Letters to the Editor
horizontal sections (Fig. 2a). The infundibular ostium showed hyperkeratosis with hair shafts split in two by a layer of red blood cells (Fig. 2b) (the hamburger sign).5 In one case several hair shafts were fragmented in three pieces. In the uppermost sections, the epidermis was visible and showed thick layers of orthokeratosis and hyperkeratosis. The broom hairs identified on dermatoscopy have been reported in trichotillomania.4 The presence of broken hairs at different lengths, amorphous hair residues and black dots, irregular coiled hairs and yellow dots,4,6,7 as well as the absence of lichenification distinguishes trichotillomania from LSC. Broom hair fibres have not been described in psoriasis or tinea capitis, which is also our experience. The broom hair fibres correspond on pathology to hair shafts split into two or rarely into three pieces at the level of infundibulum, which resemble a hamburger. The hamburger sign was originally reported in trichotillomania as an auxiliary diagnostic finding.7 We detected it in all our biopsies from LSC and we consider it a result of the traumatic splitting of the hair shafts from the constant rubbing and scratching to the scalp. Other pathological findings of LSC observed in our horizontal sections include the gear wheel sign representing the jagged acanthotic projections of the outer root sheaths around the hair canal at the level of the infundibulum. Irregular acanthosis and hyperkeratosis is the hallmark of LSC on pathology on vertical sections. In conclusion, the recognition of the broom hair fibres on dermatoscopy and the hamburger sign and the gear wheel sign on pathology provide an additional tool for the diagnosis of LSC in the scalp.
345
7 Miteva M, Tosti A. Dermatoscopy of hair shaft disorders. J Am Acad Dermatol 2013; 68: 473–481. DOI: 10.1111/jdv.12748
Dermoscopy of adamantinoid trichoblastoma Editor A 22-year-old woman presented with an asymptomatic lesion on the retroauricular area which had appeared some months before. The lesion was a shiny pink, firm nodule, 8 mm in size. Dermoscopic evaluation using contact polarized dermoscopy (DermLite Foto, 3Gen LLC, Dana Point, CA, USA) without liquid interface, revealed prominent telangiectatic vessels traversing the lesion and branching into finer capillaries, on an orange background. Three peripheral areas were appreciated, divided by the arborizing telangiectasias, with dotted vessels and some glomerular vessels on a white-to-pink background (Fig. 1). The lesion was surgically excised. Histopathological examination showed a well-circumscribed neoplasm located on the dermis and composed of well delineated nodules connected in some areas to the epidermis (Fig. 2). Lobules were constituted by a peripheral rim of basaloid cells and a central area in which a population of clear cells with abundant cytoplasm was admixed with large numbers of lymphocytes. A dense stroma surrounded the lobules and isolated foci of keratinization were observed.
~o Alvarez,2 M. Miteva3 M.V. Quaresma,1,* A.M. Marin 1
Department of Dermatology, Professor Rubem David Azulay Institute of n Dermatology, Rio de Janeiro, Brazil, 2University of Los Andes, Fundacio de Bogota , Bogota , Colombia, 3Department of Dermatology and Santa Fe Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA *Correspondence: M.V. Quaresma. E-mail: [email protected]
References 1 Robertston IM, Jordan JM, Whitlock FA. Emotions and skin (II) – the conditioning of scratch responses in cases of lichen simplex. Br J Dermatol 1975; 92: 407–412. 2 Stillians AW. Lichen simplex of the scalp. Arch Derm Syphilol 1926; 13: 819–821. 3 Bernardin RM, Altman CE, Meffert JJ. What is your diagnosis? Lichen simplex chronicus. Cutis 2006; 78: 96, 101–102. 4 Rudnicka L, Rakowska A, Olszewska M et al. Hair shafts. In Rudnicka L, Olszewska M, Rakowska A, eds. Atlas of Trichoscopy Dermoscopy in Hair and Scalp Disease. Springer, London, UK, 2012: 11–46. 5 Royer MC, Sperling LC. Splitting hairs: the ‘hamburger sign’ in trichotillomania. J Cutan Pathol 2006; 33(Suppl. 2): 63–64. 6 Lee DY, Lee JH, Yang JM, Lee ES. The use of dermatoscopy for the diagnosis of trichotillomania. J Eur Acad Dermatol Venereol 2009; 23: 731–732.
JEADV 2016, 30, 320–386
Figure 1 Branching telangiectasias crossing the lesion, glomerular vessels and dotted vessels.
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
346
In conclusion, a characteristic combination of dermoscopic structures was observed in a case of AT: arborizing telangiectasia, dotted vessels and glomerular vessels. Additional features suggestive of a keratinizing tumour, melanocytic neoplasm or basal cell carcinoma were not present. This particular assortment of vascular patterns has not been described previously. Further descriptions of the dermoscopy of AT are necessary to confirm our findings. G. Pitarch,1,* R. Botella-Estrada2 1
, Department of Dermatology, Hospital Universitari General, Castello Spain, 2Department of Dermatology, Hospital Universitario La Fe, Valencia, Spain *Correspondence: G. Pitarch. E-mail: [email protected]
References Figure 2 Lobules with a rim of basaloid cells and a centre with clear cells (Haematoxylin-eosin stain).
Adamantinoid trichoblastoma (AT) is the currently preferred term for an uncommon neoplasm previously referred to as cutaneous lymphadenoma and benign lymphoepithelial tumour of the skin. Clinically, AT usually presents as a slowly growing, skin-coloured nodule, papule or plaque without signs of inflammation, located on the head and neck of young and middle-aged adults. AT is thought to originate from hair follicles, representing a variant of trichoblastoma. Dermoscopy of AT has not been previously described. The present case depicts characteristic dermoscopic findings, with a combination of arborizing telangiectasia, dotted vessels and glomerular vessels. Arborizing telangiectasia are typical of basal cell carcinoma. In a study of vascular patterns in cutaneous tumours, arborizing vessels were found in 82.1% of basal cell carcinomas, 16.7% of sebaceous hyperplasia, 3.2% of melanocytic nevi, 2.4% of seborrhoeic keratosis and 0.7% of melanomas.1 Adnexal tumours, such as trichoepithelioma, angiohistiocytoma or poroma, may also reveal arborizing telangiectasia. Fibroepithelioma of Pinkus is characterized by short thin telangiectasias alone or associated with dotted vessels.2 Dotted vessels are suggestive of melanocytic neoplasms, such as dermal naevus, congenital naevus, Spitz naevus, Clark naevus and melanoma.3 Clear cell acanthoma reveals dotted vessels arranged in a string-like arrangement. Invasive squamous cell carcinoma may also reveal dotted vessels, but usually combined with linear irregular vessels, central crust or superficial scaling. Glomerular vessels represent a variation of dotted vessels but are larger in size and are characterized by tortuous capillaries. Both dotted and glomerular vessels often appear within the same lesion, grouped in small packed clusters.4 Although glomerular vessels represent the characteristic dermoscopic finding of Bowen disease, they can also be seen in invasive squamous cell carcinoma, seborrheic keratosis and even basal cell carcinoma.5
JEADV 2016, 30, 320–386
1 Zalaudek I, Kreusch J, Giacomel J, Ferrara G, Catricala C, Argenziano G. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part II. Nonmelanocytic skin tumors. J Am Acad Dermatol 2010; 63: 377–386. 2 Sgambato A, Zalaudek I, Ferrara G et al. Adnexal tumors: clinical and dermoscopic mimickers of basal cell carcinoma. Arch Dermatol 2008; 144: 426. 3 Argenziano G, Zalaudek I, Corona R et al. Vascular structures in skin tumors: a dermoscopy study. Arch Dermatol 2004; 140: 1485–1489. 4 Zalaudek I, Leinweber B, Citarella L et al. Dermoscopy of Bowen’s disease. Br J Dermatol 2004; 150: 1112–1116. 5 Micantonio T, Gulia A, Altobelli E et al. Vascular patterns in basal cell carcinoma. J Eur Acad Dermatol Venereol 2011; 25: 358–361. DOI: 10.1111/jdv.12752
First report of hereditary Christ–Siemens–Touraine syndrome and non-segmental vitiligo association in a young adult: contraindication for vitiligo treatment Editor Ectodermal Dysplasia (ED) includes more than 170 different genetic disorders characterized by developmental abnormalities in ectodermal structures including skin, hair, sweat glands, and teeth. X-linked hypohidrotic ectodermal dysplasia (X-HED [MIM305100]) or Christ-Siemens-Touraine syndrome is the most prevalent form of Ectodermal Dysplasia (ED) accounting for more than 70% of cases reported in the literature to now. X-HED is the result of mutations in the gene encoding ectodysplasin (EDA1 [MIM 300451]), ligand of the tumor necrosis factor (TNF) family,1 while the autosomal dominant (MIM
© 2014 European Academy of Dermatology and Venereology
horizontal sections (Fig. 2a). The infundibular ostium showed hyperkeratosis with hair shafts split in two by a layer of red blood cells (Fig. 2b) (the hamburger sign).5 In one case several hair shafts were fragmented in three pieces. In the uppermost sections, the epidermis was visible and showed thick layers of orthokeratosis and hyperkeratosis. The broom hairs identified on dermatoscopy have been reported in trichotillomania.4 The presence of broken hairs at different lengths, amorphous hair residues and black dots, irregular coiled hairs and yellow dots,4,6,7 as well as the absence of lichenification distinguishes trichotillomania from LSC. Broom hair fibres have not been described in psoriasis or tinea capitis, which is also our experience. The broom hair fibres correspond on pathology to hair shafts split into two or rarely into three pieces at the level of infundibulum, which resemble a hamburger. The hamburger sign was originally reported in trichotillomania as an auxiliary diagnostic finding.7 We detected it in all our biopsies from LSC and we consider it a result of the traumatic splitting of the hair shafts from the constant rubbing and scratching to the scalp. Other pathological findings of LSC observed in our horizontal sections include the gear wheel sign representing the jagged acanthotic projections of the outer root sheaths around the hair canal at the level of the infundibulum. Irregular acanthosis and hyperkeratosis is the hallmark of LSC on pathology on vertical sections. In conclusion, the recognition of the broom hair fibres on dermatoscopy and the hamburger sign and the gear wheel sign on pathology provide an additional tool for the diagnosis of LSC in the scalp.
345
7 Miteva M, Tosti A. Dermatoscopy of hair shaft disorders. J Am Acad Dermatol 2013; 68: 473–481. DOI: 10.1111/jdv.12748
Dermoscopy of adamantinoid trichoblastoma Editor A 22-year-old woman presented with an asymptomatic lesion on the retroauricular area which had appeared some months before. The lesion was a shiny pink, firm nodule, 8 mm in size. Dermoscopic evaluation using contact polarized dermoscopy (DermLite Foto, 3Gen LLC, Dana Point, CA, USA) without liquid interface, revealed prominent telangiectatic vessels traversing the lesion and branching into finer capillaries, on an orange background. Three peripheral areas were appreciated, divided by the arborizing telangiectasias, with dotted vessels and some glomerular vessels on a white-to-pink background (Fig. 1). The lesion was surgically excised. Histopathological examination showed a well-circumscribed neoplasm located on the dermis and composed of well delineated nodules connected in some areas to the epidermis (Fig. 2). Lobules were constituted by a peripheral rim of basaloid cells and a central area in which a population of clear cells with abundant cytoplasm was admixed with large numbers of lymphocytes. A dense stroma surrounded the lobules and isolated foci of keratinization were observed.
~o Alvarez,2 M. Miteva3 M.V. Quaresma,1,* A.M. Marin 1
Department of Dermatology, Professor Rubem David Azulay Institute of n Dermatology, Rio de Janeiro, Brazil, 2University of Los Andes, Fundacio de Bogota , Bogota , Colombia, 3Department of Dermatology and Santa Fe Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA *Correspondence: M.V. Quaresma. E-mail: [email protected]
References 1 Robertston IM, Jordan JM, Whitlock FA. Emotions and skin (II) – the conditioning of scratch responses in cases of lichen simplex. Br J Dermatol 1975; 92: 407–412. 2 Stillians AW. Lichen simplex of the scalp. Arch Derm Syphilol 1926; 13: 819–821. 3 Bernardin RM, Altman CE, Meffert JJ. What is your diagnosis? Lichen simplex chronicus. Cutis 2006; 78: 96, 101–102. 4 Rudnicka L, Rakowska A, Olszewska M et al. Hair shafts. In Rudnicka L, Olszewska M, Rakowska A, eds. Atlas of Trichoscopy Dermoscopy in Hair and Scalp Disease. Springer, London, UK, 2012: 11–46. 5 Royer MC, Sperling LC. Splitting hairs: the ‘hamburger sign’ in trichotillomania. J Cutan Pathol 2006; 33(Suppl. 2): 63–64. 6 Lee DY, Lee JH, Yang JM, Lee ES. The use of dermatoscopy for the diagnosis of trichotillomania. J Eur Acad Dermatol Venereol 2009; 23: 731–732.
JEADV 2016, 30, 320–386
Figure 1 Branching telangiectasias crossing the lesion, glomerular vessels and dotted vessels.
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
346
In conclusion, a characteristic combination of dermoscopic structures was observed in a case of AT: arborizing telangiectasia, dotted vessels and glomerular vessels. Additional features suggestive of a keratinizing tumour, melanocytic neoplasm or basal cell carcinoma were not present. This particular assortment of vascular patterns has not been described previously. Further descriptions of the dermoscopy of AT are necessary to confirm our findings. G. Pitarch,1,* R. Botella-Estrada2 1
, Department of Dermatology, Hospital Universitari General, Castello Spain, 2Department of Dermatology, Hospital Universitario La Fe, Valencia, Spain *Correspondence: G. Pitarch. E-mail: [email protected]
References Figure 2 Lobules with a rim of basaloid cells and a centre with clear cells (Haematoxylin-eosin stain).
Adamantinoid trichoblastoma (AT) is the currently preferred term for an uncommon neoplasm previously referred to as cutaneous lymphadenoma and benign lymphoepithelial tumour of the skin. Clinically, AT usually presents as a slowly growing, skin-coloured nodule, papule or plaque without signs of inflammation, located on the head and neck of young and middle-aged adults. AT is thought to originate from hair follicles, representing a variant of trichoblastoma. Dermoscopy of AT has not been previously described. The present case depicts characteristic dermoscopic findings, with a combination of arborizing telangiectasia, dotted vessels and glomerular vessels. Arborizing telangiectasia are typical of basal cell carcinoma. In a study of vascular patterns in cutaneous tumours, arborizing vessels were found in 82.1% of basal cell carcinomas, 16.7% of sebaceous hyperplasia, 3.2% of melanocytic nevi, 2.4% of seborrhoeic keratosis and 0.7% of melanomas.1 Adnexal tumours, such as trichoepithelioma, angiohistiocytoma or poroma, may also reveal arborizing telangiectasia. Fibroepithelioma of Pinkus is characterized by short thin telangiectasias alone or associated with dotted vessels.2 Dotted vessels are suggestive of melanocytic neoplasms, such as dermal naevus, congenital naevus, Spitz naevus, Clark naevus and melanoma.3 Clear cell acanthoma reveals dotted vessels arranged in a string-like arrangement. Invasive squamous cell carcinoma may also reveal dotted vessels, but usually combined with linear irregular vessels, central crust or superficial scaling. Glomerular vessels represent a variation of dotted vessels but are larger in size and are characterized by tortuous capillaries. Both dotted and glomerular vessels often appear within the same lesion, grouped in small packed clusters.4 Although glomerular vessels represent the characteristic dermoscopic finding of Bowen disease, they can also be seen in invasive squamous cell carcinoma, seborrheic keratosis and even basal cell carcinoma.5
JEADV 2016, 30, 320–386
1 Zalaudek I, Kreusch J, Giacomel J, Ferrara G, Catricala C, Argenziano G. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part II. Nonmelanocytic skin tumors. J Am Acad Dermatol 2010; 63: 377–386. 2 Sgambato A, Zalaudek I, Ferrara G et al. Adnexal tumors: clinical and dermoscopic mimickers of basal cell carcinoma. Arch Dermatol 2008; 144: 426. 3 Argenziano G, Zalaudek I, Corona R et al. Vascular structures in skin tumors: a dermoscopy study. Arch Dermatol 2004; 140: 1485–1489. 4 Zalaudek I, Leinweber B, Citarella L et al. Dermoscopy of Bowen’s disease. Br J Dermatol 2004; 150: 1112–1116. 5 Micantonio T, Gulia A, Altobelli E et al. Vascular patterns in basal cell carcinoma. J Eur Acad Dermatol Venereol 2011; 25: 358–361. DOI: 10.1111/jdv.12752
First report of hereditary Christ–Siemens–Touraine syndrome and non-segmental vitiligo association in a young adult: contraindication for vitiligo treatment Editor Ectodermal Dysplasia (ED) includes more than 170 different genetic disorders characterized by developmental abnormalities in ectodermal structures including skin, hair, sweat glands, and teeth. X-linked hypohidrotic ectodermal dysplasia (X-HED [MIM305100]) or Christ-Siemens-Touraine syndrome is the most prevalent form of Ectodermal Dysplasia (ED) accounting for more than 70% of cases reported in the literature to now. X-HED is the result of mutations in the gene encoding ectodysplasin (EDA1 [MIM 300451]), ligand of the tumor necrosis factor (TNF) family,1 while the autosomal dominant (MIM
© 2014 European Academy of Dermatology and Venereology
