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El-Darouti, M. A., S. A. Marzouk, N. Nabil, M. R. E. Abdel-Halim, M. H. M. El-Komy, and M. Abdel-Latif, "Pachyonychia congenita: treatment of the thickened nails and palmoplantar circumscribed callosities with urea 40% paste", Journal of the European Academy of Dermatology and Venereology, vol. 20, no. 5: Wiley Online Library, pp. 615–617, 2006. Abstract
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Abdelkader, H. A., J. Hamdan, A. Elbendary, and M. R. E. Abdel-Halim, "Papillary eccrine adenoma presenting as a cutaneous horn.", International journal of dermatology, 2021.
El-Nabarawy, E. A., N. Saleh, and M. R. E. Abdel-Halim, "Peculiar papular eruption on the vulva and inguinal folds.", Journal of clinical pathology, vol. 72, issue 2, pp. 185, 2018 Dec 20, 2019. Abstract

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.

Esmat, S. M., M. R. E. Abdel-Halim, H. I. GAWDAT, M. Kamel, A. E. Ramly, K. Helmy, and S. M. Esmat, "Persistent Pixel Stamping Marks: a novel complication of fractional CO laser in scar treatment.", Lasers in medical science, 2019 Jan 04. Abstract

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.

El-Mofty, M. A., S. M. Esmat, and M. R. E. Abdel-Halim, "Pigmentary disorders in the Mediterranean area", Dermatologic clinics, vol. 25, no. 3: Elsevier, pp. 401–417, 2007. Abstract
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Komy, M. E. L., E. El-Nabarawy, H. Abdelkader, M. R. E. Abdel-Halim, and R. AlAguizy, "Pigmentary mosaicism and extracutaneous defects: a case report of a rare form of twin spotting", Pigment International, vol. 8, pp. 176-8, 2021.
El-Darouti, M. A., S. A. Marzouk, M. H. M. El-Komy, and M. RE, "Preliminary Clinical, Histopathological and Laboratory Study of Cases Presenting with Pruriginous Edematous Excoriated Papular Eruption (Subacute Prurigo)", Kasr Al Aini Medical Journal, vol. 13, no. 1, pp. 7–13, 2007. Abstract
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Youssef, R., M. R. E. Abdel-Halim, D. M. ABDELHALIM, M. M. Fawzy, M. F. Hussein, M. F. Elmasry, S. S. Sayed, and N. M. Abo Eid, "PUVA-induced pityriasis lichenoides chronica-like papular lesions in patients with mycosis fungoides: a clinical, histopathological and immunohistochemical study.", Archives of dermatological research, 2019. Abstract

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.

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