Yu-Ling Hsu

Presence of human papillomavirus type 6 DNA in the perineal verrucoid lesions of Hailey‐Hailey disease

1 Cottoni F, Masia IM, Masala MV, Mulargia M, Contu L. Familial Kaposi’s sarcoma: case reports and review of the literature. Acta Derm Venereol 1996; 76: 59–61. 2 Granel B, Sterratrice J, Zandotti C et al. Conjugal HHV-8 infection with cutaneous Kaposi’s sarcomas and Castleman’s disease: fortuitous association or not? Dermatology 2000; 200: 153–154. 3 Santarelli R, De Marco R, Masala MV et al. Direct correlation between human herpesvirus-8 seroprevalence and classic Kaposi’s sarcoma incidence in Northern Sardinia. J Med Virol 2001; 65: 368–372. 4 Masala MV, Carcassi C, Cottoni F, Mulargia M, Contu L, Cerimele D. Molecular evidence of geography and sex determination of HLA-associated risk factors in classic Kaposi’s sarcoma. J Invest Dermatol 2000; 115: 284.

New-onset psoriasis associated with etanercept therapy.

Figure 2. Skin biopsy specimen shows psoriasiform epidermal hyperplasia, parakeratosis, and neutrophils in strata corneum and strata spinosum, which are typical of psoriasis (hematoxylin–eosin, original magnification ·200). Figure 1. Psoriasiform skin lesions on the patient’s left forearm. Dear Editor, Etanercept is a dimeric fusion protein which blocks the interaction of both tumor necrosis factor (TNF)-a and TNF-b with their corresponding receptors. It shows high efficacy in treating many inflammatory conditions, including rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. It has also been proved to be an effective therapy for moderate-tosevere plaque psoriasis. However, there is mounting evidence that etanercept can trigger new-onset or exacerbate pre-existing psoriasis. We describe a 43-year-old Asian male patient presenting with a 10-year history of ankylosing spondylitis, who denied personal and family history of psoriasis. He was diagnosed to have rheumatoid factor-negative rheumatoid arthritis in November 2004 (five of the 1987 revised criteria fulfilled: morning stiffness >1 h, arthritis of eight joint areas, arthritis of hand joints, symmetric arthritis, multiple erosions shown on radiograph). He was treated with sulfasalazine, methotrexate, leflunomide, and low-dose prednisolone with only partial response. Under the recommendation of rheumatologist, etanercept (Enbrel; Pfizer, Tokyo, Japan, 25 mg s.c. twice weekly) therapy was initiated in June 2006. Under etanercept therapy (with continuation of aforementioned medications), the patient’s symptoms improved markedly. Etanercept was discontinued in June 2007 because of the limitation of the health insurance. The total treatment period of etanercept was 13 months. However, 2 weeks after cessation of treatment, numerous erythematous papules and plaques with silvery scales developed over the limbs and trunk (Fig. 1). The joint symptom did not aggravate. A biopsy specimen was taken from a lesion on the abdomen. Histopathological examination showed hyperkeratosis, regular acanthosis, confluent parakeratosis, and neutrophils in the stratum corneum and stratum spinosum (Fig. 2), which were

Unilateral nevoid telangiectasia—response to long-pulsed Nd:YAG laser and pulsed dye laser: a case report

Unilateral nevoid telangiectasia (UNT) is a rare disease characterized by punctuate and stellate telangiectasias that follow dermatomal distribution.1 Its etiology remains elusive; no standard treatment currently exists. We describe a 14-year-old Asian female (skin type IV) with UNT, who underwent treatment with long-pulsed 1064-nm Nd:YAG laser and 595-nm pulsed dye laser for her disease. The patient came to our clinic with linearly arranged, punctate telangiectasias over right side of back, shoulder, and arm (Figure 1). The lesions appeared at the age of 10. The diagnosis of UNT was made based on the clinical manifestations and telangiectasias in superficial dermis (as shown on a histologic exam done previously at another hospital). Angioma serpiginosum is an important differential diagnosis of UNT in this case. Three sessions of treatment with long-pulsed 1064-nm Nd:YAG laser (GentleYAG Laser; Candela Laser, Wayland, MA, USA) were given with parameters (fluence-spot sizepulse width) of 240 J/cm2-3 mm-10 ms (first week), 240 J/ cm2-3 mm-10 ms (second week), and 280 J/cm2-3 mm-10 ms (third week). The interval between each session was 4 weeks. However, there was only slight improvement. Histologic exam performed 2 weeks after the third session revealed marked telangiectasias in papillary dermis (Figure 2). Next, two sessions of pulsed dye laser with 595 nm wavelength (Vbeam Perfecta; Candela Laser) were given with parameters of 13 J/cm2-7 mm-40 ms (fluence-spot sizepulse width) for both sessions. Significant lightening of lesions (> 90%) was observed after the second session (Figure 3). The only adverse reaction was transient purpura that lasted for approximately 2 weeks. There was no hypoor hyper-pigmentation after treatment. There are two forms of UNT, the rarer congenital form and the more common acquired form.2 Telangiectasia develops during puberty in most of the acquired cases, as in our patient. Several reports point out the systemic association of acquired UNT, such as hyperestrogenemia and chronic liver disease.2 In out patient, there was no evidence of high serum level of estrogen or hepatic disease. Both long-pulsed 1064-nm Nd:YAG laser and pulsed dye laser have been shown to be effective in treating vascular lesions.3,4 Major et al3 reported good response with the former for facial and leg telangiectasias. However, it does not seem to be a good treatment modality for UNT for the current case. One possible explanation is that while the 1064-nm Nd:YAG laser beam tends to penetrate to deeper dermis, due to its long wavelength and lesser absorption Figure 1 Clinical picture before treatment.

A fusiform nodule on the flank

An otherwise healthy 61-year-old female presented with a skin tumor on the left flank, which had been present since her early adulthood. The tumor gradually enlarged during the first 2–3 years and then stabilized in size. There were no symptoms from the tumor. On examination, a red to violaceous, shiny, polypoid, fusiform nodule with firm consis tency, measuring approximately 3.0 cm × 2.0 cm, was noted on her left flank (Figure 1). There were also many skin tumors on her face and scalp, most of which were dome-shaped, smooth surfaced, violaceous, firm nodules measuring several millimeters in diameter. These tumors were 1-cm dermal nodules that caused pain; others were rounded, skin-colored, firm papules with a size of approximately 5 mm in diameter around her nose. An excisional biopsy specimen was obtained from the tumor at the flank. Histopathologic examination revealed a tumor occupying the reticular dermis, which was composed of aggregations of neoplastic cells arranged in a jigsaw puzzle pattern. The aggregations consisted of neoplastic cells with two different appearances: (1) peripheral cells aligned in a palisade with small, dark staining columnar nuclei surrounded by a scant cytoplasm, and (2) cells with nuclei that were larger and paler, and that had a more abundant pale cytoplasm. Each aggregation was surrounded by a rim of homogenous eosinophilic basement membrane-like material. Globules of the same material were also present within the aggregations themselves (Figure 2). The patient then underwent several sessions of surgical removal for other tumors on the face and scalp, and pathology exams showed cylindroma, spiradenoma, trichoepithelioma, or combinations of them (Figure 3A: cylindroma + trichoepithelioma; Figure 3B: cylindroma + spiradenoma). She reported that two of her younger brothers and sisters also had similar skin tumors, but they were not as numerous as hers.

Generalized Edema and Telangiectasia: Unusual Presentation of Intravascular Large B-cell Lymphoma

Intravascular large B-cell lymphoma is characterized by clusters of large neoplastic B cells within small blood vessels, most commonly in the dermis and subcutis. There is no nodal or parenchymal involvement until late in the disease, and its endothelial tropism is responsible for the variable clinical features. We report the case of a 51 year-old man who presented with fever, altered mental status, generalized edema, and profound telangiectasia. The diagnosis was made by a skin biopsy from the right thigh. Histology revealed ectatic vessels in the superficial dermis and large atypical lymphoid cells filling the small blood vessels in the deep dermis. Immunohistochemical staining showed strongly positive results for CD45 and CD79a. This was a rare case of intravascular large B-cell lymphoma with generalized edema and telangiectasia as the only cutaneous manifestation.

Malignant Fibrous Histiocytoma Occurring in the Digit

Corresponding author: Yu-Ling Hsu, Department of Dermatology, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nan-Ya S. Rd., Pan-Chiao, Taipei 220, Taiwan TEL: 886-2-89667000 ext. 4286 FAX: 886-2-89665567 E-mail: peishu.huang@msa.hinet.net Funding source: none Confl ict of interest: none declared CASE REPORT A 65-year-old Taiwanese female initially presented an 1-year history of experiencing an asymptomatic dark reddish subungual mass on the left thumb (Fig. 1A). The patient’s medical history included diabetes mellitus, hypertension, coronary arterial disease, and a right hemiparesis resulting from an intracerebral hemorrhage ten years prior. No history of trauma, irradiation, or chemical exposure to her hands was disclosed. A skin biopsy from the periphery of the lesion was performed and histopathologic examination revealed multinucleated giant cells and mononuclear inflammatory cells dispersed in the dermis (Fig. 1B, C). A diagnosis of giant cell tumor of tendon sheath was made to the patient. The patient preferred to preserve the function of the left thumb and undergo a conservative course of treatment so the tumor was removed by treatment with a carbon dioxide laser. At that point the patient discontinued further follow-up. Three years later, this patient presented to our clinic with a singular, painful and gradually enlarging, ill-defi ned, pink-colored nodule at the same site on her left thumb (Fig. 2). Computed tomography (CT) detected a heterogeneous, well-enhancing soft tissue mass occupying the distal phalanx of the left thumb, along with osteolytic destruction of the distal phalanx bone. Histopathologic examination of a biopsy taken from the tumor revealed spindle cells forming a storiform pattern and focal areas composed of multinucleated giant cells. These tumor cells were immunoreactive to vimentin, but not S-100, cytokeratin, desmin, CD31, or CD34 (Fig. 3). The patient was subsequently diagnosed with malignant fi brous histiocytoma (MFH) of the storiform-pleomorphic type. For the purpose of curative treatment, amputation of the left thumb and partial resection of the proximal phalanx salvage was performed. The patient refused any additional survey for metastasis and discontinued follow-up after surgery.

Multiple Flesh-colored Tiny Papules on the Neck in a 46-year-old Man

From the Departments of Dermatology and Pathology,** Far Eastern Memorial Hospital; Department of Pathology,* National Taiwan University Hospital Accepted for publication: December 15, 2004 Reprint requests: Yu-Ling Hsu, M.D., Department of Dermatology, Far Eastern Memorial Hospital. No. 21, Sec. 2, Nan-Ya S. Road, Pan-Chiao, Taipei, Taiwan 220 TEL: 886-2-29546200 ext. 4286 FAX: 886-2-29546200 ext. 4287 Multiple Flesh-colored Tiny Papules on the Neck in a 46-year-old Man

Cutaneous Metastasis from Laryngeal Atypical Carcinoid

Carcinoid tumors are primarily regarded as tumors of the appendix and small intestine, but they have been shown to arise from almost any tissue derived from the primitive gut, including its respiratory diverticulum. Cutaneous metastasis from carcinoid tumors is distinctly rare, and only a few cases have been documented. In this report, we present one case of laryngeal atypical carcinoid tumor with skin metastasis. The diagnosis of metastastic carcinoid to the skin was established by clinical history, histopathology and immunocytochemical methods including positive stains of chromogranin, NSE, synaptophysin and cytokeratin AE1/AE3, etc.. To our knowledge, this is the first reported case of a laryngeal atypical carcinoid with skin metastasis in Taiwan. We disclose the aggravated behavior of the laryngeal atypical carcinoid tumor and remind dermatologists to be aware of the possibility of cutaneous metastasis, even if the primary tumor is a carcinoid.