Martha L. McCollough

Vertical and transverse sections of alopecia biopsy specimens: Combining the two to maximize diagnostic yield

BACKGROUND Traditional vertical sections of scalp biopsy specimens contain few hair follicles. For this reason transverse sections of scalp biopsy specimens have been advocated. Both methods have advantages and disadvantages. We have developed a simple method that we believe offers the best of both methods. OBJECTIVE Our purpose was to assess the impact of combining vertical and transverse sections of scalp biopsy specimens. METHODS Two 4 mm punch biopsies are performed. One specimen is bisected vertically: half for hematoxylin-eosin (H-E) staining, half for direct immunofluorescence. The second specimen is bisected transversely and submitted for H-E. The three pieces of tissue for H-E staining are embedded in a single cassette. RESULTS Because a biopsy specimen for direct immunofluorescence is commonly obtained in cases of alopecia, our method does not add a surgical procedure. All three pieces of tissue for H-E staining are embedded in a single paraffin block. Therefore the cost of histologic interpretation is not increased. Our diagnostic yield improved. Transverse sections were superior in cases of lupus erythematosus and lichen planopilaris with focal follicular involvement. Features of the follicular degeneration syndrome were also best demonstrated in transverse sections. Interface changes, lupus panniculitis, miniaturized hairs, and trichomalacia were better demonstrated in vertical sections. CONCLUSION Our method exploits the advantages of both vertical and transverse sections and improves diagnostic yield without increasing cost.

tattoo Pigment Mimicking Metastatic Malignant Melanoma

background The benefits of elective lymph node dissection (ELND) in the treatment of melanoma remain controversial, however, it may be beneficial in some patients. Tattoo pigment from decorative tattoos may migrate to the regional lymph nodes. In patients who develop malignant melanoma and who have been tattooed, this pigment may clinically mimic metastatic disease. objective We wish to alert clinicians that pigment from tattoos may migrate to the regional lymph nodes. In the unusual instance of a tattooed patient who develops malignant melanoma, when undergoing ELND, surgeons should rely on histologic confirmation of metastatic disease before altering operative plans. methods ELND for malignant melanoma, in a patient with a history of decorative tattoos that had been removed by dermabrasion, was performed. Black lymph nodes that clinically resembled metastatic disease were identified. Subsequent histologic examination revealed normal lymph node architecture with a heavy collection of black pigment. Mass spectrophotometry showed this pigment to be consistent with tattoo dye. results A patient who had undergone dermabrasion for removal of decorative tattoos developed malignant melanoma in the same extremity. Clinically suspicious black lymph nodes were identified during ELND. Histologic examination did not reveal metastatic disease. Additional therapy was not considered intra‐ or postoperatively even though the clinical suspicion of metastatic disease was high. The patient was not subjected to any unnecessary emotional or physical distress pending histologic confirmation. conclusions Tattoo pigment in the lymph nodes may clinically mimic metastatic melanoma. Histologic confirmation of metastatic disease should always be obtained before additional therapy is considered.

Alabaster Skin after Carbon Dioxide Laser Resurfacing with Histologic Correlation

background. Carbon dioxide laser resurfacing has gained popularity as a relatively safe and effective method of facial rejuvenation. Original reports describe mostly reversible side effects and a low incidence of scarring. Only very recently have reports of delayed hypopigmentetion surfaced. This effect is not visible until several months after resurfacing, and most likely represents a permanent change. objective. To provide an additional clinical description of the complication of delayed hypopigmentation along with the first published histologic correlation. methods. Clinical records along with a preprocedure and 7‐month postprocedure full‐thickness skin biopsy were used for this report. results. This patient experienced a striking leukoderma 6 months after a full facial carbon dioxide laser resurfacing procedure done for widespread actinic keratoses. There was a zone of dermal fibrosis extending approximately 0.4 mm on the postprocedure biopsy. Comparison of the preprocedure and postprocedure biopsies revealed no difference in the number of melanocytes by MART‐1 immunohistochemical staining, but there was a significant decrease in epidermal melanin as determined by Fontana‐Mason staining. conclusion. This patient experienced a profound expression of an increasingly recognized and reported complication of carbon dioxide laser resurfacing. Histologic correlation is similar to the results previously reported after phenol chemical peels, demonstrating a normal number of melanocytes but a decrease in epidermal melanin.

5-Fluorouracil iontophoretic therapy for Bowen's disease

BACKGROUND Topical 5-fluorouracil (5-FU) is an accepted therapy for Bowens disease. Recurrences with this method have been attributed to deep follicular involvement and poor patient compliance because of the prolonged treatment time required. OBJECTIVE We sought to determine whether iontophoresis of 5-FU is an effective therapy for Bowens disease. METHODS Twenty-six patients with biopsy-proven Bowens disease received eight 5-FU iontophoretic treatments in 4 weeks. Local excision was done 3 months after the last treatment. The specimens were step-sectioned and evaluated for any histologic evidence of bowenoid changes. RESULTS Only 1 of 26 patients showed histologic evidence of Bowens disease 3 months after treatment. CONCLUSION 5-FU iontophoresis appears to be a safe, effective, and well-tolerated therapy for Bowens disease.

Unusual serpentine hyperpigmentation associated with 5-fluorouracil: Case report and review of cutaneous manifestations associated with systemic 5-fluorouracil

A variety of cutaneous reactions have been reported with the use of systemic 5-fluorouracil. Our patient had serpentine hyperpigmented streaks appearing 5 days after bolus infusion of 5-fluorouracil. The patient also had other skin eruptions, that is, inflammation of actinic keratoses and folliculitis limited to the forehead; these reactions have been reported previously with 5-fluorouracil medication. We report this case and review the literature on skin manifestations associated with 5-fluorouracil therapy.

Hypergammaglobulinemic purpura of Waldenström

Hypergammaglobulinemic purpura of Waldenström is characterized by hypergammaglobulinemia, recurring purpura, an elevated erythrocyte sedimentation rate, and the presence of rheumatoid factor indicative of circulating immune complexes. There is a significant association with autoimmune diseases, especially Sjögrens syndrome and lupus erythematosus. Hypergammaglobulinemic purpura is considered primary when there is no other associated disease or secondary when associated with other diseases, usually autoimmune. Immune derangements are fundamental in its pathogenesis, although its cause is still unknown. Therapy is unrewarding and is probably unnecessary for this usually benign condition. Three cases are presented that are representative of patients with hypergammaglobulinemic purpura.

Frontalis-associated lipoma of the forehead

We describe a deeply placed lipoma of the forehead. This fatty tumor is usually misdiagnosed initially as an epidermal inclusion cyst. Preoperative recognition allows its proper depth within the tissue, that is, within or just below the frontalis muscle, to be anticipated.

Interpretation of Mohs micrographie frozen sections: A peer review comparison study†

The ability of the Mohs surgeon to interpret frozen sections generated during Mohs surgery has been questioned recently. In this study 1000 Mohs micrographic slides were interpreted by a Mohs surgeon and subsequently by a general pathologist. The disputed slides were then reviewed independently by two Mohs surgeons, two pathologists, and a dermatopathologist. Overall, there was a 98.9% agreement in interpretation among the Mohs surgeons, the pathologists, and the dermatopathologist. Results would indicate that a well-trained and experienced Mohs surgeon is competent to interpret slides prepared under his or her supervision during Mohs surgery.

Latent cutaneous Mycobacterium fortuitum infection in a healthy man

Mycobacterium fortuitum infection developed in the foot of an otherwise healthy man 15 years after traumatic implantation of a foreign body.

Orbital dermoid cysts showing conjunctival epithelium.

The orbital area is one of the most common sites for dermoid cysts. Most often these cysts are lined by keratinizing squamous epithelium; however, dermoid cysts may rarely be lined with conjunctival epithelium. We describe such a cyst and the features that distinguish it from other dermoid cysts.