Livedo reticularis (LR) is a unique cutaneous condition characterized by a reddish-blue to purple, net-like cyanosis of the skin, often associated with disturbances in cutaneous blood flow. This case report discusses a 30-year-old woman with a history of Hashimoto thyroiditis, vitamin D deficiency, migraines, and goiter who presents with painful, localized LR on her right flank. Despite her extensive medical history, there were no significant findings in her laboratory and imaging studies, including a normal epidermis in skin biopsies. The LR in this case is distinguished by its persistence and the presence of pain, a symptom not commonly associated with LR. Various treatments, including 5% lidocaine ointment, oral analgesics, and gabapentin, were considered, but her symptoms remained stable over 13 months. This case exemplifies the complexity of LR, particularly when presenting with atypical symptoms like pain. It highlights the need for further research into the pathophysiology and treatment of LR, especially in cases deviating from the typical symptomatology, and suggests the potential value of a multi-disciplinary approach to management.

Reported rates of Merkel cell carcinoma (MCC) recurrence range from 27-77%. Furthermore, the risk of recurrence gradually decreases over time, leading to a tendency to de-escalate surveillance. We present a rare case of a second MCC, which appeared 21 years after the first. This 94-year-old woman presented with a one-month history of a nodule on the left fifth finger. Physical exam showed a 1-cm pink, eroded nodule. She had a history of a stage I MCC of the left nasal wall, 21 years previously. The nasal lesion was a small, skin-colored papule, which was removed by a 2.5-mm punch. The specimen showed a typical MCC histology with clear margins. A wide local excision with forehead flap repair was performed; no evidence of MCC was present in the excisional specimen. Biopsy of the current lesion showed a typical MCC in which there was expansion of the dermis with sheets and nests of small, basophilic cells with nuclear molding and minimal cytoplasm. Apoptotic cells and mitoses were present. Immunohistochemistry was positive for CD56, synaptophysin, and CK20 (perinuclear dotting). Male sex, immune suppression, and advanced age are considered to be non-stage factors for planning surveillance. The highest MCC recurrence rates are within 1-3 years after diagnosis. Although some studies suggest that patients who are free of recurrence 3 years after initial diagnosis may receive de-escalating surveillance, this case emphasizes the possibility of a very late second MCC versus a very late recurrence.

Prolonged wearing of N95 respirator masks has been associated with causing or complicating a number of facial inflammatory dermatoses.• Consider the possibility of contact dermatitis secondary to formaldehyde exposure in individuals wearing N95 masks for prolonged periods.• Information on the chemical components of N95 masks would be useful for clinicians tasked with evaluating patients with facial inflammatory dermatoses.

Background: Neutrophils in the setting of systemic lupus erythematosus (SLE) are commonly associated with bullous disease. Rare cases of nonbullous neutrophilic lesions have been reported in patients with SLE.Objective: This study used clinical and histologic findings of 4 patients to further define the newly emerging entity of nonbullous neutrophilic lupus erythematosus (LE).Methods: We reviewed the clinical and pathological findings of 4 patients with known SLE who developed urticarial papules, plaques, subcutaneous nodules, or a combination of these.Results: All patients were women with established SLE. Histopathological findings in all patients included an interstitial and perivascular neutrophilic infiltrate with leukocytoclasia, and variable vacuolar alteration along the dermoepidermal junction. Direct immunofluorescence study results in two patients were positive for C3, IgG, and IgM along the basement membrane zone. One patient also presented with neutrophil-rich lupus panniculitis. All clinical lesions resolved with immunomodulating/immunosuppressive agents.Limitations: This study was limited by the small number of cases.Conclusions: Nonbullous neutrophilic LE is an important entity to consider in the differential diagnosis of neutrophil-mediated eruptions. In addition, the histologic finding of neutrophils in the setting of lupus should alert one to the possibility of systemic disease. (J Am Acad Dermatol 2012;66:92-7.)