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A 9-year-old Black boy presented to the dermatology clinic for evaluation of dark spots on the tongue. The family first noted these spots 5 months prior and reported that they remained stable during that time. The patient's medical history was notable for autism spectrum disorder and multiple food allergies. His family history was negative for similar oral pigmentation or other pigmentary anomalies. A review of systems was positive only for selective eating and rare nosebleeds. Physical examination revealed numerous dark brown, pinpoint papules across the dorsal aspect of the tongue. No hyperpigmentation of the buccal mucosae, lips, palms, or soles was identified. Several light brown streaks were present on the fingernails and toenails, consistent with longitudinal melanonychia. A prior complete blood cell count was within reference range. WHAT'S YOUR DIAGNOSIS?a. Addison disease b. black hairy tongue (or lingua villosa nigra) c. hereditary hemorrhagic telangiectasia d. Peutz-Jeghers syndrome e. pigmented fungiform papillae of the tongue Eligible for 1 MOC SA Credit From the ABD This Photo Challenge in our print edition is eligible for 1 self-assessment credit for Maintenance of Certification from the American Board of Dermatology (ABD). After completing this activity, diplomates can visit the ABD website (http://www.abderm.org) to self-report the credits under the activity title "Cutis Photo Challenge." You may report the credit after each activity is completed or after accumulating multiple credits.

Context.— Bullous dermatophytosis is a rare blistering disorder resulting from fungal infection. Limited literature describes the clinical and microscopic features of this disease. Objective.— To summarize the histopathologic and clinical features of 25 biopsy-proven cases of bullous tinea. Design.— The study was a single-center retrospective review of patients diagnosed with bullous dermatophyte infection by skin biopsy. Results.— Bullous tinea is rarely suspected clinically in biopsy-proven cases, often mimicking other spongiotic disorders that can vesiculate. In addition to classically taught histopathologic clues, several unique characteristics were observed in our population. The presence of dermal neutrophils as the nonpredominant cell type (85%; n = 17 of 20) can serve as an additional clue to diagnosis. Deep inflammation (25%; n = 5 of 20) does not exclude a superficial diagnosis. The classically taught sandwich sign (32%; n = 8 of 25) may be less relevant in the setting of bullous tinea. Hyphae were most commonly seen within the stratum corneum adjacent to this blister rather than within the blister itself, and special staining was required in a substantial number of cases (40%; n = 10 of 25) to reach the correct diagnosis. Conclusions.— Bullous tinea is unusual but should be considered in the differential diagnosis of blistering skin disorders. Hematoxylin and eosin–stained slides frequently lack obvious fungal hyphae; for this reason, periodic acid–Schiff reaction or Gomori/Grocott methenamine silver stains should be routinely considered for biopsies showing intraepidermal and/or subepidermal blister formation and prominent neutrophil infiltration to prevent misdiagnosis.

Focal dermal hypoplasia (FDH), or Goltz syndrome, is a rare genodermatosis affecting tissues of mesodermal and ectodermal origin. The characteristic skin changes have been reported to symptomatically flare in response to certain triggers as well as to progress over time in some cases. We present the case of a 5‐year‐old girl with cutaneous flaring and progression of FDH in the setting of septic shock. This case adds to the growing body of literature on both flaring and progression of the cutaneous manifestations of FDH.

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