Anand Rajpara

Pleomorphic spindle cell dermal neoplasm with dot‐like keratin reactivity: keratin‐positive AFX or carcinoma?

Atypical fibroxanthoma (AFX) is an uncommon cutaneous neoplasm of pleomorphic myofibroblast‐like cells. Diagnosis requires exclusion of other undifferentiated spindle and pleomorphic cell neoplasms by immunohistochemistry. We report two patients with p63‐non‐reactive spindle cell neoplasms which resembled AFX but demonstrated anomalous dot‐like immunolabeling with antibodies to high molecular weight keratin and keratin 5. One case recurred locally, suggesting such lesions may behave aggressively. Whether these lesions represent keratin‐positive dermal sarcomas or poorly differentiated carcinomas is debatable. Regardless of exact classification, our experience suggests such cases should be managed as high‐risk non‐melanoma skin cancers.

Flesh-colored papules and nodules on the face

A 56-year-old woman with a 6-month, pruritic, tender facial rash sought clinical evaluation and treatment. She had previously been treated with oral minocycline and showed no signs of improvement. Physical exam revealed many hyperpigmented and flesh-colored papules and nodules, some of which were located on the upper cheeks, nasal bridge, medial canthus, and lower cheeks and had central excoriation and umbilication. She had no flushing or telangiectasias (Figs 1 and 2). The patient had no systemic symptoms and did not take any medications. A punch biopsy was taken and sent for routine pathology (Fig 3).

Asymptomatic progressive symmetric telangiectatic patches of the extremities

A 30-year-old man with no significant medical history presented for evaluation of progressive discoloration of his bilateral legs, initially developing 12 years prior and recently spreading to involve the arms. There was no family history of similar lesions. Physical examination found symmetric, blanchable telangiectatic patches of the bilateral proximal lower extremities and milder involvement of the distal upper extremities (Fig 1). A dermoscopic image was obtained (Fig 2). Shave biopsy was sent for routine pathology (Fig 3).

Indurated plaque on the trunk

r-old woman presented to the clinic with erythema and induration of the left back a An 83-yea nd chest. The induration had progressed over 3 years; however, the erythema started after she developed multiple sores within the area of induration about 3 months before her presentation. Her medical history was significant for a history of breast cancer status-post double mastectomy and chemotherapy. The physical examination revealed a red to purple firm indurated plaque over her left chest wrapping around the lateral thorax to involve a large portion of the left flank (Figs 1 and 2). A punch biopsy specimen was obtained to confirm the diagnosis (Fig 3). 1. What is the most likely diagnosis? A. Psoriasis B. Mycosis fungoides C. Herpes zoster D. Carcinoma en cuirasse E. Morphea

Significant cost savings from treating peristomal irritant contact dermatitis with an over-the-counter spray

THERAPEUTIC CHALLENGE Peristomal skin irritation, primarily in the form of irritant contact dermatitis, is the most common early complication after stoma creation. More than one-third of colostomy patients andmore than twothirds of urostomy and ileostomy patients suffer from peristomal dermatoses. They are generally precipitated by contact between stomal effluent and peristomal skin. Associated pain, poor self-image, and social isolation reduce quality of life. Pharmacologic options include topical steroid sprays, gels, lotions, and wipes. Treatments must address inflammation without compromising appliance adherence; creams, ointments, and lotions are impractical because the ostomy bag will not stick. Corticosteroid sprays can be helpful, but they require prescriptions and are expensive, ranging from

A novel anesthetic technique for palmar botulinum toxin injection

251 for Clobex spray (Galderma, Fort Worth, TX) to

Treating gingival pemphigus vulgaris with cotton balls soaked in topical steroid ointment

564 for Topicort spray (Taro Pharmaceuticals, Hawthorne, NY).

Slow-growing, pink, indurated plaque on the arm

SURGICAL CHALLENGE Botulinum toxin type A effectively treats persistent palmar hyperhidrosis, but treatment-associated pain limits utility. Topical anesthesia, ethyl chloride spray, and cold packs have shown limited success. Deep-wrist nerve blocks that target the median and ulnar nerves are effective but carry risks of vessel puncture, impaired hand dexterity, and needle-related nerve trauma. Because patients typically need repeated injections at regular intervals, the compounded risks make deep nerve blocks even less attractive. We propose a local anesthesia method that is more effective than topical therapies while avoiding the complications associated with deep blocks.

Tender nodule on the finger

SOLUTION We describe use of a cotton ball technique for applying topical steroid ointment to gingival pemphigus vulgaris lesions. Topical steroid ointment is applied to the cotton ball, after which the cotton ball is inserted adjacent to the desired gingival treatment area, and left in place for 1 hour. This increases duration of contact between topical steroid and lesion, without the discomfort and bleeding risks associated with intralesional steroid injections and carrier trays.

Erythematous blanchable patches and facial asymmetry with seizures

A 73-year-old man with a history of erythrodermic psoriasis treated with cyclosporine and adalimumab presented for evaluation of a slowly growing lesion on the left arm. The physical examination revealed a solitary 18-cm 3 7-cm pink indurated plaque on the left antecubital fossa with scattered ulcerations (Fig 1). Punch biopsy specimens were obtained and sent for routine pathology and tissue culture. Periodic acid-Schiff stain was performed (Fig 2). A complete blood cell count and comprehensive metabolic panel were within normal limits, and an HIV assay was negative.