Search

Scarring that result from acne is a very distressing and difficult problem for physician and patient alike. The type of scarring following acne eruptions is also variable and each type requires a different treatment strategy. Subcision techniques or skin needling in conjunction with non-ablative lasers may be used in patients presenting milder to slightly more severe scarring. The morphology of each scar must be assessed and treatment designed accordingly. Scarring occurs in all types of acne, not linked tonodulocystic disease, but does vary with the severity and delay until effective treatment is organized. Therapeutic intervention for post-acne scarring has historically been limited by the considerable morbidity of most treatments for only marginal disease improvement. Options and treatment algorithms for dealing with post-scar scarring are explored and a systematic review of literature is performed. Hypopigmented macular scarring also called perifollicular scarring has been reasonably refractory to treatment.

The association of palmoplantar keratoderma (PPK) with the development of cutaneous squamous cell carcinomas (SCCs), dental anomalies, severe hypogenitalism with hypospadias, abnormal development of gonads with ambiguous external genitalia, gynecomastia, altered plasma sex hormones levels, and hypertriglyceridemia has not, to our knowledge, been reported previously. We describe it in 4 brothers with 46,XX karyotype, whereas the 5 sisters of their consanguineous parents were unaffected. This family may represent a new syndrome. The PPK was of the classical nonepidermolytic histologic type. The proband also had a laryngeal carcinoma diagnosed in his early forties and nodular testicular hyperplasia of Leydig cells.

Background: Melanocytic nevi in the genital, acral, and flexural sites often display clinical and histologic features that may simulate melanoma. We verified whether this is the case also for nevi of the breast. Methods: Eleven dermatopathologists, from nine Italian Institutions, collected the specimens of melanocytic lesions from the breast and other body sites, excluding the acral, genital, and flexural areas, as controls. Cases and controls were matched for sex and age. All nevi were observed ‘blindly’ and simultaneously by all participants. For each lesion, 10 histological parameters were analyzed: asymmetry, absence of lateral demarcation of melanocytes, lentiginous proliferation, nested and dyshesive pattern, intraepidermal melanocytes above the basal layer, involvement of the hair follicle, absence of maturation of dermal melanocytes, melanocytic atypia, fibroplasia of the papillary dermis, and lymphocytic dermal infiltrate. Each parameter was scored 2 when present and 1 when absent or not valuable. A total score was calculated for each lesion. Results were statistically analyzed by the chi-square test and the Mann–Whitney U-test. Results: One hundred and one nevi came from the breast area and 97 from elsewhere. Breast nevi exhibited significantly more atypical features than nevi from other sites. In particular, breast nevi with intraepidermal melanocytes, melanocytic atypia, and dermal fibroplasia were significantly more numerous. We did not find any sexual difference. Conclusions: To avoid undue concerns, dermatopathologists should be aware that melanocytic nevi of the breast may show a high degree of atypical features.

Purpose: The expression of apoptosis-related genes, such as survivin, bcl-2, bcl-X, and bax, has been evaluated by reverse transcriptase polymerase chain reaction (RT-PCR) and by immunohistochemistry in sentinel lymph nodes (SLNs) from melanoma patients and then correlated to the outcome of patients. Patients and Methods: Thirty-six SLNs were examined. After RNA extraction, an RT-PCR followed by Southern blot hybridization was performed to detect survivin, bcl-2, bcl-X, and bax mRNA. bcl-2, survivin, and bax gene expression was evaluated, whenever possible, also by immunohistochemistry at the protein level. Results: We found a significant correlation (P < .005) between survivin expression and outcome of patients; in fact, 61.5% of patients expressing survivin gene progressed or died because of the disease, whereas 38.5% are currently disease-free. Among patients negative for survivin expression, 100% are disease-free after a median follow-up time of 52.9 months. We did not find a significant correlation between bcl-2, bax, and bcl-X gene expression and outcome of patients. In fact, these genes were found equally expressed in patients with disease progression and in disease-free patients. Conclusion: Our findings show a variable expression of apoptosis-related genes in SLNs of melanoma patients; more interestingly, we found that survivin expression correlates to outcome of patients in a statistically significant way, whereas the expression of other genes, such as bcl-2, bax, and bcl-X, did not seem to correlate to progression of disease. We suggest that the detection of survivin gene expression by RT-PCR in SLNs may be a useful prognostic indicator.

L’unita pilo-sebacea e una struttura complessa; infatti, nel definirla, devono essere considerate tre componenti: l’annesso pilifero propriamente detto, una o piu ghiandole sebacee e una ghiandola apocrina. L’annesso pilifero risulta inoltre costituito, a sua volta, da vari elementi: il follicolo pilifero, il fusto del pelo, la membrana basale, la guaina connettivale perifollicolare, il muscolo pilo-erettore, la papilla dermica e le terminazioni nervose perifollicolari (Fig. 3.1).

Sinus histiocytosis with massive lymphadenopathy (SHML) (Rosai-Dorfman disease) is a rare self-limited histiocytic disorder of unknown origin, usually present with cervical lymphadenopathy, fever, elevated ESR and haematologic abnormalities. Extranodal lesions may occur as initial manifestations of the disease. In most cases skin lesions are associated with nodal or extranodal localization. A 54-year-old male is reported who, for a period of ten months, presented numerous slowly enlarging, rounded papular lesions on the face, neck, trunk as well as severe cervical lymphadenopathy without general and haematological disturbances. Thereafter a fungating mass developed in the nasal cavity. Histological, histochemical and immunohistochemical tests of skin, mucosal and lymph-node lesions were consistent with a diagnosis of SHML. The immunohistochemical characterization of the cytophagocytic S-100+ macrophages revealed that they were highly positive for the adhesion molecules Vitronectin receptor av/b3, which is used by tissue macrophages for removal of effete cells through phagocytosis.

Dermoscopy allows early detection of melanoma also on acral volar skin. The majority of melanocytic nevi on palms and soles may show three major dermoscopic patterns: the parallel-furrow pattern, the lattice-like pattern, and the fibrillar pattern. Melanomas at these sites are characterized by the parallel ridge pattern. We present the case of a 59-year-old woman who had an oval papule of bluish color, measuring 0.6 x 0.9 cm, localized on her left sole, that had been present, unchanged, for more than 10 years. Dermoscopy showed a parallel ridge pattern. The histopathological examination revealed a combined blue nevus. We present this case to underline that on acral volar skin also intradermal nevi, such as combined blue nevi, may dermoscopically exhibit a parallel ridge pattern, simulating melanoma.

This article does not have an abstract.

Background Patients with chronic renal failure, regardless of its cause, with/without hemodialysis/peritoneal dialysis, showed cutaneous alterations. Two patients had a follicular hyperkeratotic papular eruption, with clinical and histological features of perforating folliculitis. Methods A dermatological examination and multiple skin biopsies were done. Results We diagnosed acquired perforating folliculitis in two chronic renal failure patients on hemodialysis. The lesions were located predominantly on the lower extremities with hyperkeratotic papules and small nodules. Microscopically, the papule always affected the follicular structure. The follicle was widely dilated and packed with keratotic material, necrotic debris and degenerated basophilic coarse connective fibers passing which passed through follicular perforations. Conclusion Acquired perforating folliculitis is a cutaneous manifestation in chronic renal failure, with/without hemodialysis treatment, that can mimic essential primary perforating folliculitis. Transepidermal elimination mechanisms and the distinction between primary and acquired perforating dermatoses are discussed.

Summary Clear cell acanthoma (CCA) is a benign epidermal tumour with distinctive and uniform clinical and histological features. Although solitary lesions are the rule, some cases of multiple CCA, rarely with more than 10 lesions, have been previously reported. Only 22 cases of multiple CCA have been described in the English literature to date. A healthy 32-year-old woman is reported, with approximately 400 asymptomatic rounded papules, on the upper and lower extremities. Multiple skin biopsies showed the typical histological pictures of CCA. This case appears unusual because of the presence of numerous lesions scattered on the upper and lower extremities. For this reason it could be classified as disseminated eruptive CCA.

Summary A 39-year-old woman is reported who developed numerous confluent yellowish semitranslucent papules of the face over 8 months. The patient habitually exposed herself to UVA-radiation twice a week for 7 years for aesthetic reasons. Histological, histochemical and immunohisto-chemical examinations were consistent with the diagnosis of adult colloid milium. A review of the literature is discussed. This case emphasizes the close relationship between long-term sun exposure, solar elastosis and adult colloid milium.

Background. In recent years, an unusual biologic behavior of Merkel cell tumor (mct) has been noted. In some patients, the tumor was indolent and well controlled by therapy, while in others it was lethal in a few months. Even though the majority of the reported cases are between these two biologic extremes, it seems evident that there is a high variability in the clinical course of the tumor. Methods. A clinical analysis of eight cases of primary Merkel cell tumor was performed. All the patients presented with similar clinical features: age, tumor staging, duration of the disease, lack of complicating cutaneous or systemic diseases. On the basis of these common findings, which made this group quite homogeneous, our attempt was to identify other clinical signs that could correlate with the local recurrence and/or the onset of metastases. The outcome of our patients, in fact, was quite variable. Results. The tumor size, the clinical aspect at presentation (single, multiple nodules, or plaque), the histologic pattern (all were of the trabecular type), and immunohistology did not correlate with the outcome. Conclusions. We report the rare occurrence of mct in the perianal area, which suggests that it should be included in the differential diagnosis of perianal tumors, the very aggressive behavior of the tumor in two patients (death < 6 months from diagnosis), which confirms how the prognosis for mct is unpredictable even if the diagnosis is established at an incipient stage and the tumor promptly removed.

A careful overview of the classical appearances of Kaposi's sarcoma (KS) as well as of its variants were reviewed from the clinical and pathological point of view. The growth phases (stages) and the cellular patterns were histopathologically compared with emphasis on the developmental progression of disease as well as mitotic activity. Other morphological aspects were also assessed such as the features of the early phases and the incidence of hyaline bodies. One hundred and forty-three lesions from 96 patients mostly of the Italian sporadic type were investigated. A complete list of those entities which should be considered in differential diagnosis is shown and the dilemma of whether KS is a neoplasia or a hyperplasia is discussed.

Background Metatypical cell carcinoma can be considered as a new entity of skin cancer, being an intermediate typology between basal cell carcinomas and squamous cell carcinomas. The behaviour of the metatypical cell carcinoma lies between these two varieties of skin cancer. It is difficult to perform a differential diagnosis based on morphological and clinical features – therefore it is only possible by accurate histology. Methods The authors have retrospectively analysed clinical records of 240 patients who were affected by metatypical skin cancer and who were treated by surgery, radiotherapy and chemotherapy. Results MTC affected more males than females (62.5% vs 37.5%) than males. The most affected site was the cervicofacial area, 71.7%; then the trunk, 10%; the limbs, 9.6%; the scalp 3.7%; and other regions 5%. A recurrence occurred in 24 cases (10%), mainly in head and neck area. Conclusion In this manuscript, the authors have emphasised the importance of conducting a differential diagnosis, and the importance of the specific treatment for metatypical skin cancer, even though more clinical studies and long-term follow-ups are required before establishing specific guidelines.

Primary hyperidrosis (PH) is a disorder characterized by excessive eccrine sweat gland production that primarily involves the axillae as well as palms and soles. Common first-line topical treatment for PH consists of aluminum salts (AS) that act by physically blocking eccrine sweat gland ducts. However, primary irritant contact dermatitis is a common side effect of AS treatment. Recently, a new low-residue, thermophobic foam formulation containing 20% aluminum sesquichlorhydrate has been developed (Nidrox®, Mipharm S.p.A.). To evaluate the local tolerability and efficacy of 20% aluminum sesquichlorhydrate foam in the treatment of axillary and palmar PH. Twenty subjects affected by PH were enrolled in a multicenter, open-label study. Local tolerability was evaluated by physicians assessing itching, burning, and skin irritation using a four-point score (from 0: no symptoms to 3: severe symptoms). Skin irritation was quantified with a visual score. Efficacy was assessed by means of Minor test score using a four-point score (range 0–3). The foam was applied to clean dry skin, every night during the first 2 weeks and three times a week during the following 2 weeks. Clinical evaluations were performed at baseline, at day 14 and at day 28. Patients were monitored throughout the study for adverse events. All 20 subjects completed the study. The foam induced a significant reduction of the Minor score in comparison with baseline values (p = 0.0002) both at day 14 and at day 28. At the end of the 4-week treatment period, the foam reduced eccrine sweating by 61% (Minor score: 3.3 vs. 8.5). No skin irritation was observed during the trial except for one subject who experienced a mild and transient itching sensation. No other side effects were reported during the study. This new foam appears to be an effective and well-tolerated topical treatment in reducing sweating in patients with axillary and palmar PH.

The aim of the study was to investigate the efficacy, safety and compliance of 500 mg azithromycin thrice weekly for 12 weeks in moderate inflammatory acne vulgaris. An open-label, noncomparative study was carried out for 12 weeks at Department of Dermatology and Plastic Surgery, La Sapienza University in Rome. Fifty-seven patients (20 male and 37 female) between 13 and 41 years of age, affected by moderate papulopustular and nodular acne vulgaris, were enrolled in the study. Azithromycin 500 mg was administered orally thrice weekly for 12 weeks. Patients were examined at baseline, 4 weeks, 8 weeks and 12 weeks (completion of treatment), evaluating both clinical (Global Acne Grading System, GAGS) and quality of life (Acne Quality of Life Questionnaire, AQoL) improvements. Forty-six patients completed the study and showed significant improvement. Six patients interrupted their treatment, while five patients did not complete the study for unknown reasons. Side effects (diarrhea and abdominal pain) were recorded in eight patients. Azithromycin, 500 mg thrice weekly for 12 weeks, is a safe and effective treatment for moderate acne vulgaris with excellent patient compliance.

During the last 20 years, an increasing incidence of basal cell carcinoma (BCC) has been demonstrated by several studies. A ten-year retrospective analysis on 7,266 cases of primary BCC of the Department of Dermatology and Plastic Surgery of the University of Rome La Sapienza and the Department of Dermatology of the University of Naples "Federico If' is reported. Among a population aged over 35 years, BCC cases increased from 618 in 1994 up to 749 cases in 2003, while among the younger population (35 years), BCC cases increased from 30 in 1994 to 47 cases in 2003. Anatomic site distribution of BCC among people aged35 years was: head and neck=51.54%, trunk=41.40%, limbs=5.91%, others= 1.12%. On histological examination aggressive-growth BBC was recorded in 48 out of 355 cases (13.52%) among people aged35 years and in 841 out of 6,755 cases (12.45%) among patients35 years. In conclusion, an increasing incidence of basal cell carcinoma among young people over the past 20 years was reported. No significant difference in tumour aggressiveness between the young and the elderly patients was observed.

Epstein Barr Virus (EBV), also classified as Human Herpes Virus 4, infects the vast majority of adults worldwide and establishes both non-productive (latent) and productive (lytic) infection. Classical EBV diagnosis includes quantitative determination of viral DNA and serological analysis, based on the determination of IgG and IgM responses against the viral capsid antigen (VCA) and the IgG response against the EBV nuclear antigen-1 (EBNA-1). EBV-serology can be misleading in some cases, such as acute infections with low or undetectable VCA IgM, convalescent patients with persistent or reactivated VCA IgM and negative anti- EBNA-1 IgG, due to a loss of this marker during immunosuppression. In all these cases avidity determination of IgG is helpful to prevent false diagnosis. Avidity represents the stability of the antigen-antibody interaction. Its value increases during the infection, so high avidity never associates with a primary acute infection. We studied the importance of avidity determination of p18 (VCA)-IgG to achieve unequivocal interpretation of serological results. The amount of IgG and IgM is determined by Chemiluminescent Immune Assay (CLIA), a rapid and highly sensitive method suitable for automation. The intensity of luminous signal produced by antibody-antigen recognition is expressed as Relative Light Unit (RLU). p-18 IgG is determined using a recombinant p18 antigen expressed in E. coli. Avidity index is determined in CLIA by the ratio between denaturated and not denaturated IgG specific antibodies expressed in RLU. These results demonstrate that avidity determination represents an important additional marker particularly in cases with aberrant serological profile.

Background Data on the prevalence of human papillomavirus (HPV) infection in patients with penile lichen sclerosus (LS) are scant and controversial. Aim To investigate the prevalence of HPV infections in patients with penile LS. Methods HPV infection was assessed by polymerase chain reaction (PCR) in paraffin-embedded penile biopsies obtained from the glans or inner foreskin of 46 adult patients with penile LS, and in brush cytology smears of penile healthy mucosa from an equal number of randomly selected control males matched for age. Statistical evaluation was performed using conditional logistic regression analysis. Results PCR disclosed the presence of HPV infection in 17.4% of LS patients (HPV 16, six cases; HPV 18, one case; HPV 45, one case). Amongst the controls, HPV infection occurred in 8.7% of patients (HPV 16, two cases; HPV 53, one case; HPV 70, one case). Statistical regression analysis confirmed that the rate of HPV infection was higher amongst patients with genital LS than amongst healthy controls [odds ratio (OR), 2.55; 95% confidence interval (CI), 0.73–8.89]. Conclusions Infection with oncogenic “high-risk” HPV types in patients with genital LS may enhance the risk of penile cancer arising on LS.

Meta-typical carcinoma (MTC) or basosquamous carcinoma is a remarkable malignancy with features of both basal and squamous cell carcinoma. It is typically located on the back and face, often with clinical features of basal cell carcinoma but tending to be more aggressive with enhanced prospects of lymph node or distant metastases. Our report describes a huge neglected MTC of the back of ten-year duration, a giant ulcero-vegetative tumor measuring 20 x 25 cm. Histologic examination of specimens from the margins and periphery revealed aspects of both basal and squamous cell carcinoma, while the ulcerated center showed sclerotic tissue without tumor. Radical excision and reconstruction by grafts were performed. No metastases were observed after two years. There are many controversies surrounding the histologic definition and biologic behavior of MTC, including its metastasizing potential. The MTC we describe exhibited benign biologic behavior. This may have been related to an intense inflammatory host response with elimination of neoplastic tissue and consequent local sclerosis evident in the central tumor-free portion. This central tumor regression is to our knowledge a unique finding in MTC.

Penile cancer, while relatively rare in the western world, remains a disease with severe morbidity and mortality, not to mention significant psychological ramifications. Furthermore, the disease is observed with dramatically increased incidence in other parts of the world. A review of the literature has shown that the overwhelming majority of penile cancers are in situ or invasive squamous cell carcinomas, including a well-differentiated variant, verrucous carcinoma. Important predisposing factors are lack of circumcision, human papillomavirus infections, and penile lichen sclerosus, although other factors have occasionally been reported as well. Prevention, careful monitoring of patients at risk, and early diagnosis are essential to reduce the incidence of penile carcinoma and to provide a definitive cure. Public health measures, such as prophylactic use of circumcision, have proved successful but are controversial. Also, no standard therapeutic guidelines as to the best treatment strategy according to different stages, including efficacy of conservative nonsurgical modalities and indications for lymph nodal dissection, are available so far. It is common opinion that penile cancer is an emerging problem that deserves further investigations, and physicians, especially dermatologists, should be aware of this issue.At the completion of this learning activity, participants should be familiar with penile carcinoma, its risk factors, its clinical and histologic presentation, and the treatments currently available for its management.

Sebaceous carcinoma (SC) is a rare malignant tumor derived from the adnexal epithelium of sebaceous glands. It has been traditionally classiWed into two variants on the basis of its location, extraocular and ocular sebaceous carcinoma. Extraocular sebaceous carcinoma is rare (25% of reported cases [1, 2]) and occurs most commonly on the face and scalp, but they have been reported to occur almost anywhere on the body. It can exhibit such a diVerent variety of histologic patterns and clinical presentations, and the diagnosis is often delayed for months to years. These carcinomas are commonly associated with Muirr Torre Syndrome (MTS). The MTS consists of a rare autosomal dominant condition characterized by the association of cutaneous sebaceous neoplasms (sebaceous adenoma, sebaceous epithelioma, or sebaceous carcinoma, basal cell carcinoma with sebaceous diVerentiation, with or without keratoacanthomas) and the presence of at least one internal malignancy [3–8]. The biologic behavior of SC depends on the site, but particularly debated whether there is a diVerent aggressiveness of origin. Most of the literature reports that ocular tumors are highly malignant neoplasms with frequent locoregional and/or distant metastasis and intracanial extension [9–13]; extraocular sebaceous carcinoma on the other hand are considered as slow growing tumors of low malignant potential [9, 10, 14, 15]. In fact 15–30% of the patients aVected by ocular SC developed metastasis to the lymphnodes; widespread metastatic disease secondary to extraocular SC is very uncommon. Classically it has been considered that when metastases occur, only regional lymphnodes were involved [16, 17]. Many authors consider the presence of histologic and immunohistochemistry indices prognostically unfavorable (small diVerentiation, presence of vascular or lymphocytic invasion and presence of a pattern of pagetoid cells) [9, 18–20]. The discussion on the biologic aggressiveness of the neoplasia is still open. To support the opinion that the behavior of extraocular SC is not signiWcantly diVerent from those arising in the ocular region, this report describes a highly aggressive scalp SC in an MTS case.

Primary or idiopathic hyperhidrosis (PH) is a disorder of excessive eccrine sweating glands that mainly affects the axillae and the palms. The treatment options for PH involve a range of topical or systemic medication and/or surgical invasive techniques. The common topical treatments are aluminium salts which act by blocking the duct of the eccrine gland or by atrophying the secretory cells. Recently, a new low-residue thermophobic foam formulation (VersaFoam, Mipharm Spa, Milan, Italy), containing 20% of an aluminium salt (sesquichlorhydrate), has been developed. The foam is easy to apply especially in hairy body sites.to evaluate the efficacy and the tolerability of the new aluminium salt foam in the treatment of axillary and palmar PH.Twenty patients were enrolled in a single-centre, open-label follow-up study. The Minor test score (range 0-3) and the Dermatology Life Quality Index (DLQI), were used to evaluate the amount of sweating and the impact on quality of life. The foam was applied to dry, clean skin, every night during the first week of treatment, and three times a week during the second week of treatment. Evaluation of the results was performed at baseline and at 7 and 15 days after treatment. Patients were monitored throughout the study for adverse events.All of the 20 enrolled patients completed the study. The foam resulted in a significant reduction of the Minor score in comparison with baseline values in both the axillary (p = 0.0002) and palm regions (p = 0.0047). By the end of treatment (day 15) the foam had reduced the amount of sweating in the axillae and palm regions by 50% (Minor score: 4.1 vs. 8.1) and 53% (Minor score: 4.0 vs. 8.5), respectively. Use of the foam showed a positive impact in the DLQI for patients with axillary but not palm hyperhidrosis. No side effects were reported during the study duration by the patients.The new foam has been shown to be an effective topical treatment in reducing sweating in patients with axillary and palm PH. This formulation is well tolerated in the short term. Further studies are warranted to evaluate the efficacy and safety in the medium and long term.

AIMS: The histological features used in the diagnosis of melanoma may be present in benign naevi, but quantitative data are not available. The aim of this study was to establish the real prevalence of such features in naevi. METHODS: Ten dermatopathologists, from nine Italian institutions, studied a series of naevi. Eleven histological parameters currently used in melanoma diagnosis were analysed: asymmetry, poor circumscription, predominance of single melanocytes, irregular confluent nests, suprabasal melanocytes, hair follicle involvement, absence of maturation, cytological atypia, dermal lymphocytic infiltrate, mitoses, and necrosis. RESULTS: Ninety one naevi were examined: 22 junctional, 59 compound, and 10 intradermal. None of the studied parameters was seen in 22 of the benign naevi studied. One or more investigated features were found in 69 naevi. Poor circumscription was found in 49 cases, single melanocytic predominating in 42, asymmetry in 41, irregular confluent nests in 16, cytological atypia in 14, suprabasal melanocytes in seven, and hair follicle involvement in seven; absence of maturation, mitoses and necrosis were not found. CONCLUSIONS: The histological features used for the histological diagnosis of melanoma are often present in benign melanocytic naevi. This suggests a critical, non-mechanical use of them in melanoma diagnosis.

The authors described a very rare case of the cystic lymphangioma (CL) of the left upper extremity in a 12-year-old patient. The diagnosis was made by US and MRI and confirmed by histological examination of the resected specimen.

Background Sebaceous carcinoma is an unusual, aggressive, malignant tumor derived from the epithelium of sebaceous glands. It may arise in ocular or extra-ocular sites and is often evident as an ulcerated or non-ulcerated cystic nodule measuring up to 8 cm in diameter. A significant number of extra-ocular sebaceous carcinomas have been associated with metastases and high mortality rate. Methods and Results We reviewed the literature in the context of our report of a 68-year-old woman who had a morpheaform plaque of the upper lip of 15 years duration, extending into the left naso-genal groove, which histologically also showed marked stromal fibrosis. Three years after excision, there were no signs of recurrence or metastases. Conclusions This patient is unusual in clinical and histologic pattern, as a morpheaform appearance has only been described previously in only one sebaceous carcinoma. In addition, no metastatic disease 15 years after tumor onset is a fortunate and remarkable feature. J. Surg. Oncol. 2005;92:??–??. © 2005 Wiley-Liss, Inc. J. Surg. Oncol. 2005;92:344–346. © 2005 Wiley-Liss, Inc.

Background. Primary subungual squamous cell carcinoma (SCC) of the toe is seldom reported in the literature, with most described cases occurring on the fingernails. Objective. To describe the clinical, histopathologic, and laboratory findings of cases of invasive subungual SCC of the toe. Methods. All cases of SCC of the toes retrieved from our database in the last 3 years were reviewed. A search for human papillomavirus (HPV) DNA from paraffin-embedded sections was performed with polymerase chain reaction. Results. Three patients, all male, with a subungual SCC (two welldifferentiated and one poorly differentiated) of the toe were identified. Treatment consisted of surgical amputation in all cases. One patient with poorly differentiated SCC and lymph node metastases also underwent inguinal lymphadenectomy. Polymerase chain reaction search for HPV DNA was negative in all samples. Conclusions. Unlike Bowen's disease and SCC of the fingernails, a causative role of HPV infection in the development of in situ and invasive subungual SCC of the toe seems unlikely.

Background. Penile carcinoma is an invasive epithelial tumor that may arise from penile skin or mucosa. Objective. To review the pathogenesis and the clinical and histopathologic features of invasive penile carcinomas, with emphasis on current guidelines for their diagnosis and treatment. Methods. Information available from the authors' clinical experience, review articles, case reports, clinical trials, and in vitro research studies identified from a computerized literature search on MEDLINE database and from Meetings' Abstract Books, including those from non-English literature, was considered. Results. Penile cancer may develop de novo or in association with underlying factors. Conditions predisposing to the development of penile cancer are delineated. The diagnosis should be suspected by clinical findings and must be confirmed histologically. Imaging techniques may be useful for staging and planning therapy. Therapeutic options include excisional surgery, laser destruction, cryosurgery, radiotherapy, immunotherapy, and chemotherapy. Conclusions. Although there are no current guidelines for the treatment of penile carcinoma, surgical ablation probably represents the best option, as conservative treatments still deserve cautious evaluation because of the relatively small number of treated patients and the lack of good-quality comparative data. Regarding indications for lymph nodal dissection in patients showing no inguinal node enlargement, sentinel node mapping with targeted lymph node dissection is recommended for those with deeply invasive, high-grade tumors, whereas a watchful waiting may be advised for those with superficially invasive, low-grade tumors.

Abundant mucin deposition is an unusual finding in melanocytic naevi. We describe the first example, to our knowledge, of a sclerosing blue naevus with an abundant mucinous stroma in two unrelated patients. This uncommon variant of blue naevus should be differentiated from desmoplastic-neurotropic melanoma, in which the presence of mucin stromal deposition is a more typical finding.

Kaposi's sarcoma is a vascular tumour of multifocal origin occurring primarily on the extremities. The case of a 45-year-old HIV negative and HHV-8 positive man with an asymptomatic reddish macular lesion on the inner layer of the prepuce is described. Although primary penile Kaposi's sarcoma is a relatively uncommon disorder in HIV negative men, dermatologists and venereologists should consider this possibility when treating non-specific penile lesions. A minimal penile lesion with non-distinctive clinical features may sometimes be the exclusive manifestation of Kaposi's sarcoma, making histologic evaluation necessary to establish the diagnosis.

Verocytotoxin-producing Escherichia coli (VTEC) infections cause most cases of hemolytic uremic syndrome (HUS); 10–30% of patients, however, are negative for VTEC infection. The etiology of HUS in VTEC-negative cases remains poorly understood. Before the association between VTEC infection and HUS was recognized, sporadic cases of HUS with enterovirus infection were reported in the literature. Since May 1988, most cases of HUS in Italy have been reported to the Italian surveillance system, and in 73% of these, evidence of VTEC infection was demonstrated. The aim of this study was to determine whether the frequency of enteroviral infections was different in the acute phase of VTEC-positive and VTEC-negative HUS. Eighty-nine patients were investigated for enteroviral infection, of whom 58 were VTEC positive and 31 VTEC negative. Two serum samples from each patient were examined for seroconversion to enterovirus (coxsackie, echovirus, and picornavirus) by a complement fixation test. Serological evidence of acute infection with non-polio enterovirus was found in 33 patients (37%) [20/58 (34.5%) VTEC positive and 13/31 (41.9%) VTEC negative]. There was no statistically significant difference between the two groups. These results demonstrate that there are no significant differences for enteroviral infection in VTEC-positive and VTEC-negative patients and, therefore, enteroviral infections should not be considered a cause of HUS in VTEC-negative children.

Darier's erythema annulare centrifugum (EAC) is often associated with infectious, autoimmune or neoplastic disease, nevertheless, most cases of EAC remain unexplained. We report a case of EAC with neonatal onset and a clinical course of over 20 years. The patient presented from the 6th day of life with erythematous papules that enlarged centrifugally to form figurate, annular or policyclic plaques involving the entire cutaneous surface. The clinical picture had a chronic course, disappearing only during unrelated febrile episodes. Histologic examination revealed a normal epidermis and a dense perivascular lymphohistiocytic infiltrate and numerous eosinophils in the superficial and reticular dermis. Today the patient is 24 years old and his lesions are still unchanged. Recently, clinical evaluation revealed a diffuse sderodermic induration. A second biopsy showed a diffuse thickening of collagen fibers in the dermis. To our knowledge, this is the second report of EAC with neonatal onset and such a long and peculiar clinical course.

To obtain information on the prevalence of microsatellite mutations in melanomas, we analysed the status of 14 repetitive loci characterized by structurally different non-coding and coding sequence repeats in a panel of 34 primary melanocytic tumours and in lymph node metastases matched to 13 cases. Instability at one or more of the non-coding dinucleotide repeats D2S123, D3S1611, D5S107 and D18S34 was detected in ten out of the 34 primary tumours (29%) and in ten of the 13 metastases (77%). There was no instability at the non-coding mononucleotide repeats BAT25, BAT26 and APDelta3 or at the coding mononucleotide runs within the TGFbetaRII, IGFIIR, BAX, hMSH3 and hMSH6 genes. A five-repeats expansion of the coding E2F4(CAG)n run was found in the only malignant melanoma of soft parts examined, which also showed instability at two dinucleotide loci, and in a superficial spreading melanoma, which was stable at the mononucleotide and dinucleotide repeats but was the only tumour that manifested instability at the SCA1(CAG)n repeat. The absence of mutations at mononucleotide tracts indicates that, in the malignant melanomas tested, microsatellite instability was not associated with the microsatellite mutator phenotype characteristic of mismatch repair-deficient tumours. On the other hand, our results confirm that microsatellite instability at dinucleotide repeats increases with melanoma progression, and indicate that expansions of triplet repeats may occur in melanocytic tumours.

This is the report of an 80-year-old patient with diffuse brownish hyperpigmentation and velvety thickening of the skin with onset 1 year before. Warty lesions on his limbs were present as well as papillomatous and verrucous lesions on his lips, mouth and eyelid conjunctivae with hyperkeratosis of the nipples. Biopsies, performed at different sites, showed histological pictures consistent with a diagnosis of acanthosis nigricans (AN) with florid cutaneous and mucosal papillomatosis. This type of AN is frequently associated with internal malignancy. In our patient serum levels of tissue polypeptide antigen, carcinoembryonic antigen, cytokeratin fragment and squamous cell carcinoma antigen were high and chest computed tomography scan indicated a large tumour infiltrating the right lung and extending to the mediastinum. Cytological examination of bronchial drainage revealed the presence of neoplastic cells, non-small cell type carcinoma. The most frequent cancer associated with malignant AN is gastric adenocarcinoma. Lung tumour has rarely been reported with AN. Malignant AN is sometimes associated with other cutaneous and mucosal warty lesions, as in our patient. These various skin and mucosal lesions are the expression of a systemic epithelial disorder and may help clinicians to suspect a malignant form of AN.

Background: Genital lichen sclerosus (LS) has sporadically been reported to be associated with penile squamous cell carcinoma (SCC). Objective: The purpose of this study was to assess the risk of malignant degeneration in a series of male patients affected by genital LS. Methods: All cases of histologically proven epithelial malignancy associated with penile LS recorded in our pathology files over a 10-year period (1987-1997) were reviewed. Assessment for presence of human papillomavirus (HPV) was performed from paraffin-embedded tissues using polymerase chain reaction (PCR). Results: Five of 86 white and uncircumcised men with genital LS (mean age at diagnosis, 53 years; range, 22-83 years) showed malignant or premalignant histopathologic features: 3 had SCC, one had erythroplasia of Queyrat (unifocal SCC in situ), and one verrucous carcinoma. The average lag time from onset of LS was 17 years (range, 10-23 years). Histologically, transition from LS to frank neoplastic foci was evident in all cases of SCC. In these SCC cases, areas of epithelial dysplasia were well evident at the tumor periphery. In the remaining cases, the histologic findings were consistent with erythroplasia of Queyrat and verrucous carcinoma. PCR detected HPV 16 infection in 4 of the 5 cases; one SCC patient was negative for HPV. Conclusion: Malignant changes were associated with 5.8% of the cases of penile LS in our series. Therefore patients with genital LS are at considerable risk of the development of penile SCC, as well as other epithelial and in situ carcinomas, namely verrucous carcinoma and erythroplasia of Queyrat. HPV infection probably plays a major role because 4 of 5 patients were positive for HPV. Histologically, epithelial dysplasia may represent a precancerous stage before the development of neoplasia in atrophic nonproliferative LS lesions, as its presence at the tumor periphery in our SCC biopsy samples seemed to suggest. (J Am Acad Dermatol 1999;41:911-4.)

Cellular blue nevi (CBN) are benign tumors of the skin derived from dermal melanocytes histologically characterized by increased cellularity and often by a dual cell population of nevoid cells. CBN rarely tend to invade the underlying tissues. Only six cases of CBN of the scalp invading the skull have been reported. A new case of a CBN infiltrating the underlying bone is presented. The patient, a 23-year-old woman, had a large hairless area on her right parietal scalp, present since the early months of life. Her past medical history included, on the same site, the presence, at birth, of a raised, dark, soft and hairless mass that was subsequently electrodesiccated. Radiographs of the skull showed an area of osteolysis underlying the cutaneous lesion. Histologic examination of a biopsy specimen revealed a CBN of the scalp infiltrating the underlying bone. Surgical resection of the entire lesion was planned. There were no other anomalies or malignancies. The patient is currently being followed in our clinic.

Penile tumors, although not frequent, represent a difficult diagnostic and therapeutic challenge. Of the malignant penile neoplasms, the most frequent is penile carcinoma, which includes squamous cell carcinoma and its well-differentiated variant, verrucous carcinoma. Current concepts about classification, epidemiology, pathogenesis, histopathology, diagnosis, staging, prognosis, and treatment are presented.

Agminated lentiginosis (AL) is characterized by numerous lentigines confined to a body segment, with a sharp demarcation at the midline. So far, only 13 cases have been reported in the literature. We report a 30-year-old woman with a multifocal AL. The cutaneous lesions first appeared at 5 years of age and gradually increased in number with time. Clinically, they appeared as numerous brown macules, ranging in size from 1 to 5 mm in diameter, in a peppered distribution over an area extending bilaterally on the neck, chin, and cheeks. On the trunk the lesions were localized to the left shoulder and breast, involving the axilla and upper part of the abdomen down to the umbilicus. Four cafe au lait macules ranging in diameter from 10 to 15 mm were present, with no evidence of neurofibromas. Histopathology of a macule showed the features of lentigo; in addition, groupings of melanocytes were observed at the dermoepidermal junction. The differential diagnosis of AL includes speckled lentiginous nevus and segmental neurofibromatosis.

Bacillary epithelioid angiomatosis (BEA) is a rare cutaneous disorder usually affecting patients with human immunodeficiency virus (HIV) infection often misdiagnosed as a vascular tumour. We describe a 51-year-old, HIV-positive, Caucasian, homosexual male who developed scattered papulo-nodular lesions with clinicopathological and ultrastructural features of BEA. He had a dramatic therapeutic response to systemic antibiotics. There has been a lack of such reports in the European literature. The differential diagnosis is discussed and a brief review of the English literature to date is included.

An 18-month-old and an 8-year-old girl had trichothiodystrophy (TTD). Microscopic observation of the hair under polarized light showed typical alternation of bright and dark bands; amino acid analysis of the hair demonstrated a marked reduction of cystine levels. Both patients had skin lesions consisting in the older child of diffuse follicular keratosis since birth, and in the younger of an ichthyosiform dermatitis on the lower legs that appeared at age 4 months. Ultrastructural studies of the skin showed striking similarities in both cases: perinuclear vacuoles with a unit membrane in the keratinocytes, and dispersed, irregularly arranged bundles of tonofilaments particularly at the desmosome junction. The origin of the vacuoles is unknown; the abnormalities of the tonofilaments could be explained on the basis of a generalized abnormality in sulfur-containing proteins, reflecting a disturbance in the synthesis of keratins. These electron microscopy findings could be considered as a peculiar feature of ichthyotic skin in patients with TTD.