Trichoscopy: an update

Hair and scalp disorders represent a substantial complaint in most dermatologists' daily practice. Trichoscopy is a simple and easy-to-perform technique that has been utilized for diagnosis and management of these patients. The interest for this technique had increased in the last years, and knowledge had expanded. This article reviews the most important dermoscopic patterns in normal Caucasian and African scalp, as well as in the most common trichological conditions.

[Age peculiarities of the sebaceous glands in the temporal area of the scalp skin in men]

The changes of the sebaceous gland number, size and sebocyte proliferative activity were studied in the temporal area of the scalp skin in the male individuals aged 10 to 70 years (n=77, autopsy material). The minimal number of the sebaceous glands was observed in children. This index rapidly increased thereafter, reaching a peak at 20 years, then gradually decreased. These parameters correlated with the sebaceous gland size, sebocyte proliferative activity and total blood testosterone level. In older men the size of the sebaceous glands was increased.

[Age-related changes of the epidermis of men's scalp]

Histological, morphometric and immunocytochemical methods were used to study the autopsy samples of the interfollicular epidermis in the temporal region of scalp of male individuals aged from 7 months to 75 years. Monoclonal antibodies against Ki-67, involucrin and p53 were applied to evaluate the proliferative pool in the epidermis, the thickness of the layer of the cells which started the terminal differentiation, and the fraction of the apoptotic cells. Epidermis in children was thin; it had a low content of Ki-67- and p53-positive cells and small thickness of involucrin-positive cell layer. The highest proliferative activity and maximal thickness of the epidermis were detected at the age of 19-21 years. Thereafter the epidermis thinning was observed, together with the progressive decrease of keratinocyte proliferative activity and an increase of the fraction of p53-positive cells. Absolute thickness of the involucrin-positive cellular layer remained practically constant at different ages, while its proportion in the total epidermal thickness uncreased.

Askin tumor with metastasis to the scalp: a histochemical, immunohistochemical and ultrastructural study

A 29-year-old woman presented with facial edema, and imaging disclosed a tumor extending from the anterior chest wall to the anterosuperior aspect of the mediastinum. Transbronchial cytology of the primary tumor and biopsy of the metastatic scalp lesion were performed. Histologically, the tumor consisted of closely packed small round cells. The neoplastic cells generally had round nuclei, finely dispersed chromatin, and small to prominent nucleoli. Histochemically, the cytoplasm of the neoplastic cells contained abundant glycogen and stained with Grimelius silver. Immunohistochemically, the neoplastic cell membranes reacted with CD99 (MIC2) and the neoplastic nuclei reacted with Fli-1, but various other markers, including lymphocyte and skeletal muscle markers, were not detected. No neoplastic cells were also reactive for chromogranin A, synaptophysin, and neurofilament. Ultrastructurally, some neoplastic cells had delicate cytoplasmic processes and contained membrane-bound dense core granules in the cytoplasm. Even if results are immunohistochemically negative for neuroendocrine markers, the combination of immunohistochemistry of CD99 (MIC2) and Fil-1 may be useful in diagnosing Askin tumor or its metastatic lesion.

A comparative study between AFM and SEM imaging on human scalp hair

A comparative study of AFM and SEM imaging of the same area of a human scalp hair has been carried out to determine the similarity and the differences between the two techniques. Sample preparation for SEM analysis requires a metallization step and vacuum exposure, both of which could potentially induce modifications to the surface details. By contrast, AFM is a suitable technique to evaluate any effect resulting from sample manipulation because it can be applied without any specific treatment. AFM analysis demonstrates that sample metallization is responsible for modifications to the surface details of hair, mainly comprising an increase in height of scale steps and of root mean square roughness together with variation in scale profiles. Sample treatments for SEM imaging are in general potentially responsible for surface modifications to the samples involved.

Lipomatous mixed tumour of the skin: a histological, immunohistochemical and ultrastructural study

BACKGROUND

Mixed tumours are composed of an admixture of an epithelial/myoepithelial and usually a myxochondroid stromal component. Adipocytes are found more rarely, and account for a minor part of the tumour. To date, only three cases of mixed tumour/pleomorphic adenoma of the salivary gland have been described, showing an extensive adipocyte content of more than 90% of the tumour tissue. Owing to this peculiarity, some authors have defined it as 'lipomatous pleomorphic adenoma'. We are not aware of previously reported similar lesions in the skin.

OBJECTIVES

We report a case of a tumour that occurred as a 2 x 2 x 1.5 cm nodule in the scalp of a 65-year-old man. Analogies with salivary lipomatous pleomorphic adenoma, as well as histogenesis and differential diagnoses are discussed here.

METHODS

A histological, immunohistochemical and ultrastructural study was performed.

RESULTS

The tumour was well-circumscribed and showed a substantial mature adipose tissue component intermingled with epithelial cells arranged in ducts and branching tubules, embedded in a fibromyxoid stroma, which was diagnostic of a chondroid syringoma/mixed tumour. Adipocytes strongly expressed S-100 protein and cytokeratin 14. Transitional elements from epithelial/myoepithelial cells into adipocytes were observed. They coexpressed cytokeratin 14, S-100 protein and vimentin, and showed lipid droplets, desmosome-type junctions, cytoplasmic tonofilaments and basal lamina.

CONCLUSIONS

The tumour differed from lipomas with myxoid stroma and from lipoadenomas, which show non-proliferating normal sweat glands admixed with adipose tissue. Because of the similarity to lipomatous pleomorphic adenoma/mixed tumour of salivary glands, we suggest that it should be called 'lipomatous mixed tumour of the skin'.

Dandruff has an altered stratum corneum ultrastructure that is improved with zinc pyrithione shampoo

Transmission electron microscopy of scalp tape strips indicates that dandruff scalp possesses abnormal stratum corneum (SC) ultrastructure that is normalized by treatment with small-particle zinc pyrithione (ZPT). Similar abnormalities occur throughout the scalp of those with dandruff, even where no flaking is present. SC abnormalities are consistent with hyperproliferation, including parakeratosis, lipid droplets within corneocytes, few desmosomes, corneocyte membrane interdigitation, and excessive disorganized intercellular lipid. Reversal of SC abnormalities would require treatment of the cause(s) of dandruff, not merely flake removal. A protocol was developed to quantify scalp structural abnormalities by scoring cells from scalp tape strips for yeast number, amount of intercellular lipid, normal intercellular lipid structures, prevalence of intracellular lipid droplets, parakeratotic corneocytes, and corneocyte interdigitation. This protocol was used to compare dandruff and normal SC to dandruff SC treated with either commercial ZPT-containing shampoo or a placebo. Treatment with commercial ZPT shampoo significantly returned SC ultrastructure to normal, suggesting control of the cause of dandruff.

Lipedematous alopecia: a clinicopathologic, histologic and ultrastructural study

Lipedematous alopecia is a rare condition of unknown etiology characterized by a thick, boggy scalp with varying degrees of hair loss that occurs in adult black females, with no clearly associated medical or physiologic conditions. The fundamental pathologic finding consists of an approximate doubling in scalp thickness resulting from expansion of the subcutaneous fat layer in the absence of adipose tissue hypertrophy or hyperplasia. Observations by light and electron microscopy detailed in this report suggest that this alteration principally manifests by localized edema with disruption and degeneration of adipose tissue. Some diminution in the number of follicles as well as focal bulb atrophy is noted. Aberrant mucin deposition such as that seen in myxedema or other cutaneous mucinoses is not a feature. The histologic findings bear some resemblance to those seen in lipedema of the legs, a relatively common but infrequently diagnosed condition. We present a case of lipedematous alopecia with emphasis on histologic and ultrastructural features. The etiology is unknown.

A quantitative method for analysing AFM images of the outer surfaces of human hair

Cuticle step height is an important parameter for the quantitative assessment of human hair. This paper describes a novel, computational method for the rapid calculation of step heights from atomic force microscope images obtained from large numbers of specimens. Such an approach is necessary to allow a statistical analysis of the inherently wide distribution of cuticle step heights characteristic of a single hair sample. The method described will be of use to cosmetic formulation chemists and forensic scientists and also to dermatologists in the field of disease diagnosis.

Increased scalp skin and serum 5 alpha-reductase reduced androgens in a man relevant to the acquired progressive kinky hair disorder and developing androgenetic alopecia

BACKGROUND

The acquired progressive kinking of scalp hair is a disorder in which affected hairs resemble secondary sexual hairs. Some authors have evoked an androgen-related disorder that heralds the onset of androgenetic alopecia. To verify this hypothesis, we focused our attention on a 23-year-old man who has this unusual disorder, which is progressing toward androgenetic alopecia. Patient's circulating 5 alpha-reductase reduced androgen levels; scalp skin 5 alpha-dihydrotestosterone formation; and trichography, histological, scanning, and polarizing electron microscopy analyses were compared in normal and affected scalp skin areas.

OBSERVATIONS

Results of histological and scalp skin 5 alpha-dihydrotestosterone formation analyses and comparison of growth pattern of kinky hair in the affected areas with that of healthy hair were similar to those found in androgenetic alopecia.

CONCLUSIONS

No data are available to confirm the presence of a sole entity, even if our arguments support our hypothesis. The confirmation of this tendency warrants further investigation.

Ultrastructural abnormalities in the dermal papillae of both lesional and clinically normal follicles from alopecia areata scalps

Alopecia areata is a form of balding whose aetiology is uncertain. Although the dermal papilla in the hair bulb regulates the follicle and may play a part in the pathogenesis of alopecia areata, its ultrastructure has not been well described. As clinically normal, i.e. non-balding, follicles from alopecia areata scalps show abnormalities at the light microscope level, it would be expected that they should exhibit the earliest pathological changes involved in the dysfunction of the follicle. This study was designed to investigate the ultrastructure of normal human scalp follicular dermal papillae and to see if changes occurred in the ultrastructure of dermal papillae from either lesional or non-balding regions of alopecia areata. Normal dermal papillae contained well formed fibroblast-like cells with large, oval nuclei and well-developed endoplasmic reticulum; the cells were separated from each other by extracellular matrix containing small pieces of collagen and basal lamina-like material. Dermal papillae from both clinically normal and lesional alopecia areata follicles were less well organized and the dermal papilla cells exhibited signs of cell injury and contained abnormal amounts of pigment; an increased concentration of fibrous material in the extracellular matrix and thickening of the dermal papilla-epithelial junction were also seen. Follicles from lesional areas showed more pronounced changes than clinically normal ones. Ultrastructural abnormalities in the dermal papillae of clinically normal scalp follicles support the study of these follicles as a prime research target. The changes detected suggest that dermal papilla cells in alopecia areata would be less able to synthesize regulatory factors and that these may have more difficulty crossing into the epithelial compartment. They are consistent with an early pathological role for the dermal papilla in alopecia areata, but do not distinguish whether this is a primary aetiological role or a secondary response to an insult elsewhere in the follicle.

Accordion-like structure of terminal hair follicles of the human scalp

Terminal hair follicles extracted after ethylenediaminetetraacetic acid treatment preserved the basal cell surface of the outer root sheath well enough to examine the outer surface in detail. Light microscopic observations of whole mount specimens revealed several sawtooth-like structures of follicular epithelium in the lower portion of terminal hair follicle. Vertical sections of the human scalp also showed several invaginations of the outer root sheath of terminal hair follicles in the lower portion, not in association with the arrector pili muscle. Scanning electron microscopy of the same specimens demonstrated accordion-like structures below the sebaceous gland in the lower half of anagen terminal hair follicles and surrounding the entire circumference of the follicles. Sawtooth-like structures were unilaterally observed at the level of the middle or lower portion below the sebaceous gland. With transmission electron microscopy, these structures were seen as undulations of basal cells which preserved hemidesmosomes, although the basal lamina had been peeled off during the extraction procedure. Thus, this accordion-like structure is a genuine structural variation of some human anagen hair follicles and not an artifact.

Scanning electron microscopic observations of extracted terminal hair follicles of the adult human scalp and eyebrow with special references to the bulge area

Scanning electron microscopic studies of human terminal hair follicles of the scalp and eyebrow have previously been limited to the hair shaft. In this study we investigated EDTA-treated extracted whole hair follicles in which most of the basal cell surface of the outer root sheath was well preserved. In the bulge area of scalp follicles there were many knob-like or villous projections. These were located in some specimens on one side of the follicle, while in others they were located around the entire circumference of the follicle. These projections were thought to represent the anchoring points of the branched follicular end of the arrector muscles. Ring-like elevations with groove-like depressions above and below were also observed surrounding the entire follicle. These were thought to represent the track of circumfollicular arrector muscles which depressed the outer root sheath when they repeatedly contracted. Most anagen eyebrow follicles showed morphological variations in the bulge area such as lattice-window-like structures and undulation patterns. In telogen follicles, the bulge became indistinguishable from the clubbed end. The lower end of these telogen follicles showed irregularly shaped bulge areas, but did not show lattice-window-like structures or undulation patterns as observed in anagen follicles. Interestingly, a hole was found in some bulge areas of both anagen and telogen follicles. Serial vertical sections of follicles revealed invaginated areas, which seemed to correspond to the openings seen in whole mounts. In vertical sections of eyebrow follicles some keratinocytes of the outer root sheaths of the bulge area were seen to be melanized to various extents. This phenomen was independent of hair cycle phase.

Eosinophilic panniculitis

Eosinophillic panniculitis is a poorly defined entity with variable clinical features. We report a case of rapidly enlarging, asymptomatic subcutaneous scalp nodules in a 6-year-old black boy with atopic dermatitis. The nodules resolved spontaneously over two to three days. Biopsy specimens were remarkable for eosinophilic panniculitis without evidence of epidermal change or vasculitis. We believe that this is the youngest reported patient with this disorder.

Immunocytochemical localization of androgen receptors in the scalp of the stumptail macaque monkey, a model of androgenetic alopecia

The purpose of this study was to identify the distribution of androgen receptors in the bald and hairy scalp of adult male and female stumptail macaque monkeys by light microscopic biotin-avidin immunocytochemistry with a highly purified rat monoclonal antibody against the cloned human androgen receptor. Consistent, intense nuclear and minimal cytoplasmic immunostaining was observed in several distinct cell populations of the pilosebaceous unit including the dermal papilla, hair epithelium, outer root sheath, dermal sheath, and sebaceous gland. A similar distribution of androgen receptors was found in miniaturized and terminal anagen and telogen follicles of the bald and hairy scalp, respectively. Binding of androgen receptor antibody was also detected in dermal fibroblasts, basal and intermediate layers of the interfollicular epidermis, and duct and glandular cells of eccrine sweat glands. This investigation demonstrates the presence of androgen receptors in the pilosebaceous unit of the scalp of the stumptail macaque and also shows that their distribution is comparable to that previously reported for humans.

Malignant meningioma of the scalp

A nodule from the scalp of a 14-year-old boy was diagnosed by light and electron microscopy as a meningioma. There was no evidence of an intracranial lesion or involvement of the bone of the skull. The tumor was excised but recurred and metastasized to lung and chest wall.

Scanning electron microscopy of scales from pityriasis amiantacea

The scanning electron microscope has been used to examine scales taken from the scalp of 3 patients with pityriasis amiantacea alone, 3 psoriatic patients with pityriasis amiantacea and one patient with both atopic dermatitis and pityriasis amiantacea. Samples from 2 patients were additionally studied by different fixation techniques and in the frozen hydrated state, but no cementing of the scales could be observed. There was no evidence of an infective agent.

Ultrastructural localization and quantification of extracellular calcium binding sites in mouse vibrissa and human scalp follicles

The purpose of these experiments was to determine if an extracellular calcium binding site gradient is evident in freshly dissected or cultured mouse vibrissa and human scalp follicles and to measure possible drug effects on this gradient. Mouse vibrissae were cultured with or without either minoxidil or pinacidil, and human scalp follicles were cultured with or without epidermal growth factor. Anagen vibrissa and scalp follicles were dissected and placed in culture for 4 h to 4 days, then fixed in a solution containing lanthanum chloride and prepared for either quantitative energy-dispersive X-ray microanalysis (X-ray) or qualitative transmission electron microscopy (TEM). Since lanthanum has a high charge density it displaces Ca2+ ions from anionic binding sites. TEM analysis revealed extensive accumulation of electron-dense lanthanum deposits in the intercellular compartment of differentiating cells in the hair shaft and inner root sheath in the apex of the follicular bulb. Sparse lanthanum precipitate was observed in the intercellular space of the proliferative cells at the base of the bulb. This gradient of lanthanum precipitate was evident in both freshly dissected and cultured vibrissa and scalp hair follicles, irrespective of treatment with drugs that grow hair or epidermal growth factor. X-ray microanalysis indicated that percent by weight of lanthanum was markedly higher in the apex compared to the base of the follicular bulb in vibrissa and scalp follicles. These qualitative and quantitative data demonstrate that an extracellular calcium binding site gradient exists in cultured vibrissa and scalp hair follicles, and that this gradient is not significantly affected by hair growth altering drugs including minoxidil or pinacidil, and epidermal growth factor.

Characterization of inflammatory infiltrates in male pattern alopecia: implications for pathogenesis

Hair-bearing, transitional, and alopecic scalp from three males and one female with progressive pattern alopecia were examined. Ultrastructural studies disclosed measurable thickening of the follicular adventitial sheaths of transitional and alopecic zones compared with those in the non-alopecic zones. This finding was associated with mast cell degranulation and fibroblast activation within the fibrous sheaths. Immunohistochemically, control biopsies were devoid of follicular inflammation (n = 3), while transitional regions consistently showed the presence of activated T-cell infiltrates about the lower portions of follicular infundibula. These infiltrates were associated with the induction of class II antigens on the endothelial linings of venules within follicular adventitia and with apparent hyperplasia of follicular dendritic cells displaying the CD1 epitope. Inflammatory cells infiltrated the region of the follicular bulge, the putative source of stem cells in cycling follicles. The data suggest that progressive fibrosis of the perifollicular sheath occurs in lesions of pattern alopecia, and may begin with T-cell infiltration of follicular stem cell epithelium. Injury to follicular stem cell epithelium and/or thickening of adventitial sheaths may impair normal pilar cycling and result in hair loss.

Keratosis follicularis spinulosa decalvans: report of a case with ultrastructural study and unsuccessful trial of retinoids

Keratosis follicularis spinulosa decalvans (KFSD) is a genetic disorder characterized by disseminated follicular hyperkeratosis, especially localizated to scalp and face. We report the case of a new patient displaying typical features of KFSD. Ultrastructural study was performed and displayed round keratohyalin granules in follicular keratinocytes. Trial with etretinate, which has not been reported before in this disease, proved to be ineffective.

Cutaneous metastasis of renal cell carcinoma: an electron microscopic study

A case of cutaneous metastasis of renal cell carcinoma in a 67-year-old man is described. Right side nephrectomy had been performed three years earlier, and a renal cell carcinoma was diagnosed. Following a bruise, the patient noticed an erythematous nodule on the scalp. Histological examination of this skin lesion showed atypical tumor cells consisting predominantly of clear cells with a honeycomb-like or adenoid structure. Electron microscopic examination revealed that the tumor cells were divided into three groups: clear cells with abundant glycogen, dark cells with abundant mitochondria, and intermediate cells containing both glycogen and mitochondria in varying proportions. Some of the tumor cells with an adenoid pattern had a brush border-like structure in the lumen. These results support the diagnosis of metastatic renal cell carcinoma. An electron microscopic approach may aid in diagnosis of cutaneous metastasis from renal cell carcinoma.

Proliferating trichilemmal cyst with apocrine-acrosyringeal and sebaceous differentiation

An adnexal tumor on the scalp of a 74-year-old woman is described. Histologically, the tumor was composed of cystic structures showing typical trichilemmal keratinization. The tumor cells in the cyst walls often formed duct-like or squamous eddy-like structures and occasionally showed vacuolation or poroma-like change. Ultrastructurally, some tumor cells showed differentiation either toward the acrosyringium or sebaceous cells. From these findings, the present tumor is considered to differentiate toward various parts of the hair follicle including infundibulo-isthmus epithelium, apocrine acrosyringium, and sebaceous cells.

Distribution of proteoglycans during the hair growth cycle in human skin

The involvement of proteoglycans in hair growth has been recognized through the observation of increased hair growth in diseases such as the mucopolysaccharidoses and pre-tibial myxedema, which involve an increase in skin proteoglycan content. In an attempt to understand this, we have examined the distribution of chondroitin 6 sulphate (C6S), unsulphated chondroitin (COS), dermatan sulphate (DS), and heparan sulphate proteoglycans (HSPG) in frozen tissue sections of normal scalp by immunostaining. Results show that during anagen, the thick connective tissue sheath around the follicle strains strongly for C6S, COS, and DS. COS is uniquely associated with this region and is not found beneath the epidermis or infundibular epithelium. HSPG is, however, localized in the basement membrane zone adjacent to the outer root sheath. In addition, all of these proteoglycans are localized in the dermal papilla. In mid-catagen, we observed significant loss of C6S and COS staining from both the dermal papilla and the connective tissue sheath, but no decrease in staining for HSPG. In late catagen, very little staining of C6S and COS was observed. In early anagen, we observed that C6S was again present in the connective tissue sheath and dermal papilla; however, COS staining appeared to be weaker and less closely associated with the follicle. HSPG staining was observed in early anagen in a pattern very similar to that found for other basement membrane components. Results for DS were not obtained for catagen or early anagen. These results provide further evidence that hair growth is associated with the presence of chondroitin proteoglycans in the follicle environment and that the cessation of growth is associated with their removal. Further studies are underway to characterize the relationship between hair growth and proteoglycans.

The Rapp-Hodgkin syndrome

We report on a family with the Rapp-Hodgkin ectodermal dysplasia syndrome. Four affected family members are described and a review of the literature is given.

Segmental neurofibromatosis

Two patients had localized multiple cutaneous neurofibromas; one had bilateral involvement of the scalp and the other had true segmental neurofibromatosis. Other signs of neurofibromatosis were absent. Segmental neurofibromatosis may not be related to the generalized types of neurofibromatosis but may be a cutaneous hamartoma.

Cranial fasciitis

We present the clinical, roentgenographic, light-microscopic, immunohistochemical, and ultrastructural findings in two children with cranial fasciitis. A 7-year-old boy and a 3-year-old girl presented with rapidly expanding masses on the scalp. Roentgenographic studies showed erosion of the underlying cranium in one case. Both lesions showed proliferations of elongated spindle cells in a focally myxoid matrix, together with areas of hemorrhage, vascular proliferation, and chronic inflammation. Occasional cells with atypical nuclei were observed, but mitotic figures were uncommon. Immunoperoxidase studies showed negative or equivocal staining for desmin, factor VIII-associated antigen, S100 protein, and macrophage antigen. In one lesion there was focal positivity for alpha 1-antichymotrypsin, and in another lesion, some cells stained positively for smooth-muscle actin. Electron microscopy showed cells with dilated endoplasmic reticulum, bundles of microfilaments, pinocytotic vesicles, and focal external membrane material, features of myofibroblasts. Both lesions were excised and there has been no recurrence in 7 years in one case and 1 year in the other case. Cranial fasciitis is closely related to nodular fasciitis, but it has a predilection for the scalp of children. Despite its rapid growth, it has a benign clinical course and is cured by excision with or without curettage of the underlying bone. Our immunohistochemical and ultrastructural observations indicate that, like nodular fasciitis, cranial fasciitis represents a proliferation of fibroblasts and myofibroblasts.

A clear cell pilar sheath tumor of scalp: case report

A long-standing tumor of scalp is reported characterized histologically by extensive proliferation of pilar epithelium made up exclusively of cells with small round nuclei and clear cytoplasms containing glycogen granules. The tumor epithelium showed no tendency for keratinization and no cytologic atypia. The growth, however, appeared aggressive and replaced the entire thickness of the dermis and extended into the subcutaneous fat tissue.

Fungus invasion into human hair tissue in black dot ringworm: light and electron microscopic study

In order to investigate the morphology of fungi invading into the human hair tissue, three cases of black dot ringworm caused by Trichophyton violaceum and Trichophyton glabrum were studied by light and electron microscopy. Fungal elements were mainly present in the hair cortex and showed a constant morphologic change during the differentiation of hair layers. The fungal elements, located deep in the keratogenous zone of the cortex, showed less electron dense non-septate hyphae. Distally, the hyphae showed septation and contained several scattered dense bodies in the cytoplasm. At the level where the Huxley's layer was keratinized, the fungal elements were transformed into arthrospores, which occupied the large volume of the cortex; each spore was surrounded by a fiber- and melanosome-free, electron lucent halo. Fungal elements occasionally invaded the keratinized hair cuticle and keratinized inner root sheath in a few hair follicles. Fungi do not invade the hair germinative cells. There seems to be a distinct relationship between the morphology of the invading fungi and the cortical cell differentiation in black dot ringworm; a balance between the fungus proliferation and the cortical cell development may be present.

Eccrine porocarcinoma

Eccrine porocarcinoma is a rare malignancy of the eccrine sweat duct unit. This article brings to 79 the number of cases reported. Our report and a review of the literature illustrate the natural history and pathological findings of this disease. Patients' ages at the time of appearance for treatment range from 19 to 90 years. The lesions show no predilection for site; their location follows the distribution of sweat glands in the body. Thirty-nine percent of all patients had cutaneous, regional lymph node, or visceral metastases. Primary treatment is wide surgical excision. The value of adjunctive therapy has not been proved.

High-grade epithelioid angiosarcoma of the scalp. An immunohistochemical and ultrastructural study

The ultrastructural and immunohistochemical characteristics of a high-grade epithelioid angiosarcoma of the scalp are reported. By light microscopy, the neoplasm simulated a poorly differentiated carcinoma, either primary or metastatic from some occult site. Immunohistochemical study, using a specific antibody against factor VIII-related antigen, was positive when direct immunofluorescence was applied to frozen specimens of the neoplasm. Application of immunoperoxidase (avidin-biotin complex method) on paraffin-embedded tissue using the same antibody was negative. Ultrastructually, the neoplasm had a prominent cytoskeleton of intermediate filaments, numerous pinocytotic vesicles, small intercellular lumina with microvilli on their surfaces, and characteristic intracytoplasmic vacuoles. A brief discussion of the differential diagnostic features is made.

Hodgkin's disease presenting with superficial lymph nodes and tumors of the scalp

Invasion of the skin by malignant cells in Hodgkin's disease is a rare occurrence and less common than skin involvement in non-Hodgkin's lymphoma. We describe a 36-year-old man with Hodgkin's disease who presented with superficial lymph nodes and tumors on the scalp as initial clinical findings. Biopsy of a tumor of the scalp showed a diffuse dermal infiltrate composed of polynuclear neutrophils and eosinophils, large lymphocytes, and Sternberg-Reed cells. Ultrastructural examination of the skin biopsy specimens demonstrated the characteristic morphology of the Sternberg-Reed cells.

Epitheloid hemangioendothelioma of the scalp. A case report with immunohistochemical and ultrastructural study

A case of an epitheloid hemangioendothelioma of the skin and subcutaneous tissue of the scalp is described. Clinically and histologically a (metastatic) carcinoma had been considered in differential diagnosis. Of great help in recognition of the endothelial nature of this tumor was the immunohistochemical reaction with Factor-VIII associated antigen and Ulex europaeus antigen. Not only tumor cells in solid areas, but also intracytoplasmic vacuoles revealed positive staining. Thereby it could be shown, that this paranuclear vacuoles are actually compatible with developing capillary lumina. Only few tumor cells showed positive reaction with alpha-1-antichymotrypsin, pointing to a possible small histiocytic component of this tumor. Endothelial features of tumor cells and developing capillary lumina also could be demonstrated by electronmicroscopy.

Immunohistochemical and electron microscopic characterization of the cellular infiltrate in alopecia (areata, totalis, and universalis)

The inflammatory cell infiltrates in scalp skin of 35 patients, 20 with alopecia areata (AA), 7 with totalis, and 8 with universalis were characterized with the ANAE (alpha-naphthylacetate esterase) marker, monoclonal antibodies, and electron microscopy. As demonstrated by the ANAE staining, no clear difference in the main lymphocyte subclasses (T and B cells) or macrophages was seen between the different types of alopecia or as compared to control patients' scalp skin. However, T lymphocytes and macrophages were seen most frequently and in greater numbers perivascularly and infiltrating the hair bulb in those cases of AA where active hair loss took place. Using monoclonal OKT (OKT-3, -4, and -8) antibodies and the avidin-biotin immunoperoxidase method on frozen sections, a concentration of OKT-8 reactive cells (suppressor/cytotoxic T cells) was seen peribulbarly and invading the hair infundibulum. The cells affecting the hair infundibulum were further studied by electron microscopy. They could be classified into three main types: small lymphocytes (60%), macrophages (30%) and cells closely resembling large granular lymphocytes (LGL) (10%). LGL have previously been considered to be human natural killer (HNK) cells. Thus the hair follicle seems to be the target for the cellular immune response in alopecia. Whether HNK cells participate in the destruction of hair bulbs remains to be investigated.

[Spatial organization and interrelations of the structural elements in the human hair follicle]

A complex morphological investigation of the human hair follicle and root has been performed by means of scanning electron microscopy. A volumetric image on all structural elements in the hair follicle and on their spacial interrelations both with each other and with neighbouring tissues have been obtained. A connection of the hair root cuticle and the internal root shealth cuticle by means of variously directed position of their cell-squamae is demonstrated. Between the granule-containing and the pale layers of the inner root sheath (Huxley's and Henle's layers) there is an additional connection, that is mediated at the expense of entrance of pterygoid processes of cells of the granule-containing layer into the oval spaces between the cells of the pale epithelial layer. The connective tissue hair bursa consists of layer-cases inserting into each other, constructed mainly of flat collagenous fibers and connected with each other by connective fibers.

Malignant hemangioendothelioma of the skin

Three cases of malignant hemangioendotheliomas in elderly individuals are recounted. All of them died shortly after onset of the malignancies in spite of radical surgery in one; radical surgery, chemotherapy, and radiotherapy in another; and chemotherapy and radiotherapy in the third. Findings from studies of specimens of the malignancies by conventional microscopy, histochemistry, and electron microscopy are described.

[Congenital hereditary hypotrychosis. Generalized autosomal dominant hypotrichosis with pili torti (hypotrichosis congenita hereditaria Marie Unna)]

Report on a family with numerous relatives in 7 generations suffering from hypotrichosis congenita hereditaria Marie Unna type. Personal investigations were possible in 29 persons. 19 of them presented the characteristic features of the syndrome with pili torti, generalized inborn hypotrichosis and a type of baldness resembling androgenetic alopecia.