Malignant change in seborrhoeic keratoses in a region with high solar ultraviolet levels.

Regions with high solar UV levels and high skin cancer rates may experience a greater incidence of malignancy in association with seborrhoeic keratoses (SebK) than in low UV regions. Previous reports have indicated that basal cell carcinoma is the most common neoplasm with reported rates of up to 4 per cent of excised SebK. The rates of such compound lesions occurring in our practice were reviewed, indicating that Bowen's disease was the most frequently observed neoplasm with a rate of 7 per cent. In total, 10 per cent of all excised specimens showed either frank malignancy or some degree of atypia.

Seborrhoeic keratosis and malignancy: collision tumour or malignant transformation?

A retrospective study of 813 histological specimens reported as seborrhoeic keratoses included 43 (5.3%) associated with non-melanoma skin cancer. Intraepidermal carcinoma (squamous cell carcinoma in situ) was the most common of these (36). There were five basal cell carcinomas (one with intraepidermal carcinoma also) and two invasive squamous cell carcinomas. No melanomas were reported. Twenty-seven of the intraepidermal carcinomas appeared to arise within the seborrhoeic keratosis as did one of the invasive squamous cell carcinomas. Of these 28 lesions, the head was the most common site. Fourteen were clinically diagnosed as a non-melanoma skin cancer with only nine clinically felt to be a seborrhoeic keratosis. These lesions may represent malignant transformation within the seborrhoeic keratosis. Twelve specimens reported adjacent dual pathologies, with the trunk and limbs the most common sites. Seven were diagnosed clinically as a skin malignancy, whereas three were thought to be solar keratoses. Clinically, the remaining two were seborrhoeic keratoses. The origin of the malignancy in these cases is less obvious and may represent collision tumours. Three curette specimens could not be assessed for architecture.

Bowen's disease of the nail bed.

A 77-year-old man presented with a 2-year history of left thumbnail dystrophy, purulent discharge and aching pain. There was no history of trauma. On examination there was a linear area of nail dystrophy and dyschromia of the nail bed. The nail plate was thinned proximally. No other digits were affected. There was no lymphadenopathy. X-ray of the digit was normal. Longitudinal nail biopsy revealed Bowen's disease along the length of the nail bed and nail matrix specimen. After avulsion of the nail plate, the nail matrix and tumour were fully excised. The defect was repaired with a split-skin graft. His symptoms were relieved.

Granulomas in common variable immunodeficiency: a diagnostic dilemma.

A 60-year-old man with common variable immunodeficiency presented with a 7-year history of violaceous plaques and papules on the thighs, arms and trunk. In the preceding 2 years he had developed new lesions on both hands. He had been previously diagnosed with sarcoidosis on the basis of skin and visceral histology, but subsequent opinion was that these were sarcoid-like granulomas rather than being representative of true sarcoidosis. Biopsy of the hand lesions showed necrotizing granulomas, and a single acid-fast bacillus (AFB) was identified on Wade-Fite stain. Subsequent repeat tissue biopsies for histology, culture and polymerase chain reaction testing failed to confirm the presence of mycobacterial organisms and it was felt that the organism was a contaminant introduced during tissue processing. The hand lesions responded well to intralesional injections of triamcinolone acetonide 10 mg/mL and oral tetracycline 500 mg b.d. was later introduced with a good clinical response. The diagnostic dilemma of finding granulomatous inflammation in a patient with common variable immunodeficiency, and the significance of a single AFB on histology are discussed. The treatment of sarcoid-like granulomas with tetracycline therapy is also commented on.

Scurvy: a cutaneous clinical diagnosis.

Two cases of scurvy diagnosed following presentation with a purpuric rash are presented. A 44-year-old man developed scurvy as a result of poor dietary intake of vitamin C. This occurred because of a number of factors. including poor dentition, diarrhoea, depression and benzodiazepine/narcotic dependence. A 69-year-old man with acute myeloid leukaemic transformation of myelodysplastic syndrome developed mucositis, nausea, vomiting and diarrhoea as complications of chemotherapy. This led to poor dietary intake and consequently scurvy. Both cases demonstrated specific and diagnostic cutaneous manifestations of scurvy, particularly perifollicular purpura, ecchymoses and coiled corkscrew hairs. The diagnosis was supported by specific diet history. Ascorbic acid tolerance test was used as a simple laboratory method to confirm the clinical diagnosis.

Staphylococcal scalded skin syndrome complicating acute generalized pustular psoriasis.

A 60-year-old woman with psoriasis vulgaris treated with oral cyclosporin and acitretin developed an acute generalized pustular eruption with erythema and associated fever consistent with acute generalized pustular psoriasis. She was admitted to hospital and, despite intravenous fluid replacement, developed acute renal failure. In addition, she developed staphylococcal septicaemia. After transfer to the intensive care unit because of deteriorating renal function, a sudden onset of widespread flaccid blistering (Nikolsky sign positive) and superficial erosions was noted. Histology of a biopsied blister revealed subcorneal splitting of the epidermis consistent with staphylococcal scalded skin syndrome. The patient was treated with intravenous dicloxacillin and the blistering gradually improved over 10 days.