Successfully treatment of penile vitiligo patches and their sexual dysfunction consequences, by suction blister epidermal grafting

hiago Rubim Batista Bellott Nascimento: Design and planing of the study; drafting and editing of the manuscript; ollection, analysis, and interpretation of data; intellectual articipation in the propaedeutic and/or therapeutic conuct of the studied cases; critical review of the literature; ritical review of the manuscript. Flávio Barbosa Luz: Approval of the final version of the anuscript; effective participation in research orientation; ritical review of the manuscript. Rafael Brandão Varella: Approval of the final version of he manuscript; collection, analysis, and interpretation of ata; critical review of the manuscript. Mayra Carrijo Rochael: Approval of the final version of the anuscript; effective participation in research orientation; 3. Becker JC, Kauczok CS, Ugurel S, Eib S, Bröcker EB, Houben R. Merkel cell carcinoma: molecular pathogenesis, clinical features and therapy. J Dtsch Dermatol Ges. 2008;6:709--19. 4. Pang C, Sharma D, Sankar T. Spontaneous regression of Merkel cell carcinoma: A case report and review of the literature. Int J Surg Case Rep. 2015;7:104--8. 5. Walsh NM. Complete spontaneous regression of Merkel cell carcinoma (1986--2016): a 30-year perspective. J Cutan Pathol. 2016;43:1150--4.


Dear Editor,
Vitiligo is a common pigmentary disease with many psychosocial consequences such as sexual dysfunction (SD). In the treatment of refractory vitiligo such as vitiligo lesions in glabrous areas, medical treatment is disappointing. In recent years' surgical interventions such as autologous noncultured melanocyte grafting (ANCMG) and suction blister epidermal grafting (SBEG) were developed for the treatment of stable vitiligo. 1,2 But vitiligo patches on problematic-totreat areas, such as male genital even with this method may be with poor outcomes. 2,3 A 32-year-old male was presented with depigmented patches located on the glans penis and associated SD from 58 and 32 months ago respectively. Laboratory examination, including thyroid, showed no abnormal findings. The patient was married 6 years ago, but 28 months later suffered from SD, because he and his wife feared that vitiligo was contagious. He had been subjected to multiple treat-ଝ Study conducted at the Hajdaie Dermatology Clinic, Kermanshah, Iran. ments including ANCMG by dermatology and Sexual Disorder Center (SDC) but had no appropriate treatment response. New lesions had not developed in the last 12 months.
We suggested SBEG because of problematic-to-treat areas and not responding to previous treatment. Firstly, anesthetized depigmented patches were abraded. The anterolateral of the leg consider a donor site and used funnel cylinder technique 3 is in order to harvest grafts. The harvested blister was detached; was then located over the recipient site.
We recommended partial bed rest for 7 days, being very careful when using the toilet, and avoidance of situations that induce penile erection. Complete repigmentation was achieved without any complication after 3 months (Figs.
For the management of SD, we referred the patient to SDC. After 12 months, he presented with persistent repigmentation, improvement of SD and pregnancy of his wife.
Sukan and co-workers 4 demonstrated that chronic skin diseases such as vitiligo have undesirable influences on sexual activity. But other studies showed the presence or absence of genital vitiligo patches had not different effects on sexual functions. 5 It seems in our patient, SD was consequence of vitiligo, because of was absent of no abnormality finding throughout evaluations at SDC and was induced SD prior to vitiligo.
In limited studies with a few cases of genital vitiligo, that were treated by ANCMG, poor to good repigmentation outcome was obtained. 1,3  We believe that the failure of surgical interventions in male genital is related to its mobility, change in size, erection, susceptibility to infection and care, especially during the toilet.

LETTER -CLINICAL
SBEG is an efficient method for the management of limited, stable, and resistant vitiligo with variable treatment results. 2,3 In the SBEG method, fixation of recipient sites is very important in order to achieve an optimal outcome. 2 It is very difficult to keep male genital in an immobility state.
In the literature review, our patient is the first case, that successfully improved both vitiligo patches and SD through SBEG. We suggest SBEG in stable vitiligo patches on male genital with its SD consequence.
This case report was approved by the Ethics Committee of Kermanshah University of Medical Sciences. The patient signed informed consent.

Financial support
None declared.

Authors' contributions
Mahmoudreza Moradi: Study conception and planning; critical literature review.
Hossein Kavoussi: Approval of the final version of the manuscript; effective participation in research orientation; study conception and planning; manuscript critical review.
Reza Kavoussi: Intellectual participation in propaedeutic and/or therapeutic management of studied cases; preparation and writing of the manuscript. Unilateral linear syringoma on the right chest and arm ଝ

Dear Editor,
A 25-year-old man presented to the dermatology department with an 8-year history of yellowish-brown skin lesions on his right chest, axilla, and arm. The lesions first appeared on the right chest and increased in number and size gradually, showing a linear distribution, with no pain or itching. He was otherwise healthy with no other special medical history. Physical examination revealed a yellowish-brown firm, smooth papules and plaques on his right chest, axilla, and arm, ranging from 1 to 10 mm in diameter (Figs. 1---4).
The distribution of the lesions followed Blaschko's lines.
Histopathology showed multiple small tubules, cysts, and nests forming by epithelial proliferation, with some of them morphologically like a comma or a tadpole, in the superficial dermis (Fig. 5). A diagnosis of sporadic linear syringoma was made. As it is a benign disease with no malignant potential, the patient has been followed up regularly without any treatment.

Discussion
Syringoma is a benign neoplasm that derives from eccrine sweat gland ducts. The typical clinical manifestation is single or multiple skin-color or yellowish papules on the lower eyelid, 1 to 3 mm in size. Friedman and Butler classified syringoma into 4 clinical variants: generalized forms, localized forms, familial forms and variants associated with Down's syndrome. 1