Hyperkeratotic Surface Research Articles

Genital Condyloma in a 2-Year-Old Child Secondary to Circumcision: A Case Report

Accumulated condylomas are exophytic tumors with a warty and hyperkeratosic surface due to the Human papillomavirus (HPV). Its prevalence in children is difficult to estimate due to limitations in epidemiological data. Its recurrent character is found in 30% of patients. Its management is very complex in children because of skin fragility. Circumcision is an operation consisting of the removal of part of the foreskin. This practice is done either with a simple knife or a pair of non-aseptic scissors which can be a source of contamination including HPV (Condyloma). Traditional circumcision does not seem to be reported in the literature as a mode of contamination. We report a case of genital condyloma in a child 2 years after circumcision. This is a 2-year-old male with no medical history but with a surgical history of circumcision that was brought by his parents in dermatological consultation for papular lesions accumulated on the penis. At the interrogation, we found the notion of recent circumcision performed by a tradithérapeute. The physical examination finds a good general condition. Dermatological examination reveals on the glans of multiple papules, exophitic, with warty and hyperkeratotic surface, of normal skin color. Furthermore, the physical examination of both parents was normal. The diagnosis of accumulated condyloma secondary to probable circumcision was retained before the clinical appearance of the lesions. Two electrocoagulation sessions spaced one month apart under local anesthesia were the treatment with a favorable evolution.

Papillomatosis cutis lymphostatica: a sign of chronic edema

An obese 53-year-old male presented himself to our department with lymphedema of the left leg and ulcerated lesions evolving for two weeks prior. His medical history included epilepsy since childhood, mental retardation, chronic venous insufficiency, and chronic lymphedema complicated by recurrent ulceration and cellulitis. Over the previous four years, he had developed verrucous and papillomatous lesions on the left leg. A physical examination revealed an edematous leg with multiple painless coalescent verrucous skin-colored papules with a smooth or hyperkeratotic surface on the left lower leg surrounding the ulceration. The lesions were associated with oozing. A skin biopsy revealed hyperkeratosis, verrucoid acanthosis, and papillomatosis of the epidermis with moderate perivascular inflammatory infiltration of the dermis. A diagnosis of papillomatosis cutis lymphostatica (PCL) was reached based on histopathological and clinical findings. Our patient received lymphatic drainage and locally 5% salicylic acid.

Dermoscopic Clues for Diagnosing Melanomas That Resemble Seborrheic Keratosis

Melanomas that clinically mimic seborrheic keratosis (SK) can delay diagnosis and adequate treatment. However, little is known about the value of dermoscopy in recognizing these difficult-to-diagnose melanomas. To describe the dermoscopic features of SK-like melanomas to understand their clinical morphology. This observational retrospective study used 134 clinical and dermoscopic images of histopathologically proven melanomas in 134 patients treated in 9 skin cancer centers in Spain, France, Italy, and Austria. Without knowledge that the definite diagnosis for all the lesions was melanoma, 2 dermoscopy-trained observers evaluated the clinical descriptions and 48 dermoscopic features (including all melanocytic and nonmelanocytic criteria) of all 134 images and classified each dermoscopically as SK or not SK. The total dermoscopy score and the 7-point checklist score were assessed. Images of the lesions and patient data were collected from July 15, 2013, through July 31, 2014. Frequencies of specific morphologic patterns of (clinically and dermoscopically) SK-like melanomas, patient demographics, and interobserver agreement of criteria were evaluated. Of the 134 cases collected from 72 men and 61 women, all of whom were white and who had a mean (SD) age of 55.6 (17.5) years, 110 (82.1%) revealed dermoscopic features suggestive of melanoma, including pigment network (74 [55.2%]), blue-white veil (72 [53.7%]), globules and dots (68 [50.7%]), pseudopods or streaks (47 [35.1%]), and blue-black sign (43 [32.3%]). The remaining 24 cases (17.9%) were considered likely SKs, even by dermoscopy. Overall, lesions showed a scaly and hyperkeratotic surface (45 [33.6%]), yellowish keratin (42 [31.3%]), comedo-like openings (41 [30.5%]), and milia-like cysts (30 [22.4%]). The entire sample achieved a mean (SD) total dermoscopy score of 4.7 (1.6) and a 7-point checklist score of 4.4 (2.3), while dermoscopically SK-like melanomas achieved a total dermoscopy score of only 4.2 (1.3) and a 7-point checklist score of 2.0 (1.9), both in the range of benignity. The most helpful criteria in correctly diagnosing SK-like melanomas were the presence of blue-white veil, pseudopods or streaks, and pigment network. Multivariate analysis found only the blue-black sign to be significantly associated with a correct diagnosis, while hyperkeratosis and fissures and ridges were independent risk markers of dermoscopically SK-like melanomas. Seborrheic keratosis-like melanomas can be dermoscopically challenging, but the presence of the blue-black sign, pigment network, pseudopods or streaks, and/or blue-white veil, despite the presence of other SK features, allows the correct diagnosis of most of the difficult melanoma cases.

Analysis of debrided and non-debrided invasive squamous cell carcinoma skin lesions by in vivo reflectance confocal microscopy before and after therapy.

Hyperkeratosis hinders the application of reflectance confocal microscopy (RCM) to image squamous cell carcinoma (SCC). Not all lesions with SCC show hyperkeratosis, and these lesions can be directly imaged. However, lesions with hyperkeratosis can be treated by debriding the hyperkeratotic surface for further imaging. RCM was used to investigate patients with suspected SCC. Lesions without obvious keratosis underwent direct RCM examinations. Lesions with obvious keratosis were treated by debriding the hyperkeratotic surface. The following main RCM criteria were used to diagnose invasive SCC: atypical keratinocytes arranged in nests, islands, and disarrangement patterns; an atypical honeycomb pattern; the absence of a cobblestone pattern; and non-edged dermal papillae. Other characteristics of invasive SCC observed by confocal microscopy included keratin pearl structures, hyperkeratosis, and inflammatory cell infiltration. During the follow-up period after treatment, both the cobblestone pattern and edged dermal papillae were as important as the typical honeycomb pattern in suggesting a normal skin structure. Our findings indicate RCM is a valuable tool to noninvasively examine the histology of invasive SCC before and after therapy.

A case of verrucous hemangioma and its dermoscopic features.

Sir, Verrucous hemangioma is a congenital, vascular lesion characterized by a gradual, progressive development of hyperkeratosis on the surface. Rarely the lesions may present for the first time in childhood and adulthood. The lesions usually present as solitary hyperkeratotic, bluish, and partly confluent lesions. A 20-year-old male patient presented with purplish skin lesions restricted to the left lower limb. The lesions had been present since birth and there was a history of occasional bleeding from the lesions especially after trauma. The lesions had gradually increased in size and number and many of the lesions developed scaling on the surface. On examination multiple lesions were seen restricted to the left lower limb. While most of the lesions were purplish nodules, some of them had significant hyperkeratosis over the surface [Figures ​[Figures11–3]. There was no difference in limb girth between the limbs. No other significant skin or mucosal lesions were noted. Figure 1 Verrucous hemangioma lesions in different stages of evolution Figure 3 Close up of early hemangiomatous lesions Figure 2 Verrucous hemangioma lesions in different stages of evaluation—early flat lesions and evolved hyperkeratotic lesions The dermoscopic features were different depending on the type and area of the lesions. The most striking feature was a prominent bluish shade with many areas showing an appearance of a blue-white veil. Hyperkeratosis was observed in most lesions but was the dominant feature in the verrucous lesions. The periphery of the lesions showed well-defined dark blue lacunae characteristic of vascular lesions [Figures ​[Figures44–7]. Figure 4 Dermoscopy of relatively early lesions of verrucous hemangioma showing a prominent bluish white hue similar to a blue-white veil in some areas, indicating the hyperkeratosis over the underlying vascular channels, which is seen in the histopathology Figure 7 Peripheral areas of the lesion showing the dark blue lacunae characteristic of vascular lesions correlating with the vascular channels seen in histopathology Figure 5 Dermoscopy of the late lesions showing the more prominent hyperkeratosis along with the bluish lacunae indicating the underlying dilated vascular channels Figure 6 Dermoscopy showing very prominent hyperkeratosis in the fully developed lesions Biopsy from one of the lesions showed hyperkeratosis, acanthosis, papillomatous and proliferation in the epidermis. Multiple vascular channels were seen extending from the papillary dermis to the deep dermis. The histopathological appearance was suggestive of verrucous hemangioma. The location of the dilated vascular channels in the deeper dermis ruled out other possibilities such as angiokeratoma circumscriptum naeviforme [Figure 8]. Figure 8 Histopathology H and E ×20 showing hyperkeratosis, acanthosis, and multiple vascular channels in the dermis The patient was referred to reconstructive surgery for excision of the lesions. All the lesions were excised with a 1 cm margin, under tourniquet control. The smaller lesions were closed primarily while the larger lesions were covered with a skin graft. Verrucous hemangioma typically presents as solitary and localized lesions present since birth.[1,2] To the best of our knowledge, there is only one report demonstrating the dermoscopic features in verrucous hemangioma. Popadic reported the case of a solitary verrucous hemangioma over the right leg. The main dermoscopic features in the case reported by Popadic included an alveolar appearance with numerous small, oval to polygonal elements surrounded by slightly darker pigmentation. Popadic described different shades of blue, including light blue, indigo blue, and dark bluish-black and a blue-white veil. Well-defined dark lacunae were seen in the periphery. The same case described by Popadic on follow up became a dark bluish-black, raised nodule, with irregular borders and hyperkeratotic surface, and dermoscopic examination showed a more marked alveolar appearance, with more pronounced sulci. There was a dominant bluish color to the lesion.[3,4] In our case we could not find a significant alveolar pattern, but all the other features were seen. The main highlight in our case was the expected dominant hyperkeratosis seen in the verrucous lesions. The treatment of choice for verrucous hemangiomas is surgical excision, the general concept being that smaller lesions are excised in a single sitting, whereas larger lesions require multiple sessions with or without combination treatment using other modalities. Various other options that have been tried with limited results include ultrasound, lasers, and cryotherapy.[1,2,5] This particular case was interesting not only because of its rarity, but also the presence of both verrucous and preverrucous stages in the same patient and the characteristically different dermoscopic patterns in both types of lesions. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Skin SCC following mustard gas testing in a British Army recruit

An 84-year-old army veteran presented with a 1.5×1-cm keratotic lesion on the dorsum of his right hand. The lesion had developed at the site of previous mustard gas testing, which he had been subjected to as a soldier in the British army in 1944. He reported that the site had been painful, erythaematous and ulcerated for a number of years following the mustard gas tests. This had eventually settled, leaving a flat, erythaematous but generally asymptomatic lesion described as a ‘burn’ that the patient had ignored. Over the past 10 years, however, the lesion had become raised and increasingly symptomatic, with itching and occasional bleeding. It was treated by dermatologists with topical 5-flurouracil and serial curettage for 8 years but had persistently recurred. Serial biopsies had shown chronic, severely inflamed skin with evidence of Bowen’s disease. The patient was referred to our plastic surgery oncology clinic (Fig. 1). A detailed history was taken, which revealed the mustard gas tests. He had no past history or family history of skin malignancies. Examination showed an irregularly shaped pigmented lesion measuring 15 mm in diameter × 3 mm in height. Systemic examination demonstrated no palpable peripheral lymphadenopathy and no other skin malignancies. He underwent excision of the lesion under local anaesthesia with a 10-mm clearance margin. The defect required a full-thickness skin graft. Histological assessment of the lesion demonstrated a welldifferentiated, squamous cell carcinoma, measuring 3.5 mm in width × 2.2 mm in depth. The overlying epidermis was hyperplastic, with a hyperkeratotic surface, but demonstrated no evidence of dysplasia in the epidermal keratinocytes, a possible result of previous topical treatments. Vascular invasion was not identified and excision margins were clear (Fig. 2). The patient recalled that the process of mustard gas testing involved the application of a spoonful of mustard gas paste onto the back of the hand, followed by a 30-min period of observation, after which the soldiers were permitted to wash their hands. This test was conducted on 30 soldiers from his regiment. He and the rest of the subjects, at the time, were not aware of the reasons for the test.

Warty and clear-cell Bowen's disease successfully treated with photodynamic treatment

Clear cell Bowen's disease (BD) is a rare histopathological subtype of BD, characterized by epidermal atypical keratinocytes with clear-cell changes exceeding 80% of the tumor population. Warty and clear cell Bowen's disease (WCCBD) is a recently described variant of clear cell BD, with verrucous and hyperkeratotic surface changes in addition to pathological features consisting of an extremely acanthotic epidermis, hyperkeratosis and clear-cell changes. Herein we present a 72-year-old man with a 1-year history of tumoral lesion located on the left cheek with a diagnosis of WCCBD, in whom we achieved excellent result with photodynamic treatment. To the best of our knowledge, this is the second reported case of this entity.

Acral Psoriasiform Lesions

The patient presented symmetrical, erythematousviolaceous plaques on the distal phalanges of the fingers and toes; the plaques had a hyperkeratotic and desquamative surface (Figures 1 and 2). There was also slight reddening and desquamation of the lobes of the ears. In addition, the patient was asthenic, with mild jaundice of the skin and mucosas, and presented hepatomegaly and palpable right lateral cervical lymph nodes that formed a mass of approximately 4 by 3 cm (Figure 3). Additional Tests

Discoid lupus erythematosus: A case report with review of the literature

Discoid lupus erythematosus (DLE) is the most common form of chronic cutaneous lupus erythematosus. Classic DLE lesions begin as red-purple macules, papules or small plaques and rapidly develop a hyperkeratotic surface. Most patients with untreated classic DLE lesions suffer indolent progression to large areas of cutaneous dystrophy and scarring alopecia that can be psychosocially devastating. A 68-year-old male patient presented with non-healing ulcers of the mouth since 6 months and skin lesions since 2 months. Examination revealed erythematous, disc-like, scaly plaques over the face, nose and scalp, showing signs of healing accompanied by scarring and hypopigmentation. Histopathologic examination verified a diagnosis of DLE. Topical steroids and antifungals were applied to the lesions twice daily for 2 weeks. After 2 weeks of application, all lesions regressed significantly. Follow-up is important and necessary every 6 months because DLE is considered as a pre-cancerous condition and for the early detection of systemic lupus erythematosus and to minimize scarring. The recent advances in the diagnostic criteria and treatment have also been highlighted.

Acquired digital fibrokeratoma associated with ciclosporin treatment

Conflict of interest: none declared. Ciclosporin (CsA) is the favoured drug for immunosuppressive treatment in recipients of organ transplants. The principal adverse reactions to CsA treatment are renal dysfunction, tremor, hirsutism, hypertension and gingival overgrowth. We report a case of acquired digital fibrokeratoma (ADFK) and concomitant gingival overgrowth secondary to CsA treatment in a renal‐transplant recipient. A 39‐year‐old Chinese woman presented with two gradually enlarging tumours on the left great toe and with gingival overgrowth, which had been present for 2 years. The patient had received a renal transplant 6 years previously and was taking CsA. Physical examination found two solitary, skin‐coloured, firm tumours under the lateral nail folds of the left great toe. One of the tumours was verrucous and slightly erosive and about 12 × 8 × 7 mm3 in size. The other was a tall finger‐like protrusion with a hyperkeratotic surface, about 4 × 3 × 6 mm3 in size (Fig. 1). Diffuse waxy nodules and masses were present on the upper and lower gingiva (Fig. 2).

A case of generalized discoid lupus erythematosus: Successful treatment with Imiquimod cream 5%

Discoid lupus erythematosus (DLE) is the most common form of chronic cutaneous lupus erythematosus. Classic DLE lesions begin as red-purple macules, papules, or small plaques and rapidly develop a hyperkeratotic surface. Most patients with untreated classic DLE lesions suffer indolent progression to large areas of cutaneous dystrophy and scarring alopecia that can be psychosocially devastating. A 44-year old male patient presented to the clinic with erythematous scaly patches that began on his nose 1 y before. His face was most affected, however, lesions were also noted on his scalp, ears, and limbs. Histopathologic examination verified a diagnosis of DLE. Laboratory examinations and consultations revealed no signs of systemic involvement. Imiquimod cream 5% was applied to the lesions once a day 3 times a week. After 20 applications, entire lesions regressed significantly. Imiquimod cream 5% may represent an alternative treatment method for patients with DLE.

Local hypertrichosis associated with a human papillomavirus type 1-induced wart

Conflict of interest: None declared. Sir, Various causes for acquired localized hypertrichosis have been described, including application of topical steroids, infections, local trauma, long‐standing inflammatory dermatoses, venous incompetence, and the application of splints and casts.1–3 A 7‐year‐old Japanese girl noted a verrucous papule on her right knee 7 months before the first examination. It was a firm, dark red, circumscribed and elevated papule 8 mm in diameter with a hyperkeratotic surface. The most interesting finding in the case was the hypertrichosis seen alongside of the wart lesion (Fig. 1A). She had noticed the increased hair 3 months before the first examination. She did not complain of any symptoms. She was healthy and physical examination revealed no particular finding other than the skin lesion. The suspected diagnosis of a viral wart with an acquired, local hypertrichosis was made, and after informed consent was obtained, the verrucous papule was removed by scalpel. During the follow‐up period of about 9 months, the hypertrichosis gradually reduced (Fig. 1B) and finally disappeared (Fig. 1C).

Hyperkeratotic Rim of Gram-Negative Toe Web Infections

T HE LESIONS SHOWN ARE FROM THE PLANTAR surface of a foot of a 41-year-old white man (Figure1) and a foot of a 48-year-old white man (Figure 2). Each photograph represents a case of gram-negative toe web infection that was resistant to several courses of antibiotics, antifungal agents, and immunosuppressants, alone or in combination. With continued disease, development of a hyperkeratotic rim was noted in these 2 cases as well as in other cases seen at our institution. This hyperkeratotic rim pattern seems to be characteristic of toe web infections that are resistant to standard medical intervention. In our experience, surgical debridement of the hyperkeratotic rim and surface exudate with a standard curette with the patient under local anesthesia leads to rapid improvement (Figure 3) with routine wound care and without further medical therapy. The hyperkeratotic rim pattern may be the result of epidermal undermining of the polymicrobial infection and may serve both as a protected environment for the infecting agents and as a barrier to wound healing, blocking lateral epidermal migration. Editor’s Note: The skINsight section is a forum for the presentation of dermatologic images. The current effort is to foster the recognition of patterns in dermatologic disease processes that may enhance both diagnostic and research capabilities. The initial focus is on dermoscopic images. Theoretically, these patterns reflect the interaction of specific gene defects with local environmental factors. The exercise here is to group lesions with similar dermoscopic patterns—not pathologic criteria. The ultimate benign or malignant behavior is not the focus of this section.

Unusual inflammatory and hyperkeratotic halo naevus in children

Although the classic halo naevus (HN) is a melanocytic naevus with a surrounding rim of depigmentation, these naevi can present unusual features. We describe an unusual and previously unreported variety of HN in children. Between March 1999 and September 2002, 14 children (11 boys and three girls, age range 6-14 years) were referred to us for evaluation of one or more 'inflamed' naevi. All the affected naevi showed the same clinical development: (i) after an initial inflammatory stage their surfaces gradually became thickened and rough, then (ii) verrucous and raised, and finally (iii) scaly crusted. A marked halo of depigmentation subsequently developed in all lesions, with simultaneous disappearance of the hyperkeratotic surface appearance. Lesions were multiple in five cases and single in nine, and were mainly located on the back (nine cases). Excisional biopsy was performed in eight cases. The biopsies were all taken in the 'prehalo phase'. In each case, histopathology revealed a compound melanocytic naevus, with additional features that varied depending on the clinical stage of the lesion. Immunohistochemical staining of the dense inflammatory infiltrate showed a predominance of CD3(+)/CD8(+) T lymphocytes, as usually occurs in HN. On the basis of these observations, we believe that the described naevi represent an unusual variety of HN in children. Knowledge of this possible clinical evolution of HN is important to avoid unnecessary surgical excision in these young patients.

Actinic keratoses

Statement on actinic keratosis: Actinic keratoses are cutaneous neoplasms displaying chromosomal abnormalities that occur primarily on sun-exposed skin surfaces. These premalignant lesions are usually a consequence of long-term solar radiation, but may also be caused by UV light exposure from artificial sources, x-irradiation, or exposure to polycylic aromatic hydocarbons. Actinic keratoses range in size from 1 to 2 mm papules to large plaques. They may be flesh-colored, erythematous, or more deeply pigmented, and they usually have a hyperkeratotic surface. Horn formation can occur in any location. Although it is usually possible to diagnose actinic keratosis on the basis of the clinical appearance of a lesion, it may on occasion be difficult (or impossible) to distinguish one from a squamous cell carcinoma of the skin and other pathologic lesions without doing a skin biopsy (or other procedure) to obtain tissue for histologic examination. It has been demonstrated that the p53 chromosomal mutation, found in more than 90% of human cutaneous squamous cell carcinomas, is also present in actinic keratoses. Estimates of the percentage of these chromosomally abnormal skin lesions that convert to squamous cell carcinoma vary from 0.25% to 20% per year for an individual lesion. Because patients often have multiple actinic keratoses (because of the field effect of solar radiation), the risks of conversion to a malignancy increase significantly. It is impossible to predict accurately in which patient a squamous cell carcinoma will develop. Most actinic keratoses and squamous cell carcinomas are asymptomatic. Once an actinic keratosis converts to a squamous cell carcinoma, it may bleed, ulcerate, become infected, destroy anatomic structures, or even spread to internal organs. Actinic keratoses must be treated to prevent their conversion to squamous cell carcinoma. Treatment of these premalignant lesions avoids the potentially more invasive and extensive treatment of subsequent malignancy. American Academy of Dermatology

Ultraviolet light—induced confluent and reticulated papillomatosis

A 16-year-old girl initially had an eruption consisting of dark gray, flat, pin-sized, confluent papules with a slight hyperkeratotic surface. The lesions appeared after her summer holidays and were restricted to the tanned skin of sun-exposed areas, mainly the abdomen and back. Clinical and histologic findings were consistent with confluent and reticulated papillomatosis. If a basic disorder of keratinization is the cause of confluent and reticulated papillomatosis, it seems likely that the development of the disease in our patient may be due to an abnormal epidermal response to ultraviolet light.

Some measures of proliferative activity in normal and leukoplakic buccal mucosa (author's transl)

In 29 patients, the DNA synthesis rate of clinically healthy buccal mucosa epithelium in comparison to benign buccal leukoplakias has been studied by in vitro-autoradiography. The proliferative activity has been determined by means of the 3H-labelling indices of basal cells (LBC) and suprabasal cells (LSBC) including the total of labelled epithelium cells and the quotient of LBC:LSBC as well. The progenitor compartment of both leukoplakic and normal buccal epithelium comprises the stratum basale and the adjacent 2-3 layers of suprabasal cells. Around 70% of the DNA synthesis of normal mucosa was found in the suprabasal nuclei of the progenitor compartment. In the leukoplakic mucosa, some displacement of the labelled nuclei in the progenitor compartment resulting in a statistically significant change of the quotient of LBC:LSBC in favour of LBC was determined. Moreover, the leukoplakic specimens showed a moderate decrease of the mean proliferative activity of the total of labelled epithelial cells which may be due to a diminished exfoliation of cornified cells from the hyper(ortho)keratotic surface. It is supposed that in chronic oral leukoplakias some variation of the steady state between renewal and desquamative loss of epithelial cells is operating as far as no precancerous condition is present.

Fabry's Disease: Glycolipid Lipidosis

THE PURPOSE of this paper is to report skin findings not previously described in Fabry's disease and to call to the attention of physicians a simple method of diagnosis which distinguishes the disorder from another more benign condition which may have similar skin lesions. The classical skin lesions of angiokeratoma corporis diffusum are 0.1-3.0 mm diameter red to purple macules and papules on the scrotum and other areas of the body. Some have a hyperkeratotic surface. As first described by Fabry in 1898, 1 the disorder was considered to be of dermatologic importance only. Anderson, reporting another case at about the same time, suggested that renal lesions similar to those in the skin might have accounted for his patient's hematuria. 2 This condition is now known to be a systemic disease in which a glycolipid, ceramide-trihexoside, 3,4 is stored in many kinds of cells, including renal and bronchial epithelium, cardiac