Jai Kyoung Koh

Metaplastic Ossification in a Cutaneous Pyogenic Granuloma: A Case Report

Cutaneous ossification may occur in association with a variety of cutaneous neoplasms and inflammatory conditions, such as pilomatricomas, basal cell carcinomas, nevi, chondroid syringomas, venous stasis, and scars. However, it has rarely been reported in pyogenic granuloma, a relatively common benign vascular tumor of the skin and mucous membranes. We herein presented a rare case of cutaneous pyogenic granuloma with ectopic ossification on the big toe of a 37‐year‐old man, with high recurrence despite repeated CO2 laser ablations. We propose the hypothesis that vascular endothelial growth factor (VEGF) and bone morphogenetic proteins (BMPs) play pathologic roles in the development of ectopic bone formation in pyogenic granuloma.

Q-Switched Nd:YAG Laser Therapy of Acquired Bilateral Nevus of Ota-like Macules

BACKGROUNDnAcquired bilateral nevus of Ota-like macules (ABNOM) is a dermal pigmented lesion common in individuals of Oriental origin. The Q-switched Nd:YAG laser (QSNYL) has been used successfully to treat a variety of benign, dermal, pigmented lesions, including nevus of Ota lesions. The similarity between ABNOM and nevus of Ota suggested that QSNYL may also be effective in the former.nnnOBJECTIVEnTo determine the efficacy and side-effect profiles of QSNYL treatment of ABNOM in Korean patients.nnnMETHODSnOf 42 Korean patients with ABNOM, 29 were treated with QSNYL (1,064 nm, 3 mm spot size, fluence 8~9.5 J/cm(2)), for up to 10 sessions each. Clinical photographs were taken before and after treatment. Lesion clearance was graded and complications such as hyperpigmentation, scarring, hypopigmentation, and erythema were assessed.nnnRESULTSnOf the 29 treated patients, 19 (66%) showed excellent or good results. Of the patients who were treated more than 3 times, 76% showed good to excellent results. Two patients experienced post-laser hyperpigmentation (PLH), which persisted for more than one month, but no patient experienced persistent erythema or hypertrophic scarring.nnnCONCLUSIONnQSNYL is safe and effective in the treatment of ABNOM in Korean patients. Short-interval repetitive treatment is especially useful in improving therapeutic results and reducing PLH.

Bilateral mucinous eccrine nevus in an adult

Dear Editor, Eccrine nevus is a rare hamartoma with varying clinical manifestations. Microscopically, it shows an increase in the size and/or number of eccrine coils. Several types of eccrine nevus have been described. Mucinous eccrine nevus (MEN) is an extremely rare variant of eccrine nevus. To our knowledge, only five cases of MEN have been reported, each with varying clinical manifestations, but all cases showed unilateral lesions. The present report describes the first case of adulthood bilateral MEN which appeared after surgery. A 57-year-old male presented with a 3-year history of bilateral brownish nodules on both inner thighs after a rectal operation (Fig. 1). The patient reported a progressive increase in the size of the lesions. The patient did not complain of any subjective symptoms. Examination revealed a few brownish, irregular nodules, approximately 2–3 cm in diameter, which were firm on palpation. The medical history included an ileostomy and a low-anterior resection of the rectum in August 2003 due to stage 1 rectal cancer. After rectal surgery, laboratory tests, such as computed tomography, endoscopy and positron emission tomography, did not show any evidences of recurrence. A skin biopsy was performed on one nodule. Microscopic examination revealed hyperplastic ducts and secretory coils in a hamartomatous eccrine gland (Fig. 2a). Cellular components constituting the eccrine units did not show clues of malignancy including nuclear atypia and mitotic figures (Fig. 2b). Abundant mucinous material around the sweat glands stained strongly with Alcian blue, pH 2.5 (Fig. 2c). Vessels in the connective tissue close to the gland were thicker than normal vessels. The patient was treated with monthly intralesional triamcinolone acetonide injections for 4 months. The skin lesions flattened but did not change color. Eccrine nevus is considered a variant of epidermal nevus with eccrine differentiation. It is a solitary lesion most commonly occurring on extremities, present at birth or at an early age, with no gender predilection. Clinically, eccrine nevus often presents as a localized hyperhidrotic patch or as a brown hyperhidrotic plaque. Some of these lack hyperhidrosis despite an increased eccrine component. In 1994, Romer and Taira reported a type of eccrine nevus that contained both eccrine and mucinous elements, and named it as MEN. Only five cases have been reported in the published work to date. The previous cases exhibited varying clinical manifestations such as erythema nodosum-like solitary nodule, hyperpigmented plaque on the toe, multiple nodules following the lines of Blaschko, swollen patches on the toe and asymptomatic brownish nodules. Three of the

Diffuse plane xanthoma in a patient with chronic myeloid leukemia.

To the Editor: Diffuse plane xanthoma (DPX) was first described by Altman and Winkelman in 1962 (1). They insisted that the features of this disease were xanthelasma palpebrarum, diffuse plane xanthoma of the head, neck, trunk, and extremities, and normal plasma lipids level (1–3). DPX is sub-divided into two groups, idiopathic and underlying disease-associated (1–3). To date, only one case of DPX associated with chronic myeloid leukemia (CML) has been reported. We herein describe a patient with DPX which spread from xanthelasma palpebrarum after detection of CML. An 84-year-old Korean woman presented with a three month history of progressive, diffuse, yellowish patches and plaques on the face, neck, and upper chest. Four years earlier, she was diagnosed with CML and had received chemotherapy with hydroxyurea. In this patient, it appeared that the CML had been activated immediately after a splenectomy, which was performed to treat abdominal pain with splenomegaly, because the compensated state had been broken. The yellowish patches on the periorbital area first appeared approximately 40 years earlier and had not changed until the detection of the CML. After the activation of the CML, the yellowish patches on the periorbital area had become widespread to other sites on the face, including the forehead, cheek, and temple. Three months before the first visit, similar lesions developed on the neck and upper chest. Some of these lesions were slightly elevated. There was no itching or tenderness. Physical examination revealed multiple, relatively ill-defined, diffuse, yellowish patches and some plaques on the periorbital area, cheek, forehead, neck, and upper chest (Fig. 1). Histopathologic findings showed diffuse xanthomatous cells, some around blood vessels, in the upper to mid-dermis and subcutaneous fat tissues (Fig. 2). The complete blood count included the following values: hemoglobin, 10.7 g/dl; white blood cell count, 11,500/mm, with 58% polymorphonuclear leukocytes, 29% lymphocytes, 10% monocytes, and 2% eosinophils. The platelet count was 14,700/mm. Serum cholesterol and triglyceride levels were normal, although the plasma concentration of high-density lipoprotein (HDL) was low (28 mg/dl, normal The Journal of Dermatology Vol. 31: 503–505, 2004

Giant Annular Lichen Planus : Wolf's Isotopic Response

To the Editor: Several cutaneous reactions in dermatomes affected by herpes zoster, socalled ‘isotopic responses’, have been described since the first description by Wolf in 1995 (1). We experienced a patient with giant annular lichen planus on the skin sites of previous herpes zoster. This is a very exceptional posterherpetic isotopic response. A 64-year-old Korean woman presented with several itchy, annular, skin lesions on the left shoulder and upper arm of two months duration. She had a history of herpes zoster in the same location; it had been treated with oral acyclovir one year prior to this visit. Skin examination revealed several variable-sized, brown, lichenoid plaques with elevated annular margins on the left shoulder and upper arm along the previous herpes zoster scar sites (Fig. 1). In particular, the lesion located on the shoulder was very large annular plaque extending for 20 cm. She stated that the lesion had developed on part of the healed site of herpes zoster, and then gradually spread, but it still remained within the area of the previous scar. There was neither mucous membrane nor nail involvement. A skin biopsy was done on the annular margin. The histopathologic findings included ortho-hyperkeratosis, saw-tooth pattern irregular acanthosis, band-like lichenoid chronic inflammatory cell infiltration, and basal liquefaction degeneration with pigmentary incontinence (Fig. 2), all typical findings for lichen planus. She was treated with oral antihistamine and intralesional triamcinolone acetonide injections at three times. The lesions had almost flattened with postinflammatory hyperpigmentation at five months of follow-up. Several cutaneous reactions have been described in dermatomes recently affected by herpes zoster. The interval periods are variable, and there seems to be no specific correlations among the duration of the period, specific location, and the specific type of the secondary skin lesion (1–3). The most commonly described postherpetic isotopic responses are granulomatous reactions, such as granuloma annulare, followed by malignant tumors, leukemic or lymphomatous infiltrations, dysimmune reactions, infections, and comedonic-microcystic reactions (2, 3). Among these, lichen planus is a not uncommon postherpetic dysimmune response, The Journal of Dermatology Vol. 32: 311–312, 2005

Autosomal recessive type 2 pseudoxanthoma elasticum presenting with generalized skin laxity

Herein, we describe a sporadic case of recessive type 2 pseudoxanthoma elasticum. A 26‐year‐old woman without family history presented with cutis laxa‐like marked wrinkling involving the whole‐body and a serpiginous streak on the upper left arm. She denied any other systemic problems related to difficulty with visual acuity or vascular disease. A skin biopsy specimen from the loose skin showed the accumulation of calcified degenerated elastic fibers and foci of ossification in the dermis. Histopathological study from a serpiginous streak revealed mineralized debris that was eliminated through the epidermis, the finding consistent with elastosis perforans serpiginosa. Recessive type 2 pseudoxanthoma elasticum is very rare and the presenting case is interesting in that this patient presented with lesions of secondary ossification and elastosis perforans serpiginosa in association with pseudoxanthoma elasticum.

POEMS syndrome with xanthomatous cells

A diffuse xanthomatous infiltration was detected on a biopsy of the hyperpigmented patches in a 40-year-old man with POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, M-protein, Skin changes) syndrome. Multiple biopsies of the hyperpigmented patches showed diffuse or perivascular foamy histiocytes in the upper and mid dermis, a sparse infiltrate of lymphocytes, fibrosis, hyperpigmentation of the basal layer, and capillary proliferation. The foamy cells were positive for periodic acid-Schiff (PAS) with diastase, oil red-O, and CD68. To our knowledge, this is the first case with foamy histiocytes without xanthomatous-appearing skin lesions in POEMS syndrome. It would be worth searching for xanthomatous histiocytes in the hyperpigmented skin of patients with POEMS syndrome.

Papular Mucinosis Associated with Systemic Lupus Erythematosus

Papulonodular mucinosis (PNM) is a rare variant of lupus erythematosus (LE) eruptions, and PNM is characterized histologically by diffuse dermal mucin without any typical epidermal inflammatory changes. We herein describe a case of papular mucinosis that was characterized by several erythematous papules on the lower back of a 32-year-old man with systemic LE. It is interesting that he didnt display any other skin manifestations of LE such as malar rash, discoid rash and photosensitivity during the previous 2 years. He achieved remission of his PNM without recurrence after 5 months treatment with topical steroids, in addition to receiving systemic antimalarials and steroids.