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In this section we have spot diagnoses posted on a daily basis since June 2010, now over 1700! You can review the archived cases and read the suggested diagnoses by users and the final comment by Dr Uma Sundram, the Editor-in-Chief and main spot diagnosis host. Case are uploaded each week day by 10 a.m. UK time with the correct diagnosis will generally be posted at 8 p.m. UK time. Why not view the most recent spot diagnosis and proffer a diagnosis?

Case Number : Case 1995 - 29 Jan 2018 Posted By: Limin Yu

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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74 Female, vulva rash

Edited by Admin_Dermpath


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Intraepidermal malignant epithelioid lesion with a pagetoid spreading appearance. In the vulva the differential diagnosis of course lies between Paget's disease and melanoma in situ. The last two pictures appear to show pigment in the cytoplasm of the neoplastic cells suggestive of melanoma in situ. But the first three show significantly more pagetoid spread in the upper layer of the epidermis relative to malignant cells arranged in solitary units along the basal layer and no obvious nests of malignant cells along the basal layer (as commonly seen in melanoma). In figure 3 I think I see the single malignant cells lying above underlying keratinocytes instead of directly on the basement membrane as in melanoma. So overall the lesion most likely represent Paget's disease. In my practice, if I need to confirm it, I usually order only cytokeratin 7.

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Agree with the above. Third DD is Pagetoid SCC in situ.

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Thank you for the insightful discussion and comprehensive differential diagnosis!  This is an extramammary Paget's disease, confirmed by immunostains. 

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