ABSTRACT:We report an unusual case of metastatic syringocystadenocarcinoma papilliferum in an 18-year-old man who presented with cervical lymph node metastasis initially diagnosed as dedifferentiated squamous cell carcinoma of unknown primary. Extensive diagnostic workup failed to identify a primary tumor, until reexcision of a childhood scalp lesion revealed a deeply infiltrative adnexal neoplasm with ductal differentiation consistent with syringocystadenocarcinoma papilliferum, and comparison of the lymph node specimens with the scalp specimen showed cytological similarities. This case emphasizes that the working diagnosis should be questioned by the pathologist and the clinician when clinical characteristics do not seem to fit. It furthermore highlights the importance of the inclusion of prior pathology specimens into the pathological workup, and careful evaluation for ductal differentiation in atypical squamous cell carcinoma presentations.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic inflammatory condition associated with significant morbidity. While established treatments such as functional endoscopic sinus surgery (FESS) and biologic therapy have demonstrated efficacy, they come with limitations, including cost, accessibility, and patient adherence. Growing evidence suggests that dietary factors, particularly arachidonic acid and salicylic acid, influence inflammatory pathways relevant to CRSwNP, yet real-world data on dietary interventions remain scarce. This retrospective study evaluates the mid-term effects of a structured dietary intervention in patients with CRSwNP who were either unwilling to undergo FESS or biologic therapy. The outcomes were compared to those of patients receiving either FESS or dupilumab. The dietary intervention was based on the avoidance of arachidonic acid and salicylates, an increase in fiber-rich foods, and the exclusion of nonsteroidal anti-inflammatory drugs. A total of 45 patients (mean age 46.5 ± 14.1 years; 25 female and 20 male) were included, with 15 undergoing dietary intervention, 15 FESS, and 15 dupilumab therapy. Disease burden was assessed using the sino-nasal outcome test (SNOT-22), visual analog scale, endoscopy scoring, and the brief smell identification test at baseline and follow-ups at 3 and 6 months. Patients undergoing dietary intervention experienced significant symptom improvement, although the response was less pronounced compared to FESS or dupilumab. At 6 months, mean SNOT-22 scores improved from 69.8 to 19.7 (FESS), 58.0 to 16.1 (dupilumab), and 39.5 to 24.2 (dietary intervention). visual analog scale scores showed a similar trend, decreasing from 8.4 to 2.9 (FESS), 8.1 to 2.2 (dupilumab), and 5.6 to 3.5 (dietary). While objective olfactory scores (brief smell identification test) improved in all groups, it was less pronounced in the dietary intervention group. Notably, patients in the dietary intervention group reported continued adherence and tolerability of the intervention. Dietary intervention may serve as a viable adjunct for CRSwNP patients who are unable or unwilling to undergo surgery or biologics. Despite lower efficacy, its safety and accessibility merit further investigation.

Journal of the European Academy of Dermatology and VenereologyAccepted Articles LETTER TO THE EDITOR High-dose intravenous immunoglobulin co-treatment prolongs time-to-treatment escalation in autoimmune bullous diseases: a monocentric retrospective cohort study M. Bertlich, M. Bertlich University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany University Hospital Bonn, Department of Dermatology, Bonn, Germany both authors contributed equallySearch for more papers by this authorI. Bertlich, I. Bertlich University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany both authors contributed equallySearch for more papers by this authorN. Plümacher, N. Plümacher University of Kassel, Department of Electrical Engineering and Computer Science, Kassel, GermanySearch for more papers by this authorE. Hadaschik, E. Hadaschik University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany University of Duisburg-Essen, Department of Dermatology, Essen, GermanySearch for more papers by this authorA. Enk, A. Enk University Hospital Heidelberg, Department of Dermatology, Heidelberg, GermanySearch for more papers by this authorJ. H. O. Hoffmann, Corresponding Author J. H. O. Hoffmann [email protected] orcid.org/0000-0003-1579-626X University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany Correspondence Prof. Dr. med. Jochen Hoffmann, Hautklinik Heidelberg, INF 440, 69120 Heidelberg, Germany. Email: [email protected], Phone: +49 6221 56 8511Search for more papers by this author M. Bertlich, M. Bertlich University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany University Hospital Bonn, Department of Dermatology, Bonn, Germany both authors contributed equallySearch for more papers by this authorI. Bertlich, I. Bertlich University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany both authors contributed equallySearch for more papers by this authorN. Plümacher, N. Plümacher University of Kassel, Department of Electrical Engineering and Computer Science, Kassel, GermanySearch for more papers by this authorE. Hadaschik, E. Hadaschik University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany University of Duisburg-Essen, Department of Dermatology, Essen, GermanySearch for more papers by this authorA. Enk, A. Enk University Hospital Heidelberg, Department of Dermatology, Heidelberg, GermanySearch for more papers by this authorJ. H. O. Hoffmann, Corresponding Author J. H. O. Hoffmann [email protected] orcid.org/0000-0003-1579-626X University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany Correspondence Prof. Dr. med. Jochen Hoffmann, Hautklinik Heidelberg, INF 440, 69120 Heidelberg, Germany. Email: [email protected], Phone: +49 6221 56 8511Search for more papers by this author First published: 18 August 2023 https://doi.org/10.1111/jdv.19437 This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/jdv.19437. AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat Accepted ArticlesAccepted, unedited articles published online and citable. The final edited and typeset version of record will appear in the future. RelatedInformation

A 46-year-old patient presented at our clinic with erythematous papules that had developed on both legs 2 years ago and had subsequently extended across the whole body.Over time, he developed thickening and tenseness of the skin in the face, loss of eyelashes, rarefication of eyebrows, ectropion, insufficiency of eye closure and restricted mouth opening (Figure 1).Furthermore, he had been diagnosed with a dialysis-dependent renal insufficiency, AV-block, malignant hypertension, glaucoma, and a monoclonal gammopathy type kappa.We suspected a sclerosing disease and performed skin biopsies in different affected areas.These showed abundant mucin deposition, but also extensive epithelial proliferates in all specimens (Figure 2a-h).The proliferations consisted of basosquamous cell complexes, showed primitive (Figure 2a-d) and infundibular (Figure 2e-h) follicular differentiation and were surrounded by significant fibrosis (Figure 2g,h). 1 We classified these proliferations as a secondary phenomenon of a deposition disease and diagnosed scleromyxedema with atypical histopathological presentation.In the following years, the patient developed multiple skin-colored papules on the head, trunk, and extremities (Figure 3).Some turned out to be conventional

Background Botulinumtoxin application in the face is amongst the most common aesthetic procedures in the head and neck region. It also has numerous medical uses. One of the main reasons for patients to refrain from it is the subjective discomfort that is experienced during injections. Objectives The study at hand aimed to determine whether needles with 33G and 34G offer an advantage in terms of individual pain perception during botulinumtoxin injections. Methods We conducted a prospective study where patients were asked to grade subjective discomfort on a visual analogue scale for each region (forehead, glabella, temple) that was treated directly after treatment and 15 minutes after. Patients were treated with 30G, 33G or 34G needles, respectively. Results Ninety-nine patients that underwent treatment of 189 regions were included in the study. Patients were evenly distributed amongst the different needle sizes and regions. Subjective discomfort was greatest in all regions for 30G needles (3.9 ± 1.6 forehead, 4.3 ± 1.7 glabella and 4.0 ± 1.6 temple) followed by 33G (2.7 ± 1.5 forehead, 2.7 ± 1.9 glabella and 2.2 ± 1.2 temple) and 34G (1.7 ± 1.2 forehead, 1.6 ± 1.4 glabella and 1.6 ± 1.4 temple). All differences between needle size were statistically significant ( p < 0.05) Conclusion 33G and 34G needles seem to offer smaller discomfort during BTX treatments of the head and neck, with 34G being superior to 33G. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266

INTRODUCTION:Systemic hypersensitivity to hymenoptera species venom is the most common cause for anaphylaxis in adults. Due to similarities between hornet (Vespa crabro) and wasp (Vespula spp.) venom, patients with hornet venom anaphylaxis are often treated similarly to wasp-allergic patients. However, comparative data are scarce. This study aimed to analyze differences and similarities between these two groups. METHODS:A retrospective analysis with 42 patients with certain anaphylaxis to hornet venom was conducted. These were matched for age, gender, and CAP class with 42 patients with wasp venom anaphylaxis. Clinical outcomes and treatment adherence were compared. RESULTS:Patients with hornet venom anaphylaxis showed a significantly higher degree of anaphylaxis (21 vs. 9 patients with grade III/IV anaphylaxis, p < 0.001), despite similar tryptase levels (6.3 ± 8.3 vs. 5.1 ± 4.2) or presence of mastocytosis (2 vs. 3). These patients also showed significantly lower therapy adherence, resulting in fewer patients undergoing specific immune therapy (29 vs. 37, p = 0.030) or sting challenges (14 vs. 27, p = 0.046). Both groups showed high efficacy of specific immunotherapy with wasp venom extract. CONCLUSION:Hornet stings induce more severe anaphylaxis, while patients with hornet venom allergies demonstrate lower treatment compliance, likely due to inadequate education. Specific immunotherapy with wasp venom extract remains effective for both.

Background: Cutaneous B-cell lymphoma (CBCL) is part of dermatopathological routine diagnostics. However, in contrast to cutaneous T-cell lymphomas, there are only a few studies on the prevalence and possible clinical impact of lymphatic vessel involvement. Therefore, this pilot study aimed to quantify the prevalence of lymphovascular involvement in CBCL and to assess the association between lymphovascular involvement and recurrence.Methods: Thirty-nine patients from two tertiary care hospitals diagnosed with CBCL were retrospectively identified and their biopsies were histopathologically examined for the presence of lymphatic vessel involvement using H&E stain, and CD20 and D2-40 immunohistochemistry. Clinical data were retrieved from our digital documentation files.Results: Thirty patients were included in the evaluation (n(PCFCL) = 15, n(PCMZL) = 10, and n(PCLBCL) = 5). Lymphovascular involvement occurred in all three types of lymphoma and was present in 14/30 specimens. The presence of lymphatic involvement did not show a significant impact on recurrence rate (p = 0.150).Conclusions: This immunohistochemical pilot study shows that lymphovascular involvement is a relatively frequent finding in primary CBCL. Although no definitive conclusion can be drawn from our findings because of the small sample size, there were no strong signs of tendencies for recurrence in either group. Future studies with larger sample size are warranted to assess the possible clinical implications.