Annular Plaques Research Articles

Porokeratosis of mibelli of upper lip extending into oral mucosa

Porokeratosis is a rare specific disorder of keratinization with distinct clinical and histopathological features with rare malignant degeneration. Clinically, it is characterized by papular lesions or annular plaques with central atrophy and peripheral keratotic ridge and histologically with the presence of cornoid lamellae. It mainly presents on the extremities, trunk, face, and very rarely on genitals and mucous membrane. Very few cases of porokeratosis with oral mucosal involvement have been reported in the past. A 50-year-old female presented with a well-demarcated, irregular plaque with atrophic center and peripheral keratotic margin with a thin furrow involving the left side of the upper lip, angle of mouth, and adjacent labial mucosa. The patient had a history of application of topical steroid preparations intermittently over a period of 2 years. The histopathological features showed characteristic cornoid lamellae. The involvement of mucosa is uncommon, and local immunosuppression caused by topical steroids may act as a predisposing factor.

Annular elastolytic giant cell granuloma: a “visible” diagnosis

Annular elastolytic giant cell granuloma (AEGCG) is a rare granulomatous skin disease of undetermined cause, characterized by annular plaques with raised erythematous borders in sun-exposed skin. The typical histologic features are dermal infiltration by multinucleated giant cells, elastin degeneration, and elastophagocytosis. The authors describe a clinical case of AEGCG, which exhibited an excellent response to hydroxycloroquine.

A Case of Bowen's Disease Successfully Treated with Ingenol Mebutate Gel.

Bowen’s disease represents a form of squamous cellcarcinoma in situ and usually appears as a sharply demarcated erythematous plaque. It can be treated by surgery, curettage and cautery, cryotherapy, 5-fluorouracil (5-FU), laser therapy, radiotherapy, photodynamic therapy, or local or systemic injections of interferon alfa or gamma. Ingenol mebutate is a novel agent extracted from the sap of the plant Euphorbia peplus, which is known to have therapeutic effects on cancerous lesions. A 82-year-old woman visited to our clinic with 1 year history of walnut sized annular erythemaotus plaque on her right ankle. Skin biopsy was done and we could observe irregularly thickened epidermis and throughout the epidermis, the cells lie in disarray resulting in a “windblown” appearance with atypical mitoses. We applied ingenol mebutate 0.05% gel 3 consecutive days once daily to a 9cm2 contiguous field containing the affected area. The local skin reactions (erythema, vesiculation and scales) occurred as we expected. However, symptoms were transient and resolved spontaneously within 2 weeks after discontinuation. The lesion had disappeared almost completely with a mild pigmentation after 1 month. And also, she had not experienced any other adverse effects or recurrence over 2 months of follow-up. Herein we describe a case of Bowen’s disease successfully treated with ingenol mebutate gel.

Soğukla İndüklenen Nötrofilik Figüre Eritem

We herein report a 35-year-old man presented with relapsing, rigorous, annular and archiform plaques with central clearing on the trunk, back, shoulders and forehead. They were remarkably aggravated after cold exposure. He had just begun taking anti-oxidant herbal pills containing Ginkgo biloba one month ago. On histologic examination, a perivascular inflammatory cell infiltrate composed of neutrophils and mononuclear inflammatory cells in the upper dermis wer seen. The unique features of this case were the relapsing and recalcitrant character of the lesions, the onset of the lesions after cold exposure and remission after warming or a rise in the body temperature. Though the presence of leukocytoclasia might have been a clue for vasculitis, the absence of other vasculitic histopathological findings such as nuclear dusts and negative direct immunofluorescence test have excluded vasculitis. We consider our case to represent a figurate erythema with a dominant infiltration of neutrophils that might be also induced by Ginkgo biloba.

Pruritic annular papules and plaques on the face and back

Pruritic annular papules and plaques on the face and back

Solitary Annular Plaque on the Scrotum.

Solitary Annular Plaque on the Scrotum.

Annular Elastolytic Giant Cell Granuloma - A Rare Case with Systemic Involvement

Annular elastolytic giant cell granuloma (AEGCG) is a rare granulomatous dermatosis characterized by loss of elastic fibers and elastophagocytosis by multinucleated giant cells. It is characterized by annular plaques that are similar to those observed in granuloma annulare but that specifically appear in sun-exposed skin and occurs more commonly in females than males. There have been reported cases of AEGCG associated with diabetes mellitus, systemic sarcoidosis, cutaneous amyloidosis, molluscum contagiosum, squamous cell carcinoma of the lung and cutaneous T-cell lymphoma. We report a case of AEGCG in both sun-exposed as well as covered areas of a middle aged lady with hepatic nodules and Barret’s esophagus.Bangladesh Journal of Medical Science Vol.15(3) 2016 p.488-491

Éruption de kystes épidermiques après application d’imiquimod topique

Imiquimod is a local immune-response modifier that works by stimulating innate and acquired immunity. It is frequently used to treat superficial basal cell carcinoma, the most common form of skin cancer. Marked local inflammatory reaction is common during treatment. We report a case of the rare condition, multiple eruptive milia, during topical imiquimod therapy. A 67-year-old male patient presented infiltrating basal cell carcinoma above the left eyebrow. The patient underwent surgery and skin grafting. He presented superficial relapse at the periphery of the graft and was initially treated with Aldara®. Fifteen days after initiation, Aldara® was withdrawn due to a critical inflammatory reaction. A few weeks after complete healing, an erythematous annular plaque of milia, excluding the graft zone, appeared. This element was confirmed by histopathology. The most common local side effects reported with Aldara® are erythema, irritation and crusting. Reports of eruptive milia following Aldara® therapy are rare and they are never mentioned in the summary of product characteristics. Application of imiquimod in fact induces local inflammatory reaction due to stimulation of local cytokines, which can result in marked reaction in the infundibular epithelium of hair follicles and thus in the production of abnormal keratin that can cause pilosebaceous duct obstruction and thus the formation of epidermoid cysts. This pathological mechanism explains the absence of lesions on the skin graft of the inner arm. The occurrence of eruptive milia during treatment with Aldara® is rarely described. The timing of occurrence of these eruptive milia as well as the mechanism of action of the drug made such a reaction highly probable in our patient.

Generalised Granuloma Annulare-Uncommon in Clinical Practice

Generalised granuloma annulare is a benign inflammatory dermatosis characterized by dermal papules and annular plaques. It is often clinically confused with other dermatoses particular superficial fungal infection. A man of 50 years came with multiple erythematous, mildly pruritic, firm papules and annular skin lesion over the extremites and back of trunk for the last two years. He was treated with an oral antifungal for several months under diagnosis of tinea corporis without remission. The diagnosis of Generalised Granuloma Annulare was made based on skin biopsy and histopathological examination. Oral Acitretin and topical tacrolimus (0.1%) were administered and after 1 month of follow up period the lesion were started to regress. Complete remission was found after 3 months treatment.
 CBMJ 2016 July: Vol. 05 No. 02 P: 39-42

Secondary syphilis manifesting as annular lichenoid plaques

Background: Syphilis continues to be a diagnostic challenge as the myriad manifestations of secondary syphilis can mimic a lot many dermatological disorders. Annular Lichenoid syphilis is an uncommon entity, reported only occasionally in the penicillin era. We present the case of a 24-year-old man presenting with annular lichenoid lesions over face Methods & Materials: A 24-year-old male with multiple pink to brown coloured lesions over face since 1 month. At the same time he was being treated for acne vulgaris with tretinoin 0.025% cream and clindamycin 0.05% cream from private practioner. Lesion initially appeared as reddish coloured gradually spreading peripherally to become annular with central hyperpigmentation. Past history revealed homosexual unprotected sexual exposure with multiple partners, last passive exposure 1 month prior to onset of skin lesions. General and systemic examination was normal. On cutaneous examination there was evidence of multiple annular plaque over face with central hyperpigmentation. Also hyperpigmented macules over bilateral palms and soles, neck, chest, forearms, hands was present. Deep dermal tenderness was positive. Differential Diagnosis kept was Lichen Planus, Secondary Syphilis, Polymorphic light eruption disorderand Erythema Multiforme. Serological investigation showed Venereal disease research laboratory assay came out to be positive in the titres for the patient: 1:32, and Treponema pallidum haemagglutination for syphilis was Positive. Serology for Hepatitis B, and HIV was negative. Results: Biopsy from annular plaque showed interface dermatitis, perivascular and perieccrine plasma cell infiltrate and granuloma. Diagnosis kept was Secondary syphilis presenting as unusual annular lichenoid lesions was favoured. Three doses of Intramuscular Injection of Benzathine penicillin 2.4 million units was given. After 3 months all skin lesions subsided with persistence of post inflammatory hyperpigmentation over face. Conclusion: The presentations of syphilis, often described as “the great imitator,” can be varied and atypical. Thus prompt diagnosis and treatment is necessary.

UTILIDADE DA GRISEOFULVINA NO TRATAMENTO DO GRANULOMA ACTÍNICO DE O’BRIEN

O granuloma actiníco de O’Brien, ou também chamado de granuloma anular elastolítico de células gigantes é uma afecção rara. Apresenta-se clinicamente como pápulas que se confluem formando lesões anulares com centro atrófico. Histologicamente, evidencia-se elastofagocitose e elastólise. O seguinte caso relata uma paciente com 53 anos, que apresentava lesões clínicas e histopatológicas clássicas de granuloma actínico que evoluiu com melhora importante no tratamento adjuvante com griseofulvina.

Plaque with pearly raised borders on the forearm

A 29-year-old male presented with an annular plaque on his arm for 7 months. Physical examination revealed 6 mm annular plaque with raised borders and a shiny stellatepurple center (Fig. 1). Dermoscopic evaluation revealed a ring of white spiked structurless areas at the periphery; an intense structurless steel purple area was observed at the center of the lesion (Fig. 2). Hystopathological examination showed a band-like infiltrate of lymphocytes, pigment incontinence, saw tooth rete ridges, hypergranulosis and hypekeratosis (Figs. 3 and 4). Clinical Image

A Case of Acute-Onset, Painful Acral Granuloma Annulare.

Dear Editor: Acute-onset, painful acral granuloma annulare (GA), a rare variant first described by Brey et al.1 in 2006, is characterized by sudden onset of painful lesions on the hands and feet, and scattered lesions at other sites. Patients may have associated arthralgia, diarrhea, and fever. The erythrocyte sedimentation rate (ESR) may be elevated1. A 57-year-old woman presented with painful lesions on the hands and legs 4 months ago. The lesions abruptly began as small erythematous plaques and slightly enlarged after beginning. The patient experienced febrile sensations, myalgia, and back pain a month before developing the lesions. Intermittent treatment of oral prednisolone from a local clinic alleviated her back pain, but new cutaneous lesions persistently develop. Physical examination revealed tender, erythematous, annular plaques on the palms, lateral sides of the fingers, and the legs (Fig. 1). Initial laboratory examination by a rheumatologist revealed an elevated ESR of 52 with otherwise unremarkable findings for rheumatoid factor, anti-neutrophilic cytoplasmic antibody, anti-cardiolipin antibody and thyroid function test. Biopsy specimen from the left second finger revealed a palisade of histiocytes surrounding degenerated collagen and mucin in the dermis (Fig. 2A, B). Alcian blue (pH 2.5) staining highlighted mucin in the center of the granuloma (Fig. 2C). Based on the clinical and histological findings, acute-onset, painful acral GA was diagnosed. Fig. 1 Tender erythematous annular plaques on the lateral side of second and third finger. Fig. 2 (A) Palisade of histiocytes surrounding degenerated collagen and mucin in the dermis. A broad zone of mucinous degenerated collagen fibers with infiltrating lymphohistiocytic granuloma (H&E, ×100). (B) (H&E, ×400). (C) ... Although the occurrence of GA on the dorsum of the hands is frequent, the involvement of the palms appears to be very rare2,3,4,5. Generally, GA is characterized by asymptomatic or mildly pruritic lesions, but GA on the palms manifests variable clinical presentations, including painful or pruritic papules and plaques2,3,4. Acute-onset, painful acral GA also manifests unusual painful lesions similar to GA lesions on the palms. However, the former shows constitutional symptoms in addition to skin lesions, which may raise suspicion about an autoimmune disease. Therefore, unnecessary examinations and treatments may be performed and final diagnosis may be delayed. Brey et al.1 reported 2 of 4 patients presenting with arthralgia, which increased authors' concern that the disease might represent an early manifestation of an autoimmune disease. However, extensive serologic and radiologic examinations for autoimmune diseases were negative. Our patient was initially also evaluated by a rheumatologist, but all serologic findings for autoimmune diseases were unremarkable except for an elevated ESR. From this clinical viewpoint, we assume that acute-onset, painful acral GA could be classified as a distinct variant of GA distinguishing it from GA on the palms. Acute-onset painful acral GA should be differentiated from conditions including Sweet's syndrome, interstitial granulomatous dermatitis with arthritis, palisaded neutrophilic and granulomatous dermatitis, and rheumatoid nodule, which may present similar clinical presentations like painful papules or plaques and constitutional symptoms1. Herein, we report a very rare and interesting case of acute-onset, painful acral GA. Clinicians should be aware of the atypical clinical presentation of GA such as painful and/or tender acral eruptions with constitutional symptoms. To classify acute-onset, painful acral GA as a variant of GA, more reports of cases are needed.

A Case of Multiple Desmoplastic Trichoepithelioma.

Dear Editor: A 23-year-old woman presented with multiple, progressively growing, asymptomatic, depressed macules on face for 2 years. Physical examination revealed three yellowish to skin-colored annular atrophic macules 2~5 mm in size without elevated border on both cheeks (Fig. 1). She had no family or past history that scar might occur such as acne, chickenpox, herpes infection or prior laser treatment. Laboratory data including blood cell counts, biochemistry and urinalysis were unremarkable. Histopathology showed narrow strands of basaloid tumor cells in a fibrous stroma with adjacent embedded keratinous cysts (Fig. 2). The tumor strands were distributed from the upper to the deeper dermis. We performed additional exicisional biopsy with immunohistochemical staining in order to differentiate from malignant neoplasms including morpheic basal cell carcinoma (BCC) and microcystic adnexal carcinoma (MAC). Carcinoembryonic antigen (CEA), epithelial membrane antigen (EMA), CD23, and CK19 were negative, and CK20 showed focal positive. From these findings, she was diagnosed with desmoplastic trichoepithelioma (DTE), and remaining lesions were completely removed. Fig. 1 (A, B) Cutaneous examination revealed multiple yellowish to skin-colored annular, depressed macules on both cheeks. Fig. 2 (A) Biopsy specimen of left cheek reveals atrophic epidermis with upper and mid dermal cellular infiltration (H&E, ×40). (B) Tumor strands embedded in dense fibrous stroma are composed of small basaloid cells one to two cells thick (H&E, ... DTE is a rare benign skin appendageal neoplasm. It is a distinct variant of trichoepithelioma based upon its unique clinical and histopathological characteristics1. Clinically, it typically shows 3~8 mm diameter, annular, yellowish or skin-colored asymptomatic plaques, with an elevated border and a depressed or atrophic center on face1. It almost develops as a solitary lesion, although rare cases of patients with multiple lesions have been reported2. Histopathologically, DTE is characterized by following features. First, epithelial strands consist of small basaloid cuboidal cells in a one to three-cell-thick layer. Second, many keratinous cysts have a peripheral border of basaloid cuboidal cells, and sometimes have several calcification foci. Finally, stroma appears as dense fibrous stroma1. Differential diagnosis includes MAC, BCC, and scar. Although MAC presents with many horn cysts and epithelial cords, it is distinguished by ductal differentiation and infiltration to the subcutis or deeper structures3. Therefore, when biopsy is superficial, MAC can be misdiagnosed as DTE3. Assessing EMA and CEA immunohistochemistry may identify ductal differentiation and CD23 expression in MAC1. CK19 demarcates follicular bulge stem cells and its positivity favors MAC over DTE4. Both DTE and morpheic BCC can exhibit basaloid cells in strands and sclerotic stroma. However, neither cellular atypia nor peripheral palisading are seen in DTE, and morpheic BCC is not usually associated with horn cyst formation1. Also, in most DTE, retained or increased CK20-positive Merkel cells are found, but not in morpheic BCC5. Scar should be considered if multiple depressed macules appear, but it can be easily differentiated based upon its histopathology. The treatment of choice is surgical excision and Mohs micrographic surgery is recommended to achieve clear surgical margins. In our case, because multiple lesions had developed and tumor strands extended into the deep dermis, total excision was performed to exclude malignancy. Therefore, initial proper biopsy is important to make an accurate diagnosis and treatment in patients with multiple scar-like depressed macules on face. Herein, we report a rare case of multiple DTE, which should be differentiated from malignancy histopathologically.

A case of lipoatrophic panniculitis in a 2-year-old boy.

Lipoatrophic panniculitis is generally a rare condition affecting mainly children, sometimes associated with connective tissue diseases [1, 2]. There are also reports about this condition occurring in adults [3]. This idiopathic, rarely reported panniculitis is presumed to have an autoimmune pathogenesis. A histopathological analysis reveals lobular panniculitis with fat necrosis and an associated inflammatory infiltration. Other histological findings are a focally increased number of lymphocytes rimming the adipocytes and infiltration of vascular walls by mildly atypical lymphoid cells [4]. Clinical and histopathological features lead to diverse diagnostic considerations like subcutaneous panniculitis-like T-cell lymphoma, Weber-Christian disease or Rothman-Makai syndrome [5]. We present a 2-year-old boy with no clinical or laboratory features of connective tissue disease who presented a progressive appearance of annular atrophic plaques with erythema on the right ankle. Skin lesions were about 2–3 cm in diameter with palpable loss of subcutaneous tissue (Figure 1). The patient was referred to the Chair and Clinical Department of Internal Diseases, Dermatology and Allergology in Zabrze after several consultations in other dermatology and rheumatology departments, with a suspicion of morphea, granuloma annulare orlipodystrophy. All blood tests like blood count, biochemical analysis, antinuclear antibodies and inflammatory markers were normal. Also X-ray of the lower limb was correct. There was no anamnesis of arthritis, thyroid gland abnormalities or fever. The first histopathological examination revealed acanthotic epidermis, collagen fiber protrusion, reduction of elastic fibers and in subcutaneous tissue – panniculitis. On the basis of the histological image, morphea profunda was suspected. However, the clinical picture with no immunological markers of connective tissue disease was still thought-provoking. The boy was treated with topical and systemic steroids for 6 months, and also with pentoxifylline and naproxen with no significant improvement. The second histopathological examination showed lymphocytes and histiocytes infiltration in the deep layers of dermis and subcutaneous tissue, in fatty tissue atrophy and inflammatory infiltration with histiocytes, lipofages similar to Touton cells and lymphocytes (Figure 2). On the basis of analyzed data, clinical and histopathological examination we identified lipoatrophic panniculitis. The appearance of new disease outbreaks required different treatment. Methotrexate (MTX) in an oral dose of 6.125 mg once a week (10 mg/m2/week) was administered for 10 weeks. A good tolerance of medication, on the basis of clinical condition and biochemical parameters monitoring, was noticed. We observed total suppression of the process with no further progression of skin lesions during 2 years of observation. Figure 1 Skin lesions before the treatment Figure 2 Histopathological examination – lipoatrophic panniculitis We present the case to describe clinical and diagnostic difficulties in our young patient with good clinical response to methotrexate (MTX) treatment. Although lipoatrophic panniculitis is a rare condition it should be considered particularly in the case of children. Panniculitis in children is a heterogeneous group of diseases, and so is in adults; it is characterized by inflammation of the subcutaneous and fatty tissue. Only a few types of panniculitis are found in childhood only, such as fat sclerosis of the newborn, while the vast majority of other types may be found both in the pediatric age and in adults [6, 7]. Lupus panniculitis, cold panniculitis, panniculitis in Behcet's disease, and post-steroid panniculitis are mainly observed in adults [8]. There are also few rare forms of panniculitis, such as eosinophilic panniculitis or subcutaneous panniculitis T-cell lymphoma, which often give diagnostic difficulties but also mainly occur in adults [9]. Lipoatrophic panniculitis is most frequently observed in infants and children. Its clinical features are erythematous nodules and plaques followed by circumferential atrophy of the distal lower extremities, sometimes connected with fever, juvenile arthritis, or Hashimoto disease. In the diagnostic process it should be differentiated with all forms of panniculitis. Immunological, endocrine abnormalities and morphea or lupus profundus should be excluded. In our case, the patient was previously diagnosed with morphea, probably because of lack of experience in recognizing lipoatrophic panniculitis, which is rare. As described by some authors, it may be difficult to distinguish between lipoatrophic panniculitis and panniculitis of Weber-Christian or its variant – Rothmann-Makai panniculitis [10]. Histopathological examination of the deep skin biopsy seems to be crucial for differentiation. Also treatment of lipoatrophic panniculitis may be challenging. There are few reports concerning therapy with steroids, hydroxychloroquine or methotrexate (MTX) [11]. However, there are no clear indications for children's therapy. Lipoatrophic panniculitis should be considered in infants and young children with clinical features of panniculitis and fat atrophy without clinical or serologic evidence of connective tissue disease. Methotrexate may be considered as a good treatment when systemic therapy is essential.

Annular atrophic plaque over the arm.

Annular atrophic plaque over the arm.

Tufted angioma.

Sir, An 18-year-old female presented with multiple red raised lesions over the neck since the age of eight years. There was no history of trauma, bleeding from the lesions, or excessive sweating. There was no history of similar complaints in the family. Cutaneous examination revealed multiple erythematous and skin-colored plaques on the neck [Figure 1]. The lesions were firm, nontender, noncompressible, and warm on palpation. There was no thrill or bruit over the plaque. Systemic examination did not reveal any abnormality.Figure 1: Erythematous papules and nodules on the neckSkin biopsy from the nodule revealed clusters of numerous dilated, thin- and thick-walled capillaries within the dermis [Figures 2 and 3]. The capillaries were lined by plump or elongated endothelial cells. Some of the capillaries with thick walls were engorged with RBCs. The dermis surrounding these clusters revealed fibroplasia. Overlying epidermis showed mild hyperplasia.Figure 2: Clusters of dilated capillaries in the dermis (hematoxylin and eosin ×10)Figure 3: Dilated capillaries (hematoxylin and eosin ×40)Tufted angioma (TA) is a rare, benign angiomatous condition. It is also called angioblastoma of Nagakawa. It affects both the genders equally. The lesions usually arise between the ages of 1 and 5 years. Occasionally, the lesions may be present at birth.[1] They may rarely develop in adults or in old age. Partial spontaneous regression of TA may occur, but complete disappearance is extremely rare.[2] Clinically, the lesions are characterised by erythematous papules, plaques, and nodules. Atypical presentations of annular plaques may be seen. The most commonly involved sites are neck, upper trunk, and proximal part of extremities.[2] The lesions may show increased sweating, or growth of fine lanugo hair. Kasabach–Merrit phenomenon, which is characterized by trapping of the platelets in the vasculature and thrombocytopenic coagulopathy leading to petechiae and ecchymosis is a known though uncommon complication of tufted angioma. Histopathologically, tufted angioma is characterized by well-circumscribed foci of clustered capillaries in the dermis and the subcutaneous tissue. The capillaries are lined by plump or elongated endothelial cells. These ovoid tufts of capillaries give the “cannonball appearance” to the angiomatous structures. There is no mitotic activity or atypia in the cells. It is important to differentiate tufted angioma from Kaposi's sarcoma, kaposiform hemangioendothelioma, and low-grade angiosarcoma, especially in adults. Kaposi's sarcoma shows spindle-shaped endothelial cells with slit-like spaces and the promontory sign. Kaposiform hemangioendothelioma shows a lobular and infiltrative pattern, whereas differentiation from low-grade angiosarcoma can be done by the absence of atypia and mitotic figures. The various treatments that have been employed for tufted angioma include potent topical steroids, systemic steroids, interferon alpha, complete surgical excision, cryosurgery, radiotherapy, and pulsed dye laser.[3] However, the rate of recurrence is high.

Necrolytic migratory erythema associated with fatty liver disease and the psuedoglucagonoma syndrome

We report a 48-year-old woman with a past medical history of psoriasis, nonalcoholic steatohepatitis (NASH), and type II diabetes mellitus, who presented to the emergency department with a 1 week history of erosive annular plaques with associated atrophy and telangiectasias on her legs bilaterally, thighs and buttock, histopathologically consistent with necrolytic migratory erythema. Although classically associated with a pancreatic glucagonoma, this patient experienced this figurate erythema in the setting of fatty liver disease with no glucagonoma. The rarity of pseudoglucagonoma syndrome, or necrolytic migratory erythema occurring in the absence of a glucagonoma, warranted the discussion of this case.

Familial benign pemphigus atypical localization

We present an atypical case of familial benign pemphigus (Hailey-Hailey disease), which presented as crusted, annular plaques limited to the back without intertriginous involvement. We could not find in the literature another patient with plaques located solely on the back without a prior history of classical disease.

Punctate Follicular Porokeratosis

Porokeratosis is a disorder of keratinization characterized by an abnormal cornoid lamella surrounding an annular, scaly plaque with an atrophic center. A histologic variant of this condition has been proposed, termed follicular porokeratosis, in cases where follicular involvement was contiguous with an annular cornoid lamella. There has been only 1 report of punctate follicular porokeratosis, in which cornoid lamellae originated exclusively from hair follicles with no associated annular plaque. The authors present the second case of punctate follicular porokeratosis, further supporting the contention that this entity is a unique form of porokeratosis rather than a histologic variant. A 56-year-old African American female presented to the dermatology clinic with a 3-month history of keratotic lesions localized on the right posterior shoulder. Examination revealed an area of perifollicular keratotic papules, each surrounded by an erythematous rim. Histopathology revealed a cornoid lamella originating within a hair follicle, with the parakeratotic column protruding through the follicular orifice. The static nature of the condition along with exclusive involvement of hair follicles supports the notion of punctate follicular porokeratosis as a distinct clinical entity. The diagnosis of this condition relies heavily on proper histopathologic sampling revealing punctate follicular cornoid lamellae.