Multiple Military Osteoma Cutis: Report of a Case and a Brief Review of the Literature

A 39-year-old woman presented with a 4-year history of asymptomatic facial lesions that has progressively increased in number to become a cosmetic nuisance. These lesions have not responded to 6-months of topical 20% azelaic acid, 0.1% retinoic acid, and 20% vitamin C combination. She has had mild papulopustular acne. Her personal and family histories were unremarkable. On dermatologic examination, there were multiple flesh-colored to pigmented, firm ovoid to round papules, 2-5 mm in size, over the forehead and both cheeks (Figure 1). The dermatoscopic examination was nonspecific. Preliminary diagnoses were made of eccrine syringoma, steatocystoma multiplex, and papular elastorrhexis. A histopathologic examination from a punch biopsy displayed focal ossification within the dermis (Figure 2). Routine laboratory tests, including serum calcium, phosphorus, PTH, and vitamin D levels were within the normal ranges. A maxillofacial 3D CT scan, revealed multiple dermal and hypodermal ossifications, <3-5 mm in size-in the frontal, mandibular, and maxillary areas of the face (Figure 3). Scattered osteomas were also seen on the neck. A definitive diagnosis of multiple miliary osteoma cutis (MMOC) of the face and neck was firmly established based on clinical, histologic, and radiologic findings. Radiologically, the distribution and extent of the lesions were more pronounced than clinically anticipated. (SKINmed. 2022;20:469-471).

A Review on Cutaneous and Musculoskeletal Manifestations of CLOVES Syndrome

CLOVES syndrome is a novel sporadic mosaic segmental overgrowth syndrome, currently categorized under the canopy of PROS (PIK3CA-related overgrowth spectrum) disorders. All PROS disorders harbor heterozygous postzygotic activating somatic mutations involving the PIK3CA gene. As an upstream regulator of the PI3K/AKT/mTOR signal transduction pathway, activating mutations of PIK3CA gene commence in uncontrolled growth of cutaneous, vascular (capillaries, veins, and lymphatics), adipose, neural, and musculoskeletal tissues. The excessive growth is segmental, patchy, asymmetric, and confined to body parts affected by the mutation. The term ‘CLOVES’ is an acronym denoting congenital lipomatous overgrowth, vascular malformations, epidermal nevi and spinal (scoliosis) and/ or skeletal anomalies. The syndrome is characterized by an admixture of overgrown tissues, derived mainly from mesoderm and neuroectoderm. Among PROS disorders, CLOVES syndrome represents the extreme end of the spectrum with massive affection of almost the entire body. The syndrome might judiciously be treated with medications hampering with the PI3K/AKT/mTOR signal transduction pathway. This article aims at reviewing the cutaneous and musculoskeletal manifestations of CLOVES syndrome, as the paradigm for PROS disorders. CLOVES syndrome and other PROS disorders are still misdiagnosed, underdiagnosed, underreported, and undertreated by the dermatology community.

Livedoid cutaneous metastasis of signet-ring cell gastric carcinoma

Cutaneous metastasis of gastric cancer is extremely rare. Nodular forms are more common and inflammatory forms are exceptionally encountered. Herein, we report a case of inflammatory cutaneous metastasis of signet-ring cell gastric cancer (poorly cohesive gastric carcinoma with signet-ring cell component) masquerading as livedo reticularis. To our knowledge, such a clinical presentation of cutaneous metastasis has not been reported for gastric cancer. It is imperative to preserve a high index of clinical suspicion for diagnosing cutaneous metastases. Our case highlights the importance of obtaining a skin biopsy in patients with a known history of internal malignancy. Bizarre, newly erupting, evolving, persistent, or treatment-refractory dermatologic lesions (such as nodules, ulcers, erythematous, reticular, or livedoid patches) might be clues for an underlying internal malignancy and require prompt histopathological sampling. Personal medical history, histopathological examination, and immunohistochemical profiling are equally important in distinguishing primary cutaneous carcinomas from secondary metastatic deposits. Early recognition of a cutaneous metastasis might enable appropriate staging and timely intervention, thereby prolonging survival.

Circle hair: report of two cases and brief review of the literature

Circle hair (CH) is an interesting subtype of ingrown hair, characterized by the growing of hair shaft in a spiral or circular morphology underneath a translucent layer of stratum corneum, parallel to skin surface. In contrast to rolled hair (RH), neither perifollicular inflammation nor abnormal follicular keratinization are known to accompany CH. The reason why the hair shaft grows circumferentially and transversely under the skin instead of emerging through an apparently open hair follicle ostium and growing vertically remains to be determined. Although CH is a frequent benign incidental finding in normal skin examination, reports on this disorder are scarce. Herein we report two cases of CH and briefly review the existing literature. We believe that CH develops because of trauma in patients having a genetic susceptibility for this disorder and that CH is more common than the relevant medical literature suggests.

Kaposi's sarcoma in a patient with psoriasis vulgaris

A 54-year-old woman presented with angiomatous lesions located on the upper extremities and right cruris. Histopathological findings were typical of Kaposi's sarcoma (KS). She had had mild to moderate psoriasis since she was 25 years old. She had been using cilazapril (an angiotensin-converting enzyme inhibitor) for the last 9 months. She had had similar lesions in the past while taking the same medication. Because our patient's KS lesions had developed during treatment with cilazapril, the drug was stopped. One month later, spontaneous regression of KS nodules was noted and after 4 months no KS lesions were seen.

Endogenous ochronosis

Endogenous ochronosis or alkaptonuria is a rare, autosomal recessive disease of tyrosine metabolism that is caused by a deficiency of the enzyme homogentisic acid oxidase. The disease results in the accumulation and deposition of homogentisic acid in the cartilage, eyelids, forehead, cheeks, axillae, genital region, buccal mucosa, larynx, tympanic membranes, and tendons. The disease generally presents in adults with arthritis and skin abnormalities; occasionally, involvement of other organs may be seen. A 49-year-old man was referred to our clinic with verrucous lesions on his hands. On physical examination, caviar-like ochronotic papules were found around his eyes and the helix cartilage of his ears, and on the dorsa of both hands. There were brown macules on the sclera (Osler's sign). The patient had arthritis and nephrolithiasis, and a sample of his urine darkened upon standing. Histopathological examination showed deposition of ochronotic pigment. High-dose ascorbic acid was given, and the patient showed improvement on follow-up examination 6 months later.

Elephantiasis nostras verrucosa on the abdomen of a Turkish female patient caused by morbid obesity

Elephantiasis Nostras Verrucosa is a rare disorder of an extremity or a body region, which is associated with chronic lymphedema. There are 7 reported cases of abdominal elephantiasis in the medical literature. Here we report a morbidly obese female patient with elephantiasis nostras verrucosa on the abdominal wall.

Hypopigmented mycosis fungoides associated with atopy in two children

Mycosis fungoides is very rare in children. Hypopigmented lesions of this disease are usually observed in dark-skinned individuals and often show a T supressor CD8(+) phenotype. Two Caucasian children with predominantly hypopigmented lesions of mycosis fungoides are presented here. Atopy was a concomitant feature in both.

Skin involvement and outcome measures in systemic autoimmune diseases

This paper focuses on skin manifestations that can be observed in autoimmune diseases such as rheumatoid arthritis (RA), Sjögren syndrome (SS), dermatomyositis (DM) and Behçet syndrome (BS). In RA the most widely recognized skin lesion is the rheumatoid nodule. Other cutaneous manifestations can be observed either non-specific or related to the disease itself and/or to the commonly used drugs. Cutaneous manifestations are considered one of the most typical extraglandular features of primary SS, generally they are distinguished in vasculitic and non vasculitic lesions. Among non-vasculitc lesions, skin dryness (xerosis) has been shown to be very common in pSS while vasculitis lesions include typically flat and palpable purpura and urticarial vasculits. In DM the skin manifestations are also frequent and include a heliotrope rash (blue-purple discoloration) on the upper eyelids with edema, a flat red rash on the face and upper trunk, and erythema of the knuckles with a raised violaceous scaly eruption (Gottron rash). The most frequent mucocutaneous finding in BS is aphthous stomatitis which can not usually be differentiated from idiopatic reccurrent aphthous stomatitis on clinical grounds. The most typical skin manifestations are nodular lesions, which are commonly seen in BS and may be due to panniculitis [erythema nodosum (EN)-like lesions] or superficial thrombophlebitis.

Toxic Epidermal Necrolysis after Cranial Radiotherapy and Phenytoin Treatment

BACKGROUND

There are few reports about Stevens-Johnson syndrome, a bullous form of erythema multiforme, that can develop in patients treated with cranial irradiation and antiepileptic drugs, especially with phenytoin. We present a patient who developed toxic epidermal necrolysis, a rare and severe form of Stevens-Johnson syndrome, during cranial radiotherapy and phenytoin treatment.

CASE REPORT

A 65-year-old male patient with stage IIIB non-small cell lung carcinoma developed a brain metastasis. The patient was treated with phenytoin and dexamethasone. Palliative total cranial irradiation was performed. On the 23rd day of phenytoin administration, erythema and edema in the radiotherapy area and lips, as well as widespread maculopapular eruptions and rashes in the upper thoracic area were observed. The dermal lesions progressed to bullae and subsequently toxic epidermal necrolysis covering 70% of the whole body surface developed. The patient died within 15 days of appearance of the lesions due to secondary infections, despite supportive and symptomatic treatment.

CONCLUSION

Although toxic epidermal necrolysis is a rare toxicity it must always be considered during cranial irradiation and antiepileptic prophylaxis.

Congenital syphilis presenting with nephrotic syndrome and leucocytoclastic vasculitis

Nephrotic syndrome is a well-recognized entity in congenital syphilis but leucocytoclastic vasculitis has not yet been described. We report a case of nephrotic syndrome and leucocytoclastic vasculitis associated with congenital syphilis in a 45-day-old male infant who did well after treatment with intravenous penicillin.

Clinicopathologic evaluation of nodular cutaneous lesions of Behçet syndrome

Among the cutaneous manifestations, nodular lesions are rather common in Behçet syndrome. The histologic nature of these lesions has been a matter of controversy. To establish their distinguishing features, biopsy specimens from nodular lesions of 24 patients with Behçet syndrome, 25 with nodular vasculitis (NV), and 20 with erythema nodosum (EN) were compared. Statistical analysis revealed insignificant differences between most of the histologic features of Behçed syndrome and NV. However, neutrophil-predominating infiltrate in the subcutis was more common in Behçet syndrome, while necrosis and granuloma formation were encountered more frequently in NV. The differences between Behçed syndrome and EN were more significant. Septal panniculitis, lymphocyte-predominating infiltrate, absence of many vascular changes as well as vasculitis, and necrosis were features in favor of EN. Nodular lesions of Behçet syndrome are mainly neutrophilic vascular reactions with histologic features similar to NV but significantly differing from EN associated with other systemic diseases.

Familial erythromelanosis follicularis and chromosomal instability

We report a 17-year-old male patient with erythromelanosis follicularis faciei et colli (EFFC), oral leucokeratosis and diabetes mellitus without islet cell antibody. His sister also had minimal findings of EFFC and minimal follicular papules on her shoulders and extensor surfaces of the arms. The father had only fine follicular papules, but no erythromelanosis. Skin and mucous membrane lesions of the proband were investigated histopathologically. Interestingly, in peripheral lymphocyte cultures of the family members, chromosomal breakage was not observed spontaneously, but it was seen with nitrogen mustard, although this disease may be of autosomal recessive inheritance. Thus, we suggest that EFFC may be a polyaetiological disorder (i.e. familial and environmental) and might be considered one of the chromosomal instability syndromes.

An experimental study of skin flap associated with muscle: is muscle nourishment possible through the musculocutaneous perforators?

An experimental study was planned to examine whether the blood supply of muscle would be maintained by reverse flow from the cutaneous arteriolar microcirculatory system via the musculocutaneous perforators. A flap model containing both muscle and skin based on the inferior superficial epigastric vessels was designed with the blood supplied directly from the cutaneous arteriolar microcirculatory system. A total of 154 male Wistar Albino rats were divided into three groups. Group I included the standard vertical rectus abdominis musculocutaneous flap based on the superior deep epigastric vessels (N = 48). Group II included the acute cutaneous muscle flap (N = 53). Group III contained the delayed cutaneous muscle flap (N = 53). Skin flap survival area, muscle scintigraphy with technetium-99m-methoxy-isobutyl-isonitrile, microangiography, and histopathological examination of the flaps were conducted. The mean percentage of surviving skin paddle area was 96.4 +/- 5.2%, 84.9 +/- 21.6%, and 91.0 +/- 16.8% in groups I, II, and III respectively. There was no significant difference between groups. Microangiography revealed the blood flow from skin to muscle through the musculocutaneous perforators. The radioisotope uptake of the muscle flap was expressed as A percentage of the intact contralateral muscle. Mean uptake in group I was 90.1 +/- 4.9% immediately after flap elevation, 62.5 +/- 13.5% on day 2, and 88.3 +/- 12.0% on day 7. These values were 53.7 +/- 7.1%, 63.6 +/- 14.1%, and 89.2 +/- 18.1% in group II, and 64 +/- 7.8%, 75.5 +/- 9.8%, and 92.8 +/- 40.1% in group III. Radioisotope uptake in group I was significantly higher than groups II and III immediately after flap elevation (p < 0.05, analysis of variance), whereas there was no significant difference on days 2 and 7. Histopathological examination revealed surviving muscle tissue without marked atrophy. There was no marked difference between groups histopathologically. These results indicate that muscle tissue may survive by reverse flow through the musculocutaneous perforators when elevated with an axial skin flap.

An unusual long-term complication of burn injury: malignant fibrous histiocytoma developed in chronic burn scar

Development of malignant tumors in chronic burn wounds is a well-known complication. These tumors are almost always squamous cell carcinomas, although other types of malignancies such as basal cell carcinoma, malignant melanoma and sarcomas can be seen rarely. There are only three previously reported cases of malignant fibrous histiocytoma developed in chronic burn scar in the literature. Two cases with malignant fibrous histiocytoma developed in chronic, badly treated burn wounds are presented. One of the tumors was multifocal and overexpression of the p53 gene was present. Both tumors were excised widely and skin grafted. Regional lymph node dissection was performed in one case. One of the patients died due to tumor recurrence and lymphatic metastases. These cases represent a very uncommon complication of burn injury and indicate the importance of the appropriate primary treatment of the burn wound.

Anorectal melanoma metastatic to the breast

Anorectal melanoma is an extremely rare malignancy with poor prognosis. Patients generally present with a sensation of mass and rectal bleeding, which is usually attributed to hemorrhoids or polyps. It can not be diagnosed early because of these benign symptoms, so it is bulky at the time of presentation. Despite aggressive surgery, 5-year survival is less than 10%. We present a case of inoperable anorectal melanoma which metastasized to the left breast and abdominal lymph nodes. We also briefly reviewed the appropriate literature, emphasizing the diagnostic and therapeutic approaches.

Eruptive widespread Spitz nevi: can pregnancy be a stimulating factor?

Spitz nevus is most commonly a benign solitary lesion. Agminated or disseminated Spitz nevi represent an uncommon manifestation of this nevus. We report an unusual case of Spitz nevi arising and disseminating during pregnancy.