Sang Hwa Han

Clinicopathological features of mycosis fungoides in patients exposed to Agent Orange during the Vietnam War.

There are no reports on the clinicopathological features of mycosis fungoides (MF) among veterans exposed to Agent Orange, one of the herbicides used during the Vietnam War. To evaluate the clinical, histopathological and genotypic findings of Vietnam War veterans with MF and a positive history of exposure to Agent Orange, we performed a comparative clinicopathological study between MF patients with a history of Agent Orange exposure and those without a history of Agent Orange exposure. Twelve Vietnam War veterans with MF were identified. The mean interval from Agent Orange exposure to diagnosis was 24.5 years (range, 9–35). Skin lesions were significantly present on exposed and unexposed areas. Most patients (75%) experienced pruritus (mean visual analog scale score of 6.7). MF was manifested by plaques in 10 patients and by lichenification in five. Histopathological features of most cases were consistent with MF. Biopsy specimens also demonstrated irregular acanthosis (66.7%). In the comparative study, MF patients with a history of Agent Orange exposure differed significantly from those without exposure to Agent Orange in demographic and clinical characteristics. In addition, patients with exposure had an increased tendency for lesions in the exposed area. Notably, our patients showed a higher frequency (33.3%) of mycosis fungoides palmaris et plantaris than in previous studies. Histologically, irregular acanthosis was more frequently observed than ordinary MF. Our results indicate that dermatologists should pay close attention to these clinicopathological differences. Careful assessment of history of exposure to defoliants is warranted in some cases suspicious for MF.

Tick bite on glans penis: the role of dermoscopy.

Dear Editor: Since the first report of a human tick infestation in 19821, about 40 human cases have been reported in the Korean literature. The causative ticks reported in Korea were 7 species, and tick bites from Amblyomma testudinarium has been reported once in Korea2. Dermoscopy is a useful technique that allows the visualization of magnified submacroscopic structures, and by using dermoscopy, we could identify the biting tick and detect the residual part of the tick. A 75-year-old Korean man who lived in Tongyeong city, Gyeongsangnamdo, Korea presented with a small, blackish nodule on his glans penis (Fig. 1A). He had worked on a chili pepper farm the previous day. We noticed that the nodule was a tick by using dermoscopy and removed it with forceps. When we were removing the tick, the mouthpart of tick tore off. We identified the remaining part of the tick by using dermoscopy (Fig. 1B), and the tick bite site was excised. Histopathologic findings showed wedge-shaped necrosis at the site of penetration of the mouthparts, and remnants of the mouthparts of the tick. Fig. 1 (A) A tick attached to the glans penis. Inset: Dermoscopic findings revealed a female Amblyomma testudinarium. (B) Dermoscopic findings showed the remaining part of the tick. The tick was examined stereoscopically and identified as a female A. testudinarium based on the morphological characteristics as described previously3. The tick was about 18 mm in length, having 4 pairs of legs. The dorsal scutum was seen as a small shield ornamented with dark brown spots. The eyes were located on the lateral edges of the scutum (Fig. 2A). An anal groove was observed on the posterior portion of the anus (Fig. 2B). The external spur of coxa I was longer than the internal spur of coxa I. A comma-shaped spiracular plate and genital aperture were seen on the ventral side. Fig. 2 (A) Dorsal scutum was seen as a small shield ornamented with dark brown spots. The eyes (arrows) were located on the lateral edges of the scutum (×25). (B) Anal groove (arrow) was observed on the posterior portion of the anus (×25). Human tick bites by A. testudinarium have been reported mainly in regions with a warm and humid climate. In addition, A. testudinarium tends to attach to the axillary or inguinal region, which are rich in apocrine glands4. The reason why A. testudinarium prefers these sites is unknown, but it has been suggested that this tick reacts strongly to the odor from the apocrine glands. In our case, Tongyeong city is located in the southern coastal area of the Korean peninsula and has an oceanic climate. The external genitalia is rich in apocrine glands and blood supply, but the glans penis has no apocrine glands. As the patients glans penis was not covered by a prepuce after a circumcision, we suggest that the patients glans penis was easily approached by the tick. The usefulness of dermoscopy for diagnosing tick infestations was proposed previously. Especially, dermoscopy can determine whether or not the tick has been completely removed5. In our case, we could identify the biting tick and easily made a preliminary identification of the species of the tick. We also detected the remaining mouthpart of the tick by using dermoscopy. When patients present with a small nodular lesion on the glans penis, dermoscopy can be a useful diagnostic tool. In our report, A. testudinarium was identified stereoscopically. Furthermore, the dermoscopic findings helped to make a diagnosis and detect remnants of the tick. We report the second human case of a tick bite from A. testudinarium in Korea for which dermoscopy was used as an adjuvant diagnostic tool.

Evolution of urticarial vasculitis: a clinical, dermoscopic and histopathological study

Editor The clinical differentiation of urticarial vasculitis (UV) and urticaria, especially in urticarial skin lesions arising within 24 h, is a diagnostic challenge. We aimed to analyse clinicodermoscopic findings in patients with UV and disease progression in relation to histological findings and to evaluate the usefulness of polarized dermoscopy (PD) in the diagnosis of urticarial skin lesions through a comparative dermoscopic study between patients with UV and urticaria. Eleven patients (four men and seven women: mean age = 39.82 18.70 years) clinically and histologically diagnosed with UV were enrolled. At the initial medical check-up and follow-up visits patients were interviewed using a standard questionnaire and lesional changes were continuously monitored. The duration of illness and individual lesions, distribution, and symptoms were assessed. All lesions were classified as early if they occurred within 24 h and late if they occurred after 24 h according to patient self-report and lesional change features. In accordance with the standard, clinical findings and dermoscopic patterns were evaluated throughout the disease course. All lesions were examined by a dermatologist using PD (DermLite DL3, 109; 3Gen, Dana Point, CA, USA). The most distinct finding from the lesions was photographed using a digital camera (Cybershot DSC-W290, 39 optical zoom; Sony, Tokyo, Japan). Among the dermoscopic characteristics, red-purple dots or globules were quantified into four grades (Grade 0 = none or few; Grade 1 = less than 20; Grade 2 = more than 20 but less than 40; Grade 3 = more than 40) according to the number present, and mean values were calculated. After dermoscopy, a biopsy was obtained from each of the 11 patients in order to assess dermoscopic-histopathological correlations. To assess the diagnostic value of PD in this disease setting, 22 consecutive patients with a clinical diagnosis of common urticaria in the past year (10 men and 12 women: mean age = 36.21 12.50 years) were selected. Our inclusion crite-

CD25+ folliculotropic Sézary syndrome with CD30+ large cell transformation.

Folliculotropic Sézary syndrome is a rare and unique variant of cutaneous T‐cell lymphoma (CTCL) characterised by both follicular and leukaemic involvement of mycosis fungoides (MF). It is associated with a more aggressive clinical course and fatal outcomes. Large cell transformation (LCT) of mycosis fungoides/Sézary syndrome is also associated with an aggressive disease course and shortened survival, requiring an intensive therapeutic approach. This report describes a case of folliculotropic Sézary syndrome with CD30+ LCT. Most of the larger lymphocytes in the lesions were positive for CD25, the expression of which is associated with advanced CTCL. In addition, we review the literature on this unusual CTCL and provide evidence that this entity represents a distinct clinicopathological entity occasionally associated with extracutaneous involvement and LCT.

Usefulness of Dermoscopy in the Differential Diagnosis of Ruptured and Unruptured Epidermal Cysts

Background An epidermal cyst is a common keratin-filled epithelial-lined cyst. The treatment of choice for epidermal cysts is surgical excision. If the cyst becomes ruptured, incision and drainage with oral antibiotic therapy or intralesional steroid injection are required. Objective To analyze the dermoscopic features that can differentiate between ruptured and unruptured epidermal cysts. Methods The clinical and dermoscopic features of the pathologically confirmed epidermal cysts of two subgroups of 38 patients, 20 with unruptured cysts and 18 with ruptured cysts, were reviewed. Results With regard to the dermoscopic features, an ivory- white background color and punctum were commonly found in both groups (p>0.05). The unruptured-cyst group showed higher frequencies of pore sign (p<0.05), blue-white veil (p>0.05), no vascular structure, and arborizing telangiectasia (p<0.05), but the ruptured-cyst group usually had red lacunae (p>0.05) and peripheral linear branched vessels (with an erythematous rim) (p<0.05). Conclusion Dermoscopy is helpful in differentiating between ruptured and unruptured epidermal cysts.

Granulocyte Colony-Stimulating Factor-Induced Psoriasiform Dermatitis Improved by Narrowband Ultraviolet B

232 Ann Dermatol Received February 2, 2016, Revised March 31, 2016, Accepted for publication April 4, 2016 Corresponding author: Kee Suck Suh, Department of Dermatology, Kosin University College of Medicine, 262 Gamcheon-ro, Seo-gu, Busan 49267, Korea. Tel: 82-51-990-6145, Fax: 82-51-990-3041, E-mail: ksderm77@unitel.co.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright