Dermal Lymphocytic Infiltrate Research Articles

15397 Paraneoplastic dermatomyositis in a patient with an oligodendroglioma

A previously healthy 26-year-old white man presented with nausea, headache, and rash. Physical examination disclosed coalescing, erythematous to violaceous macules and patches on the eyelids, periorbital regions, cheeks, upper chest, shoulders, upper back, and posterior neck, and mild periorbital edema. Review of systems was positive for myalgias. Histopathologic examination of a shoulder lesion demonstrated vacuolar interface dermatitis and a sparse, superficial perivascular dermal lymphocytic infiltrate. Colloidal iron staining demonstrated dermal mucinosis. Based on these findings, the diagnosis of dermatomyositis was made. Labs demonstrated elevated serum creatine kinase (673 U/L); tests for rheumatoid factor, anti-nuclear antibodies, anti-SSA and anti-SSB antibodies, immunoglobulin subclasses, and a myomarker panel were within normal limits. A head MRI demonstrated a cystic mass in the right insula; stereotactic biopsy was consistent with an oligodendroglioma. He received a 60 mg oral dose of prednisone, and topical triamcinolone 0.1% and hydrocortisone 2.5% ointment. Within 10 days the rash completely resolved. He underwent a craniotomy for tumor resection several weeks after initial presentation. At follow-up four months later, he showed no recurrence of myalgias or rash. Ovarian, lung, and gastrointestinal cancers are most commonly associated with dermatomyositis in the Western world. To our knowledge, only 2 previous cases of dermatomyositis associated with an intracranial neoplasm have been reported: in a 39-year-old man following dendritic cell immunotherapy for an oligoastrocytoma and in a seven-year-old girl with a choroid plexus papilloma. Our case adds oligodendroglioma to the list of potential neoplasms to be considered when assessing a patient with dermatomyositis.

Histopathologic findings of idiopathic trachyonychia: An analysis of 30 adult patients.

Trachyonychia, a rare inflammatory disease of the nail matrix, has a more chronic course in adults compared with that in children. However, the histopathologic features of the disease have not been sufficiently reported in the literature. We retrospectively reviewed the pathologic features of idiopathic trachyonychia in adult cases at our center. A total of 30 cases were included. The median age was 55.5 years (range, 27-77 years). Median disease duration was 84 months (range, 8-384 months). Histopathologic analysis showed upper dermal lymphocytic infiltrates (93.3%), acanthosis (86.7%), exocytosis (63.3%), spongiosis (63.3%), parakeratosis (46.7%), psoriasiform hyperplasia (40%), eosinophilic infiltrates (33.3%), vacuolar degeneration (33.3%), lichenoid pattern (13.3%), Civatte body (6.7%), and collection of neutrophils in the stratum corneum (3.3%). Statistical analysis among pathologic parameters revealed associations of spongiosis with exocytosis (P < 0.001) and lichenoid infiltration with vacuolar degeneration (P = 0.008). Three patients (10%) showed fungal co-infection. The majority of cases revealed inflammatory cell infiltration with epidermal changes. Given the inflammation and chronic course of idiopathic trachyonychia in adulthood, active treatment with anti-inflammatory agents should be considered. Additionally, mycological tests should be considered during initial evaluation as there are cases with fungal coinfection.

A clinical, histopathological and laboratory study of 19 consecutive Italian paediatric patients with chilblain-like lesions: lights and shadows on the relationship with COVID-19 infection.

BackgroundAcral chilblain‐like lesions are being increasingly reported during COVID‐19 pandemic. However, only few patients proved positivity for SARS‐CoV‐2 infection. The relationship between this skin manifestation and COVID‐19 infection has not been clarified yet.ObjectiveTo thoroughly characterize a prospective group of patients with chilblain‐like lesions and to investigate the possible relationship with SARS‐CoV‐2 infection.MethodsFollowing informed consent, patients underwent (i) clinical evaluation, (ii) RT‐PCR and serology testing for SARS‐CoV‐2, (iii) digital videocapillaroscopy of finger and toe nailfolds, (iv) blood testing to screen for autoimmune diseases and coagulation anomalies, and (v) skin biopsy for histopathology, direct immunofluorescence and, in selected cases, electron microscopy.ResultsNineteen patients, all adolescents (mean age: 14 years), were recruited. 11/19 (58%) of them and/or their cohabitants reported flu‐like symptoms one to two months prior to skin manifestation onset. Lesions were localized to toes and also heels and soles. Videocapillaroscopy showed pericapillary oedema, dilated and abnormal capillaries, and microhaemorrhages both in finger and toe in the majority of patients. Major pathological findings included epidermal basal layer vacuolation, papillary dermis oedema and erythrocyte extravasation, perivascular and perieccrine dermal lymphocytic infiltrate, and mucin deposition in the dermis and hypodermis; dermal vessel thrombi were observed in two cases. Blood examinations were normal. Nasopharyngeal swab for SARS‐CoV‐2 and IgG serology for SARS‐CoV‐2 nucleocapsid protein were negative. Importantly, IgA serology for S1 domain of SARS‐CoV‐2 spike protein was positive in 6 patients and borderline in 3.ConclusionsChilblain‐like lesions during COVID‐19 pandemic have specific epidemiologic, clinical, capillaroscopic and histopathological characteristics, which distinguish them from idiopathic perniosis. Though we could not formally prove SARS‐CoV‐2 infection in our patients, history data and the detection of anti‐SARS‐COV‐2 IgA strongly suggest a relationship between skin lesions and COVID‐19. Further investigations on the mechanisms of SARS‐CoV‐2 infection in children and pathogenesis of chilblain‐like lesions are warranted.

Azathioprine Hypersensitivity Syndrome in an Asian Woman

Azathioprine Hypersensitivity Syndrome in an Asian Woman

Cutaneous leishmaniasis in Cavia porcellus (guinea pig): case report

ABSTRACT Leishmaniasis is a parasitic disease of worldwide spread. It is caused by protozoa of the genus Leishmania and is transmitted to animals and humans through the bite of sand flies. In Brazil, leishmaniasis is one of the zoonoses of major importance and expansion. The objective of this work is to describe the clinical, pathological, immunohistochemical and molecular findings of cutaneous leishmaniasis by Leishmania enriettii in guinea pig (Cavia porcellus). Three animals had nodular and alopecia lesions on the muzzle, ears and ulcerated lesions on the distal extremities of the pelvic limbs. The males (2) also had diffuse thickening of the scrotal skin. Samples of the ulcerated cutaneous lesions were evaluated by cytology which were observed as amastigote forms of Leishmania. One of the animals was euthanized and necropsied. Histopathology showed abundant dermal infiltrate of macrophages, plasma cells, lymphocytes and multinucleated giant cells. Numerous macrophages contained parasitoid vacuoles with amastigote forms, evidenced by immunohistochemical examination. The molecular characterization based on the SSUrDNA gene identified the species as L. enrietti. The diagnosis of cutaneous leishmaniasis in these cases was based on pathological findings and confirmed by immunohistochemistry, PCR and sequencing.

A localized non-healing ulcer: an unusual clinical presentation of pemphigus vulgaris

&lt;p&gt;Pemphigus vulgaris is an autoimmune blistering disorder commonly involving oral mucosa and skin&lt;strong&gt; &lt;/strong&gt;with characteristic acantholysis that results in formation of fluid filled blisters and painful erosions. Herein we report a case distinguished by its unusual clinical presentation.&lt;strong&gt; &lt;/strong&gt;A twenty-five year old man, presented to our outpatient department of dermatology, complaining of ulcer on forehead in the last one year. Examination revealed single ulcer covered with crust on right side of forehead. Clinically lupus vulgaris, pyoderma gangrenosum, recurrent herpes simplex, leishmaniasis and pemphigus vulgaris were kept as differential diagnosis. Tzanck smear revealed multiple acantholytic cells and mild neutrophilic inflammatory infiltrate. Histological examination of biopsy sample showed suprabasal clefting, acantholytic cells and mild perivascular dermal lymphocytic infiltrate. Features were suggestive of pemphigus vulgaris. Significant improvement occurred after three months of treatment with oral prednisolone, azathioprine and topical steroid. Although oral and skin involve­ment is common, in the form of flaccid blisters and erosions, but non healing ulcer is unusual. This may represent a period of limited activity during this chronic disease. There is paucity of data in literature regarding this. So, this&lt;strong&gt; &lt;/strong&gt;case report highlights a, perhaps unique, clinical presentation of this autoimmune disease.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;

Ulcerative nodules on the entire body

Ulcerative nodules on the entire body

To be a “Lymphomatoid Papulosis Type E” or not to be? That Is a Question

Lymphomatoid papulosis (LyP) Type E is a recently introduced subtype of LyP presenting with escar-like lesions and characterized with angiocentric invasion of dermal blood vessels by CD30 positive atypical lymphocytes resulting necrosis of their walls. Owing to its considerable histologic characteristics such as dense dermal infiltration of CD30 positive large atypical lymphocytes showing high mitotic activity, and angiodestructive invasion, it is challengible to discriminate LyP Type E to aggressive cutanoues lymphomas.

Iohexol-Induced Acute Generalized Exanthematous Pustulosis (AGEP): Case Report

Acute generalized exanthematous pustulosis (AGEP) is a rare adverse drug reaction characterized by numerous non-follicular sterile pustules overlying edematous, erythematous plaques. The majority of AGEP cases are associated with antimicrobial medications, although other agents and etiologies have also been implicated. Here, we report a patient with recurrent angioimmunoblastic T-cell lymphoma (AITL) who presented with a pruritic and widespread pustular eruption one week following computed tomography (CT) with iohexol contrast administration. Notably, she had a documented prior mild reaction to contrast medium and was appropriately pre-medicated with diphenhydramine and prednisone before imaging. Biopsy revealed intra-epidermal pustules, epidermal spongiosis, and dermal infiltrate of lymphocytes, neutrophils, and some eosinophils – histological findings consistent with AGEP. Systemic and topical corticosteroids plus topical mupirocin resulted in complete resolution of symptoms. While cutaneous reactions to iodinated contrast are common and often self-limited, severe manifestations such as AGEP must be considered particularly in patients with a history of prior contrast allergy.

Polymorphic lucite: about a case

Polymorphic lucite (PL) is a frequent photodermatosis, but its pathophysiologic mechanism is still poorly elucidated. We report the case of a 54-year old male teacher, with no previous medical-surgical history, presenting with recurrent papular and very pruritic rash lasting for 12 years. Clinical examination showed papular-vesicular excoriated lesions on the face, the neck and the scalp. Eczematiform lesions occurred on the back of the hands. The remainder of the integument as well as the mucous membranes were spared. The suspected diagnoses were lupus, drug-induced photosensitization or contact photosensitivity and polymorphic lucite (PL). During the interview, the patient reported that this eruption had recurred in the same period every year, namely at the beginning of spring and lasted until the end of summer. Photobiological evaluations were not performed. Antinuclear antibody test was negative, and histological examination was non-specific showing dermal dense lymphocytic infiltrate. The diagnosis of LP was suspected and the patient underwent synthetic antimalarial drug-based therapy associated with external photoprotection.

Primary Cutaneous Acral CD8+ T-Cell Lymphoma—A Single Center Review of 3 Cases and Recent Literature Review

The recently published 2016 revision of the WHO classification of lymphoid neoplasms includes primary cutaneous acral CD8-positive T-cell lymphoma (PCATCL) as a provisional entity. This is a rare indolent lymphoma characterized by papules or nodules on the ear and a dermal infiltrate of CD8-positive T-lymphocytes with cytotoxic marker expression. A retrospective review of a single institutional experience with PCATCL identified 3 patients (mean age 54; range 49-62) with papules or nodules on the ear. Lesional biopsies demonstrated a dense diffuse dermal infiltrate of atypical lymphocytes with a Grenz zone in 2 cases and focal epidermotropism in 1 case. The atypical lymphocytes were predominantly CD3 and CD8 positive with expression of cytotoxic marker TIA1. Staging evaluation failed to reveal systemic disease. Two patients underwent local excision, and the third received local radiation therapy all with complete response and no disease recurrence at last follow-up 3 months (range 2-5 months). Our cases add to the existing limited literature on the clinical and histopathological features of PCATCL. We also performed an updated systematic literature view of the entity.

Kératoses actiniques : diagnostic anatomoclinique: Clinicopathologic diagnosis of actinic keratosis

Actinic keratoses are epidermal preneoplastic lesions localised in photo-exposed areas. They are made of a keratosis of variable thickness overlying an erythematous area, that may be indurated. A field of cancerization is characterized by multiple actinic keratoses in a chronically sun exposed area, especially on the bald area of the scalp in aged males. In general, the diagnosis is made on clinical basis, but a biopsy is necessary in case of ulceration, induration, post-treatment recurrence or bleeding. Biopsy is also mandatory for atypical keratosis, especially the pigmented variants. Histopathology shows dysplasia of the epidermal basal layer, with irregular and hyperchromatic nuclei, parakeratosis and generally a dermal lymphocytic infiltrate. There are hypertrophic, atrophic, pigmented and lichenoid variants among the most common subtypes. The main clinicopathological issue is transformation of actinic keratosis into squamous cell carcinoma, defined by epidermal sheaths of atypical cells penetrating into the dermis. These cells are eosinophilic and show images of dyskeratosis or squamous whorls. Dermatoscopy (and other non invasive imaging techniques) might be useful to help decision making - when to perform a biopsy - and for differential diagnosis. © 2019 Elsevier Masson SAS. All rights reserved. Cet article fait partie du numéro supplément Kératoses actiniques : comprendre et traiter réalisé avec le soutien institutionnel de Galderma International.

A girl with alopecia and skeletal deformities: Satoyoshi syndrome with review of literature

Satoyoshi syndrome is a rare disease characterized by alopecia, recurrent muscle spasms, diarrhea, and skeletal abnormalities. It is a multisystem disorder of suspected autoimmune etiology. We report a 12-year-old-girl presented with loss of hair from the scalp for 7 years. She had a history of muscle spasms of lower limbs, which used to last for a few minutes; the attacks of spasms were intermittent in nature and involved thigh and calf muscles. She had genu valgum deformity of the right knee and knock-knee gait. Central nervous system examination showed no abnormality. Her laboratory investigations including routine screening and endocrine evaluations were within normal limits, except for microcytic hypochromic anemia. Ultrasonography (USG) abdomen revealed relatively small uterus. X-ray of the right knee showed deformed shape of the epiphysis and dense metaphyseal band of bones. Histopathological examination (HPE) scalp showed noncicatricial alopecia with the absence of functional follicles and dermal lymphocytic infiltration. On the basis of clinical investigations, blood investigations, USG, and radiological findings, diagnosis of SS was made. SS is a sporadic disease with the mean age of onset of the disease being 10 years, but a few adult cases have also been reported. The usual initial symptoms are alopecia and painful muscle spasms. Treatment with oral corticosteroids has shown good response. The case is being presented to create awareness not only among dermatologists but also among pediatricians and orthopedicians about the multisystem involvement and long-term-associated complications and to emphasize the need of early diagnosis and treatment.

Nerve alterations showing autophagy in 2 patients with lichen aureus

Lichen aureus is a rare, chronic, persistent purpuric dermatosis clinically characterized by striking yellow- to bronze-colored lesions. Histologically, lichen aureus differs from other pigmented purpuric dermatoses in containing dense, band-like infiltrates closely associated with the epidermis. This report describes 2 patients with lichen aureus, a 20-year-old woman with a lesion on her right arm and a 51-year-old man with a lesion on the right side of his groin. Skin biopsy specimens revealed almost identical findings in both patients, including dense band-like infiltrates containing lymphocytes, histiocytes with hemosiderin deposits scattered extravasated red blood cells and nerve alterations at the dermo-epidermal interface. The nerves within the lesions were filled with granules, which stained positive with antibody to microtubule-associated protein 1A/1B-light chain 3, suggesting autophagy within the nerves. These altered nerves were present only in areas of band-like dermal lymphocytic infiltration. Electron microscopy of the lesions showed the accumulation of autophagosomes in Schwann cells.

T-cell papulosis associated with B-cell malignancy: a distinctive clinicopathologic entity.

A distinctive eruption referred to as 'insect bite-like reaction' or 'eosinophilic dermatosis of haematological malignancy' has been described during the course of haematological B-cell malignancies (BCM). However, its clinical evolution, histopathological features and pathogenesis remain unclear. To characterize this eruption and to investigate its pathogenesis and relationship with the underlying BCM. In this multicenter retrospective study of the French Study Group on Cutaneous Lymphomas, 37 patients with a BCM and a cutaneous eruption consisting in chronic and/or recurrent papules, papulo-vesicles and/or nodules were included. Clinical, histopathological, immunohistochemical and molecular data were reviewed. No significant insect bite history or seasonal predominance was recorded. Patients had pruritic papules (81%), papulo-vesicles (43%) and nodules (38%), often predominated in the head and neck region (84%), without complete remission periods in most cases (57%). The predominant associated BCM was chronic lymphocytic leukaemia (73%). Histological and immunohistochemical review showed a dense dermal lymphocytic infiltrate predominantly composed of T lymphocytes (100%), with frequent eosinophils (77.6%); a perivascular and periadnexal (most often folliculotropic) pattern (77.6%), sometimes suggestive of a folliculotropic mycosis fungoides; clusters of tumour B cells were identified in 47% of cases using appropriate phenotyping markers. In 10/14 cases (71.4%) tested for B-cell IgH gene rearrangement, a B-cell clone was identified in skin lesions (identical to the blood clone in nine cases), whereas no T-cell clone was present. We propose the denomination 'T-cell papulosis associated with B-cell malignancy' (TCP-BCM) for this distinctive eruption. Although resulting in various histopathological pictures, it can be easily recognized by clinicians and may be identified by informed pathologists relying on some key features. An extravasation of tumour B cells with skin-homing properties associated with a secondary, predominant, T-cell immune reaction could explain the clinicopathologic aspect and the prolonged regressive and recurrent course of the disease.

A case of canine epitheliotropic lymphoma (mycosis fungoides)

The clinical picture, diagnosis and treatment of a dog with epitheliotropic lymphoma are presented. The dog (male, mongrel, 13-year old) was admitted to our Clinic with a 5-month history of non-pruritic skin lesions. At clinical examination a multifocal to diffuse exfoliative erythrodermia was the most striking finding. Diagnosis of epitheliotropic lymphoma was based on cutaneous histopathology, revealing a dense dermal and epidermal lymphocytic infiltration and Pautrie microabcess formation. Initial treatment with isotretinoin had a poor impact on skin lesions that progressed to the macular stage. On the contrary, combination chemotherapy with Lasparaginase and isotretinoin resulted in substantial improvement. The animal died, following a short period of depression and inappetance, 15 months after the first appearance of skin lesions and 10 months after diagnosis.

Histopathological changes in experimental infestation of Paederus fuscipes in rats.

The genus Paederus consists of approximately 621 species associated with outbreaks of dermatitis. Our aim was to determine gross and microscopic changes induced by Paederus fuscipes. Adult P. fuscipes beetles were collected from infested house and then sent to laboratory. In the first group beetles were placed on the shaved parts over the shoulders of each rat. In the second group smashed insect materials were rubbed over the ear of examined animals. Gross changes after 12 hr were noticed as erythematous papules and in 72 hr the red elevated area became bigger and swollen. Microscopic examination revealed edema and mild infiltration of inflammatory cells (lymphocytes and eosinophils) after 12 hr, cell swelling and vacuolar degeneration in basal and squamous cells after 24 hr, but by 72 hr the epidermal cells were necrotic with intense accumulation of fluid and vesicles formation. Gross and microscopic changes were compared between rats exposed with squeezed beetle materials and rats exposed to live beetles. The typical gross changes were maculopapuls on the skin that histologically showed dermal edema and infiltration of lymphocytes and eosinophils.

HPV16E7-Induced Hyperplasia Promotes CXCL9/10 Expression and Induces CXCR3+ T-Cell Migration to Skin

Chemokines regulate tissue immunity by recruiting specific subsets of immune cells. Mice expressing the E7 protein of human papilloma virus 16 as a transgene from a keratin 14 promoter (K14.E7) show increased epidermal and dermal lymphocytic infiltrates, epidermal hyperplasia, and suppressed local immunity. Here, we show that CXCL9 and CXCL10 are overexpressed in non-hematopoietic cells in skin of K14.E7 mice when compared with non-transgenic animals, and recruit CXCR3+ lymphocytes to the hyperplastic skin. Overexpression of CXCL9 and CXCL10 is not observed in E7 transgenic mice with mutated Rb gene whose protein product cannot interact with E7 (K14.E7xRbΔL/ΔL) and in consequence lack hyperplastic epithelium. CXCR3+ T cells are preferentially recruited by CXCL9 and CXCL10 in supernatants of K14.E7 but not K14.E7xRbΔL/ΔL skin cultures invitro. CXCR3 signalling promotes infiltration of a subset of effector T lymphocytes that enables donor lymphocyte deficient, E7-expressing skin graft rejection. Taken together, this suggests that recruitment of CXCR3+ T cells can be an important factor in the rejection of precancerous skin epithelium providing they can overcome local immunosuppressive mechanisms driven by skin-resident lymphocytes.

Eruption of lymphocyte recovery with atypical lymphocytes mimicking a primary cutaneous T-cell lymphoma: a series of 12 patients

Eruption of lymphocyte recovery (ELR) may occur during bone marrow aplasia after chemotherapies. We reviewed the clinical and pathologic features of 12 patients (male-female ratio, 7:5; median age, 61 years) with an atypical ELR histologically mimicking a primary cutaneous T-cell lymphoma such as Sézary syndrome or CD30+ T-cell lymphoproliferative disorder. All the patients displayed an erythematous maculopapular eruption on the trunk and the limbs associated with fever. All but one had received a polychemotherapy for an acute myeloid leukemia (n=10) or a urothelial carcinoma (n=1) before the occurrence of the skin eruption. One had an autoimmune lymphoproliferative syndrome causing chronic agranulocytosis requiring granulocyte colony-stimulating factor injection. In all patients, the skin eruption was associated with a slight increase of white blood cell count followed by bone marrow recovery within the next weeks. All skin biopsies showed a dermal perivascular lymphocytic infiltrate containing atypical medium- to large-sized CD3+, CD4+ and CD8+, CD25+, ICOS+, PD1- lymphocytes with a strong CD30 expression in most instances (n=10), suggesting the recruitment of strongly activated T cells in the skin. In 6 patients, a diagnosis of CD30+ lymphoproliferative disorder or Sézary syndrome was proposed or suspected histopathologically, and only the clinical context allowed the diagnosis of ELR with a peculiar presentation with atypical lymphocytes. We describe a series of patients with an unusual form of ELR characterized by the presence of atypical activated T cells in the skin. On a practical ground, pathologists should be aware of this distinctive and misleading presentation.

Adult-onset Hydroa Vacciniforme: A Rare Occurrence or a Lymphoma Premonition?

Sir, Hydroa vacciniforme (HV) is a photodermatosis affecting children and adolescents, with papulovesicular eruptions and varioliform scars on face and other photoexposed parts.[1] Classically, the presentation is during childhood, though very rarely late onset cases have been described.[2] A subset of cutaneous T cell lymphoma, designated as HV-like lymphoma (HVLL) has also been described, which closely mimics HV.[3] A 42-year-old male patient, farmer by occupation, reported to dermatology outpatient department with history of severe burning sensation and swelling limited to face and scalp on sun exposure. This was followed by painful skin eruptions, which further progressed to become fluid filled within 3 to 5 days, followed by brown coloured scab formation and eventually depressed scars. The patient has been experiencing similar recurrent episodes since last 8 years, from February to August every year. The patient reported mild malaise and lethargy during vesicular phase of illness, but no other symptoms like fever or chills, burning in eyes, arthralgia, weight loss, easy fatiguability, bruising tendency, abdominal discomfort, or features suggestive of lymphoproliferative etiology. There was no family history of similar illness and patient denied intake of any photosensitizing drug. On cutaneous examination, few erythematous papulovesicles 0.2 cm to 0.4 cm in size with overlying crust were noted on right cheek [Figure 1]. Both cheeks and scalp also showed multiple brown to black-colored scabs, 0.5 cm to 1.2 cm in size [Figure 2]. Multiple well-defined, depressed, and varioliform scars ranging from 0.2 cm to 1.5 cm [Figure 1] were present on forehead, cheeks, nose, and scalp. No cervical, axillary or inguinal lymphadenopathy, and hepatosplenomegaly was noted. Cytological smears and blood samples were negative for human immunodeficiency virus (HIV), Epstein-Barr virus (EBV), and herpes simplex virus (HSV). Urine samples showed no fluorescence on Wood's lamp examination and urinary and fecal porphyrin levels were within normal limits. The hemogram, peripheral blood smear, ultrasonography of abdomen and lymph nodes revealed no abnormality. A provisional diagnosis of discoid lupus erythematosus (DLE), adult-onset HV, and HVLL was arrived at and a lesional skin biopsy was obtained. Biopsy revealed intracellular edema, basal cell vacoulization, and areas of necrosis in epidermis along with mixed neutrophilic and lymphocytic dermal infiltrate [Figure 3]. There were no atypical lymphocytes or viral inclusion bodies. The immunohistochemical (IHC) studies were negative for T-cell lymphoma (CD8 and CD56). These findings were consistent with the primary diagnosis of HV. Immunofluoresence for antinuclear antibody (ANA) was negative.Figure 1: Erythematous papulovesicles and multiple depressed varioliform scars of varying size on right cheekFigure 2: Brown-colored scabs with multiple varioliform scars on left cheekFigure 3: Hematoxylin and eosin (H and E) stain of biopsy from papulovesicle showing epidermal edema, basal and suprabasal cell vacuolization and keratinocyte necrosis (depicted by black arrow) (×10)The patient was advised strict photoprotection and oral hydroxychloroquine (400 mg/day) with beta-carotene supplements. On follow-up visits at 3 and 6 weeks, patient was experiencing lesser number of episodes with decreased clinical severity. The original description of HV has been credited to Bazin, though it was confused with erythropoietic protoporphyria in those reports.[4] The disease typically affects children and adolescents as a phototoxic rash and remits by early adulthood. Typically exacerbations are noted in spring to summer season due to higher proportion of UVA rays reaching earth during this time of year. HV is sometimes confused with HVLL due to similarities in clinical presentation and age group affected. However, HVLL is typically associated with EBV infection, higher clinical severity and disfigurement, involvement of non-photoexposed parts, e.g., scalp and trunk, as well as systemic complications.[5] Unlike HV, HVLL lesions are not induced by sun exposure and do not tend to resolve with age. Involvement of scalp in our patient did not correlate with HV because dense scalp hair normally provides considerable photoprotection, hence creating a suspicion of HVLL. This; however, could possibly be due to the occupation of patient which mandates prolonged sun exposure in open spaces, hence increasing the dose of photoexposure and clinical severity. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.