Tetracycline and niacinamide: treatment alternatives in ocular cicatricial pemphigoid.

Cicatricial pemphigoid (CP) is one of the subepidermal autoimmune bullous dermatoses in which pathologic separation occurs between the epidermis and dermis. Ocular findings characteristic of CP include conjunctival cicatrization, subepithelial fibrosis, and symblepharon formation, which may progress to blindness. Ocular CP (OCP) is usually treated with steroids or immunosuppressive agents, which are problematic in and of themselves within the elderly population, which is most often afflicted with OCP. We describe the utility and effectiveness of therapy with tetracycline and niacinamide in elderly patients with OCP.

Breast and cutaneous mycobacteriosis: diagnosis by fine-needle aspiration biopsy.

The breast and skin are considered to be rare sites of extrapulmonary mycobacterial infection, comprising 0.1% to 0.5% of all tuberculosis cases, respectively. Fine-needle aspiration biopsy (FNAB) is a rapid and minimally invasive approach to diagnose extrapulmonary tuberculosis, and has been used successfully in identifying tuberculous lesions in the lymph nodes, thyroid, kidney, pancreas, vertebrae, and testis. Two cases of extrapulmonary mycobacteriosis diagnosed by FNAB are described: a 59-year-old Hispanic male with cutaneous mycobacterial infection of the head and neck region, and a 58-year-old white male with a unilateral tuberculous mastitis. In both instances, the FNAB material demonstrated acute neutrophilic exudate, few isolated aggregates of epithelioid histiocytes and lymphocytes, and on Fite-Farraco stain mycobacteria. Reported cases of tuberculosis diagnosed by FNAB have been few; this is the first case of cutaneous tuberculosis diagnosed by FNAB.

Conjunctival melanomas.

BACKGROUND: The nomenclature and the clinical and pathologic features of cutaneous and conjunctival melanomas are different. A comparison is made to familiarize dermatologists and ophthalmologists with these differences. METHODS: Five cases of conjunctival malignant melanoma from December 1983 to December 1990 were reviewed. RESULTS: The nomenclature of primary acquired melanosis is not used for cutaneous melanomas, and terms such as dysplasia and Clark's nevus are not used for conjunctival melanomas. Technical difficulties exist in orienting thin conjunctival tissues because of a tendency to curl during fixation, resulting in tangential sectioning and making a false diagnosis of a prognostically ominous pagetoid spread for an otherwise banal basilar hyperplastic pattern. Excision, cryotherapy, and rarely exenteration are the therapeutic measures in managing conjunctival melanomas; these have far more serious consequences for the patient compared with the excision of a skin melanoma. CONCLUSION: Differences exist in several aspects between melanomas located in the skin and the eye.

Cutaneous expressions of antiphospholipid syndromes.

The cutaneous clinical signs of antiphospholipid syndromes are expressed as stagnation of blood flow as livedo reticularis, purplish erythematous macules of acral areas, or end result of thrombosis as ulcers and necrosis (Fig. 6) (Table 1). Corresponding histological signs are reflected as thrombosis of dermal blood vessels (Fig. 7).

Recurrent pyogenic granulomas: a form of lobular capillary hemangioma.

Two cases of pyogenic granuloma recurred despite what was originally thought to be a sufficient surgical excision. The granulomas presented clinically as polypoid structures, one on the finger and one on the chin. On histologic examination, all showed polypoid configuration with lobules of small vessels and endothelial cell proliferation. The recurrent lesions also showed similar lobules, but interspersed between the collagen bundles in the deeper dermis. Vascular tumors such as the lobular pyogenic granulomas, intravenous capillary hemangiomas, and acquired tufted angiomas were compared to our tumors.

Fine needle aspiration cytology of cutaneous metastases.

By fine needle aspiration biopsy, 58 cases of cutaneous metastases were clinically and cytologically diagnosed at the Hines Veterans Administration Hospital from January 1987 to December 1990. Immunologic and electron microscopic studies affirmed the diagnosis and in some instances defined the primary neoplasm. The age of the patients ranged from 54 to 83 years (mean, 65). All were men. Two groups of patients emerged: group 1, 37 patients with known cancer, constituted the majority (64%). Group 2 consisted of 21 patients with cutaneous metastasis as the presenting sign (36%). Our patient survival times, a few weeks to 16 months (average, 4 months) are consistent with previous reports.

Melanoma in childhood and adolescence: clinical and pathological features of 48 cases.

Forty-eight cases of melanoma occurring in patients under 20 years of age were reviewed from a 23-year period at a single center. Fourteen of the patients were preadolescent children and 44 were Caucasian. Histological review of 44 available primary tumors showed only superficial spreading and nodular types. Thickness ranged from 0.23 mm to 8.50 mm, with a median of 1.03 mm. Ulceration was present in 7%, necrosis in 35%, evidence of regression in 16%, and antecedent nevus in 49% of the cases. The overall 5-year survival is 77%, with a median follow-up of 48 months. There is no detectable survival difference between preadolescent children and adolescents. Several treatment failures occurred after improper biopsy and/or inaccurate original diagnosis of Spitz's nevus. Of 38 stage I and II patients given definitive surgical treatment by the authors, the 5-year survival is 90%. Although histological confusion with Spitz's nevi occasionally occurs, melanoma in this age group can be treated with good results.

Transient bullous dermolysis of the newborn. Retention of anchoring fibril- and basal lamina-like structures in keratinocytes and evidence of collagenolysis.

In a freshly induced blister from transient bullous dermolysis of the newborn, we found in epidermal basal cells structures similar to anchoring fibrils and lamina densa, often in combination. In the upper dermis, collagenolysis and phagocytosis of degenerated collagen fragments were observed. It is concluded that the stellate inclusions previously reported in this disease are prematurely assembled anchoring fibrils and lamina densa. A disturbance of delivery mechanism of precursor materials for anchoring fibrils and lamina densa may cause the deficiency of these structures which are essential for the integrity of dermo-epidermal adhesion. The presence of many normal anchoring fibrils and lamina densa in perilesional skin and their prompt degeneration after rupture of the inclusions previously led us to conclude that lytic enzymes are involved in the formation of blisters in this disease. The new finding of collagen phagocytosis in the lesional dermis seemed to support this contention.

Transient bullous dermolysis of the newborn. Case report and review of pathogenesis.

A case of transient bullous dermolysis of the newborn is reported. A healthy Hispanic newborn developed bullae during the first two days of life. From age two to four weeks, the lesions healed with milia formation. There was no residual scarring or hypopigmentation. An induced blister showed dermal-epidermal separation with the PAS-positive basement membrane in the epidermal roof. PAS-positive inclusions were present in the cytoplasm of a few basal cells. Examination by electron microscopy showed degeneration of the collagen and anchoring fibrils. There were numerous stellate inclusions in the endoplasmic reticulum of the cytoplasm of the lesional basal keratinocytes.

Eccrine acrospiroma of the eyelid with oncocytic, apocrine and sebaceous differentiation. Further evidence for pluripotentiality of the adnexal epithelia.

A wide variety of sweat gland tumors occur in the eyelids. We used light and electron microscopy to investigate an eccrine acrospiroma showing areas of oncocytic, apocrine and sebaceous differentiation. To our knowledge this is the first report of an oncocytic lesion arising from an eccrine sweat gland, and only the second report of such a lesion arising from the skin. Furthermore, apocrine and sebaceous differentiation are atypical in lesions originating from sweat glands. The wide spectrum of differentiation in this adenoma lends further support to the concept of pluripotentiality of the adnexal glandular epithelia.

Acute hemorrhagic edema of childhood: an unusual variant of leukocytoclastic vasculitis.

A case of acute hemorrhagic edema in a 3-year-old boy is presented. Its cause, differential diagnosis, and relation to Schönlein-Henoch purpura are discussed. Acute hemorrhagic edema is an unusual variant of leukocytoclastic vasculitis.

Malignant melanoma of the female genitalia.

Fifteen women with genital malignant melanoma were studied. Their ages ranged from 19 to 66 years (mean 49.1 years); 12 were white, and three were black. The sites of involvement were the mons pubis (one patient), perineal body (one), labium majus (three), labium minus (three), and vagina (seven). Ten patients (66.6%) died of their disease, one is alive with disease, and four are alive without evidence of disease. For the living patients the duration of follow-up was 20 to 118 months (mean 63.6 months). Of those who died, survival ranged from 3 to 76 months (mean 25.1 months). The predominant type of malignancy was superficial spreading melanoma 50%. Nodular melanoma represented 22%, and the nodular polypoidal variant 14%. Melanoma of the squamous mucosa, also referred to as lentiginous melanoma, constituted 14%. By using Chung's method of determining levels of invasion, we found that no lesion was in situ (level I), two were level II (less than 1.0 mm thick), one was level III (between 1.0 and 2.0 mm) and the remaining 11 patients had lesions that were greater than 2.0 mm (levels IV and V). Because the subcutaneous fat is not consistently present in all sites of the female genitalia, all tumors thicker than 2.0 mm were included in level IV, and no level V tumors were classified in our study. Using Breslow's microstaging method, we found the thickness to range from 0.65 to 9.5 mm (mean 4.75 mm). When we correlated survival with level and thickness of tumor in nine patients who died, one tumor was level III and eight were level IV; thickness ranged from 1.65 to 9.0 mm (mean 5.64 mm).(ABSTRACT TRUNCATED AT 250 WORDS)

Computerized smoking cessation program for the worksite: treatment outcome and feasibility.

This study demonstrated the effectiveness of a computer-delivered smoking cessation program for the worksite. 58 VA Medical Center employees were randomly assigned to a computer group (computerized nicotine fading and stop-smoking contest) or a contest-only group. In comparison with the contest-only group, the computer group had nonsignificantly higher abstinence rates across follow-up, had marginally lower CO levels at the 3- and 6-month follow-ups, and smoked cigarettes with lower nicotine levels at the 10-day and 6-month follow-ups.

Surgical excision of trauma-induced verrucous lupus erythematosus.

Verrucous papulonodules are an uncommon manifestation of chronic discoid lupus erythematosus. The differential diagnosis and pathogenesis of this rare entity are discussed. This is the first report of successful surgical excision of trauma-induced lesions of verrucous lupus erythematosus.

Thin malignant melanomas with regression and metastases.

The significance of partial regression in thin malignant melanomas (0.76 mm or less) of the skin was evaluated to determine if the regression was associated with the later development of metastases in patients who previously were considered to have a favorable prognosis. Of 575 patients with primary cutaneous melanoma treated and followed up by the Division of Surgical Oncology at the University of Illinois, Chicago, we found that 103 (18%) had tumors that measured less than 0.76 mm. Of these, 30 (29%) showed histologic evidence of partial regression. In six (20%) of the 30 patients, visceral metastases developed and the patients died. All six had more than 77% regression of their primary tumors. Of the remaining 24 patients, only one had regression greater than 77% and she is still alive three years after diagnosis. Most of these 24 (83%) patients had regression of less than 50% (mean, 29.9%). No metastasis occurred in the 73 patients who had thin melanomas without histologic evidence of regression. It is apparent from this study that patients with thin melanomas who show partial regression cannot be included in the "low-risk" group if the extent of regression is 75% to 80% or more.

Correlative studies of Verruca vulgaris by H & E, PAP immunostaining, and electronmicroscopy.

Twenty-one specimens of Verruca vulgaris were used for an investigation to define what portion of the papillomatous structures seen in H & E stain will correspond to the areas of positive staining for papilloma virus antigen utilizing the peroxidase-antiperoxidase immunostaining technique. Vacuolar spaces filled with thready material and large ovoid parakeratotic cells seen in H & E stain stained positively for papilloma virus antigen. In the granular layer, viral antigens stained heavily, the nuclei of cells showing koilocytosis. Both round and irregularly shaped kerathohyaline granules did not stain positively for viral antigen stain. Eight of the 21 specimens showed marked positivity for papilloma virus antigen. Three other cases were positive in only focal sites. Of the 8 immunostained-positive selected cases used for ultrastructural studies, only 2 showed the viral particles. The study suggests that the PAP immunostaining is a more sensitive and yet less cumbersome method than electronmicroscopy for demonstration of papilloma virus.

Altered skin elastic fibers in hypothyroid myxedema and pretibial myxedema.

Elastic fibers account for 2% of dermal volume and are responsible for normal skin resiliency. We investigated a disorder of the dermal elastic component as the mechanism for the decreased elasticity of skin in myxedema. Skin biopsy specimens were obtained from patients with thyroid diseases and normal subjects matched for age, sex, and biopsy location. Elastic fiber concentration, determined by computerized morphometric analysis of Verhoeff-van Gieson-stained sections, was significantly lower than normal in hypothyroid and pretibial myxedema. The decreased elastin concentration was not a consequence of the glycosaminoglycan infiltration. Ultrastructural studies of myxedematous skin showed wide variability of elastic fiber diameter and decreased microfibrils. Myxedema (hypothyroid and pretibial) is consistently associated with quantitative and qualitative defects of dermal elastic fibers.