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Resumen El tratamiento de eleccion del melanoma primario localizado es la biopsia escisional seguida de una ampliacion de margenes en funcion del Indice de Breslow (IB). Las biopsias parciales pueden ser adecuadas en el estudio inicial de melanomas extensos o en localizaciones complejas. Los margenes recomendados para el melanoma in situ son de 0,5-1 cm, aunque parece ser que especialmente en los de tipo lentiginoso, son mas adecuados cuanto mas cercanos al centimetro. En cuanto a los melanomas invasivos, se recomiendan margenes de 1 cm en IB 2 mm. La exeresis en un solo tiempo se puede plantear cuando se desestime la biopsia selectiva de ganglio centinela, pero actualmente no es una actitud avalada por las guias. En aquellos casos en que se debe maximizar la precision de la exeresis completa de la lesion, fundamentalmente en el lentigo maligno facial, son recomendables las tecnicas de control de margenes. Por su parte, los melanomas acrales, tanto subungueales como palmares o plantares, requieren un tratamiento especial dada la complejidad anatomica del lugar donde se encuentran.

Resumen: Antecedentes y objetivo: El prurigo nodular (PN) es una dermatosis inflamatoria crónica caracterizada por la presencia de lesiones nodulares, intensamente pruriginosas, con gran impacto en la calidad de vida. El intenso prurito y el rascado son rasgos constantes en esta enfermedad, que se ha descrito en el contexto de diversos procesos dermatológicos —fundamentalmente dermatitis atópica—, metabólicos, neurológicos o psiquiátricos, aunque la fisiopatogenia es en buena parte desconocida. La fototerapia, en diversas de sus variantes, se ha propuesto como una opción terapéutica adecuada en el control clínico y sintomático, con un buen perfil de seguridad. En el presente estudio describimos nuestra experiencia con el uso de fototerapia en el tratamiento del PN. Material y método: Estudio observacional retrospectivo en el que se incluyeron pacientes que habían recibido su primer ciclo de fototerapia entre marzo de 2011 y octubre de 2019 para el tratamiento de su PN. Se recogieron las siguientes variables: características epidemiológicas y clínicas de los pacientes, tratamientos concomitantes, tipo de fototerapia, duración y dosis alcanzadas, y respuesta obtenida. Resultados: Incluimos un total de 44 pacientes (30 mujeres y 14 hombres, con mediana de edad de 65,5 años). La variante de fototerapia más empleada fue UVBBE (34 ciclos, 77,27%), seguida de la combinación de UVB + UVA (8 ciclos). La respuesta se consideró satisfactoria (respuestas ≥ 75%) en 24 pacientes (55,4%). Conclusiones: La fototerapia es una opción terapéutica adecuada en un porcentaje considerable de pacientes con PN; puede emplearse en monoterapia o combinada con diversos tratamientos. Abstract: Background and objective: Prurigo nodularis is a chronic inflammatory skin disease characterized by highly pruritic nodular lesions that cause constant itching and scratching and significant quality-of-life impairment. It has been described in a range of conditions, including skin diseases (mainly atopic dermatitis) and metabolic, neurological, and psychiatric disorders. The pathophysiological mechanisms are largely unknown. Various modalities of phototherapy have been described as appropriate and safe treatments for achieving clinical control and alleviating symptoms. In this article, we describe our experience with phototherapy in patients with prurigo nodularis. Material and methods: Retrospective observational study of patients who received their first cycle of phototherapy to treat prurigo nodularis between March 2011 and October 2019. Information was collected on epidemiological and clinical characteristics, concomitant treatments, type and duration of phototherapy, maximum dose reached, and response to treatment. Results: We studied 44 patients (30 women and 14 men) with a median age of 65.5 years. The most common form of phototherapy used was narrowband UV-B phototherapy (34 cycles, 77.27%) followed by a combination of UV-B and UV-A phototherapy (8 cycles). Response to treatment was considered satisfactory (clearance rate of ≥ 75%) in 24 patients (55.4%). Conclusions: Phototherapy is a suitable treatment for prurigo nodularis in a considerable proportion of patients. It can be used as monotherapy or combined with other treatments.

Altres ajuts: acords transformatius de la UAB Linear Cowden nevus, also known as linear PTEN nevus, is a type of epidermal nevus, first described in 2007, which is seen in patients with PTEN hamartoma tumor syndrome. It is considered to be a type 2 form of segmental mosaicism, and we suggest that it has certain clinical features that distinguish it from epidermal nevi seen in similar conditions, such as Proteus syndrome. We present a case of linear Cowden nevus in a 4-year-old boy and review the literature.

To the Editor: Perineural invasion (PNI) is rare and usually incidental in cutaneous squamous cell carcinoma (SCC), with an incidence of 2.5% to 14%.1 Incidental PNI is associated with poor prognosis in cutaneous SCC,2 and some evidence suggests its outcome differs, depending on the PNI pattern. We evaluated patterns of incidental PNI, using a multicenter retrospective cohort of 140 cutaneous SCCs with incidental PNI to determine the influence of nerve involvement on cutaneous SCC prognosis., Dr Canueto is partially supported ~ by grants PI18/000587 (Instituto de Salud Carlos III, cofinanced by Fondo Europeo de Desarrollo Regional) and GRS 1835/A/18 (Gerencia Regional de Salud de Castilla y Leon).

Tejera-Vaquerizo, A (Tejera-Vaquerizo, Antonio); Paradela, S (Paradela, Sabela); Toll, A (Toll, Agusti); Santos-Juanes, J (Santos-Juanes, Jorge); Jaka, A (Jaka, Ane); Lopez, A (Lopez, Alba); Canueto, J (Canueto, Javier); Bernal, A (Bernal, Alvaro); Villegas-Romero, I (Villegas-Romero, Isabel); Fernandez-Pulido, C (Fernandez-Pulido, Carla); Perandones, H (Perandones, Hector); Moreno-Ramirez, D (Moreno-Ramirez, David); Dominguez-Mahamud, C (Dominguez-Mahamud, Carolina); Salido-Vallejo, R (Salido-Vallejo, Rafael); Sanmartin, O (Sanmartin, Onofre); Almazan-Fernandez, FM (Almazan-Fernandez, Francisco M.); Rodriguez-Jimenez, P (Rodriguez-Jimenez, Pedro); Banuls, J (Banuls, Jose); Podlipnik, S (Podlipnik, Sebastian); Sandoval-Clavijo, A (Sandoval-Clavijo, Alejandra); Boada, A (Boada, Aram); Garcia-Bracamonte, B (Garcia-Bracamonte, Beatriz); Palencia, S (Palencia, Sara); Revilla-Nevreda, D (Revilla-Nevreda, David); Reola-Ramirez, E (Reola-Ramirez, Enara); Gomez-Mateo, MD (del Carmen Gomez-Mateo, Maria); Linares-Barrios, M (Linares-Barrios, Mario); Jimenez-Gallo, D (Jimenez-Gallo, David); Gonzalez-Cruz, C (Gonzalez-Cruz, Carlos); Samaniego, E (Samaniego, Elia); Navedo-De Las Heras, M (Navedo-De Las Heras, Maria); Taberner, R (Taberner, Rosa); Rodenas-Herranz, T (Rodenas-Herranz, Teresa); Garcia-Donoso, C (Garcia-Donoso, Carmen); Puig, S (Puig, Susana); Nagore, E (Nagore, Eduardo)

Graphical abstract, Background and objectives Spain is in a situation of indefinite lockdown due to the ongoing coronavirus disease 2019 (COVID-19) pandemic. One of the consequences of this lockdown is delays in medical and surgical procedures for common diseases. The aim of this study was to model the impact on survival of tumor growth caused by such delays in patients with squamous cell carcinoma (SCC) and melanoma. Material and methods Multicenter, retrospective, observational cohort study. We constructed an exponential growth model for both SCC and melanoma to estimate tumor growth between patient-reported onset and surgical excision at different time points. Results Data from 200 patients with SCC of the head and neck and 1000 patients with cutaneous melanoma were included. An exponential growth curve was calculated for each tumor type and we estimated tumor size after 1, 2, and 3 months of potential surgical delay. The proportion of patients with T3 SCC (diameter > 4 cm or thickness > 6 mm) increased from 41.5% (83 patients) in the initial study group to an estimated 58.5%, 70.5%, and 72% after 1, 2, and 3 months of delay. Disease-specific survival at 2, 5, and 10 years in patients whose surgery was delayed by 3 months decreased by 6.2%, 8.2%, and 5.2%, respectively. The proportion of patients with ultrathick melanoma (> 6 mm) increased from 6.9% in the initial study group to 21.9%, 30.2%, and 30.2% at 1, 2, and 3 months. Five- and 10-year disease-specific survival both decreased by 14.4% in patients treated after a potential delay of 3 months. Conclusions In the absence of adequate diagnosis and treatment of SCC and melanoma in the current lockdown situation in Spain, we can expect to see to a considerable increase in large and thick SCCs and melanomas. Efforts must be taken to encourage self-examination and facilitate access to dermatologists in order to prevent further delays.

Background: The 8th edition of the AJCC manual for melanoma includes many changes leading to major substage migrations, which could lead to important clinical reassessments. Objectives: To evaluate the differences and prognostic value of the 8th AJCC classification in comparison with the the 7th edition. Methods: Clinical and histopathological data were retrieved from five melanoma referral centers including 7815 melanoma patients diagnosed between January 1998 and December 2018. All patients were reclassified and compared using the 7th and 8th classifications of the AJCC. Sankey plots were used to evaluate the migration of patients between the different versions. The primary outcome was overall survival (OS), and curves based on the Kaplan-Meier method were used to investigate survival differences between the 7th and 8th editions. Results: The number of patients classified as stages IB, IIIA, and IIIB decreased while the patients classified as stages IA and IIIC increased notably. Migration analysis showed that many patients in group I were understaged whereas a significant percentage of patients in group III were upstaged. Indirect OS analysis showed a loss in the linearity in the AJCC 8th edition and the groups tended to overlap. Direct OS analysis between groups and versions of the AJCC showed a better prognosis within the new stage III patients, with no effect on those in stages I and II. Conclusion: The 8th AJCC edition represents an important change in the classification of patients. We observe that the main migratory changes occur in stage I and III, that severity linearity is lost and groups overlap, and that a more advanced stage does not mean a worse prognosis. (C) 2020 Elsevier Ltd. All rights reserved.

Resumen El carcinoma epidermoide cutaneo (CEC) es el segundo tumor mas frecuente en humanos y tiene una incidencia creciente. Aunque la cirugia representa el tratamiento de eleccion del CEC, la radioterapia adyuvante postoperatoria tiene un papel relevante en el control local y locorregional de la enfermedad. En esta revision analizamos la utilidad de la radioterapia postoperatoria en el manejo del CEC de alto riesgo (especialmente con infiltracion perineural), en el control del CEC con margenes positivos tras la cirugia y en el CEC localmente avanzado (con metastasis parotideas o ganglionares).

The therapeutic value of sentinel lymph node biopsy (SLNB) in thin melanoma remains controversial. The aim of this study is to determine the role of SLNB in the survival of thin melanomas (≤1 mm). A multicenter retrospective observational study was designed. A propensity score matching was performed to compare patients who underwent SLNB vs. observation. A multivariate Cox regression was used. A total of 1438 patients were matched by propensity score. There were no significant differences in melanoma-specific survival (MSS) between the SLNB and observation groups. Predictors of MSS in the multivariate model were age, tumor thickness, ulceration, and interferon treatment. Results were similar for disease-free survival and overall survival. The 5- and 10-year MSS rates for SLN-negative and -positive patients were 98.5% vs. 77.3% (p < 0.001) and 97.3% vs. 68.7% (p < 0.001), respectively. SLNB does not improve MSS in patients with thin melanoma. It also had no impact on DSF or OS. However, a considerable difference in MSS, DFS, and OS between SLN-positive and -negative patients exists, confirming its value as a prognostic procedure and therefore we recommend discussing the option of SLNB with patients.

Introduction: Sentinel lymph node (SLN) biopsy is useful for the prognostic stratification of patients with thick melanoma. Identifying which variables are associated with SLN involvement and establishing risk in different subgroups of patients could be useful for guiding the indication of SLN biopsy. The value of complete lymph node dissection (CLND) in patients with a positive SLN biopsy is currently under debate. Materials and methods: To identify factors associated with SLN involvement in thick melanoma we performed a multicentric retrospective cohort study involving 660 patients with thick melanoma who had undergone SLN biopsy. To analyze the role of CLND in thick melanoma patients with a positive SLN biopsy, we built a multivariate Cox proportional hazards model for melanoma-specific survival (MSS) and disease-free survival (DFS) and compared 217 patients who had undergone CLND with 44 who had not. Results: The logistic regression analysis showed that age, histologic subtype, ulceration, microscopic satellitosis, and lymphovascular invasion were associated with nodal disease. The CHAID (Chi-squared Automatic Interaction Detection) decision tree showed ulceration to be the most important predictor of lymphatic involvement. For nonulcerated melanomas, the histologic subtype lentigo maligna melanoma was associated with a low rate of SLN involvement (4.3%). No significant differences were observed for DFS and MSS between the CLND performed and not-performed groups. Nodal status on CLND was associated with differences in DFS and MSS rates. Conclusion: We identified subgroups of thick melanoma patients with a low likelihood of SLN involvement. CLND does not offer survival benefit, but provides prognostic information. (C) 2019 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

The circulating transcriptome is a valuable source of cancer biomarkers, which, with the exception of microRNAs (miRNAs), remains relatively unexplored. To elucidate which RNAs are present in plasma from melanoma patients and which could be used to distinguish cancer patients from healthy individuals, we used next generation sequencing (NGS), and validation was carried out by qPCR and/or ddPCR. We identified 442 different microRNAs in samples, eleven of which were differentially expressed (p &lt, 0.05). Levels of miR-134-5p and miR-320a-3p were significantly down-regulated (p &lt, 0.001) in melanoma samples (n = 96) compared to healthy controls (n = 28). Differentially expressed protein-encoding mRNA 5&prime, fragments were enriched for the angiopoietin, p21-activated kinase (PAK), and EIF2 pathways. Levels of ATM1, AMFR, SOS1, and CD109 gene fragments were up-regulated (p &lt, 0.001) in melanoma samples (n = 144) compared to healthy controls (n = 41) (AUC = 0.825). Over 40% of mapped reads were YRNAs, a class of non-coding RNAs that to date has been little explored. Expression levels of RNY3P1, RNY4P1, and RNY4P25 were significantly higher in patients with stage 0 disease than either healthy controls or more advanced stage disease (p &lt, 0.001). In conclusion, we have identified a number of novel RNA biomarkers, which, most importantly, we validated in multi-center retrospective and prospective cohorts, suggesting potential diagnostic use of these RNA species.

Background Perineural invasion (PNI) is a feature of poor prognosis in cutaneous squamous cell carcinoma (CSCC). The benefit of postoperative radiotherapy (PORT) in the management of CSCC with PNI is still not well established. Objectives We aimed to evaluate the usefulness of PORT in the treatment of CSCC with PNI so as to determine which patients would best benefit from this type of treatment. Methods A retrospective multicenter cohort of 110 CSCCs with PNI was evaluated. Eighteen recurrent cases were excluded for subsequent analysis. We searched for the types of PNI associated with poor outcome and analysed the effectiveness of PORT on different groups of CSCC with PNI. We also assessed for the usefulness of PORT depending on the surgical margin status (either clear or positive). Results Postoperative radiotherapy showed clear benefit over observation in CSCC with PNI and positive margins after surgery, where the management by observation increased the risk of poor outcome events 2.43 times (P = 0.025), and especially in those with positive margins and PNI >= 0.1 mm, where the risk of poor prognosis is eight times greater following a management by observation (P = 0.0065). Multivariate competing risk analysis preserved statistical significance. Conclusions The use of PORT on patients with CSCC with PNI and positive margins after surgery, especially in PNI >= 0.1 mm, significantly improves long-term outcome. The benefit of PORT in cases with clear margins is not as evident, especially in those with PNI of small-calibre nerves. Clinical trials are imperative.

Resumen Introduccion y objetivos Cetuximab y panitumumab son anticuerpos anti-factor de crecimiento epidermico (anti-EGFR) usados para el cancer colorrectal metastasico. La mayoria de los pacientes desarrollan una erupcion papulopustulosa que podria predecir la respuesta tumoral. Ademas, producen otros efectos adversos cutaneos, por lo que hemos estudiado si estos tambien podrian ser predictores clinicos de respuesta. Asi mismo, hemos realizado una revision del tratamiento de la erupcion papulopustulosa, ya que no existen directrices basadas en la evidencia. Material y metodos Estudio retrospectivo de 116 pacientes. Se incluyeron pacientes afectos de cancer colorrectal metastasico en tratamiento con los anticuerpos anti-EGFR, cetuximab o panitumumab, en el Hospital Universitario Donostia. Resultados El 81,9% de los pacientes desarrollo la erupcion papulopustulosa, siendo el riesgo mayor y de mayor intensidad cuantos mas ciclos de anti-EGFR se administraban (p = 0,03). Todos los pacientes que obtuvieron una respuesta tumoral completa desarrollaron la erupcion. Cuanto peor era la respuesta tumoral, menor era la frecuencia de la erupcion (p = 0,03). Tambien se encontro una asociacion entre la xerosis y la respuesta tumoral (el 53,4% de los que obtuvieron respuesta tumoral desarrollaron xerosis, p = 0,002). El manejo de la erupcion papulopustulosa se llevo a cabo mediante un algoritmo desarrollado por nuestro servicio. Conclusiones En la practica clinica la erupcion papulopustulosa grave y la xerosis pueden ser predictores clinicos de buena respuesta al tratamiento anti-EGFR. Los pacientes con esta erupcion deben tratarse precozmente, ya que el tratamiento suboptimo de estos efectos secundarios puede conllevar un retraso en la dosis o su interrupcion.

Background and objectives Cetuximab and panitumumab are monoclonal antibodies that target the epidermal growth factor receptor (EGFR) in the treatment of metastatic colorectal cancer. Most patients develop a papulopustular rash, which may predict tumor response. We studied whether the other adverse cutaneous effects associated with these monoclonal antibodies are also clinical predictors of response. We also reviewed publications describing approaches to treating the papulopustular rash since no evidence-based guidelines have yet been published. Material and methods We performed a retrospective study of 116 patients with metastatic colorectal cancer receiving anti-EGRF therapy with cetuximab or panitumumab at Hospital Universitario Donostia. Results In total, 81.9% of the patients developed a papulopustular rash. Patients who received the most cycles of treatment with the EGFR inhibitor were at the highest risk of developing the rash, and these patients also had the most severe rash reactions (P = .03). All of the patients who exhibited a complete tumor response had the rash, and the incidence of rash was lower in patients with poor tumor response (P = .03). We also observed an association between tumor response and xerosis (53.4% of the patients who developed xerosis also exhibited tumor response, P = .002). The papulopustular rash was managed according to an algorithm developed by our department. Conclusions Severe papulopustular rash and xerosis may be clinical predictors of good response to anti-EGFR therapy. Patients who develop a papulopustular rash should be treated promptly because suboptimal treatment of this and other adverse effects can lead to delays in taking the prescribed anti-EGFR dose or to interruption of therapy.

Dermal neurofibromas are characteristic of neurofibromatosis type one (NF1), and their developmental origin still unsolved. Although NF1 loss is required for neurofibroma initiation, some features of these benign tumors resemble a skin injury state and cutaneous trauma or other insults might support tumor development. Since adult terminal Schwann cells ensheathing nerve endings are able to dedifferentiate into a progenitor-like state in response to nerve crushing, we hypothesized that dedifferentiation of NF1-/- Schwann cells could be at the origin of human dermal neurofibromas. In support of this, here we show that CDH19 (a marker specific of Schwann cell precursors) and Schwann cell dedifferentiation marker SOX2 are significantly upregulated in NF1 tumors. We posit that onset of nerve regeneration might have a role in dermal neurofibroma initiation via dedifferentiation of NF1-/- Schwann cells.

Cutaneous squamous cell carcinoma (cSCC) is the second most common cancer in humans and its incidence is rising. Although surgery is the treatment of choice for cSCC, postoperative adjuvant radiotherapy has an important role in local and locorregional disease control. In this review, we analyze the value of postoperative radiotherapy in the management of high-risk cSCC (in particular, cases with perineural invasion), cSCC with positive surgical margins, and locally advanced cSCC (with parotid gland and/or lymph node metastasis).

Background Cutaneous squamous cell carcinoma (cSCC) is the second most common malignancy in humans and approximately 5% metastasize, usually to regional lymph nodes. Epithelial to mesenchymal transition (EMT) is a process involving loss of intercellular adhesion, acquisition of a mesenchymal phenotype and enhanced migratory potential; epithelial markers, such as E-cadherin, are down-regulated and mesenchymal proteins (Vimentin), increased. Objective To investigate the expression of EMT markers in metastatic SCC (MSCC) and their corresponding metastases, and to correlate them with clinico-pathological factors associated with an increased risk of metastasis. Methods We performed a retrospective study that included 146 cSCC samples (51 primary non-metastatic, 56 primary metastatic, 39 lymphatic metastases). Immunohistochemistry for E-cadherin, Vimentin, Snail, beta-catenin, Twist, Zeb1 and Podoplanin was performed. Results Loss of membranous E-cadherin was observed in 77% cSCCs, with no differences between MSCC and non-MSCC. Among the transcriptional factors controlling EMT, no significant Snail1 expression was detected. Twist, Zeb1, Vimentin, beta-catenin and Podoplanin were significantly overexpressed in MSCCs. Twist ectopic expression in SCC13 cells induced Zeb1, Vimentin and Podoplanin expression and E-cadherin delocalization. These changes resulted in a scattered migration pattern in vitro. Expression of EMT markers was decreased in the metastases when compared with the corresponding primary tumors. Conclusion These results suggest that a partial EMT, characterized by the expression of Twist but without a total E-cadherin depletion, is involved in the acquisition of invasive traits by cSCC, but the process is downregulated in lymph node metastases.

Cetuximab and panitumumab are epidermal growth factor receptor (EGFR) inhibitors used in metastatic colorectal cancer (mCRC). Most patients develop a papulopustular rash that may predict tumor response to treatment. EGFR gene polymorphisms may also determine tumor response and appearance of skin rash. We hypothesized an association between EGFR gene polymorphisms, papulopustular rash and response to anticancer treatment. Four EGFR polymorphisms (-216, -191, CA-SSR, R521K) were analysed in 51 patients with mCRC receiving anti-EGFR. Severity of cutaneous rash and tumor response was measured following standard scales. We report an association between SNP-216 and tumor response (P = 0.003): no tumor progression occurred in TT genotype. Moreover, 92.3% of the responder patients developed skin rash, 62.9% of them presenting a grade ≥2 (P = 0.015). Thus, although underpowered, our preliminary data suggest that SNP-216 polymorphism of the EGFR gene could be useful in predicting tumor response and the appearance of severe skin rash might also be associated.

We present the case of a 9-day-old girl with venous dilatations in lower abdomen and legs associated to cyanosis. Radiological studies revealed a congenital agenesis of the entire inferior vena cava.

Diltiazem is a calcium channel blocking agent used for the treatment of hypertension. Cutaneous adverse effects are uncommon. The most frequently reported are itching, urticaria, and maculopapular eruption. A peculiar, cutaneous photodistributed reticulated hyperpigmentation secondary to diltiazem has been recently reported. A 66-year-old white woman with a 2 year history of pruritic hyperpigmented lesions on her face was seen in the clinic. Past medical history was remarkable for hypertension, which had been treated with diltiazem. Physical examination showed slate-gray to brown reticulated hyperpigmentation in the photo-exposed areas of the face and neck. Histological examination revealed interface dermatitis with liquefactive degeneration of the basal layer, necrotic keratinocytes, lymphocytic inflammatory infiltrate, and melanophages in the superficial dermis. A diagnosis of diltiazem-induced hyperpigmentation was established and diltiazem was stopped. Gradual resolution of the hyperpigmentation was observed over the following months. Although diltiazem has been marketed for over 20 years, the first cases of this particular type of reticulated hyperpigmentation were described in 2001. Since then, to our knowledge, only 17 cases have been reported in the literature. In all cases, cutaneous lesions appeared at least 6 months after this treatment had been started. Hyperpigmentation was controlled by means of photoprotection and discontinuation of diltiazem. Diltiazem can produce a characteristic lichenoid dermatitis with reticulated hyperpigmentation on sun-exposed areas.

Varon de 35 anos, natural de Nicaragua, residente en Espana esde hacia 3 anos, derivado desde atencion primaria a nuestras onsultas por lesiones nodulares en el antebrazo derecho. Referia l inicio del cuadro 4 anos antes, tras traumatismo con laceracion perdida de sustancia de mano derecha cuando trabajaba con una izalla en el campo. Se le realizo limpieza de la herida, pero en los eses siguientes le aparecieron lesiones nodulares de trayectoria scendente (fig. 1), algunas ulceradas, con periodos de mejoria y mpeoramiento. Recibio diferentes ciclos de antibioticos, sin resuesta. Nunca presento fiebre ni otros sintomas sistemicos. Se le abian realizado ambulatoriamente serologias de virus de la inmuodeficiencia humana (VIH), rosa de Bengala, lues, Toxoplasma, itomegalovirus, virus de Epstein-Barr y determinacion de antiuerpos antinucleares, que fueron negativas. Las funciones renal hepatica, la PCR, la VSG, el hemograma y la formula leucocitaria ueron normales. A la exploracion presentaba una lesion nodular, ritematosa y ulcerada en el segundo dedo de la mano derecha fig. 2) y otros 5 nodulos de menor tamano que seguian el traecto de vasos linfaticos hasta el codo de 0,5-1,5 cm de diametro. e tomaron muestras para biopsia y cultivo.