Letters to the Editor
mucosa with a characteristic slow growth and minimal local invasion with very rare metastatic potential. There are four types of verrucous carcinoma depending on the site of occurrence: (1) Ano‑urogenital: Giant condyloma acuminatum, Buschke–Lowenstein tumor; (2) Oro‑aerodigestive: Ackerman tumor, oral florid papillomatosis; (3) Feet: Carcinoma cuniculatum, epithelioma cuniculatum; and (4) Other cutaneous sites: Cutaneous verrucous carcinoma, papillomatosis cutis carcinoides. [1,2] A majority of the cases (90%) are found on the feet. [3] Only 16 cases of verrucous carcinomas on the hand have been published in the world literature so far.[4] Our case was unusual as the site of occurrence was uncommon and the surface of the lesion was minimally verrucous. Long duration at presentation is common in verrucous carcinoma, which may be due to lack of suspicion and therefore no histological evaluation in the early stage. Our patient did not have adjacent bone infiltration, although it is reported to be higher in verrucous carcinomas of the hand (20%).[5] Metastasis to regional lymph nodes is very rare with no published data for lesions in the hand. Longstanding warty skin lesion not responding to routine treatment should be biopsied to rule out verrucous carcinoma, enabling early treatment and cure. If any bony involvement is noted, a wide excision of the tumor with amputation is the treatment of choice.[4] Routine lymphadenectomy should not be considered unless lymph node involvement is suspected. Radiotherapy is contraindicated as there is a risk of anaplastic transformation and even lymphatic spread.[4]
treatment, and should be confirmed by histopathology. Early diagnosis and surgical treatment cures the patient.
Girish P. Narayana, Sandhya I.1 Departments of Dermatology, and 1Pathology, AJIMS, Mangalore, Karnataka, India Address for correspondence: Dr. P. N. Girish, 1‑17‑898, Panchavati, Giri Nagar Main Road, Landlinks Township, Derebail, Konchady, Mangalore ‑ 575 008, Karnataka, India. E‑mail: [email protected]
REFERENCES 1. 2.
3.
4. 5.
Ackerman LV. Verrucous carcinoma of the oral cavity. Surgery 1948;23:670‑8. Schwartz RA. Verrucous carcinoma of the skin. In: Demis DJ, editor. Clinical Dermatology. 18th ed., Unit 21‑22. Philadelphia: JB Lippincott; 1991. p. 1‑8. Delahaye JF, Janser JC, Rodier JF, Auge B. Cuniculatum carcinoma. 6 cases and review of the literature. J Chir (Paris) 1994;131:73‑8. [cross ref] Carcinoma cuniculatum arising in the tongue. Head Neck Pathol 2012;6:130‑4. Gertler R, Werber KD. Management of verrucous carcinoma of the hand: A case report. Int J Dermatol 2009;48:1233‑5. Coldiron BM, Brown FC, Freeman RG. Epithelioma cuniculatum (carcinoma cuniculatum) of the thumb: A case report and literature review. J Dermatol Surg Oncol 1986;12:1150‑5. Access this article online Quick Response Code: Website: www.idoj.in
LEARNING POINTS/TAKE HOME MESSAGES Verrucous carcinoma should be suspected whenever there is a longstanding verrucous lesion that is not responding to routine
DOI: 10.4103/2229-5178.131133
Remote reverse Koebner phenomenon in generalized granuloma annulare
form small annular plaques. Lesions may be skin colored, pink, violaceous, tan, or yellow. Unlike in localized disease, the trunk is frequently involved, in addition to the neck and extremities. It runs a protracted course.[2] Various types of trauma, including that of a biopsy, have been observed to initiate resolution of lesions.[3]
Sir, Granuloma annulare is a benign, self‑limiting, necrobiotic disorder of unknown etiology. The clinical variants are localized, generalized, perforating, and subcutaneous patterns.[1] Histopathologic features comprise granulomatous inflammation in a palisaded or interstitial pattern associated with varying degrees of connective tissue degeneration and mucin deposition. Generalized granuloma annulare is a rare variant comprising 8%-15% of all cases of granuloma annulare. It presents as widespread papules some of which may coalesce to
A 66‑year‑old man presented with progressive, asymptomatic papular eruption since 5 years. The patient was in good health and denied any recent illness or ingestion of medications. He gave history of similar lesions 20 years ago that persisted for more than 8 years and resolved after medication. The nature of medication is not known. There was no history of diabetes mellitus. On examination, scattered multiple papules ranging in size from 0.5 to 1.0 cm were noted [Figure 1]; papules were distributed throughout the body, with sparing of face. They were very dense over thighs and arms.
Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
219
Letters to the Editor
Initial laboratory examination revealed the following normal or negative results; complete blood cell count, erythrocyte sedimentation rate, liver and renal function tests, urinalysis, random blood sugar, anti‑HIV and chest X‑ray. A clinical differential diagnoses of eruptive syringoma, eruptive xanthoma, and disseminated granuloma annulare were considered. A 4 mm punch biopsy was obtained from the lesion on the side of the trunk, which showed microscopic features of granuloma annulare. When the patient returned for follow‑up 4 weeks later, the lesions throughout the body had completely resolved [Figure 2]. No additional treatment was recommended, and the patient was advised to return for follow‑up once again after one month. When he returned after a month, there were no lesions evident. He showed complete resolution of all lesions which were present since five years, without any treatment. After skin biopsy, we observed a dramatic improvement. The histopathological examination revealed infiltration of histiocytes between disrupted collagen bundles and perivascular lymphocytic infiltration. There were associated mucinous changes. The findings were consistent with the interstitial variant of granuloma annulare [Figure 3]. Biopsy scar mark is seen on the lateral side of the chest [Figure 4]. Most cases of granuloma annulare resolve spontaneously. In our patient, the lesions were present since 5 years, and resolved completely after performing biopsy. Though natural resolution is a possible mechanism, biopsy as a triggering factor for resolution cannot be ruled out. A postal questionnaire survey was carried out by Wells and Smith.[4] Clinical notes of 280 patients suffering from
Figure 1: Multiple papules on the forearm
220
granuloma annulare were examined. They found that 52 patients had biopsies with no effect on the natural course of the disease. A total of 11 biopsies were performed on the group in which the lesions were still present. Some of these patients had multiple lesions, so the fate of the particular lesion biopsied was not ascertained, but in others, the lesions biopsied had persisted. Levin et al., [5] noted resolution of patch type granuloma annulare at the site of biopsy. However, lesions at the unbiopsied site persisted. Histopathology revealed interstitial variant. Interestingly in our case also, biopsy findings were consistent with interstitial variant. In the present case, lesions disappeared not only at biopsy site, but also at the unbiopsied site. Levin et al.,[5] proposed that controlled injury to the skin could alter cellular and extracellular milieu and possibly clear inflammatory process like granuloma annulare. Granuloma annulare responding to physical modalities of treatment like psoralen ultraviolet A range and cryotherapy, and the curious case of generalized granuloma annulare sparing the vaccination site[6] are cited as examples. One hypothetical mechanism by which biopsy or other forms of wounding could trigger resolution of granuloma annulare is by initiating an orderly process of wound healing with formation of granulation tissue, remodeling of the extracellular matrix, neovascularization, and wound contraction.[5,7] Malakar and Dhar[8] reported spontaneous resolution of vitiligo patches distant from autologous skin graft site and used the term remote reverse Koebner’s phenomenon. In our case also lesions distant from the biopsied site resolved spontaneously. Further research is warranted regarding the presence of remote
Figure 2: Lesions resolved after biopsy Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
Letters to the Editor
Kikkeri N Naveen, Varadraj V Pai, Sharatchandra B Athanikar, Gaurang Gupta, Hassan A Parshwanath1 Departments of Dermatology, 1Pathology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India Address for correspondence: Dr. Kikkeri Narayanasetty Naveen, Department of Dermatology, No. 10, Skin OPD, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Sattur, Dharwad ‑ 580 009, Karnataka, India. E‑mail: [email protected]
REFERENCES 1. Figure 3: Histopathologial examination revealing infiltration of histiocytes between disrupted collagen bundles and perivascular lymphocytic infiltration. There were associated mucinous changes (H and E, ×10)
2.
3.
4. 5.
6. 7. 8.
Burns DA. Necrobiotic disorders. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook’s Textbook of Dermatology. Oxford: Wiley‑Blackwell; 2010. p. 60.5‑60.7. Prendiville JS. Granuloma annulare. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ, editors. Fitzpatrick’s Dermatology in General Medicine. New York: McGraw Hill; 2008. p. 1959. Mathai R. Necrobiotic disorders. In: Valia RG, Valia AR, editors. IADVL Textbook of Dermatology. Mumbai: Bhalani Publishing House; 2010. p. 1193‑5. Wells RS, Smith MA. The natural history of granuloma annulare. Br J Dermatol 1963;75:199‑205. Levin NA, Patterson JW, Yao LL, Wilson BB. Resolution of patch‑type granuloma annulare lesions after biopsy. J Am Acad Dermatol 2002;46:426‑9. Huilgol SC, Liddell K, Black MM. Generalized granuloma annulare sparing vaccination sites. Clin Exp Dermatol 1995;20:51‑3. Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med 1999;341:738‑46. Malakar S, Dhar S. Spontaneous repigmentation of vitiligo patches distant from the autologous skin graft sites: A remote reverse Koebner›s phenomenon? Dermatology 1998;197:274.
Access this article online Quick Response Code: Website: www.idoj.in
Figure 4: Biopsy scar mark on the lateral part of chest
reverse Koebner’s phenomenon in the interstitial variant of generalized granuloma annulare.
DOI: 10.4103/2229-5178.131137
Acrocyanosis with intrahepatic carcinoid tumor
and erythroderma.[1] Acrocyanosis means symmetrical, painless bluish discoloration of the distal parts of the body. It is classified as primary, with no apparent underlying cause, and secondary, when associated with underlying pathology.[2]
Sir, Paraneoplastic disorders occur due to substances released from the internal tumors or immune cross‑reactivity with host tissue. Common mucocutaneous paraneoplastic disorders include acanthosis nigricans, dermatomyositis, pyoderma gangrenosum,
A 49‑year‑old man presented with discoloration of the fingers and toes of one month duration. He denied pain and swelling of the extremities and aggravation of symptoms in cold climate. He gave a history of intermittent abdominal pain over the right upper quadrant region associated with weight loss for the past one
Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
221
Copyright of Indian Dermatology Online Journal is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
mucosa with a characteristic slow growth and minimal local invasion with very rare metastatic potential. There are four types of verrucous carcinoma depending on the site of occurrence: (1) Ano‑urogenital: Giant condyloma acuminatum, Buschke–Lowenstein tumor; (2) Oro‑aerodigestive: Ackerman tumor, oral florid papillomatosis; (3) Feet: Carcinoma cuniculatum, epithelioma cuniculatum; and (4) Other cutaneous sites: Cutaneous verrucous carcinoma, papillomatosis cutis carcinoides. [1,2] A majority of the cases (90%) are found on the feet. [3] Only 16 cases of verrucous carcinomas on the hand have been published in the world literature so far.[4] Our case was unusual as the site of occurrence was uncommon and the surface of the lesion was minimally verrucous. Long duration at presentation is common in verrucous carcinoma, which may be due to lack of suspicion and therefore no histological evaluation in the early stage. Our patient did not have adjacent bone infiltration, although it is reported to be higher in verrucous carcinomas of the hand (20%).[5] Metastasis to regional lymph nodes is very rare with no published data for lesions in the hand. Longstanding warty skin lesion not responding to routine treatment should be biopsied to rule out verrucous carcinoma, enabling early treatment and cure. If any bony involvement is noted, a wide excision of the tumor with amputation is the treatment of choice.[4] Routine lymphadenectomy should not be considered unless lymph node involvement is suspected. Radiotherapy is contraindicated as there is a risk of anaplastic transformation and even lymphatic spread.[4]
treatment, and should be confirmed by histopathology. Early diagnosis and surgical treatment cures the patient.
Girish P. Narayana, Sandhya I.1 Departments of Dermatology, and 1Pathology, AJIMS, Mangalore, Karnataka, India Address for correspondence: Dr. P. N. Girish, 1‑17‑898, Panchavati, Giri Nagar Main Road, Landlinks Township, Derebail, Konchady, Mangalore ‑ 575 008, Karnataka, India. E‑mail: [email protected]
REFERENCES 1. 2.
3.
4. 5.
Ackerman LV. Verrucous carcinoma of the oral cavity. Surgery 1948;23:670‑8. Schwartz RA. Verrucous carcinoma of the skin. In: Demis DJ, editor. Clinical Dermatology. 18th ed., Unit 21‑22. Philadelphia: JB Lippincott; 1991. p. 1‑8. Delahaye JF, Janser JC, Rodier JF, Auge B. Cuniculatum carcinoma. 6 cases and review of the literature. J Chir (Paris) 1994;131:73‑8. [cross ref] Carcinoma cuniculatum arising in the tongue. Head Neck Pathol 2012;6:130‑4. Gertler R, Werber KD. Management of verrucous carcinoma of the hand: A case report. Int J Dermatol 2009;48:1233‑5. Coldiron BM, Brown FC, Freeman RG. Epithelioma cuniculatum (carcinoma cuniculatum) of the thumb: A case report and literature review. J Dermatol Surg Oncol 1986;12:1150‑5. Access this article online Quick Response Code: Website: www.idoj.in
LEARNING POINTS/TAKE HOME MESSAGES Verrucous carcinoma should be suspected whenever there is a longstanding verrucous lesion that is not responding to routine
DOI: 10.4103/2229-5178.131133
Remote reverse Koebner phenomenon in generalized granuloma annulare
form small annular plaques. Lesions may be skin colored, pink, violaceous, tan, or yellow. Unlike in localized disease, the trunk is frequently involved, in addition to the neck and extremities. It runs a protracted course.[2] Various types of trauma, including that of a biopsy, have been observed to initiate resolution of lesions.[3]
Sir, Granuloma annulare is a benign, self‑limiting, necrobiotic disorder of unknown etiology. The clinical variants are localized, generalized, perforating, and subcutaneous patterns.[1] Histopathologic features comprise granulomatous inflammation in a palisaded or interstitial pattern associated with varying degrees of connective tissue degeneration and mucin deposition. Generalized granuloma annulare is a rare variant comprising 8%-15% of all cases of granuloma annulare. It presents as widespread papules some of which may coalesce to
A 66‑year‑old man presented with progressive, asymptomatic papular eruption since 5 years. The patient was in good health and denied any recent illness or ingestion of medications. He gave history of similar lesions 20 years ago that persisted for more than 8 years and resolved after medication. The nature of medication is not known. There was no history of diabetes mellitus. On examination, scattered multiple papules ranging in size from 0.5 to 1.0 cm were noted [Figure 1]; papules were distributed throughout the body, with sparing of face. They were very dense over thighs and arms.
Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
219
Letters to the Editor
Initial laboratory examination revealed the following normal or negative results; complete blood cell count, erythrocyte sedimentation rate, liver and renal function tests, urinalysis, random blood sugar, anti‑HIV and chest X‑ray. A clinical differential diagnoses of eruptive syringoma, eruptive xanthoma, and disseminated granuloma annulare were considered. A 4 mm punch biopsy was obtained from the lesion on the side of the trunk, which showed microscopic features of granuloma annulare. When the patient returned for follow‑up 4 weeks later, the lesions throughout the body had completely resolved [Figure 2]. No additional treatment was recommended, and the patient was advised to return for follow‑up once again after one month. When he returned after a month, there were no lesions evident. He showed complete resolution of all lesions which were present since five years, without any treatment. After skin biopsy, we observed a dramatic improvement. The histopathological examination revealed infiltration of histiocytes between disrupted collagen bundles and perivascular lymphocytic infiltration. There were associated mucinous changes. The findings were consistent with the interstitial variant of granuloma annulare [Figure 3]. Biopsy scar mark is seen on the lateral side of the chest [Figure 4]. Most cases of granuloma annulare resolve spontaneously. In our patient, the lesions were present since 5 years, and resolved completely after performing biopsy. Though natural resolution is a possible mechanism, biopsy as a triggering factor for resolution cannot be ruled out. A postal questionnaire survey was carried out by Wells and Smith.[4] Clinical notes of 280 patients suffering from
Figure 1: Multiple papules on the forearm
220
granuloma annulare were examined. They found that 52 patients had biopsies with no effect on the natural course of the disease. A total of 11 biopsies were performed on the group in which the lesions were still present. Some of these patients had multiple lesions, so the fate of the particular lesion biopsied was not ascertained, but in others, the lesions biopsied had persisted. Levin et al., [5] noted resolution of patch type granuloma annulare at the site of biopsy. However, lesions at the unbiopsied site persisted. Histopathology revealed interstitial variant. Interestingly in our case also, biopsy findings were consistent with interstitial variant. In the present case, lesions disappeared not only at biopsy site, but also at the unbiopsied site. Levin et al.,[5] proposed that controlled injury to the skin could alter cellular and extracellular milieu and possibly clear inflammatory process like granuloma annulare. Granuloma annulare responding to physical modalities of treatment like psoralen ultraviolet A range and cryotherapy, and the curious case of generalized granuloma annulare sparing the vaccination site[6] are cited as examples. One hypothetical mechanism by which biopsy or other forms of wounding could trigger resolution of granuloma annulare is by initiating an orderly process of wound healing with formation of granulation tissue, remodeling of the extracellular matrix, neovascularization, and wound contraction.[5,7] Malakar and Dhar[8] reported spontaneous resolution of vitiligo patches distant from autologous skin graft site and used the term remote reverse Koebner’s phenomenon. In our case also lesions distant from the biopsied site resolved spontaneously. Further research is warranted regarding the presence of remote
Figure 2: Lesions resolved after biopsy Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
Letters to the Editor
Kikkeri N Naveen, Varadraj V Pai, Sharatchandra B Athanikar, Gaurang Gupta, Hassan A Parshwanath1 Departments of Dermatology, 1Pathology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India Address for correspondence: Dr. Kikkeri Narayanasetty Naveen, Department of Dermatology, No. 10, Skin OPD, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Sattur, Dharwad ‑ 580 009, Karnataka, India. E‑mail: [email protected]
REFERENCES 1. Figure 3: Histopathologial examination revealing infiltration of histiocytes between disrupted collagen bundles and perivascular lymphocytic infiltration. There were associated mucinous changes (H and E, ×10)
2.
3.
4. 5.
6. 7. 8.
Burns DA. Necrobiotic disorders. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook’s Textbook of Dermatology. Oxford: Wiley‑Blackwell; 2010. p. 60.5‑60.7. Prendiville JS. Granuloma annulare. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ, editors. Fitzpatrick’s Dermatology in General Medicine. New York: McGraw Hill; 2008. p. 1959. Mathai R. Necrobiotic disorders. In: Valia RG, Valia AR, editors. IADVL Textbook of Dermatology. Mumbai: Bhalani Publishing House; 2010. p. 1193‑5. Wells RS, Smith MA. The natural history of granuloma annulare. Br J Dermatol 1963;75:199‑205. Levin NA, Patterson JW, Yao LL, Wilson BB. Resolution of patch‑type granuloma annulare lesions after biopsy. J Am Acad Dermatol 2002;46:426‑9. Huilgol SC, Liddell K, Black MM. Generalized granuloma annulare sparing vaccination sites. Clin Exp Dermatol 1995;20:51‑3. Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med 1999;341:738‑46. Malakar S, Dhar S. Spontaneous repigmentation of vitiligo patches distant from the autologous skin graft sites: A remote reverse Koebner›s phenomenon? Dermatology 1998;197:274.
Access this article online Quick Response Code: Website: www.idoj.in
Figure 4: Biopsy scar mark on the lateral part of chest
reverse Koebner’s phenomenon in the interstitial variant of generalized granuloma annulare.
DOI: 10.4103/2229-5178.131137
Acrocyanosis with intrahepatic carcinoid tumor
and erythroderma.[1] Acrocyanosis means symmetrical, painless bluish discoloration of the distal parts of the body. It is classified as primary, with no apparent underlying cause, and secondary, when associated with underlying pathology.[2]
Sir, Paraneoplastic disorders occur due to substances released from the internal tumors or immune cross‑reactivity with host tissue. Common mucocutaneous paraneoplastic disorders include acanthosis nigricans, dermatomyositis, pyoderma gangrenosum,
A 49‑year‑old man presented with discoloration of the fingers and toes of one month duration. He denied pain and swelling of the extremities and aggravation of symptoms in cold climate. He gave a history of intermittent abdominal pain over the right upper quadrant region associated with weight loss for the past one
Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
221
Copyright of Indian Dermatology Online Journal is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
