Fig 2. Immunohistochemical study of EBV-induced lin-gual papule for CD20 (original magnification 340); CD30(3200) and Epstein-Barr virus (immunohistochemistry forLMP-1) (3400) showed intense positivity in activatedlymphocytes.

Fig 1. EBV-induced lingual papule. A pedicled lesion withtwo small whitish ulcerations at its base on posterolateralsurface of the tongue.

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EBV is transmitted via the saliva. The target withinthe mouth is the oral lymphoid tissue B cells. Oncethe B cells are infected, proliferation takes place inthe germinal centers3 with later dissemination.

We are unaware of any previous reports of apedicled tumor at the tongue as the manifestation ofinfectious mononucleosis, though the pathologicalchanges of EBV in our patient were identical to thosedescribed in involvement of the palatine tonsils bythis virus.4 This is to be expected, given that thelingual tonsil forms part of Waldeyer’s tonsillar ring,where the EBV enters the organism and startsreplicating.

Pathologically, the differential diagnosis includeslymphoproliferative processes (high-grade B lym-phoma or Hodgkin’s lymphoma). From a clinical

point of view, it must be differentiated from certainpapillomatous lesions secondary to humanpapillomavirus infection, traumatic fibromas, Abrikossoff’s tu-mor, exophytic epidermoid carcinomas, pyogenicgranuloma, and sialadenoma papilliferum.5

Leticia Sempau, MD,a Luis Miguel Valladares, MD,a

Jes�us Lomas-Garc�ıa, MD,b Nieves Alonso-Orcajo,MD,b Jos�e Mar�ıa Garc�ıa Ruiz de Morales, MD,PhD,c and Manuel �Angel Rodr�ıguez-Prieto, MDa

Departments of Dermatology,a Pathology,b andImmunology,c Complejo Asistencial Universitariode Le�on, Altos de Nava SN, 24071 Le�on, Spain

Funding sources: None.

Conflicts of interest: None declared.

Correspondence to: Leticia Sempau, MD, Depart-ment of Dermatology, Complejo Asistencial deLe�on, Altos de Nava SN, 24071 Le�on, Spain

E-mail: leticiasempau@gmail.com

REFERENCES

1. Mendoza N, Diamantis M, Arora A, Bartlett B, Gewirtzman A,

Tremaine AM, et al. Mucocutaneous manifestations of

Epstein-Barr virus infection. Am J Clin Dermatol 2008;9:

295-305.

2. Ebell MH. Epstein-Barr virus infectious mononucleosis. Am Fam

Physician 2004;70:1279-87.

3. Macsween KF, Crawford DH. Epstein-Barr virus-recent advances.

Lancet Infect Dis 2003;3:131-40.

4. Kutok JL, Wang F. Spectrum of Epstein-Barr ViruseAssociated

Diseases. Annu Rev Pathol Mech Dis 2006;1:375-404.

5. Wood NK, Goaz PW, editors. Maxillo-differential diagnosis of

oral and maxillofacial lesions. Philadelphia: Mosby-Year Book,

Inc; 1997.

http://dx.doi.org/10.1016/j.jaad.2011.09.020

Alopecia-associated pseudocyst of the scalp

To the Editor: Pseudocyst of the scalp is a rarelydescribed condition that has only been reported inthe Japanese and European literature. The author hasdocumented 11 cases observed over the last 10 years(Table I), two of which are detailed below.

A 19-year-old man presented for the first timewitha 2-week history of a tender and tense slightlyerythematous cystic swelling at the vertex (Fig 1).He noted hair loss at the onset of the swelling. Abacterial culture of the slightly viscous yellow fluidaspirated was sterile. The cyst was treated withintralesional triamcinolone acetonide (2.5 mg/mL)and the swelling resolved after 2 days. Early hairgrowth was noted 5 weeks later without any evi-dence of scarring.

Fig 1. Alopecia-associated pseudocyst of the scalp.

Table I. Demographics and clinical features of patients

Case No. Age, y Race/ethnicity Sex Site No/size (cm) of cysts Onset before visit, wk No. of occurrences*

1y,z 24 Hispanic M Vertex 1/4 4 32 22 White M Vertex 1/3 1 13 24 Black M Vertex 1/2.5 4 24y 18 White M Occiput 1/2 1 25x 32 Asian M Vertex 1/2.5 4 16x 16 Arabic M Vertex 2/3 4 47x 22 Arabic F Vertex 1/2.5 6 18 48 White F Vertex 1/2.5 8 19 19 White M Vertex 1/2 8 110z 40 Black M Vertex 1/2 4 411 28 White F Vertex 1/2 12 2

F, Female; M, male.

*All patients (except patient 11, who received no treatment) were treated only with intralesional triamcinolone acetonide 2.5 mg/mL, except

patient 1 who also received courses of tetracycline and cephalexin. Recurrences occurred in same area of scalp. Not all occurrences were

treated; some resolved spontaneously. Complete hair regrowth was documented in 8 of 11 patients; 3 patients were unavailable for

follow-up.yHistory of alopecia areata.zResolved by self-induced rupture on occasion.xAssociated with acne.

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A 16-year-old boy presented with a 1-monthhistory of hair loss in a localized area of swelling atthe vertex. He declined treatment and showedspontaneous improvement with some hair growthnoted when he was seen again 1 month later. Hereturned 3 years later with two adjacent and nearlyconfluent areas of cystic swelling with overlying hairloss at the vertex. He noted that the hair came outeasily after the appearance of the cysts. The cystscleared after two consecutive monthly treatmentswith intralesional triamcinolone acetonide (2.5mg/mL) and there was complete hair regrowth. Hehad two similar episodes during the next 2 years andeach resolved spontaneously within 1 month. He hasbeen free from recurrences for the last 2 years.

The original report in the Japanese literaturedescribed 19 cases of pseudocysts and associatedalopecia.1 Pathology was obtained in 9 cases by

complete excision, and the histology showed cysticcavities without a wall structure located in themiddleand papillary dermis surrounded by inflammatorygranulation tissue. Subsequently, 29 additional caseswere described in the Japanese, French, andEuropean English-language literature.2-5

The 11 cases reported here (Table I) presentedwith alopecic cysts inmostly young healthymen. Thecysts showed surface erythema and a few residualvellus-like hairs, and were either firm or soft andfluctuant. The hair loss was noted as the cyst began toform, and tenderness occurred with increasing cystsize. Patients responded quickly in almost all cases tointralesional triamcinolone acetonide (2.5 mg/mL),patients healed without any evidence of scarring,and hair growth was noted within 2 months oftreatment. Most cases presented as isolated eventsbut with a tendency to relapse. Cultures were sterile,confirming previous observations.1-5 It is importantto note that once the swelling resolved, the appear-ance closely resembled alopecia areata.

The rapid response to intralesional corticosteroid,and spontaneous resolution after self-induced rup-ture in some cases, suggest a mild inflammatoryprocess. Future investigations with biopsies per-formed at the onset of inflammation, and a chemicalanalysis of the cyst contents, might provide addi-tional clues to the pathogenesis. Because this condi-tion is not well recognized, it may be misdiagnosedas alopecia areata, pilar or acne cysts, or dissectingcellulitis. It is suspected that it is far more commonthan the literature suggests.

Fig 1. Toxic erythema of chemotherapy. Right hand aftertreatment with potent topical steroids for 2 weeks, lefthand untreated.

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SEPTEMBER 2012e116 Letters

Eric L. Eisenberg, MD, FRCPC

Division of Dermatology, Toronto Western Hospi-tal, University Health Network, University ofToronto, Ontario, Canada

Funding sources: None.

Conflicts of interest: None declared.

Correspondence to: Eric L. Eisenberg, MD, FRCPC,3420 Hurontario St, Suite 206, Mississauga,Ontario, Canada L5B 4A9

E-mail: eric.eisenberg@utoronto.ca

REFERENCES

1. Iwata T, Hashimoto T, Niimura M. A pseudocyst with inflam-

matory granulation tissue on the scalpepseudocyst of the

scalp. Rinsho Derma (Tokyo) 1992;46:9-16.

2. Abdennader S, Vignon-Pennamen MD, Hatchuel J, Reygagne P.

Alopecic and aseptic nodules of the scalp ( pseudocyst of the

scalp): a prospective clinicopathological study of 15 cases.

Dermatology 2011;222:31-5.

3. Tsuruta D, Hayashi A, Kobayashi H, Nakagawa K, Furukawa M,

Ishii M. Pseudocyst of the scalp. Dermatology 2005;210:333-5.

4. Abdennader S, Reygagne P. Alopecic and aseptic nodules of

the scalp. Dermatology 2009;218:86.

5. Tsuruta D. Reply [letter]. Dermatology 2009;218:87.

http://dx.doi.org/10.1016/j.jaad.2011.09.028

Chemotherapy-induced acral erythemasparing the palms

To the Editor: Jean Bolognia et al1 have suggestedthat the variously named cutaneous eruptions result-ing from toxic insult caused by high-dose chemo-therapy share a new clinical term: ‘‘toxic erythema ofchemotherapy.’’ Although proposing a further clin-ical term rarely provides resolution for the problemof conditions having too many names, ‘‘toxic ery-thema of chemotherapy’’ is, indeed, useful. In sup-port of this proposal, we present a case where thecause is clearly chemotherapy toxicity but the clinicalpresentation differs from the classic descriptions ofchemotherapy-induced acral erythema.

A 63-year-old Russian woman with stage IVadeno-carcinoma of the breast, who completed 6 treatmentsof paclitaxel (140mg) administeredweekly, presentedwith a pruritic and painful eruption on the back of herhands, beginning after her secondpaclitaxel treatment2 months earlier and progressing with subsequenttreatments. On physical examination, the skin overly-ing her metacarpal-phalangeal joints and to a lesserextent her interphalangeal joints had moderately ill-defined smooth slightly violaceous and erythematousedematous thinplaques (Fig 1).Herproximalnailfoldswere edematous and had telangiectases and ruffledcuticles. This eruption spared her palms and

palpebrae. The proximal and distal muscle strengthwas normal. The distribution and slightly violaceouscolor of the eruption along with the cuticle involve-ment supported a diagnosis of dermatomyositis-likedrug eruption. Complete sparing of the palms madechemotherapy-induced acral erythema less likely.

Punch biopsy specimens revealed moderate com-pact orthokeratosis, moderate to marked mostlyregular epidermal hyperplasia, pallor of all layersof the epidermis, several dyskeratotic keratinocytes,several atypical mitotic figures within the basal layer,diffuse mild basal vacuolization, and a moderatesuperficial perivascular lymphocytic infiltrate focallyobscuring the dermoepidermal junction. These find-ings were characteristic of chemotherapy-inducedacral erythema. Of her recent medications, onlypaclitaxel frequently associates with chemotherapy-induced acral erythema.

Discontinuation of the inciting agent is thepreferable treatment for toxic erythema of chemo-therapy; palliative treatments include topical corti-costeroids and emollients.1,2 Oral pyridoxine,3

cyclo-oxygenase-2 inhibitors,4 and local vasocon-strictive therapy via skin cooling5 have also showedefficacy. In the aforementioned patient, in additionto paclitaxel discontinuation, high-potency topicalcorticosteroids significantly decreased the durationof this eruption. She applied clobetasol propionateointment to her right hand for 2 weeks, with im-provement compared with her untreated left hand(Fig 1). The eruption markedly improved in 1 monthwith clobetasol propionate ointment use twice dailyon both hands, at which point the patient was lost tofollow-up; however, her oncologist has not notedrecrudescence. High-potency topical steroids likelyoffer both symptomatic improvement and decreasedtime to resolution.

Although the clinical presentation initially favoreddermatomyositis-like drug eruption, the histologic