Long-standing Lesions Research Articles

Co-occurrence of posterior chest wall pilonidal sinus with melanocytic nevus: a challenging presentation: a case report

IntroductionTo date, only a limited number of case reports have documented the co-occurrence of PNS and melanocytic nevus in the medical literature. This study aims to report an exceptionally rare case of posterior chest wall PNS in conjunction with a melanocytic nevus.Case presentationA 46-year-old female presented with a long-standing black lesion on her left upper posterior chest wall, that had become painful in the two months prior to presentation. There was a painful, dark blue, non-erythematous, and non-tender nodule on the left upper posterior chest wall. Based on the patient’s desire for cosmetic purposes, the lesion was excised totally with primary closure under local anaesthesia. Histopathological examination revealed intradermal melanocytic nevus with inflamed pilonidal sinus.DiscussionThe rarity of posterior chest wall PNS associated with nevi poses unique diagnostic and therapeutic challenges for clinicians. The distinct anatomical location, different from the conventional region, and the rare association between the two conditions may delay accurate diagnosis and result in mismanagement or inappropriate interventions.ConclusionThe posterior chest wall PNS is another type of atypical PNS that is extremely rare. The association between PNS and blue nevus is a fascinating medical finding that deserves further investigation.

Hourglass shaped extragenital Csillag’s disease

Lichen sclerosus (LS) is a benign, chronic inflammatory dermatosis affecting both the epidermis and dermis. It commonly affects the anogenital area and is seen predominantly in women. In only 15–20% of cases, extragenital involvement is seen. In females, long-standing anogenital lesions progress to form hourglass or dumbbell or figure of eight morphology. Here, we are reporting a case of extragenital LS at an unusual site in an hourglass morphology, which is usually encountered in females. Our patient was started on ultrapotent topical corticosteroids, following which erythema was reduced. The patient is advised regular follow-up.

EADV Task Force Pruritus White Paper on chronic pruritus and chronic prurigo: Current challenges and future solutions.

Chronic pruritus (CP) is frequent in general medicine and the most common complaint in general dermatology. The prevalence of CP is expected to rise in the future due to the ageing population. The clinical presentation, underlying aetiology and treatment strategy of CP are heterogeneous. Also, individual treatment aims and physical, psychic and economic burdens of patients might vary. Chronic prurigo (CPG) is the most severe disease in the chronic pruritus spectrum, being associated with long-standing scratch-induced skin lesions and a therapy refractory itch-scratch-cycle. It is thus important to raise disease awareness for CP and CPG in the general public and among decision-makers in the health system. Further, there is a need to support a rational clinical framework to optimize both diagnostics and therapeutics. Currently, there is still a shortcoming regarding approved therapies and understanding CP/CPG as severe medical conditions. Therefore, the EADV Task Force Pruritus decided to publish this white paper based on several consensus meetings. The group consented on the following goals: (a) ensure that CP is recognized as a serious condition, (b) increase public awareness and understanding of CP and CPG as chronic and burdensome diseases that can greatly affect a person's quality of life, (c) clarify that in most cases CP and CPG are non-communicable and not caused by a psychiatric disease, (d) improve the support and treatment given to patients with CP to help them manage their disease and (e) publicize existing therapies including current guidelines. We aim to point to necessary improvements in access and quality of care directed to decision-makers in health policy, among payers and administrations as well as in practical care.

Giant pretibial cellular fibrous histiocytoma colliding with an epidermal cyst

Histiocytomas are common benign tumors of the skin. In contrast, giant histiocytomas are a rarity. We report a 43-year-old male patient, who presented with a 7 × 6 cm large firm tumor on his left lower leg. This was a long-standing lesion, but within the last three months, the tumor developed an exophytic nodule. A skin biopsy revealed an atypical spindle-cell tumor. We decided to perform a complete excision with a safety margin. Complete histopathological analysis confirmed the diagnosis of a collision tumor composed of a cellular fibrous histiocytoma and an epidermal cyst. The resulting defect was temporarily closed by vacuum-assisted closure before eventually a meshed split skin graft was transplanted. Proliferating fibrohistiocytic lesions should be surgically removed, and a careful histopathologic analysis is necessary to avoid delayed diagnosis of possible malignant lesions.

A rare case of spiradenoma or a common sebaceous cyst? - A case study

Spiradenoma is a rare and adnexal skin tumor of the sweat gland appearing equally frequently in both female and male patients. When having a patient with a solitary, nodule occurring on a scalp, a spiradenoma diagnosis should be considered. However, it always ought be differentiated with more common skin lesions e.g. sebaceous cyst. This case report presents a 36 year old male presented with a solitary 1,5 centimeter in diameter mass on the scalp of the left temporal region. The patient underwent an ultrasound and excision biopsy which revealed spiradenoma diagnosis. This tumor transforms into malignant form extremely rarely. However, transformation is more likely in elderly patients having a long-standing lesions This is why early and wide excision is crucial and considered to be a gold standard treatment.

CUTANEOUS LICHEN PLANUS - UNEXPECTED MALIGNANT DEGENERATION

Carcinoma occurring in the cutaneous lesions of Lichen Planus (LP) though rarely mentioned in literature does occur and should be kept in mind while treating such lesions. We report a 70-year-old women who developed an SCC (Squamous Cell Carcinoma) in a long-standing lesion of hypertrophic LP on the lower leg. This observation is being presented to indicate the possibility of malignant transformation of cutaneous lichen planus to carcinoma, and suggest more regular monitoring especially in the hypertrophic forms and the need to have an early diagnosis so that it can be treated in the initial stages.

CPC05 A case of extensive hypertrophic lupus erythematosus responsive to topical steroids

Abstract Hypertrophic lupus erythematosus (HLE) is a rare variant of lupus erythematosus, occurring in 2% of cases of chronic cutaneous lupus erythematosus (CCLE). It is an exaggerated proliferative epithelial response manifesting as verrucous-appearing hypertrophic indurated lesions occurring on sun-exposed sites. We present a case of the development of extensive HLE in a patient with subacute cutaneous lupus erythematosus (SCLE) with underlying pulmonary malignancy. A 74-year-old woman with Sjögren syndrome presented to dermatology with a 2-month history of a rash affecting her face and décolletage. Laboratory studies illustrated elevated antinuclear and anti-Ro antibodies. Biopsy from her chest confirmed SCLE. Malignancy screening revealed T1aN0 pulmonary lepidic adenocarcinoma, which was successfully managed with a lower lobectomy. Hydroxychloroquine was initially trialled but required discontinuation following intolerable side-effects. Mepacrine was then initiated, which allowed clearance of the rash, alongside yellow discoloration of the skin. Six months later, she developed a raised pruritic rash on her arms, legs and buttocks, resistant to current management alongside a trial of mycophenolate mofetil. Examination revealed violaceous hypertrophic plaques affecting 40% of her body-­surface area. The differential included hypertrophic lichen planus, nodular prurigo and HLE. Repeat lesional biopsies highlighted a lichenoid inflammatory infiltrate with overlying scale, favouring HLE. Owing to patient choice, topical mometasone furoate 0.1% was used to manage cutaneous disease, with a reduction in lesion size. HLE is a distinct subset of CCLE, regarded as a separate entity to SCLE. Twenty per cent of patients with SCLE also exhibit other types of cutaneous lupus erythematosus (CLE) lesions. No cases in the literature describe progression from SCLE to CCLE, or HLE, in particular. Hallmarks of HLE include verrucous lesions, chronicity and treatment resistance. Early recognition and follow-up are essential as malignancy may arise in long-standing lesions. Lung adenocarcinomas and hypertrophic lupus are both associated with p53 mutations and decreased granzyme B expression. Mutated p53 results in constitutive cell proliferation and DNA damage can accumulate in cells. Granzyme B is a protease in cytotoxic T cells involved in immune-mediated cell lysis. Both processes result in the potential to produce exaggerated hyperproliferative lesions, such as those observed in HLE and the lepidic adenocarcinomas. HLE is a rare clinical entity that can be easily misdiagnosed clinically and histopathologically. Increased awareness of this condition is essential to highlight the variety of clinical presentations of uncommon variants of CLE, to ensure they are considered while approaching clinical diagnosis.

CPC08 Cutaneous squamous cell carcinoma and MYH9-associated elastin aggregation (MALTA) syndrome

Abstract MYH9-associated elastin aggregation (MALTA) syndrome is a rare, inherited, irregular elastin aggregation and sweat duct proliferation syndrome caused by pathogenic variants in MYH9. MALTA syndrome was proposed in 2019, unifying Nicolau Balus and Rombo syndromes as phenotypes arising from pathogenic variants in the same gene, but it has not been associated with cutaneous squamous cell carcinoma (cSCC) [Fewings E, Ziemer M, Hörtnagel K et al. Malta (MYH9 associated elastin aggregation) syndrome: germline variants in MYH9 cause rare sweat duct proliferations and irregular elastin aggregations. J Invest Dermatol 2019; 139:2238–41]. Here, we report the clinical features of a family with a novel MYH9 c.1952A>C p.(Lys651Thr) pathogenic variant, providing evidence that cSCC may be an associated feature of MALTA syndrome. A 57-year-old woman presented with a longstanding skin lesion overlying her left infraorbital ridge, which had been present for 13 years. Lesion biopsy revealed a highly infiltrative tumour within the dermis that was composed of keratocysts with small islands of basaloid cells; immunostaining was positive for CK5/6, CK7, CK19, p63 and BerEP4. These histological features were consistent with a microcystic adnexal carcinoma (MAC)-like ductal proliferation, recognized in MALTA. In addition, she had previously developed one cSCC on her left shoulder and two basal cell carcinomas and had cutaneous milia. Her sister had a history of MAC-like ductal proliferation and cSCC, and her brother had two keratoacanthoma-like cSCCs. The copresentation of MAC-like ductal proliferations and early-onset cSCC in this family prompted targeted genetic testing of MYH9. This identified a heterozygous pathogenic variant in a highly conserved region of MYH9 [c.1952A>C p.(Lys651Thr)] that segregated with the phenotype in all three affected members. MYH9 has previously been identified as an important gene in the pathogenesis of cSCC in a genetic screen in transgenic mice, and our family adds novel clinical data, underscoring its importance in cSCC development (Schramek D, Sendoel A, Segal JP et al. Direct in vivo RNAi screen unveils myosin IIa as a tumor suppressor of squamous cell carcinomas. Science 2014; 343:309–13). Based on the recurrent presentation of early-onset cSCC in three members of this family, we propose the inclusion of cSCC in MALTA syndrome. This has implications for skin cancer surveillance of MYH9 pathogenic variant carriers, and the need to consider MALTA syndrome in patients presenting with multiple early-onset cSCC.

Early Surgery Versus Watchful Waiting Strategy for Infantile Abdominoscrotal Hydrocele

BackgroundInfantile abdominoscrotal hydrocele is generally managed with early surgery. However, whether these patients actually benefit from an initial watchful waiting strategy is yet to be determined. MethodsThis single-center, comparative observational analysis included 36 consecutive patients (9 bilateral cases) diagnosed between January 1998 and December 2019. Initial 16 patients (21 lesions) underwent surgical repair shortly after diagnosis (Group A) at a mean (SD) age of 8 (4) months. Remaining 20 patients (24 lesions) underwent initial nonoperative management (Group B). Overall follow-up was 82.74 (63.84) months. ResultsSix lesions of Group B spontaneously regressed at a mean age of 23.8 (7.8) months. Remaining 18 hydroceles underwent surgical management at a mean age of 18.7 (12.6) months. Early postoperative morbidity was high (43%) in both groups (Clavien-Dindo grade I-II). During follow-up, there were 1 recurrent hydrocele and 1 testicular atrophy, both events occurring in Group A patients. Group B patients required a higher need for concomitant ipsilateral orchidopexy (61% versus 14%; p = 0.001), and developed a higher rate of ipsilateral inguinal hernia (39% versus 5%; p = 0.01), occurring within 8.3 (3.53) months of surgery. On multivariable analysis, nonoperative management was associated with unplanned second surgery (odds ratio 5.5, 95% CI 1.25–24.17, p = 0.02), regardless of the type of hydrocelectomy performed. ConclusionsNonoperative management provides effective spontaneous resolution in about 25% of infantile abdominoscrotal hydrocele. Clinicians must balance the potential benefits of such strategy against the impact of pressure induced detrimental effects on the success of future surgery when dealing with longstanding lesions. Level of EvidenceIII.

Verrucous disseminated discoid lupus erythematosus with oral and palmoplantar lesions treated with hydroxychloroquine

Lupus erythematosus (LE) is an autoimmune inflammatory disease with a wide spectrum of cutaneous and systemic manifestations. A unifying concept of this disease is difficult to develop as clinical features of patients with LE show a great variation. Our objective was to present a case of verrucous disseminated discoid lupus erythematosus (DLE) with atypical morphology, extensive involvement, and having oral and palmoplantar lesions. For confirmation of diagnosis, histopathology was done, which showed characteristic findings of DLE. Combination therapy of hydroxychloroquine with oral and topical corticosteroids resulted in resolution of skin lesions. Sometimes, DLE lesions may pose a diagnostic and therapeutic challenge, especially in a case of unusual presentation, as in the given case of hypertrophic LE. These cases require adequate therapy with clinical and histopathological follow-up considering that squamous cell carcinoma may arise in long-standing lesions.

Epidermoid Cyst: An Esthetic Challenge, If Neglected-A Comprehensive Analysis of 217 Cases.

An epidermoid cyst is a benign keratin-filled cyst, commonly located in the face, scalp, neck, and trunk. Although it is a common benign cystic neoplasm, large series of analyses in English literature are still scarce. To comprehend the clinical and pathological variation of epidermoid cysts in the sub-Himalayan region of India, as well as their clinical implications for late diagnosis, a retrospective study on epidermoid cysts was conducted. This was a retrospective observational study conducted on 217 cases of epidermoid cyst subjected for fine-needle aspiration cytology over a period of 3.6 years (from 2018 to 2021). The clinical details and other epidemiological data were archived from the pathology requisition forms. It showed slight male preponderance with head and neck site as the most common area. Most patients were adults. Few uncommon sites were also seen namely breast, parotid, epididymis, and tonsils. Few large lesions were identified measuring up to 10 cm. The skin changes were seen in 5.5% cases, 0.9% cases show extreme ulceration, and 4.1% cases show foreign body giant cell reactions. Due to the province's steep terrain and limited access to medical services, the majority of patients arrived at out patient department (OPD) late. The findings suggest that fine-needle aspiration can be used as a quick diagnostic test even in remote areas by the general practitioner who can send the slides for evaluation to a pathologist. Many times, clinically looking epidermoid cyst can reveal certain challenging entities such as a biphasic fibroepithelial tumor with cystic squamous metaplasia and proliferating pilar tumor in our series. The study of this lesion is also needed for early diagnosis as long-standing lesion may rupture and cause requirement of extensive treatment followed cosmetic impairment.

Orthopaedic and plastic surgery collaboration in resolution of plantar heloma and metatarsalgia using lipofilling: a retrospective evaluation.

Plantar heloma is a keratotic disorder that can be described as a circumscribed area of thickening with a central core that may penetrate the dermis. Although often considered a minor complaint, longstanding lesions can be debilitating and severely impact on person's quality of life. We present the first retrospective case series at long-term follow-up about the use of plantar lipofilling as a treatment for metatarsalgia caused by plantar heloma. Six patients affected by plantar heloma associated to external metatarsalgia underwent plantar lipofilling. The surgical session was performed as an outpatient procedure. Clinical evaluation was performed using the AOFAS lesser metatarsophalangeal-interphalangeal (MTP-IP) score. Mean AOFAS lesser MTP-IP score improved from a preoperative score of 66.6 ± 3.2 points (range 47-77 points) to a post-operative score of 92.8 ± 2.7 points (range 86-95 points); all patients were satisfied with the outcome at the final follow-up. Post-operative clinical examination at final follow-up showed an increase in thickness of the subcutaneous layer and a decrease of dermal layer thanks to the supporting and trophic action of fat cells. Plastic regenerative procedures applicated to a typical foot and ankle surgery field, such as metatarsal overloading, metatarsalgia and forefoot problems, should be encouraged to allow new treatment horizons.

Schwannoma: Another dermoscopic pitfall?

Schwannoma: Another dermoscopic pitfall?

Squamous Cell Carcinoma Arising in Lesions of Discoid Lupus Erythematosus in a Patient with Overlap Syndrome: A Chronic Rare Complication.

Squamous Cell Carcinoma Arising in Lesions of Discoid Lupus Erythematosus in a Patient with Overlap Syndrome: A Chronic Rare Complication.

Solitary Chondrosarcoma of the Right Ring Finger: A Case Report.

We present a case of solitary chondrosarcoma arising from the proximal phalanx of the ring finger in an elderly man. The chondrosarcoma developed over a period of 14 years, during which the phalanx became progressively more deformed. Several radiographic investigations were carried out, but the patient declined further suggested diagnostic examinations (computed tomography, magnetic resonance imaging, biopsy). Eventually, the lesion became significantly enlarged, and radiographs showed osteolytic lesions in the phalangeal bone. Ray amputation of the finger was required to establish a wide resection of the chondrosarcoma. Most osteochondral tumors arising from the phalanges are benign tumors such as enchondromas, but primary chondrogenic malignant bone tumors (chondrosarcomas) occasionally occur. Chondrosarcoma of the phalanx is difficult to distinguish from enchondroma of the phalanx, because histological investigations of the two neoplasms often produce similar findings. Even with a combination of clinical, biopsy, and imaging findings, differentiating these neoplasms is still challenging, because the characteristic clinical and radiological features of chondrosarcoma do not appear until it becomes aggressive and starts to cause destructive changes. Once that happens, radical expanded resection of the tumor is essential. Therefore, longstanding enchondroma-like lesions should be actively treated in elderly patients, even if a definite diagnosis of chondrosarcoma cannot be made.

450 Clonal history of skin adnexal neoplasms inferred by multi-sampling, whole exome sequencing

Eccrine porocarcinoma is a rare malignant skin tumor that often presents as the transformation of an underlying poroma. Nevus sebaceous is a benign skin hamartoma, from which various secondary neoplasm may arise. Since these tumors arise from long-standing precursor benign lesions, multi-sampling, genomic analysis of these tumors may provide us with insight into the life history of these tumors. Whole exome sequencing analysis of porocarcinoma showed high intra-tumor heterogeneity. The reconstructed phylogenetic tree showed a short trunk having the KRAS p.G12V mutation, and showed long branches, which may or may not have secondary driver mutations.

Extramammary Paget’s Disease Arising in the Scrotum of an Elderly Male

Extramammary Paget’s disease (EMPD) is a rare form of primary or secondary intraepithelial adenocarcinoma typically presenting within the fifth through seventh decades of life. Though cases of EMPD localized to the scrotum are typically not associated with underlying malignancy, evaluation of dermal and angiolymphatic invasion in conjunction with pertinent laboratory investigations, e.g., serum CEA, is essential to rule out malignancy and metastatic disease. We present a case of EMPD in an elderly male that presented with a history of a longstanding asymptomatic scrotal lesion that was ultimately managed with excision and skin grafting.

Alternative Approach for the Management of Complete Crown Fracture with Periapical Lesion by Apicoectomy and Orthodontic Extrusion Using Removable Appliance

Trauma induced periapical lesions often require complex treatment, as conventional root canal therapy poses a high risk of failure due to apical transportation of infection. However, complete crown fractures with a fracture line close to the gingiva or extending subgingivally may require orthodontic extrusion to re-establish the biologic width thereby achieving aesthetic and functional restoration of the tooth. The purpose of this case report is to suggest an alternative treatment approach to achieve healing of periapical lesions and causing extrusion of the teeth by moving the fracture line above the supragingival level for final aesthetic and functional restoration. This case report discusses the management of an anterior tooth with long-standing subgingival fracture and large cyst-like periapical lesion using apicoectomy and orthodontic extrusion with a removable appliance.

Adenocarcinoma arising within an intrapulmonary foregut duplication cyst: A case report

Foregut duplication cysts are congenital malformations that are usually associated with the gastrointestinal tract, but may be found in the lung. Here we report a case of a 74-year-old male who presented with a long-standing right lower lobe cystic lesion, which had recently developed a solid component which was hot on FDG-PET scanning.

Gold Dental Implant-Induced Oral Lichen Planus

Lichen planus is a chronic inflammatory cutaneous and mucosal disease mostly affecting middle-aged individuals. The etiology of lichen planus is unknown, but current literature suggests that it is an altered immune response characterized by dysregulated T-cell activation and subsequent inflammation which can be associated with conditions like allergic contact dermatitis and hepatitis C. Additionally, heavy metals like lead, tin, arsenic, and bismuth can create inflammatory and allergic reactions that can predispose to the formation of lichen planus. This report examines the case of a 64-year-old female with longstanding oral lichenoid lesions with superimposed Wickham's striae, allergic skin reactions to several medications, and a history of receiving gold-containing dental implants. As a result of her history and subsequent allergy testing, she was found to have a gold allergy. The constant mucosal irritation from her dental implants likely was associated with the development of her oral lesions, which were confirmed to be oral lichen planus. She was recommended to apply triamcinolone 0.1% ointment to her oral lesions and to follow up with her dentist for evaluation of her filings. Further, it was recommended she replaces the dental crowns with compounds lacking gold to decrease the persistent irritation. This case represents the first such instance of gold dental fillings directly having an appreciable role in the development of oral lichen planus.