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The pigmented purpuric dermatoses (PPD) are a group of diseases characterized by petechiae and bronze discoloration of the skin on the lower extremities. Histopathologically, extravasation of erythrocytes with hemosiderin deposition, a perivascular lymphocytic infiltrate centered on the superficial capillaries and endothelial cell swelling are seen. The granulomatous variant of PPD (GPPD) was described in 1996 and only 10 cases have been reported since in the literature, almost exclusively in patients of East Asian descent only involving the extremities. We present a case of GPPD in a Caucasian, North American Ashkenazi Jewish woman involving the thighs, back, forearms and wrists with concomitant non-granulomatous PPD of the shins. She presented with an asymptomatic, spreading, cayenne pepper-like rash. This rash intermittently involved the lower extremities and back for 15 years, but now involves the thighs with accompanying pink papules on the back, wrists and forearms. Histopathology of the thigh and back lesions revealed superficial lichenoid granulomatous dermatitis with palisading lymphocytes and focal interface changes. Extravasated erythrocytes were seen, but vasculitis was absent. No lymphocytic atypicality was noted and T-cell gene rearrangement studies were non-clonal. This is the second reported case of GPPD in a non-Asian patient and the first case involving sites other than the extremities.

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The vulva is an unusual site for basal cell carcinoma (BCC). Vulvar BCC accounts for <1% of all BCCs and <5% of all vulvar malignancies. We report the case of an 83 year-old woman who presented with a 2-month history of a tender labial growth, with histopathology confirming nodular BCC. We conducted a systematic literature review of the characteristics of reported cases of vulvar BCCs. A comprehensive systematic review of articles indexed for MEDLINE and Embase yielded 96 reports describing 437 patients with 446 BCCs of the vulva. The mean age at presentation was 70 (range 20-100). Most women had no underlying vulvar disease. Approximately 60% of cases were of the nodular subtype.Treatment approach varied widely with over half of cases treated with wide local or local excision. Mohs micrographic surgery (MMS) for vulvar BCC was first reported in 1988 with seven total MMS cases reported. Twenty-three cases of recurrence have been reported; 21 of these cases after local excision but none following MMS. Vulvar BCC is a rarely reported cancer that affects older women predominantly. MMS represents a promising treatment for BCC in this anatomic location. Case ReportAn 83-year-old woman with a 40-year history of treated lichen sclerosus presented with a tender growth in the genital area for 2 months. Genital examination revealed a 5-mm eroded papule on the right inferolateral labium majus arising on normal skin, and a white, sclerotic appearance of the labia minora and clitoris ( Fig. 1). Biopsy of the papule revealed a nodular BCC.The patient underwent MMS. She has no evidence of disease recurrence at 3 years.

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DEAR EDITOR, All education, including medical education, reflects society's trends and needs. Skin and skin pigmentation have both personal and societal effects on an individual. During the protests in the USA and worldwide following the killing of George Floyd, there has been a large-scale, united drive to acknowledge and establish a strong resolve against systematic racism and its insidious and lasting effects, including economic exclusion, academic and scientific marginalization, and health disparities.The study of skin conditions can be traced back to antiquity, but the establishment of dermatology as a medical specialty in 19th century Europe has shaped the field of modern dermatology today, with a predominant focus on disease in lighter skin phototypes. A paradigm shift to include the cutaneous diversity of humanity is overdue. Dermatology educators must reappraise our current teaching practice and curriculum. Our challenge is to ensure that physicians and Zondi, DPhil, and Art Papier, MD, for their contributions to this manuscript.

Challenge: Although lecturing is an efficient method for the dissemination of information, it has long been criticized for learner passivity and diminished knowledge retention. Active learning strategies to engage the audience in the learning process can facilitate a bidirectional flow of ideas and content between teacher and students during a lecture to keep learners engaged and participating.