Jeong Eun Do

The effect of 308 nm excimer laser on segmental vitiligo: a retrospective study of 80 patients with segmental vitiligo

Background: Segmental vitiligo (SV), which frequently accompanies poliosis, indicating a poor prognosis that is likely resistant to treatments.

DKK1 is highly expressed in the dermis of vitiligo lesion: Is there association between DKK1 and vitiligo?

[6] Wehrle-Haller B, Weston JA. Altered cell-surface targeting of stem cell factor causes loss of melanocyte precursors in Steel17H mutant mice. Dev Biol 1999;210:71–86. [7] Kunisada T, Yoshida H, Yamazaki H, Miyamoto A, Hemmi H, Nishimura E, et al. Transgene expression of steel factor in the basal layer of epidermis promotes survival, proliferation, differentiation and migration of melanocyte precursors. Development 1998;125:2915–23. [8] Cozzani E, Cacciapuoti M, Parodi A. Adhesion molecules in keratinocyte. Clin Dermatol 2001;19:544–50. [9] Zhang R, Zhu W, Xia M, Feng Y. Morphology of cultured human epidermal melanocytes observed by atomic force microscopy. Pigment Cell Res 2004;17: 62–5. [10] Pajerowski JD, Dahl KN, Zhong FL, Sammak PJ, Discher DE. Physical plasticity of the nucleus in stem cell differentiation. Proc Natl Acad Sci U S A 2007;104: Dheshnie Keswell, Lester M. Davids*, Susan H. Kidson University of Cape Town, Cape Town, South Africa

Rosacea fulminans with ocular involvement.

important prognostic factors of lymphangiomatosis. Younger patients have worse outcomes: of 31 children with lymphangiomatosis, 12 died from the disease (39%) or related factors, while there was no mortality among the 17 adult patients. In terms of involved sites, pleural and lung involvement are associated with poor prognoses. In previous studies, all of the children with pleural and ⁄or lung involvement died, while children without pulmonary involvement survived. Thoracic lymphangiomatosis is often misdiagnosed, and a definite diagnosis is usually delayed because of the rare occurrence of the disease and its nonspecific findings. In our case, the diagnosis of a cutaneous lymphangioma led us to consider the possibility of disseminated lymphangiomatosis as a potential cause of the recurrent chylothorax. In the case of recurrent chylothorax with unknown origin, dermatologists should consider disseminated lymphangiomatosis in the differential diagnosis together with dermatological physical examinations.

Cutaneous Schwannoma Presented as a Pedunculated Protruding Mass

Schwannoma is a benign neoplasm of the nerve sheath origin. It arises from the nerve sheath of large peripheral or cranial nerves and occurs at the level of the subcutaneous fat layer or deeper layer. Cutaneous schwannoma occurs more superficially and usually presents as a solitary dermal or subcutaneous nodule. We describe a case of cutaneous schwannoma that presented as an erythematous pedunculated protruding mass on the left flank of a 19-year-old female. It was clinically diagnosed as a granuloma pyogenicum. Shaving biopsy was conducted and histological examination revealed an encapsulated tumor mass containing dense, spindle-shaped cells whose nuclei are arranged back to back representing Verocay body, and a diagnosis of schwannoma was made. This is an unusual case of cutaneous schwannoma that presented as a pedunculated protruding mass.

Cutaneous lymphangioma as a diagnostic clue for thoracic lymphangiomatosis

MADAM, Lymphangiomatosis is a rare disease primarily observed in children. This disease is characterized by a proliferation of abnormal lymphatic channels that often involve multiple organ systems such as the lungs, mediastinum, bones, spleen, liver and skin. Thoracic lymphangiomatosis usually presents as a chylothorax that frequently leads to respiratory distress. However, the disease’s nonspecific findings can complicate the early diagnosis and lead to death. A 6-year-old boy with recurrent chylothorax of unknown origin was eventually diagnosed with lymphangiomatosis after analysis of a biopsy of cutaneous lymphangioma. A 6-year-old boy presented with an erythematous, depressed patch on his upper back that had been noticeable for the previous 9 months (Fig. 1a). He had been treated for recurrent massive chylothorax during the past year. Although several diagnostic examinations had been completed, including chest computed tomography (CT) scan and pleural biopsy, only nonspecific findings of massive bilateral pleural effusions with pleural thickening and multiple lytic bone lesions were detected (Fig. 1b,c), and the underlying cause for the chylothorax was not clearly defined. Thoracotomy, pleurodesis and pleural sclerosis performed on multiple occasions failed to stop the recurrence of the pleural effusion. A skin biopsy from the patient’s upper back demonstrated many irregularly dilated vascular channels throughout the dermis and within the subcutaneous tissue (Fig. 2a,b). The endothelium of channels stained for CD31 and D2-40 were

Familial multiple pilomatricomas showing clinical features of a giant mass without associated diseases

features of a giant mass without associated diseases An 18-year-old boy presented with multiple nodules on his left upper arm, left thigh, and nose. He had a history of similar multiple lesions on his neck and extremities, which had been excised three years earlier. In his family history, similar multiple lesions were present in his mother and younger sister. He was otherwise healthy on general examination. Physical examination revealed a 3 · 7.5 cm-sized, fluid-contained, slightly erythematous soft protruding mass on the left upper arm (Fig. 1a), a 3.5 · 4 cm-sized firm nodule on the left thigh (Fig. 1b), and a flesh-colored 0.3 · 0.2 cm-sized nodule on his nose. The largest protruding mass revealed two distinct features in correlation to the two clinically different parts of the mass: the upper soft cover and the lower hard component. Excisional biopsy was performed on all lesions. Histopathologic examination of the largest protruding mass revealed two distinct features in correlation to the two clinically different parts of the mass. The upper layer showed irregular multicystic structures with fragmented collagen in the dermis, and the lower well-demarcated mass showed basaloid basophilic cells in the periphery surrounding fully keratinized eosinophilic shadow cells (Fig. 2a,b). There were no atypical cells or invasion of the surrounding soft tissue. Other smaller masses also consisted of an island of cells in a circular configuration with enucleated shadow cells in the center and nucleated basophilic cells on the periphery. Pilomatricomas are benign, cutaneous tumors of the hair matrix cells, which demonstrate a characteristic histologic appearance, including shadow cells and areas of calcification. Although pilomatricoma usually presents as a solitary hard nodule, it comprises various clinical findings: bullous, perforating, anetodermic, lymphangiectatic,

An Acquired Anemic Patch Developed after a Cyst Excision: Is It a Variant of Nevus Anemicus?

A 53-year-old male presented with a 6-year duration of a childs-palm sized hypopigmented patch located on his neck. He had a history of surgical excision of an epidermal cyst on the neck, and the hypopigmented patch developed about one month after the excision next to the surgery site. Application of cold or heat did not make the lesion distinct from the surrounding skin. Pressure on the lesion by a glass slide made the lesion indistinguishable from surrounding uninvolved lesions. Giving friction to the lesion failed to induce erythematous change, making it clearly visible. Histologically, the lesion showed normal findings with adequate numbers of melanocytes in the basal layer. Herein, we present an interesting case of an acquired anemic patch which developed after a cyst excision. We postulate that nerve damage after surgery that regulates the vascular tone of cutaneous vessels may have been an inducing event of the anemic patch in this patient.

Leukotrichia in stable segmental vitiligo: implication of an alternate treatment option.

Dear Editor: Vitiligo is traditionally divided into two distinct clinical forms, nonsegmental vitiligo (NSV) and segmental vitiligo (SV). SV usually accompanies leukotrichia, which indicates that the condition is resistant to medical treatment and requires epidermal grafting1. In this case, perifollicular repigmentation was induced in a patient with SV and concurrent leukotrichia that was previously unresponsive to narrow-band ultraviolet B (NBUVB) phototherapy after the patient suffered an accidental burn on the denuded but uncovered area during phototherapy following an epidermal graft. A 12-year-old girl presented to our clinic with white patches that had initially developed on the right side of her trunk 2 years prior. Physical examination showed well-defined depigmented patches containing white hairs along the right T6~T12 dermatomes (Fig. 1). White accentuation with obvious fluorescence was detected using Woods lamp. She had received NBUVB phototherapy for 5 months without remarkable improvement. Upon consent, a suction blister epidermal graft was performed. Due to the sizeable lesion, several sessions of epidermal grafting were required. Fig. 1 Well-defined depigmented patches along the right T6~T12 dermatomes. One week later, after we grossly concluded that the previously uncovered areas were fully recovered, phototherapy was initiated. After 3 days, the patient returned to the clinic only to display a burn on the formerly denuded but uncovered area. Further treatment was delayed until the area was completely healed, and 10 days later, treatment was re-engaged starting with 700 mJ/cm2, with an incremental 15% increase in dose during every subsequent course. Interestingly, after 2 weeks, spontaneous repigmentation at the denuded but uncovered site was observed along with that in the covered site (Fig. 2A). On the patients subsequent visit 2 months later, the recipient area, again including the uncovered area, was almost completely pigmented (Fig. 2B). Fig. 2 (A) Diffuse and perifollicular repigmentation both on the covered and uncovered recipient site after 2 weeks. (B) Near complete repigmentation on the recipient site after 12 weeks. Surgical treatment can be considered when vitiligo does not respond to traditional treatments. The procedure is particularly suitable in cases that show complete loss of melanocytes or in cases that have a low possibility of repigmentation that is clinically indicated by the presence of leukotrichia2. It has been suggested that visualization of leukotrichia in the vitiligous lesions of patients with SV using portable digital microscopy indicates no hope of repigmentation and, therefore, that a surgical approach is recommended1. A recent preliminary study, however, reported that although tyrosinase-positive melanocytes are only observed in black hair follicles, melanocytes still exist in the white hair follicles, although they are fewer in number than those in black hair follicles2. These findings suggest that the melanocyte reservoir is not completely depleted in vitiligo lesions showing leukotrichia. According to an earlier study that revealed the promising result of combination treatment with an erbium:YAG laser and 5-fluorouracil ointment followed by NBUVB for the treatment of vitiligo, 78.1% of enrolled patients showed moderate to marked repigmentation3. In addition, microdermabrasion combined with pimecrolimus 1% cream has been reported to be effective without causing significant side effects including koebnerization in children with NSV4. The findings of these two studies suggest that epidermal damage caused by the erbium:YAG laser and microdermabrasion could induce the secretion of chemical mediators that are beneficial for melanocyte activation and enhance the NBUVB penetration and drug absorption into inactive melanocytes existing at the outer root sheath of the hair follicles. Similarly, we believe that in our case, the sunburn of the lesion uncovered by a graft after phototherapy might have induced the formation of various chemical mediators and growth factors which could stimulate epidermal melanocytes and induce the proliferation and migration of inactive melanocytes in the outer root sheaths of hair follicles in the depigmented lesions5 despite the presence of leukotrichia. The burn itself would also increase the transmittance and accessibility of NBUVB into inactive melanocytes in the outer root sheath, further inducing perifollicular repigmentation. In patients with SV, the coexistence of leukotrichia, has been considered a poor prognostic marker of disease that is often refractory to traditional treatment and eventually forces both the patient and the doctor into a surgical solution. Our case; however, shows that the few melanocytes that still remained in the hair follicles with leukotrichia could serve as a source of perifollicular repigmentation and points to an optimistic future involving treatment without the need for invasive epidermal grafting.

Letter to the EditorDKK1 is highly expressed in the dermis of vitiligo lesion: Is there association between DKK1 and vitiligo?

[6] Wehrle-Haller B, Weston JA. Altered cell-surface targeting of stem cell factor causes loss of melanocyte precursors in Steel17H mutant mice. Dev Biol 1999;210:71–86. [7] Kunisada T, Yoshida H, Yamazaki H, Miyamoto A, Hemmi H, Nishimura E, et al. Transgene expression of steel factor in the basal layer of epidermis promotes survival, proliferation, differentiation and migration of melanocyte precursors. Development 1998;125:2915–23. [8] Cozzani E, Cacciapuoti M, Parodi A. Adhesion molecules in keratinocyte. Clin Dermatol 2001;19:544–50. [9] Zhang R, Zhu W, Xia M, Feng Y. Morphology of cultured human epidermal melanocytes observed by atomic force microscopy. Pigment Cell Res 2004;17: 62–5. [10] Pajerowski JD, Dahl KN, Zhong FL, Sammak PJ, Discher DE. Physical plasticity of the nucleus in stem cell differentiation. Proc Natl Acad Sci U S A 2007;104: Dheshnie Keswell, Lester M. Davids*, Susan H. Kidson University of Cape Town, Cape Town, South Africa