Pitiporn Suwattee

Plaque-type syringoma: two cases misdiagnosed as microcystic adnexal carcinoma.

Background:  Plaque‐type syringoma is a rare variant of syringoma. This benign neoplasm may be easily misdiagnosed as microcystic adnexal carcinoma (MAC), potentially resulting in unnecessary surgery with disfiguring consequences.

Primary cutaneous apocrine carcinoma presenting as carcinoma erysipeloides.

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Tinea versicolor with interface dermatitis

To the Editor, Tinea versicolor (TV) is a common fungal infection caused by normal skin saprophytes, Malassezia species. TV has a spectrum of clinical presentations: (i) numerous, well-circumscribed, scaly, hyperor hypopigmented macules and patches on the trunk and chest, which is the most common presentation; (ii) inverse TV, seen more often in immunocompromised hosts and (iii) follicular papules and pustules, which is known as pityrosporum folliculitis. We report an atypical and likely under-recognized presentation of TV with a novel histopathological finding of interface dermatitis. A 77-year-old male was evaluated for an asymptomatic eruption on the right upper abdomen, present for over 6 months. Physical examination revealed multiple firm, 2–3 mm, monomorphic, redbrown, inflammatory papules, some of which exhibited a fine white scale (Fig. 1). No pustules were present. A punch biopsy showed a slightly acanthotic epidermis with a mild superficial perivascular lymphocytic infiltrate. Fungal hyphae and spores were identified within the stratum corneum. Interestingly, an interface lymphocytic infiltrate was observed in the superficial dermis underlying the fungal elements (Fig. 2A,B). The diagnosis of TV was thus made. The patient had complete resolution of these papules after treatment with ketoconazole cream twice daily for 4 weeks, leaving normal pigmented skin. The histological changes associated with TV are slight hyperkeratosis and acanthosis with a minimal superficial perivascular lymphocytic infiltrate. Round spores of 2–8 mm in size admixed with 2– 3 mm short, thick hyphae are identifiable in the basket-weave stratum corneum. The inflammatory infiltrate consisting of mononuclear cells is usually sparse; it can be so subtle that the biopsy may resemble normal skin. Because the organisms are Fig. 1. Multiple red-brown papules with a minimal scale.

Naildex: pilot evaluation of an onychodystrophy severity instrument.

A valid and reliable measure that captures onychodystrophy disease severity is important for both clinical and research applications. Three hundred and twenty‐two patients at two Veterans Affairs Medical Centers with clinical evidence of onychodystrophy suggesting onychomycosis (at least 25% in a distal subungual pattern) were examined using Naildex parameters. Naildex scores were calculated by a combination of: per cent of each nail infected, area of each nail and number of infected nails. Patients also completed a nail‐specific quality of life questionnaire (NailQoL) and nail samples were collected and examined mycologically. Data was analysed for all enrolled patients (n = 322) and patients with mycologically‐confirmed onychomycosis (n = 243). Inter‐rater reliability was calculated from two examiners who each evaluated 17 patients with mycologically‐confirmed onychomycosis. Significant correlations (P < 0.01) between Naildex and NailQoL as well as proxy measures (duration of infection) indicated construct validity of the instrument for all patients as well as mycologically‐confirmed cases. Strong correlation (r = 0.754, P < 0.01, n = 17) indicated high inter‐rate reliability. This pilot evaluation suggests that Naildex is a valid and reliable measure of onychomycosis severity.

Challenge. Diagnosis: Hypertrophic lupus erythematosus.

(Am J Dermatopathol 2008;30:635) An otherwise healthy 49-year-old male was referred for evaluation of verrucous papules on both forearms that had been present for 15 years. He tried multiple topical steroids without improvement. Review of system was unremarkable. Physical examination revealed multiple hyperkeratotic, verrucous papules and nodules with white, scaly, cribriform centers on the forearms (Fig. 1). He also had atrophic, depigmented patches with scales on the cheeks, eyebrows, nose, ears, chest, and upper back. Oral mucosa was clear. A verrucous papule was biopsied for histologic examination (Fig. 2).

Uveitis and Desquamating Rash of the Palms and Soles.

Syphilis, a sexually transmitted disease caused by the spirochete Treponema pallidum, can affect nearly every organ system in the body. In particular, skin manifestations of secondary syphilis are common but nonspecific and can be a true masquerader of other skin disorders. Concomitant infection with HIV has been increasing and may cause even more unusual skin presentations. We present a patient with the atypical combination of palmoplantar keratoderma and ocular symptoms that closely resembled reactive arthritis (or Reiters syndrome). When evaluating patients with HIV infection, clinicians should maintain a high level of suspicion for syphilis to accurately diagnose and treat this curable but potentially fatal disease.

Slowly growing yellow nodules: challenge. Necrobiotic xanthogranuloma.

CASE REPORT A 56-year-old man with a past medical history significant for marginal zone lymphoma with plasma cell differentiation and monoclonal immunoglobulin G (IgG) k gammopathy presented after developing slowly enlarging, asymptomatic nodules on his right forearm, bilateral shoulders, and trunk over the past year. Without any attempt at treatment, the patient continued to develop new lesions, most recently on his nose. He denied any associated constitutional symptoms. Diagnosed with lymphoma 4 years earlier, he had received several rounds of chemotherapy. He was initially treated with rituximab, vincristine, cyclophosphamide, and prednisone with improvement of the bone marrow involvement but not of the gammopathy or leukopenia. A trial of etoposide, adriamycin, vincristine, cyclophosphamide, and prednisone resulted in severe toxicity. His most recent treatment had been 1 year before presentation; it consisted of 6 cycles of bortezomib that resulted in reduction of his gammopathy. At the time of his visit, he was considering a peripheral stem cell transplant. Physical examination revealed multiple firm, yellow-orange nodules with telangiectasia (Fig. 1). A 4-cm yellowish-pink nodule with a central crust was present on the right forearm (Fig. 2). A 7-mm crusted yellow nodule was observed on the nasal bridge. Laboratory tests showed pancytopenia (hemoglobin 12.4 g/dL; reference range 13.5–16.5 g/dl, white blood cells, 2.6 3 10/mL; reference range 4.5–10.03 10/mL, platelet count, 973 10/mL; reference range 150– 450 3 10/mL) with normal liver and renal function. Serum protein electrophoresis revealed a monoclonal IgG k gammopathy (monoclonal IgG k, 13.8 g/L; reference range 2.4–4.9 g/L). A skin biopsy of the lesion on the right shoulder was performed (Figs. 3 and 4).

Multiple white facial papules

A healthy 60-year-old man presented for evaluation of asymptomatic facial papules that had been present for 3 years. On physical examination he was found to have multiple smooth, firm, skin-coloured to white, domeshaped papules, 2–4 mm in size, localized to the forehead, nose and cheeks (Fig. 1). The remaining skin examination was normal. The hair, nails and oral mucosa were unremarkable. Radiological studies found bilateral renal cysts (Fig. 2). No other family members were affected.