Justin P. Bandino

Two cases of anti-programmed cell death 1-associated bullous pemphigoid-like disease and eruptive keratoacanthomas featuring combined histopathology

References 1 Neumann HAM, Cornu-Th enard A, Junger M et al. Evidence-based (S3) guidelines for diagnostics and treatment of venous leg ulcers. J Eur Acad Dermatol Venereol 2016; 30: 1843–1875. 2 Ferreira C, Wang H. Prolidase deficiency. Gene Reviews, Available at: https://www.ncbi.nlm.nih.gov/books/NBK299584/ (last accessed 15 November 2016). 3 Shrinath M, Walter JH, Haeney M et al. Prolidase deficiency and systemic lupus erythematosus. Arch Disease Childhood 1997; 76: 441–444. 4 Goodman SI, Solomons CC, Muschenheim F et al. A syndrome resembling lathyrism associated with iminodipeptiduria. Am J Med 1968; 45: 152–159. 5 Lapi ere CM, Nusgens B. Plaies cutan ees torbides et trouble du m etabolism du collag ene. Arch Belg Dermatol Syphylogr 1969; 25: 353–356. 6 Buist NRM, Strandholm JJ, Bellinger JF et al. Further studies on a patient with iminodipeptiduria: a probable case of prolidase deficiency. Metabolism 1972; 21: 1113–1123. 7 Leoni A, Cetta G, Tenni R et al. Prolidase deficiency in two siblings with chronic leg ulcerations. Clinical, biochemical, and morphologic aspects. Arch Dermatol 1987; 123: 493–499.

Response to ‘Eruptive keratoacanthomas arising in the setting of lichenoid toxicity after patients on antiprogrammed cell death‐1 inhibition with nivolumab’

3 Red to purple macules associated with scant grey vesicles with an erythematous halo on the palms. 4 Itch/pain of the palmar lesion, which in some cases was excruciating. 5 Scarce involvement of the feet. 6 Occurrence in the third decade (mean age: 34.3; range: 30– 39). Even though some patients presented scattered lesions over the buttocks and limbs, the clinical picture was dominated by the involvement of the hand, mouth (oral and perioral) and scalp. Surprisingly, during the outbreak also one child (not included in the present report) showed an involvement of the scalp. This unusual presentation, associated with the scarce involvement of the feet, led us to refer to the infection as ‘hand, scalp and mouth disease’. Scalp involvement was seldom reported until 2013, when Lønnberg et al. focused on this peculiar feature. Afterwards, it was also mentioned in other papers, while in our cases it represents one of the most important features. Physicians should be aware that scalp localization is a part of the clinical presentation of HFMD, especially in adults, and on the basis of the published evidence and our experience, we recommend searching for scalp localization in any viral exanthem, considering that papules, vesicles and pustules with crusty evolution of the scalp should no longer be considered a feature in the differential diagnosis of chickenpox. If our observation were to be confirmed by future studies, we suggest the introduction of the word ‘scalp’ in the name of this atypical variant of the disease, to facilitate the recall of clinical features and to improve diagnosis and surveillance of the disease, also in settings where serology and PCR are not yet available. All authors have agreed to the contents of the manuscript in its submitted form.

Epidermal consumption in benign and malignant melanocytic neoplasms

Consumption of the epidermis associated with effacement of the rete ridge pattern has been cited as a useful criterion in the diagnosis of melanoma, but the significance of consumption in the absence of rete ridge effacement is unknown. We evaluated 701 melanocytic neoplasms for presence and ‘grade’ of consumption by melanocytic nests relative to diagnosis, body location, gender and age. We defined 1+ consumption as collections of melanocytes occupying greater than two thirds of the viable epidermis, with or without loss of the rete ridge pattern. Nests extending to the bottom of, within, and through the granular layer were graded 2+, 3+ and 4+, respectively. Consumption was more frequent and higher grades were found in melanomas followed by Spitz nevi compared with conventional melanocytic nevi (p < 0.001). Melanomas with higher Breslow thickness showed higher grades (p < 0.05). In conventional nevi, consumption occurred most frequently in back (13.7%), acral (11.9%) and scalp (9.8%) locations. Consumption without the requirement for rete ridge effacement occurs more frequently and at higher grades in melanoma. Higher grades correlate with higher Breslow thickness. Consumption is also common in Spitz nevi and occurs at lower grades in conventional (non‐Spitz) nevi, especially on the back, the scalp and at acral sites.

Low-grade myxofibrosarcoma presenting at the site of prior high-grade disease*

Myxofibrosarcoma is one of the most common soft tissue sarcomas occurring in older adults. It can arise de novo or can be radiation induced, and the term myxofibrosarcoma was originally devised to encompass a spectrum of myxoid tumors with characteristics similar to malignant fibrous histiocytoma (MFH). Confusion exists, however, regarding the distinction between microscopic grade and characteristics of myxofibrosarcoma and MFH. Correct classification is vital to prognosis, as the degree of myxoid change is inversely related to the incidence of metastasis. We present a case of a 76‐year‐old man with a history of high‐grade MFH of the left lower extremity, status post excision and radiation therapy, who presented 2 years later with a regional metastatic recurrence of high‐grade MFH to the left groin as well as new nodules adjacent to and within his prior excision and radiation site. These new nodules were determined to represent low‐grade myxofibrosarcoma. These new low‐grade lesions either represent a low‐grade recurrence of high‐grade sarcoma or a new, radiation‐induced soft tissue sarcoma occurring at the same site. Radiotherapy, however, is an unlikely cause; specific postradiation sarcoma criteria have not been fulfilled. This article discusses both the nosology and histopathological spectrum of these important soft tissue sarcomas, their aggressive and recurrent nature and their association with radiation therapy.