Ho-Seok Suh

Zosteriform Herpetic Folliculitis Involving Eccrine Gland

To the Editor: Within the skin, herpesvirus specifically involves the epidermis but only occasionally the follicular or sebaceous gland epithelium (1). Although some cases of herpetic folliculitis or sycosis have been reported (2–4), eccrine ductal or glandular epithelium is very rarely affected, and only a few cases of cutaneous herpesviral infection with eccrine involvement have been described in the English literature (1, 5). We present a case of herpetic folliculitis showing vacuolar changes of eccrine glands with a clinically dermatomal distribution, suggestive of herpes zoster virus infection. A 52-year-old Korean man presented with painful erythematous papules on the right arm, shoulder, and upper chest for one week. He had been diagnosed as non-small cell lung cancer with brain metastasis eight months earlier and treated with radiation therapy and systemic chemotherapy using cisplatin and prednisolone. Skin examination revealed multiple, partially crusted, erythematous papules on the right arm, shoulder, and upper chest (Fig. 1). The clinical presumptive diagnosis of folliculitis was made. Histopathologic findings showed extensive epidermal necrosis and vacuolar degeneration of follicular epithelium. Eccrine glands and ducts showed multinucleated epithelial cells and typical herpetic cytopathic features similar to those present within the epidermis and hair follicle (Fig. 2). We treated him with oral famciclovir (750 mg/day) for seven days and the painful skin lesions were much improved. Rinder and Murphy (1) first described a case of herpes zoster with eccrine gland involvement in 1984. The patient had had Hodgkin’s lymphoma and underwent radioThe Journal of Dermatology Vol. 30: 929–930, 2003

Symplastic glomus tumor

papular, or annular), along with mucosal and systemic symptoms such as malaise, headache, mild fever, anorexia, and lymph node enlargement. Alopecia is an uncommon clinical manifestation of secondary syphilis, occurring in only 4% of cases. Alopecia syphilitica often accompanies other mucocutaneous symptoms of secondary syphilis, but it is extremely rare for hair loss to be the only presenting symptom. Two basic patterns of secondary syphilitic alopecia have been described in the literature. The first type is symptomatic alopecia. This type presents with either a patchy or diffuse pattern associated with skin lesions of secondary syphilis on the scalp or elsewhere. The other type of alopecia described is essential syphilitic alopecia. This type has the same hair loss pattern as symptomatic alopecia but without any other cutaneous features of syphilis. In our patient, diffuse hair loss was the only cutaneous symptom of secondary syphilis. The histopathological finding, which mimicked alopecia areata, was nondiagnostic. Later, the results of serological tests led to a surprise diagnosis of syphilitic alopecia. The diffuse hair loss of essential syphilitic alopecia as the sole manifestation of syphilis is extremely uncommon and is seldom reported in the current literature. When syphilis produces unusual skin lesions, as in this case, it is likely to be misdiagnosed. This patient is presented to emphasize the importance of considering syphilis and performing the appropriate serological tests in patients with an at-risk sexual history and unexplained sudden hair loss.

A crescent-shaped nodule in the temple: a quiz. Nodular fasciitis.

A 32-year-old Korean woman presented to our clinic with a solitary crescent-shaped protruding nodule on the right temporal area (Fig. 1). Approximately one year previously, a single tiny papule that had not been associated with trauma had suddenly increased in size to a 2 × 1 cm, protruding, crescent-shaped nodule. At that time, the patient was pregnant and refused treatment; however, she returned to the clinic after giving birth. In the intervening period, the size and shape of the nodule had not changed. Histopathological examination showed a poorly circumscribed mass in the lower dermis, and subcutaneous fat, infiltrating into the muscular structure (Fig. 2a). Cellular atypia was not prominent. Abundant fibrous tissue and mild infiltration of inflammatory cells were also noted. Dermal collagen bundles were densely packed. Immunohistochemical analysis showed that spindle-shaped cells were positive for smooth muscle actin (Fig. 2b), but negative for CD34, CD31, factor XIII and factor VIII.