Faculty Bibliography

A 42-year-old man presented with a six-month history of a slowly-enlarging ulcer on his right sole, a 30-year history of altered pigmentation of the trunk and extremities, and hyperkeratotic papules of the palms and soles. Histopathologic examination showed an invasive squamous-cell carcinoma of the right sole and hyperkeratosis with keratinocyte atypia of the left finger and left lateral foot. The clinical and histopathologic findings are consistent with chronic arsenicism, which most commonly occurs in the setting of drinking contaminated water or after occupational exposure. Evaluation should include a physical examination, basic laboratory work-up, and measurement of a 24-hour urine arsenic concentration. Vigilant surveillance for the development of cutaneous malignancies is required. Oral retinoids may be helpful in reducing hyperkeratosis secondary to chronic arsenicism

A 59-year-old man presented with a well-demarcated, tender ulcer at the base of the penile shaft that had been present for approximately five years. The ulcer had been responsive neither to topical antibacterials, antifungals, and glucocorticoids nor to oral acyclovir. A biopsy specimen showed an intra-epidermal neoplasm consistent with extramammary Paget disease (EMPD) based on light microscopy and immunohistochemistry. Patients with EMPD require extensive medical evaluation because of its association with adnexal carcinoma and visceral malignant conditions. Evaluation should include a full body skin and lymph node examination, colonscopy, cystoscopy, and sex-specific studies including pelvic and breast examinations, with imaging for women and prostate examination with prostate specific antigen levels for men. Close monitoring after treatment is important because of the recognized risk of recurrence and malignant conditions

A 22-year-old woman with mixed connective-tissue disease presented with a 5-month history of recurrent episodes of tender, erythematous papules, nodules, and edematous plaques on the upper extremities and thighs. Cutaneous lesions occurred in the setting of livedo reticularis. A biopsy specimen showed interstitial and perivascular inflammation with lymphocytes, macrophages, neutrophils, nuclear dust, collagen alteration, extravasated erythrocytes, and fibrin within small superficial blood vessels. These changes were consistent with a diagnosis of palisaded neutrophilic and granulomatous dermatosis, which is a rare entity that includes a combination of a neutrophilic infiltrate, abnormal or altered collagen, granuloma formation, and leukocytoclastic debris in the context of an immune-mediated collagen vascular or systemic disease. The underlying mechanism remains poorly understood. Treatment is limited, and resolution of lesions typically occurs within several months to years

A 39-year-old man with foveal hypoplasia, nystagmus, and decreased visual acuity was found to have multiple, cutaneous, hypopigmented macules. Macromelanosomes were demonstrated in normal skin on histopathologic examination. The patient's constellation of findings along with a strong X-linked inheritance pattern in family members led to the diagnosis of X-linked ocular albinism, which is an uncommon condition that is characterized by congenital nystagmus, iris translucency, hypopigmentation of the ocular fundus, strabismus, foveal hypoplasia, photophobia, and impaired vision

Two patients receiving epidermal growth factor receptor inhibitors for cancer treatment developed papulopustular eruptions a few days after starting treatment. One patient is a 56-year-old man with metastatic lung cancer treated with erlotinib. Bacterial cultures of the nares and a pustule showed no growth. The eruption improved with a lowered dose of erlotinib and the application of topical clindamycin solution and triamcinolone cream. The other patient is a 53-year-old man with metastatic rectal cancer treated with cetuximab. Bacterial culture of a pustule grew Staphylococcus aureus, and a skin biopsy specimen showed a suppurative folliculitis. The eruption improved with a two-week course of oral antibiotics and the application of topical clindamycin solution and triamcinolone cream. A papulopustular eruption occurs in up to 90% of patients treated with epidermal growth factor receptor blocking agents and may correlate with a positive response to chemotherapy. Treatment options are based on anecdotal evidence and may include topical antibiotics, topical glucocorticoids, and oral antibiotics for secondary infection

Eumycetoma is a localized, chronic fungal infection of skin and subcutaneous tissues. It is characterized by tumefaction, abscess formation, draining sinuses, and sclerotia (grains) within the abscesses and fistulae. Treatment of eumycetoma is a challenge. Relapse rates are high even when a combination of surgical and medical approaches is utilized. Here we report a case of eumycetoma due to Exophiala jeanselmei arising on the foot of a man from Trinidad, West Indies

A 29-year-old male with AIDS was treated with bleomycin and vincristine for visceral Kaposi's sarcoma. Three days later, he developed two distinct eruptions simultaneously. One eruption was characterized by tender, erythematous, edematous plaques and nodules on the palmar and dorsal surfaces of the hands, forearms, and elbows. The other consisted of grouped, erythematous, hyperpigmented streaks on the trunk, buttocks, and extremities. The patient subsequently received a second treatment consisting of vincristine with adriamycin, without bleomycin, and no cutaneous effects were seen. Diagnoses of flagellate erythema and acral nodular eruption secondary to bleomycin were made and confirmed histopathologically. To our knowledge, this is the first report of two cutaneous side effects of bleomycin appearing simultaneously in a patient with AIDS

A 23-year-old man presented with a 3-year history of painful ulcerations and retiform scarring of his lower extremities. Skin biopsy revealed evidence of thrombotic vasculopathy. Livedoid vasculopathy is an uncommon condition presenting as painful lower extremity ulceration and scarring in the form of irregular, ivory-white, stellate plaques. Its pathogenesis is unclear, but it is thought to result from coagulation and fibrinolytic disorders causing occlusion of dermal vessels