The diagnosis of SGA is usually based on the biopsy

The diagnosis of SGA is usually based on the biopsy of the lesions. Nodules in the deep EZ Cap Reagent AG (3\' OMe) and subcutis are the main histopathologic changes, presenting with necrobiosis surrounded by histiocytes and lymphocytes in a palisade arrangement. The central areas of necrobiosis contain increased amounts of mucin and nuclear dust between the degenerated collagen bundles. A perivascular infiltrate of lymphocytes and histiocytes is also present. Upon histopathologic examination, the nodules of SGA may be easily mistaken for rheumatoid nodules (RNs), which are the most common extra-articular manifestation of rheumatoid arthritis (RA). However, a careful medical history and laboratory tests can lead to the correct differential diagnosis of these two diseases. Patients with RNs usually have arthritic joint complaints, along with elevated serum rheumatoid factor and ESR. In addition, radiologic changes of the joints are usually seen in patients with cutaneous nodules. Moreover, certain histologic features can be used to differentiate SGA nodules and RNs. The necrobiotic granulomas of RNs are usually located in the deep subcutis, whereas the necrobiotic granulomas of SGA nodules involve the entire dermis and extend to the subcutis. SGA nodules can be differentiated not only from RNs, but also nodules of necrobiosis lipoidica (NL). The lesions are usually localized to the pretibial shins and present as small papules or oval plaques that may grow peripherally and become atrophic and yellowish in the center with an elevated erythematous edge. Upon histopathologic examination, NL nodules appear similar to SGA nodules, but the necrobiosis of NL nodules is considered to be more extensive and less well defined. Based on the features of the lesions and the laboratory tests, NL was excluded in our case. Barzilai et al in 2005 reported 14 women with lesions similar to those presented in this case. These authors thought that the lesions most likely represented a variant of granuloma annulare and suggested the term juxta-articular nodular granuloma annulare. All the patients they reported were women, and the lesions were over bony prominences (interphalangeal and elbow joints). None of the patients experienced the development of RA or any other systemic disease. Barzilai et al indicated that the granulomata in juxta-articular nodular granuloma annulare could be distinguished from that in SGA by sex, age, location, course, and material contained therein (Table 1). Our patient is a 51-year-old woman who presented with nodules located on the dorsa of the hands and right knee that did not independently resolve. Histopathologic examination revealed that the material within the granulomata was collagen with scant mucin, as demonstrated with Masson stain and alcian blue stain. The clinical and pathologic characteristics of our patient concurred with those described by Barzilai et al. Therefore, we surmised that the juxta-articular nodules in our patient represented an uncommon form of SGA.
Acknowledgments
Introduction Squamous cell carcinoma (SCC) in patients with chronic arsenicosis is believed to be more invasive. The treatment of choice is surgical excision. However, alternative treatments may be needed for patients who cannot tolerate or refuse surgery. Imiquimod is a topical immune modifier acting mainly by exhibiting agonistic activity toward Toll-like receptors 7 and 8. Initially, it was approved to treat genital and perianal warts. In recent years, imiquimod has been used as a safe and effective treatment option for a variety of skin cancers including actinic keratosis, basal cell carcinoma, SCC in situ (Bowen\'s disease), lentigo maligna, and extramammary Paget\'s disease. Although studies of imiquimod in treating invasive SCC are limited, some case reports showed encouraging outcomes. For example, Hengge and Schaller treated a 65-year-old man with a 4 cm × 3 cm SCC on the temple area. The tumor was treated by applying 5% imiquimod cream overnight three times a week. At week 16, the tumor was cured completely, which was also confirmed by a histopathological analysis. There was no tumor recurrence at the 16-month follow-up examination.