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The patient presented to our clinic from out of state in October 2018. Previously, in 2014, he underwent an elective left total hip arthroplasty with a ceramic-on-polyethylene prosthesis for osteoarthritis. The surgery and recovery were uneventful. In November 2014, hives developed on his upper arms. Within weeks, the hives spread to his trunk and thighs but spared his face, palms, and soles. The symmetric, nonpruritic, nonpainful rash was without angioedema. The hives initially persisted for 5 days, followed by resolution for several days.

Mucous membrane pemphigoid (MMP) is a rare chronic immunobullous disease that involves the mucous membranes and may result in significant scarring and complications if diagnosis is delayed. MMP typically occurs in elderly patients, with very few cases reported in children. Here, we present a 12-year-old female patient with childhood-onset oral and genital MMP, clinically suspected to be lichen sclerosus, but eventually diagnosed as MMP after multiple supportive biopsies and confirmatory direct immunofluorescence. Although treatment was challenging, the combined use of systemic corticosteroids, dapsone, and mycophenolate mofetil was ultimately successful in achieving disease control.

We report a case of a 13-year-old boy with extensive lymphomatoid papulosis (LyP) involving his elbows, forearms, proximal thighs, and right hip, with treatment-resistant nodules on his right forearm. He was treated with full-body narrowband ultraviolet B and targeted photodynamic therapy (PDT) with 20% aminolevulinic acid (ALA). After two months, there was complete resolution of the right forearm nodules. Due to its minimal toxicity, PDT offers unique advantages and may be considered for pediatric LyP patients with symptomatic, localized disease resistant to conventional treatments.

Eccrine angiomatous hamartoma (EAH) is a rare benign vascular hamartoma characterized histologically by an increased size and number of mature eccrine glands associated with multiple foci of dilated capillaries in the dermis and subcutis. EAH typically presents in children as discrete, solitary nodules, or plaques most commonly located on the extremities. Some cases of EAH have an agminated distribution involving classic locations, or present as solitary lesions in less common locations such as the face, scalp, or trunk. We report the case of congenital EAH in a child with atypical morphological features and pattern of distribution further expanding on the range of presentations classically described.

Despite well-defined clinical and histopathological features of melanoma, atypical presentations mimicking other skin disorders can result in a delayed diagnosis or misdiagnosis and subsequent inappropriate treatment. Rosai-Dorfman disease (RDD) is a rare histiocytic disorder with unique clinical and histopathological features. We report a case of melanoma treated with cryotherapy that mimicked RDD both clinically and histopathologically. We compare this RDD-like melanoma to classic RDD, outlining the importance of clinicopathological correlation prior to treatment, as well as the potential pitfalls in diagnosis after cryotherapy of pigmented lesions.

To examine, in a prospective fashion, the utilization and efficacy of adjuvant radiation therapy (RT) in patients with resected desmoplastic melanoma (DM). Adult patients with resected, margin‐negative, and nonmetastatic DM were eligible for this single‐arm prospective phase II study. Patients were to receive postoperative RT, 30 Gy in five fractions, to the operative bed with 2‐ to 3‐cm margins (depending on the tumor location). Nodal basin RT was not allowed. The primary study endpoint was the 2‐year local recurrence rate (LRR). Secondary endpoints included the incidence of regional and distant metastatic disease, progression‐free survival, overall survival (OS), and treatment‐related toxicity. Twenty patients with a single de novo DM lesion meeting trial eligibility criteria were enrolled and treated. The 2‐year LRR was 10%, with two patients demonstrating a LR within 2 years of completion of protocol therapy. No regional or distant failures occurred. OS at 2 and 5 years was 95 and 77%, respectively. There were no grade 3 or higher acute or late adverse events that were related to the protocol therapy. Adjuvant RT after wide local excision (WLE) for DM is efficacious and well tolerated. It should be considered for DM patients after margin‐negative WLE. Additional study is needed to further refine low‐risk patient populations that can potentially have adjuvant RT omitted as part of the treatment plan.

A 64-year-old woman with a history of alopecia and hypothyroidism was diagnosed with ovarian cancer. Following hysterectomy and bilateral oophorectomy with omentectomy, surgical pathology revealed poorly differentiated serous adenocarcinoma with pelvic and omental metastasis (FIGO Stage IIIC). Chemotherapy with paclitaxel and carboplatin was administered every three weeks for six cycles. Between her second and third treatments, the patient noticed swelling of her hands and feet with roughened skin over the fingers. Her finger pads also became increasingly sensitive to temperature and touch. Angioedema was considered, but symptoms were refractory to diuretic and steroid therapy. After six months of chemotherapy, skin tightness advanced over the face, neck, upper chest, upper extremities, and feet. The patient also described classic Raynaud’s phenomenon of the distal fingers, gastroesophageal reflux, and diffuse muscular weakness. Upon physical examination, the patient’s oral aperture was restricted to 4.5 cm (Fig. 1). Her head, neck, trunk, and extremities rated at 17/51 on the modified Rodnan skin score. Digital pitting was evident bilaterally, and nail fold microscopy showed dilated nail fold capillaries (Fig. 2). There were no areas of active ulceration or calcinosis and few telangiectasias. The patient’s physical evaluation was otherwise unremarkable. Complete blood count, renal, and serum electrolyte tests were within normal limits. The erythrocyte sedimentation rate was mildly elevated at 34 mm/h. Aminotransferases were elevated at 54 U/l and 58 U/l for alanine aminotransferase (8–40 U/l) and aspartate aminotransferase (8–40 U/l), respectively. The creatine kinase level was significantly high at 1523 l/l (38–176 l/l).

Discrete nodules developed on the leg of a 27-year-old immunosuppressed woman after an allogeneic stem cell transplant. Biopsy and culture grew Legionella pneumophila serogroup 8. On day 7 of azithromycin treatment, respiratory distress and abnormal liver transaminases developed, and the patient died on day 14. Review of the medical literature identified 19 reports of Legionella species-associated skin or soft tissue infections (total of 20 patients, 13 with confirmed infection). Manifestations of the 13 confirmed cases included erythematous macular rash (n = 7), erythema after thoracentesis (n = 1), abscess formation (n = 4), respiratory symptoms (n = 6), and abnormal chest radiographs (n = 8). Six required surgical exploration and débridement, and 7 were immunocompromised. Rash and respiratory infection improved with antibiotics in 10, but 3 died. Immunosuppression may predispose transplant recipients to Legionella infections. Diagnostic biopsies may facilitate appropriate treatment.

Prurigo pigmentosa (PP) is a rare inflammatory dermatosis of unknown cause characterized by a predominantly truncal eruption of pruritic erythematous papules in a reticular pattern, resolving with hyperpigmentation. PP is twice as common in girls and women, and the mean age at onset is 25 years. Diagnosis of PP is challenging and is aided by characteristic histopathologic findings. We report a case of PP in a 17-year-old white boy. The eruption arose during strict adherence to a ketogenic diet.

Background Virtual microscopy is increasingly being used in dermatopathology educational settings. Objective The objective is to evaluate diagnostic accuracy and attitudes between virtual microscopy and traditional glass slide microscopy among dermatology residents. Methods A 48-question dermatopathology examination was administered to 35 dermatology residents at three different dermatology residency training sites during the 2011–2012 academic year with half (n = 24) of the questions using the gold standard of glass slide microscopy and half (n = 24) using whole, scanned virtual slides. Correct number of questions using glass slides and virtual slides was evaluated. Participants were surveyed regarding previous experience with digital slide imaging; quality, ease of use, and speed of slide review; and overall microscopy preferences. Results Overall, diagnostic accuracy was better with glass slides than virtual slides (p = 0.01). However, no statistically significant difference was found in diagnostic accuracy of first-year trainees (p > 0.99) or trainees with exposure to virtual microscopy greater than two times per month (p = 0.27). There was no overall personal preference for glass slide vs. virtual microscopy. Limitations Different cases and questions were used for glass slides and virtual microscopy. Conclusions Diagnostic accuracy with virtual microscopy is dependent on year of residency training and prior experience with virtual microscopy.

A 66-year-old woman was referred for evaluation of a rash on the leg. She had a 1 -year history of stage IV bronchogenic adenocarcinoma with previous metastases to the right first metatarsal-phalangeal (MTP) joint and a left supraclavicular lymph node. She underwent six cycles of chemotherapy with paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ, USA) and carboplatin (Paraplatin; Bristol-Myers Squibb Company, Princeton, NJ, USA) as well as palliative radiation therapy to the metastasis sites. One month after completing radiation therapy, the patient developed a nonpainful rash on the right thigh. This eruption was treated as a herpes zoster infection by her internist with 3 weeks of valcyclovir (Valtrex; Catalytica Pharmaceuticals, Greenville, NC, USA), but without improvement. One month later the leg became painful and swollen and the rash spread up the thigh to involve the groin and vulva. The patient was referred to the dermatology department. Physical examination revealed multiple red, indurated, crusted papules and nodules involving the medial, anterior, and lateral right thigh, labia majora, and suprapubic area. The lesions were grouped and arranged in a dermatomal zosteriform distribution (Fig. 1). There was a visible peau d'orange appearance of the right leg with pitting edema. A punch biopsy showed irregular islands of atypical glandular epithelial cells infiltrating the superficial and deep dermis, consistent with metastatic adenocarcinoma (Fig. 2a). Immunohistochemistry showed positive staining to thyroid transcription factor (TTF) and cytokeratin 7 (Fig. 2b and c). The tissue did not stain with progesterone receptor, estrogen receptor, or gross cystic disease fluid protein (BRST-2). This immunostaining pattern was identical to previous biopsies of the right first MTP joint and left supraclavicular lymph node metastases and is consistent with adenocarcinoma of the lung.