Faculty Bibliography

An otherwise-healthy 13-year-old girl with previously normal nails developed longitudinal pigmented bands on multiple fingernails. Physical examination revealed faintly pigmented bands on multiple fingernails and on the left fifth toenail. We believed that the cause of the pigmented bands was onychophagia-induced longitudinal melanonychia, a rare phenomenon, which emphasizes the need for dermatologists to question patients with melanonychia about their nail biting habits because they may not be forthcoming with this information.

BACKGROUND:Cicatricial forms of alopecia, including lichen planopilaris (LPP) and discoid lupus erythematosus (DLE), may present with overlapping clinical features. In such cases, histopathological examination may provide key information for resolving the differential diagnosis. Optimally, microscopical analysis for alopecia requires both vertical and horizontal sections, and this may necessitate multiple samples. Here, we present what we term the "HoVert" technique, which produces horizontal and vertical sections from a single biopsy. We hypothesize that the HoVert technique should be useful for differentiating DLE from LPP. METHODS:A formalin-fixed 4 mm punch scalp biopsy is transected approximately 1 mm below the skin surface to create an epidermal disc and a lower portion. The epidermal disc is bisected and embedded in conventional fashion to obtain vertical sections. The lower portion is serially sectioned and embedded to obtain horizontal sections. RESULTS:The HoVert technique yields vertical sections permitting visualization of the epidermis, the dermal-epidermal junction and perijunctional inflammation. The technique also provides horizontal sections that permit analysis of follicle number, follicle type, perifollicular inflammation and scarring. Evaluation of both vertical and horizontal sections from a single scalp biopsy maximizes the histopathological information obtained and enhances the diagnosis of LPP or DLE in specific cases. CONCLUSIONS:We believe that the HoVert technique represents a simple and diagnostically effective tool in differentiating LPP from DLE. It may also be applicable to the assessment of other forms of alopecia.

A perineurioma is a benign peripheral nerve sheath neoplasm thought to be derived from cells of the perineurium, the cellular sheathing of peripheral nerve fascicles. The histological, immunohistochemical (positive for epithelial membrane antigen, collagen type IV, laminin and vimentin but not S-100 protein) and ultrastructural features of a perineurioma form the basis for diagnosis. Two types of perineuriomas are recognized, intraneural and soft tissue (extraneural) forms. Sclerosing perineurioma is considered a variant of the soft tissue perineurioma. In all but one of the reported cases, this subtype presented as a solitary clinical lesion with a predilection for the fingers and palms of young adults. In 2002, Huang and Sung described a 16-year-old boy with one sclerosing perineurioma on each hand. The unusual case presented herein is a 21-year-old woman manifesting more than 30 cutaneous sclerosing perineuriomas on the hands and arms. This case is the most extensive presentation of sclerosing perineuriomas documented to date and extends the clinical presentation spectrum of these lesions.

Exophiala spinifera has been reported as an agent of cutaneous disease 18 times in the literature. Clinical presentations of cutaneous lesions vary widely, including erythematous papules, verrucous plaques, and deep subcutaneous abscesses. The clinical distribution and course of disease are also variable, depending on the age and immune competency of the patient. Histologic appearance occurs in one of two patterns--phaeohyphomycosis or chromoblastomycosis. While E. spinifera appears to be susceptible to multiple antimicrobial agents in vitro, clinical experience with treatment modalities has been variable. Prior to the availability of sequencing methods, species identification was based on the histopathologic presentation in tissue and morphologic features of the fungus in culture. It is likely that E. spinifera cutaneous infections have been underreported due to its incorrect identification based on earlier methods. We report an additional case of E. spinifera phaeohyphomycosis, the first to be definitively identified by sequencing. In addition, we summarize the variable clinical, histopathologic, and morphologic features, as well as treatment responses described in previously reported cutaneous infections caused by E. spinifera.

Nodular scleroderma, also known as keloidal scleroderma, is a rare form of scleroderma that may occur with either systemic sclerosis or localized scleroderma. Clinically, this disorder is characterized by keloidal nodules that form in sclerodermatous areas. These nodules may histologically show the presence of keloidal collagen. Because of the rarity of this condition, clinicians may not be familiar with the clinical and histologic features relevant to this scleroderma variant. In this report, we describe 2 cases of nodular scleroderma.

A 40-year-old woman presented with a delusion of warts on the forehead, for which she was applying podophyllin toxin. A skin biopsy was taken, which showed prominent mitotic figures in the basal and suprabasal layers of the epidermis and apoptotic keratinocytes. Histopathologically Bowen's disease was suspected, but was discounted after clinicopathological correlation was obtained and showed absence of epidermal atypia or disorganization. This case demonstrates the histological resemblance of podophyllin reaction to Bowen's disease. Differentiation of self-inflicted from organic skin disease may be difficult, especially where histopathological findings are confounded by cutaneous application of toxins.

BACKGROUND:Most cases of myiasis in North America are caused by fly larvae from South America or Africa, as these cases represent travelers returning from endemic regions. The etiology of creeping eruptions and furuncular lesions in North American patients who have no history of recent travel can therefore be a diagnostic problem. Among cases acquired in North America, Cuterebra species are the usual cause. Dermatologists and dermatopathologists should be aware that this unusual infestation may occur without a travel history. METHOD/METHODS:Here we report a case of Cuterebra cutaneous myiasis acquired in New Jersey. A world literature review of articles on Cuterebra myiasis in humans, without age or year restriction, was performed. The pertinent references of those articles were also searched. RESULTS:Most cases occur in the skin, as a furuncle. Sometimes a cutaneous creeping eruption is present. Children account for at least half of the reported cases. The infestations tend to occur in the late summer, and most frequently in the north-eastern and southern states of the United States. An overview of the clinical and histopathologic diagnostic features are presented. CONCLUSIONS:Though rare, myiasis can occur in North America without a travel history. Awareness of this entity, its epidemiologic patterns and diagnostic characteristics, can prevent lengthy delays in diagnosis and unnecessary treatments.