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condition may be increasing, especially in women. Our series of patients included eight women, all of whom were aged >70 years, infected by M. canis. Two of the patients were aged 93 years. When TC is observed in adults, the subjects are usually postmenopausal women. Qualitative and quantitative changes in sebum production, which facilitate the invasion by dermatophytes of scalp hairs, as well as alterations in the immune system have been suggested as possible predis posing factors.4,5 Furthermore, the literature suggests that TC is more common in immunocompromised patients and in patients who are using immunosuppressive drugs.5 However, none of our patients were using immunosuppres sive drugs. Our culture-proven series of cases of TC caused by M. canis shows the different clinical manifestations of TC in elderly subjects. Early diagnosis of this fungal infection in this population is challenging and requires a high level of attentiveness on the part of the medical practitioner. Therefore, we draw attention to a different form of dermatophytosis in elderly subjects in developed countries caused by zoonotic dermatophytes. If this condition is not diagnosed and treated properly, it may become epidemiologically important in the future. Tom Hillary, MD Department of Dermatology Free University of Brussels Brussels Belgium Ectopic hidradenoma papilliferum dermoscopically mimicking a blue nevus: a case report and review of the literature
Editor, Hidradenoma papilliferum is a rare, slow-growing, benign adnexal neoplasm with apocrine differentiation, usually localized in the anogenital area.1 This tumor may also occur in a non-anogenital region and is then named ‘‘ectopic’’ hidradenoma papilliferum.2 The most common sites of non-anogenital hidradenoma papilliferum are the head and neck. The lesion can only be diagnosed by histopathological examination because clinically it mimics other cutaneous neoplasms. In recent decades, dermoscopy has improved the diagnosis of many pigmented and non-pigmented skin lesions, but little is currently known about its usefulness in the diagnosis of adnexal tumors.3 We describe a patient with ectopic hidradenoma papilliferum on the scalp. We also report a literature search using MEDLINE/PubMed to identify other cases of ectopic hidradenoma papilliferum to August 2011. ª 2013 The International Society of Dermatology
Erwin Suys, MD Private Dermatology Practice Kortrijk Belgium Tom Hillary, MD Department of Dermatology Free University of Brussels Laarbeeklaan 101 1090 Jette Belgium E-mail:
[email protected]
References 1 Cremer G, Bournerias I, Vandemeleubroucke E, et al. Tinea capitis in adults: misdiagnosis or reappearance? Dermatology 1997; 194: 8–11. 2 Ginter-Hanselmayer G, Weger W, Ilkit M, Smolle J. Epidemiology of tinea capitis in Europe: current state and changing patterns. Mycoses 2007; 50(Suppl. 2): 6–13. 3 Rippon JW. The changing epidemiology and emerging patterns of dermatophyte species. Curr Topics Med Mycol 1985; 1: 208–234. 4 Buckley DA, Fuller LC, Higgins EM, du Vivier AW. Tinea capitis in adults. BMJ 2000; 320: 1389–1390. 5 Pipkin JL. Tinea capitis in the adult and adolescent. AMA Arch Derm Syphilol 1952; 66: 9–40.
A 62-year-old man presented at the Department of Dermatology, University of Rome ‘‘La Sapienza’’, with a 7-month history of an asymptomatic lesion of the scalp. Physical examination disclosed a 0.5-cm, blue-colored nodule, with regular borders, that was not attached to planes of deep tissue. The patient underwent dermoscopy, which showed a blue, homogeneous pattern associated with a peripheral, large vessel without pigmentation (Fig. 1). An atypical blue nevus was suspected, and the lesion was surgically excised. Histopathology showed an intradermal neoplasm with a complex pattern of tubules interconnected in a labyrinthine manner, with several papillary folds projecting into a cystic lumen, without epidermal connection (Fig. 2a). The lumina were lined with a double layer of small cuboidal cells on the outer layer and columnar cells on the inner layer, which showed active decapitation secretion similar to that seen in apocrine glands (Fig. 2b). These findings were consistent with ectopic hidradenoma papilliferum.
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Figure 1 Dermoscopy shows the lesion to have a blue, homo-
geneous pattern associated with a peripheral, large vessel
This neoplasm can occur on the face and scalp, where apocrine glands can sometimes be found, or in areas containing modified apocrine glands, such as the external ear canal, eyelid, and breast. We identified published reports of ectopic hidradenoma papilliferum in 33 patients (Table 1).2,4–8 A further three cases excluded from our review referred to two female patients with nipple lesions, because their tumors may actually have been papillary adenomas of the nipple rather than hidradenoma papilliferum,2 and one male patient with a neoplasm on the right eyelid, in whom histopathological findings appeared to be more
(a)
consistent with a diagnosis of syringocystadenoma papilliferum because an epidermal connection was evident.9 The prognosis in ectopic hidradenoma papilliferum is good, and the standard treatment is surgical excision. Malignant transformation can occur in rare cases; to our knowledge, only two reports of carcinoma arising in a pre-existing vulvar hidradenoma papilliferum have been documented. These concerned an intraductal carcinoma and an invasive adenosquamous carcinoma.2 Dermoscopy is considered a useful diagnostic tool for adnexal tumors,3 but, to our knowledge, this is the first description of dermoscopy of an ectopic hidradenoma papilliferum; the lesion showed a diffuse, homogeneous, blue pigmentation, usually seen in blue nevi or in dermal metastasis of melanoma. The blue color may be easily explained by the Tyndall effect, given both the cystic nature and dermal localization of the tumor: the light is scattered in a colloid suspension of particles with a cross-section of roughly 40–900 nm.10 Light with a longer wavelength is transmitted better, whereas light with a shorter wavelength is reflected via scattering, and thus blue light is scattered much more strongly than red light. This phenomenon may explain why other cystic lesions, such as trichilemmal cysts11 and eccrine acrospiromas,10 when analyzed by polarized light used in dermoscopy, can appear to be colored blue. We suggest that in the presence of cutaneous lesions which show a homogeneous blue pattern on dermoscopy, ectopic hidradenoma papilliferum and other cystic neoplasms should be included in the differential diagnosis.
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Figure 2 Histopathology shows that (a) the cystic lesion is well circumscribed and is surrounded by a thin fibrous capsule with
no connection to the overlying epidermis, and (b) the lumina is lined with a double layer of small cuboidal cells (outer layer) and columnar cells (inner layer). (Hematoxylin and eosin stain; original magnification [a] ·40, [b] ·100) International Journal of Dermatology 2014, 53, e80–e157
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Table 1 Summary of cases of ectopic hidradenoma
papilliferum reported in the English-language literature Case
Age, years
Sex
Location
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
8 32 45 55 55 56 60 61 61 63 71 75 78 ? 48 37 52 62 70 66 46 66 46 ? 39 44 ? ? ? ? ? ? ?
M F F F M F F F M F M F M M F M M M F F F M F F M F ? ? ? ? ? ? ?
Thigh (two lesions)2 External auditory canal2 Upper eyelid2 Cheek2 Posterior auricular2 Forehead2 Eyelid2 Forehead2 Axilla2 Back2 Upper limb2 Scalp2 Upper eyelid2 Face2 Back4 Nose4 Eyebrow4 Chest7 Scalp5 Nose6 Nose6 Abdomen7 Breast8 Axilla2 Eyelid2 Breast (chest)2 Upper lip4 Upper lip4 Temporal region4 Ala nasi4 Upper eyelid4 Occipital region4 Temporal region4
M, male; F, female.
Vincenzo Panasiti, MD, PhD Plastic Surgery Unit ‘‘Campus Bio-Medico’’ University Rome Italy Michela Curzio, MD Vincenzo Roberti, MD Piergiorgio Lieto, MD Silvia Gobbi, MD Valeria Devirgiliis, MD, PhD Department of Dermatology University of Rome ‘‘La Sapienza’’ Rome Italy
ª 2013 The International Society of Dermatology
Eleonora Perrella, MD Department of Pathology University of Rome ‘‘Campus Bio-Medico’’ Rome Italy Stefano Calvieri, MD Department of Dermatology University of Rome ‘‘La Sapienza’’ Rome Italy Vincenzo Panasiti, MD, PhD Plastic Surgery Unit ‘‘Campus Bio-Medico’’ University Via Alvaro del Portillo, 200 Rome 00128 Italy E-mail:
[email protected]
References 1 Klein W, Chan E, Seykora JT. Tumor of the epidermal appendages. In: Elder DE, Elenitsas R, Johnson BL Jr, Murphy GF, eds. Lever’s Histopathology of the Skin. Philadelphia, PA: Lippincott Williams & Wilkins, 2005: 893–894. 2 Vang R, Cohen PR. Ectopic hidradenoma papilliferum: a case report and review of the literature. J Am Acad Dermatol 1999; 41: 115–118. 3 Nicolino R, Zalaudek I, Ferrara G, et al. Dermoscopy of eccrine poroma. Dermatology 2007; 215: 160–163. 4 Minami S, Sadanobu N, Ito T, et al. Nonanogenital (ectopic) hidradenoma papilliferum with sebaceous differentiation: a case report and review of reported cases. J Dermatol 2006; 33: 256–259. 5 Moon JW, Na CH, Kim HR, Shin BS. Giant ectopic hidradenoma papilliferum on the scalp. J Dermatol 2009; 36: 545–547. 6 Lee EJ, Shin MK, Haw CR, Lee MH. Two cases of hidradenoma papilliferum of the nose. Acta Derm Venerol 2010; 90: 322–323. 7 Morimura S, Kadono T, Sugaya M, Sato S. Ectopic hidradenoma papilliferum on the abdomen. Eur J Dermatol 2011; 21: 278–279. 8 Kim YJ, Lee JW, Choi SJ, et al. Ectopic hidradenoma papilliferum of the breast: ultrasound finding. J Breast Cancer 2011; 14: 153–155. 9 Rosmaninho AD, de Almeida MT, Costa V, et al. Ectopic hidradenoma papilliferum. Dermatol Res Pract 2010; 2010: 709371 (3 pp.).
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10 Gatti A, di Meo N, Trevisan G. Dermoscopy of eccrine acrospiroma masquerading as nodular malignant melanoma. Acta Dermatovenerol Alp Panonica Adriat 2010; 19: 23–25.
11 Gencoglan G, Karaarslan IK, Akalin T, Ozdemir F. Trichilemmal cyst with homogeneous blue pigmentation on dermoscopy. Australas J Dermatol 2009; 50: 301–302.
Rapid improvement of psoriasis in diabetes subsequent to glucose lowering
years, he had been treated with topical vitamin D3 alone, and his skin lesions had begun to exacerbate. When he presented to us on July 29, 2011, scaly red plaques were aggravated on the back (Fig. 1a), arms, and lower legs (PASI score = 19.8). Laboratory findings showed elevated blood glucose (379 mg/dl), triglycerides (249 mg/dl), and HbA1c (10.1%). The initiation of insulin therapy decreased the patient’s blood sugar levels from 379 mg/dl to 198 mg/dl within two weeks, although his body weight and body mass index (24.2 kg/m2) remained unchanged. Surprisingly, the patient’s skin lesions significantly improved following insulin treatment, despite the fact that his treatment for psoriasis had not been altered. The red hue of the lesions faded within 10 days (Fig. 1b). Within seven weeks, the red plaques had almost disappeared, and the patient’s PASI score decreased from 19.8 to 3.8 (Fig. 1c). The present case shows an apparent correlation between psoriatic severity and blood sugar levels. To our knowledge, there are no reports on the direct relationship between psoriasis and blood glucose levels. Psoriasis is an inflammatory disease associated with the activation of Th-17 cytokines, such as interleukin 17 (IL-17), IL-21, IL-22, and tumor necrosis factor-a (TNF-a).1 TNF-a is one of the key factors inducing the inflammatory response of psoriasis, and treatment with anti-TNF-a antibodies is effective for this annoying inflammatory disorder. Adiponectin is an adipokine that regulates insulin sensitivity
Editor, Metabolic syndrome, such as is manifested in obesity, cardiovascular disease, and type 2 diabetes, is prevalent in psoriasis. However, the association between hyperglycemia and psoriasis remains to be elucidated. Herein, we report a case of psoriasis in a patient with type 2 diabetes in whom psoriatic lesions improved rapidly in association with the lowering of glucose by insulin treatment. This suggests that glycemic control may be vital in the treatment of certain patients with psoriasis accompanied by diabetes. A 57-year-old man presented at our clinic in 2003 with a 20-year history of plaque-type psoriasis. Psoriatic lesions were observed on the patient’s scalp, forehead, torso, lower arms, and lower legs. His score on the Psoriasis Area and Severity Index (PASI) was 12.3. Systemic etretinate therapy was started but discontinued because of liver dysfunction. The patient was then treated with topical vitamin D3 and intermittent narrowband ultraviolet B (NBUVB) irradiation with modest effect. Two years later, the patient’s blood glucose and hemoglobin A1c (HbA1c) levels were found to be elevated. The patient was diagnosed with type 2 diabetes and referred to an internist for glycemic control. However, the patient was reluctant to visit the internist and finally stopped ambulatory visits to the internist three years later. Over the previous two -
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Figure 1 (a) Extensive psoriatic lesions over the back before insulin treatment. (b) A marked reduction in elevation and red hue
is apparent at 10 d after the initiation of insulin treatment. (c) The psoriatic lesions are almost completely cleared at 7 weeks after the start of insulin treatment International Journal of Dermatology 2014, 53, e80–e157
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