J AM ACAD DERMATOL Letters 165

VOLUME 61, NUMBER 1

hepatitis C, gonorrhea, and chlamydia. The patient

received the following medications without improve-
ment: doxycycline, ceftriaxone, valtrex, and kenalog.
Upon further questioning, the patient explained
that the ulcers completely resolved when he stopped
his antiretroviral medications after being released
from jail. This created suspicion for medication-
induced genital ulcers.
The physical examination revealed several slightly
erythematous ulcers, up to 2.5 cm in diameter, on the
shaft and glans of the penis. Inguinal lymphadenop-
athy was appreciated, but no other oral or cutaneous Fig 1. Epidermal ulceration and a dense dermal infiltrate.
lesions were present. Biopsies from the ulcers (Hematoxylineeosin stain; original magnification: 320.)
showed an epidermal ulceration with associated
spongiosis and a dense mixed dermal infiltrate (Fig discontinuation of his antiretroviral medications.
1). No viral cytopathic changes were present, and Antiretroviral medications should be considered as
WarthineStarry, Gram, periodic acideSchiff, and a possible cause of genital ulceration in HIV patients
Giemsa stains did not reveal fungal or bacterial on HAART after a complete infectious, neoplastic,
elements. Cultures for HSV were negative. and inflammatory/rheumatologic workup has been
The patient had taken tenofovir, abacavir, lam- done.
ivudine, atazanavir, and ritonavir during the treat-
Rebecca S. Adler, BS,a Debra A. D’Aquilante, MD,b
ment of his HIV infection. Drug-induced ulcerations
and Carrie L. Kovarik, MDc
were suspected and his antiretroviral medications
were discontinued in July 2007, with complete heal- University of Pennsylvania School of Medicine,a the
ing of the ulcers by August 2007. The patient had Regional Infectious Disease Clinic, Prison Health
been on two HAART regimens in the past, both of Services,b and the Departments of Dermatology
which resulted in ulcers. Medications in common to and Internal Medicine, Division of Infectious
both regimens were ritonavir and lamivudine. The Diseases, University of Pennsylvania,c Philadel-
patient remained stable on no antiretroviral medica- phia, Pennsylvania
tions with a CD4 above 900 and a viral load less than
Funding sources: None.
300.
Since the introduction of HAART, cutaneous drug Conflicts of interest: None declared.
reactions have been reported with all antiretroviral
Reprint requests: Carrie L. Kovarik, MD, Assistant
medications; however, only zalcitabine, nevirapine,
Professor, Department of Dermatology, Univer-
and saquinavir have been described as causing
sity of Pennsylvania, 3600 Spruce St, 2 Maloney
mucocutaneous ulcerations. These ulcerations may
Bldg, Philadelphia, PA 19130
occur even months after initiation of therapy, typi-
cally resolve after cessation, and recur on rechal- E-mail: carrie.kovarik@uphs.upenn.edu
lenge.1-3
With the extensive, variable list of HAART-asso- REFERENCES
ciated cutaneous drug reactions, it is probable that 1. Martins C. Cutaneous drug reactions associated with newer
antiretroviral agents. J Drugs Dermatol 2006;5:976-82.
more than those reported have a risk of genital
2. Heller HM. Adverse cutaneous drug reactions in patients with
ulceration. Our patient developed recurrent painful human immunodeficiency virus-1 infection. Clin Dermatol
genital ulcerations on two HAART regimens, both of 2000;18:485-9.
which included ritonavir and lamivudine. Although 3. Scully C, Diz Dios P. Orofacial effects of antiretroviral therapies.
these medications are known to cause a wide spec- Oral Dis 2001;7:205-10.
trum of skin manifestations, neither of these medi-
doi:10.1016/j.jaad.2008.09.058
cations have been previously described as causing
persistent genital ulcerations.
Elucidating the time course of therapy is critical in Syphilis mimicking tinea imbricata and
the diagnosis of medication-induced genital ulcera- erythema annulare centrifugum in an
tion. This patient had virtually no improvement immunocompromised patient
while being treated with various antiviral and im- To the Editor: A 24-year-old HIV-positive African
mune-modifying therapies while taking HAART, but American transgender female presented to our clinic
had complete resolution of his penile ulcers upon with a 5-month history of a scaly and mildly pruritic
166 Letters
Fig 1. Annular, gyrate, mildly erythematous scaling pla-
ques on the left cheek.
rash on her left cheek that had spread to include her
bilateral cheeks and the dorsal surface of her nose
(Fig 1). Her medical history was significant for
Treacher Collins syndrome, gender identity disorder,
and HIV/AIDS, which had been diagnosed in 2004.
Before the onset of the rash, she reported a 2-month
period of noncompliance with her antiretroviral
medications. Her last CD4 count, drawn 2 weeks
before presentation, was 150. The patient denied
constitutional or other focal symptoms during the 5-
month course of disease. The patient denied travel
outside of the United States, but reported intimate
contact with one partner from Central America. She
denied contact with individuals who have had sim-
ilar disease features.
On physical examination, the patient appeared
healthy with facial dysmorphology consistent with
Treacher Collins syndrome. There were numerous
annular, gyrate, mildly erythematous, scaling rings
distributed bilaterally and symmetrically on the
cheeks and the dorsal surface of her nose. There
was no evidence of additional mucosal or cutaneous
lesions. A clinical diagnosis of tinea imbricata was
made, and the patient received a 3-week course of
terbinafine 250 mg daily.
Upon returning to the clinic 3 weeks after her
initial visit, the patient’s rash had extended to include
the forehead, eyelids, and chin. She also presented
with a few hyperpigmented macules on her bilateral
palms, and erythematous, indurated, annular pla-
ques with a notable rim of trailing scale on her
occipital scalp, posterior neck, and superior back
(Fig 2). A similar plaque was noted on her left
anterior shin. These plaques closely resembled the
superficial form of erythema annulare centrifugum.
The scalp was notable for a few poorly demarcated,
alopecic, nonscaling patches. A 3-mm punch biopsy
was obtained from the patient’s configurate pat-
terned facial rash, and a 4-mm punch biopsy was
obtained from the patient’s upper back.
J AM ACAD DERMATOL
JULY 2009
Fig 2. Erythematous annular plaques with trailing scale
on the upper back.
Histologic analysis showed lichenoid and focal
perifollicular lymphocytic infiltrates with scattered
plasma cells. Spirochetes were highlighted on both
the Steiner stain and with immunostains for Trepo-
nema pallidum. A rapid plasma reagin test was
reactive with a titer of 1:1024, and a diagnosis of
secondary syphilis was made. The patient was treated
with 2.4 million units of penicillin G Benzathine
intramuscularly weekly for 3 weeks. All skin findings
resolved by the third week of treatment.
Secondary syphilis is well known for its ability to
create a wide range of clinically diverse cutaneous
lesions.1 These lesions can mimic a vast number of
dermatologic diseases, and syphilis has thus been
appropriately named the ‘‘great imitator.’’2 The most
commonly observed lesions in secondary syphilis
include a generalized papulosquamous eruption,3
but annular or figurate plaques are not uncommon.
To our knowledge, concentrically arranged rings are
rare, but are more commonly noted in patients of
African American descent. Our review of the litera-
ture produced just one such case report.2 Our case
demonstrates the importance of including secondary
syphilis in the differential diagnosis of lesions that
present as annular plaques arranged in a polycyclic
and concentric, gyrate, annular, or erythema annu-
lare centrifugumelike pattern.
Catherine Cotterman, MD, Lauren Eckert, BS, and
Lindsay Ackerman, MD
Department of Dermatology, Tulane University
School of Medicine, New Orleans, Louisiana
Funding sources: None.
Conflicts of interest: None declared.
Reprint requests: Catherine Cotterman, MD, Tu-
lane University School of Medicine, Dermatology
Department, 1430 Tulane Ave, TB36, New Or-
leans, LA 70112
E-mail: ccotterm@tulane.edu
J AM ACAD DERMATOL Letters 167
VOLUME 61, NUMBER 1

REFERENCES date, and several attempts have been made to classify

1. James WD, Berger TG, Elston DM. Andrews’ diseases of the skin:
clinical dermatology. 10th ed. Canada: Elsevier; 2006 p. 358-64.
2. Sarojini PA, Dharmaratnam AD, Pavithran K, Gangadharan C.
Concentric rings simulating tinea imbricata in secondary syph-
ilis. A case report. Br J Venereal Dis 1980;56:302-3.
3. Bolognia JL, Jorizzo JL, Rapini RP. Dermatology. 2nd ed. Spain:
Elsevier; 2008 p. 1239-5.
doi:10.1016/j.jaad.2008.10.027
Periungual squamous cell carcinoma induced
by human papillomavirus type 59 in an
immunosuppressed patient
To the Editor: Human papillomavirus (HPV) is im-
plicated in the induction of hyperproliferative le-
sions in the cervix, skin, and mucosal epithelia.1
More than 100 HPV genotypes have been isolated to
HPVs.2 Some cases of periungual squamous cell
carcinoma (SCC) may be induced by high-risk on-
cogenic HPVs, such as HPV 16.3
A 29-year-old Japanese male with a history of
relapsing polychondritis presented in May 2004. He
had been treated with oral corticosteroids and
azathioprine. Multiple papillomatous papules and
plaques occurred on his palms and soles at 26 years
of age. The plaque on the nailbed of his left thumb
(Fig 1, A) had enlarged with occasional pain.
Histopathology of the biopsy specimen showed
the features of a benign verruca and was positive
for HPV immunostaining (Fig 1, B and C ). It was
diagnosed as verruca vulgaris and he was treated
with local bleomycin injections. However, the nail
lesion was resistant to the treatment although other

Fig 1. A, 1.9-cm verrucous plaque on the left thumb with half of the nail plate missing.
B, Histopathology of the biopsy specimen showed acanthosis, hyperkeratosis, and hypergran-
ulosis with papillomatosis. Nuclear atypia, mitotic figures, and a tendency toward interstitial
invasion were not evident. (Hematoxylin-eosin stain.) C, Immunohistochemical analysis using
anti-HPV capsid protein antibody (DAKO; Glostrup, Denmark) was positive.