Self-healing papular mucinosis in an adult

Papular mucinosis is a rare, idiopathic cutaneous mucinosis that is typically chronic and progressively severe. We present a case of a 59-year-old woman with a 6-month history of a dramatic papular eruption on her face and neck, with no associated internal organ involvement. A biopsy specimen demonstrated increased dermal mucin with associated plump fibroblasts, consistent with a diagnosis of papular mucinosis. Multiple therapeutic interventions were unsuccessful, and after 2 years the lesions resolved spontaneously without treatment. During the following 3 years, the patient has had no recurrence of disease.

Tea Tree Oil: Cutaneous Effects of the Extracted Oil of Melaleuca alternifolia

The use of botanical extracts for their perceived therapeutic benefits has gained increased popularity in this country and abroad. In particular, tea tree oil (the extracted oil of Melaleuca alternifolia) has gained widespread use for its purported antimicrobial and therapeutic effects. In parallel with this increased use is an expanding series of reported adverse effects, including allergic contact dermatitis, systemic contact dermatitis, linear immunoglobulin A disease, erythema multiforme-like id reactions, and systemic hypersensitivity reactions. We present a review of tea tree oil with regard to its history, chemistry, purported medicinal uses, and possible adverse cutaneous effects.

Birt-Hogg-Dubé syndrome: two patients with neural tissue tumors

We present 2 unrelated patients found to have tumors of neural tissue origin, a neurothekeoma and a meningioma, who were additionally diagnosed with the syndrome of Birt-Hogg-Dubé (BHDS). We are unaware of previous BHDS patients with neural tissue tumors. In light of recent linkage analysis studies delineating the genetic susceptibility locus for BHDS, we speculate about a possible association between BHDS and neural tissue tumors.

Birt-Hogg-Dubé syndrome: A review of the literature and the differential diagnosis of firm facial papules

Birt-Hogg-Dubé syndrome (BHDS) was originally described in 1977 as the grouping of 3 skin tumors-the fibrofolliculoma, trichodiscoma, and acrochordon-in family members with an autosomal dominant inheritance pattern. In recent years it has become clear that these 3 lesions likely represent only 1 of these tumors, the fibrofolliculoma. More important, evidence now supports a definite susceptibility to malignant renal tumors and pulmonary disease in patients with BHDS. Clinical recognition of this entity is possible in spite of the fact that several syndromes exist that are characterized by the presence of multiple firm facial papules. We will discuss the evolution of BHDS from the original description to the recent discovery of the genetic susceptibility locus, illustrate the clinical differential diagnosis, and highlight the workup needed for newly diagnosed patients and their family members.

Evaluation of the histologic characteristics of patch test confirmed allergic contact dermatitis

BACKGROUND

Microscopic features of experimentally induced allergic contact dermatitis (ACD) have been reported; however, the histologic characteristics of environmentally induced ACD have not been definitively elucidated.

OBJECTIVE

This pilot study was conducted to describe the histologic features most useful in differentiating ACD from other forms of eczematous dermatitis.

METHODS

A retrospective chart review of patients who underwent evaluation for contact dermatitis was performed. The results of skin biopsy were reviewed in a blinded manner, and two subgroups were compared: gold standard ACD cases and control cases (eczematous dermatitis with negative results of patch testing).

RESULTS

Of 317 cases reviewed, 39 fulfilled the inclusion criteria. Many histologic similarities were noted: both subgroups had substantial acanthosis and lymphocytic infiltration. In addition, present to a moderate degree in both groups were hyperkeratosis, spongiosis, eosinophils, and dermal dendritic fibrohistiocytic (DFH) cells. However, compared with the control cases, eosinophilic spongiosis and multinucleate dermal DFH cells were found to a considerably greater degree in the standard ACD cases.

CONCLUSIONS

Eosinophilic spongiosis and multinucleate dermal DFH cells, in the presence of acanthosis, lymphocytic infiltrate, dermal eosinophils, and hyperkeratosis, are particularly suggestive of ACD. While such findings alone are not diagnostic of ACD, the presence of these combined histologic features supports the pursuit of patch testing in cases of chronic eczematous dermatitis.

Papular dermatitis and a persistent patch test reaction to gold sodium thiosulfate

The role of gold in allergic contact dermatitis is poorly understood and is a subject of increasing interest. Recent studies demonstrate that gold-positive patch testing is not uncommon, but persistent patch test reactions are rarely reported. We present a case of a 53-year-old woman with a 7-year history of a scattered, pruritic papular dermatitis. Patch testing demonstrated a persistent, positive reaction to gold sodium thiosulfate. The histopathology of the patch test site and that of the cutaneous eruption were similar in nature but differing in severity. No other allergens have been identified, but gold avoidance has not yet resulted in the clearing of her eruption. This case underscores the difficulty in making a clinical correlation despite suggestive clinical pathologic evidence.

Familial basaloid follicular hamartoma: lesional characterization and review of the literature

Basaloid follicular hamartoma (BFH) is a rare cutaneous lesion associated with the acquisition of small papules that remain stable for many years. Basaloid follicular hamartoma lesions can present sporadically or as part of an inherited syndrome. Occasionally, biopsies of BFH lesions are interpreted as basal cell carcinoma (BCC), which necessitates complete removal of the lesion. In this report, we characterize a case of a familial BFH syndrome and discuss the clinical, histologic, and molecular features of BFH lesions that help to distinguish it from BCC. The BFH lesions in our patients remained stable for many years. Histologically, BFH lesions exhibit fewer mitoses and decreased single cell necrosis when compared with BCC. Immunohistochemical staining for the proliferation markers proliferating cell nuclear antigen and Ki-67 demonstrated less staining in BFH than in BCC. In addition, levels of PTCH (patched) mRNA were increased relative to unremarkable epidermis in familial BFH lesions but to a lesser degree and in a different pattern than that seen in BCC. In summary, familial BFH can be distinguished from BCC based on clinical, histologic, and molecular features and is associated with deregulation of the PTCH pathway. Basaloid follicular hamartoma may represent an indolent lesion within the spectrum of basaloid epithelial neoplasms associated with deregulation of the PTCH signaling pathway. We discuss this case in parallel with a growing body of literature that supports the nosologic designation of BFH.

Topical nitrogen mustard ointment with occlusion for Langerhans' cell histiocytosis of the scalp

BACKGROUND

Topical nitrogen mustard solution has been used as an effective alternative to corticosteroids for the treatment of cutaneous eruptions of Langerhans' cell histiocytosis (LCH). When used as an ointment under occlusion, nitrogen mustard may still be effective and possess less risk of unwanted side effects.

METHODS

A patient with scalp LCH was treated topically with nitrogen mustard ointment 0.01% under occlusion.

RESULTS

The lesions cleared in 3 weeks without irritation.

CONCLUSION

Topical nitrogen mustard ointment 0.01% under occlusion is a well-tolerated, non-irritating treatment for scalp LCH.

Angiokeratoma of Fordyce as a cause of red scrotum

Two men presented with asymptomatic diffuse redness of the scrotum. Examination showed angiokeratoma of Fordyce (AF), an associated finding. In our practice, AF and diffuse scrotal redness co-occur in 50% of patients. Providing reassurance to the patient is appropriate if this clinical link is detected.

Imported skin diseases in dermatology

Millions of afflicted people suffer from conditions which Japanese dermatologists may rarely encounter. Many of our patients travel extensively either as part of work-related business trips or during vacationing. From three to ten percent of travelers experience skin, hair or nail disorders. With worldwide travel heightening exposure to the causative agents, there is an increasing likelihood that a patient with leishmaniasis, Boutonneuse fever, onchocerciasis, loaiasis, dengue fever, cutaneous larva migrans or other recently acquired skin conditions from a far away land will visit your office for diagnosis and treatment. The clinical characteristics, diagnostic tests and therapeutic options for such imported tropical diseases will be discussed.

Great cases from the University of Pennsylvania

New skin diseases are reported yearly. Some well-known conditions may develop unusual manifestations. Other cutaneous findings are simply rare. While patients with such diseases represent only a small fraction of our practice they are an important subset of our experience. Many of these diseases are treatable, pinpoint the discovery of internal disease, or simply allow for a diagnosis and prognosis to be given to a concerned patient who had previously escaped classification. Such cases expand our knowledge and provide excitement to our day. Several patients from whom I have learned the most in the last few years are detailed for your enjoyment.

Newer skin signs of systemic disease

The skin is a well-known reflection of internal disease states. It provides the astute clinician with clues that lead to the diagnosis of systemic illness. While skin disease is rarely life-threatening, serious morbidity and mortality may be avoided by early recognition of subtle cutaneous signs signaling internal problems. The recent literature was reviewed to glean new findings that either added new associations to older syndromes or described completely new diseases. While entire books are written regarding the "Skin Signs of Internal Disease", this article focuses only on the newest of such findings.

Contact dermatitis due to printer's ink in a milk industry employee: case report and review of the allergen paraphenylenediamine

Paraphenylenediamine is a common cause of occupational dermatoses in hairdressers, metallurgy workers, and others. Hand dermatitis developed in an employee of a milk packaging facility. The employee's hands were exposed to milk cartons embossed with wet printer's ink on a daily basis for 2 years. The worker was evaluated through a history, physical examination, and patch testing with 50 standard allergens. Patch testing revealed a positive reaction to paraphenylenediamine. The hand dermatitis resolved once the patient instituted protective measures. The worker's reaction might represent a delayed-type hypersensitivity reaction to printer's ink that contained this agent. More likely, the inciting agent was some other ingredient of the printer's ink that cross-reacts with paraphenylenediamine.

Aquagenic palmoplantar keratoderma

Aquagenic palmoplantar keratoderma is an acquired condition characterized by burning and edema limited to the hands after brief immersion in water. The 3 patients described possess a striking similarity to those with transient reactive papulotranslucent acrokeratoderma. All 3 patients manifested the "hand-in-the-bucket" sign, having presented to a physician with a hand immersed in a bucket of water to more promptly demonstrate the physical findings. Aluminum chloride hexahydrate represents a potentially valuable therapeutic option for this unusual condition.

Neutrophilic dermatosis of the dorsal hands: pustular vasculitis revisited

An entity termed "pustular vasculitis of the hands" was recently described. Patients with this condition presented with low-grade fevers and erythematous plaques, pustules, and bullae limited to the dorsal hands and fingers, which were characterized histologically by a dense neutrophilic infiltrate and leukocytoclastic vasculitis. We describe patients with a similar clinical presentation, but who lacked vasculitis on biopsy findings. We describe 3 otherwise asymptomatic patients with hemorrhagic bullae, plaques, and pustules solely on the dorsal hands. Biopsy specimens showed a neutrophilic infiltrate and leukocytoclasis, but no necrotizing vasculitis, and were reminiscent of Sweet's neutrophilic dermatoses. In our patients, corticosteroids or dapsone led to clearing of the lesions, and small maintenance doses of dapsone prevented their recurrence. Our 3 patients had clinical lesions similar to those termed pustular vasculitis of the hands, but which lacked leukocytoclastic vasculitis on biopsy findings. Because of histologic findings and a therapeutic response more characteristic of Sweet's syndrome, we propose the term neutrophilic dermatosis of the dorsal hands. In addition, low-dose dapsone is proposed as a possible first-line therapy in this condition, especially in those with recurrent disease.

Cutaneous microenvironment of human immunodeficiency virus (HIV)-seropositive and HIV-seronegative individuals, with special reference to Staphylococcus aureus colonization

A cross-sectional quantitative study of cutaneous bacterial and yeast flora at seven body sites in 99 human immunodeficiency virus-seropositive and 50 seronegative military personnel was performed. Statistically significant differences in carriage rates were only observed for Staphylococcus aureus on the foreheads of seropositive individuals. Seronegative individuals demonstrated staphylococcal carriage rates 1.3 to 2 times as great as those of historical controls (defined as healthy individuals not receiving any medications) at five of six body sites. We conclude that seropositive military personnel do not exhibit statistically significant elevations in densities and carriage rates of the microorganisms examined (except Staphylococcus aureus), relative to seronegative individuals. Seropositive individuals may be predisposed to staphylococcal carriage. The elevated staphylococcal carriage rates of military personnel undergoing basic training warrants a formal evaluation of the impact of training exercises on cutaneous flora. The information gained may serve to limit the spread of infection during training exercises and battlefield conditions.

The flow of forage particles and solutes through segments of the digestive tracts of cattle

An experiment was conducted to investigate the compartmental mean residence time, (CMRT) of feed residues in segments of gastrointestinal digesta of mature Holstein steers. The objective was to evaluate assumptions that feed residues flow through ruminal digesta as sequential mixing pools having age-dependent (GN) and age-independent (G1) distributed residence times respectively (GN-->G1 flow). The basal diet was a semi-tropical hay containing 98 g crude protein and 503 g apparently digestible DM per kg DM. The hay was consumed and feed residues of different size and/or previous digestion from the hay were inserted into the reticulo-rumen (rumen) and abomasum. Marker profiles appearing at the duodenum and faeces were fitted to various compartment models to estimate CMRT. Post-abomasal CMRT did not differ among solutes or feed residues of different size and previous digestion and constituted only 5.8% of the CMRT for the entire gastrointestinal tract. Markers initially applied to orally or ruminally dosed feed residues exhibited profiles in duodenal digesta and faeces conforming to GN-->G1 flow. Previously undigested, masticated feed residues inserted into the dorsal rumen digesta had longer ruminal CMRT in the GN pool but not the G1 pool than did similarly inserted faecal small particles or normally ingested hay. These results support model assumptions of GN-->G1 flow within rumen digesta. The results support mechanisms proposed for the GN pool as the 'lag-rumination pool' and the G1 pool as the 'mass action turnover pool'. If further validated, rumen CMRT in cattle could be estimated from marker profiles in more easily obtained faeces to estimate ruminal CMRT required for feed evaluation systems.