Bullous Sweet syndrome with a unique photodistributed pattern

ent result and no side effects, with complete regression of he lesion after 10 weeks of imiquimod use.10 Finally, it is important to emphasize that lesions with nusual presentations can make the diagnosis of HSV difcult. The main therapeutic regimen remains the use of cyclovir, but in patients with immunodeficiency, the assoiation of the antiviral and the topical use of imiquimod as shown good results. Although further studies are still equired, the case reported herein may help to support the se of imiquimod as a promising drug in the treatment of enital infections caused by HSV refractory to the traditional herapy.

suffering from myelodysplastic syndrome (MDS), for which no drugs, including granulocyte-colony stimulating factor (G-CSF), were administered. Physical examination showed numerous concrescences of blisters clearly localized in the V-neck area (Fig. 1a, b). Painful erythematous nodules were scattered on the cheeks, but the tip of the nose was spared. Furthermore, there was one blister on the right forearm as well as painful erythematous nodules on the upper and lower extremities. She did not have any mucosal lesions or a prior history of recurrent oral aphthae. Laboratory examination showed a white blood cell count of 8,100/L with 3% Band, 21% Seg, 9% Lym, 7% Mono, and 57% Blast, decreased levels  of hemoglobin (8.6 g/dL) and platelets (108,000/L), and increased levels of C-reactive protein (26.02 mg/dL). Blood culture was sterile. A biopsy specimen from the peripheral edge of the bulla on the neck showed a subepidermal bulla and dense neutrophilic infiltration in the upper to mid-dermis (Fig. 2a, b). Immature myeloid cell infiltration was not detected. Infiltration of histiocytes/histiocytoid cells was not observed, and immunohistological examination showed scattered CD68-and MPO-positive cells which were not prominent. Additionally, another biopsy taken from the lower leg showed infiltration of inflammatory cells, mainly lymphocytes, around the vessels in the septa of the subcutaneous fat tissue (Fig. 2c). Hematological examination and bone marrow biopsy revealed transformation from MDS into acute myelocytic leukemia, and chemotherapy includ-ing prednisolone was immediately started in the hematology department. After about one week, all of the bullous lesions were re-epithelialized. The present case developed a sudden onset of skin lesions, which histopathologically showed a predominant neutrophilic infiltration without leukocytoclastic vasculitis. In addition, fever, elevated C-reactive protein, and rapid response to systemic steroids were observed. White blood cell count was within the upper limit of the normal range but two times higher than the usual value. Thus, the patient fulfilled the criteria for Sweet syndrome (SS). Cutaneous lesions of SS associated with myelodysplasia tend to be vesicular, bullous, or erosive. The present case developed bullous SS, simultaneously with the blastic crisis of MDS. Of interest, the lesions showed a peculiar distribution of well-circumscribed erythema in the V-neck area not protected by clothes during the season when the dose of ultraviolet radiation is increased in Japan, which was considered to be a photo-Koebner phenomenon. Only several cases of photo-induced or photo-distributed SS have been reported, in which both ultraviolet A and ultraviolet B were candidates for induction of skin lesions. 1---3 Although phototesting was not performed in the present case, the patient had no previous history of photosensitive dermatitis or of taking drugs that can induce photosensitive eruptions. To our knowledge, the current report is the first case of photolocalized bullous SS. The direct action of ultraviolet is speculated to activate and recruit neutrophils via interleukin-8, tumor necrosis factor-␣, E-selectin, interleukin-1␣, and G-CSF 4,5 as well as ultraviolet-induced local immunosuppression. Finally, the patient concurrently developed infiltrative erythematous nodules on the face and extremities. Biopsy showed septal panniculitis with lymphocytic infiltration without neutrophil infiltration in either dermis or subcutis; however, all of the concurrent lesions were considered to be part of the same spectrum.

Financial support
None declared.

Authors' contributions
Mai Endo: Designed the study; performed the research and contributed to analysis and interpretation of data; wrote the initial draft of the manuscript; read and approved the final version of the manuscript.
Miyuki Yamamoto: Performed the research and contributed to analysis and interpretation of data; read and approved the final version of the manuscript.
Mikio Ohtsuka: Performed the research and contributed to analysis and interpretation of data; read and approved the final version of the manuscript.
Toshiyuki Yamamoto: Designed the study; assisted in the preparation of the manuscript; read and approved the final version of the manuscript.

Dear Editor,
Sebaceous carcinoma (SC) is a rare malignant neoplasm derived from the adnexal epithelium of the sebaceous glands, with a higher incidence in the ocular region, particularly in the eyelid region, and has a potentially aggressive behavior. 1---3 Older age, previous radiotherapy, and association with Muir-Torre syndrome are predisposing conditions. 1---3 ଝ Study conducted at the Department of Infectology, Dermatology, Diagnostic Imaging and Radiotherapy, Faculdade de Medicina, Universidade Estadual Paulista, Campus de Botucatu, SP, Brazil. This is the case report of a 75-year-old white male patient with a history of squamous cell carcinoma (SCC), referred for treatment of facial lesion noted three months before, with rapid growth and bleeding episodes associated with trauma. Upon examination, a 5-cm, rounded, erythematousviolaceous, pre-auricular tumor was observed, with friable and necrotic areas associated with a 1-cm satellite lesion with similar characteristics and a post-SCC excision skin graft scar (Fig. 1). No regional lymph node enlargement was detected. The hypotheses were SCC, SCC metastasis, and angiosarcoma. Histopathological examination (Figs. 2 and 3) showed a dermal neoplasm with polygonal clear cells, evident nuclear pleomorphism, cell debris, and frequent mitoses. Immunohistochemistry disclosed positivity for epithelial markers AE1/AE3 and epithelial membrane antigen (EMA) which, associated with histopathological findings, allowed the diagnosis of sebaceous carcinoma (SC), and