bluuebunny/crossref_metadata_2025 huggingface dataset:
Eccrine squamous syringometaplasia in a patient with phytophotodermatosis
Authors: Goihman‐Yahr Mauricio
Published: March 2003

Case report

A 46‐year‐old man noticed, after a day of rural work, the development of burning erythematous lesions arranged in linear streaks on sun‐exposed skin. Some of the lesions became vesicular and bullous over the next few hours. The patient reported that cutaneous lesions appeared in uncovered skin areas that had been in close contact with plants, except for the face and neck.

When he visited our hospital, 1 week after the development of the skin eruption, he exhibited multiple linear erythematous lesions, with weeping and crusting patches, affecting the extensor aspect of the arms and legs ( Fig. 1). There was no history of previous allergy, photosensitivity, or drug intake. Results of all routine laboratory studies were negative or within normal limits. The patient brought the plant with him, which was classified as belonging to the family Ruthaciae.

Erythematous skin lesions arranged in linear streaks, affecting sun‐exposed skin

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A skin biopsy obtained from affected skin revealed isolated and diffuse necrosis of keratinocytes with re‐epithelialization phenomena ( Fig. 2a). Below these focal epidermal changes, the straight portion of the eccrine ducts showed squamous metaplasia (
Fig. 2b). The secretory portion of the eccrine glands was unaffected. Inflammatory infiltration adjacent to the sweat glands was scarce and not relevant.

(a) Extensive epidermal necrosis with re‐epithelialization phenomena (hematoxylin and eosin, ×200). (b) Squamous syringometaplastic changes affecting the eccrine ducts in the middle and right side of the field. There is fibro‐edematous connective tissue surrounding some of these ducts (hematoxylin and eosin, ×400)

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Reticulate postinflammatory hyperpigmentation with band‐like mucin deposition
Authors: Noto Giuseppe , Pravatà Gabriella , Aricò Mario
Published: March 2003

Background Mucinoses of the skin are a group of disorders sharing accumulation of mucin in the skin or hair follicles. Postinflammatory hyperpigmentation, with pigmentary incontinence, is due to loss of melanin from epidermal basal cells and its accumulation in dermal macrophages.

Methods We describe clinicopathologic features of two patients presenting with the association of pigmentary incontinence with an unusual diffuse, band‐like dermal deposition of mucin, clinically presenting with reticular pigmented macular lesions.

Results Two patients were observed with asymptomatic, persistent, reticular, pigmented patches located in the flexures, thighs, neck and back. Histology showed melanophages with a diffuse, band‐like dermal deposition of mucin, an increased number of fibroblasts, a slight T‐cell infiltrate and scattered mast cells. Blood markers of lupus erythematosus were negative.

Conclusions These findings may draw attention to pigmentary disorders such as lichen planus pigmentosus, erythema dyschromicum perstans, pigmentatio maculos eruptiva idiopathica, dermatopathia pigmentosa reticularis, prurigo pigmentosa and frictional melanosis. None of these entities, however, includes mucin deposition among its microscopic features. Macules were not preceded by erythema or any other lesions. We suggest that our cases could belong to group II of Rongioletti and Rebora’s classification, i.e. they could be cases of secondary mucin deposition in postinflammatory hyperpigmentation, possibly in an unusual form of lichen planus pigmentosus or, less likely, frictional melanosis.
Relapsing cutaneous polyarteritis nodosa associated with streptococcal infections
Authors: Albornoz M. Anthony , Benedetto Anthony V. , Korman Michael , McFall Susan , Tourtellotte Charles D. , Myers Allen R.
Published: March 2003

Background Polyarteritis nodosa is an aggressive, often fatal form of vasculitis associated with multi‐organ involvement. Cutaneous polyarteritis nodosa is purported to be a more benign form of this disorder with involvement limited to the skin.

Methods The identification of a female patient from childhood to adulthood documenting repeated episodes of cutaneous polyarteritis nodosa following bouts of recurrent streptococcal pharyngitis.

Results Repeated bouts of streptococcal pharyngitis at ages 11, 28, and 33 years were followed by episodes of cutaneous polyarteritis nodosa, documented by histopathologic skin changes and clinical presentation, and confirmed by therapeutic management.

Conclusions Various infectious and non‐infectious conditions have been linked both to the initiation and relapse of this disease. We describe a patient with recurrent episodes of cutaneous polyarteritis nodosa spanning a period of over 20 years with each episode appearing to be linked to a prior streptococcal infection.
Correspondence
Authors: Goihman‐Yahr Mauricio
Published: March 2003

The Correspondence Section serves as a forum for opinion exchange about subjects of general interest such as dermatologic training, relations between dermatologists and pharmaceutical houses, governmental control of dermatology and medical practice in general, peculiarities of dermatology related to geographic, climatic, or racial factors, the flow of information and publications, as well as other concerns the readership might have. Contributions are welcome and should conform to the usual format for correspondence. Manuscripts will undergo standard editorial procedures. Submit all correspondence to PO Box 020010, Miami, FL 33102.
Nurse’s cap alopecia
Authors: Hwang Sang Min , Lee Won Soo , Choi Eung Ho , Lee Seung Hun , Ahn Sung Ku
Published: March 2003

Background Traction alopecia associated with the nurse’s cap is a relatively common form of occupational hair loss.

Methods We examined 199 healthy South Korean nurses to assess the clinical and pathologic characteristics of traction alopecia caused by prolonged traction exerted at the point of attachment of the nurse’s cap.

Results Seven nurses (3.5% of 199) had hair loss at the pin site used to secure the nurse’s cap. The lesions were exclusively localized on the parieto‐occipital scalp. Histopathologic findings revealed characteristic cicatricial changes which showed a marked decrease in the number of hair follicles without inflammation.

Conclusions Nurse’s cap alopecia is not an uncommon occupational alopecia, and appears to be a distinct clinical entity which should be distinguished from other forms of patchy alopecia.
Recombinant human granulocyte‐macrophage colony‐stimulating factor applied locally in low doses enhances healing and prevents recurrence of chronic venous ulcers
Authors: Jaschke Erna , Zabernigg August , Gattringer Claus
Published: March 2003

Background Chronic venous leg ulcers have a major medical and economic impact on the elderly worldwide. Healing of the large ulcers (>10 cm2 ) occurs only in two‐thirds of the patients and reulceration of healed ulcers recurs in one‐third within 1 year. Because both healing and relapse rate influence greatly a patient’s quality of life and the overall cost of treatment, every effort should be made to improve these two parameters.

Objective To determine the safety and efficacy of topical low‐dose recombinant human granulocyte‐macrophage colony‐stimulating factor (rhu GM‐CSF) for the treatment of venous ulcers, and to document any improvement in healing rates.

Methods Thirty‐eight patients (29 women, 9 men; median age, 74 years) with chronic venous insufficiency were treated with topical rhu GM‐CSF (5 μg/mL 0.9% sodium chloride solution), followed by application of a compression dressing. All subjects were treated as outpatients.

Results Complete healing was observed in 47 of the 52 ulcers (90.4%). The average healing time was 19 weeks. No systemic or local side‐effects from the therapy were observed. Nine chronic ulcers, previously refractory to conventional treatment (pretreatment for more than 46 weeks), showed the same response rate (9/8, or 88.9%) and healing time (mean, 19 weeks). After 40 months, no reulceration of the healed ulcers was observed, but two patients developed new ulcers on the same leg. Healing remained stable, with excellent cosmetic results.

Conclusions In this first study, topically applied low‐dose rhu GM‐CSF was a safe treatment for chronic venous leg ulcers. Healing rates were significantly increased and relapse rates were minimal.
A new therapeutic approach to type II leprosy reaction
Authors: Welsh Oliverio , Gómez Minerva , Mancias Cecilia , Ibarra‐Leal Sara , Millikan Larry E.
Published: March 2003

Background An increase in tumor necrosis factor (TNF) has been implicated in type II leprosy reaction. Thalidomide, which inhibits TNF, is an effective drug, but has severe side‐effects in pregnant women. Other therapeutic drugs are required.

Methods Clofazimine and pentoxifylline were evaluated for their efficacy against severe type II leprosy reaction in four patients (three men and one woman).

Results All four patients showed a similar fast response to treatment.

Conclusions The results obtained in this study are promising; however, clofazimine and pentoxifylline must be evaluated in a larger group of patients in order to determine their value in controlling type II leprosy reaction.
Perianal candidosis—a comparative study with mupirocin and nystatin
Authors: de Wet Peter M. , Rode Heinz , van Dyk Anna , Millar Alastair J. W.
Published: March 2003

Objective To assess the efficacy and clinical outcome of 2% mupirocin in a polyethylene glycol base and nystatin cream as treatment regimens in diaper candidosis.

Design A prospective randomized comparative study.

Methods
In vitro. The susceptibility of 20 clinical isolates of Candida albicans to 2% mupirocin, nystatin, and five additional antifungal agents was evaluated using the Nathan agar‐well diffusion assay. The minimum inhibitory concentration (MIC) of mupirocin against the Candida species was determined using a tube dilution method. In vivo. Twenty patients (mean age, 12 months; range, 1 month to 4 years) with moderate to severe Monilia diaper dermatitis either had mupirocin ointment or nystatin cream applied to the infected area every 8 h or after every diaper change for a period of 7 days. Microscopic examination of skin scrapings and mycologic and microbiological cultures were performed before treatment and daily for 7 days, and progress was clinically assessed.

Results
In vitro. Topical mupirocin produced a greater zone of inhibition than nystatin cream, i.e. a mean of 27.2 mm (SD 1.55) compared with a mean of 17.3 mm (SD 1.08) for nystatin cream. MIC for mupirocin of 512 μg/mL in one case, 256 μg/mL in six cases, 200 μg/mL in 10 cases and 400 μg/mL in three cases were obtained for the 20 clinical isolates. C. albicans also displayed a universal sensitivity to mupirocin and nystatin. In vivo. Eradication of all Candida organisms was achieved within 2–6 days (mean, 2.6 days) in 10 patients receiving topical mupirocin therapy with rapid healing of the excoriated wounds (mean, 4.7 days). Both Gram‐positive and Gram‐negative bacteria were eradicated from the infected area within the trial period. Ten patients received topical nystatin cream and, in each case, Candida was successfully cleared within 5 days (mean, 2.8 days). Only three wounds were clinically healed within the trial period, however. The remaining seven wounds showed evidence of improved, but ongoing excoriated dermatitis and a heavy growth of polymicrobial organisms.

Conclusions Both agents eradicated Candida, the major difference being the marked response of the diaper dermatitis to mupirocin. Mupirocin should be applied topically 3–4 times daily or with each diaper change and is an excellent antifungal agent.
Sensory analysis of four medical spa spring waters containing various mineral concentrations
Authors: Bacle Irène , Meges Sandrine , Lauze Christophe , Macleod Patrick , Dupuy Patrick
Published: March 2003

Background Medical spa spring waters (MSSWs) have been extensively used as adjunctive treatments for various skin conditions to provide skin comfort. We carried out a double‐blind study to compare the sensory profile of four MSSWs with increasing mineral content.

Methods A panel of 36 women, trained to perform comparative sensory analysis, applied in pairs four MSSWs with mineral contents of 0.2, 0.45, 5, and 11 g/L on the right and left cheeks. At baseline, 5 min, and 10 min after the applications, the subjects evaluated each water for the following factors using a computerized analog scale: freshness, mild stinging, softness, suppleness, and comfort of the skin.

Results After 5 min, all four waters induced a sensation of freshness, irrespective of their mineral concentration. A mild stinging was also perceived with all four waters, with a magnitude that was dependent on the mineral density. After 10 min, softness, suppleness, and skin comfort were the prominent features induced by the waters, but the lower the mineral content, the greater these perceptions. Statistically significant differences were demonstrated between the 0.2 g/L group and the 5 and 11 g/L groups for stinging (P = 0.0001), softness and suppleness (P < 0.05), and skin comfort (P = 0.006) after 10 min.

Conclusions Our results indicate that the sensory effects provided by MSSWs when topically applied depend on their mineral concentration.
Notalgia paresthetica: a study on pathogenesis
Authors: Şavk Ekin , Şavk Ş. Öner , Bolukbasi Okan , Ccedilulhaci Nil , Dikicioğlu Emel , Karaman Göksun , Şendur Neslihan
Published: March 2003

Abstract

Background  Notalgia paresthetica is a sensory neuropathy involving the dorsal spinal nerves. The characteristic symptom is pruritus on the back, occasionally accompanied by pain, paresthesia, and/or hyperesthesia, which results in a well‐circumscribed hyperpigmented patch in the symptomatic area. The etiology of this condition has not yet been completely defined.

Objective  Possible mechanisms that could explain the pathogenesis of notalgia paresthetica were investigated through clinical examination and various diagnostic tests.

Methods  Ten cases of notalgia paresthetica underwent dermatologic, neurologic, and orthopedic examination. This was followed by skin biopsy, electrodiagnostic investigation, and radiography of the spine.

Results  All patients had a typical symptomatology and dermatologic picture. Neurologic examination and standard electrodiagnostic investigation results were normal in all cases. Histopathology was compatible with postinflammatory hyperpigmentation; there were no amyloid deposits. In seven cases, degenerative changes in the vertebrae were observed and, in all of these cases, these changes were most prominent in the vertebrae which corresponded to the dermatome of the cutaneous lesion.

Conclusions  The striking correlation of notalgia paresthetica localization with degenerative changes in the spine suggests that spinal nerve impingement may contribute to the pathogenesis of this entity.
Tuberculosis verrucosa cutis associated with tuberculous lymphadenitis
Authors: Pereira Mariana Burnier , Gomes Maria Katia , Pereira Francisco
Published: March 2003

A 34‐year‐old man presented with a large cutaneous lesion on his left thigh that had started as a small papule when he was 13 years of age. The lesion had enlarged slowly over the last 21 years. The patient had received bacillus Calmette–Guérin (BCG) vaccination in childhood. The family history was significant for tuberculosis.

Clinical examination revealed a large, purplish‐red, indurated plaque measuring 30 × 29 cm on the left thigh, extending to the buttock area. The edges of the lesion had a serpiginous contour with an involuted center (Fig. 1). A left inguinal lymph node was palpated.

Lesion on the left thigh, extending to the buttock area

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Chest X‐ray and blood cell count were normal. No other focus of disease was identified. Laboratory testing for human immunodeficiency virus (HIV) infection was negative. Purified protein derivative (PPD) intradermal injection disclosed a 19‐mm skin induration.

Both the cutaneous lesion and the inguinal lymph node were biopsied. Histopathologic sections of the skin fragment showed epidermal hyperkeratosis, neovascular proliferation, and a dense dermal lymphocytic infiltrate. The histopathology of the lymph node demonstrated few granulomas with focal areas of central necrosis.

Staining for fungus was negative. Ziehl–Neelsen staining was negative on both the skin and lymph node specimens. Culture for fungus and Leishmania sp. was negative. Tissue culture on Lowenstein–Jensen medium from skin and lymph node was positive for Mycobacterium colonies after 5 and 7 weeks, respectively.

Multidrug therapy was instituted with rifampin 600 mg/day, isoniazid 400 mg/day, and pyrazinamide 2 g/day for 2 months, and then rifampin 600 mg/day and isoniazid 400 mg/day alone for the next 4 months. An excellent response was obtained at the end of treatment (Fig. 2).

Lesion after treatment

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Correlation between diffuse pigmentation and keratinocyte‐derived endothelin‐1 in systemic sclerosis
Authors: Tabata Hideyuki , Hara Noriaki , Otsuka Shun , Yamakage Akio , Yamazaki Soji , Koibuchi Noriyuki
Published: March 2003

Abstract

Background  The precise mechanism of diffuse pigmentation in systemic sclerosis (SSc) is still unknown. We suspected the participation of endothelin‐1 (ET‐1), which is produced by keratinocytes, in the hyperpigmentation in SSc. The aims of this study are to demonstrate the hyperproductivity of ET‐1 from epidermal cells in SSc by in situ hybridization histochemistry, and to show a correlation between the hyperproductivity of ET‐1 in keratinocytes and skin hyperpigmentation.

Methods  In situ hybridization histochemistry was performed on nine SSc specimens (five cases of diffuse scleroderma (dSSc), four cases of acrosclerosis (lSSc)), and compared with four normal control specimens. We counted the grains on 10 × 10 μm2 of epidermis and microvessels in each histology and examined the degree of skin pigmentation using the skin reflectance factor (Y).

Results  In the specimens of the SSc patients, the number of grains on the epidermis was remarkably higher than those of the control specimens (P < 0.01). We found a close correlation between the number of grains and the skin reflectance factor in dSSc patients (P = 0.02). Correlations were not identified between serum ET‐1 and skin pigmentation and between serum ET‐1 and the frequency of grains on the epidermis. As for grains on microvessels, lSSc patients showed a greater frequency than dSSc patients.

Conclusions  The findings of this study suggest that an increase in the ET‐1 productivity of keratinocytes is experienced in SSc patients, especially in dSSc patients. The results suggest a strong correlation between the ET‐1 productivity of keratinocytes and skin pigmentation in severe cases of SSc. We conclude from these results that keratinocyte‐derived ET‐1 plays an important role in the pathogenesis of the hyperpigmentation of the skin in SSc patients.
Retiform hemangioendothelioma
Authors: Darouti M. El ,   md, Marzouk Salonas A. ,   md, Sobhi Rehab M. ,   md, Bassiouni Dalia A. ,   md
Published: March 2003

A 32‐year‐old white woman presented with a 2‐year history of a gradually enlarging, asymptomatic, cutaneous and subcutaneous, 3 Ï 5‐cm plaque with a nodular surface on the left upper thigh ( Fig. 1). There were no other complaints or physical signs. The clinical differential diagnosis included: cutaneous lymphoma, metastatic adenocarcinoma, and dermatofibrosarcoma protuberans.

Retiform hemangioendothelioma: clinical presentation is in the form of an exophytic plaque with an irregular surface

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A 6‐mm punch biopsy was taken and showed numerous dilated vascular spaces in the upper dermis lined by monomorphic endothelial cells. Some of these vessels showed endovascular papillae with hyaline collagenous cores ( Fig. 2). In addition, there were solid nests of endothelial cells observed in the vicinity of the affected vessels. Lymphocytic infiltrate was conspicuous both within the endovascular papillae and the dermis. Most of the lymphocytes within the blood vessels occurred in close association with the endothelial cells.

Area of the tumor showing an intravascular papilla with a collagenous core and lined by endothelial cells. Lymphocytes are seen in close association with some of the endothelial cells (hematoxylin and eosin, × 400)

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Staining with factor VIII related antigen was positive in the endothelial lining of the blood vessels, but not in the solid nests ( Fig. 3). At this stage, a diagnosis of Dabska's tumor was entertained; however, excision biopsy of the whole lesion showed the presence of very characteristic arborizing blood vessels (
Fig. 4), arranged in a retiform pattern, within the lower dermis. These blood vessels were lined by bland endothelial cells and contained, in some of them, endovascular papillary projections with collagenous cores. The papillary projections were lined by cuboidal endothelial cells occurring in close association with intravascular lymphocytes.

Staining with factor VIII related antigen. Endothelial cells lining the blood vessels are reactive, while the extravascular solid areas are not (factor VIII related antigen, × 400)

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Retiform hemangioendothelioma: one area of the tumor showing long arborizing blood vessels arranged in a retiform pattern reminiscent of normal rete testis. Perivascular lymphocytic infiltrate is present in the deep dermis (hematoxylin and eosin, × 40)

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The final diagnosis was retiform hemangioendothelioma. There was no recurrence or lymph node metastases during a follow‐up period of 1.5 years.
Linear IgA disease associated with membranous glomerulonephropathy
Authors: Egan Christine L. ,   md, Liu Vincent ,   md, Harris Ronald M. ,   md, White Soren M. ,   md, Lessin Stuart R. ,   md, Weinberg Jeffrey M. ,   md
Published: March 2003

A 33‐year‐old Caucasian man developed an acute nephrotic syndrome with a proteinuria of 15 g/day. His past medical history was significant for a cholecystectomy secondary to complications of hypercholesterolemia, and his medications included niacinamide, simvastatin, and multivitamins. A renal biopsy revealed a membranous glomerulonephropathy, with thickening of the capillary loops by light microscopy and 4+ granular immunoglobulin G (IgG) staining of the capillary loops by immunofluorescence. Multiple discrete subepithelial deposits were also noted by electron microscopy. He was treated with cyclophosphamide, chlorambucil, and high dose steroids. Laboratory data at that time were notable for an elevated erythrocyte sedimentation rate (ESR), decreased albumin, a negative antinuclear antibody, and normal complement levels. His symptoms improved, and the proteinuria stabilized to 7 g/day. His systemic therapy was discontinued without a flare in his renal disease.

Approximately 9 months later, he developed a pruritic, blistering eruption which began on his face and neck. An initial skin biopsy showed a subepidermal blister with many eosinophils and eosinophilic spongiosis. A direct immunofluorescence (DIF) study revealed linear deposits of IgG and IgA, and focally linear C3 at the basement membrane zone. This pattern was interpreted to be most consistent with bullous pemphigoid. He was referred to the Philadelphia VA Medical Center for further evaluation and treatment

Cutaneous examination revealed multiple urticarial plaques with tense bullae studding the peripheral margin, in a rosette pattern, distributed on his face, trunk, groin, extremities, and feet, with one healing erosion on the hard palate. Laboratory data revealed abnormal, but stable, renal disease, with an elevated blood urea nitrogen (21.1) and creatinine (1.5). Serum IgA was elevated (400), and serum albumin (3.3) and a total protein (5.5) were decreased.

A second skin biopsy from a blister edge demonstrated a subepidermal bulla with numerous eosinophils and collections of neutrophils at the dermal papillae tips ( Fig. 1). DIF revealed 3+ linear IgA deposition at the basement membrane zone (
Fig. 2), and an indirect immunofluorescence study on monkey esophagus showed linear IgA deposition in the basement membrane zone. A diagnosis of linear IgA disease was made. Dapsone 50 mg p.o. daily was started, with a dramatic improvement on his blistering within 2 weeks. His renal disease remained stable.

Biopsy specimen demonstrating subepidermal bulla with numerous eosinophils and collections of neutrophils at the dermal papillae tips, consistent with LABD (hematoxylin and eosin; original magnification, ×100)

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IF revealing linear IgA

deposition at the basement membrane zone

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Infiltrating basal cell carcinoma in the setting of a venous ulcer
Authors: Lutz Michael E. , Davis Mark D. P. , Otley Clark C.
Published: March 2003

A 77‐year‐old man was referred with a 5‐year history of an intermittently painful, nonhealing right medial ankle ulcer. The ulcer had not responded to multiple treatment modalities, including Unna boots, compression therapy, sclerotherapy, and split‐thickness skin grafting.

The past medical history was significant for a deep venous thrombosis in the right leg 30 years earlier (treated with warfarin for 3 months) and a history of greater saphenous vein harvesting for coronary bypass grafting 28 years previously. After the vein stripping, the patient had suffered from increasing right leg edema and stasis changes in the right leg. His history was also remarkable for coronary artery disease, dyslipidemia, and lymphoma treated with chemotherapy 8 years before presentation, with no evidence of recurrence. He had stopped smoking approximately 20 years earlier. Medications included atenolol, simvastatin, nicardipine, nitroglycerin, and aspirin.

Skin examination revealed a 3.0 × 3.5‐cm ulcer adjacent to the medial malleolus. The edges of the ulcer appeared raised and rolled ( Fig. 1). Centrally, there was granulation tissue, which appeared healthy. There were surrounding dermatitic changes. Dorsalis pedis and the posterior tibial pulses were normal.

of the ulcer

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Noninvasive vascular studies revealed severe venous incompetence of the right popliteal and superficial veins. Arterial studies and transcutaneous oximetry were normal. Computed tomographic scan of the pelvis did not reveal any adenopathy, and radiographic imaging did not reveal any bony changes suggestive of osteomyelitis.

Biopsy of the ulcer edge and base showed infiltrating basal cell carcinoma ( Fig. 2). Mohs' micrographic surgery required three layers; the final extent of the ulcer was 7.8 × 6.9 cm. A split‐thickness skin graft was placed.

section from biopsy specimen of edge/base of ulcer (hematoxylin and eosin; × 67)

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Retrospective study of Mycobacterium marinum skin infections
Authors: Ang Por , Rattana‐Apiromyakij Niramol , Goh Chee‐Leok
Published: March 2003

Background Although infection by Mycobacterium marinum is well reported in the literature, there have been few epidemiologic studies. The purpose of this study was to review the epidemiology of patients with cutaneous M. marinum infection over a 3‐year period at the National Skin Centre in Singapore.

Methods Patients with a diagnosis of cutaneous M. marinum infection, confirmed histologically, were collated from computerized data from 1995 to 1997. Thirty‐eight patients were diagnosed as having cutaneous M. marinum infection based on history, and clinical and histologic features.

Results Out of the 38 cases of M. marinum infection, there were 30 men and eight women. The age range was 14–85 years (mean: 44.7 years). The duration of disease ranged from 1 to 132 months (mean: 19 months). Thirteen patients (34.2%) had fish rearing as a hobby and four patients (10.5%) had occupational exposure to fish. Twelve patients (31.5%) gave a history of trauma to the disease site. All patients had biopsies of the lesions. All showed infective granulomas/granulomatous inflammation on histology. Acid‐fast bacilli were identified in five out of 38 patients (13.2%) and mycobacteria were isolated in one out of 35 patients (2.9%). Nineteen patients received treatment with cotrimoxazole–trimethoprim alone, three with minocycline alone, five with minocycline and cotrimoxazole–trimethoprim, seven with various combinations of drugs, one with excision, and three defaulted treatment. The duration of treatment ranged from 4 to 38 weeks (mean: 14.9 weeks). Twenty‐six patients (68.4%) showed clinical improvement, two (5.3%) had no response, and 10 (26.3%) were lost to follow‐up. None of the patients worsened with treatment. The follow‐up period ranged from 1 to 20 months (mean: 6.8 months).

Conclusions The diagnosis of cutaneous M. marinum infection is mainly clinical, with supporting evidence from histologic features and the response to therapy. Risk factors include a history of trauma and water/fish‐related hobbies or occupations. There is a poor yield of positive isolates in our experience; however, empirical treatment usually produces a good clinical response. In future, the polymerase chain reaction (PCR) technique may become more widely available as a rapid, sensitive, and specific means of diagnosis.
Papular perniosis mimicking erythema multiforme: the first case report in Thailand
Authors: Wessagowit Phongsakorn , Asawanonda Pravit , Noppakun Nopadon
Published: March 2003

A healthy 23‐year‐old man of Thai descent presented with skin lesions on the acral part of the feet, which developed after exposure to an Australian winter with an average temperature of 5 °C. Immediately after the exposure, the patient developed mild anesthesia around the toes which was accentuated after a bath. During the exposure, warm winter clothes, including boots and socks, were worn. Several hours later, a few itchy bumps were noted bilaterally on the fifth toes. The patient then cleansed and immersed his feet in an over‐the‐counter antiseptic preparation. By the next day, the lesions had enlarged and formed blisters filled with clear fluid. The lesions gradually progressed to cover the dorsal part of the feet within the next few days. He applied an over‐the‐counter antibacterial/antifungal cream to the lesions for 3 days without any improvement. Five days later the lesions became purplish red. Itching was the only symptom experienced. The patient was a nonsmoker who was in good health and denied a history of skin diseases, herpes simplex viral infection, or any intake of oral medication.

Physical examination, performed in Thailand, revealed symmetrically distributed, discrete, purplish papules, some with dusky red centers, on the dorsal surfaces of all toes without blisters or erosion ( Fig. 1). No lesions were detected on the plantar surfaces of the feet, the legs, hands, or elsewhere on the body. Complete blood cell count, erythrocyte sedimentation rate (ESR), venereal disease research laboratory (VDRL) test, cryoglobulin, hepatitis B surface antigen (HBsAg), and anti‐hepatitis core immunoglobulin M (anti‐HBC IgM) were within normal limits or negative.

Erythema multiforme‐like lesions on the acral part of the feet

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The clinical diagnosis at the initial visit was cold injury; however, the differential diagnosis included contact erythema multiforme and vasculitis.

Skin biopsy performed on one of the purplish papules revealed proliferation of thick‐walled blood vessels and edema of the dermal papillae. The lumens of these vessels were narrow. There was a superficial and deep perivascular lymphocytic infiltrate in the upper dermis. The epidermis revealed only mild spongiosis and focal lymphocytic exocytosis without necrotic keratinocytes ( Fig. 2). The findings were consistent with perniosis.

The patient was treated with topical triamcinolone acetonide 0.1% cream with significant improvement observed within a few days ( Fig. 3).
Melanonychia and mucocutaneous hyperpigmentation due to hydroxyurea use in an HIV‐infected patient
Authors: Laughon S. K. , Shinn L. L. , Nunley Julia R.
Published: March 2003

A 51‐year‐old black woman with human immunodeficiency virus (HIV) infection presented to the Dermatology Clinic in June of 1998. She complained of dark bands in her nails, as well as darkening of her tongue, hands, and feet. She first noticed these changes in April 1998. One month earlier she had been started on hydroxyurea, nevirapine, and didanosine. Zidovudine had been discontinued 1 year prior to presentation. No nail changes were noted at that time. Other medications included acyclovir, propanolol, trimethoprim/sulfamethoxazole, and ibuprofen.

The physical examination was remarkable for irregular, hyperpigmented patches, some confluent, on the tongue and oral mucosa (Fig. 1). Perioral hyperpigmentation was also present. Irregular, hyperpigmented macules were present on the palms and soles, and there was diffuse hyperpigmentation of the dorsal hands and feet. Blue–gray, well‐demarcated, horizontal bands were present on all 20 nails beginning at the proximal nail fold and progressing distally (Fig. 2). A diagnosis of hydroxyurea‐induced hyperpigmentation was made and hydroxyurea was discontinued. Six months later, the mucocutaneous areas of hyperpigmentation were lighter, but still present. The hyperpigmented bands on the fingernails had fully grown out and those on the toenails were more distally located.

Hyperpigmentation was evident on the oral mucosa, as seen here on the tongue

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Horizontal bands present on all 20 nails

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Duration of improvement in psoriasis after treatment with tazarotene 0.1% gel plus clobetasol propionate 0.05% ointment: comparison of maintenance treatments
Authors: Lebwohl Mark ,   md, Lombardi Kathleen ,   bsc, Tan Mei‐Heng ,   md
Published: March 2003

Fifty patients were enrolled in a double‐blind, randomized, parallel‐group study designed to determine whether tazarotene may have a role in maintenance therapy for psoriasis.

The patients had stable moderate‐to‐severe plaque psoriasis on up to 15% of their body surface area, on sites other than the face and scalp. Their mean age was 55 years and the majority had had psoriasis for more than 10 years. Washout periods were: 2 weeks for topical drugs, 4 weeks for UVB or PUVA treatment, and 8 weeks for systemic drugs that might alter the course of psoriasis.

For the initial open‐label treatment phase, patients applied tazarotene 0.1% gel plus clobetasol propionate 0.05% ointment for 6 weeks. The frequency of application of both medications was initially once daily and then was tapered to ensure gradual weaning. Thus, during weeks 1 and 2, patients applied tazarotene each morning and clobetasol propionate each evening. During weeks 3 and 4, patients applied tazarotene each morning and clobetasol propionate each Tuesday, Thursday, and Saturday evening. Finally, during weeks 5 and 6, patients applied tazarotene each Monday, Wednesday, and Friday morning, and clobetasol propionate each Tuesday and Thursday evening.

For the subsequent double‐blind maintenance phase, patients were randomized to receive one of three maintenance regimens for 20 weeks – tazarotene/clobetasol (tazarotene 0.1% gel on Monday, Wednesday, and Friday mornings, plus clobetasol propionate 0.05% ointment on Tuesday and Thursday evenings), tazarotene/vehicle (tazarotene 0.1% gel on Monday, Wednesday, and Friday mornings, plus white petrolatum on Tuesday and Thursday evenings), and vehicle (tazarotene gel vehicle on Monday, Wednesday, and Friday mornings plus white petrolatum on Tuesday and Thursday evenings).

Patients were instructed to apply a thin film of medication to their psoriatic plaques. Emollient use was permitted, but other topical formulations and excessive exposure to ultraviolet light were not.

Efficacy was evaluated – at baseline, every 2 weeks during the initial treatment phase, and every 4 weeks during the maintenance phase – in terms of overall disease severity, plaque elevation, scaling, erythema, pruritus, and global response to treatment. The first four of these were rated by the physician as 0 = none, 2 = mild, 4 = moderate, 6 = severe, and 8 = very severe. Pruritus was rated as 0 = none, 1 = trace, 2 = mild, 3 = moderate, 4 = marked, and 5 = severe. Global response was rated as 0 = cleared, 1 = almost cleared (∼90% improvement), 2 = marked (∼75%) improvement, 3 = moderate (∼50%) improvement, 4 = slight (∼25%) improvement, 5 = unchanged, and 6 = worse.

Analysis of variance and the Student's t‐test were used to compare maintenance regimens (P ≤ 0.05). In the maintenance phase, the last recorded score for each patient was carried forward to all subsequent visits.
Bluish patches on the ears and axillae with dark urine: ochronosis and alkaptonuria
Authors: Turiansky George W. ,   LTC,   MC,   USA, Levin Sondra W.
Published: March 2003

A 45‐year‐old white woman presented with a 3‐year history of bluish discoloration of her ears (Fig. 1). The patient had noted a bluish‐black staining of the armpit areas of her clothing for the prior 6 months. A review of systems and past medical history were significant for a history of constant right lower back pain and bilateral knee pain for approximately 1 year. A review of medications revealed daily use of conjugated estrogens and multivitamins and intermittent use of ibuprofen. A review of her family history revealed that a sister was affected with the same disorder, but the spouse and children were not. The patient's parents were not known to be consanguineous.

Bluish patches are present on the ear overlying the cartilage

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Mucocutaneous examination was significant for bluish‐black patches on the ears in areas overlying cartilage. Larger bluish patches were also noted in the axillary vaults. Cardiac, ophthalmologic, and dental examinations were normal. An echocardiogram was normal. Orthopedic evaluation revealed limited spinal range of motion. Examination of lumbosacral X‐rays revealed marked degenerative disc disease at the T12–S1 levels and anterior osteophytosis at the T11–L2 levels. A bilateral knee X‐ray series was normal.

Complete blood count and serum chemistries were normal. A urine sample darkened upon standing for 1 day (Fig. 2, left side) as compared to a fresh urine specimen (Fig. 2, right side). A 0.5 cm3 urine sample turned black immediately upon addition of 5 cm3 of silver nitrate solution (3 g/100 cm3 ) and alkalinization with three drops of dilute ammonia. Punch biopsy of the left ear demonstrated both degenerative change and focal yellow–brown pigmentation of the cartilage (Fig. 3). A qualitative assay for urinary homogentisic acid (HGA) was positive (Fishberg test) (Fishberg EH. The instantaneous diagnosis of alkaptonuria on a single drop of urine. JAMA 1942; 119: 882). The presence of large amounts of urinary HGA was confirmed by gas chromatography and mass spectrometry.

A urine sample darkened upon standing for 1 day (left side of figure) as compared to a fresh urine specimen (right side of figure)

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A punch biopsy from the left ear demonstrates degenerative change of the cartilage with focal yellow–brown pigmentation (× 66)

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Melasma treated with hydroquinone, tretinoin, and a fluorinated steroid
Authors: Guevara Ian L. , Pandya Amit G.
Published: March 2003

A retrospective study was conducted in six Hispanic women, 35–55 years of age, with Fitzpatrick skin types IV to VI, presenting to an academic dermatology clinic for resistant melasma (Table 1). They had all been treated with topical hydroquinone (2–4%) without success prior to being seen in our clinic.

Patient demographics

Patient
Age
Country
 
of origin
Affected
 
area
Duration of
 
disease (years)
Severity
Type of
 
melasma

1
39
El Salvador
Cheeks, upper lip
10
Moderate
Epidermal

2
37
Mexico
Cheeks
12
Moderate
Epidermal

3
35
Mexico
Cheeks
7
Moderate
Combination

4
35
Mexico
Cheeks
9
Moderate
Epidermal

5
55
Mexico
Cheeks, jaw
20
Moderate
Combination

6
32
Mexico
Cheeks, forehead
6
Moderate
Epidermal

A Wood's lamp was used to determine whether the melasma was epidermal, dermal, or a combination of the two. The patients were treated with a mixture containing 0.05% tretinoin cream, 0.05% triamcinolone acetonide cream, 6% hydroquinone, and 0.1% ascorbic acid (as a preservative) applied at night, and a sun protection factor (SPF) 15 UVB‐blocking sunscreen was applied each morning. They were instructed to use the mixture on the affected areas nightly for a period of 8 weeks. All of the patients were evaluated at baseline and monthly during the treatment period. Improvement in pigmentation was assessed at each subsequent visit by clinical examination and photography with polarized filters as well as black and white UV reflectance photography (Canfield Scientific, Inc.). Improvement was determined subjectively on a three‐point scale as follows: I, mild improvement; II, moderate improvement; III, significant improvement.
Eruptive lesions in a patient with bone marrow transplantation
Authors: Marini Mario , Saponaro Alberto , Remorino Laura , Lynch Patricia , Magariños Gabriel
Published: March 2003

A 41‐year‐old man with a diagnosis of chronic myeloid leukemia presented with several elevated, small, soft, yellow papules, disseminated over the face and upper trunk. The cutaneous lesions had developed 5 years after transplantation (Fig. 1).

Sebaceous hyperplasia on the upper trunk presenting as yellowish, dome‐shaped, asymptomatic papules, 1–2 mm in diameter. The lesion is umbilicated, with individual lobules growing out from the center; lesions may occur individually or in groups

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In December 1991, he was examined in Israel, where an allogenic bone marrow transplantation was performed, after immunosuppressive treatment with high doses of chemotherapy and lymphoid and total body irradiation.

In spite of being on cyclosporine as a preventive medication, at a dose of 3 mg/kg body weight per day, he had a graft‐vs.‐host reaction.

Later, he presented with diverse clinical complications: hemorrhagic cystitis; disseminated herpes zoster, with encephalic commitment; pneumonia and sepsis; and chronic graft‐vs.‐host reaction whose manifestations were controlled with decreasing doses of cyclosporine and prednisone.

A skin biopsy specimen was obtained, with the diagnosis of sebaceous hyperplasia (Fig. 2). The histopathologic findings consisted of several enlarged sebaceous glands containing several small ducts, with sebaceous lobules grouped around each of them. The sebaceous gland lobules appeared fully mature, with a single peripheral row of generative cells in which there were few or no lipid droplets. Some of the sebaceous lobules were closed up to the lower portion of the epidermis, from where they extended downwards into the dermis.

The sebaceous gland lobules appear fully mature, with a single peripheral row of generative cells in which there are few or no lipid droplets

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Livedoid vasculitis responding to PUVA therapy
Authors: Lee Jeong Ho , Choi Hyun‐Joo , Kim Soo Min , Hann Seung‐Kyung , Park Yoon‐Kee
Published: March 2003

Abstract

Background  Livedoid vasculitis is a chronic disorder manifested as recurrent, painful, reticulated, and ulcerative lesions of the legs, which result in ivory atrophic scars with peripheral telangiectasia and hyperpigmentation. Its etiology remains obscure and therapy is difficult. In this study, we evaluated the clinical efficacy of psoralen plus UVA (PUVA) therapy and its side‐effects in the treatment of livedoid vasculitis.

Methods  Eight South Korean patients with livedoid vasculitis were treated with UVA and 8‐methoxypsoralen (8‐MOP). Systemic PUVA was started with 4 J/cm2 of UVA two or three times a week, and then the dose was increased by 0.5 or 1 J/cm2 increments at each subsequent treatment as tolerated. The effects of treatment were evaluated using photographs of before, during, and after the study.

Results  All patients experienced rapid cessation of new lesion formation, significant symptom relief, and complete healing of primary lesions. The mean times for each of the above were 3.6, 5.9, and 10 weeks, and the mean cumulative doses of UVA for each of the above were 55.9, 96.8, and 197.9 J/cm2, respectively. The patients tolerated PUVA therapy well without unacceptable side‐effects.

Conclusions  We propose that systemic PUVA using 8‐MOP should be investigated further as an alternative treatment for patients with livedoid vasculitis.
Ultra‐late erysipeloid angiotropic metastatic malignant melanoma
Authors: Johnson Charles S. , Ramos‐Caro Francisco A. , Hassanein Ashraf M.
Published: March 2003

In 1998, a 70‐year‐old white man developed a slowly increasing swelling of the right lower extremity of 5 months' duration. During the 3 weeks prior to presentation, the patient noted intensifying erythema accompanied by increasing tenderness and warmth on palpation. A clinical diagnosis of cellulitis was made and the patient underwent a 2‐week course of oral cephalexin, 500 mg four times a day, without improvement. Dermatology was consulted.

The pertinent past medical history included: (i) wide local excision of a Clark's level II malignant melanoma from the left lower back in 1980; (ii) metastatic malignant melanoma involving the bladder removed by cystectomy in 1995, together with left inguinal node resection followed by systemic chemotherapy and radiation therapy; (iii) recurrent metastatic malignant melanoma on the right inguinal node, resected, and followed by docetaxel therapy in 1997 with resolution.

Physical examination disclosed an ill‐looking, elderly man with a moderately well‐demarcated, elevated, slightly tender, edematous, warm, erythematous, confluent plaque involving the proximal right lower extremity and the right lower flank, suggestive of erysipelas (Fig. 1). Histologic examination revealed infiltration of the superficial and deep dermal vessels (mainly small venules) by highly anaplastic cells (Fig. 2). The vascular lumina were occluded with the neoplastic cells and focal microthrombi formation. Immunohistochemical staining for S‐100 protein, HMB‐45, and vimentin confirmed the diagnosis of metastatic melanoma. CD31 immunostaining decorated the endothelial lining of the dermal vessels. Tissue cultures and special stains for bacteria and fungi were negative. A diagnosis of erysipeloid metastatic malignant melanoma involving the vessels was made. The patient and the family declined further aggressive treatments, and the patient died within a few weeks under hospice care.

Moderately well‐demarcated, edematous, erythematous plaque on the right lower flank and proximal right lower extremity with tenderness and warmth on palpation

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Malignant melanoma cells infiltrating a dermal vessel. The vascular lumen demonstrates occlusion by anaplastic cells

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