Ilko Bakardzhiev

Tinea profunda of the genital area. Successful treatment of a rare skin disease

We present a rare case of 36‐year‐old female patient, who developed a severe Majocchi granuloma in the pubis after waxing, with isolated causative agent Trichophyton mentagrophytes. The condition was initially misdiagnosed as a bacterial folliculitis and treated unsuccessfully with topical corticosteroids and antibiotics. After the adequate diagnose was confirmed by mycological examination, followed by histopathological verification, complete remission of the symptoms was achieved at the 4th week after initiating 6 weeks course of antifungal therapy with Terbinafine 250 mg/daily dose, while good therapeutic response was observed even in the 10th day. The etiopathogenesis of the disease, as well as its current treatment options are considered, in respect to the rare occurrence of this condition in the pubic area and its frequent misdiagnosis.

Plexiform Neurofibroma: A Case Report

AbstractPlexiform neurofibromas represent an uncommon variant (30%) of neurofibromatosis type 1 (NF-1) in which neurofibromas arise from multiple nerves as bulging and deforming masses involving also connective tissue and skin folds.We report a rare case of a 30-year-old man who presented with a progressive facial deformity that began in early childhood. Skin examination also revealed multiple neurofibromas and café-au-lait macules on the trunk and arms. Histopathological examination on biopsy samples showed overgrowth of peripheral nerve components and connective tissue. Two diagnostic criteria for NF-1 (plexiform variant) were met, the patient did not accept to undergo genetic testing. Craniofacial MRI confirmed the presence of a deforming mass arising from the left side of his face giving homolateral eye dislocation.Surgery is the mainstay of the treatment. However, the patient expressed the preference to avoid surgery and chose to undergo clinical follow-up every 6 months.Diagnosis of plexiform neurofibromas is usually made clinically, especially if classical hallmarks of NF-1 are present. Therapy is surgical, aiming at resecting deforming masses and cancerous tissue when malignant transformation occurs.

Impetiginized dyshidrotic eczema

A 16 years old female patient, affected by atopic dermatitis and rhinoconjunctivitis allergica since childhood, requested a dermatologic consultation for lesions which had appeared after 3 months of local treatment with clobethasole propionate. The histological analysis confirmed the diagnosis of dyshidrotic eczema and the microbiological smears demonstrated a significant infection with Staphylococcus aureus. The risk of developing corticosteroids’ side-effects depends on the potency of the product, extended period of use and the volume of product applied. Clobetasol propionate is a group I- highly potent corticosteroid, which should be used for a maximum period of 2 weeks. Several authors have found that this agent has cumulative depot effect, persisting in the epidermis for 4 days after only one application. Taking together these observations, sustained by the clinical case presented above, we can conclude that the infectious risks associated with topical corticosteroid treatment must not be neglected, particularly since treated patients are fragile, and frequently have multiple well-known risk factors.

The “different face” of esophageal cancer: cutaneous manifestation of visceral malignancies

SummarySquamous cell carcinoma is the most common type of neoplasm of the esophagus with global incidence. Its early symptoms are often nonspecific as the disease could be detected only when metastases in various organs are already presented. Esophageal metastases present an extremely small part from all cutaneous metastases as the real incidence of cutaneous metastases due to cancer of the esophagus account for 0.5–9 % and only a small part of them are reported and rarely involve the facial region. Despite this, cutaneous metastases may be the first sign of malignancy of the esophagus, which immediately determined the worst prognosis and fatal outcome in these patients. Average survival prognosis at the time of diagnosis of esophageal carcinoma in stage IV is 4–6 months, while the survival-associated expectations in cases of associated skin lesions manifestation is 4 months. We present a rare case of esophagus carcinoma in advanced stage, presented with severe cutaneous metastasis in the face region, accompanied by heavy blood coughing and hematemesis, which led to fatal outcome in the reported patient. The incidence of cutaneous metastases due to this visceral malignancy is discussed, as we highlight the frequency of metastases as a first clinical sign in esophageal cancer. The mortality rate is high due to the advanced stage of progression of the disease or presented metastases spread at the time of diagnosis, while treatment-related mortality accounts 10.3 %.ZusammenfassungDas Plattenepithelkarzinom (SCC) ist der häufigste Typ maligner Ösophagustumoren mit weltweitem Vorkommen. Seine Frühsymptome sind häufig unspezifisch, und die Diagnose wird dann erst infolge Organmetastasierung gestellt. Kutane Metastasen des Ösophaguskarzinoms sind extrem selten und stellen nur 0,5–9 % aller Metastasen dieses Tumortyps dar, wobei das Gesicht sehr selten betroffen ist. Dennoch können Hautmetastasen das erste klinische Anzeichen einer Ösophagusneoplasie sein, was dann aber auf eine schlechte Prognose und einen fatalen Ausgang hindeutet. Im Stadium IV ist die Lebenserwartung auf 4–6 Monate beschränkt, ebenso wie bei Patienten mit einer Hautmetastasierung. Wir berichten über einen seltenen Fall eines fortgeschrittenen Ösophaguskarzinoms mit ausgedehnter fazialer Metastasierung, Hämatemesis und Hämoptysis, welches zum Tode führte. Die Inzidenz kutaner Metastasen bei viszeralen Neoplasien wird besprochen, und wir verweisen auf die Rolle kutaner Absiedlungen als Erstsymptom beim Ösophaguskarzinom hin. Die Mortalität ist hoch infolge der fortgeschrittenen Erkrankung, die therapiebedingte Mortalität beträgt 10,3 %.

Basal Cell Carcinoma Surgery: Simple Undermining Approach in Two Patients with Different Tumour Locations

Basal cell carcinoma (BCC) is the most common human malignancy, accounting for the majority of all non-melanoma skin cancers (NMSC). In the past several decades the worldwide incidence of BCC has constantly been increasing. Even though it is a slow growing tumour that, left untreated, rarely metastasizes, it has a distinctive invasive growth pattern, posing a considerable risk for local invasion and destruction of underlying tissues, such as muscle, cartilage, bone or vital structures. Advanced BCCs include such locally invasive or metastatic tumours. Complete surgical excision is the standard therapy for most uncomplicated BCC cases with good prognosis and cure rates. Treatment of advanced forms of BCCs poses significant therapeutic challenges, most often requiring complicated surgery, radiotherapy, and/or targeted therapies directed towards the sonic hedgehog signalling pathway (SHH). We present two cases of large BCCs located on the scalp and posterior thorax, which underwent surgical excision with clear margins, followed by reconstruction of the defect after extensive undermining of the skin.

Fibroepithelioma of Pinkus (FeP) Located in the Left Lower Quadrant of the Abdomen - Case Report and Review of the Literature

BACKGROUND Fibroepithelioma of Pinkus (FeP) is an uncommon and controversial skin lesion, sharing features of both basal cell carcinoma (BCC) and trichoepithelioma. In this article, we present a case of FeP and synthesise current concepts on the etiopathogenesis, diagnosis and treatment of this uncommon tumour. CASE REPORT We report the case of an 88-year-old male patient presenting to the dermatology clinic for a sharply demarcated, pink, exophytic cutaneous tumour situated in the left inguinal region. The histopathological examination performed after complete surgical excision of the lesion revealed a diagnosis of FeP. A systematic review of the literature was conducted. The terms `fibroepithelioma` and `Pinkus` have been searched in bibliographical databases, including PubMed and Google Scholar, without time limitation up to February 15th, 2017. Seventy-nine articles that fulfilled all the required conditions were identified. Relevant citations and additional articles identified from references have been assessed. The systematic review included a total number of 452 cases of FeP. CONCLUSION Even though FeP is considered a relatively rare tumour, its true incidence rate might be higher than previously believed. The clinical aspects of the lesion described in this paper and its location in the left lower quadrant of the abdomen are classic features of FeP. Histopathologic examination revealed features of both BCC and trichoepithelioma. Further epidemiological studies are required to clarify whether patients with FEP should be screened for the occurrence of other malignancies.

Pigmented Paraaxillary Located "Complex" Basal Cell Carcinoma Imitating clinically irritated Melanocytic Lesion - Succesfull Surgical Approach in Bulgarian Patient

BACKGROUND Basal cell carcinoma (BCC) is the most frequently encountered neoplasm worldwide. While nodular BCC is the most frequent clinical subtype, other forms of BCC, such as superficial, cystic, morpheiform, infiltrative, and pigmented may also be encountered. CASE PRESENTATION We present the case of a 67-year-old male with a relatively well-defined infiltrative, pigmented plaque with multiple colours and peripheral growth situated in the right axillary region. The histopathologic examination performed after complete surgical excision of the tumour revealed a complex pigmented BCC with macronodular, fibroepithelioma-like, cystic, focally infiltrative and basosquamous features. CONCLUSION Uncommon locations of BCCs in sun-protected areas such as the axillary region require a higher degree of suspicion for diagnosis. The complex histology of the presented case, including subtypes with differing biologic attributes, emphasises the importance of histopathological examination in the diagnosis and therapeutic management of BCC.

Late Onset Achromatic Melanoma Arising in a Giant Congenital Melanocytic Nevus

A 61-year-old woman, with a lifelong history of a giant congenital melanocytic nevus in the occipital region with secondary development of giant melanoma is presented. Surgical excision was performed, and the histopathological evaluation confirmed the diagnosis of Giant Malignant Melanoma (GMM) with a maximum tumour thickness of 16 mm. Nowadays, there is tremendous uncertainty regarding how giant congenital melanocytic nevi (GCMN) should be treated. The standard approach to patients with late onset giant congenital melanocytic nevi (GCMN is based on two main considerations: (1) obtain an acceptable cosmetic results with the purpose to decrease the psychosocial inconvenience to each patient, and (2) to attempt to minimise the risk of development of malignant transformation. Unfortunately complete surgical removal of the GCMN is usually difficult and very often impossible without subsequent functional or cosmetic mutilations.

Disseminated trichoblastomas - successfull treatment with CO2 laser.

mediate filament interactions and causes dilated cardiomyopathy, woolly hair and keratoderma. Hum Mol Genet 2000; 9: 2761–2766. 8 Chalabreysse L, Senni F, Bruyere P et al. A new hypo/oligodontia syndrome: Carvajal/Naxos syndrome secondary to desmoplakin-dominant mutations. J Dent Res 2010; 90: 58–64. 9 Norgett E, Lucke T, Bowers B, Munro C, Leigh I, Kelsell D. Early death from cardiomyopathy in a family with autosomal dominant striate palmoplantar keratoderma and woolly hair associated with a novel insertion mutation in desmoplakin. J Invest Dermatol 2006; 126: 1651–1654.

Giant extragenital Bowen's disease.

SummaryGiant extragenital forms of Morbus Bowen are extremely rare. The already described cases in the word literature are most commonly with periungual localization, as well as located on the foot and neck area. The clinical manifestation is presented most commonly by non-specific erythematous to erythematous-squamous plaques or papules, which is confusing to the clinician. From the pathogenic point of view, it is important to be confirmed or rejected the presence of human papilloma viruses (HPVs) in each case of affected patient, as this information is mandatory in respect to the adequate selection of the subsequent regimen. If HPVs are detected, systemic antiviral therapy could be initiated to reduce the size of the lesions before subsequent surgical eradication. A postoperative prevention through vaccination could be also considered additionally. In cases of HPV-negative giant extragenital forms of Morbus Bowen (as in the described patient), the focus should be on local immunomodulation by substances such as imiquimod, which reduce the size of the lesions, thereby creating optimal opportunities for their future surgical eradication. Other possible options described in the literature include topical application of 5-fluorouracil, photodynamic therapy, cryotherapy, and laser therapy (carbon dioxide laser). The choice of the most appropriate regimen should have been an individual decision of the clinician, considering also the location and the extent of the lesion.ZusammenfassungExtragenitale Formen eines Riesentumors des Morbus Bowen werden extrem selten diagnostiziert. Die bisher in der wissenschaftlichen Literatur beschriebenen Fälle betreffen im Allgemeinen den periungualen Bereich bzw. sind auch am Fuß und im Nacken lokalisiert. Das klinische Bild mit erythematösen bis erythro-squamösen Plaques oder Papeln ist meist unspezifisch und leitet den ärztlichen Untersucher oft fehl. Aus pathogenetischer Sicht erscheint es bedeutsam zu klären, ob humane Papillomaviren (HPV) nachweisbar sind oder nicht. Daraus resultiert letztlich die Entscheidung für das entsprechende therapeutische Vorgehen. Falls HPV nachweisbar sind, sollte zunächst eine systemische antivirale Behandlung initiiert werden, mit dem Ziel, die Größe der Läsion zu reduzieren, bevor im Nachhinein eine chirurgische Eradikation erfolgt. Zusätzlich kann auch eine postoperative Prävention mittels Vakzinierung erwogen werden. Bei HPV-negativen extragenitalen Riesentumoren eines Morbus Bowen (so wie beim hier beschriebenen Patienten) sollte der Fokus der Behandlung auf der topischen Immunmodulation mit Substanzen wie Imiquimod liegen. Diese reduzieren die Tumorgröße mit dem Ziel, im Nachhinein bessere Möglichkeiten der chirurgischen Therapie zu erreichen. Weitere Therapieoptionen, die in der Literatur beschrieben wurden, schließen die topische Applikation von 5-Fluorouracil, die photodynamische Therapie, Kryotherapie und Laser (CO2-Laser) ein. Die Wahl der erfolgreichsten Therapieoption ist eine individuelle ärztliche Entscheidung, die von der Lokalisation, dem Umfang und der Größe des Tumors abhängt.