Recurrent palmoplantar hidradenitis in children

BACKGROUND

There are several reports of tender, erythematous plantar nodules occurring in pediatric patients. Despite similar morphological features, the histologic findings in these lesions have been quite diverse. A new entity called idiopathic plantar hidradenitis (also termed neutrophilic eccrine hidradenitis in children), which is characterized by tender, red nodules on the feet and unique histopathologic features, was recently described.

OBSERVATIONS

We describe two children with these unusual cutaneous lesions and histopathologic findings and compare them with patients with idiopathic plantar hidradenitis. Our patients, in contrast to those with idiopathic plantar hidradenitis, had involvement of the palms as well as the soles. Both children had self-limited recurrent lesions; in one child, the lesions were associated with low-grade fever. Biopsy specimen findings in both cases demonstrated dense neutrophilic infiltrates localized to the eccrine units.

CONCLUSIONS

Our patients had clinical and histologic findings similar to those recently reported as idiopathic plantar hidradenitis (neutrophilic eccrine hidradenitis in children). Because palms and soles can be affected and the lesions typically recur, we suggest that this condition be referred to as recurrent palmoplantar hidradenitis.

Cutaneous giant cell hyalin angiopathy

Giant cell hyalin angiopathy (GCHA) is an unusual histologic finding associated with inflammation. The lesion has previously only been reported intraorally and is usually preceded by trauma. We report the first case of cutaneous GCHA. The eosinophilic, amorphous material (so-called "hyalin") stained for light chain products, suggesting that their deposition resulted from a reactive process associated with inflammation.

Histologic comparison of autologous graft-vs-host reaction and cutaneous eruption of lymphocyte recovery

BACKGROUND AND DESIGN

The cutaneous eruptions due to allogeneic graft-vs-host disease, autologous graft-vs-host disease, and lymphocyte recovery occur in the setting of peripheral leukocyte reconstitution after marrow aplasia. Since the eruptions of lymphocyte recovery (ELR) and autologous graft-vs-host disease develop in the presence of histocompatibility, we question whether reliable histologic differentiation is possible. To this end, we performed a retrospective, blind analysis of 38 skin biopsy specimens obtained from patients who received autologous marrow transplants or intensive chemotherapy alone for various malignant neoplasms.

RESULTS

In 31% of the cases, we were unable to distinguish between an ELR and a grade 2 graft-vs-host reaction. In 40% of the ELR specimens, a significant number of dyskeratotic keratinocytes were present, leading to the false interpretation of a grade 2 graft-vs-host reaction. Satellite cell necrosis was observed in both groups. The patterns of dyskeratotic keratinocytes were similar; one ELR specimen displayed prominent follicular involvement. Most ELR specimens were consistent with grade 1 graft-vs-host reaction changes.

CONCLUSIONS

These findings indicate that the presence of dyskeratotic keratinocytes is not specific for a graft-vs-host reaction and that cutaneous eruptions after autologous marrow transplantation are best considered an ELR.

Use of computer graphic images in teaching dermatology

A microcomputer-based system for copying, storing, retrieving, and displaying color still images was assembled from commercially available components. The system was tested against 35-mm color photographic transparencies by measuring the performance of 91 medical students in a task of identifying the primary morphology of eight skin lesion images from the displayed images. There was no significant difference in the students' performance between the two display media.

Benign vulvar tumors

Benign tumors and "dark lesions" accounted for 22% of vulvar disease seen in the Vulvar Clinic at the Milwaukee County Medical Complex over an 8-year period. Biopsy confirmation was obtained for 269 lesions. The order of frequency of lesions in this study was as follows: epidermal inclusion cyst, lentigo, Bartholin's duct obstruction, carcinoma in situ, melanocytic nevi, acrochordon, mucous cyst, hemangiomas, postinflammatory hyperpigmentation, seborrheic keratoses, varicosities, hidradenomas, verruca, basal cell carcinoma, and, last, unusual tumors such as neurofibromas, ectopic tissue, syringomas, and abscesses. The variability in clinical appearance of vulvar tumors suggests that biopsy confirmation should be obtained on all lesions for which there is the least doubt regarding the diagnosis.

Interleukin 2 and granulocyte-macrophage colony-stimulating factor induce a perivascular lymphocytic infiltrate in a skin explant model

Cutaneous eruptions displaying perivascular inflammatory cell infiltrates histologically may develop with the intravenous administration of cytokines. Similar findings are seen spontaneously in some patients on recovery of peripheral blood lymphocytes after profound marrow aplasia. To investigate the production of a cutaneous perivascular infiltrate further, the ability of several cytokines to induce a perivascular lymphocytic infiltrate was studied in vitro using a skin explant model. A skin biopsy specimen obtained at the time of peripheral blood lymphocyte recovery after chemotherapy-induced marrow aplasia (n = 10) was divided and incubated for 3 days with and without a series of cytokines plus various peripheral blood mononuclear cell populations. Skin incubated with interleukin 2 and granulocyte-macrophage colony-stimulating factor induced a perivascular lymphocytic infiltrate, while control samples did not. Immunophenotypic analysis revealed that the lymphocytes were predominantly CD3+/CD4+. An infiltrate was not observed when skin was incubated with cytokines alone, without the addition of simultaneously isolated peripheral lymphocytes. A perivascular pattern was not observed with the addition of interferon gamma. Only interferon gamma induced keratinocyte intercellular adhesion molecule 1 expression in experimental tissue. Certain cytokines that affect a range of cell types are capable of inducing a common cutaneous histologic pattern, the perivascular lymphocytic infiltrate.

Discrete pigmentation after chemotherapy

Discrete areas of cutaneous hyperpigmentation were seen in two children with metastatic sarcoma who received chemotherapeutic bone marrow ablation with cyclophosphamide, etoposide, and carboplatin prior to autologous bone marrow transplantation. The hyperpigmented patches occurred only in areas of skin occluded by tape, electrocardiogram pads, or elastic bandages. Identical skin findings were reported in five adult women who received intravenous thiotepa and cyclophosphamide. Measurable levels of thiotepa were detected in these patients' serum, skin, sweat, and occluded gauze, suggesting that the chemical was excreted onto the skin surface in sweat and accumulated under occlusive dressing, thus producing some toxic effect on the epidermis or melanocytes resulting in abnormal pigmentation. We suspect that a similar mechanism was operative in our patients to produce the unusual patterned hyperpigmentation, and suggest that this complication may be prevented by minimizing sweat accumulation in areas occluded by adhesive materials.

Endothelial expression of intercellular adhesion molecule (ICAM-1) is unaffected by marrow aplasia-inducing chemotherapy

Sequential skin biopsies were obtained from five patients receiving chemotherapy for acute myelocytic leukemia. The first specimen was taken on the fourth day of initial chemotherapy and subsequent specimens were obtained at weekly intervals thereafter, until discharge. In all cases, clinically normal skin was selected as the biopsy site. A panel of monoclonal antibodies was applied to frozen tissue sections, including anti-intercellular adhesion molecule-1 (ICAM-1), anti-lymphocyte function-associated antigen-1 (LFA-1), and anti-HLA-DR. Bound antibody was detected using the avidin-biotin complex method. Endothelial cell expression of ICAM-1 and lymphocyte expression of LFA-1 were unaffected over the course of the ensuing, profound marrow aplasia. This finding suggests that this mechanism of lymphocyte trafficking in the skin remains operational despite the administration of antileukemic agents.

Intravenous administration of recombinant human granulocyte-macrophage colony-stimulating factor causes a cutaneous eruption

The intravenous administration of recombinant human granulocyte-macrophage colony-stimulating factor to three patients with leukemia who were receiving marrow aplasia-inducing chemotherapy resulted in the development of wide-spread erythematous macules and papules. The course of the eruption paralleled the time of infusion of the granulocyte-macrophage colony-stimulating factor. Skin biopsy specimens taken from two of the eruptions displayed characteristic changes consisting of a variable mixture of granulocytes and lymphocytes, increased number and size of dermal macrophages, mild to moderate epidermal exocytosis, intercellular edema, and rare dyskeratotic keratinocytes. Immunophenotypic analysis of one specimen was notable for keratinocyte intercellular adhesion molecule-1 expression. Administration of the recombinant human cytokine in pharmacologic doses is postulated to induce changes in the immunologic status of the skin, resulting in the expression of a cutaneous eruption.

Characterization of the dermal infiltrate in human immunodeficiency virus-infected patients with psoriasis

We investigated the dermal inflammatory cell infiltrates of psoriatic lesions from nine human immunodeficiency virus-infected patients and nine age-, sex-, and site-matched control specimens. The study was retrospective and observer blinded. T lymphocytes were quantitated using UCHL-1, a pan-T-cell monoclonal antibody, and plasma cell number was estimated in hematoxylin-eosin-stained sections. Differences in both variables reached statistical significance. There were fewer T cells and the number of plasma cells was significantly higher in specimens from the human immunodeficiency virus-positive individuals in comparison with control specimens. As plasma cells are readily identified on hematoxylin-eosin-stained sections, their presence in skin biopsy specimens from psoriatic leisons should arouse suspicion of human immunodeficiency virus infection. The depletion of helper/inducer T lymphocytes by the human immunodeficiency virus may promote the presence of plasma cells in cutaneous inflammatory infiltrates.

Cytomegalovirus is predictably present in perineal ulcers from immunosuppressed patients

We examined five consecutive skin biopsy specimens taken from perineal ulcers on immunosuppressed patients. Examination of hematoxylin-eosin-stained sections in conjunction with immunohistochemistry using monoclonal antibodies to early and late viral antigens resulted in identification of cytomegalovirus in all specimens. Cells containing cytomegalovirus were present in the ulcer base and papillary dermis. Herpes simplex virus was identified in three of five specimens. This series demonstrates that cytomegalovirus is predictably present in perineal ulcers from immunocompromised patients, but does not establish this virus as the cause of the ulcers.

Parry-Romberg syndrome in association with contralateral Poland syndrome

A 35-year-old woman had a 4-year history of skin depression on the right side of both the forehead and chin. A biopsy specimen showed a normal dermis and an absence of subcutaneous tissue. She also had Poland syndrome on the left side of the body, with loss of the sternocostal portion of the greater pectoral muscle. Significant cosmetic improvement was achieved with dermal fat grafts and silicone implants.

Prospective study of vulvar nevi

We report the results of a year-long prospective study to approximate the prevalence of pigmented lesions of the vulva in a gynecology practice. A total of 301 new patients were screened during their routine gynecologic examination. Thirty-one (10.3%) had pigmented lesions in the vulvar region, and an additional six (2%) had diffuse hyperpigmentation. Only seven patients (2.3%) had vulvar nevocytic nevi.

Postinflammatory elastolysis and cutis laxa. A case report

One of the rarest forms of cutis laxa is postinflammatory elastolysis and cutis laxa, a disease previously reported only in children in Africa and South America. This disease is characterized by an urticarial or papular eruption followed by acute destruction of elastic tissue that results in atrophy and severe disfigurement. It is distinguished from anetoderma and acquired cutis laxa by its clinical features, its occurrence in young children, and its relatively benign course. This article describes the first case of postinflammatory elastolysis and cutis laxa reported in a white child from North America.

Cutaneous eruptions of lymphocyte recovery

Macular and papular eruptions are ascribed to various causes, often drug-related hypersensitivity or toxicity. We observed patients with cutaneous eruptions during hospital admissions for induction or augmentation chemotherapy in the treatment of leukemia. In 10 of 14 patients, macular and papular eruptions occurred in a strikingly similar pattern, at the earliest recovery of peripheral lymphocytes, after chemotherapy-induced nadir of the leukocyte count. A concomitant sharp, transient rise in temperature accompanied the eruption of lymphocyte recovery. Skin biopsy specimens were obtained from 8 of these 10 patients and showed a superficial, perivascular mononuclear cell infiltrate. Immunohistochemical analysis of the cellular infiltrate was performed. The rash of lymphocyte recovery may be due to the actual return of immunocompetent lymphocytes to the peripheral circulation and skin after the chemotherapy-induced nadir of the leukocyte count. These observations suggest that macular and papular eruptions relate to specific immunologic events.