A 42-year-old man presented with slowly progressive asymptomatic red plaques on the left foot which developed over 4 years. He was treated by topical corticosteroids with minimal improvement. He had no weight loss, prolonged fever, or night sweat. There was no family history of similar lesions. He had a 7-year history of type 2 diabetes mellitus which was treated with oral metformin and insulin injections. He had undergone amputation of the 1st, 2nd, and 3rd toe of the left foot due to neuropathic arthropathy 5 years earlier.\nPhysical examination revealed two discrete, well-defined, moist, macerated, erythematous, verrucous plaques on a background of diffuse red-brown discoloration on the left foot (fig. , fig. ). Peripheral arterial pulses on both legs were normal and regular. There was no fever, lymphadenopathy, or hepatosplenomegaly. Other physical examinations were within normal limits. A 4-mm punch biopsy specimen was obtained from the lesion for routine histological examination.\nHistopathological results showed multiple foci of thin anastomosing strands of uniform cuboidal cells emanating from the epidermis. The epithelial strands showed ductal differentiation, embedded within fibrovascular stroma (fig. , fig. ). Doppler ultrasound of the left leg showed evidence of severe degree of venous reflux involving the left saphenofemoral junction and common femoral vein.\nIn this case, a complete excision with flap or graft was offered but the patient refused surgery. He was treated with monthly cryotherapy using liquid nitrogen spray and attended follow-ups with surveillance for malignant change. Venous stripping was performed as the treatment for severe venous reflux, which resulted in partial improvement of the lesion.
Female patient, 41 years old, of mixed race, from Tremedal, Bahia, came to the\ndermatology ambulatory reporting that since birth she had not had hair anywhere in\nher body besides nail dystrophy and palmoplantar hyperkeratosis ( and ). She denied previous history of cutaneous neoplasms, dental\nabnormalities, intolerance to heat or other significant medical problems and also\ninformed that two of her siblings presented similar symptoms.\nShe reports that for 10 years coalescent papules and nodules of pinkish color,\nverrucous aspect appeared on her feet and hands, growing in number and size with\ntime. She denied pain, burning sensation or bleeding at the site of the cutaneous\nlesions.\nDuring physical examination the presence of coalescent pinkish papules was noticed,\nforming plaques with cobblestone aspect on the feet, besides alopecia and nail\ndystrophy. Laboratory exams were normal. The possible differential diagnoses of\ncutaneous lesions included diffuse eccrine poromatosis, plane warts, Clouston\nSyndrome, pachyonychia congenita and other forms of ectodermal dysplasias ().\nAn incisional biopsy of the right foot lesion was performed, which revealed thin\ncords of anastomosed epithelial cells in continuity with the epidermis. The cords\nwere composed of round and oval nucleated cells. Luminal structures which varied in\nsize were also found, whose walls contained a single layer of cells. These findings\nwere compatible with the diagnosis of ESFA (. PCR for HPV 10 was negative.