast, the poroma cells only expressed cytokeratin MNF116. Metastatic deposits were not identified in the regional lymph nodes or distantly.

Nodular amyloidosis at the sites of insulin injections

Amyloid is characterized by its fibrillary ultrastructure, and more than 20 proteins have been described to date as possible precursors. Among them, insulin and enfuvirtide represent the only medications described as amyloidogenic substances. We describe two diabetic patients, who were undergoing long‐standing subcutaneous insulin treatment, who developed subcutaneous nodules at the sites of insulin injections. Histopathologic examination showed the presence of eosinophilic and amorphous masses in deep dermis, which stained positive with Congo red, amyloid P substance and anti‐human insulin antibody. Whether the type of injected insulin played a role or not in the pathogenesis of the process is still uncertain, because all described patients used both fast‐acting and slow‐acting insulins at the same injection sites. Our second case showed nodular insulin‐derived amyloid tumors only at the sites where exclusively fast‐acting insulin was injected, which supports the notion that fast‐acting insulin may also be the cause of this disorder. Insulin‐derived nodular amyloidosis is probably underdiagnosed because of the small body of literature in comparison with the prevalence of insulin dependent diabetic patients. This underdiagnosis probably is because of its clinical similarity with the lesions of lipohypertrophy at the sites of insulin injections, which is rarely biopsied.

Acute and severe acne in a patient treated with bevacizumab

Background  Bevacizumab is a recombinant, humanized monoclonal antibody against vascular endothelial growth factor (VEGF) that inhibits angiogenesis. Bevacizumab is typically well tolerated; its major side effects include hypertension, proteinuria, bleeding, gastrointestinal perforation, and arterial thrombotic events, among others. Cutaneous side effects associated with the use of bevacizumab are rare and involve mainly itching and exfoliative dermatitis. Nonspecific skin rash and acneiform eruptions have recently been described in patients following infusion of bevacizumab.

Immunohistochemistry in the diagnosis of cutaneous viral infections- part II: cutaneous viral infections by parvoviruses, poxviruses, paramyxoviridae, picornaviridae, retroviruses and filoviruses.

Background:Cutaneous viral infections are increasing in recent years, particularly in immunocompromised patients. Objective:Immunohistochemistry (IHC) provides a rapid and helpful tool that can be applied to confirm the diagnosis of specific viral infections that may be difficult to diagnose with certainty using routine microscopy alone. Methods:Several immunostains that are useful in histopathology have been reviewed and tested in cutaneous samples of viral infections. Emphasis is placed on new stains and novel uses of existing stains. Results:This article is an up-to-date overview of the potential uses of IHC in the histopathologic diagnosis of cutaneous viral infections by parvoviruses, polyomaviruses, poxviruses, paramyxoviridae, picornaviridae, retroviruses, and filoviruses. Limitations:Specific monoclonal antibodies are commercially available only for some members of these virus families. Conclusions:IHC may assist dermatopathologists to appropriately diagnose viral infections by parvoviruses, polyomaviruses, poxviruses, paramyxoviridae, picornaviridae, retroviruses, and filoviruses.

A rare case of primary cutaneous plasmacytoma‐like lymphoproliferative disorder following renal transplantation

Post‐transplant lymphoproliferative disorder (PTLD) is a lymphoid proliferation that develops as a complication of solid organ or bone marrow transplants. PTLD limited to the skin is very rare. Plasmacytoma‐like PTLD is an uncommon variant of monomorphic PTLD. Its presentation in the skin is extraordinary with very few cases reported in the literature. We report a new case of plasmacytoma‐like PTLD presenting as multiple skin nodules on the leg of a 74‐year‐old kidney transplant recipient. Histopathologic and immunohistochemical examination of one nodule revealed atypical plasmacytoid and plasmablastic cells that showed kappa light chain restriction and stained positive for CD138. Staging investigations excluded extracutaneous manifestations of the disease. This case is unusual for several reasons including involvement limited to the skin, plasmacytoid phenotype of the tumor, presentation 18 years following transplantation and Epstein–Barr virus negativity.