Polypoid clear cell acanthoma of the scalp.

Clear cell acanthoma (CCA) is a rare, benign epithelial tumor most frequently found on the lower extremities. Its clinical appearance may vary considerably, and cases of multiple lesions have been reported. The diagnosis is made by viewing the characteristic histologic features. This case describes an unusual scalp lesion that clinically and histologically shows unique polypoid features.

Acquired vulvar lymphangiomas: a sequela of radiation therapy.

Lymphangiomas of the vulva are rare clinical entities. Acquired or secondary lymphangiomas have characteristically been reported after radiation therapy for cervical carcinoma and appear on the vulva years after this treatment. Local surgery, scrofuloderma, and Crohn's disease may also damage vulvar lymphatic flow and lead to the development of vulvar lymphangiomas. We report a case of acquired vulvar lymphangiomas that occurred in a patient 15 years after she received radiation therapy for squamous cell carcinoma of the uterine cervix.

Migratory poliosis: A forme fruste of alopecia areata?

We describe a 19-year-old African-American man with a 14-year history of migratory poliosis. We suggest that this phenomenon may represent a forme fruste of alopecia areata.

Malignant melanoma arising in a seborrheic keratosis.

We report a case of malignant melanoma associated with seborrheic keratosis. This has been reported rarely in the literature, with disagreement regarding whether it is coincidental or whether malignant transformation occurs. Because seborrheic keratoses are common and association with malignant melanoma is very rare, we conclude that the association is coincidental. However, because of the association of other malignancies, a biopsy of any suspect or changing seborrheic keratosis is essential.

Elastic tissue in scars and alopecia.

A recent report suggests that elastic fibers appear in scars in a time-dependent fashion. This observation prompted our investigation, because we have found elastic tissue stains helpful in determining the pattern of scarring in cases of permanent alopecia. We carried out this investigation to determine if the Verhoeff-Van Gieson (VVG) elastic stain can reliably differentiate scarred from non-scarred dermis and to test our hypothesis that elastic stained sections are helpful in distinguishing lichen planopilaris (LPP) from lupus erythematosus (LE), central progressive alopecia in black females ("follicular degeneration syndrome" and "hot comb alopecia" are other terms used to describe this condition) and classic ivory white idiopathic pseudopelade. We studied histological sections from surgical scars of known duration, stained with the VVG elastic stain and VVG-stained sections of scalp biopsies from patients with established lesions of permanent alopecia. In most cases, both vertical and transverse sections were examined. In every case, the VVG stain clearly differentiated scar from the normal surrounding dermis. Distinct patterns of elastic tissue allowed for correct classification in most of the well-established cases of permanent alopecia studied. We determined that the Verhoeff-Van Gieson stain is an excellent stain to evaluate the pattern of scarring in cases of permanent alopecia and elastic tissue stains may be helpful in the histological evaluation of alopecia.

Acquired perforating dermatosis in a patient with chronic renal failure and diabetes mellitus.

Perforating disorders in patients with chronic renal failure (CRF), diabetes mellitus (DM), or both, may resemble any or all of the four classic cutaneous perforating disorders. However, due to the highly variable and overlapping histologic appearance of the lesions in patients with CRF, DM, or both, it may be useful to categorized these lesions as a distinct, yet encompassing process, termed by Rapini as acquired perforating dermatosis. We describe a patient with both CRF and DM with acquired perforating dermatosis.

Primary anetoderma.

Primary anetoderma is a rare disorder characterized by sac-like herniations and depressions in previously normal skin. On histologic examination, elastic fibers are destroyed by an inflammatory infiltrate. We describe a striking case of primary anetoderma and review the classification, differential diagnosis, causes, and treatment.

Cutaneous parachordoma. A light microscopic and immunohistochemical report of two cases and review of the literature.

Parachordomas are rare cutaneous tumors that show virtually identical histologic findings to chordomas. Therefore, the major differential diagnosis in a case of parchordoma is metastatic chordoma. Parachordomas are benign neoplasms and most often develop on the extremities adjacent to tendons, synovium or osseous structures, as opposed to chordomas, which are malignant tumors located along the craniospinal axis. While recurrences may occur in cases of parachordoma, metastases have not been reported. In this report, two cases of parachordomas are reported and the literature reviewed. By light microscopy, parachordomas show eosinophilic bands of fibrous tissue separating lobules of cells with variably vacuolated cytoplasm (physaliphorous cells) admixed with more epithelioid cells in a myxoid stroma. Parachordomas and chordomas share immunohistochemical and ultrastructural features. Both stain with S-100 protein and vimentin, and ultrastructurally both demonstrate cytoplasmic vacuoles, intermediate filaments, pinocytotic vesicles, celljunctions, and cytoplasmic membranes with microvillous processes. Chordomas more frequently express cytokeratin (98% vs. 66% in parachordomas) and epithelial membrane antigen (90% vs. 20% in parachordomas) and chordomas have a larger number of rough endoplasmic reticulum-mitochondrial complexes. Thus, positive staining with epithelial membrane antigen and the identification of a large number of rough endoplasmic reticulum-mitochondrial complexes are suggestive of metastatic chordoma. However, the definitive distinction remains a clinical one after appropriate radiologic studies of the skull and spinal chord.

Alabaster skin after carbon dioxide laser resurfacing with histologic correlation.

BACKGROUND: Carbon dioxide laser resurfacing has gained popularity as a relatively safe and effective method of facial rejuvenation. Original reports describe mostly reversible side effects and a low incidence of scarring. Only very recently have reports of delayed hypopigmentation surfaced. This effect is not visible until several months after resurfacing, and most likely represents a permanent change. OBJECTIVE: To provide an additional clinical description of the complication of delayed hypopigmentation along with the first published histologic correlation. METHODS: Clinical records along with a preprocedure and 7-month postprocedure full-thickness skin biopsy were used for this report. RESULTS: This patient experienced a striking leukoderma 6 months after a full facial carbon dioxide laser resurfacing procedure done for widespread actinic keratoses. There was a zone of dermal fibrosis extending approximately 0.4 mm on the postprocedure biopsy. Comparison of the preprocedure and postprocedure biopsies revealed no difference in the number of melanocytes by MART-1 immunohistochemical staining, but there was a significant decrease in epidermal melanin as determined by Fontana-Mason staining. CONCLUSION: This patient experienced a profound expression of an increasingly recognized and reported complication of carbon dioxide laser resurfacing. Histologic correlation is similar to the results previously reported after phenol chemical peels, demonstrating a normal number of melanocytes but a decrease in epidermal melanin.

Vesiculo-bullous dermatomyositis.

Cutaneous manifestations of dermatomyositis (DM) commonly include Gottron's papules, cuticular erythema and telangiectasia, periorbital edema with a "heliotrope" rash, a papulosquamous eruption of the hairline, face, and trunk, as well as poikiloderma. Very few references can be found concerning vesicular and bullous lesions, however. We present two patients with dermatomyositis who manifested vesicular and bullous lesions who were initially misdiagnosed. Although rare, it is important to recognize this form of DM to avoid misdiagnosis. Furthermore, in some cases, vesiculo-bullous DM may portend a poor prognosis.

Periductal mastitis. Masquerading as carcinoma.

Periductal mastitis (mammary duct ectasia) is a little appreciated, often unrecognized entity that may present to the dermatologist. We present our experience with this disease and hope to familiarize the reader with a condition not well known to most dermatologists. Periductal mastitis is a benign mammary duct disease that begins with periductal inflammation and progresses to ductal dilatation with minimal inflammation (ductal ectasia). The clinical and radiographic appearance of this disease can be indistinguishable from carcinoma of the breast.

Rheumatoid neutrophilic dermatitis.

Rheumatoid neutrophilic dermatitis (RND) is a rare cutaneous finding in patients with severe rheumatoid arthritis or with high-titer rheumatoid factors. Most commonly, these lesions are erythematous papules or plaques distributed symmetrically on extensor surfaces. On histologic examination a dense dermal neutrophilic infiltrate without vasculitis is apparent. The pathogenesis of RND is unclear, and few treatments are known. With careful clinical and histologic examination, RND may be differentiated from the wide array of other cutaneous findings in rheumatoid arthritis.

Eosinophils in fibrous tracts and near hair bulbs: a helpful diagnostic feature of alopecia areata.

BACKGROUND: When biopsy specimens lack a "swarm of bees" peribulbar lymphoid infiltrate, the diagnosis of alopecia areata depends on the recognition of other histologic features of the disease. OBJECTIVE: Our objective was to determine the frequency of the presence of eosinophils in biopsy specimens of alopecia area'a in relation to the other major histologic features of the disease. METHODS: Biopsy specimens from 71 patients with alopecia areata were studied. RESULTS: Eosinophils were present in 38 of the 71 cases. A peribulbar lymphoid infiltrate was absent in 27 of the 71 cases. Eosinophils were present in 13 of these cases. Multiple catagen hairs and pigment casts (features which may lead to confusion with trichotillomania) were present in 39 cases. The presence of eosinophils was found to be a helpful diagnostic feature in cases with potential for misdiagnoses as trichotillomania. CONCLUSION: Eosinophils are common in all stages of alopecia areata, both within the peribulbar infiltrate and within fibrous tracts. A "swarm of bees" peribulbar infiltrate may be absent. The presence of eosinophils is a helpful diagnostic feature of alopecia areata.

5-fluorouracil iontophoretic therapy for Bowen's disease.

BACKGROUND: Topical 5-fluorouracil (5-FU) is an accepted therapy for Bowen's disease. Recurrences with this method have been attributed to deep follicular involvement and poor patient compliance because of the prolonged treatment time required. OBJECTIVE: We sought to determine whether iontophoresis of 5-FU is an effective therapy for Bowen's disease. METHODS: Twenty-six patients with biopsy-proven Bowen's disease received eight 5-FU iontophoretic treatments in 4 weeks. Local excision was done 3 months after the last treatment. The specimens were step-sectioned and evaluated for any histologic evidence of bowenoid changes. RESULTS: Only 1 of 26 patients showed histologic evidence of Bowen's disease 3 months after treatment. CONCLUSION: 5-FU iontophoresis appears to be a safe, effective, and well-tolerated therapy for Bowen's disease.

A pigmented scalp nodule: malignant blue nevus.

The malignant blue nevus is an aggressive dermal melanocytic neoplasm. The lesion occurs most frequently on the scalp of men in their fifth decade of life, often metastasizes to the regional lymph nodes, and commonly results in fatality. Controversy exists as to whether this lesion is a malignant melanoma in the dermis or a separate neoplasm arising in the architecture of a cellular blue nevus. The lesion is treated with wide local excision and close monitoring for the occurrence of metastatic disease.

Tattoo pigment mimicking metastatic malignant melanoma.

BACKGROUND: The benefits of elective lymph node dissection (ELND) in the treatment of melanoma remain controversial, however, it may be beneficial in some patients. Tattoo pigment from decorative tattoos may migrate to the regional lymph nodes. In patients who develop malignant melanoma and who have been tattooed, this pigment may clinically mimic metastatic disease. OBJECTIVE: We wish to alert clinicians that pigment from tattoos may migrate to the regional lymph nodes. In the unusual instance of a tattooed patient who develops malignant melanoma, when undergoing ELND, surgeons should rely on histologic confirmation of metastatic disease before altering operative plans. METHODS: ELND for malignant melanoma, in a patient with a history of decorative tattoos that had been removed by dermabrasion, was performed. Black lymph nodes that clinically resembled metastatic disease were identified. Subsequent histologic examination revealed normal lymph node architecture with a heavy collection of black pigment. Mass spectrophotometry showed this pigment to be consistent with tattoo dye. RESULTS: A patient who had undergone dermabrasion for removal of decorative tattoos developed malignant melanoma in the same extremity. Clinically suspicious black lymph nodes were identified during ELND. Histologic examination did not reveal metastatic disease. Additional therapy was not considered intra- or postoperatively even though the clinical suspicion of metastatic disease was high. The patient was not subjected to any unnecessary emotional or physical distress pending histologic confirmation. CONCLUSIONS: Tattoo pigment in the lymph nodes may clinically mimic metastatic melanoma. Histologic confirmation of metastatic disease should always be obtained before additional therapy is considered.