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    • br Bowen s disease BD also known as

    2018-11-15


    Bowen’s disease (BD), also known as squamous cell carcinoma, may occur at any skin site; however, the involvement of the palmer aspect is rare. Skin lesions of BD typically present as a scaly erythematous plaque, whereas BD of the palms shows an atypical appearance. We herein present a case of multiple Bowen’s disease of the palms that clinically and histologically showed hypokeratosis. An 82-year-old woman presented with an 8-year history of multiple erosions on her palms. She had been treated for hand eczema. Topical corticosteroids, emollient, moisturizers, or dressings had limited effects. A physical examination revealed multiple scaly erythema, fissures, and erosions ranging from 0.2 cm × 0.2 cm to 5 cm × 6 cm on her palms (A). A dermatoscopic examination showed regularly distributed dotted vessels on a hypokeratotic area surrounded by scales and a crust (B). There was no hyperkeratotic lesion, implying arsenic exposure on her palms. Assuming circumscribed palmer hypokeratosis (CPH), skin biopsy was performed on two lesions. Histopathological findings were diagnostic for BD. The epidermis was thickened with dyskeratotic cells, and the corneum was absent (C). The alzheimer\'s association lay in complete disorder throughout the epidermis. Cells appeared highly atypical and had large hyperchromatic nuclei (D). She had drunk well water that was prohibited for use as drinking water by the government from the age of 13 years to 30 years. No other internal carcinoma was found by mass screening. She refused surgical excision. A treatment with cryosurgery was initiated, and the hypokeratotic area began to disappear. A clinical diagnosis of BD of the palms is challenging. Our patient was considered as having hand eczema or CPH, which has recently been recognized as a distinctive epidermal malformation. Although a dermatoscopic examination assisted in the diagnosis, there are currently no specific criteria for BD of the palms. Dotted vessels and scales are suggestive dermatoscopic features of BD. However, hypokeratosis, not hyperkeratosis was observed in our case. Dotted vessels in the hypokeratotic area can be observed in CPH. These dermatoscopic observations misled our diagnosis. Similar to our case, a previous report described a single erosive lesion of BD of the palm. Kanitakis et al reported a case of premalignant CPH due to heavy sun exposure. Their case had several instances of actinic keratosis on the face, neck, and forearms. A single lesion of CPH of the palm was observed, suggesting that CPH can undergo (photo)carcinogenesis. In contrast, multiple lesions were observed in our case, and no actinic keratosis was found. Our patient had drunk well water for 17 years. Since it was difficult to examine the water quality of the well that our patient had used 50 years ago, we were unable to reach a concrete diagnosis of arsenic-related BD. However, multiple BD lesions on sun-protected areas of the skin suggest arsenic-related BD, and CPH-like changes could be secondary. Alternatively, multiple BD lesions may have occurred after arsenic keratosis because the hypokeratotic area was surrounded by some scales, which is a vestige of hyperkeratosis. The development of internal carcinomas of the gut, lung, liver, and bladder has been reported. Therefore, we consider further follow-ups necessary for this patient even after the remission of BD lesions.
    A 51-year-old man presented with a 3-year history of a single, longitudinal, pigmented streak on the left index fingernail. Physical examination revealed a 1-mm-wide longitudinal pigmented band in the nail of the left index finger, originating from the distal lunula border and extending to the free margin of the nail plate (). He complained of tenderness of the lesion. He had been treated with antifungal agent for 3 months but showed no response after 1 year of follow-up. He had a history of ankylosing spondylitis and had been treated with ustekinumab for 1 year. His laboratory findings were nonspecific. Total excision was performed, and the histological findings showed papillomatous nail matrix squamous epithelial hyperplasia and a thick keratin layer in the distal nail bed (A and 2B). A periodic acid–Schiff test did not reveal any fungal elements. Additional HMB-45 stain revealed a few scattered basal melanocytes (C). The patient showed good response without recurrence. Based on these findings, a diagnosis of onychopapilloma was established.