In Hyuk Kwon

Synchronous Onset of Symmetrically Associated Extragenital Lichen Sclerosus and Vitiligo on both Breasts and the Vulva

456 Ann Dermatol Received April 24, 2014, Revised July 21, 2014, Accepted for publication August 12, 2014 Corresponding author: Jae Eun Choi, Department of Dermatology, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul 136-705, Korea. Tel: 82-2-920-5470, Fax: 82-2-928-7540, E-mail: grace79@korea.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. REFERENCES

Relationship between skin color and solar elastosis in aged Asian skin: A colorimetric–pathologic correlation

Aged skin is reported to be associated with unattractive skin color changes and solar elastosis. However, comparative studies have not documented the possible correlation between the two factors. This study investigated the plausible relationship between the facial skin color of elderly Asians and solar elastosis. A total of 22 skin specimens were collected from 22 Korean patients who underwent cheek skin biopsies. Skin color was quantitatively measured using colorimetric photography techniques to produce CIE L*a*b* values; the degree of solar elastosis was quantifiably assessed using a histologic grading scale. These values were used to investigate a correlation between the CIE L*a*b* coordinates and solar elastosis grade. The solar elastosis grade increased according to patient age (r = 0.67, p = .0006). However, the extent of solar elastosis was not statistically correlated with the CIE L*a*b* values, including L*, a*, and b* (r = 0.02, p = .95; r = 0.15, p = 0.50; r = −0.07, p = 0.76, respectively). The results showed that the solar elastosis grade increased, according to patient age, because of cumulative actinic damage. However, colorimetric skin color data did not correlate with the degree of solar elastosis. Therefore, cutaneous color changes and solar elastosis are separate, age‐related phenomena. Physicians should be aware of the possible histologic changes in actinically damaged facial skin, regardless of the skin color.

Rosacea Subtypes Visually and Optically Distinct When Viewed with Parallel-Polarized Imaging Technique

Background Parallel-polarized light (PPL) photography evaluates skin characteristics by analyzing light reflections from the skin surface. Objective The aim of this study was to determine the significance of quantitative analysis of PPL images in rosacea patients, and to provide a new objective evaluation method for use in clinical research and practice. Methods A total of 49 rosacea patients were enrolled. PPL images using green and white light emitting diodes (LEDs) were taken of the lesion and an adjacent normal area. The values from the PPL images were converted to CIELAB coordinates: L* corresponding to the brightness, a* to the red and green intensities, and b* to the yellow and blue intensities. Results A standard grading system showed negative correlations with L* (r=−0.67862, p=0.0108) and b* (r=−0.67862, p=0.0108), and a positive correlation with a* (r=0.64194, p=0.0180) with the green LEDs for papulopustular rosacea (PPR) types. The xerosis severity scale showed a positive correlation with L* (r=0.36709, p=0.0276) and a negative correlation with b* (r=−0.33068, p=0.0489) with the white LEDs for erythematotelangiectatic rosacea (ETR) types. In the ETR types, there was brighter lesional and normal skin with white LEDs and a higher score on the xerosis severity scale than the PPR types. Conclusion This technique using PPL images is applicable to the quantitative and objective assessment of rosacea in clinical settings. In addition, the two main subtypes of ETR and PPR are distinct entities visually and optically.

Sudden appearance of black macules on palmar aspect of two university chemistry students.

of two university chemistry students An 18-year-old woman presented with the sudden appearance of asymptomatic multiple black macules on both hands the day before the clinic visit (Fig. 1a). The patient was an undergraduate student at a biological science department who conducted a chemical experiment 2 days before the visit. She denied any contact with chemicals because she wore latex gloves throughout the experiment. She reported that her skin lesions appeared whitish first and turned to a black color a few hours later. Histopathologic examination revealed foreign material in the stratum corneum (Fig. 2) but did not reveal the causative agent. Two days later, a 19-year-old woman visited the clinic with similar symptoms (Fig. 1b). She was also a student in the same university. She was enrolled in the environmental science department and was taking the same chemistry course as the first patient. The two patients did not know each other. The second patient had performed the same experiment 9 days before her clinic visit. The skin lesions started to appear a day before the clinic visit. The experiment conducted by both patients was a silver mirror reaction. The experiment involved the handling of silver chloride, lead chloride, and ammonia hydroxide. The presumption was that the black macules were related to the experiment. To confirm the nature of foreign material, shaved stratum corneum was analyzed with scanning electron microscopy (SEM) and energy dispersive x-ray (EDX) spectroscopy, which revealed the presence of silver (Fig. 3). These findings were diagnostic of localized cutaneous argyria. Argyria can be localized or generalized, depending upon the mode and amount of silver absorbed. Localized argyria is the pigmentation of skin or mucous membranes due to impregnation of silver confined to the site of direct contact. The most commonly affected areas are the hands, eyes, and mucosa. In past centuries, there were many cases of argyria secondary to the ingestion and topical application of silver containing agents. The incidence of argyria is now markedly reduced because of the development of antibiotic and better pharmaceutical agents. The use of silver is mainly confined to silver dressing materials. Diagnosis of localized argyria is often challenging because it clinically resembles a melanocytic

Cutaneous Metastatic Rectal Adenocarcinoma in Zosteriform Distribution.

Dear Editor: A 54-year-old woman presented with mildly stinging, painful, grouped nodules on the left vulvar area. It shows unilateral localized grouped papulonodular lesions, resembling a zosteriform aspect (Fig. 1). The patient had a history of stage IV rectal adenocarcinoma with liver and lung metastases treated 17 months earlier with ultra-low anterior resection and chemotherapy. The patient also received external pelvic irradiation of 180 cGy/day, up to total 6,300 cGy/35 fractions, for recurrent adenocarcinoma at the anastomosis site. She presented with a zosteriform eruption on the left vulvar area during hospitalization, with no prior history of herpes zoster. The skin lesions exhibited predominantly nodular infiltration, inadequate for the tzanck test. A skin punch biopsy was performed under the differential diagnosis of herpes zoster on the left S2 dermatome, postherpetic granuloma, and cutaneous metastasis. Histopathology revealed metastatic adenocarcinoma (Fig. 2). The chest computed tomography (CT), abdomen CT, and positron emission tomographic-CT images showed consistent results of an increasing size of lung and hepatic nodules with lymph node metastasis. Pain around the vulva area was aggravated after repetitive chemotherapy and radiotherapy. Wide excision was performed to resect the visible cutaneous nodules with patient consent. The patient died eight months after the diagnosis of cutaneous metastasis, which was three years after the initial diagnosis of rectal adenocarcinoma. While the mean survival time from the diagnosis of cutaneous metastasis of colorectal cancer is 18 months1, our patient died in a shorter time span. Cutaneous metastasis from an internal malignancy is rare and can appear in many different forms, including the multiple nodular type, inflammatory or erysipeloid form, sclerodermoid form, alopecia neoplastica, or bullous form. The nodular type is the most common clinical appearance, while the zosteriform pattern is very rare2. The exact mechanism of zosteriform cutaneous metastasis is unknown. A Koebner-like phenomenon at the site of herpes zoster, invasion of the perineural lymphatic or dorsal root ganglion, direct invasion of tumor cells, and accidental surgical implantation have all been proposed 2,3. Colonofiberscopy and magnetic resonance imaging revealed an ulcerated fungating mass located on the left posterolateral wall of rectum. The metastatic lesion of the vulva was observed about 17 months later after a laparoscopic resection. However, an asymptomatic skin lesion may have appeared earlier. It is possible that the metastatic skin lesions may have been due to direct seeding of the tumor cells to the left side, but the exact mechanism remains unclear. The patient was undergoing chemotherapy when the metastatic lesions were observed, and herpes zoster occurs more frequently in immunosuppressed patients. It has been reported that many patients with cutaneous metastasis of zosteriform distribution are initially misdiagnosed with herpes zoster and treated with antiviral drugs4. Considering the pain and unilaterality, this may be easily misdiagnosed as herpes zoster. Herein, we report an unusual case of cutaneous metastasis of rectal adenocarcinoma that mimicked herpes zoster. This must be considered in any patient with a history of malignant neoplasm experiencing non-healing zosteriform lesions. Therefore, early biopsy for suspicious skin lesions is very important. Fig. 1 Stinging painful erythematous grouped nodules on the left vulvar area. Fig. 2 Dermal infiltration by intestinal type atypical glands, showing metastatic skin adenocarcinoma (H&E, ×100).

Adult Multiple Myofibromas on an Atrophic Patch on the Thigh.

Dear Editor: Myofibroma is an uncommon, benign myofibroblastic neoplasm of vascular origin, mostly occurring on the skin. It can also involve skeletal muscles, bones, or viscera, which can be fatal. As about 90% of myofibromas develop before the age of 2 years, it was previously termed infantile myofibroma. Adult-onset myofibroma is rare and is distinguishable from the infantile form. It is exclusively solitary and confined to the dermis and subcutis. However, a few cases of adult multiple myofibromas have been reported1,2. Herein, we report a rare and unusual case of adult multiple myofibromas occurring on a preexisting atrophic patch. A 62-year-old healthy woman presented with multiple firm subcutaneous nodules under a preexisting atrophic patch on the left thigh (Fig. 1). The patch was soft and heterogeneous, composed of atrophic and hypertrophic portions, and was >10 years old. During the last 3 years, multiple firm nodules developed under the patch. She had no history of trauma, burns, or treatment. Two incisional biopsies were performed on the nodule and the patch. Histopathological examination of the nodule showed well-circumscribed, biphasic tumors composed of intersecting fascicles of spindle cells and a vascular compartment resembling a hemangiopericytoma with polygonal cells (Fig. 2A~C). The tumor cells were positive for smooth muscle actin (SMA) staining and were negative for CD34, desmin, and S-100 staining (Fig. 2D, E), consistent with a myofibroma. Histopathological examination of the patch showed mild epidermal and dermal atrophy; however, these findings were not diagnostic. A small tumor suggestive of myofibroma was incidentally found in the dermis; this tumor was not clinically noticeable (Fig. 2F). She is currently being observed without excision, showing no remarkable change for 1 year. Fig. 1 Multiple firm subcutaneous nodules under the atrophic and telangiectatic soft patch on the left thigh. Fig. 2 Skin biopsy of the nodule showed well-circumscribed, biphasic tumors (A: H&E, ×12.5) composed of intersecting fascicles of spindle cells (B: H&E, ×200) and a vascular compartment with polygonal cells (C: H&E, ×200). ... Myofibromas are histologically well-circumscribed, biphasic- patterned tumors consisting of spindle and vascular portions; however, monophasic variants can occur. A myofibroma shows an arrangement of interlacing fascicles of spindle-shaped cells resembling myofibroblasts, and vascular foci resembling hemangiopericytoma with polygonal cells. Spindled cells express vimentin and SMA and are usually negative for desmin3. In our patient, the preexisting patch was clinically suspected to be smooth muscle hamartoma; however, the pathologic results were not diagnostic. The patch included a small myofibroma in the dermal layer, which implied that multiple myofibromas would continue to develop under the patch. Kim et al.4 previously reported a case of multiple myofibromas with congenital smooth muscle hamartoma on the thigh of a woman, which had very similar clinical manifestation as our case. The pericytes in vascular foci are considered to be the origin of spindle-shaped neoplastic cells that show myofibroblastic differentiation. However, the pericytes can also differentiate into other mesenchymal cells; their differentiation into smooth muscle cells was demonstrated in ultrastructural studies of hemangiopericytomas5. Therefore, smooth muscle hamartoma might develop from multipotent pericytes that later create myofibromas. Although the patch was not diagnosed in our case, we suggest the possibility that the preexisting patch and the myofibromas might have originated from the same parental cells before differentiation. Further investigations may help find their possible relation.