Mona Abdel-Halim

Fractional CO laser rejuvenation of scars offers a high safety profile. Laser marks usually disappear clinically within 1 week. The authors observed occasional persistence of the laser marks on the scar surface. The purpose of this study is to report the incidence and to describe the clinical, dermoscopic, and histological features of a novel observed complication of fractional CO laser scar rejuvenation "Persistent Pixel Stamping Marks (PPSM)".One hundred seventy-one cases were consecutively recruited from patients assigned for fractional CO laser scar rejuvenation. Patients who developed the phenomenon 1 month post laser session were recorded and subjected to clinical photography, dermoscopy, and optical coherence tomography (OCT) as well as a 4-mm punch biopsy from pixelated scars. The evolution of PPSM was followed up for 6 months. PPSM developed in 16 patients (9.4%), 15 of which were post burn hypertrophic scars. PPSM was significantly related to darker skin type, darker scar color, and longer scar duration. Histopathological findings included characteristic holes in stratum corneum and superficial dermis, thick collagen bundles perpendicular to the skin surface with loss of elastic tissue, focal interface changes, and triangular focus of fibroblastic proliferation. The marks disappeared in 5 and lasted in 11 patients. Their longevity was significantly related to longer dwell times and lower densities. PPSM represent miniature scarring at the sites of the microscopic thermal zones or a sign of their delayed healing. They tend to follow fractional CO laser resurfacing of hyperpigmented, long-standing burn scars. Longer dwell times and lower densities make them last longer.

CLINICAL QUESTION: A 26-year-old woman presented with asymptomatic skin coloured to whitish keratotic papules on the vulva, inguinal folds and inner thighs of 6 years duration. She had no similar lesions elsewhere and no family history. A biopsy was taken from one of the papules.Review the high-quality, interactive digital Aperio slide at http://virtualacp.com/JCPCases/jclinpath-2018-205434/ and consider your diagnosis. WHAT IS YOUR DIAGNOSIS?: Darrier's diseaseHailey-Hailey diseaseGenital wartsPapular acantholytic dyskeratosis of genitocrural areaPemphigus vegetansThe correct answer is after the discussion.

DISCUSSION: Papular acantholytic dyskeratosis (PAD) of the genitocrural area is a peculiar acantholytic dermatosis with dyskeratosis localised to the vulva and inguinal folds with possible extension to the thighs and perineum.1 It mainly involves young or middle-aged females.1 Cases affecting males and involving genitalia, thighs and perianal region have been reported.2 It represents an allelic variant of Hailey-Hailey disease as heterozygous mutations in gene (intron 5 and exon 24) have been reported in some cases.3 Clinically, PAD of the genitocrural area is typically characterised by solitary or grouped keratotic flesh coloured or white papules.1 Other clinical presentations include: vesicles, bullae, patches and plaques.4 Although the lesions are mainly asymptomatic, patients may experience variable degrees of itching or burning sensation.Histopathologically, the lesions show hyperkeratosis, hypergranulosis, acanthosis and acantholytic dyskeratosis in the spinous layer (figure 1). Typically, direct immunoflourescence (DIF) is negative.5 jclinpath;jclinpath-2018-205434v1/F1F1F1Figure 1Photomicrograph representing histopathological findings: hyperkeratosis, hypergranulosis, acanthosis and acanthloytic dyskeratosis involving the spinous layer; 254×143 mm.The most important differential diagnoses of this sporadic condition include: Darier's and Hailey-Hailey, both of which are familial. Hailey-Hailey involves also other flexural areas and presents with eroded crusted lesions with foul odour. Pathologically, the acantholytic process in PAD of the genitocrural area is rather focal compared with the broad zone of acantholysis in Hailey-Hailey, and columns of parakeratosis overlying suprabasilar acantholysis are characteristic of Darier's disease. Although, some cases of PAD of the genitocrural area can present with vesicles and bullae, the presence of dyskeratotic cells and the negative DIF speaks against pemphigus.Treatment options for this condition include topical and systemic retinoids. Cryotherapy and laser have been also reported to be effective. Topical steroids might be effective in reducing pruritus.

A 77-year-old female patient presented with bilateral tender, swollen, erythematous, focally crusted cheeks with a discharge of pus and necrotic material, which had developed one month after autologous fat transfer and a corrective injection procedure conducted to correct an overdone fat transfer. Histopathological examination of the discharged material using routine hematoxylin and eosin staining revealed degenerated collagen admixed with three different filler materials. Scattered all throughout the specimen were numerous thick-walled, basophilic, nonbudding spherical bodies of variable sizes. The bodies stained positively with Periodic acid-Schiff and Alcian blue and showed internal septation and sporangia with a morula-like appearance. The morphology of these bodies was characteristic of a infection. The patient was treated by surgical drainage accompanied by itraconazole 200mg daily for six months, ultimately showing marked improvement.

Mycosis fungoides is the most common type of primary cutaneous T cell lymphomas. Doxycycline promoted apoptosis in different human malignant cell lines and in vivo models. To test for the therapeutic efficacy of doxycycline in comparison to PUVA in early stages of classic MF and its effect on T cell apoptosis. Thirty-six patients were randomized into either: doxycycline 200 mg daily ( = 18) or PUVA (3 weekly sessions) ( = 18) for 12 weeks. The primary outcome (therapeutic efficacy) was defined in terms of objective response rate (ORR) which was measured according to changes in the modified severity weighted assessment tool (mSWAT). Doxycycline achieved significantly less ORR (partial response) in comparison to PUVA (11.1%, 50%, respectively,  = .016). The percent reduction in mSWAT, CAILS, histopathology score and CD3 expression was significantly less in the doxycycline group ( = .001,  = .001,  ˂ .001, and  = .004, respectively). Within the doxycycline group, changes in mSWAT and CAILS showed no correlation with changes in the CD3 or Bcl-2 expression. Gastric upset was significantly more encountered in the doxycycline group ( = .001). Doxycycline is not suitable as a sole agent in the treatment of early stages of classic MF, acting mainly by anti-inflammatory rather apoptotic function. NCT03454945 ( www.clinicaltrials.gov ).

Mycosis fungoides (MF) is the most common form of cutaneous T cell lymphoma (CTCL) with many clinical variants including papular and pityriasis lichenoides chronica (PLC)-like variants. During psoralen and ultraviolet A (PUVA) treatment of MF, PLC-like papular lesions were observed to appear. The exact nature of these lesions is not fully understood. This work aimed to study PLC-like papular lesions arising in MF patients receiving PUVA therapy clinically, histopathologically and immunohistochemically (using monoclonal antibodies against CD4 and CD8) and to compare them with lesions in classic PLC patients. Fifteen MF patients with PLC-like papular lesions arising during PUVA treatment were included and 15 patients with classic PLC served as controls. While the extent of these lesions significantly correlated with their duration (p < 0.05), it showed no significant correlation with the TNMB stage of MF, number of phototherapy sessions or cumulative UVA dose at which they started to appear. The response status of MF to PUVA did not affect their development. Compared to classic PLC, these lesions showed significantly more acute onset (p = 0.003). None of these lesions showed histopathological features essential to diagnose papular/PLC-like MF and no significant difference existed with regard to their histopathological and CD4/CD8 phenotypic features compared to classic PLC. Papular lesions mimicking PLC in MF patients receiving PUVA mostly represent an upgrading reaction with possible good prognostic implication.

Hypopigmented interface T-cell dyscrasia (HITCD) is a distinct form of lymphoid dyscrasia that may progress to hypopigmented mycosis fungoides (HMF). We compared both diseases as regards their CD4/CD8 phenotype and expression of granzyme B and tumor necrosis factor-alpha (TNF-α) and how these are affected by narrow-band UVB (nb-UVB). The study included 11 patients with HITCD and 9 patients with HMF. They received nb-UVB thrice weekly until complete repigmentation or a maximum of 48 sessions. Pretreatment and posttreatment biopsies were stained using anti CD4, CD8, TNF-α, and granzyme B monoclonal antibodies. Epidermal lymphocytes were CD8 predominant in 54.5% and 66.7% of HITCD and HMF cases, respectively, whereas dermal lymphocytes were CD4 predominant in 63.6% and 66.7%, respectively. Significantly, more dermal infiltrate was encountered in HMF (P = 0.041). In both diseases, granzyme B was only expressed in the dermis, whereas TNF-α was expressed both in the epidermis and dermis. No difference existed as regards the number of sessions needed to achieve repigmentation or cumulative nb-UVB dose reached at end of study. (P > 0.05). Narrow-band UVB significantly reduced only the epidermal lymphocytes in both diseases (P ≤ 0.05) with their complete disappearance in 8 (72.7%) HITCD and 6 (66.7%) HMF cases. In both diseases, nb-UVB did not affect granzyme B or TNF-α expression (P > 0.05). In conclusion, both diseases share the same phenotype, with HITCD being a milder form of T-cell dysfunction. In both diseases, epidermal lymphocytes are mainly CD8-exhausted cells lacking cytotoxicity, whereas dermal cells are mostly reactive cells exerting antitumor cytotoxicity. Tumor necrosis factor-alpha mediates hypopigmentation in both diseases and prevents disease progression. Repigmentation after nb-UVB in both diseases occurs before and independently from disappearance of the dermal infiltrate.

BACKGROUND: The distinction of trichoepithelioma from basal cell carcinoma in small superficial biopsies is important but often challenging. This has inspired many scientists to test the validity of immunohistochemical markers in the differential diagnosis.

OBJECTIVES: To develop an immunohistochemical protocol that helps in differentiation between both trichoepithelioma (TE) and basal cell carcinoma (BCC) with higher sensitivity and specificity.

METHODS: Using standard immunohistochemical techniques, we examined 10 TEs and 19 BCCs for the expression of CK19, Ki-67, androgen receptors (AR), CD10, and PHLDA1.

RESULTS: Immunoreactivity of AR, Ki-67, and CD10 in tumor cells was significantly higher in BCC than TE with a diagnostic accuracy in BCC of 75.5%, 75.8%, and 79.3% respectively, whereas immunoreactivity of PHLDA1 in tumor cells and stromal CD10 was significantly higher in TE than BCC with a diagnostic accuracy in TE of 100% and 82.8%, respectively. In contrast, immunoreactivity for CK19 showed no statistically significant differences between both tumors.

CONCLUSION: The analysis of CD10, Ki-67, and PHLDA1 can be used as a helpful immunohistochemical panel in the distinction between TE and BCC especially in small and superficial biopsies.

The purpose of this study was to evaluate the efficacy of fractional carbon dioxide laser use in the treatment of mature burn scars. This was an uncontrolled, open-label clinical trial. The setting for this study was Dermatology Department at Cairo University in Cairo, Egypt. Twenty patients with mature burn scars were included in the study. Three fractional carbon dioxide laser sessions were given, 4 to 8 weeks apart. Primary outcome was measured using two scar scales, the Vancouver Scar Scale and the Patient and Observer Scar Assessment Scale. Secondary outcomes included evaluation of collagen and elastic fibers using routine hematoxylin and eosin, Masson's trichrome, and orcein stains. Outcomes were measured two months after the last laser session. Both Vancouver Scar Scale and Patient and Observer Scar Assessment Scale showed significant reduction following treatment (<0.001). Scar relief and pliability improved most followed by vascularity. Pigmentation improved the least. Percent improvement in Patient and Observer Scar Assessment Scale patients' overall assessment was 44.44 percent. The pattern and arrangement of collagen and elastic fibers showed significant improvement (<0.001, =0.001, respectively), together with significant improvement in their amounts (=0.020, <0.001, respectively). No significant correlation existed between clinical and histopathological/histochemical scores. Side effects and complications were mild and tolerable. Fractional carbon dioxide laser use is an effective and safe method for treating burn scars with a significant change in the opinion of the patients about their scar appearance.

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