Hyoung Il Kwon

Toxic epidermal necrolysis with isolated neutropenia related to the use of levetiracetam

and placebo groups for mean change in hair diameter. For patients’ self-assessments, the minoxidil group was significantly superior to the placebo group using the Mann–Whitney U-test (P = 0.013). The adverse reactions were mild and not statistically significantly different between groups. Topical minoxidil has been used to treat androgenetic alopecia. We also demonstrated that it could be used for eyebrow hypotrichosis. In this trial, minoxidil lotion was superior to placebo for beard enhancement based on the global photographic scores, mean change from baseline in hair count and patients’ self-assessments. There was no statistically significant difference between groups for changes in hair diameter from baseline. This can be explained by: (i) the increase in hair count, especially non-terminal hairs; and (ii) measurement of hair was done on both terminal and non-terminal hairs. The exact mechanism of minoxidil in promoting hair growth is still unclear but there are many hypotheses. In conclusion, minoxidil 3% lotion is effective and safe for beard enhancement.

A Case of Multiple Desmoplastic Trichoepithelioma.

Dear Editor: A 23-year-old woman presented with multiple, progressively growing, asymptomatic, depressed macules on face for 2 years. Physical examination revealed three yellowish to skin-colored annular atrophic macules 2~5 mm in size without elevated border on both cheeks (Fig. 1). She had no family or past history that scar might occur such as acne, chickenpox, herpes infection or prior laser treatment. Laboratory data including blood cell counts, biochemistry and urinalysis were unremarkable. Histopathology showed narrow strands of basaloid tumor cells in a fibrous stroma with adjacent embedded keratinous cysts (Fig. 2). The tumor strands were distributed from the upper to the deeper dermis. We performed additional exicisional biopsy with immunohistochemical staining in order to differentiate from malignant neoplasms including morpheic basal cell carcinoma (BCC) and microcystic adnexal carcinoma (MAC). Carcinoembryonic antigen (CEA), epithelial membrane antigen (EMA), CD23, and CK19 were negative, and CK20 showed focal positive. From these findings, she was diagnosed with desmoplastic trichoepithelioma (DTE), and remaining lesions were completely removed. Fig. 1 (A, B) Cutaneous examination revealed multiple yellowish to skin-colored annular, depressed macules on both cheeks. Fig. 2 (A) Biopsy specimen of left cheek reveals atrophic epidermis with upper and mid dermal cellular infiltration (H&E, ×40). (B) Tumor strands embedded in dense fibrous stroma are composed of small basaloid cells one to two cells thick (H&E, ... DTE is a rare benign skin appendageal neoplasm. It is a distinct variant of trichoepithelioma based upon its unique clinical and histopathological characteristics1. Clinically, it typically shows 3~8 mm diameter, annular, yellowish or skin-colored asymptomatic plaques, with an elevated border and a depressed or atrophic center on face1. It almost develops as a solitary lesion, although rare cases of patients with multiple lesions have been reported2. Histopathologically, DTE is characterized by following features. First, epithelial strands consist of small basaloid cuboidal cells in a one to three-cell-thick layer. Second, many keratinous cysts have a peripheral border of basaloid cuboidal cells, and sometimes have several calcification foci. Finally, stroma appears as dense fibrous stroma1. Differential diagnosis includes MAC, BCC, and scar. Although MAC presents with many horn cysts and epithelial cords, it is distinguished by ductal differentiation and infiltration to the subcutis or deeper structures3. Therefore, when biopsy is superficial, MAC can be misdiagnosed as DTE3. Assessing EMA and CEA immunohistochemistry may identify ductal differentiation and CD23 expression in MAC1. CK19 demarcates follicular bulge stem cells and its positivity favors MAC over DTE4. Both DTE and morpheic BCC can exhibit basaloid cells in strands and sclerotic stroma. However, neither cellular atypia nor peripheral palisading are seen in DTE, and morpheic BCC is not usually associated with horn cyst formation1. Also, in most DTE, retained or increased CK20-positive Merkel cells are found, but not in morpheic BCC5. Scar should be considered if multiple depressed macules appear, but it can be easily differentiated based upon its histopathology. The treatment of choice is surgical excision and Mohs micrographic surgery is recommended to achieve clear surgical margins. In our case, because multiple lesions had developed and tumor strands extended into the deep dermis, total excision was performed to exclude malignancy. Therefore, initial proper biopsy is important to make an accurate diagnosis and treatment in patients with multiple scar-like depressed macules on face. Herein, we report a rare case of multiple DTE, which should be differentiated from malignancy histopathologically.

A Digital Squamous Cell Carcinoma Mimicking a Diabetic Foot Ulcer, With Early Inguinal Metastasis and Cancer-Related Lymphedema

Although squamous cell carcinoma (SCC) is the second most common nonmelanoma skin cancer, clinicians have difficulty diagnosing SCC of the toe because its clinical features can mimic other less serious diseases. Clinicians are especially prone to misdiagnose SCC of the toe as diabetic foot ulcer in patients with diabetes mellitus because of the clinical similarity of the 2 ailments. SCC of the toe is generally considered to have a low risk of metastasis. Locoregional or distant metastases without bone or tendon involvement are particularly rare. The authors report here an interesting case of rapidly spreading SCC of the toe with metastasis to multiple lymph nodes and cancer-related lymphedema. Physicians should be aware of the possibility of malignancy when they encounter chronic and recalcitrant ulcerative lesions of the digits.

Pyoderma Gangrenosum in a Patient With Hereditary Spherocytosis

Pyoderma gangrenosum (PG) is a rare, relapsing cutaneous disease with 4 distinctive clinical manifestations: ulcerative, bullous, pustular, and vegetative lesions. It mainly occurs in adults and is frequently associated with systemic diseases, most commonly inflammatory bowel disease, rheumatologic disease, or hematological dyscrasias. However, there have been no previous reports of PG in a patient with hereditary spherocytosis, a common inherited hemolytic anemia. We report here a unique case of PG in a 15-year-old boy with underlying hereditary spherocytosis.