Elisabeth Riedl

Dermatoscopy of pigmented Bowen's disease

BACKGROUND Pigmented Bowens disease is not well characterized. OBJECTIVE To characterize the clinical and dermatoscopic appearance of pigmented Bowens disease. METHODS We performed a retrospective analysis of 52 consecutive cases of pigmented Bowens disease. RESULTS Of 951 histopathologically verified cases of Bowens disease that underwent biopsy during the study period, 52 (5.5%) were pigmented. Dermatoscopically pigmented Bowens disease is typified by a pattern of dots and/or structureless zones. In 21.2% (n=11), we observed brown or gray dots arranged in a linear fashion. Vessels were identified in 67.3% of lesions with a predomination of coiled vessels. A linear arrangement of vessels was seen in 11.5%. LIMITATIONS Conclusions are limited by the fact that this was a retrospective, uncontrolled study. CONCLUSIONS Pigmented Bowens disease has a characteristic dermatoscopic pattern. Linear arrangement of brown and/or gray dots and/or coiled vessels is a specific clue to pigmented Bowens disease.

Platelet endothelial cell adhesion molecule-1 (PECAM-1/CD31) and CD99 are critical in lymphatic transmigration of human dendritic cells.

The reverse transmigration (RT) of tissue-resident dendritic cells (DCs) across lymphatic endothelia is prerequisite for the initiation of adaptive immune responses and might be regulated in a manner similar to diapedesis. Specifically, CD31 and CD99, which act as gatekeepers during diapedesis, might have a role in RT of DCs. We found that human lymphatic endothelial cells (LECs) and DCs in vitro and in human skin explants express CD31 and CD99. In human skin, CD31 was enriched along intercellular surfaces of LECs, whereas CD99 was preferentially confined to luminal surfaces as evidenced by immunoelectron microscopy. Confocal microscopy analysis revealed that tumor necrosis factor-alpha (TNF-α) and CXCL12 acted as inducers of RT in vitro, but only CXCL12 stimulation resulted in a significant increase in migration rate of DCs. Upon TNF-α stimulation, CXCL12 mRNA levels transiently increased in human fibroblasts and LECs, whereas CXCL12 protein expression levels did not significantly change. Blocking mAbs to CD31 and CD99 significantly reduced RT of DCs across cultured human LEC monolayers and blocked CXCL12-induced migration of DCs in whole-skin explants. In sum, this study shows that CD31 and CD99 are involved in the RT of DCs across LECs and that similar mechanisms promote both diapedesis and RT.

Pyoderma Gangrenosum in a Patient With Seronegative Rheumatoid Arthritis During Therapy With Adalimumab : Toxic Effects of Adalimumab or Failure of Adalimumab to Prevent the Onset of This Phenomenon?

Comment. In 1997, Langley et al presented a case, reviewed the literature, and proposed a classification system for this rare condition. Since then, other cases have been reported. In the analysis, eruptive milia were noted to occur in 3 settings: (1) spontaneously with no known cause or association; (2) in familial syndromes with autosomal dominant transmission; or (3) as a component of genodermatosis. For example, it has been described in a 3-year-old child who presented with palmoplantar keratoderma, solitary nodular calcinosis, and numerous milia during the first few months of life. Milia in that case cleared spontaneously after several months. Four generations in this family had similar constellations of findings. The case presented herein, like that reported by Langely et al, fits into the first group. Rapid clearing with topical tretinoin cream was demonstrated, which suggests superficiality more responsive to a desquamative effect.

Fixed drug eruption caused by mefenamic acid: a case series and diagnostic algorithms

Background: Fixed drug eruption is a fairly common drug‐induced hypersensitivity reaction of the skin and the mucous membranes, which is characterized by the re‐occurrence of the lesion(s) exactly on the previously involved sites after repeated administration. The pathogenetic mechanisms of this site‐specificity are not fully elucidated.

A study assessing the feasibility and diagnostic accuracy of real-time teledermatopathology.

Dermatopathology represents the gold standard for the diagnosis of skin diseases and neoplasms that cannot be diagnosed on clinical grounds alone. The aim of this study was to test the feasibility and to assess the accuracy of an Internet-based real-time (live) teledermatopathology consultation. Twenty teaching cases and 10 randomly selected routine cases were presented to four expert dermatopathologists, first by real-time teledermatopathology and, subsequently, in a blinded fashion, using light microscopy. Throughout the study the overall diagnostic accuracy did not differ for the two methods. However, the mean level of confidence and the mean observation times differed significantly between real-time teledermatopathology and light microscopy (92.6±0.24% versus 99.5±0.02%, and 96.31±11.55 sec versus 25.47±3.85 sec, respectively). Assessment of routine cases did not produce significant diagnostic differences between the two methods. These results prove that real-time teledermatopathology offers an affordable and technically simple technology that lends itself to training as well as to diagnosis of lesions from routine practice by experts situated at remote sites.

An itchy rash in a young Caucasian woman.

We report of a 23-year-old woman who presented with a six-month history of a recurring, pruritic rash located on her chest, upper abdomen and most recently on the lower back. Until then the patient had been healthy. She did not take any medications, was not aware of any allergies or a family his-tory of skin diseases.The rash had occurred initially six months ago and was marked by an acute onset and a chronic recurrent course. The patient noted a timely association between the onset of the skin lesions and the start of a vegetarian diet. Further-more physical activity and sweating worsened the symptoms.Clinically the woman presented with erythematous patches and urticarial papules as well as crusted vesicles and pustules with an erythematous base that were located on the chest and the inframammary folds and distributed in a symmetrical fashion (Figure 1A, B). Under the provisional diagnosis of an autoimmune bullous disease, the woman had recently received systemic and topical corticosteroids. Lesions progressed under this therapy. Additionally, new pink, slightly urticarial papules and plaques developed on the back. Intense pruritus was the main complaint of the patient. This symptom did not respond to antihistamine or steroid therapy.Routine laboratory tests including blood count, blood chemistry, and serum protein levels were normal. No ele-vated antinuclear antibody titers were found. Direct and indirect immunofluorescence assays and an ELISA to rule out an autoimmune bullous disease were performed and were negative.A skin biopsy taken from one of the most recent lesions on the back showed a sparse perivascular lymphocytic cell infiltrate with occasional neutrophils and a discrete edema of the papillary dermis (Figure 2). No epidermal changes were present. In contrast to these subtle changes, a skin biopsy taken from a fully developed inframammary lesion displayed dramatic epidermal changes consisting of ballooning of kera -tinocytes, necrosis en masse of keratinocytes with intraepi-dermal vesiculation and exocytosis of neutrophils and eosin -ophils. The epidermal changes were accompanied by a dense superficial interstitial and perivascular dermal inflammatory cell infiltrate consisting of lymphocytes mainly, but also neu -trophils and eosinophils (Figures 3, 4).The clinical and histopathologic findings summoned up to the diagnosis of prurigo pigmentosa. Alternative diagno-