A 52-year-old white man was referred to the Department of Dermatology, University of Palermo (Italy) with a six-month history of psoriasiform plaques with superficial erosion and fissuring on the palms () and the soles. Within a few weeks red violet and infiltrated plaques with moderate hyperkeratosis and scaling developed on the scalp and upper limps accompanied by itching. The patient was misdiagnosed as having psoriasis vulgaris. Various mid- and high-potency topical corticosteroids did not offer significant relief. Four months prior to referral he developed red to violaceous nodules which coalesced to form large plaques on the face. Skin examination at the time of hospital admission, approximately six months from the onset of his illness, revealed reddish brown ulcerated tumors and indurated erythematous plaques with superficial erosion on the forehead, glabella, cheeks (), scalp and neck. In addition, numerous plaques, accompanied by itching, were found on trunk and extremities in a generalized distribution. Plaques appeared as sharply delineated, scaly, elevated lesions that were dusky red to violaceous and variably indurated (). His nails were intact without pitting or dystrophy. He had cervical, scalp, neck, axial and inguinal lymphadenopathy. His chest was clear on auscultation. There was no hepatosplenomegaly and his abdomen was soft with normal bowel sounds. His cardiovascular, musculoskeletal and neurological exams were normal. His past medical history was unremarkable. He was not on medications. There was no history of anorexia, weight loss, fever or night sweats. The blood count showed normal red cell count and a slight leukocytosis (11.42 × 103/μl) comprised of 74.6% neutrophils, 7.2% eosinophils, 0.7% basophils, 11.1% lymphocytes and 6.4% monocytes. Further laboratory investigations of the blood showed alpha 1-globulin 5.25% and an erythrocyte sedimentation rate of 44 mm/h. Chemistry and liver function tests were unremarkable.
Erythematous plaques with superficial erosion on the face (a), psoriasiform plaques with superficial erosion and fissuring on the palms (b) and sharply delineated plaques on trunk (c).
A biopsy specimen was obtained from affected areas of the face, fixed in 10% buffered formalin and embedded in paraffin. For routine histology, 5-μm-thick sections were stained with hematoxylin and eosin. Immunohistochemical stains were performed according to the markers presented in . Chest X-ray, total body computed tomography scanning and excisional biopsy of the inguinal lymph node were obtained.
Summary of immunohistochemical methods and results