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• Four patients had squamous tumors of the perioral skin with clinical and microscopic hallmarks of keratoacanthoma. In addition, the lesions exhibited extensive perineural invasion and intravenous growth. Two of the tumors recurred soon after excision and required additional surgery. In another case, two subsequent keratoacanthomas developed in adjacent skin. There were no further recurrences after follow-up periods of 7, 24, 42, and 44 months. Lesions in two patients were extremely painful. Perineural invasion was found in each of nine pathologic specimens. The number of involved nerves in single sections of each lesion ranged from two to 59 and exceeded 20 in four specimens from three patients. Intravenous growth by keratoacanthoma was seen in five specimens from three patients. Nine veins were affected in one instance and four in another. Several of the tumors had a dispersed and deeply infiltrative pattern of growth. Measuring vertically from the surface of the lesion, the deepest focus of perineural invasion observed in the four patients ranged from 4.2 to 17 mm. Keratoacanthomas with this unusual constellation of findings may have a predilection for the central portion of the face.(Arch Dermatol 1988;124:1397-1401)

Goldstein et al,1 in 1982, described six neoplasms that they called "microcystic adnexal carcinoma" (MAC). The authors believed that the tumors exhibited both follicular and sweat gland differentiation but observed that the terms malignant syringoma or sweat gland carcinoma with syringomatous features might be preferred by some pathologists. The clinical and pathologic features of 20 patients with similar neoplasms have recently been reported under the term sclerosing sweat duct (syringoma-tous) carcinoma (SSDC).2 The contributions of Lupton and McMarlin3 and Nickoloff and co-workers4 in this issue of the Archives focus the attention of dermatologists on this important neoplastic entity.The literature now contains descriptions of at least 36 patients whose neoplasms probably or definitely belong in the category under consideration.1-14 The patients ranged in age from the second to the eighth decades. Male and female patients were affected equally

• A patient had primary cutaneous adenoid cystic carcinoma. The tumor closely resembled adenoid cystic carcinoma of salivary gland origin and was composed of cribriform and tubular masses of basaloid cells. Lumina formed by neoplastic cells contained mucin and hyalin, and similar constituents were located between neoplastic cell masses and adjacent dermis. Perineural invasion was observed. A review of seven other primary cutaneous adenoid cystic carcinomas indicates that this neoplasm tends to affect middle-aged and older individuals, is often present for several years prior to diagnosis, has a propensity for local recurrence, but has not produced metastases in regional lymph nodes or distant sites. Therapy should employ wide surgical excision that extends well beyond the clinical confines of the neoplasm.(Arch Dermatol 1984;120:774-777)

• Multiple cutaneous xanthomas developed in a patient at the age of 10 months, and juvenile chronic myeloid leukemia (JCML) developed at the age of 30 months. The xanthomas were histopathologically consistent with a diagnosis of juvenile xanthogranuloma (JXG). A review of other cases of JCML with JXG indicates that the cutaneous lesions have many clinical and histopathologic similarities to sporadic JXG but are more often multiple or papular and confluent. In addition to JXG, a few children with JCML also have multiple café-au-lait spots and a family history of neurofibromatosis.(Arch Dermatol 1984;120:371-375)

† Since its initial description, microcystic adnexal carcinoma (MAC) of the skin has been controversial. In particular, it features keratin production of the type seen in some pilar neoplasms, and has been thought to pursue partial follicular differentiation. Diagnostically, MAC may be difficult to separate from desmoplastic trichoepithelioma (DTE) in superficial biopsy specimens. We studied 12 MACs, 22 malignant eccrine acrospiromas, 7 sudoriferous syringometaplasias, 6 syringomas, 5 DTEs, and 40 other benign pilar neoplasms immuno-histochemically. Paraffin sections and antibodies to "hard" (pilar) keratins, epithelial membrane antigen (EMA), carcinoembryonic antigen (CEA), Leu-M1, and S 100 protein were employed. The MACs exhibited reactivity for hard keratin subclasses AE13 and AE14, EMA, CEA, and Leu-M1. Desmoplastic trichoepitheliomas expressed positivity for AE14, EMA, and Leu-M1 focally, but lacked the other specified markers. Syringomas and malignant acrospiromas displayed EMA, CEA, and AE14 reactivity, and 5 syringometaplastic lesions were AE14-reactive. Benign pilar tumors aside from DTEs were reactive only for AE13, AE14, or both. These data indicate that MAC exhibits an immunophenotype that is a "hybrid" of those seen in pure sweat glandular and follicular neoplasms, and suggest that it may indeed show combined pilar and sudoriferous differentiation. Based on these results, it also appears that immunohistochemical analysis may be useful in the diagnostic separation of MAC and DTE.(Arch Dermatol. 1990; 126:189-194)

† Bipolaris spicifera is a dematiaceous fungus that has rarely been reported to cause cutaneous infection in humans. A patient with leukemia was examined for a nonhealing ulcer on her leg that developed following minor trauma. Histopathologic study revealed groups of nonpigmented, septate fungal hyphae located predominantly in the necrotic ulcer base. Cultures of a biopsy specimen yielded colonies that were gray to black with a black reverse. Microscopic examination revealed dematiaceous, straight, oblong conidia consistent with B spicifera. The ulcer was successfully treated with surgical excision, skin graft, and amphotericin B.(Arch Dermatol. 1989;125:1383-1386)

• A neonate with a congenital mechanobullous disorder is described and compared with similar patterns from the literature. The blisters were subepidermal, remitted within a few months, and have not recurred on long-term follow-up. The relation of the congenital self-healing mechanobullous dermatoses to epidermolysis bullosa is unclear.(Arch Dermatol 1988;124:240-243)

• Two patients are described in whom malignant transformation occurred within an eccrine spiradenoma. Their findings were compared with those of six similar patients from the literature, and a characteristic clinicopathologic picture was evident. The typical history was one of rapid enlargement of a cutaneous nodule of long standing. The neoplasms were composed, at least in part, of large, markedly atypical basaloid cells with numerous mitotic figures. Adjacent benign spiradenoma was observed microscopically in each case, and some of the carcinomas retained architectural features reminiscent of spiradenoma. One patient died of disseminated tumor, but follow-up was short or lacking in several cases. Malignant transformation of eccrine spiradenoma shares many clinical and pathologic features with malignant transformation of dermal cylindroma.(Arch Dermatol 1985;121:1445-1448)

• Forty-eight malignant melanomas of the extremities, 1 mm or less in maximal thickness, were studied to better define microscopic criteria of regression in thin melanomas. Eleven tumors (23%) exhibited definite regression in the form of one or more segmental areas (defects) where the invasive component was replaced by mononuclear cell infiltrate and fibrosis. Thirteen other tumors (27%) had diffuse, nonsegmental changes classified as probable regression. Nineteen lesions (40%) lacked regression, although 14 of these contained focal evidence of host response. Five melanomas (17% of lesions <0.75 mm thick) were equivocal for regression. There were no recurrences or metastases. The histologic diagnosis of regression in thin melanomas requires subjective judgments, but segmental defects represent a potentially reproducible criterion. Their width can be measured, and the proportion of the melanoma that has undergone regression can be estimated. The preponderance of data from the literature, supported by this study, indicates that regression has no prognostic importance in the vast majority of thin melanomas. There are observations, however, to suggest that in rare cases, regression may negate the prognostic value of microstaging of a thin melanoma. To date, the type and extent of such regressive changes have not been adequately defined.(Arch Dermatol 1985;121:1127-1131)

• Five cases of subcutaneous angiomatous tumors had a microscopic appearance identical to the deeper portions of conventional polypoid granuloma pyogenicum. Clinically, the lesions were nonspecific subcutaneous nodules of short duration, located on the upper extremity. Microscopically, there was a distinctive and diagnostic pattern of cellular capillary lobules separated by fibrous stroma. This appearance was easily distinguished from that of granulation tissue and other vascular lesions. Granuloma pyogenicum is a specific pathologic entity that can be recognized by its histologic features. The more accurate descriptive term, "lobular capillary hemangioma," could include the entire category of polypoid, intradermal, subcutaneous, and intravenous hemangiomas that have identical microscopic findings.(Arch Dermatol 1982;118:30-33)

Skin biopsy specimens from 21 patients with Ehlers-Danlos syndrome (EDS) were compared with controls. With two exceptions, the appearance of the dermal collagen and elastic tissue as seen in the two groups was indistinguishable. One example of type 4 EDS contained a dermis composed of fibers that resembled actinically damaged elastic tissue. The single example of type 6 EDS contained particularly thin collagen fibers. The dermal thickness of specimens of EDS was similar to that of controls, although the abnormal-appearing specimen of type 4 EDS was also abnormally thin. Since the other two biopsy specimens of type 4 appeared to be within the range of normal, there may be heterogeneity in this form of EDS.(Arch Dermatol 115:40-42, 1979)

• We describe four patients with panniculitis attributable to a combination of cold exposure and equestrian activities. All were young, healthy women who rode horses for at least two consecutive hours per day throughout the winter. Initially, several small, erythematous, pruritic papules appeared on the superior-lateral portions of one or both thighs. During one week, the lesions progressed to indurated, red-to-violaceous, tender plaques and nodules. Studies for cryofibrinogens and cryoglobulins were negative. The histologic picture was that of a panniculitis with prominent inflammation of veins most notable at the dermal-subcutaneous fat junction. Cold panniculitis is not limited to infancy and childhood. The distribution of lesions in our patients may have been caused, in part, by the use of tightfitting, uninsulated riding pants. Such attire may have slowed blood flow through the skin, thereby further reducing tissue temperature.(Arch Dermatol 116:1025-1027, 1980)

We describe two brothers with dyskeratosis congenita and intracranial calcifications. The calcifications were massive, approximately symmetric, and showed a predilection for the basal ganglia and dentate nuclei. No underlying causes for this finding were identified. Idiopathic familial intracranial calcification of this type has been described, but an association with dyskeratosis congenita has not previously been observed.(Arch Dermatol 115:1437-1439, 1979)

Periorbital depigmentation developed in a black man approximately six months after the application of an ophthalmic solution containing thiotepa. The drug was used postoperatively to prevent revascularization after removal of a pterygium. By light and electron microscopy, melanocytes were apparently absent in the depigmented area. The list of medications and chemicals that can cause cutaneous depigmentation is growing. An appropriate history may be of considerable value in the evaluation of vitiligo-like conditions.(Arch Dermatol 115:973-974, 1979)

To our knowledge, keratoacanthoma has not been reported to develop within a linear epidermal nevus. We describe herein a patient with the simultaneous development of two keratoacanthomas in a linear epidermal nevus. REPORT OF A CASE A 26-year-old woman was referred to the University of Virginia Dermatology Clinic, Charlottesville, for evaluation of two asymptomatic nodules that had developed within a "birthmark" on her right arm. The lesions had appeared suddenly, one month earlier, and had continued to enlarge since that time. There was no history of preceding trauma.On physical examination, the patient had a zosteriform epidermal nevus that extended proximally from the distal aspect of her right thumb to her right shoulder (Fig 1). There were two dome-shaped nodules, each 1 cm in diameter, located within the nevus. One was located on the dorsal aspect of the wrist and the other was immediately proximal to the elbow (Fig 1).

• Livedo reticularis developed on the lower extremities of a 37-year-old woman with primary oxalosis and renal failure that was treated by hemodialysis. Biopsy results of the involved skin indicated oxalate crystals in the walls of the blood vessels of the dermis and subcutaneous tissue. Oxalosis with vascular involvement should be included in the long list of causes of livedo reticularis.(Arch Dermatol 116:213-214, 1980)

Chromomycosis is a chronic, slowly progressive disease of the skin and subcutaneous tissue produced by several species of dematiaceous or pigmented fungi, especially Phialophora gougeroti. Verrucous nodules and flattened annular plaques are the most frequently reported skin lesions in chromomycosis, but deep abscesses and cystic lesions have also been reported. We describe herein a case of cystic chromomycosis due to Wangiella dermatitidis that developed following a nonpenetrating injury to the thumb.(Arch Dermatol 115:1433-1434, 1979)

Erythema chronicum migrans with an intensely purpuric border developed in a 70-year-old woman. A biopsy specimen, in addition to showing the usual perivascular mononuclear infiltrate, demonstrated numerous polymorphonuclear leukocytes associated with leukocytoclasis. Immunofluorescence study showed vascular deposition of IgM and C3.(Arch Dermatol 115:873-874, 1979)