Dermatology Online Journal

The results of skin biopsies over a 10 year period were reviewed from the outpatient dermatology clinic at the Brody School of Medicine in Greenville, North Carolina. This research was conducted because there are very few studies that characterize this information over a long-term horizon. The biopsy rate per patient encounter, the clinical reason for the biopsy, the biopsy outcomes, the distribution of cutaneous malignancies per encounter, and the distribution of the subtypes of basal cell carcinoma, squamous cell carcinoma, and melanoma were analyzed. Biopsy logs from January 1, 2001 to December 31, 2010 were reviewed. Our investigation found that 20% of patient encounters resulted in a biopsy. Of these biopsies, 87.9% were performed to rule out malignancy and 12.1% were completed on patients suspected of having inflammatory skin conditions. The basal cell carcinomas diagnosed in Greenville, NC have more aggressive histologic subtypes compared to other studies, whereas the squamous cell carcinomas and melanomas were less aggressive.

Background: Osteoma cutis is a rare soft tissue ossification of cutaneous tissue and may be primary or secondary. In the majorityof cases it is clinically asymptomatic and may detected incidentally on radiographic examination. Cone beam computed tomography (CBCT) has can be of great assistance in the detection of this asymptomatic lesion.Objectives: In this retrospective study, the prevalence and different radiographic appearance of osteoma cutis was evaluated.Materials and Methods: A total of 6,500 CBCT images were evaluated for the presence of osteoma cutis. Ectopic existence of calcified tissue within the soft tissue of the dermis or epidermis that was incompatible with the calcification of other anatomic structures or soft tissue calcifications was considered to be osteoma cutis. Accordingly, the detected patterns were divided into four distinct groups: (1) a single nodule, (2) plate-like lesion, (3) single or multiple depth lesion(s), trans-epidermal, and (4) multiple, disseminated lesions of various sizes known as multiple miliary. The data were evaluated in terms of prevalence and variations. The frequency, total prevalence, percentage and the prevalence of different radiographic forms of this lesion were calculated.Results: One hundred and forty eight (2.27%) cases of 6,500 evaluated tomograms had osteoma cutis. Of these, 5 (0.07%) were in the form of a single nodule, 4 (0.06%) were single, plate-like lesions, 7 (0.1%) were multiple plate-like lesions, 2 (0.03%) were in the form of a deep thread-like lesion, and 130 (2%) presented as multiple disseminated lesions.Conclusion: According to the radiographic views, osteoma cutis may be categorized into single nodular, single or multiple plate- like, deep, and multiple disseminated forms. Of the mentioned radiogarphic patterns, the multiple disseminated form (miliary) hada higher prevalence in our study. CBCT images enable accurate evaluation of the nature and frequency of osteoma cutis.

Poikiloderma-like cutaneous amyloidosis (PCA) is a rare variant of primary cutaneous amyloidosis. It was first described in 1929 and there are two clinical forms of PCA, the ordinary type and PCA syndrome. The characteristics of PCA include poikiloderma-like skin changes, lichenoid papules, blister formation, and cutaneous amyloid deposits on histological examination. These skin lesions usually occur at the extremities, consistent with the few cases that have been reported. We present a case of a 62-year-old man who presented with the features of poikiloderma-like cutaneous amyloidosis. Diagnosis of this unique condition is a challenge and a skin biopsy is necessary in such instances. A discussion of the differential diagnosis of this condition is also included.

Cyclosporine-induced sebaceous hyperplasia (SH) is a well-documented entity, occurring in up to 30% of renal transplant patients treated with cyclosporine and has also been reported to occur following heart or hematopoetic stem cell transplantation (HCST). Cyclosporine has a stimulatory effect on undifferentiated sebocytes, resulting in the clinical and histologic findings in these patients. Sebaceous hyperplasia most commonly presents as asymptomatic papules over the face, chest, or groin. Herein we describe a case of a 27-year-old man who developed facial sebaceous hyperplasia five months after completing cyclosporine therapy for cutaneous graft versus host disease (GVHD) following HSCT.

Rosai-Dorfman disease rarely presents in a solely cutaneous form. A subset of patients with skin limited disease have associated immune disorders such as lupus, autoimmune hemolytic anemia, and Crohn disease. We report an interesting case of cutaneous Rosai Dorfman disease in a patient with human immunodeficiency virus (HIV).

Pemphigus and pemphigoid are two unique acquired immunobullous diseases with distinct clinical presentations, histological findings, and characteristic serology; they are rarely reported to coexist in the same patient. Herein we present a 29-year-old woman with a history of pemphigus vulgaris, diagnosed by histology and positive desmoglein-3 antibodies on ELISA. She presented to our clinic shortly after the delivery of her first child with tense vesicles and bullae on an erythematous base on her abdomen. Biopsy was consistent with pemphigoid gestationis and direct immunofluorescence confirmed the diagnosis. To our knowledge, there are no other reported cases of pemphigoid gestationis occurring in a patient with pemphigus vulgaris.

Disseminated candidiasis in immunosuppressed patients has been classically associated with an erythematous papular eruption, however more severe presentations are possible. We present a patient who developed disseminated Candida tropicalis that presented with hemorrhagic bullae that progressed to large necrotic ulcers.

Primary cutaneous plasmacytosis (PCP) is an uncommon reactive lymphoplasmacytic disorder of uncertain etiology. It has been mainly described in patients of Japanese descent, with only few reports in Caucasians and Chinese. We present a case of isolated benign PCP in a 45-year-old man, who clinically manifested with a localized ulcerated nodule overlying a hyperpigmented plaque on the upper back. To the best of our knowledge, PCP from India has not been described before.

Extramammary Paget disease (EMPD) is a rare malignant neoplasm of apocrine sweat glands that is morphologically and histologically identical to Paget disease of the breast. The primary lesion is usually a solitary, well-demarcated, erythematous, scaly plaque that may contain crust, erosions, or ulcerations. The vulva is the most common site, but any area containing apocrine sweat glands may be involved. We present a case of triple extramammary Paget disease of the groin and bilateral axillae in a diabetic patient whose axillary lesions appeared consistent with acanthosis nigricans. This case demonstrates the need to consider EMPD in the evaluation of acanthosis of the axilla given its ability to mimic more common conditions.

Scurvy results from a deficiency of vitamin C, a nutrient otherwise known as ascorbic acid. Today, scurvy is rare yet emerges inselect patients. The patient reported herein developed scurvy secondary to deliberate avoidance of vitamin C-rich foods. Classic cutaneous manifestations of scurvy include follicular hyperkeratosis and perifollicular hemorrhage encompassing coiled “corkscrew” hairs and hairs bent into “swan-neck” deformities. Ecchymoses, purpura, and petechiae are also characteristically prominent. Classic oral abnormalities include erythematous, swollen gingivae that hemorrhage from subtle microtrauma.Subungual linear splinter hemorrhages may also manifest as a sign of the disease.To establish the diagnosis requirements include characteristic physical exam findings, evidence of inadequate dietary intake, and rapid reversal of symptoms upon supplementation. Although unnecessary for diagnosis, histological findings demonstrate perifollicular inflammation and hemorrhage, fibrosis, and hyperkeratosis, amongst dilated hair follicles and keratin plugging.Although citrus fruit allergies have been historically documented, ascorbic acid has not been previously reported as an allergen. Although lacking absolute certainty, this report suggests a presumed case of ascorbic acid allergy based on patient history andfavorable response to ascorbic acid desensitization therapy.

Background: The scrotum is an uncommon site for cutaneous metastases from visceral malignancies.Purpose: A man with colon cancer, which subsequently developed cutaneous metastasis to the scrotum is described.Materials and Methods: PubMed medical database was used to search the following terms separately and in combination: cutaneous metastasis, skin metastasis, scrotal metastasis, scrotum, rectal cancer, and colon cancer.Results: Cutaneous metastasis most frequently occur in the vicinity of the primary tumor. Skin sites of metastatic cancer may include the abdomen, back, chest, face, scalp, and genitalia. The reported patient developed metastatic cutaneous lesions of his colon cancer not only on the abdomen but also on the scrotum. Including our patient, 9 men have been described with metastatic colon or rectal carcinoma localized to the scrotum. The lesions were the presenting sign of malignancy in one man and in the others, the lesions appeared within 24 months of their initial diagnosis of cancer. The skin metastases were pleomorphic; they appeared as papules, nodules and/or cutaneous induration. Survival data was only reported in five of the patients.  However, colon or rectal metastases to the scrotum is a poor prognostic sign with a mean survival time of 11 months.Conclusion: Scrotal metastases from carcinoma of the colon or rectum may be the initial presentation of malignancy or herald the discovery of recurrent disease. The morphology of the metastatic tumor is variable: papules, nodules and/or sclerosis. The development of scrotal metastases from colon or rectal carcinoma portends a poor prognosis. Most of the patients succumb to theirmetastatic disease within a year.

Varicella zoster virus (VZV) is an uncommon cause of folliculitis. We present a case of a 29-year-old woman who presented with an atypical follicularly-based eruption localized to her inner thigh with an associated pain in her lower back and inner thigh prior to the papular eruption. She was successfully treated with valacyclovir 1,000 mg three times daily with no complications.

The predisposition to epithelial neoplasms in nevus sebaceous is well established; most tumors occur in adults and are benign. Hidradenoma is a relatively rare benign tumor of sweat gland origin that can rarely arise within a nevus sebaceous. We present an interesting case of a hidradenoma and sebaceoma arising within a nevus sebaceous and present a literature review of the 2 conditions. Even though hidradenoma is a benign tumor, we would advocate complete excision given the potential for malignant transformation.

A three-year-old boy presented to our oculoplastic clinic with complaints of painless gradually increasing right upper lid mass for the last 6 months. On examination a firm mass measuring roughly 1x1 cm was present on the upper lid. The mass was non tender with fine superficial vessels running over it. A differential diagnosis of epidermoid cyst, vascular malformation, pilomatrixoma, and juvenile xanthogranuloma was considered. The patient underwent excisional biopsy of the mass. On gross examination the mass had a brain like appearance. Histopathological examination confirmed the diagnosis of molluscum contagiosum. It is rare for molluscum contagiosum to present as a solitary lid tumor. A brain like appearance of the excised mass can provide a clue towards the diagnosis

Bullous pemphigoid (BP) is a common pemphigoid disorder, which is localized in approximately 16-29% of cases. A small subset of localized BP cases is associated with prior radiation therapy, most commonly for breast carcinoma. We present a patient with an unusual presentation of localized BP after receiving partial accelerated breast irradiation (a type of brachytherapy that has a decreased amount of radiation to the skin as compared to the more common external beam radiation therapy).

Methotrexate-induced cutaneous ulceration is a rare but potentially serious drug adverse reaction. This adverse reaction of methotrexate therapy has been initially described in psoriasis patients and is unusual in patients with cutaneous T-cell lymphoma. In 1978, Mc Donald et al reported the first three cases of cutaneous ulcerations in patients treated for a mycosis fungoides with intravenous infusions of methotrexate [1]. Since then, few cases of methotrexate-induced skin ulcers in patients with mycosis fungoides have been published [2-5]. We report an additional patient with erythrodermic mycosis fungoides who developed cutaneous ulcerations as a sole manifestation of methotrexate toxicity.

Melanoma is an aggressive tumor with advanced disease characterized by widespread metastatic lesions and the tumor hastraditionally been resistant to most forms of treatment. Indeed, metastatic melanoma has a very poor prognosis with a median survival time of 8–9 months and an estimated 3-year survival rate of less than 15 % [1].Recent advances in our understanding of the genetic profile of melanoma cells and the molecular factors that drive malignant transformation have resulted in the identification of numerous new therapeutic targets.KIT is an established therapeutic target in cancers with activating mutations of KIT, such as gastrointestinal stromal tumors (GIST), and considerable efficacy has been achieved with various small molecule inhibitors of KIT including imatinib mesylate [2].Nilotinib is an inhibitor of ligand-induced PDGFRα and PDFGRβ kinase activity and autophosphorylation of constitutively activated KIT harboring exon 13 or exon 11 mutations (IC50 values of 0.2 and 0.027 μmol/L, respectively), with efficacy comparable to that of imatinib [2].We report a case of non-kit mutated metastatic vaginal melanoma showing impressive response to nilotinib.