Desmoplastic Melanoma as a Diagnostic Pitfall.

Dear Editor, Desmoplastic melanoma (DM) is a rare histological subtype of melanoma, usually presenting as a slowly-growing, amelanotic, discoid, and/or firm lesion composed of spindle cells with abundant collagen (1). It is more common on sun-exposed areas, especially on head and neck in elderly patients (2). Regional lymph node involvement is reported to be less frequent than in other cutaneous melanomas (3). Desmoplastic melanoma can clinically mimic a wide spectrum of benign and malignant lesions, including Bowen's disease, desmoplastic nevus, basal cell carcinoma, squamous cell carcinoma, lentigo maligna, dermatofibrosarcoma protuberans, peripheral nerve sheath tumors, cysts, or hypertrophic/keloid scars (4). Regarding its appearance, at the time of diagnosis DM frequently presents as advanced lesions with deep infiltration. A 60-year-old man presented with an one-year history of an asymptomatic, erythematous, well-defined plaque in the right lumbar region (Figure 1). Dermatological examination revealed a 5×5 cm, pink/red infiltrated plaque accompanied by a 6 mm dark-brown melanocytic lesion. Dermoscopically, atypical vascular structures in the form of linear, irregular, and dotted vessels, milky-red areas, and atypical pigment network, and streaks were observed near the melanocytic lesion (Figure 2). A 4 mm punch biopsy was performed on the erythematous plaque next to the melanocytic lesion, and a dermal-based, paucicellular proliferation of atypical spindle cells without melanin in a sclerotic stroma was found histologically (Figure 3, a). Immunohistochemically, dermal spindle cells were stained with S-100 and HMB45 antibodies (Figure 3, b). The patient was histologically diagnosed with melanoma, of the desmoplastic subtype. The lesion was totally excised with 2 cm clear margins. A diagnosis of nonulcerated nodular melanoma with a Breslow thickness of 4 mm and a mitotic index 1/mm2 was established. Sentinel lymph node biopsy revealed no metastases. No systemic metastases were detected in PET-CT scanning and cranial magnetic resonance imaging. The patient remained under follow-up and has been free of any local recurrence or primary or systemic metastasis for 3 years. Dermoscopic characteristics of DM are not well known, probably due to it not being considered a melanocytic lesion. Debarbieux et al. first reported the dermoscopic features of desmoplastic melanoma in six cases (5). They found that only half of the cases presented one classical feature of a melanocytic lesion, whereas the other cases were diagnosed based on the presence of figures of regression such as white scar-like and "peppering", multiple (>4) color, and melanoma-related vascular patterns (five out of six) such as linear-irregular vessels and milky-red areas (5). In the largest DM case series, Jaime et al. reported that all DM featured at least 1 melanoma-specific structure, with atypical vascular structures being the most common (6). Similarly, in our patient dermoscopy showed an atypical pigment network and streaks, atypical vascular structures, and milky-red areas, which is predictive for melanoma. We reported this case to serve as a reminder to consider desmoplastic melanoma in the differential diagnosis of pink tumoral lesions despite its rarity and atypical localization.

Complementary and Alternative Therapies Used by Patients of Pediatric Dermatology Outpatient Clinics in Turkey: A Multicenter Study.

BACKGROUND: The aim of this study was to determine the frequency of complementary and alternative medicine (CAM) methods used in children and adolescents with chronic skin diseases, which methods parents prefer, and to what extent these methods are useful. MATERIAL AND METHODS: This cross-sectional study was conducted between June and November 2014 in patients with chronic skin diseases attending the outpatient pediatric dermatology clinics of three hospitals in Turkey. Data were collected using self-administered questionnaires from the parents of the patients. RESULTS: A total of 307 patients were included in the study, 168 (54.7%) of whom were female and 139 (45.3%) male. The mean age was 12.3 ± 4.3 years. Eighty of the children (26.1%) had used CAM methods in the previous year. Longer disease duration and having a father with at least a university degree were highly associated with CAM use (p < 0.05). The most used method was herbal remedies available at home. Most patients used CAM methods to support the primary treatment given by their dermatologists. Only eight CAM users (2.6%) reported any side effects. Thirty-nine (48.8%) did not mention CAM use to their doctors. The overall satisfaction rate was 4.5 ± 3.1 on a 10-point rating scale. CONCLUSION: CAM use rates are high in children with chronic skin problems, and parents generally prefer herbal treatments. Satisfaction with the results of CAM use is moderate. Parents generally do not share CAM use information with their doctors unless they are asked.

Prevalence of Congenital Cutaneous Anomalies in 1000 Newborns and a Review of the Literature.

OBJECTIVE: There are limited reports studying on congenital cutaneous anomalies in newborns, particularly in Turkey. Some of congenital cutaneous anomalies serve as an important clue for accompanying syndromes or other medical conditions. This study aimed to determine the prevalence of congenital cutaneous anomalies in newborns and to discuss their clinical significance with a brief review of literature. STUDY DESIGN: A total of 1,000 newborns were examined by a dermatologist in a hospital-based, cross-sectional, prospective study between October 2011 and April 2012. RESULTS: We observed 11 different congenital cutaneous anomalies in 48 newborns of 1,000 (4.8%). The most commonly seen anomalies were sacral dimple, accessory nipple, acrochordon, hypospadias, open spinal dysraphism, and accessory tragus. None of the newborns with cutaneous anomalies had any association. CONCLUSIONS: Although congenital cutaneous anomalies are rare in newborns, clinicians should be aware of them as they may be in association with syndromes and other medical conditions. It is also important to give appropriately provided information to avoid parents concerns.

Genital involvement in pemphigus vulgaris (PV): correlation with clinical and cervicovaginal Pap smear findings.

BACKGROUND: The frequency of genital involvement in pemphigus vulgaris (PV) has not been clearly defined. OBJECTIVES: We sought to evaluate the frequency of cervical, vaginal, and vulvar involvement in PV and to determine their association with genital symptoms, clinical involvement, and cytological status. METHODS: The current study's sample included 34 female patients with PV. Gynecologic and ear, nose, and throat examinations and indirect immunofluorescence analyses were performed, and Pap smears were collected. RESULTS: Genital involvement was observed in 44.1% of patients. It was significantly associated with disease severity and clinical involvement. Pharyngeal involvement was observed in 61.8% of patients and was the second-most frequently involved mucosal region. Genital involvement was significantly associated with nasal mucosa involvement. Cervicovaginal Pap smears showed acantholytic cells of PV in 35.3% of patients. LIMITATION: The sample size is small. CONCLUSION: Genital involvement in PV is not rare. Genital mucosa is the most affected mucosal region after oral and pharyngeal mucosa. Furthermore, genital involvement is significantly associated with nasal involvement and genital symptoms. The need for complete gynecologic evaluations of patients with PV, nasal involvement, and genital symptoms is emphasized.

A CD30(-) Transformed Mycosis Fungoides Case Responding Very Well to Systemic Bexarotene and Methotrexate.

The course of mycosis fungoides (MF) is indolent except when transformation to a large T-cell lymphoma occurs. The diagnosis of transformed MF relies on the presence of more than 25% of large cells on biopsy of an MF lesion. Treatment of transformed MF is a major challenge as these patients have poor outcome. Here, we report a 61-year-old man presenting with tumoral ulcer on the plantar area of the foot who was diagnosed cutaneous CD30(-) large cell transformed MF and treated with systemic methotraxate and bexarotene therapy.

Treatment of pediatric molluscum contagiosum with 10% potassium hydroxide solution.

BACKGROUND: Molluscum contagiosum (MC) is a common cutaneous viral infection of the skin that is frequently seen in children. Although lesions can resolve spontaneously, treatment is mandatory because of the psychological effect of widespread lesions in children. Potassium hydroxide (KOH) is a strong alkali that has been used by dermatologists for a long time in identifying the fungal infections from skin scrapings. AIMS: We evaluated 40 children with MC for the safety and efficacy of treatment with topical 10% KOH aqueous solution. METHODS: Parents were instructed to apply a 10% KOH aqueous solution, twice daily, with a cotton stick to all lesions. Treatment was continued till the lesions showed signs of inflammation or superficial ulceration. Assessments of response and side effects were performed at the end of week 2, week 4, week 8 and week 12. RESULTS: We found complete clearance of lesions in 37 (92.5%) patients receiving topical 10%KOH solution after a mean period of four weeks. Three children dropped out of the study; two children reported severe stinging of the lesions and discontinued the treatment; the other patient developed hypopigmentation during the treatment. Local side effects were observed in 12 children (32.4%). CONCLUSION: Even though 10% KOH solution is associated with some local side effects, it is a safe, effective, inexpensive and noninvasive alternative treatment of MC in children.

Disseminated lupus vulgaris: a case report.

Lupus vulgaris is a secondary form of cutaneous tuberculosis which persists for years if not treated. The head and neck are the most commonly affected sites. While less frequently arms and legs, and rarely the trunk and the scalp are involved. Herein, we describe a 73-year-old man with a 5-year history of slowly growing, atrophic, some eroded and ulcerated, red-brown plaques on his forehead, nose, cheeks, ear lobes, trunk and extremites. All of his disseminated lesions healed after antituberculosis therapy.

Annular sarcoidosis mimicking granuloma annulare: a case report.

Cutaneous sarcoidosis is a great imitator and we have to remember this mimicker also in the differential diagnosis of erythematous annular lesions. We report the case of a 50-year- old man with a 7-year history of erythematous, annular or serpiginous, scaly plaques on his scalp, forehead, preauricular region and around his mouth who was misdiagnosed as granuloma annulare.

Acute generalized exanthematous pustulosis induced by etanercept: another dermatologic adverse effect.

Acute generalized exanthematous pustulosis (AGEP) is a skin eruption that is primarily drug induced and characterized by the formation of numerous acute and sterile pustules on an erythematous background as mentioned by Weinblatt et al. (1999). We present a case of AGEP, following administration of etanercept, an antitumour necrosis factor alpha (TNF- α ) antibody, in a patient with psoriasis. Recognition of this reaction pattern is important given the frequent reliance on etanercept in treating psoriasis.

The evaluation of thyroid diseases in patients with pemphigus vulgaris.

BACKGROUND: Thyroid disorders may affect all of the organ systems of the body and they are also highly associated with a wide variety of skin disorders. The aim of this study was to investigate the prevalence of thyroid function abnormalities and thyroid autoimmunity in patients with pemphigus vulgaris (PV) and to determine the association between thyroid disorders and clinical involvement and systemic corticosteroid treatment in patients with PV. METHODS: The study consisted of eighty patients with PV and eighty healthy individuals. Thyroid functions (fT3, fT4, and TSH) and thyroid autoimmunity (anti-thyroid peroxidase (anti-TPO), and anti-thyroglobulin (anti-Tg) antibodies) were investigated in both groups. Primary thyroid disease (PTD) was diagnosed with one or more of the following diagnostic criteria: (i) positive antithyroid antibodies, (ii) primary thyroid function abnormalities. RESULTS: Significant changes in the serum thyroid profile were found in 16% (13/80) of the PV group and 5% (4/80) of the control group. Positive titers of antithyroid antibodies (anti-TPO and anti-Tg) were observed in 7 patients (9%) with PV and one in the control group (1,2%). Hashimoto thyroiditis was diagnosed in 9% of PV patients and it was found to be more prevalent in the mucosal form of PV. PTD was found in 13 of (%16) PV patients which was significantly high compared to controls. PTD was not found to be associated with systemic corticosteroid use. Free T3 levels were significantly lower in PV group compared to the control group and free T4 levels were significantly higher in PV group compared to the controls. CONCLUSIONS: PV may exist together with autoimmune thyroid diseases especially Hashimoto thyroiditis and primer thyroid diseases. Laboratory work-up for thyroid function tests and thyroid autoantibodies should be performed to determine underlying thyroid diseases in patients with PV.

Prevalence of metabolic syndrome in patients with psoriasis.

BACKGROUND: Psoriasis is a chronic inflammatory skin disorder in which proinflammatory cytokines including IL-6 and TNF-α increase both locally and systematically. It is thought that chronic inflammation results in metabolic diseases and proinflammatory cytokines give rise to the development of atherogenesis, peripheral insulin resistance, hypertension, and type 2 diabetes. Our aim was to investigate the prevalence of metabolic syndrome in patients with psoriasis vulgaris. METHODS: Study consisted of 115 plaque-type psoriasis patients and 140 healthy individuals. Data including body weight, height, waist circumference, body-mass index, and arterial blood pressure were collected. Fasting blood glucose, triglyceride, and HDL levels were determined. International Diabetes Federation Criteria for Metabolic Syndrome and Insulin Resistance were used for evaluating patients with metabolic syndrome and diabetes. RESULTS: Compared to the control group, metabolic syndrome, diabetes mellitus, and hypertension were found to be higher in psoriasis patients. Metabolic syndrome was increased by 3-folds in psoriasis patients and was more prevalent in women than in men. It was determined that the prevalence of metabolic syndrome was higher in psoriasis patients after the age of 40. Metabolic syndrome was not related to smoking, severity of psoriasis, and duration of disease. CONCLUSIONS: Our findings suggest that psoriasis preconditions occurrence of a group of diseases such as diabetes mellitus, hypertension, and metabolic syndrome. For this reason, patients with psoriasis should be treated early and they should be followed with respect to metabolic diseases.

Skin autoreactivity in Hashimoto's thyroiditis patients without urticaria: autologous serum skin test positivity correlation with thyroid antibodies, sonographical volume and grading.

Recent studies have shown an association between anti-thyroid antibodies and autologous serum skin test (ASST) positive urticaria patients. However, a connection between thyroid and this reliable skin test for mast cell autoreactivity, ASST, has not been reported yet. We investigated ASST in patients with Hashimoto's thyroiditis (HT) without urticaria and compared the results with laboratory and sonographical findings of HT. 154 HT patients, 100 healthy volunteers without HT as a first control group and 46 patients with multinodular goitre but without autoimmune thyroid disease as a second control group underwent testing with ASST. ASST was applied to these groups according to two criteria, first as ASST(new): autologous serum red wheal response 1.5 mm bigger than negative control; second as ASST(old): serum red wheal response 5 mm bigger than negative control accepted as positive. Free triiodothyronine (fT3), free thyroxine (fT4), thyroid-stimulating hormone (TSH), thyroid peroxidase antibody (anti-TPO) and thyroglobulin antibody (anti-Tg) levels were measured. ASST(old), ASST(new) scored positive in 51.3-60.4% of HT patients, with statistically significant differences. Thyroid volume grades were inversely proportional with ASST(old) and (new) positivity. Moderate (+) titers of anti-Tg in ASST(old) and (new) (+) cases were significantly higher than the same titers of anti-Tg in ASST(old) and (new) (-) cases. The prevalence of ASST positivity in HT patients was not affected by the following factors: gender, age at screening, laboratory measurements of thyroid function tests, anti-TPO antibodies and thyroid ultrasound (US) echogenicity. Positivity of ASST in HT has shown that there is a skin mast cell autoreactivity in HT patients independent of autoreactive chronic urticaria (ACU).

Autologous whole blood and autologous serum injections are equally effective as placebo injections in reducing disease activity in patients with chronic spontaneous urticaria: a placebo controlled, randomized, single-blind study.

BACKGROUND: Recent demonstration of circulating anti-IgG antibodies towards IgE and its receptor (FcϵRI) has led to an interest in inducing tolerance to circulating histamine-releasing factors with autologous blood injections as a treatment option in chronic spontaneous urticaria (CU). The aim of the study was to assess the efficacy of autologous whole blood (AWB) and autologous serum (AS) injections in patients with CU compared to placebo. METHODS: A total of 88 CU patients with (+) autologous serum skin test (ASST) (59) and (-) ASST (29) were randomized into three parallel subgroups and were treated with weekly injections of AWB, AS or placebo for 10 weeks. Clinical assessments included urticaria activity score (UAS) and dermatology life quality index. RESULTS: In ASST (+) patients, the percentages of patients with >30% improvement in UAS and DLQI were 85% and 90% in AWB group, 65% and 65% in AS group and 79% and 90% in placebo group, respectively. In ASST (-) patients, these figures were 67% and 89% in the AWB group, 80% and 80% in the AS group and 60% and 70% in the placebo group. The intergroup difference for complete subsidence was not statistically significant. CONCLUSIONS: Even though we could not show a better efficacy than placebo, autohemotherapy resulted in a marked decrease in disease activity and improvement in quality of life scores in CU patients.

Primary cutaneous follicle center lymphoma responsive to interferon alfa-2a.

Follicular lymphoma is the most common type of primary cutaneous B-cell lymphomas with a predilection for the scalp, forehead, and trunk. Herein we report a case of primary cutaneous follicle center lymphoma on the scalp of 72-year-old female. The diagnosis was made histopathologically, confirming the presence of centrocytes and centroblasts. Complete resolution was achieved following administration of subcutaneous interferon α-2a at a dose of 4.5 × 106 IU three times weekly for 3 months.

Successful treatment of generalized childhood Schamberg's disease with narrowband ultraviolet B therapy.

Pigmented purpuric dermatoses are a group of dermatoses characterized by petechia and hyperpigmented macules that occur predominantly on the lower extremities. Although it is most commonly seen in adults, this disease can also affect children. Phototherapy has been shown to be effective in some cases in the literature. Here, we present two cases of Schamberg's disease that improved rapidly with narrowband ultraviolet B (UVB) therapy. To our knowledge, they were the first pediatric cases of successful narrowband UVB therapy in this disease.