Grenz Zone Research Articles

Primary Cerebral Diffuse Large B-cell Lymphoma Relapsed Solely in the Skin With the Same Clonal Origin

Diffuse large B-cell lymphoma is the most common type of primary central nervous system (CNS) lymphoma(PCNSL) with poor prognosis. Relapse occurs early and most commonly in CNS, whereas systemic relapse solely in skin is exceptional. We presented a unique case of PCNSL in an 82-year-old man with 2 consecutive skin relapses without concomitant local failure or other systemic involvement. The lymphoma cells of all 3 specimens were of the same histology and immunophenotype with expression of CD20, IgM, bcl-2, bcl-6, and MUM1 but not CD3, CD10, CD30, IgD, cyclin D1,or cutaneous lymphocyte-associated antigen. The skin tumors were in the dermis and subcutis with a spared grenz zone. The brain and skin tumors demonstrated the same clonal origin by B-cell clonality study followed by cloning and sequencing. To our knowledge, this is the first case of PCNSL relapsed solely in the skin with proven clonal identity.

Primary cutaneous CD4+/CD56+ hematodermic neoplasm (blastic NK‐cell lymphoma): a case report

A previously healthy 44‐year‐old Chinese man presented with a nonitching, painless, skin lesion on the right lateral abdomen of 1‐year duration. This lesion presented initially as a nodule of approximately 0.5 cm in diameter, which eventually grew to the size of an egg by August 2006. The patient had experienced no systemic symptoms, and his past medical and family history were noncontributory. Physical examination was normal except for the skin lesion. Peripheral lymph nodes were not palpable. Skin examination showed a lobulated, contusiform, brownish, infiltrated nodule with a wide base on the right lateral abdomen (Fig. 1).A lobulated, contusiform, brownish, infiltrated nodule with a wide base on the right lateral abdomenimage Histologic examination of a biopsy specimen taken from the lesion revealed the presence of a dense dermal lymphomatous infiltrate with a diffuse growth pattern, which extended into the subcutis. The Grenz zone was present. No signs of necrosis, karyorrhexis, hemophagocytosis, or angiocentric infiltrate were found (Fig. 2a). The tumor was composed of medium‐sized pleomorphic cells with dispersed chromatin and absent or indistinct nucleoli, resembling lymphoblasts. Frequent mitosis was seen (Fig. 2b).(a) Dense dermal lymphomatous infiltrate with a diffuse growth pattern. The Grenz zone was present. No signs of necrosis, karyorrhexis, hemophagocytosis, or angiocentric infiltrate were found (hematoxylin and eosin, ×40). (b) The tumor was composed of medium‐sized pleomorphic cells with dispersed chromatin and absent or indistinct nucleoli, resembling lymphoblasts. Frequent mitosis was seen (hematoxylin and eosin, ×400)image Immunohistochemical studies revealed the reactivity of more than 90% of the cells with CD56, CD4, and CD43 (Fig. 3a,b). Immunostaining for CD3, CD8, CD20, CD30, CD68, CD79a, CD99, T‐cell intracellular antigen‐1 (TIA‐1), Gallyas–Braak silver (GB), L26, Kp‐1, myeloperoxidase (MPO), and terminal deoxynucleotidyl transferase (TdT) was either weak or negative. Clonal rearrangement of the T‐cell receptor (TCR) was not detected by polymerase chain reaction (PCR). Epstein–Barr virus (EBV) staining of the skin biopsy specimen was negative.Immunohistochemical studies revealed the reactivity of more than 90% of the cells with CD4 (a) and CD56 (b) (SP, streptavidin‐perosidase, ×400)image Laboratory examinations, including complete blood examination with peripheral blood smear, liver enzymes, electrolyte levels, kidney function, antinuclear antibody, and urine analysis, were all normal. EBV antibodies were negative. Chest radiograph, nasal bone X‐ray, and bone marrow biopsy revealed no abnormal findings. Computed tomography of the nasal cavity, abdomen, and pelvis was normal. On the basis of the aforementioned clinical, histopathologic, and immunohistochemical findings, the patient was diagnosed with primary cutaneous CD4+/CD56+ hematodermic neoplasm [blastic natural killer (NK)‐cell lymphoma]. After receiving a diagnosis of a very aggressive malignancy, the patient refused chemotherapy until right groin lymphadenopathy occurred 6 months later. In February 2007, the lesion was excised and showed the same pathologic features, consistent with cutaneous blastic NK‐cell lymphoma. From March 2007, the patient received five courses of polychemotherapy with cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP). The lymphadenopathy disappeared after one cycle of chemotherapy. The patient received four more cycles of chemotherapy and no recurrence was observed over the following 6 months.

Molluscoid skin lesions in histoid leprosy with pseudo‐isomorphic Koebner phenomenon

A 30‐year‐old Indian man presented with multiple asymptomatic skin lesions on the arms, buttocks, trunk, and knees of 4 months’ duration. These lesions had started over the right arm and gradually increased in number and spread to involve the other sites. There was no history of any skin lesions in the past. Family members were normal. Cutaneous examination showed multiple, skin‐colored, shiny papules abruptly arising over the surrounding normal skin of the arms, buttocks, legs, trunk, and pinnae, varying from 2 to 3 mm in size. Some of the papules over the trunk and arms showed central umbilication resembling molluscum contagiosum, and a few showed superficial erosions and/or crusting (Fig. 1a,b). A few similar, erythematous papules over the left buttock showed a linear distribution, suggestive of pseudo‐isomorphic Koebner phenomenon (Fig. 2a,b). There was hypoesthesia in the distal part of the arms and legs for thermal, touch, and pain sensation, and the bilateral lateral popliteal and ulnar nerves were thick and mildly tender. The clinical features were suggestive of histoid leprosy. Systemic and eye examination were normal. Routine hematology and liver and kidney function tests were normal, and blood venereal disease research laboratory (VDRL) test and enzyme‐linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) 1 and 2 were negative. Histopathology from a papular lesion showed a thinned out epidermis, flattened rete ridges, a subepidermal Grenz zone, and granulomas of closely packed, spindle‐shaped histiocytes arranged in whorls, with foamy macrophages. In addition to the above histologic findings, the molluscoid lesion also showed an epidermal erosion with acid‐fast bacilli demonstrated by Ziehl–Neelsen stain (Fig. 3a,b). Slit skin smear examination from both the ear lobes and umbilicated lesions was highly positive, with a bacillary index (BI) of 6+ (> 1000 bacilli per oil immersion field) and a morphologic index (MI) of 80% (Fig. 3c). A diagnosis of histoid leprosy was made. The patient was treated with daily rifampicin and ofloxacin for 2 months, followed by standard multibacillary (MB) multidrug therapy (MDT) with daily dapsone and clofazimine with monthly rifampicin for 2 years. An excellent response to treatment was obtained with regression of all the skin lesions.(a) Umbilicated and shiny papular skin lesions arising abruptly over normal skin. (b) Umbilicated, crusted, and eroded pigmented lesions over the armimage(a) Multiple shiny papular lesions over both buttocks, showing linearly arranged skin lesions on the outer aspect of the upper lateral quadrant of the left buttock. (b) Close‐up view of the linearly arranged papular skin lesions on the buttockimage(a) Histopathology from a ruptured umbilicated papule showing a thinned out epidermis with flattened rete ridges, an epidermal erosion in the center, a subepidermal Grenz zone, and granuloma of closely packed spindle‐shaped histiocytes arranged in whorls, with foamy macrophages (Ziehl–Neelsen stain; original magnification, ×40). (b) Close‐up view of the marked portion of (a) showing acid‐fast bacilli at the mouth of the ruptured area arranged in a globus and discretely, shown by red arrows (Ziehl–Neelsen stain; original magnification, oil immersion, ×1000). (c) Slit smear examination from a skin lesion showing long, thick, acid‐fast bacilli, arranged in clumps and discretely (Ziehl–Neelsen stain; original magnification, oil immersion, ×1000)image

Multiple leiomyoma as a possible sign of aggressive renal cancer

A 53-year-old Chinese man presented with a history of painful lesions on the chest of 20 years' duration. He experienced sharp pain especially on touching and after spicy food. The lesions were stable with no increase in size or number. He was otherwise well. There was no significant family history. Physical examination revealed multiple, grouped, pink papules on the left chest, extending to the right back in a segmental distribution, each measuring 2-5 mm (Figs 1 and 2). They appeared pearly and keloid-like, and had a firm consistency. A punch biopsy specimen was obtained and sent for histopathologic examination (Figs 3 and 4). This revealed a circumscribed, nonencapsulated tumor with a Grenz zone below the epidermis. It was composed of interlacing fascicles of bland spindle cells with elongated nuclei and blunt ends, typical of a cutaneous leiomyoma. The patient subsequently underwent computed tomography of the abdomen, which did not show any renal or abdominal masses.

Localized Lepromatous Leprosy in Household Contact of Multibacillary Disease

Lepromatous leprosy (LL) is a generalized disease, usually with numerous papules, nodules, or plaques containing abundant Mycobacterium leprae and affecting wide areas of the skin. To report on an LL patient presenting with two lesions on the face and to discuss its epidemiologic significance in the current context of leprosy elimination. A 52-year-old housewife presented to our department with erythematous lesions over her face for 2 months. Her husband and son were treated for multibacillary leprosy 15 years previously. An infiltrated erythematous nodule was located over the right supraorbital area, and a single papule was present on the right eyelid. The rest of the examination was normal. A slit skin smear from the lesion revealed a bacillary index of 6+ and a morphologic index of 6%. A skin biopsy showed atrophic epidermis with an underlying clear grenz zone; the dermis showed massive infiltration of foamy macrophages, filled with bacilli and a few lymphocytes. The presentation of LL or borderline lepromatous leprosy (BL) as a single cutaneous lesion (or localized lesions) is a rare presentation of multibacillary disease, and such cases can be undertreated. This case also highlights the need to further explore the role of immunoprophylaxis or chemoprophylaxis in the contacts of multibacillary cases.

Indolent CD8-positive Lymphoid Proliferation of the Ear

The authors report 4 cases of cutaneous lymphoproliferation unusual by their histology and their clinical presentation. Each presented with a history of a slow growing nodule on the ear. Despite the indolent clinical evolution, the histology suggested a high-grade lymphoma. All lesions consisted of a dense, diffuse proliferation of monomorphous medium-sized T cells throughout the dermis and subcutis. There was no epidermotropism and a grenz zone was clearly present in each case. The tumor cells displayed irregular blastlike nuclei, with small nucleoli and clear chromatin and had a CD3+, CD8+, CD4+, TIA1+, granzyme B(-)immunophenotype with a loss of other T-cell antigens. The 3 cases with available material for polymerase chain reaction studies displayed a monoclonal T-cell rearrangement of the T-cell receptor-gamma chain. These cases do not correspond to a recognized cutaneous T-cell lymphoma as described in the recent WHO/EORTC classification. The apparent striking propensity for the ear suggests that they might represent a specific entity. Further cases are needed to confirm this hypothesis. It is important for such indolent lesions to be known to avoid over treatment.

Successful treatment of primary cutaneous follicle centre lymphoma with topical 5% imiquimod

Conflicts of interest: none declared. Sir, Imiquimod, a topical immune response modifier, has potent antitumour activity through local augmentation of innate and cell‐mediated immunity.1 It is increasingly being used to treat a wide variety of cutaneous tumours, including cutaneous T‐cell lymphomas.2, 3 It has not previously been shown to be fully efficacious for the treatment of cutaneous B‐cell lymphoma. We report a 59‐year‐old man with primary cutaneous follicle centre lymphoma successfully treated with topical 5% imiquimod. Our patient presented with a 5‐year history of multiple asymptomatic lesions grouped over the lateral surface of his upper right arm. Individual lesions had gradually appeared and enlarged over this time. Examination revealed smooth‐surfaced soft dermal papules and nodules (Fig. 1a). There was no associated palpable lymphadenopathy, nor organomegaly. Skin biopsy showed a lymphoid lesion involving superficial and deep dermis. The epidermis was intact and a Grenz zone was present (Fig. 2). On higher magnification, the infiltrate was noted to be polymorphic and composed of intermixed small and large lymphoid cells, with sparse germinal centres.

Extrafacial granuloma eosinophilicum

Three patients with a rare extrafacial granuloma eosinophilicum are presented. Lesions were localized on the scalp, the upper back or the upper arm. Only one patient had a typical facial granuloma eosinophilicum at the same time. Diagnosis was established by histopathology. The histopathological findings vary with the age of the lesion. Early lesions are characterized by a vasculitis with many eosinophils separated by a Grenz zone from epidermis and follicular structures. With time the inflammation changes and hyalin fibrosis takes place.

Granuloma Faciale With Extrafacial Lesions

A 35-year-old man presented with a 7-year history of gradually enlarging plaques on his face and trunk. The first lesions had developed on both sides of the forehead and the left cheekbone (Figure 1). Four years later similar lesions appeared on his neck and back. He presented a histologic report of a biopsy specimen from a facial plaque performed 5 years earlier that was diagnostic for granuloma faciale. He had different treatments such as topical steroids and cryotherapy without improvement. The appearance of new lesions on his trunk and the gradual enlarging of the old lesions convinced the patient to seek further treatment. Physical examination revealed dusky, violaceous plaques and papules, 0.5 to 2 cm, well-circumscribed, slightly elevated, and located on the face and trunk, with mild pruritus (Figure 1 and Figure 2). Laboratory investigations, including complete blood cell count, VDRL test, antinuclear antibody test, biochemical parameters, and chest x-ray, did not reveal any abnormalities. A skin biopsy taken from the upper part of the back showed similar features to the facial lesion, detected 5 years before, revealing a dense, polymorphous infiltrate involving mid and deep dermis and displaying a diffuse and perivascular pattern (Figure 3A). A narrow grenz zone of normal collagen was consistently observed between dermal infiltrate and epidermis as well as around the pilosebaceous follicles (Figure 3A). The infiltrate mainly consisted of eosinophils and lymphocytes, but neutrophils (often displaying leukocytoclasis), macrophages, and plasma cells were also present (Figures 3B, 3C). Some mast cells were also identified by staining with toluidine blue (Figure 3D). Perivascular infiltrates were often seen, sometimes penetrating vessel walls and in association with leukocytoclasis. Hyalinization of vessel walls, extravasation of red blood cells around capillaries, and nuclear dust were also noted. The epidermis did not show any remarkable change except for slight acanthosis. A diagnosis of granuloma faciale with extrafacial lesions was made, and a systemic therapy with hydroxychloroquine (200 mg twice daily for 6 weeks) was recommended.(1,2).

Collagen naevus in a zosteriform distribution

Conflict of interest: none declared A 25‐year‐old man presented with gradually progressive asymptomatic nodular lesions over the lower back, of 4 years' duration. There was no history of associated systemic complaints or family history of a similar disease. On examination, there were multiple, variable‐sized, firm, flesh‐coloured to brownish, smooth‐surfaced papules and nodules on the right side of his lower back and abdomen in a zosteriform distribution, not crossing the midline. Some lesions were discrete, while others had coalesced to form plaques. (Fig. 1) The intervening skin was normal. ‘Buttonhole’ sign was negative. No other soft tissue or bony abnormality was detected in the local area. Radiography of the lumbosacral spine and chest was within normal limits. The clinical possibility of collagenoma and segmental neurofibroma was considered. Histopathological examination of one of the papular lesions showed localized overdeposition of sheets of collagen in a haphazard pattern in the dermis with sparing of the subepidermal (Grenz) zone, and presence of normal elastin and glycosaminoglycan, consistent with the diagnosis of collagen naevus (Fig. 2).

Colloid milium arising on a non‐sun‐exposed area in an adult

A 59-year-old woman presented with multiple translucent papules on the inner surface of the tragus of the right ear. Initially they were treated with cryotherapy, with a later biopsy revealing the diagnosis of colloid milium. The histology was unusual for adult colloid milium as the lesion lacked a Grenz zone and evidence of solar elastosis. This together with a lack of aetiological factors made it difficult to classify the subtype of colloid milium.

Multicenter Study of the Safety and Efficacy of a 585 nm Pulsed-Dye Laser for the Nonablative Treatment of Facial Rhytides

Objective The objective of this study was to assess the safety and efficacy of a 585 nm flashlamp pulsed-dye laser for the nonablative treatment of facial rhytides. Methods A multicenter prospective randomized controlled study on 58 volunteers was performed. A split-face approach was adopted, with one periorbital region acting as a control and the other receiving either one or two treatments. Patients were photographed and imaged three-dimensionally before and after treatment. Histologic sections were analyzed. Results Three-dimensional topographic evaluation showed improvements of 9.8% (p= .0022) and 15% (p= .0029) in surface roughness for single and double treatments, respectively. Histology revealed an increase in type I collagen messenger ribonucleic acid expression, type III procollagen, chondroitin sulfate, and grenz zone thickness. Two treatments resulted in greater improvement than one treatment. Conclusion Clinical improvement was achieved following a single treatment. Further improvement was observed following a second treatment. The subjective evaluation of clinical improvement was consistent with both histologic and topographic quantitative measurements. SUZANNE KILMER, MD, AND JAY BURNS, MD, RECEIVED THE USE OF THE LASER FOR RESEARCH AND A DISCOUNTED PURCHASE AGREEMENT. THEY BOTH ACKNOWLEDGE RECEIVING HONORARIA FOR LECTURING FROM THE MANUFACTURER. BRIAN ZELICKSON, MD, RECEIVED RESEARCH GRANTS FROM ICN.

Granuloma faciale: A clinicopathologic study of 66 patients

Only case reports or studies of small series of patients have focused on granuloma faciale (GF). We sought to describe the clinicopathologic characteristics of GF in a large series of patients. We conducted a retrospective analysis of 66 patients and 73 skin specimens. GF mostly presented as reddish plaques or nodules in middle-aged adults. One third of patients had multiple sites involved and 5 patients had extrafacial lesions. A clinical diagnosis of GF was made in only 10 cases; sarcoidosis, lymphoma, lupus, and basal cell carcinoma were the main differential diagnoses. The most frequent histopathologic features were the presence of a grenz zone, neutrophils, and telangiectases. Vascular changes were frequent, although necrotizing vasculitis appeared to be rare. There was often an association of acute and chronic inflammatory patterns, suggesting that GF follows a chronic history with recurrent acute phases, rather than distinct successive acute and chronic stages. In this retrospective study, a reliable analysis of the outcome of patients could not be performed. Results of direct immunofluorescence tests and laboratory investigations were lacking in many cases. GF is often clinically misdiagnosed; its morphologic spectrum is broader than usually described and includes a lack of eosinophils, the presence of vascular changes with rare vessel wall necrosis, and associated acute and chronic inflammatory patterns.

Histological Evaluation of a Topically Applied Retinol-Vitamin C Combination

Two double-blind studies versus vehicle were carried out to investigate the effects of a topically applied retinol plus vitamin C combination on epidermal and dermal compartments of aged or photoaged human skin. The two studies were performed on postmenopausal women who were selected for treatment based on the mild level of elastosis of their facial skin. At completion of treatment, skin biopsies were collected and processed for classical histology and immunohistochemistry. In the first study (aged skin), 8 volunteers applied the retinol- and vitamin C-containing preparation on the ventral side of one elbow and the vehicle on the other elbow twice daily for 3 months. After the 3-month treatment we observed histological changes mainly within the epidermis. The stratum corneum was thinner with a compact pattern, whereas the epidermal proliferation increased, resulting in a thickening of the viable epidermis. Moreover, the interdigitation index was increased. In the second study (photoaged skin), 11 volunteers were divided in two groups; one applied the retinol- and vitamin C-containing preparation and the other one the vehicle on their face twice daily for 6 months. Facial skin samples presented histologic hallmarks of photoaging, i.e. accumulation of elastotic material in the papillary dermis. After the 6-month topical treatment, the observed histological changes were mainly concentrated at the dermal level. Both treated and control groups showed the same distribution pattern of type I procollagen, however, the high level of type III procollagen originally observed in photoaged skin was reduced in the retinol- and vitamin C-treated group, resulting in a lower type III-to-type I procollagen ratio. Furthermore, a wide band of eosinophilic material just beneath the epidermis, devoid of oxytalan fibers and forming the ‘grenz zone’, appeared more frequently and was larger in the retinol- and vitamin C-treated group. In conclusion, our results show that repeated topical application of a preparation containing both retinol and vitamin C is able to reverse, at least in part, skin changes induced by both chronologic aging and photoaging.

Paracolloid of the Skin

The concept of paracolloid was raised by Dupre et al. in 1979 to describe a rare lesion, in which large amounts of homogeneous, pale pink, non‐amyloid material in sun‐exposed skin. The deposits consisted of haphazardly arranged microfilaments of 3–4 nm in diameter. Here we report another case. A 54‐year‐old white male presented with a 2 × 2 cm boggy, erythematous plaque involving the bridge and tip of the nose for two years. The lesion enlarged slowly and intermittently drained pinkish fluid. A shave biopsy revealed extensive homogeneous, pale pink material with fissure and clefts in the dermis. The deposits wrapped up hair follicles and sebaceous glands, and superficially mixed with scattered solar elastic fibers and globules. There were scattered fibroblasts, focal mild perivascular and perifollicular lymphocyte and plasma cells. Adjacent skin showed prominent solar elastosis. A thin grenz zone was present abutting an atrophic epidermis with actinic keratosis. The deposits showed faint Congo red stain with focal weak apple‐green birefringence, faint PAS stain, and negative Verhoeff‐van Gieson stain. Masson’s trichrome stain and immunohistochemical stain for collagen IV were negative.

Acute Monocytic Leukaemia with Cutaneous Manifestation

A 50‐year‐old Caucasian male presented with generalised skin rash. Gingival hyperplasia and hepatosplenomegaly were also noted. His laboratory data showed hemoglobin of 10.3 g/dL, white blood cell count of 203.6 K/uL and platelet count of 72 K/uL. Peripheral blood smears revealed that 67% of the white blood cells was monoblasts, 25% was promonocytes and atypical monocytes. Bone marrow aspirate smears showed that 97% of the nucleated cells were composed of monoblasts and promonocytes. Approximately 80% of the immature cells showed intense non‐specific butyrate esterase activity. The morphologic and cytochemical findings were compatible with a diagnosis of acute monocytic leukaemia. Skin biopsy taken from the left medial thigh revealed a Grenz zone and a dense infiltrate of atypical cells throughout the dermis. The cells were positive for KP1 (CD68) immunohistochemical stain. The findings were consistent with cutaneous manifestation of leukaemia (leukaemia cutis). The patient’s condition deteriorated rapidly despite chemotherapy and expired 10 days after initial presentation. Leukaemia cutis is more common in acute monoblastic/monocytic leukaemia (AMoL) than in other subtypes of leukaemia. Leukaemia gingival hyperplasia is another characteristic feature of AMoL. Dissemination to the skin is generally associated with a poor prognosis.

Multicenter Study of the Safety and Efficacy of a 585 nm Pulsed-Dye Laser for the Nonablative Treatment of Facial Rhytides

The objective of this study was to assess the safety and efficacy of a 585 nm flashlamp pulsed-dye laser for the nonablative treatment of facial rhytides. A multicenter prospective randomized controlled study on 58 volunteers was performed. A split-face approach was adopted, with one periorbital region acting as a control and the other receiving either one or two treatments. Patients were photographed and imaged three-dimensionally before and after treatment. Histologic sections were analyzed. Three-dimensional topographic evaluation showed improvements of 9.8% (p = .0022) and 15% (p = .0029) in surface roughness for single and double treatments, respectively. Histology revealed an increase in type I collagen messenger ribonucleic acid expression, type III procollagen, chondroitin sulfate, and grenz zone thickness. Two treatments resulted in greater improvement than one treatment. Clinical improvement was achieved following a single treatment. Further improvement was observed following a second treatment. The subjective evaluation of clinical improvement was consistent with both histologic and topographic quantitative measurements.

Keloid in Iraqi Patients

BACKGROUND Keloid is a benign, well-demarcated area of fibrous tissue overgrowth that extends beyond the original defect. It is not an uncommon problem and is encountered frequently in daily practice. OBJECTIVE To evaluate the different clinical and histopathologic aspects of this disease in Iraqi people. METHODS Eighty-eight patients with keloid were clinically assessed. Histopathologic examination was performed in 16 patients. Giemsa stain was used in eight patients to assess the presence of mast cells. RESULTS There were 47 females and 41 males. The disease started in the second and third decades of life in 62 patients (70.5%). Itching was present in 46 patients (52.2%) and was more predominant in those with early lesions. Darier sign was elicited in 22 patients (25%); all of them had itching. The duration of the disease ranged from 0.33 to 20 years, with a mean of 5.4 years. Spontaneous keloid was found in 30 patients (34%). The lesions were mainly single (63.4%). All of these patients had lesions on the face and upper trunk in addition to involvement of extremities in five of them (16.7%). BCG keloid was observed in females only, and it showed downward gravitational extension in three of seven patients (43%). The histopathologic examination of keloid in 16 patients showed many interesting findings, such as the presence of hyperplastic epidermis in six specimens (37.5%), Grenz zone in 11 patients (68.75%), telangiectasia in 12 patients (75%), and pseudopodia extension of the growth to the adjacent tissues in half of the patients. Giemsa stain of eight specimens demonstrated the presence of mast cells in four patients (50%), more in biopsies that were taken from early lesions.

Keloid in Iraqi patients: a clinicohistopathologic study.

Keloid is a benign, well-demarcated area of fibrous tissue overgrowth that extends beyond the original defect. It is not an uncommon problem and is encountered frequently in daily practice. To evaluate the different clinical and histopathologic aspects of this disease in Iraqi people. Eighty-eight patients with keloid were clinically assessed. Histopathologic examination was performed in 16 patients. Giemsa stain was used in eight patients to assess the presence of mast cells. There were 47 females and 41 males. The disease started in the second and third decades of life in 62 patients (70.5%). Itching was present in 46 patients (52.2%) and was more predominant in those with early lesions. Darier sign was elicited in 22 patients (25%); all of them had itching. The duration of the disease ranged from 0.33 to 20 years, with a mean of 5.4 years. Spontaneous keloid was found in 30 patients (34%). The lesions were mainly single (63.4%). All of these patients had lesions on the face and upper trunk in addition to involvement of extremities in five of them (16.7%). BCG keloid was observed in females only, and it showed downward gravitational extension in three of seven patients (43%). The histopathologic examination of keloid in 16 patients showed many interesting findings, such as the presence of hyperplastic epidermis in six specimens (37.5%), Grenz zone in 11 patients (68.75%), telangiectasia in 12 patients (75%), and pseudopodia extension of the growth to the adjacent tissues in half of the patients. Giemsa stain of eight specimens demonstrated the presence of mast cells in four patients (50%), more in biopsies that were taken from early lesions.

Reversal of photodamage with topical growth factors: a pilot study

BACKGROUND: Interest in the reversal of facial photodamage has increased significantly among patients and physicians in the past decade. Though surgical procedures may be very effective, the associated healing time and potential risks have spurred the development of non‐surgical treatments. There has also been an increasing depth of knowledge regarding wound healing and its control by growth factors as well as its modulation by the topical application of growth factors. Bioengineered tissue cultures have resulted in the ability to collect naturally occurring human growth factors in their tissue concentrations.OBJECTIVE: The objective of this study is to determine if the twice daily application of a combination of multiple growth factors to photodamaged facial skin results in any evidence of improvement after 60 days.METHODS: Fourteen patients applied a gel containing a mixture of eight different growth factors (Nouricel‐MD) to photodamaged facial skin twice daily. Prior to the study and at 60 days there were clinical evaluations of photodamage (Fitzpatrick scale), 3 mm punch biopsies and optical profilometry. Patient questionnaires were answered at 60 days.RESULTS: Eleven of 14 patients showed clinical improvement in at least one facial area. The peri‐orbital region showed a statistically significant improvement (p=0.0003). Optical profilometry showed a statistically significant reduction in Ra measurement (p=0.0075) and shadowing (p=0.02), both indicating a decrease in the depth and number of textural irregularities or fine lines. Biopsies revealed new collagen formation in the Grenz zone (37% increase in thickness) and thickening of the epidermis by 27%. Eight of 14 patients felt their wrinkles were improved, while 12 of 14 felt their skin texture was improved.CONCLUSIONS: The application of a mixture of topical growth factors may stimulate the repair of facial photodamage resulting in new collagen formation, epidermal thickening and the clinical appearance of smoother skin with less visible wrinkling.