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BACKGROUND: Suspected toenail onychomycosis is a frequent problem. Clinical diagnosis has been considered inadequate. OBJECTIVES: To assess the diagnostic accuracy of clinical findings for detecting fungi in toenails, and to develop and validate a clinical diagnostic rule aimed at improving dermatologists' diagnosis of onychomycosis. METHODS: A cross-sectional diagnostic study was performed including a total of 277 patients seen by 12 dermatologists. The gold standard was the presence of dermatophytes on culture or a positive nail plate biopsy. For each sign we described prevalence, sensitivity, specificity, positive and negative predictive values, and likelihood ratios for positive and negative results. We developed a diagnostic clinical rule and validated it in a subsample. RESULTS: Helpful findings to predict the presence of fungi are: previous diagnosis of fungal disease; abnormal plantar desquamation (affecting > 25% of the sole); onychomycosis considered the most probable diagnosis by a dermatologist; and presence of interdigital tinea. When dermatologists considered onychomycosis the most probable diagnosis and plantar desquamation was present (13% of patients), the positive predictive value for presence of fungi was 81%. When both signs were absent (34% of patients), the positive predictive value for absence of fungi was 71%. In other situations, clinical diagnosis might not give enough information to decide on therapy. CONCLUSIONS: In 13% of the patients (a large number in absolute terms), when dermatologists consider onychomycosis the most probable diagnosis and plantar desquamation is present, therapy should be started without any further test, as clinical diagnosis is at least as accurate as laboratory tests. In other situations, an optimal management strategy should be defined.

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El xantoma plano difuso es una forma de presentación poco frecuente de xantomatosis en general normolipémica. Frecuentemente se ha visto su asociación con trastornos hematológicos. Describimos el caso de un varón de 62 años que presentaba lesiones cutáneas de xantoma plano difuso asociado a gammapatía monoclonal de significado incierto que había sido diagnosticado años antes. Posteriormente se detecta una crioglobulinemia tipo 1, hipocomplementaria y hepatopatía no obstructiva con anticuerpos anti-LKM positivos. Destacamos la necesidad del seguimiento estrecho de estos pacientes, ya que otros procesos se pueden ir sumando a la patología inicial a lo largo del tiempo (AU)

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La enfermedad de Bowen es un carcinoma intraepidérmico, en cuya patogenia se han sido implicado diversos factores; entre ellos las infecciones con el virus del papiloma humano (VPH), sobre todo el serotipo 16. Presentamos un paciente varón, VIH+, estadio B2, con una enfermedad de Bowen pigmentada localizada en región infraumbilical. Mediante técnicas de reacción en cadena de polimerasa (RCP) fue aislado el serotipo 31 del VPH, hallazgo poco referido en la literatura. (AU)

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Rubinstein-Taybi syndrome is characterized by the presence of a peculiar facies, mental retardation, and broad thumbs and great toes. Several associated cutaneous abnormalities have been reported with this syndrome. Ulerythema ophryogenes is a form of follicular keratosis associated occasionally with other ectodermal defects and congenital anomalies. We describe a 9-year-old child with Rubinstein-Taybi syndrome and ulerythema ophryogenes. This association has not been described previously to our knowledge.

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A 74-year-old man presented with a tumor on his scalp that he had since birth. The authors observed a verrucous pink crusted plaque. The tumor was clinically diagnosed as nevus sebaceus and was removed. Histopathologic study showed, arising from nevus sebaceus, a lobular neoplasm with the classic features of trichilemmoma. Desmoplasia was present in the center of the trichilemmomatous area. This description is typical of a special, uncommon type of trichilemmoma that histologically mimics invasive carcinoma.

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Milia en plaque typically occurs in the retroauricular area. We report the case of an 84-year-old woman with this disorder occurring bilaterally in the submandibular region. The diagnosis was confirmed by histological examination.

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Eccrine angiomatous hamartoma is a rare cutaneous lesion. Histologically it is characterized by the proliferation of eccrine glands, vascular structures and occasionally other elements in the middle and deep dermis; we now report seven further cases of this condition, two with lipomatous involvement and also discuss its nosology.

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