Chloracne with acantholytic dyskeratosis associated with herbicides: a new histological variant?

Chloracne with acantholytic dyskeratosis associated with herbicides: A new histological variant? To the Editor: Chloracne was first identified by Herxheimer1 in 1889. It is characterized by noninflammatory keratinization of pilosebaceous units with comedones and dilated infundibulum after exposure to aromatic chlorinated hydrocarbons of various structures.2 However, no report has been issued on chloracne showing Darier-like changes. We report an unusual case of chloracne associated with herbicides in the Vietnam War, which showed typical noninflammatory comedones and Darier-like changes, ie, acantholytic dyskeratosis and corps ronds. A 56-year-old Korean man was referred to the Department of Dermatology, Yonsei University College of Medicine, complaining of multiple blackhead comedones on the scalp, preauricular and retroauricular areas, chest, and back over a 10-year period. He had been exposed to herbicides during the Vietnam War and has not been exposed to other comedogenic agents such as oil, tars, waxes, and halogenated phenols. His familial and occupational histories were not contributory. A physical examination revealed multiple, 3-5 mm comedones filled with keratotic plugs (Fig 1). His hair, nails, and mucous membranes were normal. The histology of 5 biopsy specimens from papules on the scalp, preauricular and retroauricular areas, chest, and back showed the similar feature of a cup-shaped, dilated hair follicle with a central keratotic plug (Fig 2, A). In the lower part of the follicular wall, split at a suprabasal level with upward projection of the dermal papilla, so-called villi and acantholytic cells, and a large number of corps ronds were observed. In the lower dermis, there were sparse inflammatory cells (Fig 2, B). Many treatment methods had been tried in other clinics, including acne extraction and various kinds of topical and systemic acne medications (including antibiotics and retinoids). However, no improvement had occurred and he refused further treatment. Chloracne caused by herbicides can be diagnosed after considering the following points3: 1. A history of exposure to herbicides 2. Typical acneiform eruption and predilection sites: preauricular and retroauricular areas, scrotum, and involvement of the meibomian glands

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3. Histological features: noninflammatory comedone and dilated infundibulum of the pilosebaceous unit 4. No response to conventional acne treatment Acantholytic dyskeratosis is a typical finding in Darier’s disease, but it is also found in a variety of clinical conditions such as warty dyskeratoma, transient acantholytic dermatosis, and familial dyskeratotic comedones. Hayakawa and Nagashima4 reported a 72-year-old patient who developed comedonal papules on the scalp, which showed acantholytic dyskeratosis, and Nakagawa et al5 also reported comedo-like acantholytic dyskeratosis of the face and scalp. Therefore, we consider that chloracne related to herbicide exposure may show acantholytic dyskeratosis, but the mechanism of acantholytic dyskeratosis is unclear. Sanghoon Lee, MDa Sang Gun Park, MDb Min-Geol Lee, MD, PhDb Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju,a and Department of Dermatology and Cutaneous Biology Research Institute,b Yonsei University College of Medicine, BK21 Project for Medical Science, Yonsei University, Seoul, Korea Reprint requests: Min-Geol Lee, MD, PhD, Department of Dermatology, Yonsei University College of Medicine, 134 Shinchon-Dong, Seodaemoon-Gu, Seoul 120-752, Korea E-mail: mglee@yumc. yonsei.ac.kr REFERENCES 1. Herxheimer K. Uber Chlorakne. Munch Med Wochenschr 1899; 46:278. 2. Coenraads PJ, Brouwer A, Olie K, Tang N. Chloracne. Some recent issues. Dermatol Clin 1994;12:569-76. 3. Tindall JP. Chloracne and chloracnegens. J Am Acad Dermatol 1985;13:539-58. 4. Hayakawa K, Nagashima M. A rare presentation of acantholytic dyskeratosis. Br J Dermatol 1995;133:487-9. 5. Nakagawa T, Masada M, Moriue T, Takaiwa T. Comedo-like dyskeratosis of the face and scalp: a new entity? Br J Dermatol 2000; 142:1047-8.

Published online J Am Acad Dermatol 2004;50:e8 0190-9622/$30.00 © 2004 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2003.09.029

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Fig 1. Scattered skin-colored, keratotic papules on the malar crescent, scalp (A) and postauricular area (B).

Fig 2. A, Biopsy specimens from the comedonal papules of the scalp, face, and back have similar features, showing deep epidermal invagination with a large central keratotic plug and rare inflammatory cell infiltrate in the dermis. B, Acantholytic epidermal cell separation is shown with upward projection of dermal papillae at a suprabasal level, and a large number of corps ronds are present above the split. (A and B, Hematoxylin-eosin stain; original magnifications: A, ⫻40; B, ⫻100.)