Pink Papules Research Articles

Actinic granuloma occurring in an unusual association with cutaneous B‐cell chronic lymphocytic leukemia

Granulomatous cutaneous reactions are well described in association with T-cell non-Hodgkin lymphoma and Hodgkin lymphoma, but are rarely seen in association with B-cell non-Hodgkin lymphoma or leukemia. We report a case of a 65-year-old woman with B-cell chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) who presented with multiple, tender, firm pink papules on the face, upper trunk and upper extremities 6 years after diagnosis of CLL. Biopsy revealed both palisading granulomatous dermatitis consistent with actinic granuloma and a dense perivascular lymphocytic infiltrate consistent with the patient's known history of leukemia. This is an unusual manifestation of cutaneous B-cell CLL that is rarely seen.

The Evolution of Histopathologic Findings in Adult Still Disease

Adult Still disease is an inflammatory arthritis classically associated with daily spiking fevers, evanescent rash, organomegaly, lymphadenopathy, and laboratory anomalies. The typical cutaneous lesions are thin pink papules in a morbilliform distribution, of short duration. Histologically, these lesions are characterized by a superficial perivascular and interstitial mixed dermatitis with lymphocytes and variable neutrophils. A variant clinical presentation is increasingly recognized, which demonstrates persistent hyperpigmented plaques, often with a rippled or linear appearance. The histologic findings consist of upper epidermal dyskeratotic keratinocytes, increased dermal mucin, and a superficial perivascular infiltrate of lymphocytes and possibly neutrophils or eosinophils. We encountered 2 patients who presented with the characteristic rash of adult Still disease, both of whom progressed to develop the pigmented cutaneous plaques. We propose that this variant clinical and histologic appearance is the outcome of persistent disease activity.

Eczema Herpeticum

A 24-year-old man with a history of eczema presented to the Emergency Department (ED) with rash. He was seen at another ED 2 days before presentation as he developed papules within his chronic eczema patches on his face and right wrist. At that time he was placed on a prednisone taper. His eruption spread from a few clustered papules to involve most of his areas of chronic eczema, namely, his face and wrists. His eyes became injected and irritated. The physical examination was notable for discrete, umbilicated, pink papules overlying chronic eczematous plaques on the forehead, around bilateral eyes, cheeks, and bilateral dorsal wrists (Figures 1, 2).

Granulomatous pigmented purpura: report of a case and review of the literature

The pigmented purpuric dermatoses (PPD) are a group of diseases characterized by petechiae and bronze discoloration of the skin on the lower extremities. Histopathologically, extravasation of erythrocytes with hemosiderin deposition, a perivascular lymphocytic infiltrate centered on the superficial capillaries and endothelial cell swelling are seen. The granulomatous variant of PPD (GPPD) was described in 1996 and only 10 cases have been reported since in the literature, almost exclusively in patients of East Asian descent only involving the extremities. We present a case of GPPD in a Caucasian, North American Ashkenazi Jewish woman involving the thighs, back, forearms and wrists with concomitant non-granulomatous PPD of the shins. She presented with an asymptomatic, spreading, cayenne pepper-like rash. This rash intermittently involved the lower extremities and back for 15 years, but now involves the thighs with accompanying pink papules on the back, wrists and forearms. Histopathology of the thigh and back lesions revealed superficial lichenoid granulomatous dermatitis with palisading lymphocytes and focal interface changes. Extravasated erythrocytes were seen, but vasculitis was absent. No lymphocytic atypicality was noted and T-cell gene rearrangement studies were non-clonal. This is the second reported case of GPPD in a non-Asian patient and the first case involving sites other than the extremities.

Photodistribution of rash in phenytoin-induced drug rash with eosinophilia and systemic symptoms

Conflict of interest: none declared. A 45‐year‐old woman had a monomorphic rash of pink papules on the photoexposed sites of her face, neck, dorsal hands and forearms. She reported 5 days of abdominal pain. Her only medication was phenytoin 100 mg three times daily, which had been prescribed for the past 1 month for generalized tonic–clonic seizures secondary to neurocysticercosis. On physical examination, a firm, tender and non‐matted bilateral cervical lymphadenopathy without hepatosplenomegaly was noted. There was a papular rash with vesiculation and sharp demarcation, with sparing of covered areas (Fig. 1a,b). The mucosae were unaffected. On histological examination of biopsies taken from forearm skin, orthokeratosis, acanthosis, spongiosis and marked dermal oedema with a dense perivascular lymphomononuclear and dermal eosinophillic infiltrate were seen. Initial laboratory investigations showed a raised total white count, lymphocytosis, moderate eosinophilia (1.09 × 109/L; normal range 0–0.1 × 109/L) and no circulating atypical lymphocytes. Platelet count and coagulation profile were normal. There were low serum levels of sodium (126 mEq/L; 136–145 mEq/L) and potassium (3.2 mEq/L; 3.5–5.2 mEq/L) with normal renal biochemistry except for mild proteinuria. Hepatic function was abnormal, with raised levels of aspartate aminotransferase (69 IU/L; 5–40 IU/L) and alanine aminotransferase (70 IU/L;5–35 IU/L). Other tests, including human immunodeficiency virus‐1 serology, were negative. A diagnosis of phenytoin‐induced hypersensitivity syndrome was made, and the drug was discontinued. After 5 days on oral methylprednisolone 32 mg/day, there was marked clinical improvement, with normalization of blood biochemistry. (Fig. 2a,b). Clobazam 20 mg twice daily was started, and methylprednisolone was tapered over the next 2 weeks. At follow‐up at 6 week and 1 year, the patient was asymptomatic and tolerating clobazam well.

Hepatosplenic T-cell lymphoma: clinicopathologic, immunophenotypic, and molecular characterization of17 Chinese cases

Hepatosplenic T-cell lymphoma is a highly aggressive tumor with a poor outcome. About 210 cases were identified through PubMed, of which fewer than 20 originated in Asia. We reviewed 17 Chinese cases of hepatosplenic T-cell lymphoma, including an unusual one with cutaneous pink papules, for clinicopathologic, immunophenotypic, and genotypic features; Epstein-Barr virus status; treatment; and outcome. The median age of the patients was 23 years. All patients had splenomegaly, and 88.2% of them had hepatomegaly as well. Bone marrow involvement was present in 53.3%. Eleven patients underwent splenectomy for diagnosis and treatment. Twelve specimens were collected by image-guided liver core biopsy or wedge resection. Histologically, the homogeneous small- to medium-size neoplastic lymphoid cells infiltrated the sinuses or sinusoids of the spleen, bone marrow, and liver. Diagnosis was based on image-guided core-needle biopsy of the liver alone in 41.2% of the cases. Immunohistochemically, 15 of the lesions were hepatosplenic γδ T-cell lymphoma, and the remaining 2 were hepatosplenic αβ T-cell lymphoma. Epstein-Barr virus was detected in both cases of hepatosplenic αβ T-cell lymphoma and one case of hepatosplenic γδ T-cell lymphoma. Most of the patients received cyclophosphamide, doxorubicin, vincristine, and prednisone therapy or regimens similar to it. Follow-up data were available in 70.6% of the patients; half of them died of the tumor, and the median survival time was 6 months. The frequency of bone marrow involvement was lower than that reported in the literature. Image-guided core-needle biopsy of the liver is recommended for diagnosis.

Perioral dermatitis

Perioral dermatitis is a relatively common inflammatory disorder of facial skin, often appearing in patients with rosacea, but with less inflammation. A typical perioral dermatitis presentation occurs with the eruption of papules and pustules confined to the nasolabial folds and the skin of the chin. Clinically, small pink papules and pustules may recur over weeks to months, sometimes with fine scales. The differential diagnosis includes seborrheic dermatitis, systemic lupus erythematosus, acne vulgaris, lupus miliaris disseminatus faciei, steroid-induced rosacea, and even basal cell carcinoma. The histopathology is similar to that found in rosacea. With advancement of the process, a perivascular and perifollicular lymphohistiocytic infiltrate develops. Sebaceous hyperplasia may be prominent in some patients. The most severe forms of disease show perifollicular noncaseating epithelioid granulomas. Treatment may include topical metronidazole as for rosacea (once or twice daily), azelaic acid cream, benzyl peroxide preparations, and to a lesser degree, topical erythromycin, clindamycin, or tetracycline. Oral tetracycline, doxycycline, or minocycline may also be helpful in presentations that are more resistant.

Atypical Fibroxanthoma: A Review of the Literature

Atypical fibroxanthoma (AFX) is an uncommon superficial fibrohistiocytic tumor. It was originally described as a low-grade dermal tumor of atypical spindle cells, but this view has changed, and it is generally considered to be a tumor of intermediate malignant potential. To review the current literature on AFX pertaining to epidemiology, pathogenesis and etiology, clinical presentation, histology, immunohistochemistry, prognosis and follow-up, and treatment. Extensive literature review was conducted using OVID Medline and Pubmed searching for articles relating to AFX. AFX typically presents as a red or pink papule or nodule on the head or neck of an elderly man. The pathogenesis is most commonly related to ultraviolet radiation. It can clinically mimic other cutaneous malignancies and histologically can mimic squamous cell carcinoma, desmoplastic melanoma, and undifferentiated pleomorphic sarcoma. Immunohistochemistry is important in making the distinction. The prognosis is generally excellent, although there are rare cases of metastatic disease. There is a higher cure rate with Mohs' micrographic surgery than with wide local excision. CONCLUSIONS People with AFX generally have had significant ultraviolet radiation exposure. They should be examined at least every 6 months for recurrence, metastasis, and the development of additional skin cancers.

Crusted pink papule in a 20‐year‐old

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Trichodysplasia Spinulosa-A Rare Complication in Immunosuppressed Patients

Immunosuppression is necessary in a large number of conditions to modify immune responses and control disease severity. It is a vital part of treatment regimes following organ and bone marrow transplants. However, the use of immunosuppressive drugs has been shown to cause infections with common and unusual pathogens. We present the case of a 5-year-old female heart transplant recipient. Nine months after the transplant, she developed a tender acneiform eruption on her face consisting of numerous small yellowish to pink papules and pustules. Many of the lesions had a central, firm, small spinulous excrescence or a central dell. Histopathology demonstrated abnormal maturation of the hair follicles, nucleated eosinophilic cells with trichohyalin granules. The clinical presentation and histological features were in keeping with trichodysplasia spinulosa, a rare complication in immunosuppressed subjects. Treatment trials included reduction of immunosuppression combined with topical and oral retinoids, topical acyclovir, and oral valganciclovir with limited success.

An outbreak of Mycobacterium chelonae infections in tattoos

Nontuberculous mycobacteria infections may occur after cutaneous procedures. Review of the medical records of patients who developed a rash within a tattoo revealed 6 patients with skin infections caused by Mycobacterium chelonae after receiving tattoos by one artist at a single tattoo establishment. The interval between tattoo placement and the skin findings was 1 to 2 weeks. All patients received alternate diagnoses before mycobacterial infection was identified. Skin findings included pink, red, or purple papules; papules with scale; pustules; granulomatous papules; and lichenoid papules and plaques. Histopathologic examination revealed granuloma, lymphohistiocytic infiltrate, or mixed inflammation; acid-fast bacilli stains produced negative results. Diagnosis was made by culture in 3 patients, histopathology in two patients, and clinical/epidemiologic association in one patient. The M chelonae isolates were clarithromycin susceptible, and the infections responded to macrolide antibiotics. Physicians should consider mycobacterial infections in patients with skin findings within a new tattoo.

Lichen striatus avec dystrophie unguéale chez un nourrisson

Lichen striatus is an acquired eruption that develops in a linear pattern along Blaschko's lines, most commonly on the limbs. It is most often seen in children aged between 3 and 10 years. Nail involvement is uncommon. We report the case of an infant with lichen striatus and nail involvement. A 10-month-old boy was referred for evaluation of acquired onychodystrophy on his right third and fourth fingers present for 2 months. On physical examination, lateral longitudinal ridging and splitting were seen on the right third and fourth fingernails with onychodystrophy. Linear bands of bright pink papules were seen on the inside and outside edges of the third and fourth fingers. Skin biopsy revealed a lymphocytic infiltrate in the superficial dermis with exocytosis and very few dyskeratotic cells, suggesting lichen striatus. Skin and nails lesions resolved spontaneously over 9 months. Nail involvement in lichen striatus is uncommon and is frequently associated with typical skin lesions. Thirty cases have been reported in the literature since 1941. None of the subjects affected was younger than 2-years-old. Nail involvement was more frequent on the fingers, especially the thumb. As in the present case, longitudinal ridging, splitting and thinning with onychodystrophy are common clinical features of nail involvement. The diagnosis of lichen striatus is based on the presence of skin lesions and can be confirmed by biopsy.

A pink papule

A 33-year-old woman attended for skin examination bydigital dermoscopy (mole mapping). She was fair skinned(Fitzpatrick phototype I) with blue eyes and red hair. Shereported many sunburns in childhood, and exposure tosunbeds two or three times weekly for several years duringher early 20s. There was no known personal or familyhistory of skin cancer. Examination revealed moderatefreckling and few tan-coloured melanocytic naevi. Thepatient was concerned about a lesion that first appearedover her right hip 6–12 months ago, and had recently dark-ened in colour.Examination revealed a dome-shaped pink papule, 6 mmin diameter (Fig. 1a). Dermoscopy revealed a prominentcentral cluster of red globules and red dotted vessels(Fig. 1b). There was no pigment network.

Painless pink papules with central porcelain-white scars

A 61-year-old woman presented with a 2-year history of asymptomatic, erythematous to pink papules with central porcelain-white atrophic scars and a telangiectactic rim ([Figure 1][1]). A progressive number of lesions had developed on her abdomen, back and thighs. Skin histology showed epidermal

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.

A Teenage Girl with Rash

<P>A teenage girl presented with a 2-week history of a mildly pruritic, erythematous, maculopapular rash on her back. The patient reported that a few weeks prior to onset of this rash, she remembered seeing a large “spot” on her lower abdomen. She presented to the dermatologist because she was concerned that her rash was contagious. She denied any sick contacts. On physical examination, she had numerous pink macules and papules, with scaly borders located on her trunk along axial lines (see Figure 1 and Figure 2). However, we were not able to visualize the “spot” she described on her abdomen.</P><H4>ABOUT THE AUTHORS</H4><P>Amor Khachemoune, MD, CWS, is with the Department of Dermatology, New York University School of Medicine, New York, NY. Zoey Glick, BA, is a Medical Student, George Washington University Medical School, Washington, DC.</P><P>Address correspondence to: Amor Khachemoune, MD, CWS, 530 First Avenue, Suite 7R, New York, NY 10016; fax (212) 263-7680; or e-mail: <a href="mailto:amorkh@pol.net">amorkh@pol.net</a>.</P><P>The authors have disclosed no relevant financial relationships.</P>

Degos' disease with delayed involvement of the gastrointestinal tract

A 75-year-old woman presented with pink papules over the trunk and limbs. Over the next few weeks, the papules became umbilicated and then developed into porcelain-white lesions with a rose or violaceous rim. A biopsy of one of these lesions revealed superficial and deep dermal lymphohistiocytic inflammation, mainly perivascular with a central zone of infarction consistent with Degos' disease. Three years later, she presented with increasing abdominal pain, anaemia, raised inflammatory markers and an abdominal bruit. Angiography showed splanchnic vessel stenosis possibly secondary to vasculitis and she underwent successful balloon dilatation. Treatment with prednisolone was commenced. There has been no recurrence of lesions in the 12 months since the balloon dilatation.

Multiple Lesions of Cutaneous Focal Mucinosis in a Teenager

A 19-year-old Hispanic woman presented to our clinic with a chief complaint of multiple pink papules on her face (Figure 1). The lesions were asymptomatic, had appeared several years before her consultation, and had remained stable in size. Similar lesions on her trunk and extremities had spontaneously resolved before presentation. She had no significant medical history and was not on any medications. Cutaneous examination was remarkable for a few scattered, well-demarcated, slightly raised pink papules and plaques with no scale, ranging from 0.5 to 1 cm in diameter. The lesions were distributed on the right cheek, right temple, left lower eyelid, and neck area. The rest of the cutaneous examination was unremarkable. A punch biopsy was performed from a lesion near the left premandibular area. Hematoxylin and eosin staining of the biopsy specimen revealed superficial perivascular dermatitis with a slight increase in the number of fibroblasts (Figure 2). Colloidal iron staining was diffusely positive with replacement of collagen with mucinous material in the dermal layer (Figure 3). Laboratory values for a complete blood cell count, metabolic panel, serum protein electrophoresis, urine protein electrophoresis, thyroid-stimulating hormone, and antinuclear antibody were within normal limits. The patient was diagnosed with cutaneous focal mucinosis. Because of cosmetic concerns, the patient declined surgical excision and intralesional corticosteroid injections. A 4-month trial of topical tacrolimus 0.1% ointment was ineffective.

Dermoscopic features of accessory nipples

CASE 1: A 27-year-old woman presented with a 6 x 6 mm, soft, pink-brown papule located on the right axilla (Fig. 1). Dermoscopic examination showed a central scar-like white-colored area, a cleft-like appearance in the central area, and a fine pigment network in the periphery of the lesion (Fig. 2). CASE 2: A 5-year-old girl presented with a 4 x 4 mm pink nodule on her left abdominal region. Dermoscopic examination showed a central scar-like white-colored area, and a fine pigment network in the periphery of the lesion. CASE 3: An 18-year-old man presented to our outpatient clinic suffering from a firm, tender, painful, 7 x 7 mm brownish pink nodule located on his left hypochondrium. Upon dermoscopic examination, a central white scar-like area was detected. A cleft-like appearance was also detected in the central region. In the periphery of the lesion, there was a fine pigment network. CASE 4: An 8-year-old girl reported to our outpatient clinic with a congenital 5 x 5 mm brownish papule on her right inguinal region. Dermoscopic examination showed a central white scar-like area, a cleft-like appearance in the central region, and a fine pigment network in the periphery of the lesion (Fig. 3). CASE 5: A 2-month-old girl was referred to our pigmented lesions clinic with a 3 x 3 mm brownish pink papule located on the right subcostal region lesion that had been noted by a pediatrician. Dermoscopic examination showed a central white area, central streak, and a very faint pigmented network at the periphery.

Elastosis Perforans Serpiginosa

A 41-year-old white man with Down syndrome presented with a slightly pruritic, papular eruption on bilateral forearms of several years' duration. Physical examination revealed multiple 2- to 3-mm keratotic, umbilicated pink papules in an annular configuration distributed symmetrically on the flexural surfaces of the forearms (Figure 1). The skin surrounding these papules was noted to be hyperpigmented and somewhat atrophic. The remainder of his skin examination was unremarkable. A shave biopsy of 1 papule was performed and stained with hematoxylin-eosin. Hematoxylin-eosin-stained sections showed clumps of bright red fibers being extruded through an acanthotic epidermis with a central invagination (Figure 2). Verhoeff-van Gieson stain confirmed these fibers to be elastin (Figure 3). Elastosis perforans serpiginosa was diagnosed.