Joyce Siong-See Lee

Lymphocytic Thrombophilic Arteritis: A Newly Described Medium-Sized Vessel Arteritis of the Skin

BACKGROUND We encountered a distinct arteriolar histopathologic finding of lymphocytic vasculitis associated with a hyalinized fibrin ring in vessel lumina. Identical histologic findings have previously been described as macular arteritis. OBSERVATIONS We describe 5 women (mean age, 25 years; age range, 20-34 years) with persistent, slowly progressive, patchy and reticular hyperpigmentation associated with livedo racemosa affecting predominantly the lower limbs. In the biopsy samples, infiltration of muscular vessel wall by inflammatory cells, affecting small arteries of the dermosubcutaneous junction or superficial subcutis, was present. Of the infiltrate, 90% or more consisted of mononuclear cells, mainly lymphocytes with an admixture of histiocytes. Neutrophils and eosinophils were absent or scant. Inflammation was confined to the vicinity of the vessel and the immediate surrounding panniculus. A concentric fibrin ring involving the entire periphery of the lumina of affected vessels was present in all the patients. Laboratory investigation results revealed that 4 patients had antiphospholipid antibodies in their serum. One of these patients had a heterozygous mutation of the factor V Leiden gene. Conclusion We term this arteritis lymphocytic thrombophilic arteritis to reflect the histologic features that combine lymphocytic vascular inflammation with changes representing a thrombophilic endovasculitis.

A rare combination of sebaceoma with carcinomatous change (sebaceous carcinoma), trichoblastoma, and poroma arising from a nevus sebaceus.

We report a case of a 48‐year‐old Malay female who presented with multiple tumors arising from a large nevus sebaceus on her right parieto‐temporal scalp. Histologically, the tumors corresponded to a sebaceoma with carcinomatous change, a poroma and a trichoblastoma. Immunohistochemical staining of the sebaceous tumor with p53 showed strong within the areas of carcinomatous change, while there was negative to weak staining within the sebaceoma‐like areas. A discussion on the potential secondary neoplasms from a nevus sebaceus ensues, with a review of this literature on multiple tumors from a nevus sebaceus.

Paraneoplastic pemphigus resembling linear IgA bullous dermatosis

A 69‐year‐old Chinese man presented in 2001 with a blistering eruption over the upper and lower limbs associated with oral ulceration for 1 month. He had stage IIIA follicular small cell cleaved non‐Hodgkins lymphoma diagnosed 5 years previously, and had received several lines of palliative chemotherapy, including two courses of chlorambucil, six cycles of cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP), and two four‐cycle courses of rituximab, with disease stabilization at the time of presentation.

Fas-ligand staining in non-drug- and drug-induced maculopapular rashes

Background: Morphologically and histopathologically, drug‐ and non‐drug‐induced maculopapular rashes can be almost indistinguishable. It has been postulated that Fas‐ligand (Fas‐L) is involved in the pathogenesis of drug rashes but not in the genesis of rashes, such as viral exanthems, that are not induced by medications.

Noninvasive real-time characterization of non-melanoma skin cancers with handheld optoacoustic probes

Currently, imaging technologies that enable dermsurgeons to visualize non-melanoma skin cancers (NMSC) in vivo preoperatively are lacking, resulting in excessive or incomplete removal. Multispectral optoacoustic tomography (MSOT) is a volumetric imaging tool to differentiate tissue chromophores and exogenous contrast agents, based on differences in their spectral signatures and used for high-resolution imaging of functional and molecular contrast at centimeter scale depth. We performed MSOT imaging with two- and three-dimensional handheld scanners on 21 Asian patients with NMSC. The tumors and their oxygenation parameters could be distinguished from normal skin endogenously. The lesion dimensions and depths were extracted from the spectral melanin component with three-dimensional spatial resolution up to 80 μm. The intraclass correlation coefficient correlating tumor dimension measurements between MSOT and ex vivo histology of excised tumors, showed good correlation. Real-time 3D imaging was found to provide information on lesion morphology and its underlying neovasculature, indicators of the tumor’s aggressiveness.

Is Propionibacterium acnes associated with hair casts and alopecia

We report a series of four patients who presented with complaints of diffuse non-scarring alopecia. They had similar clinical features of alopecia, hyperseborrhea, and distinct keratinaceous hair casts that encircled the hair shafts. Propionibacterium acnes was isolated from two of the patients’ scalp, and Gram-positive, Giemsa-positive bacteria were seen in the hair follicles in the scalp biopsy of one of the patients. The patients’ symptoms did not respond to standard treatment for seborrheic dermatitis, but responded to a course of systemic antibiotics targeting P. acnes. We propose a role for P. acnes colonization of the terminal hair follicles in the pathogenesis of hair casts, and possibly diffuse non-scarring alopecia. Possible mechanisms of pathogenesis are discussed with a literature review.

Macular lymphocytic arteritis.

To the Editor, We read with interest the article by Saleh and Mutasim1 on macular lymphocytic arterititis. They propose that this is the most appropriate term for this recently recognized vasculitis, rather than lymphocytic thrombophilic arteritis which we chose as it defines the distinctive histopathology seen in this setting. Although the clinical presentation may appear macular, it is also often reticular and arborizing in a pattern seen with livedo racemosa. This is a useful clinical clue and would be expected for a vasculitis which is targeting the medium-sized arteries within the deep dermis and subcutis. Furthermore, despite the macular appearance of the skin lesions palpation often reveals the presence of subtle subcutaneous induration or frank nodules. We chose the term lymphocytic thrombophilic arteritis2 to highlight the striking histopathological features that had been observed in previous cases described by the authors as macular arteritis,3,4 namely, the presence of a striking thick fibrin ring that can be appreciated on low power microscopy within arterioles in the deep dermis and subcutis in association with a prominent lymphocytic infiltrate (Fig. 1A and B). All of our five published cases had this feature as a defining criterion for inclusion and represents an unusual thrombophilic endarteritis. The authors have not highlighted this aspect in their illustrated histopathology in their additional cases but included narrowed arterioles that may be seen as an end result of a large range of vasculopathies including cutaneous polyarteritis nodosa.5 The striking cover illustration of a markedly inflamed arteriole with intramural lymphocytes may be important as it may represent the early phase of this lymphocytic arteritis prior to the development of the distinctive fibrin ring. This observation raises the question of whether the fibrin ring is primarily deposited on the inner aspect of the vessels as a result of lymphocytic-mediated injury to the subendothelial zone of the arterioles. One of the intriguing aspects in these patients is the prolonged course, often over years without the presence of ulceration or cutaneous infarction and may be dependent on the location of A

Systematized Epidermal Nevus with Epidermolytic Hyperkeratosis Improving with Topical Calcipotriol/Betametasone Dipropionate Combination Ointment

Abstract:  We present the case of a 5‐year‐old boy who presented with systematized epidermal nevus with evidence of epidermolytic hyperkeratosis on skin biopsy. He was otherwise well, with normal growth and development and no evidence of other organ system involvement. He had experienced only mild improvement with potent topical corticosteroids. He reported more‐marked improvement after 2 months of topical calcipotriol/betamethasone dipropionate combination ointment once a day to the lesions. Extensive epidermal nevi can lead to severe cosmetic disfigurement. We recommend a trial of topical calcipotriol/betamethasone dipropionate ointment for patients with extensive epidermal nevus not amenable to surgical treatment.

Structural and functional 3D mapping of skin tumours with non-invasive multispectral optoacoustic tomography

Recent advances in technology have enabled the development of various non‐invasive skin imaging tools to aid real‐time diagnosis of both benign and malignant skin tumours, minimizing the need for invasive skin biopsy. Multispectral optoacoustic tomography (MSOT) is a recently developed non‐invasive imaging tool, which offers the unique capacity for high resolution three dimensional (3D) optical mapping of tissue by further delivering highly specific optical contrast from a depth of several millimetres to centimetres in living tissues. MSOT enables volumetric, spectroscopic differentiation of tissue, both in vivo and in real time, with and without the application of biomarker‐specific probes, and is further able of providing spatial maps of skin chromophores, as well as underlying blood vasculature.

Eruptive disseminated Spitz naevus (EDSN) in a young girl of Indian origin

Eruptive disseminated Spitz naevus (EDSN) is a rare entity and has never been documented in a South‐east Asian individual (of Indian origin) previously. We report an adolescent with this condition which, to our knowledge, has only been previously reported a few times.