Santiago Gómez-Díez

Dermoscopy for Discriminating Between Lichenoid Sarcoidosis and Lichen Planus

T HE LESIONS SHOWN WERE LOCATED ON the forearm of a 47-year-old man (Figure 1A), the forearm of a 51-yearold man (Figure 1B), and the trunk of a 55-year-old woman (Figure 1C), all of them presenting with a lichenoid rash. Dermoscopy revealed 2 differential patterns in these lesions: (1) reticular, white Wickham striae (WS) (Figure 2A) in the papules shown in Figure 1A and (2) round to oval, yellowbrown, homogeneous patches (YPs) (Figure 2B and C) and absence of WS in the lesions shown in Figure 1B and C. A histopathologic diagnosis of lichen planus (LP) was made in 1 patient (Figure 1A, inset), and lichenoid sarcoidosis was diagnosed in the other 2 patients (Figure 1B and C, insets). Lichenoid sarcoidosis represents 1% to 2% of cutaneous sarcoidosis cases and mimics LP. The examples illustrated herein show that dermoscopy may be useful for discriminating between the lesions of LP and those of lichenoid sarcoidosis. The absence of WS and the presence of YPs should prompt clinicians to perform a biopsy to rule out a granulomatous skin disease in clinically lichenoid lesions. Dermoscopy and diascopy of sarcoidosis lesions reveal individual yellow nodules (“grains of sand”) or a yellow-brown discoloration (“applejelly” sign). Yellow-brown homogeneous patches are not specific for sarcoidosis, but they are indicative of a granulomatous skin disease (sarcoidosis, lupus vulgaris, leishmaniasis). Conversely, dermoscopy of active LP lesions reveals the characteristic WS but not the YPs.

Lesión cutánea ulcerada y supurativa de evolución tórpida en el cuello de una mujer de 83 años

Una mujer de 83 anos, con antecedentes de hipertension arterial (HTA), consulto por una lesion cutanea localizada en la region laterocervical izquierda de varios meses de evolucion. La lesion habia crecido paulatinamente hasta ulcerar la superficie cutanea, con varios episodios posteriores de supuracion; no presentaba fiebre ni otra sintomatologia general asociada. La paciente habia recibido tratamiento con antibioticos topicos y orales sin mejoria. Referia, asimismo, que durante la juventud presento lesiones similares en esta localizacion, las cuales regresaron dejando cicatrices residuales. En la exploracion se observaba una lesion tuberosa de tonalidad violacea, indurada a la palpacion y de 2,5 × 1 cm de diametro (fig. 1). El centro de la lesion estaba ulcerado, apreciandose un fondo necrotico y profundo que drenaba material purulento a la presion. Adyacente a ella se apreciaban varios orificios fistulosos y cicatrices lineales deprimidas. No presentaba adenopatias palpables y el resto de la exploracion fisica general fue normal. Entre los estudios de laboratorio, incluidos hemograma con formula leucocitaria, bioquimica completa, proteinograma y analisis de orina solo destacaba acido urico de 8 mg/dl (normal, 3,4-7 mg/dl). La velocidad de sedimentacion globular (VSG) era de 53 mm/h. La prueba de la tuberculina fue positiva, con induracion de 25 mm a las 72 h. La radiografia de torax y la ecografia abdominal no mostraron imagenes patologicas. Las serologias de VIH y sifilis fueron negativas. Mediante la introduccion de contrate a traves del fondo de la ulcera se observo un trayecto fistuloso de 5 cm (fig. 2). Se realizo biopsia cutanea para estudio anatomopatologico y microbiologico. El examen histopatologico mostraba la presencia en el centro de la lesion de ulceras superficiales y formacion de abscesos. En la periferia se evidenciaban granulomas epitelioides con necrosis central localizados a nivel de la dermis profunda (fig. 3). No se detectaron bacilos acido-alcohol resistentes (BAAR) con la tincion de Ziehl-Neelsen.

Vitamin A Deficiency and Bowel-Associated Dermatosis-Arthritis Syndrome Secondary to Biliopancreatic Diversion for Obesity

Morbid obesity is a public health problem in the developed world and is considered the second most important preventable cause of death after smoking. Biliopancreatic diversion (BPD), consisting of a distal gastrectomy with Roux-en-Y reconstruction, is a surgical technique used to treat obesity.1,2 The reduction in fat and carbohydrate absorption associated with this procedure can achieve a maintained loss of 75% of the excess weight.2 We describe the case of a patient with BPD who presented 2 different types of skin lesions. The patient consulted 2 years after surgery with phrynoderma and night blindness due to vitamin A deficiency and later, 8 years after surgery, she presented skin lesions consistent with intestinal bypass arthritis-dermatitis syndrome. Case Report

Skin Metastases as the Initial Presentation of Pancreatic Carcinoma

Figure 1 Ulcerated, erythematous-violaceous tumor situated in the left frontoparietal region. Metástasis cutánea por carcinoma pancreático como primera manifestación clínica To t he Edit or: Cancer of the pancreas is the fourth most common cause of cancer-related death in the United States. 1 In Spain, its incidence is around 7 cases per 100 000 population and there has been a considerable increase in recent decades. 2 The most important skin manifestations related to cancer of the pancreas are jaundice and pruritus caused by biliary tract obstruction. In some cases there may be an associated pancreatic panniculitis 3 and superficial thrombophlebitis migrans. Skin metastases are rare and, when they occur, they tend to appear in the umbilical region. 4 We present a case of skin metastasis due to adenocarcinoma of the head of the pancreas; a tumor on the scalp was the first manifestation of the disease. A 53-year-old woman with no past personal or family history of interest was seen for a tumor on the scalp, which had appeared approximately 2 months earlier and had grown progressively. On examination of the skin, a round, erythematous-violaceous nodule of 2.5 cm diameter was observed in the left frontoparietal region. The nodule was ulcerated, of rubbery consistency, adherent to the deep planes, and was not tender (Figure 1). In addition, the patient presented marked jaundice that had developed 4 days earlier and that had led to her referral and admission to the gastroenterology department for evaluation. The most relevant findings in the blood tests were anemia (hemoglobin, 9.7 g/dL), leucocytosis (15 900/ µL), thrombocytosis (513 000 platelets/µL), elevated total bilirubin (19.48 mg/dL [normal value, 0.1–0.2 mg/ dL]) and direct bilirubin (17.66 mg/d [normal value, 0.05–0.25 mg/dL]), and increased levels of the following enzymes: amylase (304 U/L [normal value, 28–100 U/L]), lipase (1189 U/L [normal value, 17–60 U/L]), lactate dehydrogenase (841 U/L [normal value, 230–460 U/L]), alkaline phosphatase (863 U/L [normal value, 35–104 U/L]), aspartate aminotransferase (185 U/L [normal value, 1–31 U/L]), alanine aminotransferase (129 U/L [normal value, 1–31 U/L]), and g-glutamyltransferase (983 U/L [normal value, 5–39 U/L]). The chest radiograph was normal. Abdominal computed tomography revealed a mass in the head of the pancreas of 49×40×61 mm, with marked dilatation of the intrahepatic and extrahepatic biliary tract and of the gallbladder. There were also focal lesions in the liver, kidney, and bone characteristic of metastases, and multiple enlarged lymph nodes in the mesenteric …

Letter: benign subcutaneous emphysema after a skin biopsy.

A 76-year-old female patient required evaluation at our dermatologic department because of 2 days of long swelling of her left arm. Fever or general malaise were not present. A skin biopsy had been made over the area 3 days before. On examination, a notable, diffuse, crackling sound (crepitus) was heard upon palpation extending from the wrist to the elbow (Figure 1). Erythema, induration, local heat, or necrosis was not present. A loosely sutured biopsy wound was evident near the elbow. Pressure over this area was applied to assess if purulent discharge was present. Numerous, large, clear bubbles mixed with a serohematic exudate became evident (Figure 2). On making a clinical diagnosis of benign SE secondary to the biopsy injury, the sutures were removed and the subcutaneous air was forced out by local pressure. After this maneuver, the SE resolved within a few days, and no relapse occurred. The absence of air within muscle on both the radiograph and the echography of the arm confirmed that a deep, gasproducing soft tissue infection was not present. Circumferential SE was noted on the upper extremity radiograph but not on the chest radiograph.

Angiomas planos adquiridos en mancha de vino de Oporto

The development of flat angiomas in the form of a «port-wine stain» is an infrequent event in adults. We describe two cases of acquired flat angioma in the form of a «port-wine stain,» which began in the second decade of life and grew slowly and steadily until reaching a large size. In the first case, it affected the front and back of the trunk, and in the second patient, the neck and left shoulder. Histopathology showed ectatic vessels in the papillary and reticular dermis, with no proliferation of endothelial cells.

Escleromixedema: estudio ultraestructural

Scleromyxedema is a type of mucinosis that presents with some well defined clinical and histopathological characteristics. We describe the findings observed with transmission electron microscopy in a case that we recently studied. The patient was a 56-year-old female with a localized eruption of lichenoid papules on the face, upper trunk and limbs. It was accompanied by IgG lambda gammopathy. Optical microscopy showed the findings typical of scleromyxedema. Electron microscopy revealed the existence of a large number of fibroblasts with high activity levels in the synthesis and release of collagen fibers and a mucoid substance.

Letter: Benign Subcutaneous Emphysema after a Skin Biopsy: LETTER TO THE EDITOR

A 76-year-old female patient required evaluation at our dermatologic department because of 2 days of long swelling of her left arm. Fever or general malaise were not present. A skin biopsy had been made over the area 3 days before. On examination, a notable, diffuse, crackling sound (crepitus) was heard upon palpation extending from the wrist to the elbow (Figure 1). Erythema, induration, local heat, or necrosis was not present. A loosely sutured biopsy wound was evident near the elbow. Pressure over this area was applied to assess if purulent discharge was present. Numerous, large, clear bubbles mixed with a serohematic exudate became evident (Figure 2). On making a clinical diagnosis of benign SE secondary to the biopsy injury, the sutures were removed and the subcutaneous air was forced out by local pressure. After this maneuver, the SE resolved within a few days, and no relapse occurred. The absence of air within muscle on both the radiograph and the echography of the arm confirmed that a deep, gasproducing soft tissue infection was not present. Circumferential SE was noted on the upper extremity radiograph but not on the chest radiograph.

Síndrome cardiofaciocutáneo con acantosis nigricans

Resumen —Se describe un nuevo caso de sindrome cardiofaciocutaneo, y se hace especial referencia a la presencia de lesiones tipicas de acantosis nigricans en axilas. Se trataba de un varon de 17 anos que presentaba como rasgos generales retraso mental moderado, anomalias en el fenotipo craneofacial y miocardiopatia hipertrofica. Desde el punto de vista cutaneo mostraba queratosis folicular diseminada con alopecia cicatrizal en cejas, multiples nevos pigmentarios, acantosis nigricans en axilas y cabello ensortijado.