dr [page 4] [dermatology reports 2010; 2:e2] cutaneous papules in a patient with acquired immunodeficiency syndrome pascale quatresooz, claudine piérardfranchimont, philippe paquet, gérald e. piérard department of dermatopathology, university hospital of liège, liège, belgium abstract during the past decade or so, the incidence of syphilis has increased in most parts of the world. in some urban regions, a coinfection with human immunodeficiency virus is disclosed in nearly 50% of the cases. owing to the polymorphism of the lesions, the clinical diagnosis may be puzzling. the homing patterns and migration paths of treponema pallidum in the skin during early syphilis represent the preliminary steps preceding dissemination to other organs. immunohistochemistry directed to t. pallidum is a convenient means for reaching the diagnosis and for exploring the dissemination process. the present case illustrates the dermal clustering and the vascular spread of t. pallidum in a woman with acquired immu no deficiency syndrome. introduction a number of skin disorders have been described in patients with acquired immunodeficiency syndrome (aids). among them, secondary infections are common, but their incidence has decreased considerably following the introduction of combined therapies targeted to the human immunodeficiency virus (hiv). some clinical presentations may be puzzling, particularly in secondary syphilis exhibiting lesions showing a marked tendency to polymorphism. the histopathological examination often proves to bring about the diagnosis. design and methods a 29-year-old woman with a three-year history of aids presented with polymorphic papules on the face and abdomen. the lesions reaching 0.5-1.5 cm in diameter had been present for about two months. they were diagnosed tentatively as pityriasis rosea, pityriasis lichenoides, and secondary syphilis. the skin lesions were asymptomatic but the patient complained of discrete malaise, stiff neck, myalgia headache, and mild fever. a biopsy specimen was taken from a papule on the abdomen. a series of 5-µm thick sections were cut from the formalin-fixed paraffin-embedded biopsy. an immunohistochemical assessment was performed using a rabbit polyclonal antibody directed to treponema pallidum (1:200 biocare medical, walnut creek, ca, usa). this antibody is highly sensitive for detecting spirochetes in human tissues. the avidin-biotin peroxidase method was performed as previously described.1,2 a one-hour incubation time was used with the t. pallidum antibody. the envision (dakopatts, glostrup, denmark) polymer-based revelation system and fast red (dakopatts) staining were used. negative immunohistochemical controls were performed by omitting or substituting the primary and the secondary antibodies in the laboratory procedure. results the dermoepidermal junction contained a band-like infiltrate composed mostly of lymphocytes, histiocytes, and plasma cells. a deeper cell infiltrate of similar composition extended along the microvasculature, hair follicles, and sweat glands. endothelial cells appeared plump. immunohistochemistry demonstrated innumerable t. pallidum in the dermis. the dermatology reports 2010; volume 2:e2 correspondence: g.e. piérard, department of dermatopathology, chu sart tilman, b-4000 liège, belgium. e-mail: gerald.pierard@ulg.ac.be key words: syphilis, aids, immunohistochemistry. contributions: all authors contributed equally in the collection of clinical and histopathological information. acknowledgements: this work was supported by a grant from the “fonds d’investissement de la recherche scientifique” of the university hospital of liège. no other sources of funding were used to assist in the preparation of this manuscript. the authors appreciate the excellent secretarial assistance of mrs. ida leclercq and marie pugliese. conflict of interest: the authors report no conflicts of interest that are directly relevant to the content of this work. received for publication: 19 october 2009. revision received: 17 december 2009. accepted for publication: 17 december 2009. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright p. quatresooz et al., 2010 licensee pagepress, italy dermatology reports 2010; 2:e2 doi:10.4081/dr.2010.e2 figure 1. early syphilis. dermal homing of t. pallidum on immunohistochemistry: (a) multiple interstitial clumps of spirochetes (200x); (b) vascular trapping of spirochetes (400x); (c) prominent accumulation of spirochetes in the microvasculature wall (400x). a b c no nco mm er cia l u se on ly [dermatology reports 2010; 2:e2] [page 5] typical spiral, corkscrew, and threadlike spirochetes were highlighted by the red chromogen, and the contrast with the clear background was striking (figure 1a, b, c). their presence inside the lichenoid infiltrate was associated with a dense superficial and deep perivascular cuff of spirochetes. the latter slender spirochetes were clustered in the dermal stroma (figure 1a) and in rims confined to the perivascular areas (figure 1b, c). in addition, some t. pallidum were evident in the cytoplasm of cells, particularly endothelial cells (figure 1c). a few of these spirochetes protruded into the vascular lumen. none of the negative controls showed spirochete immuno reactivity. discussion in the present case, skin immunohistochemistry shed some light on the diagnosis of syphilis in an aids patient and showed the dermal homing and the microvascular tropism of t. pallidum. it is acknowledged that during a five-year period after inoculation, t. pallidum spreads to every organ. then the disease is intermittently contagious. later syphilis usually becomes dormant or latent for many years. a long time later, it commonly re-emerges as a chronic and deadly illness. at any stage in its evolution, syphilis may mimic a number of other unrelated diseases. during the past decade, a sizable proportion of the population with syphilis corresponded to gay men coinfected with hiv.3,4 when the clinical diagnosis of syphilis is not established, a skin biopsy sometimes is submitted to the dermatopathologist without any relevant information. at the conventional histological examination, the diagnostic clues for syphilis are not always obvious because the disease presentation depends on both the host immunological response to the infection and the diverse angioinvasive propensity of the t. pallidum strains.5 an appropriate silver stain revealing spirochetes may remain negative or doubtful. indeed, the histochemical silver stain may be difficult to interpret owing to heavy background staining.1 immunohistochemistry using an antibody directed to t. pallidum was reported to improve the histological diagnostic accuracy of syphilis.1,2,6,7 the present finding was assumed to illustrate the migration of t. pallidum toward the microvasculature during early syphilis. in summary, t. pallidum were abundant and heavily clustered in some specific portions of the skin. the peculiar homing of t. pallidum in the skin appears quite specific as it has not been reported for any other infectious microorganism. references 1. quatresooz p, piérard ge. skin homing of treponema pallidum in early syphilis. an immunohistochemical study. appl immu no histochem mol morph 2009;17:47-50. 2. quatresooz p, piérard ge. perivascular cuff and spread of treponema pallidum. dermatology 2009;219:259-2. 3. frauenfelder c. incidence of syphilis in uk rises as hiv diagnoses hold steady. br med j 2006;333:1089. 4. kerani rp, handsfield hh, stenger ms, et al. rising rates of syphilis in the era of syphilis elimination. sex transmitted dis 2007;34:154-61. 5. lautenschlager s. cutaneous manifestations of syphilis. recognition and management. am j clin dermatol 2006;7:291-304. 6. hoang mp, high wa, molberg kh. secondary syphilis: a histologic and immu nohistochemical evaluation. j cutan pathol 2004;31:595-9. 7. buffet m, grange pa, gerhardt p, et al. diagnosing treponema pallidum in secondary syphilis by pcr and immunohistochemistry. j invest dermatol 2007;127: 2345-50. article no nco mm er cia l u se on ly dr [page 40] [dermatology reports 2011; 3:e18] epidemiologic and clinicopathologic aspects of leprosy in dakar; evaluation of 73 new cases suzanne oumou niang,1 moussa diallo,1 maodo ndiaye,1 assane diop,1 boubacar ahy diatta,1 mohamed wadih,1 assane kane,1 mame thierno dieng,1 charles insa badiane2 1centre hospitalier universitaire aristide le dantec, dakar, senegal; 2institut de léprologie appliquée de dakar, senegal abstract hundreds of new leprosy cases are still diagnosed in dakar despite all the efforts in the struggle by the national program for elimination of leprosy by the institute of applied leprosy in dakar. the aim of our study was to evaluate the epidemiological, clinicopathological and outcome of new cases of leprosy. a prospective study was conducted over a period of one year listing all new cases of leprosy based on clinical diagnosis, bacteriology and histology. 73 new cases were recorded. the sex ratio was 1.5 and the mean age of 39.5 years. children aged from 0 to 15 years old represented 12%. the clinical forms were rated in order of decreasing frequency borderline 47.94%, 30.13% lepromatous lepromatous, indeterminate 8.21, borderline lepromatous 6.84, tt: 5.47%, 1.36 and neurological bb%. neurological signs were enlarged nerve in 50 cases, a neurological deficit in 16 cases and a sensitive deficit in 16 cases. the complications were burns and ulcerations in 10 cases, a claw in 7 cases, a reversal reaction in 7 cases, erythema nodosum in 4 cases and neuritis in 8 cases. the number of new cases mutilated was 24.65%. the smear was positive in 42% and histology contribution in 91.37% of cases. our study highlights the significant number of patients with multibacillary contagious, affected children, the high proportion of disability grade 2/oms reflecting the delay in diagnosis. this delay is due to ignorance, to traditional treatments and low socio-economic status and lack of trained diagnostic teams in different areas apart from referral centres. introduction although leprosy does not constitute a public health problem in senegal since 1995, it still persists. each year, hundreds of patients are diagnosed by the staff of the national program for elimination of leprosy (npel) and the institute of applied leprology of dakar (iald). in 2006, there were 353 new cases of leprosy and 282 in 20071 in the whole territory of senegal. the aim of our study was to evaluate the epidemiological and clinicopathological profile and the outcome of new cases of leprosy in dakar, the capital of senegal. materials and methods we undertook this prospective study including patients diagnosed with new cases of leprosy during 2008 and being treated at the iald. the diagnosis was based on clinical, bacteriological (slit skin smear (sss) of at least 3 sites, accounting for the bacteriological and morphological index, bi, mi) and pathology criteria (the skin biopsy or the musculocutaneous nerve of the elbow). riedley & jopling classification was used and added to the pure neurological leprosy (pnl). a thorough neurological exam allowed us to classify the patients following the disability criteria of the who (world health organization). the who treatment protocol was used: the standard multidrug therapy (mdt) for 12 months if multi-bacillary (mb) leprosy when the ib was positive and multidrug therapy (mdt) for 6 months if pauci-bacillary (pb) leprosy when the ib was negative. the systemic corticosteroids were prescribed for a period of 6 months in case of severe reactions or recent neuropathy. a secondary prevention of disabilities, with information, education and communication and physical therapy, proper footwear and measures of self protection was set up. restorative surgery like nerve decompression, palliative surgery or wound debridement, when necessary completed this global care. a dermatological and neurological exam was done every month during their regular follow up visits. results epidemiology during the study period, 73 new leprosy patients were registered,they were referred from different centers (table 1). thirty-three patients (45.2%) initially used traditional medicine. patients comprised 44 men and 29 women with a sex ratio of 1.5. distribution by age is shown in figure 1. the mean age of patients was 39.5 and ranged from 4 (figure 2) to 75 years (figure 3) (mean 39.5). 38 patients (52.05%) were single versus 35 patients (47.94%) were married. 38 patients (52.05%) worked in the informal sector, 8 patients (10.95) in the formal sector. thirteen patients (17.80%) were students or pupils and 14 patients (19.80%) were unemployed. forty patients (56.16%) were from dakar and its suburbs, 32 patients (43.83%) from other regions of senegal and 3 patients (4.10%) from neighboring countries. clinicopathological data present complaints were dermatological and neurological symptoms. seventy-two patients (98.63%) presented dermatological complains; with spots in 64 patients (84.67%) and sores in 16 patients (21.91%); 23 patients (31.5%) had neurological symptoms with painless burn in 9 patients (12.32%), ulnar claw in 4 patients (5.47), nerve pain in one patient and paresthesis in 9 patients (12.32%). the time of the first visit in relation to appearance of symptoms or signs was variable from less than a year to more than 10 years (table 2). in 14 patients (19.18%) there had been a close contact with a leprosy family member. the different clinical presentations are shown on table 3, 41 patients (56.16%) had borderline leprosy, immunologically unstable, while 33 patients (45.05%) had the polar leprosy form which is stable. sixty-three patients (86.30%) had normal sensory or hypoesthesic hypochromic macular lesions, 21 patients (28.73%) had papulo-nodular lesions and 5 patients (6.84%) had hypo or anesthetic plaques. fifty patients (68.49%) had nerve hypertrophy, cubital nerve in 37 patients (50.68%); superficial cervical plexus in 7 cases (9.58%)and superficial peroneal nerve in 6 cases (8.21%), 16 patients had motor deficit (21.91%), and 14 patients(19.17%) had a sensitive deficit. twenty patients (28.76%) had nasal obstruction with or without crusted dermatology reports 2011; volume 3:e18 correspondence: suzanne oumou niang, centre hospitalier universitaire aristide le dantec, 30 avenue pasteur b.p. 3001 dakar, senegal. e-mail: suzeoumou@yahoo.com key words: leprosy, senegal. received for publication: 7 june 2011. revision received: 3 august 2011. accepted for publication: 6 august 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright s.o. niang et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e18 doi:10.4081/dr.2011.e18 no nco mm er cia l u se on ly [dermatology reports 2011; 3:e18] [page 41] rhinitis, and 13 of them (17.80%) had epistaxis. thirty-seven patients (50.68%) were hospitalized because of complications (table 4), claw fingers and reversal reactions (figure 5) were noted in 7 patients each.18 patients (24.65%) had who disability grade 2 at his initial visit. forty-two(58%) patients had a negative sss, and 31 patients (42%) had a positive one with the bi equal or superior to 4 + in 5 patients. biopsies were done in 58 patients (figure 6) and were conclusive in 53 patients (91.37%). at the end, 37 patients (50.6%) had paucibacillary (pb) leprosy, 30 patients (41.09%) had multi-bacillary (mb) leprosy. who therapeutic standard recommendations were applied to all the patients, except in 5 cases were the bi equal or superior a 4+, the treatment were conducted for a period of 24 months. corticotherapy was given to 29 patients (39.72%) who had either neuritis or reaction.40 patients (55%) suffered from a psychosocial impact, 37 patients (51%) had some functional impairment and 22 patients (30%) had some professional impact. regression of the skin lesions was noted in all the cases after the first month of therapy. discussion we report 73 new cases of leprosy during a period of one year, this number does not reflect the real situation in the country, because ilad is a referral center, staffed by doctors and equipped with a laboratory, while at the npel, the diagnosis is done by leprosy nurses specialist lns, who used the who case report table 4. distribution of cases per complications. complication number of cases % ulcers or burns of the extremities 10 13.69 motor deficit 11 15.06 reversal reaction 07 9.58 erythema nodusum leprosum 04 5.47 pure neuritis 04 5.47 lagophtalmia 01 1.36 table 3. distribution of different leprosy forms. forms of leprosy bt ll i bl tt pnl bb number of cases 35 22 6 5 4 1 0 percentage 47.94 30.13 8.21 6.84 5.47 1.36 0 bt, borderline tuberculoid; ll, lepromatous leprosy; i, indeterminate leprosy; bl, borderline lepromatous; tt, tuberculoid leprosy; pnl, pure neurological leprosy; bb, borderline borderline. figure 3. lepromatous leprosy form in a 70-yearsold woman. figure 4. a post burn digital ulcer in ll patient. table 2. distribution of cases per timeline of the first visit. timeline of number % the first visit of cases <1 year 39 53.42 1-5 years 25 34.24 5-10 years 07 9.58 >10 years 02 2.73 table 1. distribution of cases per referring centers. referring number % center of cases hospitals 40 54.78 health centers 13 17.8 iald 12 16.43 private practice 08 10.95 total 73 100 figure 1. age distribution of new leprosy cases. figure 2. a bt form in a 4-years-old kid. figure 5. reverse reaction in a borderline tuberculoid form. figure 6. granulomatous peri-annexial infiltrate in a tuberculoid leprosy.no nco mm er cia l u se on ly [page 42] [dermatology reports 2011; 3:e18] clinical classification. the particularities of our study were the relatively large number of multi-bacillary (mb) leprosy patients, potentially contagious and the number of affected kids, the high proportion of who disability grade 2, reflecting late diagnosis and continued transmission of the disease. the limitations of our study were, its short duration, which did not allow a long term outcome. the number of recruited patients represents a quarter of the total new cases of leprosy observed in 2007, in the whole territory of senegal. male predominance observed in our study was noted by many other authors2,3,4 and the percentage of affected females (39.73%) matches the one reported by the npel, it is less than the 60% seen in uganda and far superior to the 8.5% reported in the democratic republic of congo.1 the mean age of 32 years is higher than the one (32 years) reported at the marchoux institute in mali.5 the time of the first visit was long, more than 1 year in almost half the cases. this delay is certainly due to ignorance, low economic status, but most importantly due to diagnostic error induced by the use of traditional medicine as we found in 45% of the cases. the same factors that delayed the diagnosis were also noted by keita at the marchoux institute in mali, muller in guadeloupe.5,6 the predominance of interpolar forms (54.75%) is similar to the one reported in the literature, while the indeterminate leprosy (8.22%) stays inferior to that as reported by bobin and flageul evaluated between 20 and 80%,2,3 and can translate also the lack of early diagnosis. the positive sss in 42% underline the significant presence of the bacteria as reported in other studies.2,7,8 the pathology was very contributory because it confirmed the diagnosis in 91.37% of the cases. in the case where the histological study was unavailable or non contributory and the sss negative (27.39%), the diagnosis was based only on clinical arguments (27.39%). the number of disabilities reported in our study (24.65%) reflects the severity of the neurological involvement that is 2 times higher than the npel (11.3%) and the who (12.46%). conclusions the diagnosis of hundreds of new annual cases of leprosy, and the severity of the neurological impairment justify more vigilance in the primary prevention of the disease. it makes it essential to early diagnosis in order to prevent disabilities. such struggle includes training highly competent health staff in both hospitals and community clinics. references 1. oms. comité régional de l’afrique. elimination de la lèpre. rapport de situation. afr/rc57/inf.doc/2 :5 avril 2007. 2. bobin p. lèpre. encycl méd. chir. maladies infectieuses 8-038-f-10,2007. 3. flageul b. maladie de hansen. lèpre. encycl méd chir. dermatologie 98-370-a-10,2001. 4. keita s, faye o, konare hd, sow so, ndiaye ht, traore i. evaluation de la classification clinique des nouveaux cas. etude réalisée à l’institut marchoux (bamako, mali). ann dermatol venereol 2003;130:184-6. 5. keita s, tiendrebeogo a, berthé d, faye o, ndiaye ht. valeur prédictive des motifs de consultation pour le diagnostic de lèpre à bamako (mali). ann dermatol venereol 2002;129:1009-11. 6. muller p, frederic m, salzer b, strobel m. lèpre en guadeloupe: maladie en decline, délai diagnostic en hausse. ann dermatol venereol 2003;130:619-21. 7. bobin p. peut-on envisager l’élimination de la lèpre dans le monde? ann dermatol venereol 2001;128:205-6. 8. kadji f, lucht f, helenon r, leoture a. epidemiologie de la lèpre en martinique. bull allf 2001;8:19-23. case report no nco mm er cia l u se on ly dr [dermatology reports 2011; 3:e38] [page 83] epidermolysis bullosa acquisita: current diagnosis and therapy christine r. mehren,1 robert gniadecki2 1department of dermatology, bispebjerg hospital, copenhagen; 2university of copenhagen, bispebjerg hospital, denmark abstract epidermolysis bullosa acquisita (eba) is an acquired, autoimmune subepidermal blistering disease with an approximate prevalence of 0,2/million people. the hallmark of eba is the presence of autoantibodies (mainly igg class) to anchoring fibril collagen (type vii collagen) located at the dermal-epidermal junction. clinically eba is subdivided into the inflammatory and the non-inflammatory phenotypes, depending on the level of the cleavage in the basal membrane. a recent addition to the diagnostic techniques is the analysis of the serration pattern of the autoantibody deposits at the basal membrane in the direct immunofluorescence. eba and the closely related bullous systemic lupus erythematosus are the only diseases presenting with the so-called u-serration pattern which distinguishes them from many other autoimmune subepidermal blistering diseases. we also discuss the recent advances in therapy, including the experience with rituximab. clinical features epidermolysis bullosa acquisita (eba) was described for a century ago by ellliot.1 it is a rare disease with an approximate prevalence of 0.2/million people.2 eba is an acquired, autoimmune cutaneous subepidermal blistering disease that primarily involves the skin, and sometimes mucous membranes. there is no racial or gender predilection. eba often presents in the fourth to fifth decades of life. the hallmark of eba is the presence of autoantibodies (mainly igg class) to type vii collagen, a major component of anchoring fibrils at the dermal-epidermal junction. the disease occurs in approximately 5% of unselected patients with basement membrane zone antibodies.3 the blister-inducing potential of autoantibodies to type vii collagen have been shown by demonstrating their capacity to trigger an fcγdependent inflammation leading to split formation in cryosections of human skin.4 clinically eba is subdivided into two clinical types: the inflammatory and the non-inflammatory phenotype.5 patients with the noninflammatory form of eba (the classical eba type) have increased skin fragility with subsequent formation of blisters or erosions on the trauma-prone areas of the skin, such as extensor surfaces of elbows, knees, ankles, and buttocks. tense vesicles and bullae appear on noninflamed skin or scarred skin. nail dystrophy and scarring alopecia have been observed in some patients with the classical eba. the inflammatory form of eba can mimic almost all other chronic bullous diseases, and its clinical differentiation from bullous pemphigoid, mucous membrane pemphigoid and linear iga bullous dermatosis may be difficult.6 it presents with widespread, tense vesicles and bullae and is not localized to trauma-prone sites and generally heals with minimal scarring and milia formation. progressive and recurrent disease in the mucosal tissues can result in irreversible complications similar to those seen in mucous membrane pemphigoid (mmp) including blindness and oesophageal strictures.7 by electron microscopy, the cleavage plane can be seen within the lamina lucida or sub-lamina densa regions of the dermal-epidermal junction. if the cleavage is within the lamina lucida, it is associated with the presence of an inflammatory infiltrate rich in polymorphonuclear neutrophils.8 the deeper level of split in the non-inflammatory eba type may explain why it usually heals with significant scar and milia formation, which is only rarely observed in the inflammatory type (table 1). diagnostic techniques the first diagnostic criteria for eba were established in the early 1970s by roenigk and associates. they were i) spontaneous or trauma-induced blisters resembling hereditary dystrophic eb, ii) adult onset, iii) a negative family history for eb, and iv) the exclusion of all other bullous diseases.17 however, since then at least 33 verified cases of childhood eba have been reported in the literature, mainly of the inflammatory subtype.18 in addition a diagnosis of eba cannot be done reliably solely by clinical findings, because of the variable clinical and histological presentations. immunofluorescence techniques remains the cornerstone of the diagnosis of eba and have increasingly replaced the immunoelectron microscopy (iem) as the gold standard.19 other investigative diagnostic techniques are immunoblotting, elisa, and immunoprecipitation. direct immunofluorescence (dif) on perilesional skin demonstrates linear immune deposits of immunoreactants, mainly igg, at the basement membrane zone. however deposits of iga, igm, c3, c4, or properdin may be detected as well. in eba depositions of igg in the absence of c3 is seen more commonly than in bp. furthermore, deposits of multiple conjugates (including igg, iga, igm, c3, c4, or properdin) are seen more frequently in the setting of eba.7 indirect immunofluorescence (iif) can detect the presence of circulating igg autoantibodies, directed against type vii collagen in the basement membrane, it usually detects the igg autoantibodies that binds to the dermal floor on salt split skin. salt split skin substrate can be used to distinguish eba and bullous pemphigoid (bp), because igg autoantibodies from patients with bullous pemphigoid bind to the epidermal roof (upper part) of salt-split skin. if the antibody labels the dermal side of the separation, the patient usually has either eba or bullous sle (there are, however, other diseases with dermal staining; anti-epiligrin (lamina-5), cicatricial pemphigoid, chan’s disease, zilliken’s disease and ghohestani’s disease).19 a breakthrough in the diagnostics was the observation of specific serration patterns in the autoantibody deposits at the basement membrane in direct immunofluorescence. besides a true linear staining pattern, two dif immunodeposition patterns have been described i) a u-serrated staining pattern is typical of eba, and ii) an n-serrated staining pattern in other subepidermal immunobullous diseases.9 the binding of autoantibodies in eba to type vii collagen, can ultrastructurally be seen as upstanding arms between the rootlets of the basal keratinocytes, resulting in u shapes. consequently these two distinct patterns can be applied in order to differentiate eba from other pemphigoid variants by dif only. the type of serration in the case of iga and igg is similar, however, in the case of iga it is more easily recognized due to better fluorescence image contrast. diseases such as iga-mediated eba and inflammatory eba may look like bp, however, using the serration patterns algorithm, patients with eba who otherwise would have been erroneously diagnosed can be detected. immunoelectron microscopy (iem) documents the localization of the immune deposits within the dermal-epidermal junction of the skin of eba patients. by direct immunoelec dermatology reports 2011; volume 3:e38 correspondence: christine r. mehren, department of dermatology, bispebjerg hospital, copenhagen, denmark. e-mail: c_mehren@hotmail.com key words: bullous pemphigoid, epidermolysis bullosa, serration pattern, immunofluorescence. received for publication: 14 april 2011. accepted for publication: 9 august 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright c.r. mehren and r. gniadecki., 2011 licensee pagepress, italy dermatology reports 2011; 3:e38 doi:10.4081/dr.2011.e38 no nco mm er cia l u se on ly [page 84] [dermatology reports 2011; 3:e38] review table 1. comparison of the clinical and immunopathological features of subepidermal blistering diseases. subepidermal immunobullous clinical characteristic dif binding on serration disease features salt split skin pattern bullous elderly, most common autoimmune blistering igg and c3 or c3 alone (± epidermal n-serrated9 pemphigoid (bp) disease. tense blisters on inflammed or non weaker staining igm, iga) at (few dermal) inflamed skin. pruritus common, variable the dermal-epidermal junction. severity. more common in patients with multiple sclerosis. predilection sites: the inner or anterior thighs, groins, flexor surfaces of the upper extremities and lower abdomen. oral mucosal lesions are rare. pemphigoid during pregnancy and/or puerperium; urticarial linear deposition of c3 epidermal as bp; gestationis plaques and/or tense blisters. pruritus typically ± igg at the dermaln-serrated severe. epidermal junction. predilection sites: umbilical and periumbilical regions; trunk and extremities. lichen planus usually benign, tense blisters and lesions of linear deposits of igg at the epidermal unknown pemphigoides lichen planus (usually persistent) on top of dermal-epidermal lichen planus lesions or on clinically normal skin. junction. predilection sites: the extremities, trunk and oral mucosa. mucous membrane elderly (female) patients. in anti-bp180 mmp and epidermal in n-serrated9 pemphigoid tense blisters and erosions with scar antilamin 332 mmp10: linear anti-bp 180 mmp formation. igg, ±c3 occasionally iga. and ocular mmp predilection sites: mucosa of the mouth, eyes, nose, larynx, eosohagus or anogenital in ocular mmp:11 linear dermal in antilamin regions. iga ±igg. 332 mmp dermatitis herpetiformis adult patients. erythematous papules, granular papillary and negative irrelevant urticarial plaques, papulovesicles, vesicles and basement membrane iga. rarely bullae, isolated or in herpetiform grouping often healing with scar formation. intensely pruritic. predilection sites: symmetrically distributed lesions on extensor surface of the extremities, scalp, nape, shoulders, sacral region and buttocks. linear iga disease papulovesicular eruption in cluster of jewels linear iga (rarerly granular) at epidermal n-serrated9 configuration. pruritic the dermal-epidermal junction. (few dermal) (ranging from mild to severe). predilection sites: trunk, extremitites, the face, abdomen and perineum. frequent mucous membrane involvement (may induce severe complications). linear iga/igg bullous dermatosis12 resemble the lesions of bp, annular vesicobullous linear iga and igg ± c3 at the epidermal (few probably lesions with frequent involvement of the oral dermal-epidermal junction. dermal or both n-serrated mucosa. epidermal and dermal) predilection sites: no specific anti-p450-pemphigoid13 only one case in literature, fujiwara et al.14 only one case in literature, epidermal13 unknown fujiwara et al.14 anti-p200 pemphigoid32 often resembles bp, could resemble dermatitis linear igg and c3 at the dermaldermal n-serrated9 herpetiformis, linear iga disease or eba. could epidermal junction. involve mucous membranes. often coexisting psoriasis. (rapid response to treatment) epidermolysis bullosa acquisita classical eba: skin fragility, traumainduced linear igg (± iga, igm), c3 dermal u-serrated9 blisters and erosions. at the dermal-epidermal predilection sites: extensor surfaces of the junction. extremities. ± mucous membrane lesion. inflammatory eba: widespread eruptions of tense blisters on erythematous or normal appearing skin. predilection sites: usually on flexural and/or intertriginous areas. ± mucous membrane lesions bullous sle mainly adult patients. tense blisters on normal or linear or granular depositions dermal (rarely u-serrated9 erythematous skin, eruptions usually in a of igg (± igm, iga, c3) at the epidermal or herpetiform arrangement in patients with sle. dermal-epidermal junction. combined binding) pruritus may be severe. predilection sites: trunk and flexural surfaces. frequently oral lesions. anti-p105-pemphigoid16 bullae and erosions on mucous membrane and linear igg and c3 deposition dermal13 unknown skin, resembling toxic epidermal necrolysis or at the skin basement pemphigus vulgaris13 membrane zone13 no nco mm er cia l u se on ly [dermatology reports 2011; 3:e38] [page 85] tron microscopy the ultrastructural localization of in vivo-bound igg autoantibodies at the basement membrane is documented. with indirect immunoelectron microscopy the binding site of circulating igg autoantibodies at the basement membrane is detected. iem detects igg autoantibodies at the lamina densa and sublamina densa areas of skin basement membrane. bullous pemphigoid igg autoantibodies, on the contrary, are localized to the hemidesmosome and upper lamina lucida.20 immunoblotting represents a sensitive detection method for eba.21 eba sera will bind to a 290-kda band in western blots of human skin basement membrane proteins containing type vii collagen, whereas sera from all other primary blistering diseases will not. this band corresponds to a single alpha chain of the type vii collagen homotrimer molecule.22 western blotting differentiates between anti-p200 pemphigoid and eba. to distinguish between the latter two disorders, patients’ sera have to be subjected to western blotting of extract from human dermis and then react with 200 and 290 kda proteins in antip-200 pemphigoid and eba, respectively.2 elisa (enzyme-linked immunosorbent assay) documents the specific basement membrane antigen recognized by the patient's igg circulating autoantibodies. the elisa method identifies non-denaturated, nonreduced proteins and is more sensitive than immunoblotting, which only detects denatured, reduced proteins.7 treatment compared with other autoimmune blistering diseases, eba has a decreased responsiveness to therapy. inflammatory eba, eba presenting in children and iga-eba, respond more favourably to the conventional treatment approach of high-dose corticosteroids and corticosteroid sparing agents. in most cases of iga-eba, the skin lesions respond to therapy with dapsone alone. dapsone and low-dose prednisone are usually effective in treating childhood eba.18 however, high doses of corticosteroids are not recommended as maintenance therapies as the adverse effects of corticosteroids are both time and dose dependent. non-inflammatory (classical) eba is often refractory to systemic corticosteroids, azathioprine, methotrexate, and cyclophosphamide.23 therapeutic options that have proven effective in retrospective observations include extracorporeal photochemotherapy (ecp), i.v. immunoglobulin (ivig), and rituximab. the treatment of eba patients with ivig has shown encouraging results. in one retrospective analysis two patients with severe eba were treated with monthly cycles of ivig. one of the patients had a complete response, defined as absence of lesions for more than 4 weeks without any treatment. the other patient responded to the treatment, however, due to metastatic lung cancer the treatment was discontinued.24 another case describes a patient treated with 6 cycles of ivig at a dose of 400 mg/kg per day for 5 consecutive days (repeating the cycle every 4 weeks). after the second cycle, most of the erosions had healed and marked remission was observed during the 6-month follow-up period. the patient did not experience any negative side effects.25 patients that have had unsatisfactory response to steroid, immunosuppressive agents and ivig may benefit from the therapy with rituximab. this monoclonal antibody reacting against cd20 depletes mature, autoreactive b-cells. of the reported cases of eba patients treated with rituximab, either complete remission or very good partial remissions have been reported. in one retrospective analysis the patient, a 58-year old woman, had to be hospitalized due to the severity of eba. she had extensive cutaneous and oral ulceration, cellulitis and a deep vein thrombosis secondary to immobility. after four rituximab infusions at a dose of 375 mg m-2, she experienced complete remission.26 another patient, a 54-year-old woman experienced a partial remission within a month after the onset of rituximab. after twelve rituximab infusions at a dose of 375 mg m-2, she experienced almost complete cutaneous clearance with improved oral intake and mobility.27 rituximab can safely be combined with high-dose ivig, which may exert a synergistic effect and simultaneously protect against serious infection-related adverse events.28,29 long-term ecp has been reported to induce remission in three patients with drug resistant, aggressive cases of eba.30 ecp is based on separation of a leukocyte/lymphocyte-enriched cell fraction from the peripheral blood, extracorporeal treatment of the cells with 8mop/uva, and subsequent reinfusion of the cells in the patient. the main effects in eba seem to consist in inhibition of pathogenetic autoantibody production by b lymphocytes and generation of regulatory t cells. when treating a patient with eba, it is important to be aware of coexisting systemic diseases that might influence the choice of therapy. among the systemic diseases reported in association with eba, are malignancies and autoimmune diseases.23 inflammatory bowel disease (ibd) is one of the more common systemic illnesses associated with eba; 25% of eba patients have ibd.31 there are a few cases of eba patients with coexisting psoriasis.32 ultraviolet radiation is not a treatment option in this case as it has been demonstrated that it can induce blistering in patients with eba.33 references 1. elliott gt. two cases of epidermolysis bullosa. j cutan genitourin dis 1895;13:108. 2. ishii n, hamada t, dainichi t, et al. epidermolysis bullosa acquisita; what’s new. j dermatol 2010;37:220-30. 3. zhu xj, niimi y, bystryn jc. epidermolysis bullosa acquisita. incidence in patients with basement membrane zone antibodies. arch dermatol 1990;126:171-4. 4. sitaru c, kromminga a, hashimoto t, et al. autoantibodies to type vii collagen mediate fcgamma-dependent granulocyte activation and induce dermal-epidermal separation in cryosections of human skin. am j pathol 2002;161:301-11. 5. tanka h, ishida, yamamoto a, et al. a novel variant of aquired epidermolysis bullosa with autoantibodies against the central triple-helical domain of type vii collagen. lab invest 1997;77:623-32. 6. roengik hh, ryan jg, bergfeld wf. epidermolysis bullosa acquisita. report of three cases and review of all published cases. arch dermatol 1971;103:1-10. 7. lehman js, camilleri mj, gibsom le. epidermolysis bullosa acquisita: concise review and practical considerations. int j dermatol 2009;48:227-36. 8. mihai s, sitaru c. immunopathology and molecular diagnosis of autoimmune bullous diseases. j cell mol med 2007;11:46281. 9. vodegel rm, jonkman mf, pas hh, de jong mc. u-serrated immunodeposition pattern differentiates type vii collagentargeting bullous disease from other subepidermal bullous automimmune diseases. br j dermatol 2004;151:112-8. 10. natsuga k, nishie w, shinkuma s, et al. circulating iga and ige autoantibodies in antilaminin-332 mucous membrane pemphigoid. br j dermatol 2010;162:513-7. 11. smith ep, taylor tb, meyer lj, zone jj. identification of a basement membrane zone antigen reactive with circulating iga antibody in ocular cicatricial pemphigoid. j invest dermatol 1993;101:619-23. 12. shimizu s, natsuga k, shinkuma s, et al. localized linear iga/igg dermatosis. acta derm venereol 2010;90:621-4. 13. georgi m, jainta s, bröcker eb, zillikens d. autoantigens of subepidermal bullous autoimmune dermatoses. hautarzt 2001; 52:1079-89. 14. fujiwara s, shinkai h, takayasu s, et al. a case of subepidermal blister disease associated with autoantibody against 450 kd protein. j dermatol 1992;19:610-3. 15. chen kr, shimizu s, miyakawa s, et al. coexistence of psoriasis and an unusual igg-mediated subepidermal bullous der review no nco mm er cia l u se on ly [page 86] [dermatology reports 2011; 3:e38] matosis: identification of a novel 200-kda lower lamina lucida target antigen. br j dermatol 1996;134:340-6. 16. chan ls, cooper kd. a novel immunemediated subepidermal bullous dermatosis characterized by igg autoantibodies to a lower lamina lucida component. arch dermatol 1994;130:343-7. 17. roenigk hh jr, ryan jg, bergfeld wf. epidermolysis bullosa acquisita. report of three cases and review of all published cases. arch dermatol 1971;103:1-10. 18. mayuzumi m, akiyama m, nishie w, et al. childhood epidermolysis bullosa acquisita with autoantibodies against the noncollagenous 1 and 2 domains of type vii collagen: case report and review of the literature. br j dermatol 2006;155:1048-52. 19. woodley d, remington j, chen m. autoimmunity to type vii collagen: epidermolysis bullosa acquisita. clin rev allerg immunol 2007;33:78-84. 20. vodegel rm, de jong mc, pas hh, jonkman mf. iga-mediated epidermolysis bullosa acquisita: two cases and review of the literature. j am acad dermatol 2002; 6:919-25. 21. schmidt e, zillikens d. research in practice: diagnosis of subepidermal autoimmune bullous disorders. j dtsch dermatol ges 2009;7:296-300. 22. woodley dt, briggaman ra, o'keefe ej, et al. identification of the skin basementmembrane autoantigen in epidermolysis bullosa acquisita. n engl j med 1984; 310:1007-13. 23. hallel-halevy, nadelman c, chen m, woodley dt. epidermolysis bullosa acquisita: update and review. clin dermatol 2001;19:712-8. 24. sanli h, akay bn, ayyildiz e, et al. remission of severe autoimmune bullous disorders induced by long-term extracorporeal photochemotherapy. transf apheres sci 2010;43:353-9. 25. segura s, iranzo p, martínez-de pablo i, et al. high-dose intravenous immunoglobulins for the treatment of autoimmune mucocutaneous blistering diseases: evaluation of its use in 19 cases. j am acad dermatol 2007;56:960-7. 26. gourgiotou k, exadaklyou d, aroni k, et al. epidermolysis bullosa acquisita: treatment with intravenous immunoglobulins. j eur acad dermatol venereol 2002;16:77-80. 27. crichlow sm, mortimer nj, harman ke. a successful therapeutic trial of rituximab in the treatment of a patient with recalcitrant high-titre epidermolysis bullosa acquisita. br j dermatol 2007;156:194-6. 28. saha m, cutler t, bhogal b, et al. refractory epidermolysis bullosa acquisita: successful treatment with rituximab. clin exp dermatol 2009;34:e979-e980. 29. peterson jd, chan ls. effectiveness and side effects of anti-cd20 therapy for autoantibody-mediated blistering skin diseases: a comprehensive survey of 71 consecutive patients from the initial use to 2007. ther clin risk manag 2009; 5:1-7. 30. schmidt e, bröcker e-b, goebeler m. rituximab in treatment-resistant autoimmune blistering skin disorders. clin rev allerg immunol 2008;34:56-64. 31. chen m, o´toole ea, sanghavi j, et al. the epidermolysis bullosa acquisita antigen (type vii collagen) is present in human colon and patients with chron’s disease have autoantibodies to type vii collagen. j invest dermatol 2002;6:1059-64. 32. kabashima r, hino r, bito t, et al. epidermolysis bullosa acquisita associated with psoriasis. acta dermatol venereol 2010; 90:314-6. 33. jappe u, zillikens d, bonnekoh b, gollnick h. epidermolysis bullosa acquisita with ultraviolet radiation sensitivity. br j dermatol 2000;142:517-20. review no nco mm er cia l u se on ly hrev_master [page 12] [dermatology reports 2009; 1:e4] a case of rheumatic fever with acute post-streptococcal glomerulonephritis and nephrotic syndrome caused by a cutaneous infection with beta-hemolytic streptococci carsten sauer mikkelsen,1 allan gelvan,1 ahmad ibrahim,2 karin ladefoged1 1department of medicine, queen ingrid’s hospital, nuuk, greenland; 2department of nephrology, copenhagen university hospital (rigshospitalet), denmark case report a 44-year old woman of greenlandic origin was referred to queen ingrid’s hospital. she was previously healthy apart from excessive alcohol consumption and pulmonary tuberculosis diagnosed two years earlier for which she had received full antimycobacterial treatment. the patient initially complained of a painful traumatic skin lesion of the right lower extremity with a diameter of approximately 2 cm. a few days later, her temperature rose to 39.5°c and bullous erysipelas of the area of initial trauma was noted. laboratory tests revealed a markedly elevated sedimentation rate of 111 mm/l hour [2-21], an elevated c reactive protein of 144 mg/l [<10], leukocytosis 18¥109/l [4.4-11] with neutrophilia and ¥109/l [150-450]. intravenous dicloxacillin and phenoxymethylpenicillin were administered. culture from the lesion of the right lower extremity was positive for group a βhemolytic streptococci (gabhs). in spite of relevant antibiotic treatment, the clinical condition rapidly deteriorated with involvement of the deeper layers of the skin and subcutaneous tissue, spreading across the fascial planes of the subcutis (figure 1). necrotizing fasciitis (nf) was diagnosed. based on positive skin cultures, this condition was considered to be due to gabhs. the patient had no other predisposing factors to nf, specifically no diabetes mellitus, no intravenous abuse and no daily intake of non-steroidal anti-inflammatory drugs (nsaid). radiological examination of the right lower extremity and foot showed no signs of osseous involvement. extensive surgical revision of the nf-lesion was performed and meropenem, ciprofloxacin and clindamycin were administered. approximately three weeks after the initial presentation, impairment of renal function with azotemia and severe nephrotic syndrome with periorbital and peripheral edema were noted. laboratory tests showed an elevated creatinine of 386 umol/l [44-115], bun: 23.6 mmol/l [2.56.7], normochromic, normocytic anemia with hemoglobin: 4.9 mmol/l [7.5-9.0], as well as macroscopic hematuria, renal-creatinine clearance: 30 ml/min and u-protein: 5.8 g/24 h [<0.15]. anti nuclear antibodies (ana), antineutrophil cytoplasmic antibodies (anca), iga, igg, igm and protein electrophoresis were all normal. blood pressure was increased to 165/100. the hypertension was efficiently treated by ace-inhibitors and beta blockers. the patient was transferred to rigshospitalet, copenhagen where a renal biopsy was performed. the biopsy demonstrated endocapillary glomerulonephritis with proliferation of endothelial cells and infiltration of polymorphonuclear cells. using immunofluorescence techniques, granular deposits of igg and c3 were identified as typically seen in acute post-streptococcal glomerulonephritis (apsgn) (figure 2). during the same period, the patient complained of chest pain. electrocardiogram (ecg) showed sinus rhythm with no signs of ischemia and no elevation of cardiac troponin i was found. echocardiography showed moderate reduced left ventricular ejection fraction (lvef): 35% [50-65%] and moderate mitral regurgitation (grade ii). pulmonary pressure was significantly increased > 60 mm hg [1825]. brain natriuretic peptide (bnp) was significantly increased >8000 pg/ml [<100]. there were complaints of arthralgia of the left elbow. there were no other signs of acute rheumatic fever (arf) and no signs of pharyngitis in the whole period. chest x ray and hr-ct of the thorax showed changes in both lungs consistent with old tuberculosis. two weeks after the first analysis, renal function had improved and uprotein had decreased to 2.6 g/24 h, creatinine 139 umol/l, bun 9.5 mmol/l. ultrasound of the kidneys was normal. echocardiography still dermatology reports 2009; volume 1:e4 correspondence: carsten sauer mikkelsen, department of dermatology, stavanger university hospital, arnauer hansensvej 20, postbox 8100 postterminalen, 4068 stavanger norway. e-mail: c.s.mikkelsen@privat.dk and c.s.mikkelsen@hotmail.com key words: rheumatic fever, acute post-streptococcal glomerulonephritis, nephrotic syndrome. received for publication: 18 november 2009. accepted for publication: 14 december 2009. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright c.s. mikkelsen et al., 2009 licensee pagepress, italy dermatology reports 2009; 1:e4 doi:10.4081/dr.2009.e4 figure 1. group a b-hemolytic streptococci with involvement of the deeper layers of the skin and subcutaneous tissue, spreading across the fascial planes of the subcutis. figure 2. diffuse proliferative glomerulonephritis with approximately 40% halfmoons. significant tubulus atrophy and interstitial fibrosis with inflammation. endocapillary glomerulonephritis, with accumulation of endothelial cells and inflammatory cells in the capillary lumina. changes compatible with acute poststreptococcal glomerulonephritis. no signs of systemic disease or vasculitis. no nco mm er cia l regurgitation (grade ii). pulmonary pressure no nco mm er cia l regurgitation (grade ii). pulmonary pressurewas significantly increased > 60 mm hg [18no nco mm er cia l was significantly increased > 60 mm hg [18-25]. brain natriuretic peptide (bnp) was signo nco mm er cia l 25]. brain natriuretic peptide (bnp) was signo nco mm er cia l and phenoxymethylpenicillin were adminisno nco mm er cia l and phenoxymethylpenicillin were administered. culture from the lesion of the right no nco mm er cia l tered. culture from the lesion of the right lower extremity was positive for group a no nco mm er cia l lower extremity was positive for group a β no nco mm er cia l βno nco mm er cia l hemolytic streptococci (gabhs). in spite of no nco mm er cia l hemolytic streptococci (gabhs). in spite of relevant antibiotic treatment, the clinical conno nco mm er cia l relevant antibiotic treatment, the clinical condition rapidly deteriorated with involvement ofno nco mm er cia l dition rapidly deteriorated with involvement of the deeper layers of the skin and subcutaneousno nco mm er cia l the deeper layers of the skin and subcutaneousno nco mm er cia l u se found. echocardiography showed moderate us e found. echocardiography showed moderatereduced left ventricular ejection fraction us e reduced left ventricular ejection fraction (lvef): 35% [50-65%] and moderate mitralus e (lvef): 35% [50-65%] and moderate mitral regurgitation (grade ii). pulmonary pressureus e regurgitation (grade ii). pulmonary pressure was significantly increased > 60 mm hg [18-us e was significantly increased > 60 mm hg [18the whole period. chest x ray and hr-ct of the us e the whole period. chest x ray and hr-ct of the thorax showed changes in both lungs consistent us e thorax showed changes in both lungs consistentwith old tuberculosis. two weeks after the first us e with old tuberculosis. two weeks after the firsto nly nificantly increased >8000 pg/ml [<100]. on lynificantly increased >8000 pg/ml [<100]. on lythere were complaints of arthralgia of the left on lythere were complaints of arthralgia of the leftelbow. there were no other signs of acute rheuon lyelbow. there were no other signs of acute rheumatic fever (arf) and no signs of pharyngitis inon ly matic fever (arf) and no signs of pharyngitis in the whole period. chest x ray and hr-ct of theon ly the whole period. chest x ray and hr-ct of the thorax showed changes in both lungs consistent on ly thorax showed changes in both lungs consistent on ly [dermatology reports 2009; 1:e4] [page 13] showed moderate reduced left ventricular ejection fraction (lvef): 35% with mild mitral regurgitation (grade i). continued follow-up of renal and cardiac function is planned. discussion this case illustrates the simultaneous development of carditis, arthralgia and endocapillary glomerulonephritis with severe nephrotic syndrome preceded by a cutaneous gabhs in the lower right leg. the patient fulfils the revised and updated jones criteria for classification of arf based on fever, arthralgia, carditis, increased acute phase reactants (crp, esr) and a positive culture of gabhs. arf develops after group a streptococcal pharyngitis1,2 and is only seldom described after gabhs skin infections.3-5 our patient had no signs of pharyngitis but developed nf presumably from a traumatic skin lesion. culture from the initial lesion of the right lower extremity was positive for gabhs.we propose that our patient developed arf from her skin infection. we are aware of no history of sore throat described in the literature in cases of arf.6 also throat swab will be positive in only a third of patients infected with group a streptococcus before antibiotic treatment and in only a tenth of patients afterwards.7 gas pyoderma rather than pharyngitis as a driving force behind arf has been described in aboriginal communities in northern australia.8,9 repeated exposure to gabhs can play a central role in the development of arf10 as a sort of immune priming.8 in our case there was no previous history of pharyngitis or other focus of gabhs infections. arf and apsgn, two important sequelae of streptococcal throat or skin infections, according to current concepts may be elicited by autoimmune mechanisms due to molecular mimicry between gabhs and human tissue.11 apsgn follows infection with a limited number of gabhs serotypes. type 12 is the most frequent m serotype causing apsgn after pharyngitis or tonsillitis, whereas m-49 is the type most frequently related to pyoderma-associated nephritis.12 the patient had no earlier symptoms of heart disease and so we strongly suspect the high bnp and and moderate mitral regurgitation to be carditis related to arf. in affluent societies where gabhs disease is uncommon apart from pharyngitis in childhood, increasing numbers of nf and streptococcal toxic shock syndrome (stss) have been seen, as well as an upsurge of acute rheumatic fever apparently restricted to parts of the united states.13-16 in some of these locations, a virulent m1 serotype gabhs clone has been found.17 we suggest a possible relation between a virulent gabhs clone causing nf and arf. references 1. wannamaker l. the chain that links the heart to the throat. circulation 1973;48:918. 2. wannamaker l. differences between streptococcal infections of the throat and of the skin. n engl j med 1970;282:78-85 3. popat k. riding w. acute rheumatic fever following streptococcal wound infection. postgrad med j 1976;52:165-70. 4. mcdonald mi, towers rj, andrews r, et al. the dynamic nature of group a streptococcal epidemiology in tropical communities with high rates of rheumatic heart disease. epidemiol infect 2008;136:529-39. 5. mcdonald mi, towers rj, andrews r, et al. molecular typing of streptococcus pyogenes from remote aboriginal communities where rheumatic fever is common and pyoderma is the predominant streptococcal infection. epidemiol infect 2007; 135:1398-405. 6. wilson nj, neutze jm. echocardiographic diagnosis of subclinical carditis in acute rheumatic fever. int j cardiol 1995;50:1-6 7. jansen tltha, janssen m, van reil plcm. acute rheumatic fever or post-streptococccal reactive arthritis: a clinical problem revisited. br j rheumatol 1998;37:335-40. 8. mcdonald m, currie bj, carapetis jr. acute rheumatic fever: a chink in the chain that links the heart to the throat. lancet infect dis 2004:4:240-5. 9. currie bj, carapetis jr. skin infections and infestations in aboriginal communities in northern australia. australas j dermatol 2000;41:139-43. 10. cunningham mw. pathogenesis of group a streptococcal infections. clin microbiol rev 2000;13:470-511 11. burova al, nagornev va, pigarevsky pv, gladilina mm, seliverstova, et al. myocardial tissue damage in rabbits injected with group a streptococci, types m1 and m22. role of bacterial immunoglobulin gbinding surface proteins. apmis 2005; 113:21-30. 12. bisno al, brito mo, collins cm. molecular basis of group a streptococcal virulence. lancet infect dis 2003:3:191-200. 13. stevens dl. the flesh-eating bacterium: what`s next? j infect dis 1999;179:s36674. 14. chelsom j, halstensen a, haga t, højby ea. necrotising fasciitis due to group a streptococci in western norway: incidence and clinical features. lancet 1994;344: 1111-15. 15. kaul r, mcgeer a, low de, gren k, schwartz b. population based surveillance for group a streptococcal necrotizing fasciitis: clinical features, prognostic indicators, and microbiologic analysis of seventy cases. am j med 1997;103:18-24. 16. haywood c, mcgeer a, low d. clinical experience with 20 cases of group a streptococcus necrotizing fasciitis and myo necrosis: 1995-1997. plast reconst. surg 1999, 103: 1567-73 17. cleary pp, kaplan el, handley jp, et al. clonal basis for resurgence of serious streptococcus pyogenes disease in the 1980`s. lancet 1992;339:518-21. case report no nco mm er cia l 3. popat k. riding w. acute rheumatic fever no nco mm er cia l 3. popat k. riding w. acute rheumatic feverfollowing streptococcal wound infection. no nco mm er cia l following streptococcal wound infection. postgrad med j 1976;52:165-70. no nco mm er cia l postgrad med j 1976;52:165-70. no nco mm er cia l pharyngitis or other focus of gabhs infecno nco mm er cia l pharyngitis or other focus of gabhs infections. arf and apsgn, two important sequelae no nco mm er cia l tions. arf and apsgn, two important sequelae of streptococcal throat or skin infections, no nco mm er cia l of streptococcal throat or skin infections, according to current concepts may be elicited no nco mm er cia l according to current concepts may be elicited by autoimmune mechanisms due to molecular no nco mm er cia l by autoimmune mechanisms due to molecular mimicry between gabhs and human tissue. no nco mm er cia l mimicry between gabhs and human tissue. apsgn follows infection with a limited numberno nco mm er cia l apsgn follows infection with a limited number of gabhs serotypes. type 12 is the most fre-no nco mm er cia l of gabhs serotypes. type 12 is the most fre4. mcdonald mi, towers rj, andrews r, et al. no nco mm er cia l 4. mcdonald mi, towers rj, andrews r, et al. the dynamic nature of group a streptococno nco mm er cia l the dynamic nature of group a streptococcal epidemiology in tropical communities no nco mm er cia l cal epidemiology in tropical communities with high rates of rheumatic heart disno nco mm er cia l with high rates of rheumatic heart disease. epidemiol infect 2008;136:529-39. no nco mm er cia l ease. epidemiol infect 2008;136:529-39. 5. mcdonald mi, towers rj, andrews r, et al. no nco mm er cia l 5. mcdonald mi, towers rj, andrews r, et al. molecular typing of streptococcus pyono nco mm er cia l molecular typing of streptococcus pyogenes from remote aboriginal communino nco mm er cia l genes from remote aboriginal communities where rheumatic fever is common and no nco mm er cia l ties where rheumatic fever is common and us e 2. wannamaker l. differences between us e 2. wannamaker l. differences betweenstreptococcal infections of the throat and us e streptococcal infections of the throat and of the skin. n engl j med 1970;282:78-85us e of the skin. n engl j med 1970;282:78-85 3. popat k. riding w. acute rheumatic feverus e 3. popat k. riding w. acute rheumatic fever on ly heart to the throat. circulation 1973;48:9on ly heart to the throat. circulation 1973;48:9binding surface proteins. apmis 2005; on ly binding surface proteins. apmis 2005; 113:21-30. on ly113:21-30.12. bisno al, brito mo, collins cm. molecular on ly12. bisno al, brito mo, collins cm. molecularbasis of group a streptococcal virulence. on lybasis of group a streptococcal virulence. lancet infect dis 2003:3:191-200.on ly lancet infect dis 2003:3:191-200.on ly 13. stevens dl. the flesh-eating bacterium:on ly 13. stevens dl. the flesh-eating bacterium: dr [page 1] [dermatology reports 2011; 3:e1] a severe case of tetracyclineinduced intracranial hypertension anders vedel holst,1 patricia l. danielsen,2 bertil romner1 1department of neurosurgery, rigshospitalet, copenhagen university hospital; 2bispebjerg university hospital, department of dermatology and venerology, copenhagen, denmark abstract tetracykline is a first-line treatment of the common skin disorder acne vulgaris. a rare side effect of tetracycline treatment is intracranial hypertension also called pseudotumor cerebri (ptc). we report a severe case of ptc with cranial nerve palsy and visual loss in a 16 year old girl following acne vulgaris treatment with tetracycline. introduction pseudotumor cerebri (ptc) is characterized by elevated intracranial pressure without paraclinical or radiologic manifestations that is idiopathic or can be produced by various medications e.g. tetracycline. it most frequently occurs in obese women of childbearing age and the incidence in the general population has been estimated to 0.9 per 100,000.1,2 because of increasing obesity the incidence might be rising. clinically patients present with papilledema as the most important sign and symptoms of headache, visual disturbances and photosensitivity.3 the most feared consequence is visual loss that may be severe and permanent, and cerebral ventriculoperitoneal shunting may be necessary for symptomatic treatment.4 acne vulgaris is an extremely common skin disorder that affects virtually all individuals at least once in life with a peak at age 18. inflammatory lesions include papules, pustules and nodules usually located to face, neck, chest, upper back and upper arms.5 for the moderate to severe form tetracycline is the first-line treatment of choice.6 tetracycline has a bacteriostatic effect on p. acnes that possibly begins the inflammatory cascade leading to acne, though other unclear mechanisms of the drug also exist.7 case report a 16 year-old obese (bmi 32) girl, (figure 1) otherwise healthy, was admitted to the department of neurosurgery on suspicion of ptc. during the last year she had experienced intermittent episodes of headache. six weeks before admittance her gp had initiated tetracycline treatment 500 mg po per day because of acne vulgaris. three weeks after her headaches worsened and no longer responded on acetaminophene, codeine or asa treatment. she also experienced nausea and multiple episodes of vomiting. four weeks after she developed diplopia and on her own initiative she stopped taking tetracycline. she was seen by an ophtalmologist who discovered bilateral papilledema and paresis of the right abducens nerve. acetozolamide treatment po 250 mg two times daily was initiated. ct and mr scans showed no pathological findings and lumbar puncture showed no signs of infection. pressure measurement was not performed. four days later symptoms had worsened with further loss of vision, bilateral abducens nerve palsy and a fixed dilated right pupil. the patient was transferred to the department of neurosurgery where an external ventricular drain (evd) was inserted in the right lateral ventricle. initial intracranial pressure was measured to 42 mmhg (normal pressure 5-15 mmhg). drainage volumes were as high as 400 ml/day. intracranial pressure was measured every hour and near-normalized to about 20 mmhg. after placement of evd headache resolved completely and bilateral abducens palsy cleared. two days later the drain was converted to a permanent ventriculoperitoneal shunt. discussion the general practitioner as well as the dermatologist is often confronted with patients with acne vulgaris. ptc can occur idiopathic in obese women, even without the use of medication. obese women with a history of headache treated with tetracycline, doxycycline, minocyline and isotretinoin complaining of worsening in intensity or frequency should evoke suspicion of this rare complication on a low threshold. combination therapy with tetracycline and retinoids may hold a higher risk of ptc. references 1. ireland b, corbett jj, wallace rb. the search for causes of intracranial hypertension. arch neurol 1990;47:315-20. 2. durcan fj, corbett jj, wall m. the incidence of pseudotumor cerebri: population studies in iowa and louisiana. arch neurol 1988;45:875-7. 3. wall m, george d. idiopathic intracranial hypertension: a prospective study of 50 patients. brain 1991;114:155-80. 4. bynke g, zemack g, bynke h, romner b. ventriculoperitoneal shunting for idiopathic intracranial hypertension. neurol ogy 2004;63:1314-16. 5. brown sk, shalita ar. acne vulgaris. lancet 1998;351:1871-6. 6. haider a, shaw, jc. treatment of acne vulgaris. jama 2004;292:726-35. 7. friedman di. medication-induced intra cranial hypertension in dermatology. am j clin dermatology 2005;6:29-37. dermatology reports 2011; volume 3:e1 correspondence: patricia l. danielsen, bispebjerg university hospital, department of dermatology and venerology2, copenhagen, denmark. e-mail: patriciadanielsen@yahoo.dk key words: tetracycline, intracranial hypertension. received for publication: 27 september 2010. revision received: 13 october 2010. accepted for publication: 18 october 2010. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a.v. holst et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e1 doi:10.4081/dr.2011.e1 figure 1. 16-year old girl with moderate acne vulgaris after insertion of external ventricular drain. no nco mm er cia l u se on ly hrev_master [dermatology reports 2009; 1:e1] [page 9] 2002;6:593-8. 13. olszewski wl, moscicka m, zolich d, et al. human keratinocyte stem cells survive for months in sodium chloride and can be successfully transplanted. transplant proc 2005;37:525-6. 14. hong kk, lew bl, kim yi, et al. the effect of tnf-alpha and inf-gamma on the telomerase activity of cultured human keratinocyte. ann dermatol 2007;19:147-52. 15. korzeniewski c, callewaert dm. an enzyme-release assay for natural cytotoxicity. j immunol methods 1983;64:313-20. 16. kaur p, li a. adhesive properties of human basal epidermal cells: an analysis of keratinocyte stem cells, transit amplifying cells, and postmitotic differentiating cells. j invest dermatol 2000;114:413-20. 17. choi jh. epidermal stem cells. korean j invest dermatol 2003;10:137-42. 18. nijhof jg, van pelt c, mulder aa, et al. epidermal stem and progenitor cells in murine epidermis accumulate uv damage despite ner proficiency. carcinogenesis 2007;28:792-800. 19. caricchio r, mcphie l, cohen pl. ultraviolet b radiation-induced cell death: critical role of ultraviolet dose in inflammation and lupus autoantigen redistribution. j immunol 2003;171:5778-86. 20. kim pk, weller r, hua y, et al. ultraviolet irradiation increases fadd protein in apoptotic human keratinocytes. biochem biophys res comm 2003;302:290-5. 21. jeong ej, choi sh, chang se, et al. putative progenitor/stem cells isolated from human oral mucosa are resistant to ionizing radiation. j dermatol sci 2008; 50:65-8. 22. reya t, morrison sj, clarke mf, et al. stem cells, cancer, and cancer stem cells. nature 2001;414:105-11. article no nco mm er cia l u se on ly dr [page 122] [dermatology reports 2011; 3:e54] bullous mycosis fungoides associated with an extensive ulcer and a severe leukemoid reaction shuei sato,1 osamu okamoto,1 michifumi kawamoto,1 masaki oishi,1 naomi yada,2 kazuhiro kohno,3 shigeo yokoyama,2 sakuhei fujiwara1 1department of dermatology, 2pathology and 3hematological unit of internal medicine, faculty of medicine, oita university, 1-1 idaigaoka, hasama-machi, yufu-shi, oita, japan abstract this report presents a case of bullous mycosis fungoides associated with an extensive ulcer and a severe leukemoid reaction. the rash began as indurated erythema which was always followed by ulceration. the rashes initially responded to radiation therapy, but multiple recurrences appeared. several bullae appeared on the trunk during the course of the illness, without any evidence of paraneoplastic pemphigus. finally, the ulcer covered a large part of the trunk, and the patient died of sepsis with an extreme leukocyte count of 118,000/μl. a bone marrow analysis revealed a leukemoid reaction and an autopsy revealed pseudomembranous colitis. introduction bullous mycosis fungoides (bullous mf) is a rare clinical condition and the cases showing an extensive ulcer are quite problematic. it is supposed that mf patients could become septic following the formation of ulcers, and their prognosis would be poor. reactive leukocytosis with a leukocyte count over about 25,000 is called a leukemoid reaction. various causes of leukemoid reactions, such as infections, malignant tumors, etc., are known,1,2 and pseudomembranous colitis is a frequent cause of such infections.1,3 notably, an extensive leukemoid reaction which takes the leukocyte count over 50,000/µl has a poor prognosis,3 and the development of a leukocyte count of over 100,000/µl is very rare. this report presents a case of bullous mf demonstrating a strong tendency to form skin ulcers. another notable abnormality of this case was extreme leukocytosis up to 118,000/µl before death. the leukocytosis was proven to be a leukemoid reaction, and pseudomembranous colitis was revealed by an autopsy. in this case, the ulcer formation due to bullous mf, pseudomembranous colitis, and the leukemoid reaction were all assumed to be related. therefore, this report presents a thorough description of the case, together with a review of two rare clinical conditions of bullous mf and of a severe leukemoid reaction. case report a 65-year-old male noted enlarging reddish rashes on his abdomen and left arm in october of 2005. his previous history of rashes was unclear. he was examined at a clinic and a biopsy indicated a diagnosis of cutaneous lymphoma. he was therefore transferred to our hospital and was admitted in january of 2006. an examination revealed freshly-red plaques distributed mainly in non-exposed areas (figure 1a and 1b), and a tumor on the left upper arm (figure 1a). many of the rashes were associated with ulcers (figure 1a and 1b). a blood analysis demonstrated 1% atypical lymphocytes in 9,800/μl leukocytes, and the soluble interleukin-2 receptor (sil-2r) level was 21,900 u/ml (normal value: 145-519), but human t cell lymphoma/leukemia virus-1 antibody was negative. there was a monoclonal gene rearrangement in the cβ1 t-cell receptors from lymphocytes from the skin lesion. a biopsy specimen showed pautrier’s microabscesses in the epidermis as well as a prominent epidermotropism (figure 1c). dense and patchy infiltrations composed of highly atypical lymphocytes were distributed around dermal blood vessels and in the fat layer (figure 1c). over 80 % of the abnormal lymphocytes was cd3(-)/cd4(+)/cd8(+)/cd20(-)/cd30()/cd56(-), about 10% of the cells was cd3()/cd4(+)/cd8(+)/cd20(-)/cd30(+)/cd56(-), and a minor fraction of the cells were cd3(+). from the clinical symptoms and the laboratory findings, the patient was diagnosed to have mf.4 the clinical course of this patient is summarized in figure 2. systemic chop chemotherapy was initiated; the sil-2r level significantly decreased, however, no evident change was seen in the skin eruption. radiation therapy was added at a dose of 30 gy/lesion beginning in april of 2006. the cutaneous plaques initially ulcerated, but healed 5 months later. no active skin lesions were seen between august of 2006 and april of 2007 (figure 2), thus an induction of partial remission was successful. in april 2007, a tumor recurred on the left temporal area, followed by the left side of the lip, and the right upper eyelid, in july and september, respectively (figure 2). these lesions were associated with ulcers on the surface, and they responded to the radiation therapy in the same fashion as before. in november 2007, several bullae developed on the trunk over the course of several days (figure 1d). the bullae were formed subepidermally and the covering epidermis contained prominent pautrier’s microabscesses, and appeared degenerative (figure 1e). paraneoplastic pemphigus was ruled out by direct immunofluorescence. the patient was, therefore, diagnosed to have bullous mf. multiple erythema and ulcers rapidly recurred on the trunk by the end of 2007, and these lesions covered a wide area of the trunk by early january of 2008 (figure 1f). the patient subsequently demonstrated severe hypoproteinemia because of the large amount of exudate from the ulcers, and sepsis, and therefore, the patient was treated with substantial doses of antibiotics. the sil-2r value was elevated again as the eruptions enlarged (33,200 u/ml; figure 2). marked leukocytosis developed on february 11, 2008, and the patient died the next day. the patient’s leukocyte count at the time of his death was 118,000/μl (stab cell 30%, segment cell 10%, myelocyte 37%, metamyelocyte 8%, lymphocyte 7%, and monocyte 4%), and the blood granulocyte colony stimulating factor (g-csf) value was 1300 pg/ml (normal value: 5.78-27.5). an autopsy revealed that the colon was covered with discrete whitish-yellow plaques (figure 3a). the crypts were disrupted and contained fibrinoprulent necrotic debris in a wedge pattern (figure 3b). these findings indicated a diagnosis of pseudomembranous colitis, probably due to the administration of antibiotics to treat the sepsis. a cd45-blast gating analysis of the bone marrow indicated dermatology reports 2011; volume 3:e54 correspondence: osamu okamoto, md, department of dermatology, faculty of medicine, oita university, 1-1 idaigaoka, hasama-machi, yufu-shi, oita, 879-5593, japan. tel: +81.975.86.5882 fax: +81.975.86.5889. e-mail: ookamoto@med.oita-u.ac.jp key words: bullous mycosis fungoides, leukemoid reaction, pseudomembranous colitis. conflict of interest: none declared (the authors report no conflict of interest). received for publication: 17 march 2011. revision received: 16 november 2011. accepted for publication: 18 november 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright s. sato et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e54 doi:10.4081/dr.2011.e54 no nco mm er cia l l leukocytes, and the no nco mm er cia l l leukocytes, and thesoluble interleukin-2 receptor (sil-2r) level no nco mm er cia l soluble interleukin-2 receptor (sil-2r) level was 21,900 u/ml (normal value: 145-519), but no nco mm er cia l was 21,900 u/ml (normal value: 145-519), but human t cell lymphoma/leukemia virus-1 antino nco mm er cia l human t cell lymphoma/leukemia virus-1 antibody was negative. there was a monoclonal no nco mm er cia l body was negative. there was a monoclonal gene rearrangement in the c no nco mm er cia l gene rearrangement in the c tors from lymphocytes from the skin lesion. a no nco mm er cia l tors from lymphocytes from the skin lesion. a biopsy specimen showed pautrier’s microabno nco mm er cia l biopsy specimen showed pautrier’s microabscesses in the epidermis as well as a promino nco mm er cia l scesses in the epidermis as well as a promino nco mm er cia l no nco mm er cia l no nco mm er cia l bullous mycosis fungoides (bullous mf) is a no nco mm er cia l bullous mycosis fungoides (bullous mf) is a rare clinical condition and the cases showingno nco mm er cia l rare clinical condition and the cases showing an extensive ulcer are quite problematic. it isno nco mm er cia l an extensive ulcer are quite problematic. it is nent epidermotropism (figure 1c). dense and no nco mm er cia l nent epidermotropism (figure 1c). dense and patchy infiltrations composed of highly atypino nco mm er cia l patchy infiltrations composed of highly atypical lymphocytes were distributed around derno nco mm er cia l cal lymphocytes were distributed around dermal blood vessels and in the fat layer (figure no nco mm er cia l mal blood vessels and in the fat layer (figure 1c). over 80 % of the abnormal lymphocytes no nco mm er cia l 1c). over 80 % of the abnormal lymphocytes us e were associated with ulcers (figure 1a and us e were associated with ulcers (figure 1a and a blood analysis demonstrated 1% atypicalus e a blood analysis demonstrated 1% atypical l leukocytes, and theus e l leukocytes, and the on the surface, and they responded to the radius e on the surface, and they responded to the radi-ation therapy in the same fashion as before. in us e ation therapy in the same fashion as before. in on ly on ly©copyright s. sato et al., 2011 on ly©copyright s. sato et al., 2011licensee pagepress, italy on lylicensee pagepress, italydermatology reports 2011; 3:e54 on lydermatology reports 2011; 3:e54 doi:10.4081/dr.2011.e54on ly doi:10.4081/dr.2011.e54 [dermatology reports 2011; 3:e54] [page 123] that the major fraction of the cells in the bone marrow to be mature granulocytes, and no blastic change was seen (figure 3c). therefore the leukocytosis was determined to be due to a leukemoid reaction. when the pathological specimen was stained with antig-csf antibody, the tumor cells showed negative staining. discussion because of the wide area of the rashes and a formation of large tumors, we preferred the chemotherapies rather than local therapies such as radiation. however, the effect was marginal, and the fact happened to support a therapeutic guideline of eortc.5 in our case, most of the tumor cells were doubly-positive for cd4 and 8. from other histological findings, this case is diagnosed to have mf,6 however, we could rarely find such cases in the literature.7 although the meaning of a double positivity for cd4 and 8 in mf remains to be determined, it is worth recording this finding. bullous mf is a rare clinical condition. a review of the literature described 9 cases over 30 years,8 and this variant is rarely reported even recently.9 the possible mechanisms of bulla formation in mf include epidermal degeneration due to epidermotropism;10,11 extensive dermal edema due to lymphoma cell infiltration;12 and extensive spongiosis.8,13 the possibility of epidermotropism for the formation of bulla is consistent with the pathology of the current case. the prognosis of bullous mf is generally poor; with about half of the affected patients dying within 1 year after the appearance of the bulla.8 therefore, the formation of bulla during the course of mf indicates a poor prognosis, and the extensive ulceration seen in the current case may reflect a step toward his ultimate death. many causes of leukemoid reaction are known, including infections, malignant tumors, etc.1,2 in the current case, the leukemoid reaction was likely caused by the lymphoma or pseudomembranous colitis. regarding cutaneous lymphoma, the only type which is known to cause a leukemoid reaction to date is anaplastic large cell lymphoma, and the tumor cells usually produce g-csf.14 our patient had mf, and the tumor was negative for g-csf, therefore, the possibility of mf as the cause of the leukemoid reaction is unlikely. in contrast, pseudomembranous colitis is a more common cause of the reaction; a large clinical study showed that 20 out of 334 cases were associated with a leukemoid reaction.3 taken together, the leukemoid reaction in the current case was likely caused by the pseudomembranous colitis. ten of those 20 cases in the clinical study were fatal, and all of the cases had a brief report figure 1. initial appearance of the patient: a) multiple indurated plaques are present on the trunk and extremities. inlet: an ulcerated tumor on the left upper arm; b) a view from the right side. inlet: rashes around the waist. in (a) and (b), ulcers are indicated by arrowheads. note that the distribution of most of the rashes was in non-exposed areas, thus representing an underwear distribution; c) histological appearance of a rash on the trunk (original magnification x40). upper inlet: pautrier’s microabscess in the epidermis (original magnification x400). lower inlet: close-up view of the infiltrate (original magnification x400); d) bulla on the trunk; e) histological appearance of the bulla (original magnification x40). inlet: roof of the bulla (original magnification x400). many pautrier’s microabscesses can be seen; f) appearance 3 weeks before death. most of the trunk is covered by ulcers with serous exudate. figure 2. clinical course of the case. top panel: transition of sil-2r (△), crp levels (○) and leukocyte counts (●). systemic chemotherapies are indicated by the filled arrows; the duration of the radiotherapy is indicated by boxes; recurrent areas are indicated by arrows. the transition of the area of cutaneous ulcers is indicated at the bottom. no nco mm er cia l mis (original magnification x400). lower inlet: close-up view of the infiltrate (original no nco mm er cia l mis (original magnification x400). lower inlet: close-up view of the infiltrate (originalmagnification x400); d) bulla on the trunk; e) histological appearance of the bulla (origno nco mm er cia l magnification x400); d) bulla on the trunk; e) histological appearance of the bulla (origno nco mm er cia l ed patients dying within 1 year after the no nco mm er cia l ed patients dying within 1 year after the therefore, the formano nco mm er cia l therefore, the formation of bulla during the course of mf indicates no nco mm er cia l tion of bulla during the course of mf indicates a poor prognosis, and the extensive ulceration no nco mm er cia l a poor prognosis, and the extensive ulceration seen in the current case may reflect a step no nco mm er cia l seen in the current case may reflect a step many causes of leukemoid reaction areno nco mm er cia l many causes of leukemoid reaction are known, including infections, malignantno nco mm er cia l known, including infections, malignant inal magnification x40). inlet: roof of the bulla (original magnification x400). many no nco mm er cia l inal magnification x40). inlet: roof of the bulla (original magnification x400). many pautrier’s microabscesses can be seen; f) appearance 3 weeks before death. most of the no nco mm er cia l pautrier’s microabscesses can be seen; f) appearance 3 weeks before death. most of the no nco mm er cia l trunk is covered by ulcers with serous exudate. no nco mm er cia l trunk is covered by ulcers with serous exudate. no nco mm er cia l u se the trunk and extremities. inlet: an ulcerated tumor on the left upper arm; b) a view from us e the trunk and extremities. inlet: an ulcerated tumor on the left upper arm; b) a view from the right side. inlet: rashes around the waist. in (a) and (b), ulcers are indicated by us e the right side. inlet: rashes around the waist. in (a) and (b), ulcers are indicated byarrowheads. note that the distribution of most of the rashes was in non-exposed areas, us e arrowheads. note that the distribution of most of the rashes was in non-exposed areas,thus representing an underwear distribution; c) histological appearance of a rash on the us e thus representing an underwear distribution; c) histological appearance of a rash on the trunk (original magnification x40). upper inlet: pautrier’s microabscess in the epider-us e trunk (original magnification x40). upper inlet: pautrier’s microabscess in the epidermis (original magnification x400). lower inlet: close-up view of the infiltrate (originalus e mis (original magnification x400). lower inlet: close-up view of the infiltrate (original magnification x400); d) bulla on the trunk; e) histological appearance of the bulla (orig-us e magnification x400); d) bulla on the trunk; e) histological appearance of the bulla (origon ly on ly figure 1. initial appearance of the patient: a) multiple indurated plaques are present onon ly figure 1. initial appearance of the patient: a) multiple indurated plaques are present on the trunk and extremities. inlet: an ulcerated tumor on the left upper arm; b) a view fromon ly the trunk and extremities. inlet: an ulcerated tumor on the left upper arm; b) a view from the right side. inlet: rashes around the waist. in (a) and (b), ulcers are indicated byon ly the right side. inlet: rashes around the waist. in (a) and (b), ulcers are indicated byon ly [page 124] [dermatology reports 2011; 3:e54] leukocyte count over 50,000/µl.3 these findings indicate that a higher leukocyte count in the leukemoid reaction is a predictive factor for a poor prognosis. in particular, the severe leukemoid reaction observed in the current case is exceptional: only 2 other cases have been reported to have a leukocyte count of >100,000/µl.3,15 pseudomembranous colitis should therefore be considered as an underlying disease when a patient develops a leukemoid reaction. we reported a case of bullous mf which showed a strong tendency to form ulcers. the recurrent ulcer induced sepsis, and administration of antibiotics lead to pseudomembranous colitis. finally a severe leukemoid reaction occurred because of the colitis, demonstrating a rare extremely high leukocyte count before death. although a systemic chemotherapy had a marginal effect, the rashes briefly responded to radiation therapy, enabling a partial remission for 8 months. considering from the clinical course of the patient, ulcer formation in malignant lymphoma may require certain specific treatment. by accumulating similar cases, a therapeutic protocol for treating ulcer-forming malignant lymphoma can be developed. references 1. sakka v, tsiodras s, giamarellosbourboulis ej, giamarellou h. an update on the etiology and diagnostic evaluation of a leukemoid reaction. eur j intern med 2006;17:394-8. 2. granger jm, kontoyiannis dp. etiology and outcome of extreme leukocytosis in 758 nonhematologic cancer patients: a retrospective, single-institution study. cancer 2009;115:3919-23. 3. marinella ma, burdette sd, bedimo r, et al. leukemoid reactions complicating colitis due to clostridium difficile. south med j 2004;97:959-63. 4. ralfkiaer e, cerroni l, sander ca, et al. mycosis fungoides. in: swerdlow sh, campo e, harris nl, et al., editors. who classification of tumours of haematopoietic and lymphoid tissues, lyon: iarc press, 2008: pp 296–298. 5. jones gw, kacinski bm, wilson ld, et al. total skin electron radiation in the management of mycosis fungoides: consensus of the european organization for research and treatment of cancer (eortc) cutaneous lymphoma project group. j am acad dermatol 2002;47:36470. 6. pimpinelli n, olsen ea, santucci m, et al. defining early mycosis fungoides. j am acad dermatol 2005;53:1053-63. 7. munn se, mcgregor jm, jones a, et al. clinical and pathological heterogeneity in cutaneous gamma-delta t-cell lymphoma: a report of three cases and a review of the literature. br j dermatol 1996;135:976-81. 8. bowman ph, hogan dj, sanusi id. mycosis fungoides bullosa: report of a case and review of the literature. j am acad dermatol 2001;45:934-9. 9. bernardini ml, brandozzi g, campanati a, et al. bullous-vesicular variant of mycosis fungoides presenting as erythema annulare centrifugum: a case report. j eur acad dermatol venereol 2009;23:839-40. 10. kamran b, fatemeh m, ahmadreza r, et al. bullous mycosis fungoides: a case report. dermatol on line j 2008;14:11-6. 11. kartsonis j, brettschneider f, weissmann a, et al. mycosis fungoides bullosa. am j dermatopathol 1990;12:76-80. 12. okano m, nakajima c, uehara h, et al. bullous lymphoma of the skin. br j dermatol 1994;131:709-12. 13. mcbride sr, dahl mg, slater dn, et al. vesicular mycosis fungoides. br j dermatol 1998;138:141-4. 14. el-osta he, salyers wj jr, palko w, et al. anaplastic large-cell lymphoma with leukemoid reaction. j clin oncol 2008;26:4356-8. 15. de toledo fg, symes sn. leukemoid reaction due to clostridium difficile infection in acquired immunodeficiency syndrome: two case reports and a review of the literature. south med j 2004;97:388-92. brief report figure. 3. autopsy findings: a) descending colon, gross view; b) microscopic view of the plaque on the colon (original magnification x100); c) cd 45-blast gating analysis of the bone marrow cells. representative fractions of the cells are indicated by circles. no nco mm er cia l no nco mm er cia l no nco mm er cia l figure. 3. autopsy findings: a) descending colon, gross view; b) microscopic view of the no nco mm er cia l figure. 3. autopsy findings: a) descending colon, gross view; b) microscopic view of the no nco mm er cia l plaque on the colon (original magnification x100); c) cd 45-blast gating analysis of the no nco mm er cia l plaque on the colon (original magnification x100); c) cd 45-blast gating analysis of the no nco mm er cia l case is exceptional: only 2 other cases have no nco mm er cia l case is exceptional: only 2 other cases have been reported to have a leukocyte count of no nco mm er cia l been reported to have a leukocyte count of pseudomembranous colitis no nco mm er cia l pseudomembranous colitis should therefore be considered as an underlyno nco mm er cia l should therefore be considered as an underlying disease when a patient develops a leuke-no nco mm er cia l ing disease when a patient develops a leukeilar cases, a therapeutic protocol for treating no nco mm er cia l ilar cases, a therapeutic protocol for treating ulcer-forming malignant lymphoma can be no nco mm er cia l ulcer-forming malignant lymphoma can be developed. no nco mm er cia l developed. no nco mm er cia l no nco mm er cia l references no nco mm er cia l references no nco mm er cia l bone marrow cells. representative fractions of the cells are indicated by circles. no nco mm er cia l bone marrow cells. representative fractions of the cells are indicated by circles. us e us e o nly clinical and pathological heterogeneity in on ly clinical and pathological heterogeneity in cutaneous gamma-delta t-cell lymphoma: on ly cutaneous gamma-delta t-cell lymphoma: a report of three cases and a review of the on lya report of three cases and a review of the literature. br j dermatol 1996;135:976-81. on ly literature. br j dermatol 1996;135:976-81. 8. bowman ph, hogan dj, sanusi id.on ly 8. bowman ph, hogan dj, sanusi id. mycosis fungoides bullosa: report of a on ly mycosis fungoides bullosa: report of a dr [dermatology reports 2010; 2:e17] [page 45] the interaction of inflammatory cells in granuloma faciale takeshi nakahara,1 yoichi moroi,1 akari tashiro,1 hiromaro kiryu,2 masutaka furue1 1department of dermatology, graduate school of medical sciences, kyushu university, fukuoka, japan; 2department of dermatopathology, kiryu clinic, fukuoka, japan abstract granuloma faciale (gf) is a rare chronic inflammatory skin disease characterized by single or multiple reddish-brown cutaneous plaques or nodules. although this condition is benign, its clinical course is extremely chronic with poor response to therapy. the typical histopathological features of gf include vasculitis with mixed cellular infiltration; however, its etiopathogenesis remains unknown. here, we describe the case of a 76-year-old man with gf resistant to topical steroids. biopsy of the lesion revealed i) dense mixed inflammatory cellular infiltrates of lymphocytes, histiocytes, neutrophils, and eosino phils, ii) mild perivascular nuclear dust and swollen endothelium of blood vessels, and iii) a narrow grenz zone beneath the epidermis. immunohistochemical staining demonstrated mixed cellular infiltrates intermixed with cd1a+ dendritic cells, cd68+ histiocytes, and cd4+ and cd8+ t cells. introduction granuloma faciale (gf) is a chronic inflammatory skin disorder appearing as a solitary lesion or multiple reddish-brown infiltrating lesions on the face, usually on the cheeks, nose, and forehead. although its etiopathogenesis remains unknown, vasculitis with mixed cell inflammation is considered to be the typical histological feature.1 exposure to sunlight is regarded as a triggering factor; however, other causative factors such as infections, immunological disorders and associated malignancies might be responsible for its pathogenesis.2 recently, the production of interleukin (il)-5 by the clonal t-cell population has been implicated in the attraction of eosinophils to the lesions.3 here, we report a male patient who was clinically and histopathologically diagnosed with gf. mixed cellular infiltrates intermixed with cd1a+ dendritic cells (dcs), cd68+ histiocytes, and cd4+ and cd8+ t cells were detected immunohistochemically. case report the patient was a 76-year-old male who developed a reddish-brown cutaneous plaque with exaggerated follicular openings on the left cheek (figure 1a and b). the lesion was slightly elevated and slowly progressive, and showed no response to topical steroids. no underlying associated disease was detected, and his routine laboratory examinations were all within the normal limits. screening for antinuclear antibodies was negative. clinically, gf, sarcoidosis, discoid lupus erythematosus, follicular mucinosis and pseudolymphoma were considered as differential diagnosis. punch biopsy from the lesion showed a dense dermal inflammatory and granulomatous infiltrate of mononuclear cells with numerous eosinophils and neutrophils. the features of mild leukocytoclastic vasculitis: perivascular neutrophilic infiltrate with debris and swollen endothelium of blood vessels were also evident. stromal fibrosis was found around the granulomatous lesions. a narrow grenz zone was also observed beneath the epidermis, and adnexal structure was intact (figure 2a and b). these histopathological findings were consistent with gf. immunohistochemically, both cd8+ lymphocytes and cd68+ histiocytes were present mainly inside the granulomatous lesions (figures 3a and b), whereas scattered cd4+ lymphocytes and cd1a+ dcs surrounded the lesions, and to a lesser extent, occurred within the lesions (figure 3c and d). the cutaneous plaque lesion was treated with local injection of a corticosteroid. in a few months of treatment, infiltration was reduced but the reddish-brown cutaneous plaque lesion persisted. discussion gf is a rare inflammatory skin disease with typical clinical and histopathological entity. a previous extensive review of gf comprising 66 patients revealed that more than 90% of the patients had only facial lesions and 62% of the patients of this series had a solitary lesion. gf has a tendency to appear in areas exposed to sunlight, such as the forehead, cheek, and nose.4 it is mostly asymptomatic but occasional burning or itching sensation is experienced. dense granulomatous infiltration of lymphocytes, plasma cells, neutrophils, histiocytes and eosino phils is observed in the reticular dermis. interestingly, a typical granulomatous lesion predominantly composed of histiocytes does not normally occur in gf, making gf one of the misnomers in dermatology. fibrous tissue accompanying capillary proliferation can be observed in old lesions. one of the most important dermatology reports 2010; volume 2:e17 correspondence: takeshi nakahara, 3-1-1 maidashi, higashiku, fukuoka 812-8582, japan, e-mail: nakahara@dermatol.med.kyushu-u.ac.jp key words: granuloma faciale, dendritic cells, helper t cells, histiocytes received for publication: 2 august 2010. revision received: 25 october 20010. accepted for publication: 1 november 2010. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright t. nakahara et al., 2010 licensee pagepress, italy dermatology reports 2010; 2:e17 doi:10.4081/dr.2010.e17 figure 1. (a) solitary, reddish-brown plaque on the left cheek. (b) exaggerated follicular openings on the plaque. no nco mm er cia l u se on ly [page 46] [dermatology reports 2010; 2:e17] histopathological findings in gf is the presence of the grenz zone, which is an area between the epidermis and the upper dermis devoid of cells.1,4 thus, the present case showed representative clinical and histopathological features of gf. for the clinical differential diagnosis, sarcoidosis, lupus vulgaris, fungal infections, discoid lupus erythematosus, follicular mucinosis, and pseudolymphoma should be considered.1-4 histopathological examination is useful in distinguishing gf from other diseases. histopathological differential diagnosis of gf should be made with erythema elevatum diutinum (eed). similar to gf, eed starts with the appearance of neutrophils and neutrophilic nuclear dust around small vessels containing fibrin in their wall.5 in most eed cases, the eruption is bilateral and symmetric. histopa thologically, eosinophils are few or absent and neutrophils predominate with plasma cells only present episodically. the sites of eed predilection are different – the face is usually spared, and the skin on the dorsal aspects of joints is usually the target site. different etiologies regarding the pathogenesis of gf have been suggested, but most of them remain controversial. because light-exposed areas are favored as exemplified in the majority of gf cases with facial involvement, actinic exposure has been suggested to play an important role.4 it is suggested that it may be a form of vasculitis mediated by localized arthus-like response.6 it might also be due to a localized persistent immune complex disease or persistent allergic hypersensitivity reaction to a retained antigen or both.6 selvaag and roald showed in their immunohistochemical study of gf that eosinophils have a strong reaction to eosinophil cationic protein antibodies, and are activated; thus, they claimed that eosinophils play an important etiologic role.7 immunohisto chemically, cd4+ lymphocytes and a high lesional production of il-5, a cytokine important for eosinophil recruitment3 were observed. in line with previous reports, our results suggest that the interaction between dcs and helper t cells might be one of the important factors for the formation of lesions because dcs can modulate helper t cell functions such as cytokine production. although multiple treatments of gf have been attempted, beneficial therapeutic effects have not yet been observed. local therapies have also been used, including surgical excision, cryotherapy, and laser therapy;8 however, most of these may result in pigmentation changes or scarring. recently, a number of reports on the successful use of tacrolimus in gf have been published.9,10 tacrolimus decreases the number of langerhans cells and antigen-presenting cells in the skin and inhibits the propagation of the inflammatory cascade. because an immunopa thological etiology is suspected in our study and previous reports, it was assumed that local control of the interaction of dcs and helper t cells by topical immunosuppressants may show a positive therapeutic effect. references 1. leboit pe. granuloma faciale: a diagnosis deserving of dignity. am j dermatopathol 2002;24:440-3. 2. de d, kanwar aj, radotra bd, gupta s. extrafacial granuloma faciale: report of a case. j eur acad dermatol venereol 2007;21: 1284-6. 3. gauger a, ronet c, schnopp c, et al. m. high local interleukin 5 production in granuloma faciale (eosinophilicum): role of clonally expanded skin-specific cd4+ cells. br j dermatol 2005;153:454-7. 4. ortonne n, wechsler j, bagot m, et al. granuloma faciale: a clinicopathologic study of 66 patients. j am acad dermatol 2005;53: 1002-9. 5. konohana a. extrafacial granuloma faciale. j dermatol 1994;21:680-2. 6. marcoval j, moreno a, peyr j. granuloma faciale: a clinicopathologic study of 11 patients. j am acad dermatol 2004;51:26973. 7. selvaag e, roald b. immunohistochemical findings in granuloma faciale. the role of eosinophilic granulocytes. j eur acad dermatol venereol 2000;14:517-8. 8. ludwig e, allam jp, bieber t, novak n. new treatment modalities for granuloma faciale. br j dermatol 2003;149:634-7. 9. marcoval j, moreno a, bordas x, peyrí j. granuloma faciale: treatment with topical tacrolimus. j am acad dermatol 2006;55: s110-1. 10. tomson n, sterling jc, salvary i. granuloma faciale treated successfully with topical tacrolimus. clin exp dermatol 2009;34:424-5. case report figure 2. histopathological characteristics of the plaque lesion. (a) a dense dermal inflammatory and granulomatous infiltrate of mononuclear cells with numerous eosinophils and neutrophils.(original magnification x40). (b) mild leukocytoclastic vasculitis: perivascular neutrophilic infiltrate with debris and swollen endothelium of blood vessels are evident. stromal fibrosis is observed around the granulomatous lesions. (original magnification x400). figure 3. predominant infiltration of cd68+ histiocytes (a) and cd8+ lymphocytes (b) into the granulomatous lesions, and cd4+ lymphocytes (c) and cd1a+ dendritic cells (d) around the lesions. no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. dr [dermatology reports 2011; 3:e35] [page 75] unilateral blaschkoid lichen planus in successive pregnancies shiva kumar, rajendra okade, yasmin abdul rahman department of dermatology, venereology and leprosy, sri devarajurs, medical college, tamaka, kolar, india abstract a number of genetic, congenital and acquired dermatoses have been known to follow blaschko’s lines. a common disorder like lichen planus can very rarely present with pruritic lesions in atypical patterns such as unilateral distribution, painful eruptions and along blaschko’s lines. various triggering factors varying from viral infections and vaccinations to trauma have been implicated in lichen planus. we describe a female patient in the second trimester of her second pregnancy who developed unilateral lichen planus along blaschko’s lines during both pregnancies. no case of lichen planus along blaschko’s lines recurring during pregnancy is reported so far. could pregnancy itself be a contributory factor towards onset of lichen planus in this case? introduction lichen planus (lp) is a common inflammatory disorder that affects skin, mucous membrane, nails and hair. it is classically characterised by pruritic, shiny, violaceous, flat topped, polygonal papules which retain skin lines and maybe closely aggregated or widely dispersed.1 various etiological factors include immunological mediation, chronic liver disease, hepatitis c infection2-3 and hereditary causes among others . variants of this disorder include hypertrophic lp, follicular lp, linear lp, annular lp, vesicobullous lp, actinic lp, erosive and nonerosive mucous membrane lp.1 blaschko’s lines were delineated in 1901 by a german dermatologist alfred blaschko . the original description by blaschko referred to a system of lines on the human skin which the linear naevi and dermatoses follow.4 the pattern is attributed to lines of migration of epidermal cells during embrogenesis.5 these lines are curved over scalp and face, v shaped in upper spine, inverted u shaped over chest and upper arm, s – shaped whorls on the chest and abdomen and perpendicular over the front and back of extremities. types of blaschko’s pattern include narrow band, large band, checkerboard and phylloid.6 case report a 24-year-old female in the 2nd trimester of her 2nd pregnancy presented with a history of itchy skin lesions which started over dorsum of her left hand 3 months back. new lesions progressively appeared in a linear pattern extending proximally to involve the left forearm, arm and shoulder. simultaneously new elevated discoloured lesions appeared over left flank, abdomen and breast. patient had similar lesions in the same areas during her 1st pregnancy 2 year’s back which had spontaneously resolved within 3 months after delivery with residual post inflammatory hyperpigmentation in the affected areas which still persisted. on examination, violaceus flat topped 2-5 mm papules were noted, some of which showed typical lacy white pattern of wickham’s striae extending from left thumb uptoleft arm in a wave like pattern along blaschko’s lines (figure 1), they were discrete at few places while at others they appeared to be coalescing. similar papules in a wavy pattern were noted over left shoulder, upper back (figure 2), discontinuous papules and hyperpigmented macules were seen over left flank, abdomen (figure 3) and left breast in 3 curved lines. post inflammatory hyperpigmented macules of lesions which developed during the previous pregnancy were seen along the same blaschko’s lines. none of the eruptions crossed the midline. the patient had no oral lesions or nail changes. a working diagnosis of lichen planus was made. preliminary routine investigations were within normal limits and tests for hepatitis b and c were negative. punch biopsy of left forearm lesions showed typical features of lichen planus (figure 4). discussion lichen planus is a subacute to chronic dermatosis, which is benign and self limiting , although recurrences can occur. the disease has a predilection for flexor surfaces of forearms, legs and glans penis. inverse lichen planus eruption occurs in flexures like axilla, inframammary folds and groins. eruptions may be localised or extensive and koebner’s phenomenon is commonly seen. oral lesions of lichen planus are frequently seen either as sole manifestations or associated with cutaneous involvement. apart from the known variants of lichen planus, a few rare cases of lichen planus along blaschko’s lines has been described.1 histopathology examination reveals compact orthokeratosis, wedge shaped hypergranulosis irregular acanthosis, vacuolar alteration of the basal layer. rete ridges may show saw tooth appearance. degenerating epidermal cells form colloid bodies and a band like infiltration of lymphocytes may obliterate the dermo epidermal junction.7 blaschko’s lines do not correspond to any vascular, lymphatic or neural structures and are invisible and become apparent in certain disease states such as pigmentary disorders (naevus achromicus, epidermal naevus), x linked genetic skin disease (incontinentia pigmenti) , acquired inflammatory skin disorders (lp, lichen striatus) and chimerism.6 case reports of unilateral cutaneous lichen planus,1,8-9 lichen planus along with unilateral mucosal involvement,10 linear lichen pigmentosus11 and painful atrophic lichen planus12 have been reported along blaschko’s lines. long et al. described a case of bilateral linear lichen planus along blaschko’s lines.13 wolfs isotopic response is the occurrence of new skin disorder exactly at the site of another, unrelated and already resolved skin disease, this phenomenon has been seen in dermatomal lichen planus following herpes zoster at the same location.14 krasowska et al. reported a case of a 33 year old healthy woman who developed recurrent unilateral lichen planus along blaschko’s lines following 3 successive deliveries of healthy babies15. our patient presented with history of onset of lesions during first trimester and to the best of our knowledge this is the first case of lichen planus along blaschko’s lines occurring during successive pregnancies. considering the fact that various known and idiopathic causes have been known to trigger dermatology reports 2011; volume 3:e35 correspondence: shiva kumar, no. 66, 11th cross, indiranagar, 1st stage, bangalore560038, india. tel. +91-9886151969. e-mail: dermashiva@rediffmail.com key words: lichen planus, pregnancy, blaschko’slines. received for publication: 23 august 2011. accepted for publication: 6 september 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright s. kumar et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e35 doi:10.4081/dr.2011.e35 no nco mm er cia l u se on ly [page 76] [dermatology reports 2011; 3:e35] lichen planus, a need to follow up the patient in current and subsequent pregnancies becomes essential to find a positive correlation between pregnancy and lichen planus and to establish whether pregnancy itself could have triggered lichen planus. references 1. lehman js, tollefson mm, gibson le. lichen planus. int j dermatol 2009;48:68294. 2. bellman b, reddy rk, falanga v. lichen planus associated with hepatitis c. lancet 1995;346:1234. 3. cribier b, garnier c, laustriat d, heid e. lichen planus and hepatitis c virus infection: an epidemiologic study. j am acad dermatol 1994;31:1070-2. 4. harper ji ,trembath rc. genetics and genodermatosis. in: burns t, breathnach s, cox n, griffith c, editors. rook’s text book of dermatology. 7th ed . oxford: blackwell science; 2004. pp. 12-17. 5. mcgrath ja, mclean whi. genetics in relation to skin. in: wolff k , goldsmith la , stephen ik, et al., editors. fitzpatrick’s dermatology in general medicine. 7th ed. new york, ny: mcgraw -hill; 2008. p. 83. 6. bolognia jl, orlow sj, glick sa. lines of blaschko. j am acad dermatol 1994; 31:15790. 7. mobini n, toussaint s, kamino h. noninfectious erythematous, papular and squamous diseases. in: elder de, editor . lever’s histopathology of the skin. 10th ed. philadelphia, pa: lippincott williams and wilkins; 2010. pp.185-186. 8. saxena ak, nigam pk. unilateral lichen planus. cutis 1988;42:142-3. 9. gupta ak, gorsulowsky dc. unilateral lichen planus: an unusual presentation. arch dermatol 1987;123:295-6. 10. hartl c, steen kh, wegner h, et al. unilateral linear lichen planus with mucous membrane involvement. acta dermvenerol 1999;79:145-6. 11. seo jk, lee hj, lee d, et al. a case of linear lichen planus pigmentosus. ann dermatol 2010;22:323-5. 12. lakshmi c, divakaran j, sivaraman a, et al. painful linear atrophic lichen planus along lines of blaschko. ind j dermatol 2006;51:42-3. 13. long cc, finlay ay. multiple linear lichen planus in the lines of blaschko. br j dermatol 1996;135:275-6. 14. braun rp, barua d, masouye i. zosteriform lichen plaus after herpes zoster. dermatology 1998;197:87-8. 15. krasowska d, pietrzak a, lecewicz-torun b. unilateral multiple linear lichen planus following the blaschko lines recurring after deliveries. dermatology 2001;202: 340. case report figure 1. typical violaceous papules over thumb and forearm in a linear distribution. figure 3. gravid abdomen showing linear pigmented macules and papules. figure 4. histopathology showing dense lichenoid infiltrate and saw toothed rete ridges. figure 2. pigmented papules and macules over shoulder. no nco mm er cia l u se on ly dr [dermatology reports 2010; 2:e4] [page 9] acitretin systemic and retinoic acid 0.1% cream supression of basal cell carcinoma xi-bao zhang,1 san-quan zhang,1 chang-xing li,2 zhen-ming huang,1 yu-wu luo1 1guangzhou institute of dermatology, guangzhou, china; 2dongguan institute of dermatology, dongguan, china abstract retinoids have been used for years as monotherapy and/or in combination for treatment and suppression of cutaneous malignancies in patients with basal cell nevus syndrome, xeroderma pigmentosum, or cutaneous t-cell lymphoma (ctcl) basal cell carcinoma (bcc). we report 4 cases with bcc confirmed by histopathology who were treated by shortterm systemic acitretin combined with retinoic acid 0.1% cream. the 4 cases with bcc showed good response to the treatment without severe adverse effects during treatment and followup. the finding suggests that acitretin may be an appropriate treatment option for elderly patients who require less invasive treatment for bcc. introduction bcc may be treated by surgery, curettage and electrodesiccation, cryosurgery, mohs’ micrographic surgery, co2 laser surgery and topical 5-fluorouracil.1-3 a recent study by giannotti et al.4 demonstrated that topical application of imiquimod 5% cream and oral acitretin treated a 15-year old boy with xeroderma pigmentosum (xp) who presented with multiple facial bcc previously treated by surgical excision. acitretin, a recommended treatment option for anogenital warts, has been shown to be effective in treating many other skin disorders, such as human papilloma virus-associated warts and skin carcinomas including bcc.5-8 we report a novel method of treating facial bcc patients with oral acitretin and combination with topical application of retinoic acid 0.1% cream. case reports case #1 an 82-year old chinese man presented with an ulcer on the right nasal wall that persisted for six years. the first appearance of lesion was a brownish papule on the right nasal wall, and size progressively increased with advancing age. the lesion developed into an ulcer with bleeding and pruritus in the past year. physical examination showed a freckle and sable ulcer, measuring 2¥1 cm in diameter on the right nasal wall. the edge of the lesion has a characteristic rolled border, and hemorrhagic effusion on the surface of the ulcer (figure 1a). a punch biopsy specimen of the lesion showed nets of basaloid cells infiltrated in the dermis characteristic of peripheral palisading and cleft, which is between tumor focal and matrix (figure 1b). the patient was treated with oral acitretin at a dose of 30 mg/d (0.6 mg/kg) and topically applied retinoc acid 0.1% cream two times daily. within eight weeks, the ulcer had been progressively reduced in size. we reduced the acitretin dose to 20 mg daily (0.4 mg/kg). the ulcer was completely cleared after six months of treatment (figure 1c). the patient has undergone follow-up every four weeks for four years and there has been no relapse of the lesion. skin biopsy revealed no tumor cells in the slide (figure 1d). during the course of treatment, the patient showed no side effects except mild skin fragility, cheilitis and mild local erythema. on follow-up, laboratory results have remained within normal limits. case #2 a 70-year old chinese woman presented with an ulcer she had had on the right temple for five years. the first appearance of lesion was initially reported at the age of 65 years. as the ulcer grew, the lesion developed into an ulcer with bleeding. the lesion was asymptomatic and the size progressively increased with advancing age. in may 2006, the patient presented at our department with increasingly rapid growth of the ulcer with pruritus. physical examination showed an ulcer with blood crust measuring 2.0¥1.5 cm in diameter on the right temple. the lesion had a characteristic rolled border (figure 2a). a punch biopsy specimen of the lesion showed cystic spaces or necrosis in the centre of mass (figure 2b).the patient was initially treated with oral acitretin at a dose of 20 mg/d (0.4 mg/kg) and topical applied retinoc acid 0.1% cream two times daily. within four weeks the size of the lesion had been progressively reduced and the acitretin dose was slowly increased up to 40 mg/d (0.8 mg/kg). after 16 weeks, the lesion has disappeared (figure 2c). skin biopsy revealed infiltration of lymphocytes around the vessels in dermis and no focal of tumor was seen (figure 2d). the patient has undergone follow-up every four weeks for two years and there has been no relapse of the lesion. during the course of treatment, the patient showed no side effects except mild skin fragility, cheilitis and mild local erythema. on follow-up, laboratory results have remained within normal limits. case #3 an 82-year old chinese woman presented with two nodules on the left temple that had persisted for two years. two years ago, the patient had had two nodules on the left temple with pruritus and hemorrhagic effusion after scratching. the nodule is characterized by chronicity and gradual enlargement over time. in june 2005, the patient presented at our department with increasingly rapid growth of the ulcer over the last three months. physical examination showed two tight conjointed nodules on the left temple, measuring 2.0¥2.0 cm and 1.0¥1.0 cm in diameter, respectively. the center of the lesions had hemorrhagic effusion on the surface of the nodule. the edge of the lesions had a characteristic rolled border (figure 3a). a punch biopsy specimen of the lesions showed cystic spaces or necrosis in the center of mass (figure 3b). the patient was prescribed oral acitretin 30 mg two times daily (1 mg/kg) and topically applied retinoc acid 0.1% cream two times daily. two weeks later the size of lesions had been progressively reduced. the lesions were completely clear after eight weeks treatment (figure 3c). skin biopsy revealed infiltration of lymphocytes around the vessels in dermis and no focal of tumor cells was seen (figure 3d). during the course of treatment, the patient did not report any adverse events. the patient has undergone follow-up every four weeks for three years and there has been no relapse of the lesions. during the course of treatment, the patient showed no side effects except mild skin fragility, cheilitis and mild local erythema. on follow-up, laboratory results have remained dermatology reports 2010; volume 2:e4 correspondence: xi-bao zhang, department of dermatology, guangzhou institute of dermatology, guangzhou 510095, guangdong province, p r of china. e-mail: lilichangxing@163.com key words: acitretin, basal cell carcinoma. conflict of interest: the authors report no conflicts of interest. received for publication: 5 september 2009. revision received: 12 december 2009. accepted for publication: 14 december 2009. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright x-b zhang et al., 2010 licensee pagepress, italy dermatology reports 2010; 2:e4 doi:10.4081/dr.2010.e4 no nco mm er cia l u se on ly [page 10] [dermatology reports 2010; 2:e4] within normal limits. case #4 a 77-year old chinese man presented with a pigmented patch on the left nasal wing that had persisted for three years. the first appearance of a lesion was a 0.5¥0.5 cm papula on the left nasal wing that was incorrectly initially diagnosed as seborheic keratosis. the size of the lesion progressively increased with prutitus and bleeding following a slight injury was a common sign. in may 2008, the patient presented at our department with rapidly increasing growth of the lesions over the last six months, and partially infiltrated with obvious pruritus. physical examination showed a patch with blood crust measuring 2¥1.5 cm in diameter on the right temple. the edge of the lesion had swollen up with a characteristic rolled border (figure 4a). telangiectases were seen through the lesion. a punch biopsy specimen of the lesion showed large islands of tumor predominate (figure 4b). the patient was prescribed oral acitretin 30 mg two times daily (1 mg/kg) and topically applied retinoc acid 0.1% cream two times daily. two weeks after treatment, the size of lesion had been progressively reduced. the tumor was completely clear at the 6-week follow-up visit (figure 4c). skin biopsy revealed epidermis infiltrated by lymphocytes (figure 4d). the patient has undergone follow-up every four weeks for five months and there has been no relapse of the lesion. during the course of treatment, the patient showed no side effects except mild skin fragility, cheilitis and mild local erythema. on follow-up, laboratory results have remained within normal limits. discussion bbc lesions are most frequently found on the face (85% are found in the head and neck regions) and especially on the nose. excessive sunlight exposure, chemical cocarcinogens, and genetic determinants are implicated as causes of bbc.1 for this reason it is mostly seen in middle-aged and elderly subjects. in the current cases, the lesion found on the nose and temple suggest common features of bcc. systemic therapy including cisplatin, doxorubicin, cyclophosphamide, and adriamycin have all been used in various degrees. no single treatment method is ideal for all lesions, such as biopsy, excision, mohs’ microsurgery, ionizing radiation, cryosurgery, curettage, electrosurgery, laser therapy, or topical cytotoxic therapy such as 5-fluorouracil. these methods, although effective on isolated carcinomas, are not ideal treating facial bcc, primarily because of a higher risk of causing disfiguring scarring.1,4,5 the aim in treatment is for a percase report figure 1 (a) a freckle and sable ulcer, measuring 2cm×1cm in diameter on the right nasal wall. (b) histology showed nets of basaloid cells infiltrated in the dermis (×200). (c) the tumor was completely cleared at the 6-month follow-up visit. (d) after treatment, there are no tumor cells in this slide (×100). figure 2 (a) an ulcer with blood crust, measuring 2.0cm×1.5 cm in diameter on the right temple. (b) histology showed cystic spaces or necrosis in the centre of mass (×100). (c) the tumor was completely cleared at the 4-month follow-up visit. (d) skin biopsy revealed infiltration of lymphocytes around the vessels in dermis, and no focal of tumor being seen (×100). figure 3 (a) two tightening conjointed nodules on the left temple, measuring 2.0 cm×2.0cm and 1.0 cm×1.0cm in diameter, respectively. (b) a punch biopsy specimen of the lesion showed cystic spaces or necrosis in the centre of mass (×100). (c) the tumor was completely cleared at the 8-week follow-up visit. (d) skin biopsy revealed infiltration of lymphocytes around the vessels indermis, and no focal of tumor cell being seen (×40). figure 4 (a) a patch with blood crust, measuring 2cm×1.5cm in diameter on the right temple. (b) histology showed large islands of tumor predominate (×100). (c) the tumor was completely cleared at the 8-week follow-up visit. (d) skin biopsy revealed epidermis was infiltrated by lymphocytes (×100). no nco mm er cia l u se on ly [dermatology reports 2010; 2:e4] [page 11] manent cure with the best cosmetic results, important because the most frequent site of the basal cell carcinoma is the face. retinoids, natural and synthetic derivatives of vitamin a, are biological regulators of differentiation, proliferation, apoptosis, and immune response.9 retinoic acid receptor selective retinoids have been used for years as monotherapy and/or in combination for treatment of ctcl and bbc.9-12 recently, one case report showed that a 15-year old boy with xp presented with multiple facial bcc because of the risk of scarring, and the patient refused further surgery. as an alternative, three times weekly application of imiquimod 5% cream in combination with oral acitretin (20 mg daily) was prescribed for 4-6 weeks. all tumors had resolved at the 6-month follow-up visit, highlighting the therapeutic potential with a combination of oral acitretin and imiquimod 5% cream.4 ingves et al. also reported a 48-year old woman with bcc who was successfully treated with topical imiquimod and systemic acitretin.13 this evidence suggests that acitretin combination with imiquimod seem to be possible when treating superficial tumors in areas where the cosmetic outcome is particularly important. in the current 4 cases of bcc confirmed by clinical and histopathology, the patients refused surgery. as an alternative, twice daily application of retinoic acid 0.1% cream in combination with oral acitretin (0.4-1 mg/kg daily) was prescribed after appropriate discussion with the patient and his or her sons. during follow-up, laboratory results remained within normal limits and examined by histopathology on completion of therapy. the 4 cases showed good response to the treatment without severe adverse effects. all cases have been followed up to date with no evidence of recurrence. this evidence highlights the therapeutic potential of oral acitretin for bcc. references 1. drake la, ceilley ri, cornelison rl, et al. guidelines of care for basal cell carcinoma. the american academy of dermatology committee on guidelines of care. j am acad dermatol 1992;26:117-20. 2. kopera d, cerroni l, fink-puches r, et al. different treatment modalities for the management of a patient with the nevoid basal cell carcinoma syndrome. j am acad dermatol 1996;345:937-9. 3. hamouda b, jamila z, najet r, et al. topical 5-fluorouracil to treat multiple or unresectable facial squamous cell carcinomas in xeroderma pigmentosum. j am acad dermatol 2001;44:1054. 4. giannotti b, vanzi l, difonzo em, et al. the treatment of basal cell carcinomas in a patient with xeroderma pigmentosum with a combination of imiquimod 5% cream and oral acitretin. clin exp dermatol 2003;28:33-5. 5. edwards l, ferenczy a, eron l, et al. selfadministered topical 5% imiquimod cream for external anogenital warts. arch dermatol 1998;134:25-30. 6. hengge ur, esser s, schultewolter t, et al. self-administered topical 5% imiquimod for the treatment of common warts and molluscum contagiosum. br j dermatol 2000;143:1026-31. 7. schroeder tl, sengelmann rd. squamous cell carcinoma in situ of the penis successfully treated with imiquimod 5% cream. j am acad dermatol 2002;46:545-8. 8. beutner kr, geisse jk, helman d, et al. therapeutic response of basal carcinoma to the immune response modifier imiquimod 5% cream. j am acad dermatol 1999;41:1002-7. 9. duvic m, cather jc. emerging therapies in ctcl. clin dermatol 2000;18:147-56. 10. zackheim hs. treatment of cutaneous tcell lymphoma with retinoids. dermatol ther 1998;8:15-20. 11. zhang c l, duvic m. treatment of cutaneous t-cell lymphoma with retionids. dermato therap 2006;19:264-71. 12. chen k, craig jc, shumack s. oral retinoids for the prevention of skin cancers in solid organ transplant recipients: a systematic review of randomized controlled trials. br j dermatol 2005;152:51823. 13. ingves c, jemec gb. combined imiquimod and acitretin for non-surgical treatment of basal cell carcinoma. scand j plast reconstr surg hand surg 2003;37:293-5. case report no nco mm er cia l u se on ly dr [dermatology reports 2012; 4:e5] [page 17] granulosis rubra nasi: a rare condition treated successfully with topical tacrolimus piyush kumar,1 anubhav gosai,2 ashim kumar mondal,2 niharika ranjan lal,2 ramesh chandra gharami2 1katihar medical college and hospital; 2medical college and hospital, kolkata, india abstract a 20 years-old girl presented with multiple asymptomatic reddish vesicles on face for four years. it used to get worse in summer and was associated with localized hyperhidrosis. the lesions were notable for disappearance on diascopy. histopathology from the vesicle showed mononuclear cell infiltration in the upper dermis, especially around eccrine sweat apparatus, along with dilatation of superficial capillaries and lymphatics. based on clinical presentation and histopathology, diagnosis of granulosis rubra nasi (grn) was made. grn usually resolves at puberty; however, rarely it may persist in adulthood. we here report a case of grn having lesions persisting in adulthood. moreover, she showed excellent response to topical tacrolimus, a finding not observed in literature. introduction granulosis rubra nasi (grn) is an inflammatory condition involving eccrine sweat glands of central face and clinically presents as erythema, hyperhidrosis, papules, pustules and vesicles over central face.1 it usually presents in childhood with peak age of presentation 7-12 years. it runs a chronic course and resolves at puberty without any sequale.2 however, it may persist indefinitely.2 here, we report a case of this rare condition, who had grn persisting into adulthood and showed excellent response to topical tacrolimus ointment. case report a 20 years-old girl presented with multiple discrete asymptomatic reddish vesicles over cheeks, nose, and forehead for four years (figure 1). she had first noticed redness and increased sweating over central face 10 years back. within 1 year, she developed multiple erythematous papules (patient stated lesions did not express fluid or whitish material on excoriation) over nose and cheeks. they used to heal without any sequale but new lesions kept appearing. there was history of summer aggravation; however, she was never lesions free, even during winter months. she had consulted various doctors and was advised many medications, including anti-acne, antibiotic, antifungal and topical steroids, with no benefit. in next 4-5 years, papular lesions stopped appearing. however, erythema over the central face was persisting. in next 1-2 years, she developed small erythematous lesions, which expressed clear and sometimes, hemorrhagic fluid on excoriation, on the central face. these lesions were persistent in nature; however, they used to increase in size on sun exposure and used to get smaller in the shade. new lesions kept appearing. patient had noticed decreased sweating over the area, once vesicles started to appear. there were no other mucocutaneous or systemic features. on examination, multiple discrete tense vesicles on an erythematous base were present over central part of facenose, cheeks and lower part of the forehead (figure 1). most of these lesions were reddish in colour and expressed small amount of serosanguineous fluid. on diascopy, lesions used to disappear; however, they used to reappear after relieving the pressure. few telangiectatic blood vessels were noted on and around the nose. rest of the mucocutaneous and systemic examination did not reveal any abnormality. a provisional diagnosis of granulosis rubra nasi was made, and hidrocystoma and rosacea were considered as differential diagnosis. histopathology from the vesicle revealed mononuclear cell infiltration in the upper dermis along with dilatation of superficial capillaries and lymphatics (figure 2a,b). similar infiltration around sweat ducts too was noticed (figure 2c). the findings were consistent with the diagnosis of granulosis rubra nasi. patient was counseled regarding the disease and poor response to treatment. a therapy with atropine 1% cream in morning and tacrolimus 0.03% ointment at bedtime was undertaken. on follow up after three weeks, size of the vesicles had decreased and patient stated no increase in size of the vesicles, even on sun exposure. atropine cream was stopped fearing ocular side effects; however, tacrolimus ointment was continued. on second follow up after another one month, patient was almost lesion free, with only few vesicles persisting (figure 3). after having the discussion with patient, decision was made to continue tacrolimus. after another three months of follow up, patient had not developed any new lesions and had not experienced any significant side effects of tacrolimus. however, telangiectatic blood vessels and some erythema were still persisting. discussion grn is an inflammatory condition involving eccrine sweat glands of nose, cheeks and chin.1 this benign condition of unknown etiology and chronic course is extremely rare and the literature is dominated by case reports only. it is widely believed that it was first described in 1901 by jadassohn.1,2 grn is believed to be an inherited condition.2,3 familial cases are known and inheritance is believed to be autosomal dominant.2,3 however, etiology and pathogenesis of this disorder have not been elucidated.3 it is believed that persistent localized hyperhidrosis of central face is responsible for this condition.4 at times, hyperhidrosis of palm and sole too has been noted.2,3 pinkus and lebet have separately reported an association with hidrocystoma, another eccrine gland disorder.5,6 summer aggravation of lesions is occasionally found. it usually presents in childhood between 6 months and 15 years of age.7 peak incidence is from age 7-12 years.2 pinkus has described a case in man aged 59 years.5 there is no known racial or sexual predilection.2 it usually resolves spontaneously at puberty; however, it occasionally persists indefinitely.2 excessive sweating may precede other changes by several years. it is seen over tip of nose and sometimes, cheeks. with persistent hyperhidrosis, diffuse erythema develops on nose, cheeks, and chin. this erythema may be studded with sweat droplets, giving damp glistening appearance.1,2 after this, erythematous macule, papule, or vesicle may form at sweat duct orifices.2,3 these lesions disappear on diascopy, and reappear on relieving pressure.1 the condition is largely asymptomatic; however, itching or tingling sensation may be appreciated.3 the course of the disease is extremely chronic. it usually resolves at puberty without any sequale. however, in some cases it may dermatology reports 2012; volume 4:e5 correspondence: piyush kumar, katihar medical college and hospital, kolkata, india. e-mail: docpiyush@gmail.com key words: granulosis rubra nasi , grn, eccrine sweat glands, face, hyperhidrosis. received for publication: 15 july 2011. revision received: 2 january 2012. accepted for publication: 3 january 2012. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright p. kumar et al., 2012 licensee pagepress srl, italy dermatology reports 2012; 4:e5 doi:10.4081/dr.2012.e5 no nco mm er cia l u se on ly [page 18] [dermatology reports 2012; 4:e5] persist in adulthood.1,3 residual telangiectasia and occasional small cysts dominate the clinical picture in such cases.2,8 the common differential diagnoses include miliaria crystallina, hidrocystoma, rosacea, periorificial dermatitis, acne vulgaris and milia.1,2,3 perioral dermatitis presents with monomorphic small papules and pustules, erythema, and scaling with a distribution primarily around the mouth. rosacea can be differentiated by accentuation of the erythema by vasomotor instability, which is not a feature of grn.7 moreover, hyperhidrosis seen in grn is not a feature of rosacea. hidrocystoma is characterized by cystic papules of about 1-3 mm in diameter usually appearing in the periorbital area of middle-aged or elderly women.9 histopathology can differentiate between these two conditions. the diagnosis is usually made clinically. histologically, dilation of dermal blood, and lymphatic vessels with perivascular lymphocytic infiltration and dilation of sweat ducts (at times simulating a hidrocystoma) are seen. the epidermis, connective tissue and pilosebaceous apparatus are otherwise normal and no heterotopic apocrine glands are found.2,3 no preventive measures or complications are reported and the disease has an excellent prognosis with self resolution at puberty in most cases. hence reassurance is what is needed.8,10 treatment with botulinum toxin a is under trial.11 our case presented late with vesicular lesions. at this stage, hyperhidrosis, the characteristic feature of grn, was absent/ minimal. the authors believe that inflammation around sweat ducts are responsible for decreased sweating and hence, vesicle formationfindings in the late stage of grn. owing to scarcity of literature, authors could not ascertain if other authors have had similar observation of decreased sweating in late stages. further case reports and case series can establish/contradict our observation. persistence of inflammation around sweat apparatus prompted us to undertake therapy with topical tacrolimus, considering poor response to topical steroids in past. we are not in a position to comment on the response of tacrolimus in earlier stages of disease process, when hyperhidrosis is prominent as we got the patient in a very late stage. we hope this case report will prompt other authors to use and document the response of tacrolimus in various stages of grn. references 1. mendoza pj, saldana ls, patricia ar, et al. nasi rubra granulosis. dermatol peru 2003,13:125-7. case report figure 1. discrete erythematous tense vesicles over face. figure 2. (a) patchy mononuclear cell infiltration in upper dermis with dilatation of capillaries and lymphatics (haematoxylin and eosin stain ¥100); b) patchy mononuclear cell infiltration with dilatation of capillaries and lymphatics (haematoxylin and eosin stain ¥400); c) mononuclear cell infiltration around sweat duct (haematoxylin and eosin stain ¥400). figure 3. successful treatment with topic. no nco mm er cia l u se on ly [dermatology reports 2012; 4:e5] [page 19] 2. hantash bm, rashid rm. granulosis rubra nasi. avaialble from http://emedicine.medscape.com/article/1072459-overview. accessed on march 6, 2011 3. miller jl, hurley hj. diseases of the eccrine and apocrine sweat glands. in: bolognia jl, jorizzo jl, rapini rp, editors. dermatology. 2nd edn. philadelphia: mosby elsevier; 2008. pp 567-588. 4. kreiden op, boni r, burg g. hyperhidrosis and botulinum toxic in dermatology. curr probi dermato 2002;30:178-87. 5. pinkus f. ueber die beziehungen des hidrocystoms zur granulosis rubra nasi. dermatologische zeitschrift 1904;11:642-5. 6. lebet. constitution a l'étude de l'hidrocystome (avec une note sur la granulosis rubra nasi). annales 1903:273. 7. akhdari n. granulosis rubra nasi. int j dermatol 2007;46:396. 8. coulson ih. disorders of sweat glands. in: burns t, breathnach s, cox n, griffiths c (eds). rook's textbook of dermatology. 8th edition. west sussex: wiley blackwell publishers; 2010. pp 44-18. 9. ghosh sk, bandyopadhyay d, biswas sk, mandal rk. multiple translucent papules on the face of a middle-aged woman. indian j dermatol venereol leprol 2010; 76:721-2. 10. james wd, berger tg, elston dm . diseases of the skin appandages. in: james wd, berger tg, elston dm (eds). andrew's disease of the skin. 10th edition. canada: saunders elsevier publications; 2009. p 780. 11. grazziotin tc, buffon rb, da silva manzoni ap, et al. treatment of granulosis rubra nasi with botulinum toxin type a. dermatol surg 2009;35:1298-9. case report no nco mm er cia l u se on ly dr taxane-induced morphea in a patient with crest syndrome susan m. bouchard, melinda r. mohr, robert j. pariser department of dermatology, eastern virginia medical school, norfolk, va, usa abstract the taxanes, docetaxel and paclitaxel, are microtubule stabilizing chemotherapeutic agents that have demonstrated antineoplastic effects in a variety of solid tumors. they have been linked to the development of localized cutaneous sclerosis in some patients. we present a case of docetaxel-induced cutaneous sclerosis of the lower extremities in a patient with pre-existing crest syndrome. we propose that patients with a history of limited or diffuse systemic sclerosis should be given taxane chemotherapy with caution, as these patients may have an immunological predisposition for the development of drug-induced morphea. case report a 73-year old caucasian woman received docetaxel and cyclophosphamide chemotherapy for treatment of poorly differentiated infiltrating ductal carcinoma of the breast. past medical history was significant for osteoporosis, hypothyroidism, and crest syndrome for 20 to 30 years. medications included esomeprazole, zoledronate, calcium with vitamin d, levothyroxine, fish oil, aspirin, and a multivitamin. prior to initiation of docetaxel, she exhibited physical changes consistent with longstanding crest syndrome, including sclerodactyly, firm subcutaneous nodules consistent with calcinosis cutis, teleangiectasias, and gastroesophageal reflux without overt esophageal dysmotility. on review of systems, she cited a history of infrequent dyspneic episodes. during therapy with docetaxel, she noticed significant swelling of her legs. three months after completion of her chemotherapy regimen, she presented with firm, erythematous, burning plaques of her lower legs (figure 1). additionally, she noticed worsening of her gastroesophageal reflux symptoms. fluticasone propionate lotion was applied to the legs twice daily for 18 days without benefit. six months after completion of her chemotherapy, she noticed a slight decrease in pain and stiffness of her legs without any other specific treatment. discussion scleroderma is a disease characterized by cutaneous and sometimes visceral sclerosis, vasculopathy, and the presence of autoantibodies. localized cutaneous sclerosis is commonly termed morphea.1 systemic sclerosis (ssc) may be categorized into diffuse cutaneous systemic sclerosis (dssc) and limited cutaneous systemic sclerosis (lssc). diffuse cutaneous ssc is characterized by truncal and acral skin involvement, early visceral disease, and a poorer prognosis. alternatively, limited cutaneous ssc is limited to acral cutaneous involvement of the hands, face, feet, and forearms with occasional late visceral (predominately pulmonary) involvement.1 crest syndrome represents a form of lssc and is manifested by calcinosis cutis, raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasias.2 the development of cutaneous sclerosis is typically preceded by tissue inflammation, endothelial cell activation, and edema.3 histopathological changes include dermal thickening with immense collagen accumulation and resulting epidermal atrophy, flattening of rete pegs, and obliteration of hair follicles and sebaceous and sweat glands.2 inflammatory cells commonly aggregate at the dermal-adipose junction, particularly in early lesions.4 cytokines produced by these inflammatory cells (transforming growth factor-b,2 tumor necrosis factor-a (tnf-a),5,6 interferon gamma (ifn-g),6 and interleukin-6 (il-6)7) are all present at high levels in the serum of patients with scleroderma, and are thought to play a central role in the pathogenesis of the disease.8 several studies have demonstrated an increased incidence of breast and lung cancers in patients with pre-existing ssc. because the cases studied have typically shown a close temporal relationship between the onset of ssc and breast cancer, a number of theories have been proposed to illuminate a pathophysiological link between the two. one theory implicates the aforementioned inflammatory cytokines as promoters of breast and lung cancers. also, increased endothelial cell activation seen in ssc may stimulate tumor development by elevating the levels of various growth factors. others have investigated ssc as a possible paraneoplastic syndrome in these cases. perhaps the most widely accepted theory is that ssc is often the result of the cancer treatment itself.9 a variety of chemical agents, including rapeseed oil, organic solvents, herbicides, silica, cocaine, bleomycin, penicillamine, l-tryptophan, pentazocine, ethosuximide,10 and the taxane family of chemotherapeutic medications11 have been associated with scleroderma or scleroderma-like changes of the skin. the taxanes, which include docetaxel and paclitaxel, exert their antineoplastic effects by stabilizing microtubules thus halting mitosis and by inhibiting bcl-2 to allow apoptosis.12 these medicines are widely used in the treatment of breast, lung, and ovarian carcinomas.13 established toxicities include peripheral edema, neutropenia, and neuropathy.11 in addition to scleroderma-like changes, cutaneous reactions of the taxanes include acral erythema, pustular eruption, bullous fixed drug eruption, erythema multiforme, onycholysis, erythrodyesthesia, and alopecia.11,14 there is a well-established association between the taxanes and scleroderma-like skin changes. edema characteristically precedes the development of generalized morphea by a few months, and the sclerosis develops most prominently on the lower legs, sparing the hands and feet.11 the taxanes cause an dermatology reports 2010; volume 2:e9 correspondence: susan m. bouchard, 7741 dunfield place, apt. 4, norfolk, va 23505, usa. e-mail: susan.bouchard@gmail.com key words: crest syndrome, scleroderma, morphea, docetaxel, taxane. contributions: smb primary author; mrm clinical investigator and first editor; rjp clinical investigator and second editor. conflicts of interest: the authors have no conflict of interest to disclose. received for publication: 29 june 2010. accepted for publication: 1 july 2010. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.m. bouchard et al., 2010 licensee pagepress, italy dermatology reports 2010; 2:e9 doi:10.4081/dr.2010.e9 figure 1. firm, indurated, slightly erythematous plaques on bilateral lower legs. [dermatology reports 2010; 2:e9] [page 23] no nco mm er cia l u se on ly [page 24] [dermatology reports 2010; 2:e9] increase in the expression of several of the same inflammatory cytokines that are naturally increased in patients with scleroderma, including tnf-a, il-2, il-6, and inf-g.2,11 this immunological milieu likely contributes to both the taxanes’ therapeutic efficacy and the development of skin sclerosis. several cases of taxane-induced scleroderma have displayed dramatic improvement with simple withdrawal of chemotherapy.14,15 alternatively, it may be treated with systemic steroids and/or d-penicillamine.11,16 ironically, pencillamine has also been implicated as a cause of cutaneous sclerosis.10 we present this case because of our patient’s distinguishing feature of pre-existing crest syndrome. patients with a history of scleroderma and subsequent or concurrent neoplasia may be immunologically predisposed to the development of drug-induced morphea. we propose that this population should be given taxane chemotherapy with caution in order to decrease the incidence of this rare, but potentially debilitating, side effect. references 1. leroy ec, krieg t, black c, et al. scleroderma (systemic sclerosis): classification, subsets and pathogenesis. j rheumatol 1988;15:202-5. 2. jimenez sa, derk ct. following the molecular pathways toward an understanding of the pathogenesis of systemic sclerosis. ann intern med 2004;140:441-51. 3. krieg t, takehara k. skin disease: a cardinal feature of systemic sclerosis. rheumatol 2009;48:14-8. 4. fleischmajer r, perlish js, reeves jrt. cellular infiltrates in scleroderma skin. arthritis rheum 1977;20:975-84. 5. sharpe rj, margolis rj, askari m, et al. induction of dermal and subcutaneous inflammation by recombinant cachectin tumor necrosis factor (tnf-alpha) in the mouse. j invest dermatol 1988;91:353-7. 6. gruschwitz ms, vieth g. up-regulation of class ii major histocompatibility complex and intercellular adhesion molecule 1 expression on scleroderma fibroblasts and endothelial cells by interferon-gamma and tumor necrosis factor alpha in the early disease stage. arthritis rheum 1997;40: 540-50. 7. hasegawa m, sato s, ihn h, et al. enhanced production of interleukin-6 (il6), oncostatin m and soluble il-6 receptor by cultured peripheral blood mononuclear cells from patients with systemic sclerosis. rheumatol 1999;38:612-7. 8. sato s. abnormalities of adhesion molecules and chemokines in scleroderma. curr op rheumatol 1999;11:503-7. 9. launay d, le berre r, hatron py, et al. association between systemic sclerosis and breast cancer: eight new cases and review of the literature. clin rheumatol 2004;23:516-22. 10. zhai h, wilhelm k-p, maibach hi. dermatotoxicology. fair lawn, nj: informa healthcare; 2007. 11. itoh m, yanaba k, kobayashi t, et al. taxane-induced scleroderma. br j dermatol 2007;156:363-7. 12. schiff pb, fant j, horwitz sb. promotion of microtubule assembly in vitro by taxol. nature 1979;277:665-7. 13. kingston dgi, bane s , snyder jp. the taxol pharmacophore and the t-taxol bridging principle. cell cycle 2005;4:279-89. 14. kupfer i, balguerie x, courville p, et al. scleroderma-like cutaneous lesions induced by paclitaxel: a case study. j am acad dermatol 2003;48:279-81. 15. battafarano df, zimmerman gc, older sa, et al. docetaxel (taxotere) associated scleroderma-like changes of the lowerextremities – a report of 3 cases. cancer 1995;76:110-5. 16. de angelis r, bugatti l, cerioni a, et al. diffuse scleroderma occurring after the use of paclitaxel for ovarian cancer. clin rheumatol 2003;22:49-52. case report no nco mm er cia l u se on ly dr [dermatology reports 2011; 3:e48] [page 107] lupus erythematosus and lichen planus overlap syndrome:a case report with a rapid response to topical corticosteroid therapy gulsen tukenmez demirci,1 ilknur kıvanç altunay,1 sezgi sarıkaya,1 damlanur sakiz2 1dermatology department and 2pathology department, sisli etfal training and research hospital, istanbul, turkey abstract lupus erythematosus (le) and lichen planus (lp) may occur as an overlap syndrome. we report the clinical characteristics of a young man with lesions diagnosed as le and lp by histopathological and direct immunoflurosence examinations. we achieved remarkable clinical response from the treatment with topical corticosteroids and no recurrence was seen in a 6 months of follow up time. we found this case interesting because of the rapid improvement with corticosteroid and discussed if there is a real overlap or a coexistence according to the literature. introduction lupus erythematosus (le) and lichen planus (lp) are two distinct and well established dermatoses which occasionally can occur as an overlap syndrome. overlap syndrome is characterized by mixed clinical and histopathological features of both le and lp.1 although le and lp are relatively common diseases, an overlap is considered as an uncommon entity. approximately 50 cases of le/lp overlap syndrome have been reported in the literature.2 however, some authors suggest that most of the cases could be missed as a consequence of its variable clinical and histopathological appearances.2,3 we report a case diagnosed as le/lp overlap syndrome with a rapid improvement to topical corticosteroid treatment. there was no recurrence at 6 months. case report a 26-year-old male presented to our outpatient clinic with a 8-months history of persistent, erythematous lesions on his back and widely scattered mildly itching papules on upper and lower extremities. dermatological examination revealed erythematous, slightly scaly, irregularly bordered, infiltrated large plaques with central atrophy on his back, a butterfly type rash involving nose and malar region and erythema on his ears and neck. (figure 1a and 1b), the skin of his retroauricular regions were intact. he also had widespread violaceous lichenoid papules on his upper and lower extremites (figure 1c), but no mucosal or nail involvement was noted. laboratory examinations, including complete blood counts, erythrocyte sedimantation rate, routine urine tests were within normal limits except for mild elevations of alanin transaminase and aspartate aminotransferase (44 u/l, 46 u/l; normal limits 0-35 u/l, 045u/l) antinuclear antibodies, anti-dsdna, anti-ssa, anti-ssb, anti-sm were all negative. complement c3 and c4 levels were all normal. two cutaneous biopsies were taken from a plaque on the back and from the dorsum part of one hand. histopathology of the biopsy specimen from his back which showed thinning of the epidermis, basal layer vacuolar degeneration, perifollicular chronic inflammatory infiltrates and deposition of mucin in the dermis was consistent with subacute cutaneous le. mucin deposition was also shown with alcian blue staining. direct immunofluorescence (dif) examination of the plaque lesion revealed deposits of immunoglobulin (igm> igg, iga) and c3 forming a granuler pattern (feature of le) and linear fibrinogen deposition at the basal membrane zone (bmz) (feature of lp). (figure 2) a biopsy specimen from the dorsum of the hand was consistent with the diagnosis of lp with hypergranulosis, with a band-like mononuclear infiltrate at the dermo-epidermal junction (figure 3). the patient was diagnosed as having le/lp overlap syndrome after clinical, histopathological and immunohistological examinations. he was treated topically with mometasone furoat 0.1% cream applied twice daily for two weeks. a rapid improvement of the lesions were seen at the end of the second week. discussion le/lp overlap syndrome can be diagnosed with the combination of clinical, histopathological and/or immunopathological features of both diseases in the same patient and/or at the same lesion of one patient.2 histopathological features can be consistent with either lp or le or both while dif usually suggests former.4 there is still some controversy regarding the definion of this syndrome. it is suggested that true le\lp overlap is defined as the presence of le and lp in the same lesion, whereas the presence of le features in one lesion and lp features in other one should be considered as a coexistence of le and lp rather than overlap.5,6 nagao et al. reported a true overlapped le\lp patient presenting with single lesion showing combined features of le and lp which was confirmed by both dif and histopathological studies. furthermore, in a study conducted by de jong et al., with the immunohistochemical examination of the markers for extracellular matrix proteins, it was asserted that le/lp overlap syndrome can be considered as lp-like le rather than as a distinct disease.7 the lesions on the back in our patient were more consistent with le clinically and histopathologically,while those on his hands were consistent with lp clinically and histopathologically. dif taken from his back showed combined immunfluorescence features of lp and le. in most cases clinical and histopathological features enable us to differantiate between le and lp, but it may be difficult where as lesions are less typical or an overlapping occurs. both diseases may show similar histopathological and immunopathological findings of basement membrane changes and colloid bodies.6,8,9 as for therapy, topical tacrolimus 0.1%, systemic retinoids and cyclosporine have been reported to be effective in the treatment of this condition.1,10,11 we only tried topical corticosteroids. a dramatic improvement occurred in only two weeks. in fact, topical steroids are considered to be inadequate in each disease and systemic therapy is needed. it is interesting to obtain a good response with only topical therapy and also in a relatively short period of 2 weeks in our patient. follow up seems to be mandatory because the chance of conversion of the syndrome into systemic lupus erythe dermatology reports 2011; volume 3:e48 correspondence: gulsen tukenmez demirci, sisli etfal eğitim ve araştırma hastanesi dermatoloji kliniği, 19 mayıs cad. etfal sok. sisli, 34377 istanbul, turkey tel. +90.212.373.5000 fax. +90.212.353.5976. e-mail: gulsentukenmez@yahoo.com key words: cutaneous lupus erythematosus, discoid lupus erythematosus, lichenoid eruption. received for publication: 16 june 2011. revision received: 4 july 2011. accepted for publication: 6 october 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright g.t. demirci et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e48 doi:10.4081/dr.2011.e48 no nco mm er cia l u se on ly [page 108] [dermatology reports 2011; 3:e48] matosus is reported to be about 5-10%.12 we did not see any recurrence during 6 months follow-up. conclusions we report a case which can be identified as le/lp coexistence depending on the clinical picture. although deposition of immunoglobulines in a granuler pattern and fibrinogen in a linear pattern at bmz supports a true overlapping, the lack of cytoid bodies staining with igm prevents us from suggesting true overlap of le/lp. additionally, success of local corticosteroid therapy alone in this combination of two difficult diseases is another debateble issue. we think it is necessary with more data from more patients to delineate le/lp overlap and coexistence. it seems that the mistery of the disease continues to remain. references 1. kim h, pomeranz mk. lupus erythematosus/lichen planus overlap syndrome. j drugs dersmatol;3:311-2. 2. inaloz hs, chowdhury mmu, motley rj. lupus erythematosus/lichen planus overlap syndrome with scarring alopecia. j eur acad dermatol venereol 2001;15:171-4. 3. mahler v, hornstein op, meyer s, et al. lupus erythematosus/lichen ruber planus overlap syndrome. 5 cases in a patient sample of the erlangen university dermatology clinic (1894-1895). hautarzt 1998;49:295-302. 4. james wd, berger tg, elston dm. andrews' diseases of the skin: clinical dermatology. 10th ed. new york: elsevier; 2006. 5. nagao k, chen kr. a case of lupus erythematosus/lichen planus overlap syndrome. j dermatol 2006;33:187-90. 6. lever wh, schaumburg-lever g. histopathology of the skin, 7th ed. jb lippincott company: philadelphia; 1990. pp 494–505. 7. de jong em, van der vleuten cj, van vlijmen-willems im. differences in extracellüler matrix proteins, epidermal growth and differentiation in discoid lupus erythematosus, lichen planus and the overlap syndrome. acta derm venereol 1997;77: 356-60. 8. romero rw, nesbitt lt jr, reed rj. unusual variant of lupus erythematosus or lichen planus. clinical, histopathologic and immunofluorescent studies. arch dermatol 1977;113:741-8. 9. camisa c, neff jc, olsen rg. use of indirect immunofluorescence in the lupus erythematosus/lichen planus overlap syndrome: an additional diagnostic clue. j am acad dermatol 1984;11:1050-9. 10. grabbe s, kolde g. coexisting lichen planus and subacute cutaneous lupus erythematosus. clin exp dermatol 1995;20: 249-54. 11. tursen u, oz o, ikizoglu g, et al. a case of lichen planus lupus erythematosus overlap syndrome with eyelid involvement. eur j ophthalmol 2002;12:244-6. 12. jablonska s, blaszozyk m. lupus erythematosus. what’s new? j eur acad dermatol venereol 2000;15:103-5. case report figure 2. deposition of immunoglobulin g, immunoglobulin m, c3 and fibrinogen in lupus erythematosus (le) and lichen planus (lp) lesions on the back has been shown by direct immunofluorescent (direct immunofluorescence ¥ 200). figure 3. histopathologic features of the specimen from the dorsum of the hand. the presence band-like mononuclear cell infiltration and hypergranulosis (hematoxylin and eosin stain ¥ 100). figure 1. a) erythematous, slightly, scaly, irregularly bordered, infiltrated three large plaques with central atrophy on the back. b) butterfly type rash involving the nose and malar region. c) violaceous lichenoid papules on the upper and lower extremities. a b c no nco mm er cia l u se on ly dr [dermatology reports 2010; 2:e8] [page 21] growth dynamics and cyclin expression in cutaneous t-cell lymphoma cell lines edyta biskup,1 valentina manfé,1 maria r. kamstrup,1 robert gniadecki1,2 1department of dermatology, bispebjerg hospital, copenhagen; 2faculty of health sciences, university of copenhagen, denmark abstract we have investigated cell growth dynamics and cyclins b1 and e expression in cell lines derived from mycosis fungoides (myla), sézary syndrome (seax), and cd30+ lymphoproliferative diseases (mac1, mac2a, jk). mac1 and mac2a had the highest growth rate (doubling time 18-28 h, >90% cycling cells) whereas seax was proliferating slowly (doubling time 55 h, approximately 35% cycling cells). expression of cyclin b1 correlated positively with doubling time whereas expression of cyclin e was unscheduled and constant across the investigated cell lines. all cell lines exhibited high expression of pcna. thus, we concluded that cyclin b1 could be used for rapid screening of cell proliferation in malignant lymphocytes derived from cutaneous tcell lymphoma. introduction cutaneous t-cell lymphomas (ctcls) belong to the extra-nodal lymphomas arising primarily in the skin.1 common types of ctcls (mycosis fungoides, sézary’s syndrome, and cd30+ lympho-proliferative diseases) are lowgrade neoplasias presenting a chronic, relapsing course. curative treatments are not available, but ctcls are responsive to ionizing radiation and puva (psoralen ultraviolet a therapy) in the early stages. development of new medications for the advanced disease is hampered by a lack of suitable animal models, and cell lines have been used for the screening of new compounds. the most commonly used cell lines have been myla2 and seax3 derived from mycosis fungoides and sézary syndrome, respectively, and mac1, mac2a,4 or jk5 obtained from patients with cd30+ lympho-proliferative diseases. in this study we investigated growth dynamics and cell cycle characteristics in these cell lines. particularly, we focused on the cell cycle distribution and expression of cyclins b1 and e, which are the key regulators of proliferation via activation of the cyclin-dependent kinases. cyclin expression takes place at specific and well-defined points of the cell cycle;6 however, in cancer cells unscheduled cyclin expression may be observed.7 results and discussion the proliferation rate of neoplastic cells often reflects their degree of malignancy. in this study we analyzed the growth dynamics of five ctcl cell lines and the expression pattern of cell cycle regulators. the time required for cell population doubling differed significantly between cell lines tested (figure 1), with mac1 and mac2a being the fastest growing cells (doubling time between 20 and 35 h) and seax showing the slowest growth (between 40 and 80 h). these observations were confirmed by brdu incorp oration analysis. after a 20-min pulse with 10 µm brdu, we observed >90% brdu positive cells in the case of mac1, mac2a, and jk whereas only 40% in the case of myla and seax cell lines (figure 1). cyclin b1 is an essential g2 cyclin necessary for cdk1 activation and cell entrance into the m phase. its accumulation begins in the late s phase, reaches the maximal level as the cell enters mitosis, and is degraded rapidly at the beginning of anaphase. an altered expression pattern was observed in several neoplastic cell lines. for example, cyclin b1 has been detected in the g1 phase in hl-60 (leukemic), hs578t, and t-47d (derived from breast carcin oma) cells.6 we did not observe this phenomenon in any of the cell lines we tested. the dermatology reports 2010; volume 2:e8 correspondence: robert gniadecki, department of dermatology d, bispebjerg hospital, bispebjerg bakke 23, dk-2400 copenhagen, denmark e-mail: rgni0001@bbh.regionh.dk key words: cutaneous lymhomas, cyclins, proliferation. received for publication: 25 march 2010. accepted for publication: 31 march 2010. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright e. biskup et al., 2010 licensee pagepress, italy dermatology reports 2010; 2:e8 doi:10.4081/dr.2010.e8 figure 1. growth dynamics of cutaneous t-cell lymphoma cell lines. (a) measurement of cell doubling time. cells were seeded in the culture flasks at a density 2¥¥105/ml. mac1, mac2a and jk cells were grown in rpmi 1640 medium supplemented with 10% fcs; myla and seax cells were grown in glutamax dulbecco modified essential medium (dmem) supplemented with 1 mm l-glutamine and 10% fcs. media, supplements, and serum were obtained from gibco brl. cell counting was performed twice daily by flow cytometry (becton-coulter) until the stationary phase was reached. the time required to double the cell population was calculated using graphpad prism (graphpad software, san diego ca, usa). (b) brdu incorporation rate. cells were pulsed for 20 min with 10 mm brdu, fixed in ice-cold 70% ethanol for at least 20 hr, washed with pbs, and incubated in 2 n hcl for 30 min prior to the addition of anti-brdu mouse antibodies (becton dickinson). goat anti-mouse antibodies labeled with alexa-fluor 488 (1:1000; invitrogen) were applied as secondary antibodies. dna was stained with 7-amino-actinomycin d (7aad; beckman coulter). the percentage of brdu positive cells was determined by flow cytometry analysis. brdu incorporation rate (fl1) was plotted versus cellular dna content (fl3). quantification of flow cytometry data is provided in (c). [page 22] [dermatology reports 2010; 2:e8] cyclin b1 expression was perfectly scheduled, although the expression level differed among the cell lines tested and tended to be highest in the most rapidly proliferating cells (figure 2). in contrast, the cyclin e pattern was similar in all cell lines. this factor is essential for cell entrance into the s phase, and therefore it is predominantly expressed in the g1 phase and decreases in the s and g2/m phases. however, we observed that a proportion of s and g2/m cells remained cyclin e positive (figure 2). this phenomenon represents unscheduled cyclin e expression and has been described before in leukemic cell lines, namely jurkat, k562, and u937.8 pcna, a subunit of dna polymerase ∂, is a marker for growing cells. its content increases in the late g1, peaks in the s, and decreases in the g2/m phase.9 in the case of all ctcl cell lines tested, >90% of cells were pcna positive, regardless of the growth rate of the cells. we concluded that the cyclin b1 expression is normal in ctcl cell lines and the level of expression roughly correlated with growth rate. in contrast, cyclin e expression is unscheduled and constant in the cell lines we tested. furthermore, pcna is not useful as a marker of proliferation rate. references 1. olsen e, vonderheid e, pimpinelli n, et al. revisions to the staging and classification of mycosis fungoides and sezary syndrome: a proposal of the international society for cutaneous lymphomas (iscl) and the cutaneous lymphoma task force of the european organization of research and treatment of cancer (eortc). blood 2007;110:1713-22. 2. kaltoft k, bisballe s, dyrberg t, et al. establishment of two continuous t-cell strains from a single plaque of a patient with mycosis fungoides. in vitro cell dev biol 1992;28a:161-7. 3. kaltoft k, bisballe s, rasmussen hf, et al. a continuous t-cell line from a patient with sezary syndrome. arch dermatol res 1987;279:293-8. 4. davis th, morton cc, miller-cassman r, et al. hodgkin's disease, lymphomatoid papulosis, and cutaneous t-cell lymphoma derived from a common t-cell clone. n engl j med 1992;326:1115-22. 5. schiemann wp, pfeifer wm, levi e, et al. a deletion in the gene for transforming growth factor beta type i receptor abolishes growth regulation by transforming growth factor beta in a cutaneous t-cell lymphoma. blood 1999;94:2854-61. 6. darzynkiewicz z, gong j, juan g, et al. cytometry of cyclin proteins. cytometry 1996;25:1-13. 7. gong j, ardelt b, traganos f, et al. unscheduled expression of cyclin bl and cyclin e in several leukemic and solid tumor cell lines. cancer res 1994; 54: 4285-8. 8. viallard jf, lacombe f, dupouy m, et al. flow cytometry study of human cyclin b1 and cyclin e expression in leukemic cell lines: cell cycle kinetics and cell localization. exp cell res 1999;247:208-19. 9. kurki p, vanderlaan m, dolbeare f, et al. expression of proliferating cell nuclear antigen (pcna)/cyclin during the cell cycle. exp cell res 1986;166:209-19. article figure 2. cyclin b1 and cyclin e expression in cutaneous t-cell lymphoma cell lines. cells (2¥¥106) were washed in pbs and fixed in ice-cold 70% ethanol for at least 20 hr. subsequently, cells were washed again, permeabilized using 0.25% triton-x 100 (5 min) and stained using appropriate antibodies. in the case of cyclin b1 and pcna staining, primary fitc labeled antibodies were used (diluted 1:50; bd pharmingen™) for 2 hr. in the case of cyclin e, cells were stained with primary mouse anti-human cyclin e antibodies (1:150; bd pharmingen™) for 1 hr, followed by 1 hr treatment with secondary goat anti-mouse antibodies labeled with alexa-fluor 488 (1:1000; invitrogen). in all cases the appriopriate isotype control (for direct staining) or secondary control (for indirect staining) was used. dna was stained with 7-amino-actinomycin d (7aad; beckman coulter). cellular fluorescence was measured using flow cytometer (beckman coulter). total percentage of positive cells and percentage per cell cycle phase were calculated. flow cytometry diagrams show cyclin b1 (a) and cyclin e (b) staining in mac1, myla, and seax cells. quantification of flow cytom etry data is shown in (c). dr [dermatology reports 2011; 3:e12] [page 23] telangiectasia macularis eruptiva perstans: more than skin deep casey e. watkins,1 winston b. bokor,1 stuart leicht,1,2 george youngberg,1,3 guha krishnaswamy1,4,5 1east tennessee state university, quillen college of medicine, johnson city, tn; 2department of dermatology, quillen college of medicine, johnson city, tn; 3department of pathology, quillen college of medicine, johnson city, tn; 4department allergy and immunology, quillen college of medicine, johnson city, tn; 5veterans affairs medical center, mountain home, tn, usa abstract systemic mastocytosis is a rare disease involving the infiltration and accumulation of active mast cells within any organ system. by far, the most common organ affected is the skin. cutaneous manifestations of mastocytosis, including urticaria pigmentosa (up), cutaneous mastocytoma or telangiectasia macularis eruptive perstans (tmep), may indicate a more serious and potentially life-threatening underlying disease. the presence of either up or tmep in a patient with anaphylactic symptoms should suggest the likelihood of systemic mastocytosis, with the caveat that systemic complications are more likely to occur in patients with up. tmep can usually be identified by the typical morphology, but a skin biopsy is confirmative. in patients with elevated tryptase levels or those with frequent systemic manifestations, a bone marrow biopsy is essential in order to demonstrate mast cell infiltration. further genetic testing for mutations of c-kit gene or the fip1l1 gene may help with disease classification and/or therapeutic approaches. rarely, tmep has been described with malignancy, radiation therapy, and myeloproliferative disorders. a few familial cases have also been described. in this review, we discuss the clinical features, diagnosis and management of patients with tmep. we also discuss the possible molecular pathogenesis and the role of genetics in disease classification and treatment. introduction cutaneous eruptions can occasionally provide significant insight to underlying disease. a case in point is systemic mastocytosis, which can present with a plethora of dermatological manifestations. tmep is a rare form of cutaneous mastocytosis (cm) that can occasionally be associated with an underlying systemic mastocytosis (sm).1-3 patients who present with this rare cutaneous disease should undergo routine testing to search for systemic disease. development of additional morbidities, such as reactions to bee stings, systemic anaphylaxis, osteoporosis or bleeding secondary to heparin release from mast cells, may occur and may complicate the diagnosis, unless suspected.4-8 on occasion, the disease may evolve into a hematological malignancy, making early diagnosis, classification and monitoring an essential aspect of disease management.9 this review will discuss the diagnosis, pathology, pathogenesis and mast cell biology as well as the management of tmep, complicated by systemic mastocytosis. case report a 43-year-old female was referred to the allergy and immunology clinic by her primary care physician for evaluation of a persistent skin eruption. worsening diffuse, erythematous skin eruptions that originated predominantly on the thighs and trunk region had been present for over a year. the lesions were described as itchy and raised at times but often appeared as merely discolorations of the skin. the rash waxed and waned periodically but had continued to spread and become generalized. the patient was evaluated by a dermatologist one year prior and a biopsy of the skin at that time was reported as benign. twice daily loratadine was also started at that time with no change in the rash. local treatments with steroid injections temporarily helped to alleviate the symptoms but the rash returned soon after. the patient could not pinpoint a single etiology. she had tried changing many environmental factors, including foods and detergents, to no avail. the patient had developed several episodes of systemic anaphylaxis associated with angioedema and flushing, but denied wheezing or syncope. she has otherwise been in good health with the exception of seasonal allergic rhinoconjunctivitis with sensitivity to dust, mold and pollen as well as a few instances of bronchitis and sinusitis. physical exam of the skin reveals a diffuse erythematous macular eruption with overlying dilated capillaries located on the thighs, upper extremities and back (figure 1a, 1b). the patient was also found to have a very weakly positive darier's sign (rubbing of the skin produces wheal and flare reaction with localized erythema, pruritis and edema).10,11 these exam findings were consistent with a diagnosis of tmep. further work-up included a skin biopsy, complete blood count with differential, comprehensive chemistry panel, thyroid stimulating hormone levels, anti-nuclear antibody, rheumatoid factor, erythrocyte sedimentation rate, c reactive protein as well as serum tryptase and 24-hour urine histamine levels. in addition, allergy testing (radioallergosorbent testing or rast for specific ige), levels of complement components (c3, c4) and serum immunoglobulins (immunoglobulins g, a, m and e) were obtained. flow cytometry for tand blymphocyte subsets (cd4, cd8, nkcells and cd19 positive b cells) was performed and plasma levels of interleukins 4, 5 and 6 were analyzed with particular attention paid to interleukin 6 which correlates with mast cell burden. a bone marrow biopsy was performed to look for evidence of systemic mastocytosis. a bone density test was also scheduled to rule out osteoporosis which is commonly associated with mastocytosis. abnormalities noted from the extensive work-up included elevated serum tryptase level which was found to be 89.7 μg/l (reference range 0.4-19.9 μg/l) and an elevated 24-hour urinary histamine level of 79 ng/24 hours (reference range, 13-62 ng/24 hours). a 3-mm punch biopsy of the right thigh showed superficial perivascular chronic inflammation. a dermatology reports 2011; volume 3:e12 correspondence: casey e. watkins, quillen college of medicine, box 70580, johnson city, tn, usa 37614. e-mail: watkince@goldmail.etsu.edu key words: telangiectasia macularis eruptiva perstans, mastocytosis, scorma index, serum tryptase, d816v mutation. contributions: cew, literature search, manuscript drafting, figures and tables creation, references management; wbb, literature search, manuscript drafting, final version proofreading; sl, manuscript revision for important clinical and dermatological content; gy, prepared the histological figures and legends and assisted in finalizing the manuscript; gk, manuscript drafting and final approval. conflict of interest: the authors report no conflicts of interest. received for publication: 27 june 2011. revision received: 6 july 2011. accepted for publication: 7 july 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright c.e. watkins et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e12 doi:10.4081/dr.2011.e12 no nco mm er cia l u se on ly [page 24] [dermatology reports 2011; 3:e12] mast cell tryptase immunohistochemical stain was used to identify mast cells (figure 1c, 1d). greater than 15 mast cells per perivascular high power field were observed. these findings are consistent with, and support the clinical diagnosis of, tmep. bone marrow aspiration and core biopsy revealed 5-10% infiltration by mast cells, confirming the diagnosis of indolent systemic mastocytosis (ism). many of the mast cells within the aspirate were reported as hypogranular and some were spindle-shaped. mast cell infiltrates were identified from ill-defined nodules within the bone marrow interstitium. cd117/c-kit/asp816val mutation analysis of the bone marrow by polymerase chain reaction (pcr) was strongly positive. fluorescent in situ hybridization (fish) testing of chic2/pdgfra/fip1l1 gene regions was found to be within normal limits. no diagnostic features of an associated myeloproliferative neoplasm or myelodysplastic syndrome were identified. a mutated (and an unmutated) form of c-kit was detected in the patient by flow cytometry (figure 2). the patient was subsequently referred back to dermatology for psoralen plus ultraviolet a (puva) light therapy which alleviated cutaneous symptoms to some extent. the antihistamines loratadine, cetirizine and famotidine were all prescribed to the patient for daily use. a dual-emission x-ray absorptiometry (dexa) was performed to look for signs of osteoporosis or other bone involvement. the patient was also instructed to follow patterson protocol for iv contrast prophylaxis with any future contrast imaging studies. two injectable epinephrine pens were also administered to the patient for prophylactic use with an anaphylactic episode. she has had two breakthrough anaphylactic episodes since the original diagnosis. at last follow up, the patient was seemingly doing well without anaphylactic reactions, but with persistent skin involvement. materials and methods review of the medical records provided information about history, skin punch biopsies and histological examination, serum tryptase levels, 24-hour urinary histamine, extensive autoimmune testing, radioallergosorbernt (rast) testing and bone marrow biopsy. cells obtained from bone marrow biopsy were tested for cd117/c-kit/asp816val and filp1/pdgfra mutations. a thorough review of the literature was performed using pubmed/mesh database search. available case reports and current review articles were investigated to provide up-to-date information about mastocytosis and tmep. this case report has been approved by the east tennessee state case report figure 2. flow cytometry used to detect c-kit mutation. both non-mutated peaks (a) and mutated peaks (b) were present in the patient. all patients with the c-kit mutation associated with mastocytosis should have some unmutated dna present. these figures were kindly provided by dr. rebecca f. mcclure of mayo clinic, rochester, minnesota. figure 1. (a) spontaneous telangiectasia macularis eruptiva perstans macular eruption. (b) magnified view of the skin manifestations with small tan macules and red brown streaking. images are produced with permission of the patient. (c) a cellular infiltrate is concentrated around superficial dermal blood vessels. hematoxylin and eosin stain. 200x magnification. (d) the infiltrate demonstrates a substantial mast cell component (>15 per perivascular high power field). many more mast cells are present than could be appreciated on the h&estained section. mast cell tryptase immunohistochemical stain. 200x magnification. no nco mm er cia l u se on ly [dermatology reports 2011; 3:e12] [page 25] university (etsu) and etsu/veterans affairs institutional review board. patient consent was obtained for photographs and appropriate clinical procedures. discussion mastocytosis is a rare disease caused by an abnormal accumulation of mast cells in one or more organ systems. the most common organ affected by mastocytosis is the skin.12,13 mastocytosis has a bimodal distribution with the majority of cases occurring in childhood and then peaking again at age 30-50 years. men and women are affected equally but the caucasian population is reported to be affected more commonly than any other race.8,11 the true incidence and prevalence of mastocytosis is unknown. studies suggest there are between 1/50,000 and 1/150,000 patients who present with mastocytosis per year.11,14 mastocytosis encompasses a wide spectrum of disease processes ranging from purely cutaneous to indolent or aggressive systemic disease to malignancy or hematological disease.15 more than 1 out of 4 adult patients with systemic disease also have cutaneous findings, therefore, recognizing the cutaneous manifestations of mastocytosis is an essential skill for clinicians.11,16 systemic mastocytosis is diagnosed according to major and minor criteria. the single major criteria is multifocal dense aggregates of mast cells (>15 mcs in aggregate) in bone marrow or another organ. the four minor criteria include abnormal morphology seen in >25% of mast cells, c-kit mutation d816v, bone marrow mast cell expression of cd2 or cd25 and tryptase levels >20 ng/ml.17 the presence of either one major and one minor criteria or three minor criteria is required for diagnosis. the various forms of sm include indolent systemic mastocytosis (ism), systemic mastocytosis with an associated clonal hematologic non-mast cell lineage disease (sm-ahnmd), aggressive systemic mastocytosis (asm), mast cell leukemia (mcl), mast cell sarcoma (mcs) and extracutaneous mastocytoma (table 1). ism is the most common and was the form of sm observed in the patient presented in this report. bone marrow is involved in nearly all cases of ism, however, mast cell infiltrates are typically low (<30%).1 ism affects younger patients and has a good prognosis. survival times are comparable to patients not affected by sm.17,18 systemic mastocytosis mastocytosis, often presenting as dermatological disease, is classified according to the world health organization (who) criteria released in 2001.17,19 there are six main categories of mastocytosis which will be discussed in this article (table 1). the diagnosis of cm, made by clinical observation and skin biopsy, is an indication for further evaluation of the patient to rule out sm. serum tryptase levels and 24-hour urinary histamine levels are two common, non-invasive methods of looking for systemic involvement. a bone marrow biopsy is ultimately indicated to look for proliferation of mast cells and specific cytogenetic mutations. a specific mutation of the c-kit receptor on mast cells, referred to as asp816val or d816v, is the most common genetic mutation associated with mastocytosis (figure 3). the bone marrow is probably the most common site of systemic involvement in the disease.20 this may be attributed to the fact that mast cell progenitor cells originate in the bone marrow. other organs may also be examined for systemic involvement, especially if organomegaly is present. yearly complete blood count, comprehensive metabolic panel, serum tryptase levels and 24hour urinary histamine levels should be obtained to follow disease progression. there is a possibility of transformation to mast cell leukemia or other hematological malignancy in all patients with mastocytosis. case report figure 3. schematic diagram of c-kit tyrosine kinase receptor. the most common mutations, particularly the d816v mutation, that result in mastocytosis affect this specific protein on mast cells. table 1. who classification of mastocytosis. the official who classification system which is based on the concensus classification for mastocytosis proposed in 2001.19 this classification system and its criteria enable differentiation among the multiple forms of mastocytosis. common abbreviations are also listed for reference. *most common manifestation. cutaneous mastocytosis cm maculopapular cutaneous mastocytosis urticaria pigmentosa* up/mpcp telangiectasia macularis eruptiva perstans tmep diffuse cutaneous mastocytosis dcm mastocytoma of the skin indolent systemic mastocytosis ism smoldering mastocytosis isolated bone marrow mastocytosis systemic mastocytosis with an associated clonal hematologic non-mast cell lineage disease sm-ahnmd aggressive systemic mastocytosis asm mast cell leukemia mcl mast cell sarcoma mcs extracutaneous mastocytoma no nco mm er cia l u se on ly [page 26] [dermatology reports 2011; 3:e12] cutaneous mastocytosis according to the world health organization (who) classification, cm is divided into urticaria pigmentosum or maculopapular cutaneous mastocytosis (up/mpcm), diffuse cutaneous mastocytosis (dcm), and mastocytoma of the skin (table 2). up/mpcm is present in the vast majority of cm cases. it presents with a maculopapular rash and positive darier's sign. the three subvariants of up/mpcm are a plaque form, a nodular form and a telangiectectatic form known as tmep.1,17,21 dcm presents with a diffuse erythrodermic rash and the skin may be diffusely thickened. mastocytomas are usually solitary or few, less than 1 cm in diameter and reddish or yellow in color. by definition, cm is restricted to the skin so wherever extracutaneous involvement exists, the diagnosis is sm. pure cm is most common in children. many adults with cutaneous disease actually have an underlying sm. telangiectasia macularis eruptiva perstans tmep is a very rare cutaneous finding seen in less than one percent of patients with mastocytosis.16,22-24 it was first described in the 1930s by parks weber.25 the lesions of tmep typically appear as small, irregular reddishbrown telangiectatic macules overlying tan to brown background. individual lesions are usually between 2 and 4 mm in diameter.16 the telangiectatic lesions will classically blanch on diascopy. one study discussed the use of dermatoscopy to identify telangiectatic vessels arranged in a reticular pattern; these findings are considered unique to and characteristic of tmep.21 lesions are typically located on the trunk and proximal extremities in a symmetrical pattern and are non-pruritic. palms, soles and face are spared in most cases. darier's sign, a common finding of up/mpcm, is typically negative or slight in patients with tmep due to the relatively smaller number of mast cells involved.8,16 diagnosis is usually based on clinical exam and confirmed by skin biopsy with histological examination. histologically, tmep typically involves only a slight increase in mast cells with infiltration of the superficial dermis and epidermal hyperpigmentation.16 mast cells are primarily located around dilated capillaries and venules of the superficial venous plexus found in the upper third of the dermis.21,22,26,27 giemsa and toludine-blue stains highlight the metachromatic intracytoplasmic granules and are good for recognizing mast cells.20 immunohistochemical staining for c-kit and/or tryptase is more sensitive and may also be used to confirm the diagnosis (figure 1d).22 unlike the other forms of cm, tmep most commonly manifests in adulthood. there have been reports of tmep in children, infants and familial cases but these are extremely rare.27,28 tmep is traditionally thought to be restricted to the skin, however, it has been reported in association with sm.10,29 bone marrow, gastrointestinal tract, liver, spleen and lymph node involvement have all been described in patients with tmep.22 systemic involvement should always be suspected if symptoms such as flushing, diarrhea, dyspnea, tachycardia, pruritis, syncope or signs of anaphylaxis are present in addition to the characteristic skin lesions.26 one study suggests bone marrow biopsy and aspirates should be routine in all adult patients with cm for baseline staging purposes.30 cm is commonly restricted to the skin in children and adolescents. it is not necessary to perform bone marrow biopsy in these patients without symptomatic indications or abnormal tests. serum tryptase and 24-hour urine histamine are good preliminary tests to investigate for systemic involvement.17 some cases of tmep have been described as familial, with a clustering within families. 27,31 there have been rare cases described in patients undergoing radiation, in patients with breast or renal carcinoma,32 malignant melanoma,33 or in patients with sjogrens syndrome.34 other cases have been described in patients with multiple myeloma,35 myeloproliferative disorders (such as polycythemia rubra vera)36 and in association with leukemia or myelofibrosis.9,37,38 coexistence of up and tmep has also been described in rare cases.37,39-41 on occasion, tmep may present as unexplained pruritis.42 some cases of tmep may present in atypical locations such as unilaterally on the face43,44 and/or localized to the upper arms.26 neurological complications such as prolonged loss of consciousness or the kounis-like phenomenon have also been described.45 diagnosis and evaluation due to the range of organs that can be affected as well as the esoteric nature of the symptoms of systemic disease, the diagnosis may be missed for years. delay in diagnosis may put patients at risk for life-threatening events including anaphylaxis and histaminemediated vascular collapse.7,12,13,46 skin findings suggestive of cutaneous mastocytosis should be biopsied to confirm clinical suspicions. avoid the use of local anesthetic containing epinephrine during skin biopsy due to the ability of epinephrine to stimulate mast cell degranulation. adults who present with cutaneous forms of mastocytosis should also be carefully considered for further investigation into an underlying systemic disease.17,30 systemic symptoms of mastocytosis may occasionally mimic carcinoid syndrome, which should be considered in the differential diagnosis. strategies for diagnosing mastocytosis are discussed in table 3. tryptase, the main protein component of the secretory granules found within mast cells, is a good indicator of total mast cell burden.15 in case report table 2. telangiectasia macularis eruptive perstans and other cutaneous mastocytoses. a brief summary of the prominent clinical, histopathological and demographic descriptors of telangiectasia macularis eruptive perstans as well as the other forms of cutaneous mastocytosis. cm clinical findings pathological findings demographics tmep red-brown, maculo-papular, telangiectatic, subtle increase in mc, perivascular almost exclusively in adults. irregular, 2-6 mm. located on trunk location, upper 1/3 of dermis, dilated seen in <1% of patients with mastocytosis. & extremities. darier's sign negative or slight. superficial capillaries. up red-brown, maculopapular rash, increased number of mature mc. presents at any age, peak incidence in childhood 0.5-3.5 mm, flushing, pruritis, and again in 3rd decade of life. positive darier's sign, dermatographism. most common cm. mastocytoma red-brown nodules or plaques, large, solitary collection of densely most appear in first 3 months of life. usually <1 cm, positive darier's sign. packed mc. rare in adults. dcm* thickened red-brown edematous skin, diffuse, generalized band-like present before age 3. orange-peel texture, positive darier's sign, infiltration of mc. dermatographism. cm, cutaneous mastocytosis, tmep, telangiectasia macularis eruptiva perstans, up, urticaria pigmentosa (also referred to as maculopapular cutaneous mastocytosis), dcm, diffuse cutaneous mastocytosis. *two variants have been described: i)diffuse erythrodermic cutaneous mastocytosis (dermatographia, blistering and systemic disease are common) and ii) pseudoxanthomatous mastocytosis, or xanthelasmoidea (lasting through adult life).2 no nco mm er cia l u se on ly [dermatology reports 2011; 3:e12] [page 27] general, most patients with pure cm exhibit normal serum tryptase levels. tryptase levels > 20 μg/l are typically seen with sm.20,47 elevated 24-hour urinary histamine is another common finding associated with systemic mastocytosis but is non-specific. the metabolite of histamine, n-methylhistamine, is a more sensitive test and should be used when possible.15 a practical tool for the evaluation of cm is the scorma (scoring mastocytosis) index (table 4). it consists of three parts: (a) the extent of skin affected expressed as a percent, (b) the intensity of the skin abnormality based on pigmentation/erythema, vesiculation, elevation and darier's sign and (c) five subjective symptoms which include triggers, flushing, diarrhea, pruritis and bone pain. these parts are each scored and applied to a formula to calculate the final scorma index. this clinical tool may be useful to initially evaluate severity. it is considered comparable to serum tryptase levels in predicting systemic involvement. scorma index is also an excellent method for monitoring disease progression and treatment efficacy.47 in general, patients with cutaneous lesions have a good prognosis despite involvement of other organs.11 this fact may be attributed to tendency for earlier diagnosis if skin lesions are present and predilection of skin disease with ism, which in itself has a better prognosis than the other types of sm. ism has a prolonged clinical course with survival times estimated at two decades and more if transformation into another disease category does not occur.20 cytogenetics and molecular aspects essential aspects of mast cell biology and the role of these cells in the immune-inflammatory response has been reviewed by us.48-50 the relationship between mast cells and t cells, fibroblasts and eosinophils have important implications for disease pathogenesis.51-53 mast cells can be activated by a variety of procceses, including antigens (such as venom stings or food allergens), cytokines as well as by some bacteria.54-57 the involvement of mitogen-activated protein kinase (mapk) and nuclear factor kappa b (nf-κb) pathway in signaling may explain the efficacy of drugs such as the glucocorticoids in some complications. these aspects may also explain the complications of bee stings or drug/food reactions in patients with mastocytosis, and the resultant recommendation of avoidance of contact with some of these triggers.4,8,46 a list of triggers in sm is provided in table 5. an important genetic component of mastocytosis involves a mutation in the type iii transmembrane tyrosine kinase receptor c-kit (figure 3). this receptor has an extracellular domain that binds to mast cell growth factor which functions to promote growth and functionality of mast cells.16 the most common type of mutation occurs within codon 816 (known as d816v) and causes constitutive activation of the c-kit receptor.10 testing for the d816v mutation can be done on bone marrow biopsy, as was performed in the case described, or on skin biopsy. this mutation does not differentiate cutaneous and extracutaneous involvement but is found in nearly all adult cases of systemic mastocytosis.10,15 many promising drugs that specifically target mast cells and the c-kit receptor are currently under investigation, including pkc412, amn107 and dasacase report table 3. diagnostic strategies in telangiectasia macularis eruptive perstans and/or suspected mastocytosis. summary of diagnostic strategies that may be employed when mastocytosis is suspected. for patients with tmep or up skin biopsy complete blood count and differential comprehensive chemistry serum tryptase level bone marrow biopsy with evaluations for mutations* for patients with suspected systemic mastocytosis urine collection for biochemical testing bone scan dexa study/bone mineral density gastrointestinal endoscopy (for gi tract symptoms or diarrhea) tissue biopsy (for involved sites such as liver or gi mucosa) computed tomography of the abdomen, chest and/or pelvis exclude other disease presenting in a similar fashion (flushing, diarrhea, wheezing, hypotension) carcinoid syndrome (urine 5-hiaa) tmep, telangiectasia macularis eruptiva perstans; up, urticaria mastocytosis; dexa, dual-energy x-ray absorptiometry; gi, gastrointestinal; 5-hiaa, 5-hydroxyindoleacetic acid. *mutations including c-kit (d816v) and fip1l1. table 4. scorma index. the clinical components of the scorma index. the severity of cutaneous mastocytosis can be evaluated using the listed criteria. it may also be used as a tool for disease surveillance.47 part a extent of skin abnormality measured as percent body surface area present on physical examination. involved. part b 1. pigmentation/erthyema measured according to examiners' observation. 2. vesiculation absent = 0, mild = 1, moderate = 2, severe = 3. 3. elevation 4. positive darier's sign part c 1. provoking factor(s) subjective severity of symptoms 2. flushing reported by the patient on a scale of 1-10. 3. diarrhea 4. pruritis 5. localized bone pain scorma 9ndex = a/4 + 5b + 2c/5 scores range from 5.2 to 100 table 5. triggers that can activate mast cells. physical stimuli and substances that can activate mast cells. these may be considered triggers for systemic symptoms or anaphylaxis in patients with mastocytosis. alcohol bacterial toxins emotional stress exercise food allergens (e.g., shellfish, peanuts) immunologic stimuli (e.g., ige) sunlight temperature extremes venoms (e.g., hymenoptera) pharmaceutical agents acetylsalicylic acid amphotericin b d-tubocurarine dextromethorphan gallium narcotics (e.g., morphine, meperidine, codeine) nonsteroidal anti-inflammatory drugs polymyxin b polymeric eye drops quinine radiographic contrast containing iodine reserpine scopolomine no nco mm er cia l u se on ly [page 28] [dermatology reports 2011; 3:e12] tinib.20 a less common mutation located in the fip1-like 1 gene (fip1l1) is routinely tested for in patients with sm because it is a good indicator of response to treatment with the targeted tyrosine kinase inhibitor imatinib.7 constitutive signaling resulting from any mutation leads to uncontrolled proliferation of mast cells. increased release of the c-kit ligand, known as mast cell growth factor (mcgf) or stem cell factor (scf), may also contribute by acting locally to cause mast cell proliferation. additionally, mcgf has been shown to cause melanocyte proliferation with increased production of melanin pigment. this likely accounts for the hyperpigmentation typical of up/mpcm lesions.21 subsequent localized release of mast cell mediators and angiogenic factors from the activated mast cells can cause permanent vasodilation. this mechanism is responsible for the telangiectasias and erythematous nature of the lesions seen with tmep.26 systemic release of excess mast cell mediators causes the clinical signs and symptoms of mastocytosis. some of the main mast cell mediators include histamine, heparin, tryptase, leukotrienes and interleukins. histamine causes vasodilation, erythema, edema, pruritis and increased gastric acid.13 heparin and tryptase are both thought to be involved in the premature development of osteoporosis in patients with sm. these two factors are also responsible for inhibition of coagulation and possible increased bleeding risk. leukotrienes are involved in bronchoconstriction and increased vascular permeability.13 treatment at this time most commonly consists of modulating the effects of these mast cell mediators. treatment there is no established first-line therapy for tmep or systemic mastocytosis and much of treatment is focused on symptomatic relief. the literature suggests a combination of avoidance of triggers, limiting release of mast cell mediators and blocking the effects of these mediators.58 the more aggressive forms, including asm and mcl, may require a more intensive therapeutic regimen. cytoreductive and chemotherapeutic agents may be required in such cases. common triggers for patients with mastocytosis (table 5) include alcohol, exercise, extreme temperatures, venoms, aspirin, nonsteroidal anti-inflammatory drugs, anesthesia and narcotics.7,13 patients should be educated about exposure to triggers and should be managed on an individual basis. for cutaneous manifestations, oral psoralen plus uva photochemotherapy, high-dose uva1 and narrow-band ultraviolet b phototherapy (uvb) have all proven beneficial both cosmetically and symptomatically.22,59,60 surgery with 585 nm flashlamp-pumped dye laser is also thought to improve cutaneous symptoms.61 in nearly all cases, the symptom relief was transient and therapy had to be repeated. if pure cm is diagnosed, observation and conservative management of skin lesions is reasonable. with underlying sm, treatment of systemic disease is reported to provide relief of cutaneous symptoms as well. antihistamines are a well-established option for symptoms of sm. h1-histaminereceptor antagonists are used for pruritis and urticaria and h2 antagonists for excess gastric acid secretion.62,63 the anti-mediator drug ketotifen may also be used to relieve pruritis, urticaria, flushing and bone pain.1,10 additionally, leukotriene receptor antagonists have proven successful for short-term control of mediator-induced symptoms.58,64 agents that stabilize mast cells, such as oral disodium cromoglycate, are used to block the release of mediators and decrease pruritis and flushing. oral cromolyn sodium appears to work particularly well for gastrointestinal symptoms.65-67 corticosteroids, both intravenous and topical, have also been used and may be beneficial in patients with frequent hypotensive episodes.20 topical steroids may help to alleviate skin symptoms. table 6 demonstrates treatment options with respect to mediator-related symptoms. interferon-α, immunosuppressants and other cytoreductive agents have been reported as possible treatments for more severe and aggressive forms of mastocytosis.20,68,69 prophylactic measures should also be taken in patients with sm. patients should be educated about common triggers, risks with surgery and using the patterson protocol for procedures involving iv contrast due to the increased risk of anaphylaxis. providing patients with epinephrine injections for emergency use in cases of anaphylaxis or episodes of hypotension is highly recommended.5 dexa scans should also be obtained due to the higher risk of osteopenia and osteoporois in these patients. also encourage careful follow-up with yearly monitoring of cbc, serum tryptase and 24-hour urinary histamine for disease surveillance. investigation into the cytogenetics of mastocytosis continues to reveal encouraging treatment targets. imatinib may be used as treatment for sm, however, the d816v mutation is an indicator of poor response to this therapy.7 only patients with the fip1l1 mutation have been shown to have a good response to imatinib therapy.7 increasing knowledge of the genetics of mastocytosis enables progression of treatment options. the most promising agents appear to be those that specifically target the c-kit kinase receptor on mast cells. therapies targeting the specific cytogenetics of mastocytosis have potential to be the first and only curative modality. further research and development in this field is needed. conclusions characteristic skin findings can sometimes indicate the need for a high index of suspicion for an underlying systemic illness. it is essential to recognize and investigate cutaneous manifestations of diseases, especially those that may prove potentially fatal. mastocytosis is a rare disease that most commonly presents with cutaneous manifestations. the symptoms of mastocytosis are caused by release of mediators from mast cells that may cause, in severe cases, anaphylaxis or histamine-mediated vascular collapse. progressing, eruptive erythematous lesions with reddish-brown macules and telangiectasias of the trunk and extremities are seen with telangiectasia macularis eruptive perstans (tmep), a rare form of maculopapular cutaneous mastocytosis. further work-up case report table 6. treatment of telangiectasia macularis eruptive perstans and systemic mastocytosis. mast cell components that cause typical symptoms of mastocytosis and how to treat based on symptomatology. component symptom treatment mast cell plethora cromoglycate histamine vasodilation h1 receptor antagonists excess gastric acid h2 receptor antagonists tyrosine kinase mast cell proliferation imatinib and congeners nf-κb inflammation glucocorticoids ltc4 inflammation leukotriene inhibitors multiple mediators hypotension epinephrine/autoinjectors mast cell proliferation systemic disease biological agents (e.g., interferon α) mast cell infiltration up/tmep puva (phototherapy) mastocytoma excision tmep, telangiectasia macularis eruptiva perstans; sm, systemic mastocytosis; nf-κb, nuclear factor kappa b; ltc4, leukotriene c4; up, urticaria pigmentosa; puva, psoralens and ultraviolet a. no nco mm er cia l u se on ly [dermatology reports 2011; 3:e12] [page 29] should be initiated, especially in adult patients with new-onset skin manifestations of mastocytosis, in order to look for systemic involvement. treatment options include but are not limited to phototherapy (puva and uvb), antihistamines (h1 and h2 blockers) and injectable epinephrine due to the increased risk for anaphylaxis. yearly complete blood count, comprehensive metabolic panel, serum tryptase levels, 24hour urine histamine and scorma index are excellent options for disease surveillance and monitoring response to treatment. patients should be followed closely due to the possibility of transformation to mast cell leukemia or other hematological malignancy. due to the prevalence of the d816v mutation in adults with mastocytosis, further investigation into cytogenetics and targeted therapy is promising. references 1. valent p, horny hp, escribano l, et al. diagnostic criteria and classification of mastocytosis: a consensus proposal. leuk res 2001;25:603-25. 2. briley ld, phillips cm. cutaneous mastocytosis: a review focusing on the pediatric population. clin pediatr (phila) 2008;47:757-61. 3. gibbs nf, friedlander sf, harpster ef. telangiectasia macularis eruptiva perstans. pediatr dermatol 2000;17:194-7. 4. biedermann t, rueff f, sander ca, et al. mastocytosis associated with severe wasp sting anaphylaxis detected by elevated serum 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2003;8:a40-a47. 58. tolar j, tope wd, neglia jp. leukotrienereceptor inhibition for the treatment of systemic mastocytosis. n engl j med 2004;350:735-6. 59. prignano f, troiano m, lotti t. cutaneous mastocytosis: successful treatment with narrowband ultraviolet b phototherapy. clin exp dermatol 2010;35:914-5. 60. czarnetzki bm, rosenbach t, kolde g, et al. phototherapy of urticaria pigmentosa: clinical response and changes of cutaneous reactivity, histamine and chemotactic leukotrienes. arch dermatol res 1985;277:105-13. 61. monahan tp, petropolis aa. treatment of telangiectasia macularis eruptiva perstans with total skin electron beam radiation. cutis 2003;71:357-9. 62. crawhall jc, wilkinson rd. systemic mastocytosis: management of an unusual case with histamine (h1 and h2) antagonists and cyclooxygenase inhibition. clin invest med 1987;10:1-4. 63. johnson gj, silvis se, roitman b, et al. long-term treatment of systemic mastocytosis with histamine h2 receptor antagonists. am j gastroenterol 1980;74:485-9. 64. cengizlier r, hucumenoglu s, ozen a, et al. treatment of telangiectasia macularis eruptiva perstans with montelukast. allergol immunopathol (madr) 2009;37: 334-6. 65. ferkovic tj, lanese tr, long bd. use of oral cromolyn sodium in systemic mastocytosis. clin pharm 1982;1:377-9. 66. soter na, austen kf, wasserman si. oral disodium cromoglycate in the treatment of systemic mastocytosis. n engl j med 1979; 301:465-9. 67. dolovich j, punthakee nd, macmillan ab, et al. systemic mastocytosis: control of lifelong diarrhea by ingested disodium cromoglycate. can med assoc j 1974;111: 684-5. 68. kluin-nelemans hc, jansen jh, breukelman h, et al. response to interferon alfa-2b in a patient with systemic mastocytosis. n engl j med 1992;326:619-23. 69. yoshida c, takeuchi m, tsuchiyama j, et al. successful treatment of kit d816v-positive, imatinib-resistant systemic mastocytosis with interferon-alpha. intern med 2009;48:1973-8. case report no nco mm er cia l u se on ly dr [page 20] [dermatology reports 2011; 3:e10] dermatology reports 2011; volume 3:e10 the important role of interdisciplinary collaboration in the management of a melanocytic skin lesion anna balato,1 annunziata raimondo,1 mariateresa cantelli,1 maria siano,2 serena lembo,1 massimiliano scalvenzi,1 nicola balato1 1department of dermatology, university of naples federico ii, naples, italy; 2department of biomorphological and functional sciences, pathology section, school of medicine, university federico ii of naples, naples, italy abstract one of the most confounding characteristics, commonly seen in malignant, but even in benign melanocytic nevi, is represented by the regression phenomenon. the identification of regression, through dermoscopical observation, can be predictive of a tricky histopathological examination. therefore, this feature should be an alert to a meticulous clinical, dermoscopical and histopathological correlation for correct analysis of melanocytic skin lesions. a 26-year-old man was referred to our department for a pigmented skin lesion localized on his trunk. it was clinically and dermoscopically diagnosed as atypical melanocytic nevus with central regression. after 1 year the lesion underwent considerable changes, leading to a nearly complete regression. the lesion was excised and, on the basis of clinical, dermoscopical and histopathological correlation, was interpreted as a junctional melanocytic nevus with regression. in our case the association of clinical, dermoscopical and histopathological experience, resulted an important and useful method, in order to proper interpret and correctly diagnose an atypical melanocytic skin lesion. in november 2009, a 26-year-old man was referred to our department for a pigmented skin lesion on his trunk. the lesion appeared as a brown macule, sized 5 mm in diameter, with an irregular shape and no associated pruritus or discomfort. family history of dysplastic nevi or melanoma was negative. dermoscopic examination showed: reticular pattern with central regression, constituted by blue-white areas, and diffuse dots/globules (figure 1a). a diagnosis of atypical melanocytic nevus with partial regression was made and excision of the lesion was recommended, but the patient did not show up, even after several reminders. he presented for a follow up after 1 year, when the lesion was almost totally disappeared. it was dermoscopically re-analyzed revealing diffuse white area with only a small central residual light brown pigmentation network (figure 1b). the lesion was finally excised and histopathologic examination performed, diagnosing it as a melanocytic blue nevus. since there was no concordance between histo pathology, dermoscopy and clinical history the specimen was re-analyzed histopathologically. the examination confirmed the presence of fibrosis, neovascularization and heavily-pigmented dendritic melanocytes in the dermis (figure 1c), but it showed also areas with irregular junctional melanocytic activity with a focal trend toward the upward spreading (pagetoid). the dermal component was constituted of melanocytes with small round nuclei, with rare nucleoli, and showed a solid growth pattern, with deep nodular areas characterized by high cellularity, without significant atypia (figure 1d). this component showed a striking immunoreactivity for s-100 protein and ki-67 (mib-1), but it was negative for hmb45. based on the review of clinical, dermoscopical and histopathological features, the lesion was now diagnosed as a junctional melanocytic nevus with regression. a strict follow-up every 6 months was recommended. the regression phenomenon represents one of the most confounding characteristics, commonly seen in malignant, but even in benign melanocytic nevi. it has been reported in the literature using various terms and definitions, reflecting the great morphological variability of this phenomenon. the presence of regression might be confounding not only on dermoscopic grounds but also on histopathological correspondence: serena lembo, department of dermatology university of naples federico ii via s. pansini 5, 80131 naples, italy. tel. +39.081.7462457 fax +39.081.7462442. e-mail: serenalembo@yahoo.it key words: melanocytic skin lesion, dermoscopy, histopathology, regression, interdisciplinary collaboration. conflict of interest: the authors report no conflicts of interest. received for publication: 30 may 2011. revision received: 20 june 2011. accepted for publication: 22 june 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright a. balato et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e10 doi:10.4081/dr.2011.e10 figure 1. (a) dermoscopic examination at the first observation and (b) after 1 year. histopathological examination: (c) fibrosis, neovascularization and heavily-pigmented dendritic melanocytes in the dermis (arrows) (hematoxylin and eosin stain; h&e, x1020 magnification); (d) irregular junctional melanocytic activity with a focal trend toward the upward spreading (pagetoid) (arrow). in the dermis presence of melanocytes with small round nuclei, rare nucleoli, and a solid growth pattern with high cellularity, but no significant atypia (hematoxylin and eosin stain; h&e, x20-40). no nco mm er cia l u se on ly [dermatology reports 2011; 3:e10] [page 21] article ones. zalaudek et al.1 showed an absolute correspondence between the dermoscopic bluewhite structures and the presence of partial or focal regression histopathologically. ackerman et al.2 reported a dermoscopical histopathological correlation between blue areas and the melanosis type of regression as well as between white areas and the fibrosis type of regression. our case completely fitted with these findings. in the last two decades several studies have been performed investigating the diagnostic impact of dermoscopy, demonstrating the increase of accuracy in diagnosing pigmented skin lesions compared with clinical examination by the naked eye.3,4 however, dermoscopy is not 100% accurate in differentiating melanocytic skin lesions as these entities frequently are characterized by ‘overlapping’ dermoscopic features.5,6 the loss of typical dermoscopic features over time, as in our case, represents a challenge for the dermatologist. ferrara et al.7 showed that the presence of features as regression in melanocytic lesions might lead to an interobserver disagreement on diagnosis from a dermoscopical but also histopathological point of view. the knowledge of a dermoscopic pattern which might be predictive of a histopathological difficulty for the analysis of melanocytic skin lesions should be an alert to a meticulous clinical, dermoscopical and histopathological correlation.8 this report confirmed this correlation as an important and useful method in order to interpret and diagnose an atypical melanocytic skin lesion. in conclusion, we want to emphasize the important role of the interdisciplinary collaboration in the management of melanocytic skin moles. references 1. zalaudek i, argenziano g, ferrara g, et al. clinically equivocal melanocytic skin lesions with features of regression: a dermoscopic–pathological study. br j dermatol 2004;150:64-71. 2. ackerman ab, cerroni l, kerl h. pitfalls in histopathologic diagnosis of malignant melanoma. philadelphia: lea & febiger;1994. 3. mayer j. systematic review of the diagnostic accuracy of dermatoscopy in detecting malignant melanoma. med j aust 1997; 167:206-10. 4. kittler h, pehamberger h, wolff k, binder m. diagnostic accuracy of dermoscopy. lancet oncol 2002;3:159-65. 5. hofmann-wellenhof r, blum a, wolf ih, et al. dermoscopic classification of atypical melanocytic nevi (clark nevi). arch dermatol 2001;137:1575-80. 6. argenziano g, scalvenzi m, staibano s, et al. dermatoscopic pitfalls in differentiating pigmented spitz naevi from cutaneous melanomas. br j dermatol 1999;141:78893. 7. ferrara g, argenziano g, soyer hp, et al. dermoscopic and histopathologic diagnosis of equivocal melanocytic skin lesions: an interdisciplinary study on 107 cases. cancer 2002;95:1094-100. 8. ferrara g, argenziano g, soyer hp, et al. histopathologic interobserver agreement on the diagnosis of melanocytic skin lesions with equivocal dermoscopic features: a pilot study. tumori 2000;86:445-9. case report no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. dr [page 36] [dermatology reports 2010; 2:e14] a characterization of the expression of 14-3-3 isoforms in psoriasis, basal cell carcinoma, atopic dermatitis and contact dermatitis line raaby, kristian otkjær, maria luise salvskov-iversen, claus johansen, lars iversen department of dermatology, aarhus university hospital, aarhus, denmark abstract 14-3-3 is a highly conserved protein involved in a number of cellular processes including cell signalling, cell cycle regulation and gene transcription. seven isoforms of the protein have been identified; β, γ, ε, ζ, η, σ and τ. the expression profile of the various isoforms in skin diseases is unknown. to investigate the expression of the seven 14-3-3 isoforms in involved and uninvolved skin from psoriasis, basal cell carcinoma (bcc), atopic dermatitis and nickel induced allergic contact dermatitis. punch biopsies from involved and uninvolved skin were analyzed with quantitative reverse transcription-polymerase chain reaction to determine the mrna expression of the 14-3-3 isoforms. the protein level of 14-3-3 isoforms was measured by western blot technique in keratome biopsies from patients with psoriasis. evaluation of dermal and epidermal protein expression was performed by immunofluorescence staining. increased 14-3-3τ mrna levels were detected in involved skin from patients with psoriasis, contact dermatitis and bcc. 14-3-3σ mrna expression was increased in psoriasis and contact dermatitis, but not in bcc. in atopic dermatitis no significant difference between involved and uninvolved skin was found. the expression of the 14-3-3 isoforms was also studied at the protein level in psoriasis. only 14-3-3τ expression was significantly increased in involved psoriatic skin compared with uninvolved skin. immuno fluorescence staining with 14-3-3τand 14-33σ-specific antibodies showed localization of both isoforms to the cytoplasm of the keratinocytes in the various skin sections. these results demonstrate a disease specific expression profile of the 14-3-3τ and 14-3-3σ isoforms. introduction 14-3-3 is a highly conserved protein family comprising seven different isoforms with molecular weights of 29-33 kda.1,2 the 14-3-3 protein was first discovered in 1967 by moore and perez as an abundant brain protein3 and it has been found in all eukaryote organisms investigated so far .4 14-3-3 is found in all tissues5 and interacts with more than 200 proteins.6 it is involved in a number of cellular processes including cell signalling, regulation of the cell cycle, intracellular trafficking, regulation of the cytoskeletal structure and control of gene transcription.2 in general the cellular effects of 14-3-3 can be classified into three categories7: i) directing cell conformational changes; ii) binding to target proteins and modulation of their activity and/or interactions with other cellular components; iii) acting as a phosphorylation-dependent scaffold protein that recruits other proteins. seven different isoforms of 14-3-3 have been identified and are denominated σ, ζ, η, γ, τ, ε and β. further more, α and δ isoforms have been identified as phosphorylated forms of β and ζ, respectively.2,8 the functions of the different isoforms are not yet clarified. 14-3-3σ is the best characterized isoform and is in particular expressed in epithelial cells.9 the expression of 14-3-3σ increases in the cells after dna damage and together with p53 it plays an important role for the g2/m checkpoint in the cell cycle.10 the gene can be inactivated by cpg methylation (epigenetic silencing) of the promoter region, which is seen in different types of carcinomas, including basal cell carcinoma.9,11 the 14-3-3τ isoform is important in embryogenesis and both knockout mice and xenopus with inactivated 14-3-3τ do not survive embryonic development.12,13 14-3-3ζ downregulates the level of p53 and is upregulated in more than 40% of advanced breast cancers.14 14-3-3γ and 14-3-3β also seem to have oncogenic potential when overexpressed. overexpression of 14-3-3β in nih 3t3 cells stimulate cell growth and when injected in nude mice, it augments tumor formation,15 while overexpression of 14-3-3γ in h322 lung cancer cells results in abnormal dna replication and polyploidization.16 the expression of 14-3-3ε is upregulated in aged skin compared with young skin, and the protein is induced and accumulated after ultraviolet radiation. the expression is higher in sunexposed skin compared with sun-protected skin from the same patient.17 taken together, these findings demonstrate distinct properties of the various 14-3-3 isoforms. all seven isoforms have been identified in human keratinocytes in vitro, whereas all isoforms except 14-3-3σ were found in fibroblasts.18 western blot analysis of intact human epidermis and immunohistochemical staining of human skin sections detected six isoforms but not the 14-3-3τ.18 although the 14-3-3 protein is expressed in human skin the role of 143-3 proteins in inflammatory skin diseases has only been sparsely investigated. using immunohistochemistry and polymerase chain reaction (pcr) technique lodygin et al. found similar 14-3-3σ expression level in both involved psoriatic skin and normal skin, whereas 14-3-3σ expression was reduced or absent in basal cell carcinoma.11 the role of 14-3-3 in different common skin diseases is therefore unclear. the aim of this study was to characterize the mrna profile of the seven 14-3-3 isoforms in four common skin diseases; i) psoriasis, a benign, th-1 and th-17 driven chronic inflammatory, hyperproliferating skin disorder; ii) atopic dermatitis, a th-2 driven chronic inflammatory skin disease; iii) acute, allergic nickel induced contact dermatitis, a th-1 and th-2 dominated disease19 and iv) basal cell carcinoma (bcc), a malignant hyperproliferating skin disorder. the protein profile of the seven 14-3-3 isoforms was only characterized in psoriatic skin because this was the only disease where sufficient tissue material could be collected allowing protein determination. dermatology reports 2010; volume 2:e14 correspondence: claus johansen, dept. of dermatology, aarhus university hospital, p.p. ørumsgade 11 dk-8000 aarhus c, denmark. e-mail: claus.johansen@ki.au.dk key words: 14-3-3 proteins, psoriasis, basal cell carcinoma, allergic contact dermatitis, atopic dermatitis. contributions: lr has done all experimental work (except from growing the cell cultures) and analysed the results. has also taken part in the design of the study and collecting biopsies; ko has taken part in the design of the study and collecting biopsies, has supervised the experimental work, especially the part concerning qrt-pcr; mls-i collecting biopsies and has grown the cell cultures; cj, taken part in the design of the study and selecting the methods, supervised the experimental work and the statistical analysis; li has designed the study and been the main supervisor of the project. acknowledgments: this work was supported by the novo nordisk foundation, lundbeck foundation, the andreassens and hougaards foundation, master cabinetmaker sophus jacobsen and wife astrid jacobsen’s fond, the danish research agency. conflicts of interest: the authors have no conflict of interest to disclose. received for publication: 28 september 2010. accepted for publication: 8 october 2010. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright l. raaby et al., 2010 licensee pagepress, italy dermatology reports 2010; 2:e14 doi:10.4081/dr.2010.e14 no nco mm er cia l u se on ly [dermatology reports 2010; 2:e14] [page 37] materials and methods biopsies bcc biopsies were taken from patients with histologically verified superficial or nodular bcc. the biopsies were taken from the center of the carcinoma. biopsies from uninvolved skin were taken from normal skin from the same body region. from patients with atopic dermatitis punch biopsies from involved and uninvolved skin were taken from the same body region. the patients did not receive any systemic therapy. to investigate allergic contact dermatitis, skin biopsies from positive nickel patch test were used. the nickel patches were attached for 48 hours and the biopsies were taken 24 hours after the patch was removed. uninvolved biopsies were taken from the same body region. the psoriatic skin biopsies were taken from patients with moderate to severe plaque psoriasis. the patients did not receive any systemic therapy for four weeks and no topical treatment for two weeks prior to the procedure. the involved skin biopsies were taken from the center of the plaque and the uninvolved skin biopsies were collected from the same body region. for quantitative reverse transcription-polymerase chain reaction (qrtpcr) analysis and immunofluorescence staining, 4 mm punch biopsies were taken while keratome biopsies were used for western blotting. biopsies for western blotting and qrtpcr were immediately snap-frozen in liquid nitrogen, whereas biopsies for immunofluorescence staining were embedded in paraffin. the study was conducted according to the declaration of helsinki principles. the medical ethical committee of aarhus university hospital approved the study. informed, written consent was obtained from each patient. cell cultures normal adult human keratinocytes were obtained by trypsinization of skin samples from patients undergoing plastic surgery as previously described.20 second passage cultures were grown in keratinocyte serum-free medium with supplement containing epidermal growth factor (egf) human recombinant and bovine pituitary extract, and gentamicin (gibco/invitrogen, carlsbad, ca, usa.) to approximately 80% confluency. twenty-four hours before stimulation the medium was changed to keratinocyte serum free media without supplement, in which the cells were stimulated. for stimulation we used tumor necrosis factors alpha (tnf-α) (10 ng ml–1), interferon-gamma (ifn-γ) (10 ng ml–1), interleukin-1beta (il-1β) (1 ng ml–1) (r&d systems, abingdon, uk), anisomysin (300 ng ml–1) and 12-o-tetradecanonylphorbol-13acetat (tpa) (50 nm), (sigma-aldrich, inc., st. louis, mo, usa). keratinocytes stimulated with cacl2 (0.3 mm) was maintained in growth-supplemented medium throughout the experiment (merck, darmstadt, germany). western blotting the protein extract was prepared from keratome biopsies. biopsies were homogenized in a cell lysis buffer (20 mm tris-base (ph 7.5), 150 mm nacl, 1 mm edta, 1 % triton x-100, 2.5 mm sodium pyrophosphate, 1 mm na3vo4, 1 μg ml–1 leupeptin and 1 mm pmsf) and left on ice for 30 minutes. the samples were centrifuged at 10,000 x g for 10 minutes at 4°c, after which the supernatant constituted the cell lysate. equal amounts of protein (determined by bradford) were separated by sds-page and blotted onto nitrocellulose membranes. the membranes were incubated with the following primary antibodies 14-3-3β (catalog no. #9636), 14-3-3γ (catalog no. #9637), 14-3-3ε (catalog no. #9635), 14-3-3ζ (catalog no. #9639), 14-3-3η (catalog no. #9640), 14-3-3τ (catalog no. #9638) from cell signaling technology, beverly, ma, usa, and 14-3-3σ (catalog no. sc-100638) from santa cruz biotechnology, santa cruz, ca, usa. antibodies were detected with horseradish peroxidase-conjugated anti-rabbit (catalog no. #7074 from cell signaling technology, beverly, ma, u.s.a.) or anti-mouse (catalog no. p0447, dako, glostrup, denmark) in a standard ecl reaction (ge healthcare, wessling, germany). to estimate the protein size a biotinylated protein ladder molecular weight maker was used followed by anti-biotin (catalog no. #7727 and #7075 from cell signaling technology, beverly, ma, usa). densitometric analysis of the band intensity was carried out using kodak 1d image analysis software. rna isolation from biopsies punch biopsies were transferred to 1 ml of 80°c cold rnalater-ice (ambion inc., austin, tx, usa) and kept at -80°c. 24 hours before purification the biopsies were transferred to -20°c. upon rna purification, biopsies were removed from rnalater-ice to 175 μl sv rna lysis buffer (added β-mercaptoethanol) and homogenized. rna purification, including dnase treatment, was completed according to the manufacturer’s instructions (sv total rna isolation systems; promega, madison, wi, usa). the rna was stored at -80°c until further use. rna isolation from cell cultures the cell supernatant was discarded and while on ice the keratinocytes were washed once in ice-cold sterile phosphate buffered saline (gibco/invitrogen, carlsbad, ca, usa). 150 μl rna cell lysis buffer were added and the prepared lysate transferred to eppendorf tubes and kept at -80°c until rna purification. the purification was completed according to manufacturer’s instructions (sv 96 total rna isolation systems; madison, wi, usa) rna was stored at -80°c until further use. quantitative reverse transcriptionpolymerase chain reaction for reverse transcription taqman rt reagens (applied biosystems, foster city, ca, usa) were used. primers/probes for qrt-pcr were taqmangene expression assay; (assay id: 14-3-3 β, hs00268732_m1; 14-3-3γ, hs01113553_mh; 14-3-3ε, hs00356749_g1; 143-3ζ, hs00237047_m1; 14-3-3η, hs00607046_m1; 14-3-3σ, hs00356613_m1; 14-3-3τ, hs00863277_m1) (applied biosystems). as housekeeping gene rplp0 was used (assay id: hs9999902_m1). the probes were fam-labelled mgb with a nonflourescent quencher. the expression of each gene was analysed in triplicate with 5 μl of cdna and 20 μl pcr mastermix. the mastermix was platinum® qpcr supermix-udg (invitrogen, carlsbad, ca, u.s.a.). the real-time pcr machine was a rotergene-3000 (corbett reseach, sydney, australia). relative gene expression levels were determined using the relative standard curve method as outlined in user bulletin no. 2 (abi prism 7700 sequencing detection systems; applied biosystems). briefly, a standard curve for each gene was made of 4-fold serial dilutions of total rna from a punch biopsy from a psoriatic plaque. the curve was used to calculate relative amounts of mrna in the samples. for 14-3-3σ the standard curve was made from rna from normal adult human keratinocytes. immunofluorescence the tissue sections were deparaffinized in xylene and hydrated through a descending ethanol series. for antigen unmasking, the sections were heated at 90°c for 15 min. in a tris/egta buffer (ph 9.0) followed by cooling for 20 min. to block non-specific binding sites the sections were incubated with image it fx signal enhancer (molecular probes, invitrogen, carlsbad, ca, usa) for 30 min. the sections were immunostained with 14-3-3τ antibody (cell signaling technology, beverly, ma, usa no 9638) and 14-3-3σ antibody (santa cruz biotechnology, no sc-100638) overnight at 4°c. the next day the sections were incubated with secondary antibody (alexa flour 488 from molecular probes, invitrogen) for 1 hour. nuclear staining was performed by mounting samples in prolong gold antifade reagent with dapi (molecular probes, invitrogen). as negative control, sections were incubated with either blocking buffer without primary antibody or with normal rabbit igg. article no nco mm er cia l u se on ly [page 38] [dermatology reports 2010; 2:e14] statistical analysis for statistical analysis a student’s t-test (two-tailed) was preformed. p<0.05 was regarded as statically significant. the results are expressed as mean ± standard deviation. results 14-3-3 mrna expression profiles in psoriasis, atopic dermatitis, allergic contact dermatitis and basal cell carcinoma to investigate the mrna expression profile of the 14-3-3 family members in psoriasis, atopic dermatitis, allergic contact dermatitis, and basal cell carcinoma, paired punch biopsies were obtained from involved and uninvolved skin. total rna was isolated and analysed by qrt-pcr. 14-3-3β, γ, ε, ζ, σ, and τ mrna expression levels were significantly increased in involved psoriatic skin compared with uninvolved psoriatic skin (n=9) (figure 1a). the 14-3-3σ and -τ mrna levels were 2fold increased whereas 14-3-3β, γ, ε and ζ mrna levels were less than 2-fold increased in involved psoriatic skin, compared with paired tissue samples of uninvolved psoriatic skin. no significant changes were seen for 14-3-3η mrna expression in psoriatic skin. in biopsies from basal cell carcinomas (n=3) a significant 1.6-fold increase in 14-3-3ε mrna expression was seen when compared with biopsies from normal skin from the patients (figure 1b). 14-3-3τ mrna expression was increased 2.4 fold (p=0.052) in biopsies from basal cell carcinomas. no significant changes were seen in mrna levels of any of the other isoforms. figure 1c shows the mrna level of the various 14-3-3 isoforms in three patients with atopic dermatitis (n=3). although some variation in mrna expression was found, no statistically significant differences were seen between involved and uninvolved atopic skin for any of the investigated 14-3-3 isoforms. the results from three patients with nickelinduced contact dermatitis are displayed in figure 1d. biopsies were collected 72 hours after patch testing with nickel. analysis showed a significant 2.7-fold increase in 14-3-3τ and -σ mrna expression in involved skin compared with uninvolved skin. 14-3-3 β, -γ and -η mrna levels were also increased in involved skin, but the differences were not statistically significant. 14-3-3 protein expression in psoriatic skin to assess 14-3-3 isoform protein expression levels by western blotting technique, keratome biopsies from nine psoriasis patients were collected. it was not feasible to collect keratome biopsies from patients with bcc, atopic eczema or contact dermatitis. the protein expression in involved psoriatic skin was compared with paired samples of uninvolved psoriatic skin. 143-3τ was the only isoform showing a consistent and significantly increased expression in involved psoriatic skin compared with uninvolved psoriatic skin. on the other hand, 14-33ε protein expression was slightly, but significantly (p<0.05), decreased in involved psoriatic skin. no significant changes in the protein expression in psoriatic skin were observed for the other 14-3-3 isoforms (figure 2a-b). article figure 1. 14-3-3 mrna expression in psoriasis (a), basal cell carcinoma (b), atopic dermatitis (c) and contact dermatitis (d). mrna expression was analysed in paired punch biopsies from involved and uninvolved skin by quantitative reverse transcription-polymerase chain reaction. mrna levels were normalized to the housekeeping gene rplp0 and uninvolved biopsies were indexed to one. bars indicate mean ± sd. *p<0.05. (n=9 for psoriasis, n=3 for bcc, atopic dermatitis and contact dermatitis). figure 2. increased level of 14-3-3τ protein in involved compared with uninvolved psoriatic skin. protein extracts prepared from keratome biopsies taken from involved and uninvolved psoriatic skin were analysed with western blot technique. (a) shows the membrane probed with an antibody detecting 14-3-3τ. β-actin was added to demonstrate equal protein loading. pt. 1-4 is randomly chosen between the nine patients totally included. (b) shows the protein level of all seven 14-3-3 isoforms. band intensity was quantified using kodak 1d image analysis software. the protein level was normalized to β-actin and uninvolved biopsies were indexed to one. bars indicate mean ± sd. *p<0.05. no nco mm er cia l u se on ly immunofluorescence of 14-3-3τ and 14-3-3σ because the mrna expression of 14-3-3τ and 14-3-3σ was significantly upregulated by more than two fold in involved skin from both psoriasis and nickel induced contact dermatitis and a marked although statistically insignificant upregulation of 14-3-3τ was seen in bcc’s, the localization of 14-3-3τ and 14-33σ was examined by immunofluorescence in involved and uninvolved tissue sections from these diseases. both 14-3-3τ and 14-3-3σ showed solid staining of the whole epidermis and higher magnification revealed localization of the proteins to the cytoplasm of the keratinocytes. the distribution of 14-3-3τ (figure 3a-f) as well as 14-3-3σ (figure 4a-f) was similar in involved and uninvolved skin in all investigated skin diseases. regulation of 14-3-3τ expression in cultured normal human keratino cytes the mechanisms leading to increased 14-33τ mrna expression in psoriasis, bcc, and allergic contact dermatitis are unknown. in an attempt to identify stimuli resulting in increased 14-3-3τ mrna expression, in vitro experiments were conducted with cultured normal human keratinocytes. keratinocytes were stimulated with tnf-α, ifn-γ, il-1β, tpa or anisomycin, respectively, for 3, 6, 12, and 24 hours. subsequently 14-3-3τ mrna levels were analyzed using qrt-pcr. no regulation of 143-3τ mrna expression was seen for any of the stimuli investigated (figure 5a). when keratinocyte differentiation was induced by calcium (0.3 mm) the 14-3-3τ mrna level increased. at 24 hours, 14-3-3τ mrna was increased 1.3-fold compared with medium controls (p<0.05). at 48 hours, increased calcium concentrations resulted in a 1.4-fold increase in 14-3-3τ mrna. however, at this time point the increase was not statistically significant compared with medium controls (figure 5b). discussion 14-3-3 isoforms are involved in the regulation of numerous cellular processes, but their expression in common skin disease has not previously been studied. the present study demonstrates a significant 2-fold increase in the mrna expression of 14-3-3τ and -σ in involved psoriatic skin and in involved skin from nickel-induced allergic contact dermatitis compared with paired samples of uninvolved skin. in basal cell carcinomas only 14-33τ mrna expression was increased more than 2-fold, whereas the 14-3-3σ mrna level were slightly, although not significantly, decreased. in involved and uninvolved atopic dermatitis skin no significant differences in the mrna expression of the various isoforms could be detected. 14-3-3 protein expression was only studied in tissue samples from psoriasis patients and only the expression of the 14-33τ protein was significantly increased in involved psoriatic skin compared with uninvolved psoriatic skin. 14-3-3 protein is involved in the regulation of transcription and translation by interacting with dna/mrna-binding proteins. triste traprolin (ttp) is a mrna regulating protein, which through binding to au-rich elements in cytokine mrna (e.g. tnf-α), induces mrna destabilization and subsequently degradation.21 mapk-activated protein kinase 2 (mk2) -induced phosphorylation of ttp creates a [dermatology reports 2010; 2:e14] [page 39] article figure 4. immuno fluorescence staining with 14-3-3σ. localisation of 143-3σ in the epidermis and dermis was analysed with immunofluorescence staining. nuclear staining was performed using dapi (blue). green (alexa fluor 488) demonstrates 14-33σ. the following paired tissue sections were stained: (a) uninvolved psoriatic skin, (b) involved psoriatic skin, (c) uninvolved bcc, (d) involved bcc, (e) uninvolved allergic contact dermatitis, (f) involved allergic contact dermatitis. figure 3. immuno fluorescence staining with 14-3-3τ. localisation of 143-3τ in the epidermis and dermis was analysed with im munofluorescence staining. nuclear staining was performed using dapi (blue). green (alexa fluor 488) demonstrates 14-3-3τ. the following paired tissue sections were stained: (a) uninvolved psoriatic skin, (b) involved psoriatic skin, (c) uninvolved bcc, (d) involved bcc, (e) uninvolved allergic contact dermatitis, (f) involved allergic contact dermatitis. no nco mm er cia l u se on ly [page 40] [dermatology reports 2010; 2:e14] functional binding site for 14-3-3. when 14-3-3 binds to ttp, the mrna-degrading capabilities of ttp is inhibited.22 a previous work from our group demonstrated increased mk2 activation in involved psoriatic skin compared with uninvolved skin. the protein expression of tnf-α was also elevated in psoriatic skin compared with uninvolved skin, whereas the tnf-α mrna level was similar, indicating a posttranscriptional regulation of tnf-α expression in psoriasis and mk2 was suggested to play a role in this posttranscriptional regulation.23 it is possible that mk2 regulates tnf-α expression through ttp and 14-3-3. own unpublished results showed no regulation of ttp mrna and protein expression in involved psoriatic skin compared with uninvolved psoriatic skin (data not shown). instead this study showed that the mrna expression of six isoforms of 14-3-3 was elevated in involved psoriatic skin compared with uninvolved skin, but only 14-33τ was significantly elevated at the protein level. the precise role of 14-3-3τ in the regulation of tnf-α expression in psoriasis is not yet known. it is intriguing to speculate that an increased activity of mk2 combined with elevated protein expression of 14-3-3τ inhibits the destabilising effect of ttp on tnf-α mrna thereby promoting tnf-α protein expression, but further studies are needed to clarify this. powell et al.24 demonstrated that mk2 phophorylation of 14-3-3ζ at ser-58 compromises 14-3-3 dimerization. we found no regulation of 14-3-3ζ protein expression in involved psoriatic skin compared with uninvolved, but increased phosphorylation of 14-33ζ might affect its binding of ttp. 14-3-3σ regulates the g2/m cell cycle checkpoint and dna damage induces 14-3-3σ protein expression in a p53 dependent manner.10 loss of 14-3-3σ increases the genomic instability in cells. breast cancer cells lacking 14-33σ expression shows an increased number of chromosomal breaks and gaps when exposed to gamma-irradiation25 and 14-3-3σ knockout cells have an increased frequency of chromosome aberrations.26 14-3-3σ can be inactivated by cpg-metylation (epigenetic silencing) of the promoter region.25 cpg methylation is a common event during carcinogenesis and has been reported in breast cancer, gastric, hepatocellular and small-cell carcinoma, oral squamous cell carcinoma, and basal cell carcinoma.9,27 using immunohistochemistry lodygin et al.11 observed a strongly reduced 14-3-3σ expression in basal cell carcinomas compared with normal skin, whereas the 14-3-3σ expression level in lesional psoriatic skin was comparable to normal skin. interestingly, we found no regulation of 14-3-3σ mrna expression in basal cell carcinomas, whereas an increased mrna expression in involved psoriatic skin and in allergic contact dermatitis was detected in this study. furthermore, a slight although statistically insignificant increase in 14-3-3σ protein expression was seen in involved psoriatic skin compared with uninvolved skin. these differences may be explained by the different techniques used in the two studies. we detected mrna using qrt-pcr whereas protein levels were detected by immunohistochemistry by lodygin et al.11 maintaining or even increasing the expression of 14-3-3σ in hyperproliferative skin disorders like psoriasis and allergic contact dermatitis may be a key control point in preventing malignant transformation by activating the g2/m checkpoint in the cell cycles. taken together, we showed an upregulation of 14-3-3τ expression in psoriasis, allergic contact dermatitis and bcc whereas the expression of 14-3-3σ was increased only in psoriasis and allergic contact dermatitis. thus, functional studies of the individual 14-3-3 isoforms in keratinocytes are highly needed in order to increase our understanding of a possible role of the various 14-3-3 isoforms in the pathogenesis of both benign and malignant skin diseases. references 1. martens gj, piosik pa, danen eh. evolutionary conservation of the 14-3-3 protein. biochem biophys res commun 1992;184:1456-9. 2. aitken a. 14-3-3 proteins: a historic overview. semin cancer biol 2006;16:16272. 3. carlson fd. physiological and biochemical aspects of nervous integration: a symposium held under the auspices of the society of general physiologists at its annual meeting at the marine biological laboratory woods hole, mass., aug. 30sept. 2, 1967. englewood cliffs, n.j.: 1968. 4. van hemert mj, steensma hy, van heusden gp. 14-3-3 proteins: key regulators of cell division, signalling and apoptosis. bioessays 2001;23:936-46. 5. boston pf, jackson p, thompson rj. human 14-3-3 protein: radioimmunoassay, tissue distribution, and cerebrospinal fluid levels in patients with neurological disorarticle figure 5. 14-3-3τ mrna expression in cultured normal human keratinocytes in vitro. keratinocyte cultures were stimulated with a panel of different stimuli. mrna expression was analysed by quantitative reverse transcription-polymerase chain reaction and the detected levels were normalized to the housekeeping gene rplp0. cell cultures incubated with vehicles were indexed to one. (a) shows the different stimuli, incubation period and whether there was an induction of 14-3-3τ mrna expression or not. no significant induction was defined as no significant changes in the 14-3-3τ mrna level compared with vehicle. (b) only incubation with calcium resulted in a significantly increased mrna level of 14-3-3τ in the keratinocytes. bars indicate mean ± sd. *p<0.05. n= 3. no nco mm er cia l u se on ly [dermatology reports 2010; 2:e14] [page 41] ders. j neurochem 1982;38:1475-82. 6. pozuelo rm, geraghty km, wong bh et al. 14-3-3-affinity purification of over 200 human phosphoproteins reveals new links to regulation of cellular metabolism, proliferation and trafficking. biochem j 2004;379:395-408. 7. bridges d, moorhead gb. 14-3-3 proteins: a number of functions for a numbered protein. sci stke 2004;re10. 8. ichimura t, isobe t, okuyama t et al. molecular cloning of cdna coding for brain-specific 14-3-3 protein, a protein kinase-dependent activator of tyrosine and tryptophan hydroxylases. proc natl acad sci usa 1988;85:7084-8. 9. hermeking h. the 14-3-3 cancer connection. nat rev cancer 2003;3:931-43. 10. hermeking h, lengauer c, polyak k et al. 14-3-3 sigma is a p53-regulated inhibitor of g2/m progression. mol cell 1997;1:3-11. 11. lodygin d, yazdi as, sander ca, et al. analysis of 14-3-3sigma expression in hyperproliferative skin diseases reveals selective loss associated with cpg-methylation in basal cell carcinoma. oncogene 2003;22:5519-24. 12. lau jm, wu c, muslin aj. differential role of 14-3-3 family members in xenopus development. dev dyn 2006;235:1761-76. 13. lau jm, jin x, ren j et al. the 14-3-3tau phosphoserine-binding protein is required for cardiomyocyte survival. mol cell biol 2007;27:1455-66. 14. danes cg, wyszomierski sl, lu j, et al. 143-3 zeta down-regulates p53 in mammary epithelial cells and confers luminal filling. cancer res 2008;68:1760-7. 15. takihara y, matsuda y, hara j. role of the beta isoform of 14-3-3 proteins in cellular proliferation and oncogenic transformation. carcinogenesis 2000;21:2073-7. 16. qi w, liu x, chen w, et al. overexpression of 14-3-3gamma causes polyploidization in h322 lung cancer cells. mol carcinog 2007;46:847-56. 17. choi kc, lee s, kwak sy et al. increased expression of 14-3-3varepsilon protein in intrinsically aged and photoaged human skin in vivo. mech ageing dev 2005; 126:629-36. 18. kilani rt, medina a, aitken a, et al. identification of different isoforms of 14-33 protein family in human dermal and epidermal layers. mol cell biochem 2008;314: 161-9. 19. minang jt, troye-blomberg m, lundeberg l, ahlborg n. nickel elicits concomitant and correlated in vitro production of th1-, th2-type and regulatory cytokines in subjects with contact allergy to nickel. scand j immunol 2005;62:289-96. 20. kragballe k, fallon jd. increased aggregation and arachidonic acid transformation by psoriatic platelets: evidence that platelet-derived 12-hydroxy-eicosatetraenoic acid increases keratinocyte dna synthesis in vitro. arch dermatol res 1986;278:449-53. 21. chrestensen ca, schroeder mj, shabanowitz j et al. mapkap kinase 2 phosphorylates tristetraprolin on in vivo sites including ser178, a site required for 14-3-3 binding. j biol chem 2004;279: 10176-84. 22. stoecklin g, stubbs t, kedersha n et al. mk2-induced tristetraprolin:14-3-3 complexes prevent stress granule association and are-mrna decay. embo j 2004;23: 1313-24. 23. johansen c, funding at, otkjaer k et al. protein expression of tnf-alpha in psoriatic skin is regulated at a posttranscriptional level by mapk-activated protein kinase 2. j immunol 2006;176:1431-8. 24. powell dw, rane mj, joughin ba et al. proteomic identification of 14-3-3zeta as a mitogen-activated protein kinase-activated protein kinase 2 substrate: role in dimer formation and ligand binding. mol cell biol 2003;23:5376-87. 25. ferguson at, evron e, umbricht cb et al. high frequency of hypermethylation at the 14-3-3 sigma locus leads to gene silencing in breast cancer. proc natl acad sci usa 2000;97:6049-54. 26. dhar s, squire ja, hande mp, et al. inactivation of 14-3-3sigma influences telomere behavior and ionizing radiationinduced chromosomal instability. mol cell biol 2000;20:7764-72. 27. lodygin d, hermeking h. the role of epigenetic inactivation of 14-3-3sigma in human cancer. cell res 2005;15:237-46. article no nco mm er cia l u se on ly dr [dermatology reports 2010; 2:e11] [page 27] side-effects to the use of laptop computers: erythema ab igne lisa linnea søholm secher, dina vind-kezunovic, claus otto carl zachariae department of dermatology, copenhagen university hospital gentofte, denmark abstract the use of laptop computers is increasing, and many children and young adults spend hours with their laptops on their laps daily. we report a case with erythema ab igne on the thigh of a 17-year-old girl, induced by use of laptop computers four to five hours daily for nine months. case report the use of laptop computers has become popular over the last ten years. computer technology is refined continuously and the need for immediate access to information from the internet increases. a 17-year-old girl with no past medical his tory presented with symptoms of burning and itching experienced on the front of the left thigh for nine months. on physical examin ation, there was a brown, reticular, nonblanchable cutis marmorata on the left anterior thigh, approximately the size of a palm (figure 1). blood tests including ana screening were normal. a skin biopsy showed minimal dermal inflammation. the patient had not been exposed to heat sources, such as radiators, stoves, or hot-water bottles. on further questioning, it was found that three months before the symptoms appeared our patient purchased a laptop, which she used four to five hours daily. when asked directly, our patient remembered that the discomfort of the area often appeared when using the laptop. the laptop’s battery was localized at the left side of the computer, which corresponded with the localization of the rash. the diagnosis was erythema ab igne causae laptop. the temperature on the thighs was measured after our patient had been sitting with the laptop on her thighs for an hour (figure 2). the temperature started at 27°c on both thighs, and after an hour the temperature of the left and right thighs was 38°c and 33°c, respectively. discussion erythema ab igne (“redness from fire”) is seen rarely in young patients. the condition is seen usually in elderly people exposed to heating from repeated applications of heating pads or hot-water bottles. erythema ab igne also occurs in cooks and bakers exposed to stoves,1 and historically it was seen in workers shoveling hot coals. the continuous exposure to infrared radiation initially causes transient erythema, progressing to reticulate pigmentation and keratosis. these lesions can develop later into squamous cell carcinomas.2 because erythema ab igne is a precancerosis in line with actinic keratoses,3 it is important to recognize this new cause of erythema ab igne, especially as we must expect to see it more in children in the coming years. if the heat exposure is stopped early, the prognosis is extremely good. erythema ab igne may not be the only side-effect to the use of laptops on the thighs. some studies suggest that the use can influence male fertility. when laptops are placed on the anterior aspects of the thighs, the scrotal temperature rises approximately three degrees after an hour, which perturbs spermatogenesis, and hence can influence male fertility.4 although the name laptop invites using the computers directly on the lap, we believe it is necessary to warn about the possible sideeffects, as it may cause chronic damage to the skin. use of a protective blanket or plate is advisable. references 1. bachmeyer c, benaid p, bégon e. laptop computer as a modern cause of erythema ab igne. j eur acad dermatol venereol 2009;23:736-7. 2. jagtman ba. erythema ab igne due to laptop computer. contact dermatitits 2004; 50:105. 3. bilic m, adams bb. erythema ab igne induced by a laptop computer. j am acad dermatol 2004;50:973-4. 4. sheynkin y, jung m, yoo p, et al. increase in scrotal temperature in laptop computer users. hum reprod 2005;20:452-5. dermatology reports 2010; volume 2:e11 correspondence: lisa l.s. secher, callisensvej 12, 2.tv, dk-2900 hellerup, denmark. e-mail: lisa.secher@webspeed.dk key words: laptop, erythema, side-effect, reticulate pigmentation. contributions: llss main idea, primary manuscript written in danish; dv-k translation to english, proofreading; cocz writing the main manuscript, proofreading. conflict of interest: the authors report no conflicts of interest. received for publication: 8 july 2010. accepted for publication: 8 july 2010. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright l.l.s. secher et al., 2010 licensee pagepress, italy dermatology reports 2010; 2:e11 doi:10.4081/dr.2010.e11 figure 1. erythema ab igne on the left thigh. figure 2. our patient in her usual working position with the laptop, while thigh temperature was being measured. no nco mm er cia l u se on ly dr [page 38] [dermatology reports 2011; 3:e17] ulcerated cutaneous epithelioid hemangioendothelioma in an 8-month old infant silonie sachdeva carolena skin, laser & research centre jalandhar punjab, india abstract epithelioid hemangioendothelioma is an uncommon malignant vascular tumour usually involving soft tissue and rarely only skin. it is considered to be a borderline neoplasm between angiolymphoid hyperplasia with eosinophilia and an epithelioid angiosarcoma and is mostly found in adults with few cases reported in children. we herein report a case of ulcerated cutaneous epithelioid hemangioendothelioma in an infant of 8 months. this tumour has not been reported at such a young age in literature. introduction epithelioid hemangioendotheliomas are unique vascular tumors characterized by epithelioid or histiocytoid endothelial cells that mainly affect adults. the tumor usually involves the soft tissue and, in rare cases, the skin. we report here a case of ulcerated cutaneous epithelioid hemangioendothelioma in an 8 month old infant. the tumor at such a young age has not been reported so far. case report an 8 month old male infant was brought by his parents with swelling on the left arm which appeared at the age of four months. there was history of oozing of blood and pus from the swelling. no predisposing factors for occurrence of lesion could be identified in history. there was no history of any accompanying systemic complaints. on dermatological examination, a well defined large swelling, round in shape, partly skin colored and partly dusky red in color with ulceration and exudation of the serosanguious fluid was seen on lateral aspect of left upper arm (figure 1). rest of the dermatological examination was normal. axillary lymph nodes and cervical lymph nodes were not enlarged. systemic examination revealed no abnormality. the infant’s miles stones were normal as per his age. a small biopsy was taken from the edge of the lesion. histopathology revealed focal areas of infiltrative lobules of predominantly spindle cells in deeper dermis with small sized vascular channels lined by plump endothelial cells. there were foci of intravascular endothelial proliferation with the adjacent areas showing capillary proliferation with hobnail appearance (figure 2). there was no cellular atypia, mitotic activity or necrosis suggestive of malignant activity. immunohistochemical staining was positive for the endothelial markers cd31, cd34. mri of the arm confirmed no underlying bone tumour. on the basis of these findings, diagnosis of ulcerated cutaneous epithelioid hemangioendothelioma was made. the infant was referred to the plastic surgery department for removal of tumor and reconstruction surgery. a conservative surgical excision with one centimeter margins all around the tumor was done. patient is on follow up for last 6 months with no recurrence. discussion epithelioid hemangioendothelioma (ehe), first described by weiss and enzinger in the year 1982, is an uncommon malignant vascular tumor which usually involves soft tissue and in rare cases the skin. histologically and biologically it is considered to be a borderline neoplasm between angiolymphoid hyperplasia with eosinophilia and an epithelioid angiosarcoma.1,2 ehe affects men and women about equally at almost any age but rarely in childhood. no predisposing factors have been yet identified. usually it appears as a solitary, slightly painful soft-tissue tumor which can occur at almost any anatomical location but more frequently on extremities, trunk, head and neck. in review of the literature, cutaneous ehe appears to be limited to a few reports in children and has been seen in age group ranging 11-12 years.3-5 in a series of 16 cases of islolated cutaneous ehe, the average age of tumor was found to be 47 years. all of these cases presented as dome-shaped nodules which are sometimes painful and can have a multifocal distribution. the main locations are the extremities (25% on the palms), the head and the trunk. our case is the first case report of ulcerated cutaneous ehe in an infant as young as 8 months. ehe has malignant potential and its prognosis remains uncertain. nevertheless, the prognosis of isolated cutaneous ehe after simple complete surgical excision seems good compared with systemic ehe or with cutaneous ehe with underlying bone tumor.7 in our patient, the tumor was benign as histopathology ruled out any cellular atypia, dermatology reports 2011; volume 3:e17 correspondence: silonie sachdeva, md, consultant dermatologist, carolena skin, laser & research centre, jalandhar punjab-144022, india. e-mail: siloniederm@yahoo.com key words: ulcerated, epitheloid, hemangioendothelioma. conflict of interest: the author has no conflict of interest to disclose. received for publication: 21 may 2011. accepted for publication: 9 august 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright s. sachdeva, 2011 licensee pagepress, italy dermatology reports 2011; 3:e17 doi:10.4081/dr.2011.e17 figure 1. a well defined, large sized swelling, round shaped, dusky red in color with ulceration on lateral side of left upper arm. figure 2. histopathology with h & e stain, 100x showing focal areas of infiltrative vague lobules of predominantly spindle cells in deeper dermis with small sized vascular channels lined by plump endothelial cells. there are foci of intravascular endothelial proliferation with the adjacent areas showing capillary proliferation with hobnail appearance. (see arrow). no nco mm er cia l u se on ly [dermatology reports 2011; 3:e17] [page 39] mitotic activity or necrosis. the tumor was positive for the endothelial markers cd31, cd34 which confirmed the histological and clinical diagnosis. besides these endothelial markers, it is advised that analysis of factor viiirag and alpha smooth-muscle actin which are also important immunohistochemical markers for cutaneous ehe should be done wherever the facility is available. differential diagnosis of cutaneous epithelioid hemangioendothelioma include epithelioid angiosarcoma which on histological examination shows more nuclear atypia and mitotic activity, more necrosis than ehe and an interstitial or sinusoidal growth pattern in its peripheral areas. the specific interest of our case is the clinical presentation of this tumor at an age of 8 months, which has not been previously reported in literature. also, we want to emphasize that early detection and removal of tumor can lessen the chances of tumor turning malignant and can be life saving. references 1. weiss sw, enzinger fm. epithelioid hemangioendothelioma. a vascular tumor often mistaken for a carcinoma. cancer 1982;50:970-81. 2. resnik ks, kantor gr, spielvogel rl, ryan e. cutaneous epithelioid hemangioendothelioma without systemic involvment. am j dermatopathol 1993;15:272-76. 3. polk p, webb jm. isolated cutaneous epithelioid hemangioendothelioma. j am acad dermatol 1997;36:1026-28. 4. quante m, patel nk, hill s, et al. epithelioid hemangioendothelioma presenting in the skin. a clinicopathologic study of eight cases 1998;20:541-46. 5. zhang w, he j, wang j, et al. ulcerated epithelioid hemangioendothelioma of the right armpit in childhood. j pediatr hematol oncol 2009;31:595-98. 6. forschner a, harms d, metzler g, et al. ulcerated epithelioid hemangioendothelioma of the foot in childhood. j am acad dermatol 2003;49:113-6. 7. grézard p, balme b, ceruse p, et al. ulcerated cutaneous epithelioid hemangioendothelioma. eur j dermatol 1999;9:487-90. case report no nco mm er cia l u se on ly dr [dermatology reports 2011; 3:e15] [page 35] eruptive keloids after chickenpox nicolas kluger,1,2 antoine mahé,3 bernard guillot1 1université de montpellier i, service de dermatologie, hôpital saint-eloi, montpellier, france; 2departments of dermatology, allergology and venereology, institute of clinical medicine, university of helsinki, skin and allergies hospital, helsinki university central hospital, helsinki, finland; 3service de dermatologie, hôpital pasteur (hcc) colmar cedex, france abstract hypertrophic scars and keloids result from abnormal wound healing in predisposed individuals. they occur within months of cutaneous trauma (surgical wounds, piercing, lacerations) or inflammation (acne, folliculitis, vaccination site). they have rarely been reported after chickenpox. herein we report a dramatic case in a 4-year-old black girl and discuss the issues related to the management of hypertrophic scars and keloids in this peculiar situation. introduction hypertrophic scars and keloids result from an abnormal wound healing process in predisposed individuals. they occur within months of a cutaneous trauma or inflammation. we report a dramatic case in a young black girl after chickenpox. case report a 4-year-old congolese girl was referred for numerous raised skin lesions on chickenpox scars. chickenpox occurred 4 months earlier, without complications and 3 weeks prior to consultation, new cutaneous lesions abruptly appeared. the patient had numerous (over 30) scattered, small, firm, pruritic, darkskinned coloured nodules on the chest, shoulders, flanks and upper arms (figures 1 and 2). lesions were restricted to the chickenpox scars but infiltrated into surrounding normal tissue, favouring keloids rather than hypertrophic scars. examination was otherwise unremarkable. there was no similar familial history. the localisation, the number of lesions and her age, prompted to initiate pressure therapy with a custom-made compressive garment that had to be worn 23 hours a day for at least 6 months. discussion hypertrophic scars and keloids, which result from abnormal wound healing in predisposed individuals,1 occur within months of cutaneous trauma (surgical wounds, piercing, lacerations) or inflammation (acne, folliculitis, vaccination site). they are located mainly on the upper part of the body (earlobes, neck, shoulders, back), may be pruritic or painful, and do not regress spontaneously.1 chickenpox is a rare cause of keloids described since the 1960s: the lesions occur as either small eruptive keloids or gigantic and monstrous ones on the chickenpox scars.2-4 numerous treatments have been proposed with varying degrees of efficacy: surgical excision, intralesional corticosteroid injections, cryotherapy, topical silicone gel, laser therapy, and 5-fluorouracil and bleomycin injections,1 among others. our case illustrates the issues related to the management of a young dark-skinned pre-pubertal girl. the high number of lesions, the young age, and the skin phototype were contraindications for a wide range of treatments, including highly potent local corticosteroid ointments, intralesional corticosteroid injections and cryotherapy. all are efficient but painful and expose to transitory hypopigmentation. repeated steroid injections can lead to adverse systemic effects. laser must be used with caution in dark-skinned patients. therefore, we proposed pressure therapy as it is widely used for burn scar patients.5 its precise mechanism of action is not understood but pressure appears clinically to enhance the scar maturation process.1 however, the efficacy has never been proven in scientific or clinical trial and the optimum pressure for treatment is not known.5 the vest must be worn by the patient almost 24 hours a day and success is related to compliance as pressure garment therapy exposes to overheating, pruritus, cutaneous rash and abnormal bone growth.5 in our case, garment can be changed every three months to follow the growth of the child. our case is a reminder of the burden of darkskinned individuals exposed to the risk of keloids and their cosmetic consequences. it illustrates the difficulties in the management of young children when the lesions are scattered over the body. dermatology reports 2011; volume 3:e15 correspondence: nicolas kluger, departments of dermatology, allergology and venereology,, skin and allergies hospital, helsinki university central hospital, meilahdentie 2, p.o. box 160, fi-00029 hus, finland. e-mail: nicolaskluger@yahoo.fr key words: keloid, chickenpox, scar, cicatrix, child. the mother of the patient gave consent for publication of the pictures. received for publication: 15 july 2011. accepted for publication: 20 july 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright n. kluger et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e15 doi:10.4081/dr.2011.e15 figure 1. eruptive keloids of the trunk on chickenpox scars. figure 2. close up view of the lesions. no nco mm er cia l u se on ly [page 36] [dermatology reports 2011; 3:e15] references 1. wolfram d, tzankov a, pülzl p, et al. hypertrophic scars and keloids--a review of their pathophysiology, risk factors, and therapeutic management. dermatol surg 2009;35:171-81. 2. scheinfeld n, cohen sr. varicella causes skin pits and keloids--more reasons for the varicella vaccine. pediatrics 2000;106:160. 3. duperrat b, puissant a, goetschel ge, et al. monstrous keloid. bull soc fr dermatol syphiligr 1972;79:210-11. 4. matheis h. keloid eruption following chickenpox. dermatologica 1971;143:31927. 5. macintyre l, baird m. pressure garments for use in the treatment of hypertrophic scars a review of the problems associated with their use. burns 2006;32:10-15. case report no nco mm er cia l u se on ly dr [dermatology reports 2011; 3:e19] [page 43] a new combination of multiple autoimmune syndrome? coexistence of vitiligo, autoimmune thyroid disease and ulcerative colitis firdevs topal,1 engin senel,2 sabiye akbulut,3 fatih topal,4 yasemin dölek5 1clinics of gastroenterelogy; 2dermatology, çankiri state hospital, çankiri; 3department of gastroenterology, kartal kosuyolu high specialty education and research hospital, istanbul; 4clinics of emergency medicine; 5pathology, çankiri state hospital, çankiri, turkey abstract the occurrence of three or more autoimmune disorders in one patient defines multiple autoimmune syndrome. the pathogenesis of multiple autoimmune syndrome is not known yet and environmental triggers and genetic susceptibility have been suggested to be involved. herein, we report a 47-year-old woman who had hashimoto’s thyroiditis, vitiligo and newly diagnosed ulcerative colitis. diagnosis of ulcerative colitis was confirmed with histopathologic examination. this case presents a new combination of multiple autoimmune syndrome. introduction a multiple autoimmune syndrome (mas) consists of three or more well-defined autoimmune conditions in the same patient. it was first proposed by humbert in 1988 and described with increasing frequency.1 although exact pathogenesis of the syndrome is obscure, environmental triggers and genetic susceptibility may be involved.2 case report a 47-year-old woman who had hashimoto’s thyroiditis for 26 years and vitiligo for 37 years presented to gastroenterology service of our hospital with bloody diarrhea for three months. dermatological examination showed multiple depigmented macules and patches on her trunk and extremities (figure 1). colonoscopy revealed a hemorrhagic edematous mucosa of the colon. histopathological examination disclosed superficial ulceration and numerous crypt abscesses, and mixed leukocytic infiltrates in lamina propria (figure 2). a diagnosis of rectosigmoid ulcerative colitis was established by colonoscopy and histopathological examination. discussion autoimmune disorders are conditions in which there is the development of antibodies against self-cells. multiple autoimmune syndrome is defined as a combination of at least three autoimmune diseases in the same patient. mas can be classified into three subtypes in which certain disorders frequently occur together (table 1).2,3 hla-b8, -dr3 or -dr5 have been suggested to be an important factor for subtype 3. acquired primary hypogonadism, hypophysitis, romatoid arthritis, relapsing polychondritis, multiple sclerosis, cah, ulcerative colitis, and scleroderma have been reported to be associated with mas subtype 3.1,2 the pathogenesis of mas is not clear yet. environmental triggers and genetic susceptibility have been proposed to be involved.2,4,5 autoimmunity has been proposed to be a prominent factor for inflammatory bowel diseases.6 snook et al. found that at least one autoimmune disorder was present in 7% of the patients with ulcerative colitis and 2% of the controls.7 our patient had autoimmune thyroid disease, vitiligo and ulcerative colitis. although this combination of autoimmune disorders has dermatology reports 2011; volume 3:e19 correspondence: engin senel, çankiri state hospital, clinic of dermatology, aksu mah. ogretmenler sokak, 18200 çankiri, turkey. tel. +90.376.2131098. e-mail: enginsenel@enginsenel.com key words: multiple autoimmune syndrome, autoimmunity, vitiligo, ulcerative colitis, autoimmune thyroiditis. received for publication: 15 july 2011. accepted for publication: 15 july 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright f. topal et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e19 doi:10.4081/dr.2011.e19 figure 1. depigmented patches on the back. table 1. classification of multiple autoimmune syndrome. mas type 1 mas type 2 mas type 3 thymoma rheumatoid arthritis autoimmune thyroid disease myasthenia gravis sjögren’s syndrome myasthenia polymyositis pemphigus vulgaris thymoma giant cell myocarditis primary biliary cirrhosis sjögren’s syndrome, pernicious anemia pemphigus vulgaris scleroderma idiopathic thrombocytopenic purpura bullous pemphigoid autoimmune thyroid disease addison’s disease insulin-dependent diabetes vitiligo autoimmune hemolytic anemia systemic lupus erythematosus dermatitis herpetiformis figure 2. crypt abscesses and mixed leukocytic infiltrates in lamina propria (h&e, x10).no nco mm er cia l u se on ly [page 44] [dermatology reports 2011; 3:e19] not been reported before this case presents a new association that meets the requirements for the diagnosis of mas. we suggest that this combination should be included in mas subtype 3. references 1. humbert p, dupond jl. [multiple autoimmune syndromes]. ann med interne (paris) 1988;39:159-68. 2. mohan mp, ramesh tc. multiple autoimmune syndrome. indian j dermatol venereol leprol 2003;69:298-9. 3. tirado-sanchez a, montes-de-oca g. coexistence of bullous pemphigoid, vitiligo, and thyroid disease: a multiple autoimmune syndrome? dermatol online j 2005;11:20. 4. humbert p, dupond jl, vuitton d, agache p. dermatological autoimmune diseases and the multiple autoimmune syndromes. acta derm venereol suppl (stockh) 1989; 148:1-8. 5. pasic a, ljubojevic s, lipozencic j, et al. coexistence of psoriasis vulgaris, bullous pemphigoid and vitiligo: a case report. j eur acad dermatol venereol 2002;16:426-7. 6. thompson dm, robinson tw, lennardjones j. alopecia areata, vitiligo, scleroderma and ulcerative colitis. proc r soc med 1974;67:1010-2. 7. snook ja, de silva hj, jewell dp. the association of autoimmune disorders with inflammatory bowel disease. q j med 1989; 72:835-40. case report no nco mm er cia l u se on ly dr [page 22] [dermatology reports 2011; 3:e11] chronic lymphoedema caused by recurrent infections in a patient with allergic hand eczema beatrice dyring-andersen, lone skov, peter jensen department of dermato-allergology, copenhagen university hospital gentofte, copenhagen, denmark abstract allergic contact dermatitis is very common and may be complicated by secondary infections. chronic lymphoedema is a potentially debilitating condition, which may occur due to secondary infections or the dermatitis itself. the problem of chronic lymphoedema following allergic contact dermatitis has been infrequently reported. we report a case of a 47-yearold woman with severe allergic contact dermatitis complicated by chronic, intractable lymphoedema of the hands and forearms. this case report reminds us that allergic hand dermatitis may be complicated by a chronic and debilitating state of lymphoedema. also, it underlines the importance of fast and adequate treatment of both the dermatitis and the secondary infections. introduction allergic contact dermatitis is a common disease, which may be complicated by secondary infections. chronic lymphoedema due to destruction of lymphatic vessels is a potentially debilitating condition, which may occur due to secondary infections or the dermatitis itself. the problem of chronic lymphoedema following allergic contact dermatitis has been infrequently reported.1-5 case report we report a case of a 47-year-old woman with severe allergic contact dermatitis complicated by chronic lymphoedema. at time of referral, clinical examination showed acute eczema on the hands. patch testing was performed with the european standard series using finn chambers© (epitest., oy, finland) on scanpor tape© (norgesplaster a/s, alpharma, as, norway). the patch tests were applied to the upper back and occluded for two days and readings were done on d2, d3 and d7. there were positive reactions to formaldehyde, chromium, balsam of peru, sesquiterpene lactone mix and colophonium. all reactions were of clinical relevance for the patient, who worked as a kindergarten teacher. the patient was instructed to avoid the known allergens and treatment with topical steroid was initiated but with little effect on the dermatitis. over the following months she had numerous secondary infections, which necessitated several courses of systemic antibiotic therapy. to achieve disease control, the patient received therapy with per oral prednisolone followed by treatment with azathioprine. however, because of her compositae allergy, the hand eczema flared every summer and despite systemic anti-inflammatory treatment it was often complicated by secondary infections (staphylococcus aureus) with lymphangitis. every infectious episode was treated with relevant antibiotics often in combination with potassium permanganate baths. in spite of this, the patient developed chronic lymphoedema of the hands and forearms (figure 1). the diagnosis was confirmed by a lymphoscintigraphy which showed complete functional failure of the peripheral lymphatic vessels. now, two years later, the patient is being treated with compression garments with limited effect. she remains unable to work as a kindergarten teacher and she was also unable to complete a work rehabilitation programme due to her swollen and painful arms. discussion we describe here a case of a chronic debilitating lymphoedema of the hands and forearms secondary to recurrent infections in a woman with severe, intractable allergic hand dermatitis. chronic lymphoedema secondary to allergic or irritant contact dermatitis has been infrequently reported.1-5 approximately half of the patients have no history of infection involving the affected areas prior to the debut of lymphoedema.1-5 therefore, one may give consideration to the aetiology of the lymphoedema and the pathology involved in the destruction of the lymphatic vessels. a plausible mechanism in the present case could be obliterating bacterial lymphangitis which may lead to lymphatic insufficiency in patients with recurrent secondary infections. in patients with chronic lymphoedema without recurrent infections, damage to the lymphatic vessels may be caused by the harmful effect of the dermatitis itself.1,2 this case report reminds us that allergic hand dermatitis may be complicated by a chronic and debilitating state of lymphoedema. also, it underlines the importance of fast and adequate treatment of both the dermatitis and the secondary infections. references 1. worm am, staberg b, thomsen k. persistant oedema in allergic contact dermatitis. contact dermatitis 1983;9:517-8. 2. pearce vj, mortimer ps. hand dermatitis and lymphoedema. br j dermatol 2009; 161:177-80. 3. fitzgerald da, english js. lymphoedema of the hands as a complication of chronic allergic contact dermatitis. contact dermatitis 1994;30:310. 4. lynde cw, mitchell jc. unusual complication of allergic contact dermatitis of the hands -recurrent lymphangitis and persistent lymphoedema. contact dermatitis 1982;8:279-80. 5. proske s, uter w, schwanitz hj. [secondary lymphedema of the hand as a complication of recurrent erysipelas in irritant contact dermatitis]. hautarzt 2001;52:888-90. dermatology reports 2011; volume 3:e11 correspondence: peter jensen, department of dermato-allergology, copenhagen university hospital gentofte niels andersens vej 65, dk-2900 hellerup, copenhagen, denmark. tel. +45.3977.7538 fax: +45.3965.7137. e-mail: peterj01@geh.regionh.dk key words: allergic contact dermatitis, hand eczema, lymphoedema, lymphangitis, recurrent infections. acknowledgments: peter jensen was supported by a grant from the michaelsen foundation and beatrice dyring-andersen was supported by a grant from the aage bang foundation. conflict of interest: the authors report no conflicts of interest. received for publication: 20 june 2011. accepted for publication: 22 june 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright b. dyring-andersen et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e11 doi:10.4081/dr.2011.e11 figure 1. chronic lymphoedema of the hand and forearm. no nco mm er cia l u se on ly dr [page 4] [dermatology reports 2011; 3:e3] becker nevus on the neck with ear involvement khalid mohammad al aboud department of dermatology, king faisal hospital, makkah, saudi arabia abstract this is a concise observation of becker nevus located on the right side of the neck with involvement of the ear. case report a 30-year old man presented with a hyperpigmented patch on the right side of the neck that extended to the right ear (figure 1). the lesion appeared during adolescence and gradually increased in size. no increase in hairs were observed in the lesion. there was no history of preceding drug intake nor associated systemic diseases. skin biopsy showed hyperpigmentation of basal cell layer on histopathology and there were smooth muscles in the dermis. the picture was consistent with becker nevus. becker nevus (bn) is an uncommon cutaneous hamartoma. it usually presents in adolescence as a unilateral, hyperpigmented, hairy patch or plaque, often seen on the upper trunk.1-4 bn may involve other sites in the body like the head or the limbs. cephalic bn may present with asymmetrical growth of beard hairs.4 alfadley et al.,3 reported 12 cases of bn with atypical features. only one of them was a female with bn involving the left side of the neck. it was associated with hypertrichosis. alghamdi et al.,2 reported 11 cases with atypical features; only one of them that involved the chin and neck was a 5-year-old boy with bn. it was also associated with hypertrichosis. none of the above two cases involved the ear. the present case is different as it involved the external ear and was not associated with hypertrichosis. in contrast to widely held belief, i concur with others2,3 that cases of bn in atypical locations like the neck are not uncommon and may be under-reported. references 1. al aboud k, al hawsawi k. becker nevus on the hand. eur j dermatol 2002;12:588. 2. alghamdi km, alkhalifah ai, alsheikh am, alsaif fm. clinicopathologic profile of becker's melanosis with atypical features. j drugs dermatol 2009;8:745-8. 3. alfadley a, hainau b, al robaee a, banka n. becker's melanosis: a report of 12 cases with atypical presentation. int j dermatol 2005;44:20-4. 4. kiliç a, kaya i, gül u, et al. becker nevus on face with asymmetrical growth of beard hair. j eur acad dermatol venereol 2008; 22:246-7. dermatology reports 2011; volume 3:e3 correspondence: khalid al aboud, p.o box 5440, makkah, saudi arabia. tel. +966.2.5566411 fax +966.2.5563523/ 5574350. e-mail: amoa65@hotmail.com key words: becker nevus, head, skin. received for publication: 12 january 2011. accepted for publication: 22 february 2011. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright k.m. al aboud, 2011 licensee pagepress, italy dermatology reports 2011; 3:e3 doi:10.4081/dr.2011.e3 figure 1. becker nevus on the right side of the neck extending to the right ear. no nco mm er cia l u se on ly dr [dermatology reports 2011; 3:e7] [page 13] focal dermal hypoplasia in a male leni george, nisha agrawal, peter hogan children’s hospital, westmead, sydney, australia abstract focal dermal hypoplasia (fdh) is a rare mesoectodermal dysplasia syndrome characterized by cutaneous, skeletal, dental, ocular and soft-tissue defects. an x-linked dominant mode of inheritance with lethality in male subjects has been proposed. only around 30 cases of fdh have been reported in male subjects. live born affected males are mosaic for mutations in porcn gene . we present the mosaic pattern of fdh in a young boy. case report focal dermal hypoplasia (fdh ) is a rare genodermatosis with multisystem involvement. it is an x-linked dominant disorder with high male lethality.1 pathogenic mutations in the porcn gene (locusxp11.23) is the molecular basis of fdh.2 only around 30 cases have been reported in male subjects. live-born affected males (10% of affected individuals) are mosaic for mutations in porcn. we present the mosaic pattern of fdh in a young boy. a 11 year old boy, born of a non-consanguineous marriage, presented with a linear eruption that was first noticed around 18 months of age. it later progressed to involve most of the posterior aspect of his left calf (figure 1). there were no systemic manifestations or any significant family history. examination revealed erythema, hypopigmentation and subtle atrophy on an area of about 6 ¥ 2 cm on the posterior aspect of his left leg. there were no other significant findings. two skin biopsies were taken, from the lesional and the nonlesional skin to distinguish focal dermal hypoplasia from eccrine porokeratotic dermal duct nevus and aplasia cutis. the lesional skin showed mature adipose tissue in the papillary and subpapillary dermis with reduction in the total thickness of the dermis compared to the nonlesional skin (2.0 mm vs 2.4 mm). this picture was consistent with fdh [figures 2 and 3]. a dental evaluation revealed defective enamel and underdevelopment of the roots. ophthalmologic and radiologic examinations were noncontributory. genetic studies excluded klinefelter’s syndrome (xxy) phenotype. based on the characteristic clinical and microscopic features, the patient was diagnosed to have a mosaic form of fdh. the inheritance pattern of fdh is x-linked dominant with a high lethality in males. most male conceptuses with the mutant porcn allele are presumed to be spontaneously aborted. there are three possible explanations for focal dermal hypoplasia in males: i) 47xxy constitution and patients survive because of the extra xchromosome; ii) genomic x-chromosomal mosaicism resulting from early post zygotic mutation; iii) gametic half-chromatid mutation in which skin involvement is usually widespread, systematized and bilateral. the most accepted explanation for male cases of fdh is attributed to postzygotic halfchromatid mutations, resulting in mosaicism, and the characteristic linear skin and bone defects.3 mosaicism is a phenomenon in which only certain tissues are at risk of expressing the mutant x-chromosome as exemplified in our patient. happle and lenz suggested that the linear arrangement of the skin lesions may be the results of functional x chromosome mosaicism.4 affected males are generally more mildly affected than females and this is probably due to the phenomenon of mosaicism. a recent review of the clinical and molecular features of individuals with fdh and porcn gene mutations suggested that there was no clear genotype-phenotype correlation despite the variable clinical severity.5 although molecular genetic testing could not be performed to confirm our diagnosis, clinically he had mosaic form of goltz syndrome, which was confirmed on histopathology. as he had no major manifestations apart from dental anomalies, he was advised preventative dental care to reduce dental caries and follow up regularly to look for progression of the disease. references 1. goltz rw. focal dermal hypoplasia syndrome: an update. arch dermatol 1992;128:1108-11. dermatology reports 2011; volume 3:e7 correspondence: peter hogan, the children’s hospital at westmead,westmead nsw 2145, sydney, australia. tel. +91.02.98450000 fax. +91.02.98453489. e-mail: pandmhogan@optusnet.com.au. key words: focal dermal hypoplasia, mosaicism, postzygotic mutation. received for publication: 12 june 2011. accepted for publication: 14 june 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright l. george et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e7 doi:10.4081/dr.2011.e7 figure 1. linear cutaneous atrophy on the calf. figure 2. low power view of lesion: replacement of papillary and upper reticular dermis by adipose tissue. figure 3. low power view of normal skin for comparison. no nco mm er cia l u se on ly [page 14] [dermatology reports 2011; 3:e7] 2. wang x, reid sutton v, omar perazallanes j, et al. mutations in x-linked porcn, a putative regulator of wnt signaling, cause focal dermal hypoplasia. nat genet 2007;39:836-8. 3. quain rd, militello g, junkins-hopkins j, et al. erythematous atrophic macules and papules following the lines of blaschko. arch dermatol 2007;143:109-14. 4. happle r, lenz w. striation of bones in focal dermal hypoplasia, a manifestation of functional mosaicism. br j dermatol 1977;96:133. 5. clements se, mellerio je, holden st, et al. porcn gene mutations and the protean nature of focal dermal hypoplasia. br j dermatol 2009;160:1103-9. case report no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. dr dr 2-chlorodeoxyadenosine treatment for cutaneous t-cell lymphoma małgorzata sokołowska-wojdyło, magdalena trzeciak, jadwiga roszkiewicz department of dermatology, venereology and allergology, medical university of gdańsk, gdańsk, poland abstract the primary cutaneous lymphomas are often indolent but difficult to treat. in the early stages psoralen and ultraviolet-a therapy is the standard treatment whereas at the tumor stage chemotherapy (e.g. pegylated doxorubicin) is often used for debulking. the purine analog 2chlorodeoxyadenosine (2cda) acts in nonhodgkin’s lymphoma and has been used in our center for the treatment of advanced primary cutaneous t-cell lyphomas (ctcl). here, we report on the efficacy and side effects of 2cda in six patients with ctcl. one patient died owing to myelosuppression. partial responses were seen in four cases but full remission was observed in only one case. we concluded that 2cda has a limited usefulness in the management of advanced ctcl. introduction a purine analog 2-chlorodeoxyadenosine (2cda) has been accepted as the treatment of choice in hairy cell leukemia and low-grade non-hodgkin’s lymphomas. it has also been recommended in stage iv a/b of cutaneous t-cell lymphomas (ctcl), along with chlorambucil, liposomal doxorubicin, chop polychemother apy, denileukin difitox, and others.1-11 the aim of our study was to analyze the efficacy and side effects of 2cda treatment for ctcl. materials and methods we treated six ctcl patients (five with mycosis fungoides; four in stage iib, one in ivb, and one with peripheral cutaneous t-cell lymphoma (ptcl), unspecified) with 2cda (pulses of 0.12 mg/kg/day/5 days).10,12-20 the patients failed standard therapies including glucocorticoids, retinoids, methotrexate, radiotherapy, and phototherapy. the efficacy of the treatment was established based on the clinical evaluation of skin lesions and internal involvement. results the patients received 1-8 pulses of 2cda (table 1, figures 1-4). one patient achieved total remission (patient 46/f, figure 2a and b), lasting six months. partial remission was achieved in four cases. progression of the disease during treatment appeared in one case (patient 71/f, figure 4). one patient died because of myelosupression and staphylococcal sepsis just after the second pulse with 2cda (patient 43/f, figure 1). we tried to avoid the dermatology reports 2010; volume 2:e12 correspondence: jadwiga roszkiewicz, depart ment of dermatology, venereology and allergology, medical university of gdańsk, 7th debinki street, 80-211 gdańsk, poland. e-mail: mwojd@amg.gda.pl key words: 2-chlorodeoxyadenosine (2cda), cutaneous t-cell lymphoma, mycosis fungoides, sézary syndrome, treatment, side effect. received for publication: 17 february 2010. revision received: 16 april 2010. accepted for publication: 26 july 2010. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright m. sokołowska-wojdyło et al., 2010 licensee pagepress, italy dermatology reports 2010; 2:e12 doi:10.4081/dr.2010.e12 table 1. characteristics of the patients. age/gender diagnosis and stage1 duration of the disease previous treatment 43/f (fig. 1) mf iib 13 mth prednison, puva, repuva cyclofosphamid 46/f (fig. 2a, b) mf ivb 31 mth puva 46/f ptcl 6 mth acitretin 65/f (fig. 3a, b) mf iib 6 mth acitretin, acitretin + mtx 58/m mf iib 16 mth acitretin, mtx, local electron beam therapy (department of radiotherapy) 71/f (fig. 4a, b) mf iib 4 yr prednisone, mtx, uvb311, acitretin, bexaroten (severe side effects: total skin peeling, bullae, and progression of the disease to mf iv) mf, mycosis fungoides; ptcl, primary cutaneous peripheral t-cell lymphoma. [page 28] [dermatology reports 2010; 2:e12] figure 1. (a and b) before 2cda treatment: patient died of s. aureus sepsis after the second pulse. a b no nco mm er cia l u se on ly article [dermatology reports 2010; 2:e12] [page 29] figure 3. (a) patient 65/f before2cda treatment; and (b) after treatment (remission but new tumors have appeared). table 2. response to 2-chlorodeoxyadenosine. patient no of cycles/dose duration of the lymph node outcome per cycle (1 cycle = 5 d) cutaneous response status (response) 43/k (fig. 1) 2/0.12 mg/kg (7 mg/d) no response slight death because of s. aureus sepsis 46/k (fig. 2a-e) 8/0.12 mg/kg (7 mg/d) 6 mounth total death because of dissemination of mf (6 mth after end of 2cda) 46/k 3/0.12 mg/kg (8 mg/d) 6 mounth total death, metastasis of lymphoma to central nervous system 65/k (fig. 3a, b) 6/0.12 mg/kg (7 mg/d) 2 weeks moderate progressive disease 58/m 6/0.12 mg/kg (13 mg/d) 8 mounth not applicable progressive disease 71/k (fig. 4a, b) 1/0.12 mg/kg (7 mg/d) progressive disease not applicable progressive disease response: slight, <25%; moderate, 25-50%; significant, 50-75%; total, 100%; ptcl, primary cutaneous peripheral t-cell lymphoma. figure 2. (a, b and c) before 2cda treatment; (d and e) after six pulses of 2cda (mf mimicking lichen planus). a c b d a b e no nco mm er cia l u se on ly infections by chemoprophylaxis with co-trimoxazol and acyclovir during and after 2cda treatment. one patient died because of progression of the lymphoma to the central ner vous system a few months after the end of treatment (patient 46/f with ptcl). the other two patients achieved partial remission and required further chemotherapy (table 2). discussion 2cda therapy was mostly well tolerated in view of the known side effects (table 4) although one patient died just after the second pulse because of myelosupression. the observed remissions were short-lasting. table 3 shows the experience with 2cda in other article table 4. dose-dependent side effects after 2-chlorodeoxyadenosine, based on data in the literature8,13,21-23 side effect time of appearance (*) headache (22%, 7% >2nd week) immediate erythema (5-27%, 10% >2nd week) early nausea (0-28%) immediate myelosupression (neutropenia, thrombocytopenia, lymphocytopenia) early, distant, late cutaneous side effects, including panniculitis (19%) immediate paraparesis, tetraparesis (rare) distant hyperuricemia immediate renal finction disturbances (rare) early fever (46%) immediate fatigue (45%, 11% >2nd week) immediate *the time of side effects’ appearance: immediate, hours; early, days, weeks; distant, weeks, months; late, months, years. [page 30] [dermatology reports 2010; 2:e12] figure 4. (a) patient 71/f before 2cda treatment; and (b, c and d) after one pulse of 2cda treatment: rapid progression just after the treatment showing faces leonona. this was followed by seven pulses of chop with only 7-10 days’ lasting remission, then by tseb. table 3. response to 2-chlorodeoxyadenosine in ctcl patients – results from different centers and from the dermatological department, gdansk, poland. number complete (%) partial no response (%) of patients remission remission (%) bouwhius et al., 2002, usa3 6 13 50 37 kuzel et al., 1996, usa12 21 14 14 72 saven et al., 1992, canada25 16 20 27 47 rummel et al., 1998, germany20 66 38 nd nd kay et al., 1992, canada9 40 20 22.5 57.5 kong et al., 1997, usa11 24 12 12 76 o’brien et al., 1994, usa23 22 18 23 59 dept. of dermatology, poland 6 33 50 17 (present report) nd, no data. a b c d no nco mm er cia l u se on ly dr [page 6] [dermatology reports 2010; 2:e3] proteus syndrome: a case report and a case study review in china xi-bao zhang,1 chang-xing li,2 yu-qing he,1 san-quan zhang,1 yan-xia cai1 1guangzhou institute of dermatology, guangzhou, china; 2dongguan institute of dermatology, dongguan, china abstract proteus syndrome (ps) is a rare and sporadic disorder characterized by overgrowth of multiple tissues and a propensity to develop particular neoplasms. the clinical manifestations of ps include macrodactyly, vertebral abnormalities, asymmetric limb overgrowth and length discrepancy, hyperostosis, abnormal and asymmetric fat distribution, asymmetric muscle development, connective tissue nevi, and vascular malformations. we report a 16-year old female patient who manifested a number of these complications and review the chinese literature about the diagnosis, natural history, and management of ps. introduction the malformations in ps can involve skin, subcutaneous tissue, connective tissue (in clud ing bone), the central nervous system, and viscera. the main clinical manifestations of ps include hemihypertrophic macrodactyly, subcutaneous tumors, palmar and metatarsal cerebriform connective tissue nevi, lipomas, exogenesis bone mammilla, epidermal nevi, vascular malformations, lipohypoplasia, and dermalhypoplasia.1 in this article, we report a ps case that has a number of clinical manifestations, and review the literature on this unique disorder in china. case report a 16-year old chinese girl was born to nonconsanguineous parents. the pregnancy and delivery were uneventful. her mother denied any drug use, radiation exposure, or infections during pregnancy. she presented to our institute at the age of 16 with facial dysmorphism and verrucous hyperplasia on the right side of her body. she was born with deafness of the right ear and dry, rough, light brown color patterns on the right trunk. as she grew, the patient developed more abnormalities, including right face, ear, tongue, and lip hyperplasia and overgrowth. the skin of the right trunk thickened and darkened, as the left side remained normal. her parents, 3 sisters and brother are all normal, and there was no other similar disorder in her family. physical examination the patient was noted to have normal intelligence. her height and weight were 153 cm and 44 kg, respectively. her vital signs were within normal limits. the patient showed several anomalies. there was hemihypertrophy involving the entire right side of the head, including the skull, face, ear, palate, tongue, lip and neck. there was an epidermal nevus on the right side of the body, showing general cornification pachydermia. hyperpigmented swirled and linear skin lesions were present on the right side of the neck and trunk, and verrucous epidermal nevi were seen on the right side of neck. she had malocclusion of the teeth, papillomarous hyperplasia of the tongue, hypertrophy of the right auricle, obstruction of the right auditory meatus, and a vascular malformation and lipomas on the right of the face. the distal right maniphalanx was enlarged and hammer-like. the right planta had an amber hyperplastic plaque that was moderately hard in texture and lacked pain sensation (figures 1 and 2). laboratory and auxiliary examination computer tomography scan of the patient’s head and face showed a large lipoma in the right face, but there were no abnormalities of the brain. plain radiographs showed hyperplasia and hypertrophy of the jaw bone. there was a mild protrusion on the side of the thorax and the left tibia was mildly thickened. electro cardiography was within normal limits. ultrasounds for the other organs, such as liver, kidney, spleen, pancreas, uterus and both adnexa, were all within normal limits. the histopathological changes in the epidermis were hyperplastic and affected chiefly the stratum corneum and stratum malpighii. evaluation of the firm nodule adjacent to the right nasal ala revealed dense collagen consistent with a connective tissue nevus or linear verrucous epidermal nevus. discussion etiology of proteus syndrome the cause of ps is still unknown, but a genetic mutation that is viable only in a mosaic state has been postulated.2 such a mutation might affect local production or regulation of tissue growth factor receptors. this theory would explain the sporadic nature of the syndrome, its occurrence in various ethnic groups and both sexes, and its interindividual variability, as well as the mosaic pattern of lesion distribution in all who are affected. in recent years, some authors have suggested that ps may be caused by germline mutations within the pten gene.3 the presence of a germline pten mutation in a subset of dermatology reports 2010; volume 2:e3 correspondence: xi-bao zhang, department of dermatology, guangzhou institute of dermatology, guangzhou 510095, guangdong province, p r of china. e-mail: lilichangxing@163.com key words: proteus syndrome, clinical manifestation, diagnosis acknowledgments. the authors are deeply grateful to dr. t joseph and dr. c helena for their kind suggestions. conflict of interest: the authors have no conflicts of interest to declare. received for publication: 2 november 2009 revision received: 23 december 2009 accepted for publication: 28 december 2009 this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright x-b. zhang et al., 2010 licensee pagepress, italy dermatology reports 2010; 2:e3 doi:10.4081/dr.2010.e3 figure 1. there was hemihypertrophy involving the entire right side of the head,including the skull, face, ear, palate, tongue, lip and neck. no nco mm er cia l u se on ly [dermatology reports 2010; 2:e3] [page 7] patients with ps has been confirmed by the identification of a de novo pten mutation in a patient with classical ps conforming to the criteria described by biesecker et al.4 manifestations of proteus syndrome ps is a rare and sporadic disorder that causes postnatal overgrowth of multiple tissues in a mosaic pattern.5 while patients with ps have a variable clinical appearance, they exhibit a defined constellation of skin abnormalities. extracutaneous manifestations were divided into the following categories: skeletal overgrowth, visceral overgrowth, other overgrowth, tumors, cysts, vascular abnormalities, deformity, and hypoplasia/maldevelopment.6-8 infants affected by the disorder usually appear normal or show only mild asymmetry at birth but progressively develop the characteristic features of the disease during childhood.9 complications of ps include, among others, progressive skeletal deformities, invasive lipomas, benign and malignant tumors, and deep venous thrombosis with pulmonary embolism. progressive skeletal abnormalities such as macrodactyly, scoliosis, asymmetric overgrowth, and limb length discrepancy are the most frequent and striking findings in patients with ps, followed by soft-tissue abnormalities such as fatty, muscular, and vascular malformations. visceral anomalies such as spleno megaly, asymmetric megalencephaly, whitematter abnormalities, and nephromegaly as well as masses other than fatty, muscular, and vascular malformations are less common.10 the diagnosis of ps was based on published criteria.4 the current situation of investigation on proteus syndrome in china all 8 patients reported11-18 in china had at least 2 different skin abnormalities and had other abnormalities, including lipomas, telangiectatic nevi or other vascular lesions, plantar cerebriform connective tissue nevi, or linear lesions of an epidermal nevus. remarkably, connective tissue nevi were also found on the article figure 2. verrucous epidermal nevi were seen on the right side of neck. t ab le 1 . su m m ar y o f 8 c as es w it h p ro te u s sy n d ro m e in c h in a. c as e 1 c as e 2 c as e 3 c as e 4 c as e 5 c as e 6 c as e 7 c as e 8 se x fe m al e fe m al e fe m al e fe m al e m al e fe m al e m al e fe m al e ag e 30 y ea rs 12 y ea rs 6 ye ar s 16 y ea rs 9 ye ar s 30 y ea rs 28 y ea rs 26 y ea rs ab no rm al ity le ft th um b le ft h an d le ft li m b ri gh t f ac e, ri gh t f ac e le ft le g le ft fa ce le ft fi ng er an d le g he m ih yp er he m ih yp er -, ea r, to ng ue , an d no se he m ih yp er an d he ad an d ri gh t f oo t he m ih yp er tr op hy , tr op hy , an d ec to la bi um he m ih yp er tr op hy , tr op hy , b ot h he m ih yp er he m ih yp er tr op hy , tr op hy , b on e ep id er m al n ev i, le ft h an d gi an t he m ih yp er tr op hy , ep id er m al n ev i, lo w er , e xt re m ity tr op hy , c on ne ct iv e ri gh t l ow er e xt re m ity th ic ke ni ng , fib ro ne ur om a fin ge r, ep id er m al ri gh t f ac e lip om as , co nn ec tiv e tis su e ve no us tis su e ne vu s, ve no us m al fo rm at io ns , co nn ec tiv e of h ea d an d fa ce , ne vi , l ef t a rm ri gh t f ac e ne vu s, b on e m al fo rm at io n, fib ro lip om a, ep id er m al n ev i, tis su e ne vi , ao rt ic op ul m on ar y an gi om a, h ig h te la ng ie ct at ic th ic ke ni ng co nn ec tiv e tis su e se ba ce ou s cy st , gi an t h em an gi om as o f le ft fi rs t fis tu la o r w in do w, ar cu s pa la tin us ne vi , d en te s ne vu s, li m b bo ne th ic ke ni ng , th e sp le en ph al an x m ic ro m an di bu la r m al oc cl us io n, le ng th lim b le ng th ex og en es is de fo rm ity , f ro nt al ri gh t a ud ito ry di sc re pa nc y di sc re pa nc y m am m ill a an tr um n ul lim ea tu s ob st ru ct , de ve lo pm en t, au ri cu la ri s m ag nu s de nt es en la rg em en t, m al oc cl us io n, ri gh t h yp er pl as ia ja w b on e of p ar ot id g la nd , ex og en es is ep id er m al n ev i, m am m ill a co nn ec tiv e tis su e ne vi , j aw b on e ex og en es is m am m ill a, si de p ro tr ud in g th or ac ic v er te br a no nco mm er cia l u se on ly [page 8] [dermatology reports 2010; 2:e3] palms, forearms, trunk, and face. epidermal nevi were examined histopathologically in all 8 patients (table 1). the reported cases were 6 females and 2 males; the youngest was six years old and the oldest was 30 years old. that only 8 cases have been reported in china suggests that many cases of ps may go unrecognized. china, as the most populated country on the globe at 1.2 billion people, should have more cases than have already been reported. the problem might be that both the clinical manifestations and diagnostic criteria are not familiar to dermatologists. moreover, medical services are not as accessible to citizens because of china’s status as a developing country. for these reasons, many cases may have been misdiagnosed or undiagnosed. although progress is being made in the clinical understanding of ps, much remains to be done. the existence of numerous case reports of patients who do not meet current clinical diagnostic criteria generates confusion about the natural history, the range of manifestations, and effective management techniques for what is now considered to be “true” ps. references 1. nguyen d, turner jt, olsen c, biesecker lg, darling tn. cutaneous manifestations of proteus syndrome: correlations with general clinical severity. arch dermatol. 2004;140:947-53. 2. eng c, thiele h, zhou xp, gorlin rj, hennekam rc, winter rm. pten mutations and proteus syndrome. lancet. 2001;358:2079-80. 3. cohen mm jr, turner jt, biesecker lg. proteus syndrome: misdiagnosis with pten mutations. am j med gene. 2003;122a:323-4. 4. biesecker lg, happle r, mulliken jb, weksberg r, graham jm jr, viljoen dl, et al. proteus syndrome: diagnostic criteria, differential diagnosis, and patient evaluation. am j med genet. 1999;84:389-95. 5. happle r, rogers m. epidermal nevi. adv dermatol. 2002;18:175-201. 6. biesecker lg, peters kf, darling tn, choyke p, hill s, schimke n, et al. clinical differentiation between proteus syndrome and hemihyperplasia: description of a distinct form of hemihyperplasia. am j med genet. 1998;79:311-8. 7. happle r. elattoproteus syndrome: delineation of an inverse form of proteus syndrome. am j med genet. 1999;84:25-8. 8. fishman sj, mulliken jb. vascular anomalies: a primer for pediatricians. pediatr clin north am. 1998;45:1455-77. 9. happle r, könig a. cutaneous mosaicism. pediatric dermatology. 2003:368-76. 10. gilbert-barness e, cohen mm jr, opitz jm. multiple meningiomas, craniofacial hyperostosis and retinal abnormalities in proteus syndrome. am j med genet. 2000;93:234-40. 11. ma dong-lai, zuo ya-gang, zheng he-yi, wang bao-xi. proteus syndrome: a case report. j clin dermatol. 2005,34:205-7. 12. chen rengui, jiang yuanfang, zhang dingguo, chen ge. proteus syndrome: a case report. j clin dermatol. 1995,4:242-3. 13. yang rui-fang, wang ming-yi, wang jizhou. proteus syndrome: a case report. chinese journal of birth health & heredity. 1998,6:93-4. 14. he yu-qing, zhang san-quan, cai yanxia, zhang xi-bao. proteus syndrome: one case report. chin j dermatol. 2007,40:76970. 15. wang qing-fang, li chen-jin, sun lin, yu feng-zhang, pan shao-chuan. proteus syndroome: a case report. chin j pediatr surg. 2007,28:669-70. 16. luo su-ju, feng yi-guo, wang jun-ming, zhen yan, peng zhen-hui, liu chao. chin j med genet. 2006,23:366-7. 17. lu jiang-yang, wang xiao-hong, liu qian, yang yi, li an-ran. proteus syndrome: a clinicopathological observation. 2007;14: 339-43. 18. wang zhao-yue, su yan-hua, yang haiyan, yu zi-qiang, cao li-juan, zhao xiaojuan, et al. proteus syndrome with a giant hemangiomas in the spleen associated with chronic dic – two case report and literature review. chin j hematol. 2007; 28: 152-5. article no nco mm er cia l u se on ly hrev_master [dermatology reports 2009; 1:e1] [page 1] tight junctions in hailey-hailey and darier’s diseases laura raiko,1 pekka leinonen,2,3 päivi m. hägg,3 juha peltonen,4 aarne oikarinen,3 sirkku peltonen1 1department of dermatology, university of turku and turku university central hospital, turku, finland; 2department of anatomy and cell biology and 3department of dermatology, university of oulu, oulu, finland; 4institute of biomedicine, department of anatomy, university of turku, turku, finland abstract hailey-hailey disease (hhd) and darier’s disease (dd) are caused by mutations in ca2+atpases with the end result of desmosomal disruption and suprabasal acantholysis. tight junctions (tj) are located in the granular cell layer in normal skin and contribute to the epidermal barrier. aberrations in the epidermal differentiation, such as in psoriasis, have been shown to lead to changes in the expression of tj components. our aim was to elucidate the expression and dynamics of the tj proteins during the disruption of desmosomes in hhd and dd lesions. indirect immunofluorescence and avidin-biotin labeling for tj, desmosomal and adherens junction proteins, and subsequent analyses with the confocal laser scanning microscope were carried out on 14 hhd and 14 dd skin samples. transepidermal water loss (tewl) was measured in normal and lesional epidermis of nine hhd and eight dd patients to evaluate the function of the epidermal barrier in hhd and dd skin. the localization of tj proteins claudin-1, claudin-4, zo-1, and occludin in perilesional hhd and dd epidermis was similar to that previously described in normal skin. in hhd lesions the tissue distribution of zo-1 expanded to the acantholytic spinous cells. in agreement with previous findings, desmoplakin was localized intracellularly. in contrast claudin-1 and zo-1 persisted in the cell-cell contact sites of acantholytic cells. tewl was increased in the lesional skin. the current results suggest that tj components follow different dynamics in acantholysis of hhd and dd compared to desmosomal and adherens junction proteins. introduction hailey-hailey disease (hhd, omim 16960) and darier’s disease (dd, omim 124200) are rare blistering skin diseases inherited as an autosomal dominant trait. hhd results in mutations in the atp2c1 gene, which encodes the golgi secretory pathway ca2+/mn2+ atpase (hspca1).1,2 dd is caused by mutations in the atp2a2 gene encoding ca2+-atpase type 2 (serca2, sarcoplasmic/endoplasmic reticulum ca2+-transport atpase isoform 2b).3 the most prominent common epidermal histological feature of dd and hhd is suprabasal acantholysis, which results from desmosomal disintegration. in addition dd and hhd epidermis show differentiation and keratinization defects.4-6 specifically transition of keratin 14 to keratin 10 is abnormal as demonstrated by the presence of suprabasal keratinocytes expressing both cytokeratins that usually are exclusive in normal epidermis.6 although the primary abnormalities in calcium metabolism in hhd and dd are known, the sequence of events leading to acantholysis is not understood fully yet. in normal human epidermis, tight junctions (tj) are located in the granular layer7,8 where they contribute to the epidermal barrier function, especially the diffusion of water from inside out.9-11 the most important transmembrane proteins of epidermal tj are the members of the claudin family; namely claudins-1 and -4, which are expressed in all vital epidermal layers.8,12 transmembrane protein occludin and intracellular linking molecule zonula occludens protein 1 (zo-1) are restricted to the granular layer normally.7 previously we have shown that abnormal epidermal differentiation is associated with disturbances in distribution of tj proteins.13 examples of aberrant differentiation include psoriatic epidermis and hypertrophic edges of healing blisters, which show spreading of zo1 and occludin to the acanthotic spinous cell layers.7,13,14 up-regulation of zo-1 and occludin is reversible and disappears during the healing of the psoriasis lesion.13 regulation of tj proteins in epidermis is not well known but the presence of tj in the granular cell layers suggests that the prerequisite for the formation of tj is high extracellular calcium concentration. in fact studies on cultured keratinocytes have shown that development of tj is calcium-inducible.7,15 we have demonstrated recently that in hhd and dd lesions the calcium concentration in the basal layer is lower than in normal skin.6 in addition to being decreased in the basal cells in the lesional hh and dd epidermis, the calcium content was decreased in non-lesional dd epidermis, probably linking to the keratinization defect seen especially in dd.6 the localization of adherens junction and desmosomal proteins in acantholytic lesions of dd and hhd has been studied in detail previously.16 however the dynamics of tj proteins has not been studied in acantholysis. studies on epidermal cadherin knockout mice suggest the importance of cadherins in assembly and/or stability of tj and desmosomes.17,18 thus desmosomes and tj seem to be at least partly co-regulated. the aims of this study were: (1) to elucidate the role of tj in the epidermal barrier in blistering disease; (2) to study the localization of tj in an abnormal epidermal calcium gradient; (3) to see whether the aberrant differentiation in dd has an effect on tj in the analogy of psoriatic skin and healing wounds; (4) to compare the dynamics of tj components to that of desmosomal and adherens junction proteins at the cellular level in the acantholytic process. specifically we investigated the localization of tj components claudin-1, claudin-4, zo-1, and occludin in frozen and paraffin-embedded skin of 14 hhd and 14 dd patients using commercial antibodies for indirect immunofluorescence and dermatology reports 2009; volume 1:e1 correspondence: laura raiko, department of dermatology, university of turku, 20520 turku, finland. e-mail: laura.raiko@utu.fi key words: adherens junction, claudin, darierwhite disease, tight junction, zonula occludens protein 1. acknowledgments: we thank dr lauri talve, department of pathology, turku university central hospital for providing the archival tissue material. this study was supported financially by grants from the finnish medical foundation, finnish cultural foundation, academy of finland, the turku university foundation, the southwest finland hospital district, and northern ostrobothnia hospital district, finland. contributions: lr, immunolabeling, confocal microscopy, writing the manuscript, and designing the figures; pl, tewl measurements, immunolabeling for frozen sections; pmh, obtaining patient samples in oulu, tewl measurements; jp, writing the manuscript and supervising the work; ao, patient samples and supervising the work in oulu; sp, coordinating the work and participating in all parts except tewl measurements. conflict of interest: the authors reported no conflicts of interest. received for publication: 1 october 2009. revision received: 2 november 2009. accepted for publication: 3 november 2009. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright l. raiko et al., 2009 licensee pagepress, italy dermatology reports 2009; 1:e1 doi:10.4081/dr.2009.e1 no nco mm er cia l u se on ly [page 2] [dermatology reports 2009; 1:e1] avidin-biotin immunolabeling. co-localization of tj proteins with adherens junction and desmosomal components was demonstrated using the confocal laser scanning microscope. in addition transepidermal water loss (tewl) was elucidated by measuring tewl in apparently normal and lesional hh and dd skin. the results showed that in both diseases the tissue localization of tj proteins remained apparently normal in the lesional and perilesional epidermis, while acantholysis was associated with changes in the distribution of tj proteins at the cellular level. materials and methods biopsy samples the skin biopsies were taken at the department of dermatology, turku university central hospital and the department of dermatology, oulu university hospital, finland, with approval of the ethical committee of the southwest finland hospital district and the joint ethical committee of the oulu university hospital, respectively. the diagnosis of dd or hhd was based on clinical appearance and histological diagnosis. the patients gave their written consent. four-millimeter skin biopsies were taken from apparently healthy skin and lesional areas in eight dd patients aged 35-69 years and nine hhd patients aged 45-80 years. in addition three patients with dd and three patients with hhd gave biopsies from lesional skin only. paraffinembedded skin biopsies of four hhd patients and five dd patients were obtained from the department of pathology, turku university central hospital. three control samples were obtained from otherwise healthy patients undergoing plastic surgery. the fresh skin samples were frozen in liquid nitrogen or in isopentane cooled in liquid nitrogen and stored at -70°c or in liquid nitrogen. primary antibodies the following primary antibodies were used: affinity-purified rabbit polyclonal antibodies to human claudin-1 (51-9000), zo-1 (61-7300), and occludin (71-1500); and mouse monoclonal antibodies to human claudin-4 (18-7341), ecadherin (33-4000), and zo-1 (33-9100), all from zymed laboratories inc., south san francisco, ca, usa. mouse monoclonal antibody to β-catenin (m3539) was purchased from dako (glostrup, denmark). nonimmunized mouse (2025) and rabbit (2027) igg were purchased from santa cruz biotechnology inc., (santa cruz, ca, usa). all antibodies against junctional proteins recognized intracellular epitopes. indirect immunofluorescence labeling punch biopsy samples were cut into 7 µm cryosections, mounted on silanated glass slides, and fixed in 100% methyl alcohol at -20°c for 10 min. to prevent nonspecific binding, the samples were preincubated in 1% bovine serum albumin (bsa) in phosphate buffered saline (pbs) for 15 min. antibodies were diluted in 1% bsa-pbs, and incubated on the samples at 4°c for 20 h. either primary antibodies were used alone or antibodies raised in mouse and rabbit were mixed for double labeling. following five 5-min washes in pbs, the samples were incubated with secondary antibodies and hoechst nuclear stain (dilution 1:10,000) at 20°c for 1 h. secondary antibodies used were alexa fluor 568 conjugated goat anti-rabbit igg (a11011) or alexa fluor 488 conjugated goat anti-mouse igg (a11029) from molecular probes inc. (eugene, or, usa). in double labeling the secondary antibodies for mouse and rabbit were mixed. the samples were washed in pbs, dipped in double-distilled water and mounted with glycergel (dako, glostrup, denmark). in control immunoreactions primary antibodies were replaced with 1% bsa-pbs or nonimmunized mouse or rabbit igg. avidin-biotin immunolabeling of paraffin-embedded tissues formalin-fixed and paraffin-embedded skin specimens were immunolabeled with the avidin-biotin method. the sections were cut and mounted on superfrost plus microscope slides (menzel-gläser; braunschweig, germany), deparaffinized, and hydrated in descending ethanol series. to retrieve tj antigens zo-1 and claudin-1, the samples were boiled for 10 min in a microwave oven in 10 mm tris, 1 mm ethylene diamine tetra-acetic acid (edta), ph 9, and subsequently cooled in the same solution at room temperature for 30 min. endogenous peroxidase activity was quenched by treating the sections in 0.3% h2o2 for 30 min. to prevent nonspecific binding the sections were incubated in horse serum diluted in pbs. antibodies to tj were diluted in pbs supplemented with 1% bsa and incubated on the samples overnight at 4ºc. the bound antibodies were visualized using the appropriate avidin-biotin peroxidase kit (vectastain; vector laboratories, burlingame, ca, usa) with 3.3’–diaminobenzidine tetrahydrochloride (dab) as a chromogen (dab peroxidase substrate kit; vector laboratories). sections were counterstained with mayer’s hematoxylin. in negative control reactions the primary antibody was replaced with 1% bsa-pbs. microscopy all examples of indirect immunofluorescence labeling were photographed using the confocal microscope. confocal laser scanning microscopy was carried out using a zeiss lsm 510 meta confocal microscope equipped with argon-ion and helium-neon lasers (zeiss; jena, germany) and lsm 3.0 software. the objectives were 40x (oil immersion, numeric aperture 1.3) and 63x (oil immersion, numeric aperture 1.4). for excitation, the 405-nm line was used for hoechst, the 488-nm line for alexa fluortm 488, and the 543-nm line for alexa fluortm 568 and cy3. the images were saved in an lsm image browser program and exported to adobe photoshop in jpg format. tewl measurements the vapometer with a closed cylindrical chamber (delfin technologies ltd, kuopio, finland) was used for tewl analyses. tewl was measured from lesional skin of nine patients with hhd and eight patients with dd. measurements were obtained from lesional and a corresponding healthy abdominal skin area of each patient. in hhd patients lesional areas included axillary (6), groin (1), leg (1), and chest (1) areas, while all lesional values from dd patients were measured from the chest (8) area. the average values were calculated for normal and lesional skin. results to investigate the function of the epidermal barrier in hhd and dd, tewl was measured in nine patients with hhd and eight patients with dd. the values of non-lesional and lesional skin were compared. the results showed that tewl in lesional hhd and dd areas was increased fourand three-fold, respectively, compared to the normal skin. the average tewl for non-lesional hhd skin was 12.4, while the average tewl value for lesional skin was 44.6. in non-lesional dd skin the average tewl value was 17.8, while in the lesional skin the average value was 50.0. the p-values were calculated using the t-test for independent samples, and resulted in a p-value of <0.01 for both diseases (figure 1). the localization of tj components claudins1 and -4, zo-1, and occludin in frozen and paraffin-embedded skin of 14 cases of hhd and 14 cases of dd was demonstrated using indirect immunofluorescence and avidinbiotin immunolabeling. the results showed that the localization of tj proteins in the healthy looking epidermis in both diseases was similar to that of the control skin. the expression of tj proteins remained normal in the vicinity of the lesions. in hhd lesions typical suprabasal blistering was observed. groups of acantholytic cells were noted in the blister fluid (figure 2a-e). in dd lesions characteristic acanthosis and acanarticle no nco mm er cia l u se on ly [dermatology reports 2009; 1:e1] [page 3] tholysis were detected (figure 2f-j). in hhd and dd samples zo-1 was located in the blister roof (figure 2b, g). in addition, in hhd zo1 was seen in the remaining cell-cell contacts of acantholytic spinous cells (figure 2b). occludin was present in the intercellular junctions of the granular cell layer located in the blister roof (figure 2c, h). claudin-1 was detected in all living cell layers (figure 2d, i), the basal cell layer being only faintly labeled. claudin-4 was localized mainly in the upper epidermis (figure 2e, j). to conclude, the general distribution of tj proteins occludin, and claudin-1 and -4 corresponded to that described earlier for normal skin. thus the acanthosis of dd could not be shown to induce spreading of tj to the spinous cell layers. to correlate the dynamics of tj proteins with that of desmosomal and adherens junction proteins, we double-labeled the sections with antibodies to tj proteins and desmoplakin, β-catenin, or e-cadherin. the antibody recognizing the intracellular part of e-cadherin showed labeling of the intercellular contacts in the acantholytic cells (figure 2c, h). this finding was in accordance with a previous study.16 desmoplakin was co-localized with claudin-1 in the granular cell layer (figure 2d, i). in acantholytic cells desmoplakin showed a diffuse cytoplasmic pattern while claudin-1 stayed in the remaining intercellular contacts (figure 2d). the co-localization of tj proteins with β-catenin, desmoplakin, and e-cadherin in acantholytic cells was studied in more detail in the hhd lesions (figure 3). double labeling for zo-1 and β-catenin revealed the presence of both proteins in the cell periphery, although some cytoplasmic zo-1 labeling was noted as well (figure 3a). double-labeling for claudin-1 with β-catenin revealed localization of both proteins at the plasma membrane (figure 3b). plenty of cytoplasmic β-catenin was seen in acantholytic cells (figure 3a, b), thus suggesting that claudin-1 and β-catenin follow different patterns in acantholysis. in addition to being present in intercellular contacts, claudin-1 was seen in the periphery of some cells without an apparent contacting cell (figure 3c). double labeling of claudin-1 and desmoplakin also demonstrated different dynamics of these proteins: claudin-1 remained at the plasma membrane of the intercellular contacts while desmoplakin was diffusely distributed in the cytoplasm. in acantholysis the cells gradually lost contacts with almost all the neighboring cells. during this process claudin-1 finally disappeared from the plasma membrane. however no clear cytoplasmic redistribution of claudin-1 could be seen. claudin-1 co-localized with e-cadherin in the granular cell layer as well as in some intercellular contacts of the acantholytic cells (figure 3d). article figure 1. average tewl values of nine patients with haileyhailey disease (hhd) and eight patients with darier’s disease (dd). lesional skin shows threeto four-fold higher tewl values compared to the non-lesional skin. hhd nonlesional (12.4) compared to lesional (44.6): p<0.01; dd non-lesional (17.8) compared to lesional (50.0): p<0.01. figure 2. hailey-hailey disease (hhd) (a-e) and darier’s disease (dd) (f-j) lesions immunolabeled for tight junction proteins claudin-1 (a, f ), zo-1 (b, g), and claudin-4 (e, j); double labeling for e-cadherin and occludin (c, h), and desmoplakin and claudin-1 (d, i). in (a) the inset is a control without any primary antibody. avidin-biotin immunolabeling visualizes the suprabasal blisters (asterisks) in lesions of both diseases (a, f ). claudin-1 is expressed in all epidermal cell layers (a, f ). zo-1 localizes to the upper epidermis and acantholytic cells in the hhd blister (b) while in dd, zo-1 is expressed only in the granular cell layer (g). occludin (red) is restricted to the granular cell layer in both diseases, while ecadherin (green) is seen in intercellular junctions in all epidermal cell layers (c, h). claudin-1 and desmoplakin are visible in all epidermal cell layers (d, i). claudin-4 localizes to the upper epidermis and acantholytic cells in the hailey-hailey blister and in dd (e, j). scale bar: 100 µm in (a), (c), (e), (f ), (h), (i) and (j); 50 µm in (b), (d) and (g). no nco mm er cia l u se on ly [page 4] [dermatology reports 2009; 1:e1] discussion based on genetically engineered mouse models, tjs are known to contribute to the epidermal barrier by regulating the tewl.9 in the present study, tewl was measured in normal and lesional hhd and dd skin. the results showed that tewl in lesional areas was increased fourand three-fold, respectively, compared to the non-lesional skin, although the granular cell layer in the blistering area had all the elements needed for complete tjs; namely zo-1, occludin, and two claudins. excess evaporation of water apparently takes place through the broken blisters. the formation of tj in vitro is dependent on external calcium concentration.7,8,15 here we investigated tj in diseases in which the epidermal calcium gradient is aberrant, which might have an impact on the expression of tj proteins. the results showed that zo-1 was present in acantholytic suprabasal cells unlike in non-lesional epidermis, where zo-1 was detected only in the granular cell layer. the expression of all the other tj proteins studied remained essentially the same in the tissue level compared to the non-lesional skin. thus the expression of zo-1 can be speculated to show different regulation compared to the other tj components studied. aberrant epidermal differentiation previously has been shown to change the expression pattern of tj proteins, zo-1 in particular. specifically healing of an experimental wound leads to epidermal hypertrophy, which displays an intense expression of zo-1.14 in psoriasis acanthosis is associated also with expression of zo-1 in the spinous cell layers.13 in contrast acanthosis of dd epidermis was characterized with the lack of zo-1 in the spinous cells. this suggests that the epidermal keratinocytes of dd follow different regulation of tj components compared to psoriasis. in addition the expression of zo1 can be seen as a sensitive indicator of abnormal differentiation. this study compared the dynamics of tj proteins with desmosomal and adherens junction proteins at a single cell level. previously it has been shown that intraand extracellular domains of desmosomal cadherins and e-cadherin dissociate, and desmoplakin is internalized in acantholytic cells in hhd and dd.4,16 the present evidence suggests that tj components claudin-1, zo-1, and occludin have somewhat different dynamics in acantholysis compared to desmosomal and adherens junction proteins. for instance, desmoplakin exhibited a diffuse cytoplasmic distribution in the acantholytic cells while tj proteins claudin-1 and occludin remained in the cell-cell contact sites. claudin1 was seen even in the free cell border of some cells that were not in contact with neighboring cells. the absence of cytoplasmic claudin-1 in the acantholytic cells may be because of the fact that it remains in the cell border or it is rapidly degraded if internalized. the intracellular plaque protein zo-1 was present in the remaining intercellular contacts of the acantholytic cells, but was not detectable in the free cell borders. in contrast to claudin-1, some cytoplasmic zo-1 could be seen. to conclude, in hhd and dd lesions the abnormalities in the calcium gradient and epidermal differentiation have little effect on the expression of tj proteins at the tissue level, while the acantholytic process merely has an impact on the dynamics of existing proteins at the single cell level. references 1. sudbrak r, brown j, dobson-stone c, et al. hailey-hailey disease is caused by mutations in atp2c1 encoding a novel ca(2+) pump. hum mol genet 2000;9:1131-40. 2. hu z, bonifas jm, beech j, et al. mutations in atp2c1, encoding a calcium pump, cause hailey-hailey disease. nat genet 2000;24:61-5. 3. sakuntabhai a, ruiz-perez v, carter s, et al. mutations in atp2a2, encoding a ca2+ pump, cause daries disease. nat genet 1999;21:271-7. 4. burge sm, garrod dr. an immunohistological study of desmosomes in darier’s disease and hailey-hailey disease. br j dermatol 1991;124:242-51. 5. foggia l, hovnanian a. calcium pump disorders of the skin. am j med genet c semin med genet 2004;131c:20-31. 6. leinonen pt, hägg pm, peltonen s, et al. re-evaluation of the normal epidermal calcium gradient, and analysis of calcium levels and atp receptors in hailey-hailey and darier epidermis. j invest dermatol 2009; 129:1379-87. article figure 3. acantholytic cells in hailey-hailey disease (hhd) lesions, double immunolabeled for tj proteins and adherens junction or desmosomal components. zo-1 (red) and β-catenin (green) are present in some of the remaining intercellular junctions, while both proteins can be detected intracellularly and in plasma membranes not in contact with neighboring cells (arrows) (a). claudin-1 and β-catenin in the cell-cell contacts (b). claudin-1 is seen in the plasma membranes of cells not in contact with the neighboring cells (arrows) (b,c). double labeling for desmoplakin (green) and claudin -1 (red) shows internalization of desmoplakin while claudin-1 stays in the plasma membrane (c). e-cadherin (green) and claudin-1 (red) are present at the plasma membrane (d). scale-bar: 20 µm in (a), (b), (d); 50 µm in (c). no nco mm er cia l u se on ly [dermatology reports 2009; 1:e1] [page 5] 7. pummi k, malminen m, aho h, et al. epidermal tight junctions: zo-1 and occludin are expressed in mature, developing, and affected skin, and in vitro differentiating keratinocytes. j invest dermatol 2001;117:1050-8. 8. brandner jm, kief s, grund c, et al. organization and formation of the tight junction system in human epidermis and cultured keratinocytes. eur j cell biol 2002;81:253-63. 9. furuse m, hata m, furuse k, et al. claudin-based tight junctions are crucial for the mammalian epidermal barrier: a lesson from claudin-1-deficient mice. j cell biol 2002;156:1099-111. 10. turksen k, troy tc. permeability barrier dysfunction in transgenic mice overexpressing claudin 6. development 2002;129: 1775-84. 11. troy tc, rahbar r, arabzadeh a, et al. delayed epidermal permeability barrier formation and hair follicle aberrations in inv-cldn6 mice. mech dev 2005;122:80519. 12. morita k, miyachi y. tight junctions in the skin. j dermatol sci 2003;31:81-9. 13. peltonen s, riehokainen j, pummi k, et al. tight junction components occludin, zo-1, and claudin-1, -4 and -5 in active and healing psoriasis. br j dermatol 2007;156:46672. 14. malminen m, koivukangas v, peltonen j, et al. immunohistochemical distribution of the tight junction components zo-1 and occludin in regenerating human epidermis. br j dermatol 2003;149:255-60. 15. yuki t, haratake a, koishikawa h, et al. tight junction proteins in keratinocytes: localization and contribution to barrier function. exp dermatol 2007;16:324-30. 16. hakuno m, shimizu h, akiyama m, et al. dissociation of intraand extracellular domains of desmosomal cadherins and ecadherin in hailey-hailey disease and darier’s disease. br j dermatol 2000;142: 702-11. 17. muller sl, portwich m, schmidt a, et al. the tight junction protein occludin and the adherens junction protein alpha-catenin share a common interaction mechanism with zo-1. j biol chem 2005;280:3747-56. 18. tinkle cl, pasolli ha, stokes n, et al. new insights into cadherin function in epidermal sheet formation and maintenance of tissue integrity. proc natl acad sci usa 2008;105:15405-10. article no nco mm er cia l u se on ly dr [page 18] [dermatology reports 2010; 2:e7] quality of life in swedish children with congenital ichthyosis agneta gånemo department of dermatology, skåne university hospital, malmö, sweden abstract congenital ichthyosis encompasses a large group of keratinizing disorders with widespread scaling and a variable degree of erythema. little is known about the quality of life in children with congenital ichthyosis and the impact of the disease on their family. fifteen children aged 5-16 years with lamellar ichthyosis, netherton’s syndrome, epidermolytic hyperkeratosis or harlequin ichthyosis, were investigated concerning the effect of their ichthyosis on their quality of life. this was measured with the established children’s dermatology life quality index (cdlqi), and the dermatitis family impact questionnaire (dfi) modified by substituting the word ichthyosis for eczema. the questionnaires covered the preceding seven days and each had a maximum score of 30: the higher the score, the greater the quality of life impairment. the median score was 9.0 (range 2-19) for the cdlqi and 9.0 (range 3-21) for dfi. there was a significant correlation between the dfi and the cdlqi scores. the item in the cdlqi questionnaire that showed the highest score was “itchy, scratchy, sore or painful skin” and the most highly scored item in the dfi questionnaire was effect on “housework, e.g. washing, cleaning”; both items related to the children’s symptoms. the results of the study clearly establish that congenital ichthyosis impairs the quality of life of the affected children and their families. introduction congenital ichthyosis encompasses a heterogeneous group of hereditary skin disorders all of which are present at birth.1 after the neonatal period the affected children have widespread scaling and a variable degree of erythema or, in epidermolytic hyperkeratosis (ehk), extremely thickened skin and blisters over the body.2 in general, clinical examinations together with dna tests confirm the diagnosis lamellar ichthyosis (li), netherton’s syndrome (ns), ehk or harlequin ichthyosis (hi).2 there is at present no cure for ichthyosis. the life-long treatment includes baths and daily applications of topical emollients and, for very severe symptoms, oral acitretin.3,4 quality of life (qol) studies in adults with ichthyosis have shown that their skin disease has affected them negatively and that the most problematic period has been their childhood.5,6 many skin diseases in children have been associated with impaired qol.7,8 data on qol in children with congenital ichthyosis are sparse. the aim of the present study was to investigate qol in swedish children with different forms of congenital ichthyosis and also the impact of the children’s disease on the qol of their families. materials and methods children with the diagnosis of congenital ichthyosis aged 5-16 years were recruited in the years 2003-2007 through the uppsala genodermatosis centre and the swedish ichthyosis association. inclusion criteria were a diagnosis from a dermatology clinic, age 5-16 years, command of the swedish language, and oral and written informed consent. fifteen children were enrolled in the study. their diagnosis was based on clinical examination and in 7 cases it was further confirmed by dna tests. the research ethics committee of uppsala university approved the study (03166). qol was assessed with the established questionnaires, children’s dermatology life quality index (cdlqi)9 and dermatitis family impact questionnaire (dfi),10 in the swedish language. the latter was modified with exchange of the word eczema for ichthyosis. the questionnaires covered the preceding seven days and each had 10 questions scoring 0-3, giving a maximum score of 30: the higher the score, the greater the impairment of qol. the author contacted the children’s parents by telephone and study aim and design were explained. all agreed to participate. information and a questionnaire about the child’s medical history and present medical condition were mailed to the parents. the children were investigated in their homes (n=13) or at an annual meeting of the swedish ichthyosis association (n=2). the disease was rated by the investigator as mild, moderate, or severe, using a semi-quantitative global clinical assessment, based on degree of scaling, hyperkeratosis, erythema, and extension. after informed consent had been obtained and the severity of the ichthyosis had been scored, the parent(s) left the room and completed the dfi. the cdlqi was completed by the author and the child alone; the author asked the questions and filled in the child’s answers. statistical analysis was performed with the software platform version 2.4.1.11 spearman’s rank order correlation coefficient was computed as a measure of the association between cdlqi and dfi, and between the qol results. results fifteen children (6 boys, 9 girls) aged 5-16 years (median 9 years) met the inclusion criteria li (n=10), ns (n=3), ehk (n=1) or hi (n=1). demographic and clinical characteristics of the participants are presented in table 1. all patients were receiving some type of topical therapy for ichthyosis and 2 were being treated with oral acitretin. quality of life the median total score for cdlqi was 9 (range 2-19). the three items in the cdlqi questionnaire that had the highest score were question 1 “itchy or painful skin”, question 10 “treatment problems”, and question 8 “calling you names, bullying or avoiding you”. the median total score for dfi was 9 (range 3-21). the three items in the dfi questionnaire that were given the highest score were question 1 “effect on housework”, question 10 “helping with the child’s treatment”, and question 6 dermatology reports 2010; volume 2:e7 correspondence: agneta gånemo, department of dermatology, skåne university hospital, se 20502 malmö, sweden. e-mail: agneta.ganemo@skane.se key words: ichthyosis, netherton’s syndrome, harlequin ichthyosis, children’s dermatology life quality index, skin disease. acknowledgments: i thank all the children and parents for their participation in this study. i also thank fredrik nilsson for help with medical statistics. the study was supported by grants from the edvard welander-finsen foundation, the swedish dermatological and venereological nursing association, the first of may flower annual campaign for children’s health, and the sunnerdahl disability foundation. conflict of interest: the author reports no conflicts of interest. received for publication: 18 august 2009. revision received: 24 march 2010. accepted for publication: 24 march 2010. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a. gånemo, 2010 licensee pagepress, italy dermatology reports 2010; 2:e7 doi:10.4081/dr.2010.e7 no nco mm er cia l u se on ly [dermatology reports 2010; 2:e7] [page 19] “expenditure”. there was a significant correlation between the dfi and cdlqi scores (p= 0.0048). the median and mean total scores for cdlqi and dfi for the children and for the two genders (male/female), for three age groups (5-8 years, 9-12 years and 13-16 years) and for different forms of ichthyosis are shown in table 2. discussion this study of the impact of congenital ichthyosis on the qol of afflicted children and of their families confirms that the ichthyosis affects both the children and the families. the observed impact on the children’s qol is in line with findings in two previous swedish studies concerning adults with ichthyosis.5,6 the two items showing the highest cdlqi and dfi scores concern problems related to the children’s ichthyosis symptoms and the treatment. in this study, it was shown that both the patients and their parents need support and help to cope with this chronic disease. the mean total cdlqi score in this study was 9.0, which was higher than in a study presented as an abstract from france, where the total cdlqi score was 6.7.12 the present study comprised only children with congenital ichthyosis, while the french study included both congenital and non-congenital forms of the disease. it seems reasonable that patients with congenital ichthyosis, a more severe condition, will score higher than study groups of patients including both the more common types of ichthyosis and congenital ichthyosis. an important consideration is how representative our patients were. the number of patients in the present study group was small, but on the other hand the study included virtually all swedish children with congenital ichthyosis in the age group in question. there was a small gender difference in cdlqi scores when the children themselves answered the questions and also a gender difference in the dfi scores when parent(s) answered (not significant) (table 2). the children’s ages influenced the cdlqi and dfi scores; a finding in line with results for children with eczema.7,13 in one study,14 the mother of an ichthyosis patient described her frustration about the shedding of her son’s skin in their home. in that study, it was found that parents of children (n=2) with ichthyosis also have an extra financial burden. this is in line with the findings in the present study concerning housework and the fact that the expenditure had an impact on their qol. when children have a article table 1. demographic and clinical characteristics of the children. patient n. sex/age diagnosis global assessment hypohidrosis ectropion/ ear-problems pruritus alopecia/ creams (y) of disease severity eye problems abnormal hair containing 1 f/5 li +++ + + + + l/p 2 f/6 li +++ + + + l/p 3 f/7 li + + + + p+l/p 4 f/7 li +++ + + + l/p 5 f/9 li ++ + + u l/p 6 m/9 li + + + l/p 7 m/12 li ++ + l/p 8 m/13 li +++ + + + + u+l/p 9 f/14 li ++ + + be+gc 10 f/16 li + + + l/p 11 m/8 ns ++ + + + + be 12 f/11 ns + + + + u+gc 13 m/14 ns +++ + p+gc 14 m/13 ehk +++ + + u 15 f/8 hi +++ + + + be ns= netherton’s syndrome, li= lamellar ichthyosis, ehk = epidermolytic hyperkeratosis, hi= harlequin ichthyosis. global score of skin disease '+ = mild disease, ++ = moderate disease and +++ = severe skin disease. hypohidrosis, eye problems, ear problems, eczema/pruritus, yes = +, no = – creams: u = urea, l/p = lactic acid /propylene glycol, p = propylene glycol, be = bland emollient, gc = glucocorticoid. table 2. the total quality of life scores for cdlqi and dfi and the scores distributed by gender, age-groups and ichthyosis forms. cdlqi dfi number median mean total median mean total score, score, if only if only one one patient patient all 15 9 9.3 9 9.0 sex (children) male 6 8.5 8.3 6.5 7.2 female 9 9 9.4 10.0 70.7 age (children) 5-8 years 6 13 13.3 12.5 12 9-12 years 4 8 7.8 7.5 7.3 13-16 years 5 8 6.8 5 5.8 ichthyosis lamellar ichthyosis 10 9 8.6 9 9.7 netherton’s syndrome 3 8 10.3 8 7.7 harlequin ichthyosis 1 16 14 epidermolytic hyperkeratosis 1 2 5 parent (s) who completed the questionnaire both together 4 6 6.8 mother 10 9 10 father 1 17 12 no nco mm er cia l u se on ly [page 20] [dermatology reports 2010; 2:e7] congenital disease, such as epidermolysis bullosa (eb) or congenital ichthyosis, they have their disease from birth to the end of their life. in a study comprising 30 children with different forms of eb,15 the total cdlqi scores were much higher than the total cdlqi scores in this study. on the other hand, the results of this study verify that ichthyosis causes greater impairment of qol than other skin diseases in children. general questionnaires16 and many new studies are needed to compare the impact on qol of ichthyosis with other congenital and chronic diseases. in conclusion, this study showed that congenital ichthyosis considerably impaired the qol of afflicted swedish children and their families. furthermore, the findings confirm the result of a previous interview study on older patients with congenital ichthyosis who described their childhood as the most problematic period in their lives. references 1. traupe h. the ichthyoses: a guide to clinical diagnosis, genetic counseling, and therapy. berlin; new york: springerverlag;1989. 2. digiovanna jj, robinson-bostom l. ichthyosis etiology, diagnosis, and management. a clin dermatol 2003;4:81-95. 3. vahlquist a, gånemo a, virtanen m. congenital ichthyosis: an overview of current and emerging therapies. acta derm venereol 2008;88:4-14. 4. ganemo a, virtanen m, vahlquist a. improved topical treatment of lamellar ichthyosis: a double-blind study of four different cream formulations. br j dermatol 1999;141:1027-32. 5. ganemo a, lindholm c, lindberg m, sjoden po, vahlquist a. quality of life in adults with congenital ichthyosis. j adv nursing 2003;44:412-9. 6. ganemo a, sjoden po, johansson e, et al. health-related quality of life among patients with ichthyosis. eur j dermatol 2004;14:61-6. 7. ganemo a, svensson a, lindberg m, wahlgren cf. quality of life in swedish children with eczema. acta derm venereol 2007;87:345-9. 8. holm ea, wulf hc, stegmann h, jemec gb. life quality assessment among patients with atopic eczema. br j dermatol 2006;154:719-25. 9. lewis-jones ms, finlay ay. the children's dermatology life quality index (cdlqi): initial validation and practical use. br j dermatol 1995;132:942-9. 10. lawson v, lewis-jones ms, finlay ay, et al. the family impact of childhood atopic dermatitis: the dermatitis family impact questionnaire. br j dermatol 1998;138: 107-13. 11. r development core team. r:a language for statistical computing. foundation for statistical computing 2006. 12. blanchet-bardon cc, j-m. nguyen le, c. health-related quality of life in ichthyosis patients and family members. j am acad dermatol. 2005;52(3, supplement 1):p110. 13. hon kl, leung tf, wong ky, chow cm, chuh a, ng pc. does age or gender influence quality of life in children with atopic dermatitis? clin exp dermatol 2008;33: 705-9. 14. basra mk, finlay ay. the family impact of skin diseases: the greater patient concept. br j dermatol 2007;156:929-37. 15. horn hm, tidman mj. quality of life in epidermolysis bullosa. clin exp dermatol 2002;27:707-10. 16. beattie pe, lewis-jones ms. a comparative study of impairment of quality of life in children with skin disease and children with other chronic childhood diseases. br j dermatol 2006;155:145-51. article no nco mm er cia l u se on ly dr [page 8] [dermatology reports 2011; 3:e5] cumulative life damage in dermatology kristina ibler, gregor b.e. jemec department of dermatology, roskilde hospital; health sciences faculty, university of copenhagen, denmark abstract cumulative life damage is an old concept of considerable face validity, which has attracted more scientific interest in the fields of sociology and psychology than in medicine over the years. the research examines the interconnectivity of the many factors which shape the development of individuals or institutions over time. by focussing on time, context and process, life course research highlights the different effects seemingly similar events may have at different points in time and in different contexts. introduction cumulative life damage is an old concept of considerable face validity, which has attracted more scientific interest in the fields of sociology and psychology than in medicine over the years. in a philosophical context the concept of determinism has been the subject of much discussion. in sociology the analysis of factors which convey either advantages or disadvantages to the development of an individual over the entire course of their life have been traditional area of interest. in an empirical rather than a theoretical context it is of obvious interest how general conditions, resources and single events in the course of a lifetime add up to shape the entire life course. life course can be defined as a sequence of socially defined events and roles that the individual enacts over time1 and the research examines the interconnectivity of the many factors which shape the development of individuals or institutions over time. by focussing on time, context and process, life course research highlights the different effects seemingly similar events may have at different points in time and in different contexts. in a health context, this may be particularly appropriate in chronic diseases where the morbidity is influenced by several factors over long periods of time. here life course research is looking at how related negative health events, assembled into a specific diagnosis but spread over a lifetime, summate under the influence of the persons abilities and resources to produce an overall impact of the disease. life course research has therefore been applied in studies of degenerative disease, but the perspective offered may also provide important insights into e.g. adolescent disease where major life events shape the responsiveness of the patients to patophysiological changes. cumulative life course impairment in dermatology in medicine it may be directly linked to the concepts proposed by the world health organisation in the definition of health. three core concepts are used to describe morbidity: impairment, disability and handicap. impairment is defined as the loss or abnormality of physical bodily structure or function, of logic-psychic origin, or physiological or anatomical origin. the impairment is the basic pathology of the disease, e.g. the eczema, the scleroderma or the tumour. impairments lead to disabilities. disability is defined as any limitation or function loss deriving from impairment that prevents the performance of an activity in the time-lapse considered normal for a human being. the disability in a dermatological context is therefore e.g. the psychosocial consequences to the individual with a severe acne vulgaris. the disability may in turn lead to a handicap, which is defined as the disadvantaged condition deriving from impairment or disability limiting a person performing a role considered normal in respect of their age, sex and social and cultural factors. a dermatological example of handicap would be the loss of employment suffered in consequence of hand eczema. in many ways the concept of cumulative life course impairment (clci) is particularly suited to dermatology, as the diseases are rarely lethal and well within the realm of the psychosocial sphere due to their immediate visibility and obvious presence even to the untrained eye. stigma as well as socialisation are therefore important factors when assessing the impact of skin disease on patients. in addition to these psychosocial consequences of skin disease, dermatological conditions frequently have symptoms that are difficult to control adequately influencing the resources of the patients negatively. the balance between the stressors and coping abilities of the patients may therefore be more volatile, which over the course of longstanding disease may lead to more negative events and life course changing consequences. it may be argued that clci reflects the handicap of the disease in the broadest sense of the word, but offers the dynamic perspectives of time and context thereby identifying additional opportunities for adjuvant interventions beyond the narrow biological process at the root of the handicap. in the following we will review some of the evidence supporting the concept of clci in dermatology. hand eczema hand eczema is a major occupational hazard in many countries, and management often difficult. it has an acknowledged negative impact on the quality of life,2-5 but studies also suggest that the development of hand eczema causes clci. in a one year follow-up study of secondary individual prevention in health care workers with occupational hand eczema by diepgen and co-workers, a beneficial effect of the intervention was found, but in spite the structured intervention 9% of the patients studied had left their job due to the skin disease.6 this suggests that even with specific interventions aimed at improving the coping abilities of the patients, occupational hand eczema has a significant life course impact. a similar result was found in a study of kitchen employees.7 the relevance of clci in occupational hand eczema is underlined by the findings in a study by cvetkovski et al. that indicating the consequences of the disease are affected by the life conditions of the patients. patients with lower socioeconomic status were found to have a higher risk of prolonged sick leave, job change, and loss of job, whereas the identification of a specific contact allergy was not found to be a risk factor for poor prognosis.8 severe hand eczema and lower socioeconomic status were both associated with a lower quality of life.2 in a study by fowler et al. it was found that hand eczema had a detrimental effect on working productivity, activity impairment and health care costs.3 acne acne is a common skin disease, and in milder forms often seen as physiological. in dermatology reports 2011; volume 3:e5 correspondence: gregor b.e. jemec, department of dermatology, roskilde hospital; health sciences faculty, university of copenhagen, denmark. tel. +45.47322603 fax: +45.47322699. e-mail: gbj@regionsjaelland.dk key words: handicap, cumulative life impairment, morbidity, quality of life, skin disease. received for publication: 30 march 2011. accepted for publication: 30 march 2011. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright k. ibler and g.b.e. jemec, 2011 licensee pagepress, italy dermatology reports 2011; 3:e5 doi:10.4081/dr.2011.e5 no nco mm er cia l u se on ly [dermatology reports 2011; 3:e5] [page 9] terms of clci two factors have been described in the literature: psychological consequences and social consequences. this is a skin disease that affects predominantly teenagers, i.e. persons at a dramatic developmental stage of their life, making them susceptible to many factors. it is well established that quality of life is adversely affected by acne, and the consequences of this has been the topic of some debate. although studies have found no increase in depression among acne patients,9 a recent population based study found acne associated with depression, suggesting insufficient coping in this group of patients.10 it has previously been shown that acne is a common diagnosis among dermatological patients who commit suicide due to their disease, indicating that acne may be associated with the ultimate clci.11 in societal terms data exist to suggest that acne can have a considerable negative clci, as unemployment has been shown to be higher among acne patients than controls, suggesting that the changed appearance and possible pre judice associated with skin disease negatively affects the prospects of acne patients. these observations may however also be secondary to the self-image of acne patients or due to other hitherto undescribed mechanisms. atopic eczema atopic eczema (ae) is a frequent disease affecting up to 1 in 5 preschool children, and although the majority of cases appear to resolve spontaneously, a history of ae conveys a lifelong increase in the risk of developing hand eczema. because of the frequent spontaneous resolution ae is more difficult to study in a clci context. it has never the less been shown that patients with severe ae in childhood have delayed socialization, indicating that the skin disease has psychosocial consequences which reach beyond signs and symptoms of the disease itself. several studies have described the negative effects on the quality of life of the individual patient, and recently this has been extended to the household.12,13 by describing the family impact of skin disease, finlay and coworkers have suggested that the family unit as a whole is adversely affected by skin disease, indicating that clci may occur indirectly as a consequence of illness in the family. for adult ae patients it has however been shown that ae leads to job changes and increased number of sick days off work. the flares as well as the increased risk of flares associated with jobs that involve a chemical or mechanical strain on the skin play a role in the career choice of ae patients, thereby providing long-term influence on their life course. finally ae may lead to job loss, and if severe to disability pension.14 although the numbers are small it is also suggested that a number of patients receive permanent disability pensions due to ae indicating major clci. psoriasis psoriasis is often taken as a prototypical skin disease causing embarrassment and stigma. it is also suggested that it may be triggered by significant life events, suggesting that it is at least temporarily linked to major traumatic life events.15 it has furthermore been suggested that while most diseases may be associated depression at their onset, psoriasis, myocardial infarction, and migraine are also associated with with depression on subsequent flares, suggesting that the disease may have a more profound effect on the psyche than many other diseases.16 whether any subsequent psychosocial impact of psoriasis on the lives of patients is a consequence of this psychological mechanism or due to stigma is not currently known, but it has been shown that psoriasis is associated with low quality of life particularly among the socioeconomically challenged.17 the relationship between the psychosocial burden of psoriasis, the disease severity and the social and economical achievements of psoriasis patients is at best described as complex.18 it is however clear that the diagnosis of psoriasis, and in particular severe psoriasis, is associated with concrete life-event differences from other patients.19 for psoriasis patients approximately 30 years old, higher divorce rates are seen than in others, suggesting the disease affects social connectivity, which may also reflect in the worklife of patients.20 this is further supported by the observation that psoriasis is the second most common disease associated with disability pensions.21 psoriasis has therefore been suggested as a model of dermatological life impairment.22 conclusions the concept of clci appears well suited to describe the handicap of dermatological disease. the chronic recurrent nature of the diseases, coupled with their visibility and the ability of lay persons to recognise pathology immediately, indicates that skin disease may affect both context and process repeatedly leading to handicap. data are however sorely lacking to provide an adequate model of clci in dermatological disease. the present know ledge is based on few descriptive surveys, most often without a control group making it difficult to draw conclusions. furthermore, data have not been gathered systematically, which means that a number of possible confounders such as education, socioeconomic status, family context etc. are not available. the introduction of clci into dermatological research therefore necessitates the development of appropriate technologies to identify the mechanisms that would allow predictions to be made and in consequence possible intervention studies. in addition to methodological developments such as prospective databases, additional casecontrol studies are needed to further describe the available data and substantiate the role of clci in dermatology. references 1. giele jz, elder gh jr. (). methods of life course research: qualitative and quantitative approaches. thousand oaks ca: sage 1998 p.22. 2. cvetkovski rs, zachariae r, jensen h, et al. quality of life and depression in a population of occupational hand eczema patients. contact dermatitis 2006;54:10611. 3. fowler jf, ghosh a, sung j, et al. impact of chronic hand dermatitis on quality of life, work productivity, activity impairment, and medical costs. j am acad dermatol 2006;54:448-57. 4. agner t, andersen ke, brandao fm, et al. hand eczema severity and quality of life: a cross-sectional, multicentre study of hand eczema patients. contact dermatitis 2008;59:43-7. 5. skoet r, zachariae r, agner t. contact dermatitis and quality of life: a structured review of the literature. br j dermatol 2003;149:452-6. 6. apfelbacher cj, soder s, diepgen tl, weisshaar e.the impact of measures for secondary individual prevention of workrelated skin diseases in health care workers: 1-year follow-up study. contact dermatitis 2009;60:144-9. 7. soder s, diepgen tl, radulescu m, et al. occupational skin diseases in cleaning and kitchen employees: course and quality of life after measures of secondary individual prevention. j dtsch dermatol ges 2007;5:670-6. 8. cvetkovski rs, zachariae r, jensen h, et al. prognosis of occupational hand eczema: a follow-up study. arch dermatol 2006;142:305-11. 9. rehn lm, meririnne e, höök-nikanne j, et al. depressive symptoms, suicidal ideation and acne: a study of male finnish conscripts. j eur acad dermatol venereol 2008;22:561-7. 10. halvorsen ja, stern rs, dalgard f, et al. suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: a population-based study. j invest dermatol 2011;131:363-70. review no nco mm er cia l u se on ly [page 10] [dermatology reports 2011; 3:e5] 11. purvis d, robinson e, merry s, watson p. acne, anxiety, depression and suicide in teenagers: a cross-sectional survey of new zealand secondary school students. j paediatr child health 2006;42:793-6. 12. kemp as. cost of illness of atopic dermatitis in children: a societal perspective. pharmacoeconomics 2003;21:105-13. 13. kemp as. atopic eczema: its social and financial costs. j paediatr child health 1999;35:229-31. 14. holm ea, esmann s, jemec gb. the handicap caused by atopic dermatitis--sick leave and job avoidance. j eur acad dermatol venereol 2006;20:255-9. 15. arslanagić n, arslanagić r. effect of psychological trauma caused by war on manifestations of psoriasis. med arh 2003;57: 145-7. 16. gili m, garcia-toro m, vives m, et al. medical comorbidity in recurrent versus first-episode depressive patients. acta psychiatr scand 2011;123:220-7. 17. o'neill p, kelly p. postal questionnaire study of disability in the community associated with psoriasis. bmj 1996;313:91921. 18. kimball ab, jacobson c, weiss s, et al. the psychosocial burden of psoriasis. am j clin dermatol 2005;6:383-92. 19. seidler em, kimball ab. socioeconomic disability in psoriasis. br j dermatol 2009;161:1410-2. 20. frangoes je, kimball ab. divorce/marriage ratio in patients with psoriasis compared to patients with other chronic medical conditions. j invest dermatol 2008; 128:s87. 21. menné t, bachmann e. permanent disability from skin diseases. a study of 564patients registered over a six year period. derm beruf umwelt 1979;27:37-42. 22. kimball ab, gieler u, linder d, et al. psoriasis: is the impairment to a patient's life cumulative? j eur acad dermatol venereol 2010;24:989-1004. review no nco mm er cia l u se on ly dr [dermatology reports 2011; 3:e14] [page 33] bacterial colonization of psoriasis plaques. is it relevant? eva marcus, diana demmler, andreas rudolph, matthias fischer department of dermatology and venerology, helios klinikum aue, aue, germany abstract bacterial colonization was investigated retrospectively in patients with plaque psoriasis (n=98 inpatient treatments, n=73 patients). at least one pathogen was found in 46% of all cases. staphylococcus aureus was the most frequent bacterium. bacterial colonization of psoriasis plaques could be relevant in individual cases. the exacerbation of psoriasis vulgaris can be caused by various triggers.1 while bacterial infiltration of afflicted skin is known to be a trigger factor in chronic inflammatory dermatoses such as atopic dermatitis,2 the bacterial flora of psoriasis plaques and their possible importance have received only little attention thus far. the bacterial smears of lesional skin performed routinely on admission to our clinic were examined retrospectively for all psoriasis patients. the observation period was 16 months. the data of n=98 inpatient treatments (n=73 patients) were assessed, whereby n=56 patients were treated once, n=12 patients twice and n=5 patients underwent repeated inpatient treatments. overall, n=45 (46% of all psoriasis cases) had colonization of the psoriasis plaques with pathogenic bacteria, whereby gram-positive bacteria were found most frequently (figure 1). of these patients with pathogenic colonization, n=22 had one pathogen, while n=18 of those examined had two bacteria and n=5 three or four different bacteria. staphylococcus aureus, streptococcus pyogenes, streptococcus agalactiae, enterococcus faecalis, klebsiella pneumoniae and oxytoca, acinetobacter baumannii, proteus mirabilis, stenotrophomonas maltophilia, serratia marcescens, acinetobacter lwoffii, pseudomonas aeruginosa and escherichia coli were identified as pathogenic bacteria. the most prevalent bacterium was staphylococcus aureus (n=31). clinically, the plaques covered with pathological bacterial flora were in part erosive. the pasi on admission for patients with pathological colonization was 16.1 versus 14.0 in patients without proof of bacterial colonization or resident flora (not significant (ttest)). the patients admitted two or more times showed a change in bacterial colonization in eleven cases without any regular pattern. there was a change between gram-positive and gram-negative colonization, as well as new colonization of previously-sterile plaques with various pathogenic bacteria. however, in three cases, colonization with staphylococcus aureus was no longer present on re-admission (sterile finding in each case). these three patients did not receive any antimicrobial treatment between their in-house treatments. one woman developed erysipelas of the abdominal wall out of a navel plaque with colonization by staphylococcus aureus (figure 2). nearly half of the patients examined had colonization of the psoriasis plaques with (potentially) pathogenic bacteria. examina tions to date of the bacterial flora in psoriasis have concentrated on the proof of staphylo coccus aureus and found a prevalence of up to 64% in lesional skin of patients with plaque psoriasis.3,4 corresponding to this, staphylo coccus aureus has also been found as the most prevalent bacterium in patients with superinfected pustular psoriasis.5 the frequency of 46% bacterial colonization in the group we examined was lower than that reported in the literature, but it showed a considerably broader spectrum of pathogens, especially including gram-negative bacteria. in most patients, the pathogens appear as (transient) colonization or superinfection. this is supported by the lack of difference in the pasi scores on admission and the changing flora in patients admitted more than once. nonetheless, bacterial colonization may have systemic and local effects. for example a superantigen effect has been described in psoriasis especially for staphylococcus aureus, the most-frequently found bacterium.3,4 enterotoxins seem to play an important role in this superantigen activity.4 moreover, triggering of psoriasis by streptococci is known.1,6 on the other hand, local effects on single colonized plaques might be possible, since the clinical picture with crusting and erosive surface indicates an immunoresponse. local infections of psoriasis plaques are usually prevented by high concentrations of antimicrobial peptides.7 nonetheless this barrier seems to be breached in single cases. in the group of patients we examined, one woman developed erysipelas which began clinically in the area of a psoriasis plaque. this shows that systemic infections from local bacterial colonization could not be prevented in individual cases in spite of an overexpressed innate immune system in psoriasis. additional investigations are needed to better estimate the clinical relevance of colonization and potential breaches of the innate immune system in psoriasis patients. dermatology reports 2011; volume 3:e14 correspondence: matthias fischer, heliosklinikum aue, department of dermatology and venerology, gartenstraße 6, d-08280 aue, germany. e-mail: matthias.fischer@helios-kliniken.de key words: psoriasis, bacteria, staphylococcus aureus, trigger. conflict of interest: the authors report no conflicts of interest. received for publication: 8 june 2011. accepted for publication: 12 july 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright e. marcus et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e14 doi:10.4081/dr.2011.e14 figure 1. distribution of bacterial infection of psoriasis plaques. mix= combination of gram-positive and gramnegative pathogens. figure 2. erysipelas of the abdominal wall starting from an umbilical psoriasis plaque with proof of staphylococcus aureus. no nco mm er cia l u se on ly [page 34] [dermatology reports 2011; 3:e14] references 1. schön mp, boehncke wh. psoriasis. n engl j med 2005;352:1899-912. 2. brook i. secondary bacterial infections complicating skin lesions. j med microbiol 2002;51:808-12. 3. balci dd, duran n, ozer b, et al. high prevalence of staphylococcus aureus cultivation and superantigen production in patients with psoriasis. eur j dermatol 2009;19:238-42. 4. tomi ns, kränke b, aberer e. staphylococcal toxins in patients with psoriasis, atopic dermatitis, and erythroderma, and in healthy control subjects. j am acad dermatol 2005;53:67-72. 5. brook i, frazier eh, yeager jk. microbiology of infected pustular psoriasis lesions. int j dermatol 1999;38:579-81. 6. herbst ra, hoch o, kapp a, et al. guttate psoriasis triggered by perianal streptococcal dermatitis in a four-year-old boy. j am acad dermatol 2000;42:885-7. 7. harder j, schröder jm. psoriatic scales: a promising source for the isolation of human skin-derived antimicrobial proteins. j leukoc biol 2005;77:476-86. case report no nco mm er cia l u se on ly 502 bad gateway the server returned an invalid or incomplete response. 429 too many requests you have sent too many requests in a given amount of time. dr [page 68] [dermatology reports 2011; 3:e30] tegafur-induced acral hyperpigmentation vera teixeira, ricardo vieira, américo figueiredo department of dermatology, coimbra university hospital, portugal abstract tegafur is a prodrug of 5-fluorouracil (5-fu) with a similar spectrum of antitumor activity. it is used in the treatment of advanced gastrointestinal neoplasms. over 5-fu, tegafur has the advantage of oral administration and less hematologic toxicity. gastrointestinal toxicity is its main dose-limiting factor. the cutaneous adverse effects of tegafur include mucositis, photosensitivity, diffuse or nail-restricted hyperpigmentation, palmoplantar erythrodysesthesia syndrome, palmoplantar keratoderma, sclerodactyly and raynaud phenomenon. we report here the case of a patient who developed acral hyperpigmentation during treatment with tegafur. case report a 48-year-old woman, phototype v, with an advanced rectal adenocarcinoma stage c (duke’s classification) diagnosed in december 2009, who developed acral hyperpigmentation during tegafur intake. radio-therapy and chemotherapy (including tegafur) were initiated as neoadjuvant agents followed by rectal anterior resection. tegafur (500 mg/d) was reintroduced one month after surgery. four months later, the patient appeared with multiple 2-10 mm round and oval-shaped brown macules on the face (figure 1), tongue (figure 2a), hands, soles and nails. almost all nails were involved, and longitudinal melano-nychia was identified in the 2nd e 3rd fingernails of her right hand (figure 2b). the skin biopsy revealed mild basal pigmentation. the diagnosis of tegafur-induced hiperpigmentation was made. one month after discontinuation of tegafur, the hyperpigmented acral lesions began to clear. discussion the cutaneous adverse effects of tegafur include mucositis, photosensitivity, diffuse or nail-restricted hyperpigmentation, palmoplantar erythrodysesthesia syndrome, palmoplantar keratoderma, sclerodactyly and raynaud phenomenon1-4. hyperpigmentation of the skin, mucosa and nails is a side effect associated with various chemotherapy drugs, including 5fu and its prodrugs.5 the time course of tegafur therapy, the cutaneous reaction and its clearance after discontinuing the treatment suggest a causal relationship based on chronological criteria. the cause of such pigmentation is unknown, although there may be a mechanism common to other chemotherapy drugs. these substances may increase pigmentation by direct or msh-mediated stimulation of melanocytes.6 in 1991, llistosella et col. proposed a mixed mechanism involving melanocyte hyperplasia and a decreased keratinocyte turnover, as basal pigmentation and dermal melanophages were observed histologically.1 clinicians should be aware of this side effect of tegafur, since it is being increasingly used in patients with advanced colon cancer. references 1. llistosella e, codina a, alvarez r, et al. tegafur-induced acral hyperpigmentation. cutis 1991;48: 205-7. 2. rios-buceta l, buezo gf, peñas pf, et al. palmo-plantar erythrodysaesthesia syndrome and other cutaneous side-effects after treatment with tegafur. acta derm venereol 1996;77:80-1. 3. jucglà a, sais g, navarro m, et al. palmoplantar keratoderma secondary to chronic acral erythema due to tegafur. arch dermatol 1995; 131:364-5. 4. seishima m, izumi t, kanoh h. raynaud’s phenomenon possibly induced by a compound drug of tegafur and uracil. eur j dermatol 2000;10:55-8. 5. revenga f. cutaneous side-effects caused by tegafur. int j dermatology 1999;38: 955-6. 6. fukushima s, hatta n. atypical moles in patient undergoing chemotherapy with oral 5-fluorouracil prodrug. br j dermatol 2004;151:698-700. dermatology reports 2011; volume 3:e30 correspondence: vera teixeira, serviço de dermatologia, hospitais da universidade de coimbra, praceta mota pinto, 3000-075 coimbra, portugal. e-mail: verafmup@hotmail.com key words: tegafur, 5-fluorouracil, acral hyperpigmentation. received for publication: 23 august 2011. accepted for publication: 24 august 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright v. teixeira et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e30 doi:10.4081/dr.2011.e30 figure 1. brown macules on the face. figure 2. hyperpigmentation on the tongue (a) and longitudinal melanonychia in the 2nd e 3rd fingernails (b). a b no nco mm er cia l u se on ly dr [dermatology reports 2011; 3:e36] [page 77] ellagic acid inhibits melanoma growth in vitro j. daniel jensen,1 jeffrey h. dunn,1 yuchun luo,1 weimin liu,1 mayumi fujita,1,2 robert p. dellavalle1,2 1department of dermatology, school of medicine, university of colorado denver, aurora; 2denver veterans’ affairs medical center, denver, co, usa abstract ellagic is a polyphenolic compound with anti-fibrotic and antioxidant properties, and exhibits antitumor properties against various cancer cells in vitro. there are few studies, however, which examine the effects of ellagic acid on melanoma. in the present study, we observe effects of ellagic acid on melanoma cells in vitro. three metastatic melanoma cell lines (1205lu, wm852c and a375) were examined to determine the effects of ellagic acid on melanoma cell viability, cell-cycle, apoptosis, nf-κβ activity, and il-1β & il-8 secretion. cell viability assays demonstrated that ellagic acid possesses an inhibitory effect on cell proliferation at concentrations between 25 and 100 mm. in addition, ellagic acid promoted g1 cell cycle arrest, increased levels of apoptosis and decreased synthesis of il-1β and il-8 in melanoma cells. ellagic acid also decreased nf-κβ activity, suggesting at least one potential mechanism by which ellagic acid may exert its effects in melanoma cells. our findings support further investigation into prospective roles for ellagic acid as a therapeutic, adjuvant, or preventive agent for melanoma. introduction ellagic acid (ea) is a polyphenolic compound found in various types of fruit, including berries, pomegranates, and nuts, and is becoming a popular dietary supplement. it possesses antifibrotic,1,2 antiproliferative,3,4 and antitumorigenic5,6 properties. ea is known to be protective against several types of cancer. ea has been shown to induce apoptosis in human melanoma cells in vitro.7 few studies have investigated the effects of ea on melanoma, however, and the mechanistic action of ea in this setting is not well defined. in vitro studies have shown that ea decreases tyrosinase activity in mouse melanoma cells by chelating the copper tyrosinase cofactor.8 we are not aware of any other studies that have defined a mechanism by which ea exerts its effects in melanoma. the exact mechanism by which ea exerts its effects in other types of cancer is also unclear, but several potential mechanisms have been suggested. ea has been shown to modulate a variety of signaling pathways in cancer cells, including nf-κb, inos, and wnt. alternative mechanisms through which ea exerts anticancer effects have also been proposed. one group9 showed that ea prevented copper and catecholamine transmitter-mediated oxidative dna damage, thus suggesting a protective role for ea in preventing reactive oxygen species production, lipid peroxidation, and dna strand breaks. ea has also been shown to induce apoptosis via caspase pathways as well as potentiating trans-retinoic acid-mediated cell-differentiation on human leukemia cell lines.10 another study showed that ea inhibits components of wnt signaling pathways known to play a pivotal role in human colon carcinogenesis.11 additionally, ea has been shown to reduce hepatic phase i cyp enzymes responsible for converting estrogen to harmful metabolites implicated in mammary tumorigenesis.12 ea has been shown to downregulate inos, cox-2, tnf-a and il-6 secretion by inhibiting nuclear factor-kappa β (nf-κβ) in colon and pancreatic cancers.13 pomegranate fruit extracts (including ea) decrease nf-κβ expression in uvb-stimulated keratinocytes, decreasing skin tumorigenesis.14,15 here we report on the effect of ea on melanoma cells, including inhibition of the nf-κb pathway. materials and methods tissue culture human metastatic melanoma cell lines (1205lu, wm852c and a375) were cultured in rpmi 1640 medium (gibco brl, gaithersburg, maryland, usa) supplemented with 10% fetal bovine serum (fbs, gemini bio-products, inc., woodland, ca, usa) and antibiotics (penicillin (10,000 iu/ml), streptomycin (10,000 iu/ml), and amphotericin b (25 microg/ml, cellgro, manassas, va, usa) and were incubated at 37°c and 5% co2. ellagic acid treatment ea was obtained from (mp biochemicals, solon, oh, usa) and dissolved in sterile dmso (5 mm) and stored at -20°c. separate, fresh 100 ml aliquots of ea were used for each experiment and excess reagent was disposed of according to protocol. cell titer 96 aqueous one solution cell proliferation assay (mts assay) for the quantification of cell viability experiments were performed according to the manufacturer’s instructions (promega, madison, wi, usa). approximately 2.5¥103 cells were seeded in 96-well plates and incubated at 37c° and 5% co2 for 1 day. ea was added to cells in 0, 25, 50 and 100 mm concentrations and cells were incubated for 24, 48 and 72 h under previously described conditions. mts reagent was added to the cells and incubated for 1 h, followed by spectophotometric analysis using an elx808 ultra microplate reader (bio-tek instruments, inc., winooski, vt, usa) and kcjunior v. 1.10 software (biotek instruments). annexin v apoptosis detection assay an annexin-fitc apoptosis detection kit (bd biosciences pharmingen, san diego, ca, usa) was used, following the manufacturer’s instructions; 4¥105 cells were seeded in 10 cm plates and incubated for 24 h. cells were treated with ellagic acid in dmso at 0, 25, 50 and 100 mm concentrations. cells were incubated as previously described for 72 h and stained with annexin v antibodies and pi. samples were analyzed by the facs core using a beckman coulter fc500 flow cytometer (beckman coulter). apoptotic cells were defined as being positive for annexin v. cell cycle analysis 4¥105 cells were seeded on 10 cm tissue culture dish and incubated overnight prior to treatment with ea. cells were treated with 0 or 50 mm ea and incubated at 37°c for 48 h. cells were then detached from the plate, stained with propidium iodide (pi) and allowed to incubate overnight at 4°c. cells were then analyzed with by the university of colorado denver fluorescent activated cell sorting (facs) core using a beckman coulter fc500 flow cytometer (beckman coulter inc, brea, ca, usa). dermatology reports 2011; volume 3:e36 correspondence: robert p. dellavalle, chief, dermatology service, department of veteran affairs medical center, 1055 clermont street, box 165 denver, co 80220, usa. tel. +1.303.399.8020, ext. 2475 fax: +1.303.393.4686. e-mail: robert.dellavalle@ucdenver.edu key words: ellagic acid, melanoma, nf-κb, il-1β, il-8. received for publication: 27 august 2011. accepted for publication: 31 august 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright j.d. jensen et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e36 doi:10.4081/dr.2011.e36 no nco mm er cia l u se on ly [page 78] [dermatology reports 2011; 3:e36] nf-κβ luciferase reporter assay 2.5x103 cells were seeded into 24-well plates and were transfected after 12 h of incubation. transfection with pnfκβ-metluc2 reporter vector (clontech, mountain view, ca, usa) was performed according to protocol described by the lipofectamine 2000 kit (invitrogen, carlsbad, ca, usa). cells were then treated with 0, 25, 50 and 100 mm ea and incubated for 24 or 48 h. luminescence was then measured with a luminometer (promega, madison, wi, usa). measurement of gene expression (il-1β, il-8) 1205lu metastatic melanoma cells were seeded and incubated for 24 h under previously described conditions. cells were then treated with 0 or 50 mm ea for 48 h. cells were detached from culture dishes and rna was extracted from treated and untreated cells using the rnaqueous-micro kit (ambion, austin, tx, usa), and subsequently reverse transcribed using random primers and mmlv reverse transcriptase (promega, madison, wi, usa). realtime quantitative reserve transcription-pcr (qrt-pcr) was performed with power sybr green pcr master mix (applied biosystems, foster city, ca, usa) on the mx3000p pcr system (strategene, la jolla, ca, usa). primers were designed to generate a pcr product of 50 to 150 bp. thermal cycling conditions were 95°c for 10 min followed by 42 cycles of 15 s at 95°c, 1 min at 60°c. gapdh was used as a control to normalize the results. statistical analysis the viabilities of each treated cell line were compared to control was evaluated using a student’s t-test. values of p <0.05 were considered to be statistically significant. results melanoma cell viability is inhibited by ellagic acid cells were incubated with different concentrations of ea for 24, 48, and 72 h and cell viability was measured using the mts assay (figure 1a, b). inhibition of cell growth was detected as early as 24 h at 50 and 100 mm concentrations ea for 1205lu cells (p<0.01 and p<0.05, respectively) and at 25, 50, and 100 µm concentrations ea for wm852c cells (p <0.05, p<0.05 and p <0.01, respectively). ea continued to inhibit cell growth for a 72 h period at 25, 50 and 100 mm concentrations (p <0.05, p<0.01 or p<0.001 for all data points measured). ellagic acid induces apoptosis in melanoma cell lines decreased viability is caused by cell death and/or decreased cell growth. in order to determine if ea exerted a proapoptotic effect in metastatic melanoma, three cell lines (1205lu, wm852c, a375) were incubated in 25, 50 and 100 mm concentrations of ea for 72 h (figure 2a). after staining for the apoptotic marker annexin v, cell lines were sorted with flow cytometry. 1205lu cells demonstrated increased apoptosis when compared to controls at 50 and 100 mm (p<0.01 and 0<0.001, respectively). furthermore, both wm852c and a375 cell lines had increased levels of apoptotic cells at 100 mm concentrations ea (p <0.05). in general, there was a trend toward increased apoptosis with increasing concentrations of ea. ellagic acid induced g1 cell cycle arrest in order to determine if ea inhibited cell proliferation via cell cycle arrest, wm852c cells were incubated for 48 h in 50 mm ea. after staining, cells were sorted according to the phase of their cell cycle (figure 2b). cell cycle analysis of wm852c cells in g1 phase suggested disruption of cellular replication (p<0.01), suggesting that ea inhibited melanoma cell proliferation via g1 cell cycle arrest. ellagic acid downregulates nf-κβ activity in metastatic melanoma cells several studies reported that ea modulates the nf-κβpathway in cancer cells, therefore nfκβ activity and expression in ea-treated cells was compared to untreated controls (figure 3a, b). at 24 h, nf-κβ expression was decreased in both cell lines for all concentrations tested except for 25 mm in 1205lu (for 1205lu, p<0.001 for 50 and 100 mm concentrations; for wm852, p <0.01 for 50 mm, p <0.001 for 25 and 100 mm ea). at 48 h, there was decreased expression of nf-κβ with ea treatment at 25, 50 and 100 mm (for 1205lu, p <0.01 for all concentrations; for wm852, p <0.05, p<0.01 and p<0.01 for 25, 50 and 100 mm ea, respectively). ellagic acid decreases synthesis of il-1β and il-8 in metastatic melanoma cells downstream effectors of the nf-κβ pathway which control cell proliferation and apoptosis were measured using quantitative rt-pcr. as indicated in figure 4, mrna coding for il-1β and il-8 8 were significantly decreased (p<0.05) by treatment with ea. discussion this study suggests that ea induces apoptosis and g1 cell cycle arrest in melanoma cells at in vitro concentrations between 25 and 100 mm. inhibition of the nf-κβ pathway was also shown to be a potential mechanism by which ea exerts its antiproliferative effects. the nfκβ pathway frequently plays a central role in the pathogenesis of many types of cancer, and therapeutic modalities which target the nf-κβ pathway and its downstream intermediates are under investigation. dysregulation of the nf-κβ pathway in the article figure 1. cell growth over time with different concentrations of ea. a) wm852c and b) 1205lu cells were incubated with different concentrations of ea for 24, 48, and 72 h and cell viability was measured using mts assay. figure 2. a) apoptotic cells at 72 h. three cell lines (1205lu, wm852c, a375) were incubated in 25, 50 and 100 mm concentrations of ea for 72 h. after staining for the apoptotic marker annexin v, cell lines were then sorted with flow cytometry. b) cell cycle analysis. wm852c cells were incubated for 48 h in 50 mm ea. after staining, cells were sorted according to the phase of their cell cycle. a b a bno nco mm er cia l u se on ly [dermatology reports 2011; 3:e36] [page 79] setting of melanoma, a particularly treatmentresistant malignancy, is very common. inhibition of nf-κβ has been explored as a potential therapeutic strategy against melanoma with positive results.16 for example, nf-κβ upregulation has been shown to promote angiogenesis in melanoma,17 a key mechanism in tumor growth and maintenance. nf-κβ also increases the rate of melanoma metastasis.18 conversely, suppression of nf-κβ attenuates the invasive potential of tumors.19 further evidence of the importance of the nf-κβ pathway in melanoma is that ablation of an upstream effector of the nfκβ pathway, ikappaβ kinase beta (ikκβ), inhibits melanoma tumorigenesis20 and increased susceptibility to chemotherapy.21 furthermore, p53 is inversely related to nf-κβ expression,22 and p53-mediated g1 cell cycle arrest may result from downregulation of nfκβ in cancer cell.4 these findings support a potential role for ea as a therapeutic, adjuvant, or preventive agent for melanoma. future work, however, should address the limitations of this study. while our data shows some evidence that ea treatment is associated with increased cellcycle arrest and apoptosis, as well as decreased melanoma cell viability and nf-κβ activity, these results were not obtained in the presence of a vehicle control. follow up work is therefore indicated to determine if ea specifically inhibits melanoma through the pathways observed in this study. furthermore, the concentrations of ea used in our study are higher than levels that are generally sustainable by normal consumption of ea-containing foods (typically ranging from 5-15 mm.23,24 while the use of higher doses of ea as an adjuvant to other therapies may prove to be of some benefit to patients it is not clear from these results if ea may exert therapeutic benefits at practical dietary doses. references 1. thresiamma kc, kuttan r. inhibition of liver fibrosis by ellagic acid. indian j physiol pharmacol 1996;40:363-6. 2. devipriya n, sudheer ar, srinivasan m, menon vp. effect of ellagic acid, a plant polyphenol, on fibrotic markers (mmps and timps) during alcohol-induced hepatotoxicity. toxicol mech methods 2007;17:349-56. 3. losso jn, bansode rr, trappey a 2nd, et al. in vitro anti-proliferative activities of ellagic acid. j nutr biochem 2004;15:6728. 4. narayanan ba, geoffroy o, willingham mc, et al. p53/p21(waf1/cip1) expression and its possible role in g1 arrest and apoptosis in ellagic acid treated cancer cells. cancer lett 1999;136:215-21. 5. mukhtar h, das m, khan wa, et al. exceptional activity of tannic acid among naturally occurring plant phenols in protecting against 7,12 dimethylbenz(a)anthracene-, benzo(a)pyrene-, 3-methylcholanthrene-, and n-methyl-n-nitrosourea-induced skin tumorigenesis in mice. cancer res 1988;48:2361-5. 6. kowalczyk mc, kowalczyk p, tolstykh o, et al. synergistic effects of combined phytochemicals and skin cancer prevention in sencar mice. cancer prev res (phila) 2010;3:170-8. 7. kim s, liu y, gaber mw, et al. development of chitosan-ellagic acid films as a local drug delivery system to induce apoptotic death of human melanoma cells. j biomed mater res b appl biomater 2009; 90:145-55. 8. shimogaki h, tanaka y, tamai h, masuda m. in vitro and in vivo evaluation of ellagic acid on melanogenesis inhibition. int j cosmet sci 2000;22:291-303. 9. spencer wa, jeyabalan j, kichambre s, gupta rc. oxidatively generated dna damage after cu(ii) catalysis of dopamine and related catecholamine neurotransmitters and neurotoxins: role of reactive oxygen species. free radic biol med 2010; 50:139-47. 10. hagiwara y, kasukabe t, kaneko y, et al. ellagic acid, a natural polyphenolic compound, induces apoptosis and potentiates retinoic acid-induced differentiation of human leukemia hl-60 cells. int j hematol 2010;92:136-43. 11. sharma m, li l, celver j, et al. effects of fruit ellagitannin extracts, ellagic acid, and their colonic metabolite, urolithin a, on wnt signaling. j agric food chem 2009; 58:3965-9. 12. aiyer h, gupta rc. berries and ellagic acid prevent estrogen-induced mammary tumorigenesis by modulating enzymes of estrogen metabolism. cancer prev res (phila) 2010;3:727-37. 13. umesalma s, sudhandiran g. differential inhibitory effects of the polyphenol ellagic acid on inflammatory mediators nfkappab, inos, cox-2, tnf-alpha, and il-6 in 1,2-dimethylhydrazine-induced rat colon carcinogenesis. basic clin pharmacol toxicol 2010;107:650-5. 14. afaq f, malik a, syed d, et al. pomegranate fruit extract modulates uv-b-mediated phosphorylation of mitogen-activated protein kinases and activation of nuclear factor kappa b in normal human epidermal keratinocytes paragraph sign. photochem photobiol 2005;81:38-45. 15. afaq f, saleem m, krueger cg, et al. anthocyaninand hydrolyzable tannin-rich pomegranate fruit extract modulates mapk and nf-kappab pathways and inhibits skin tumorigenesis in cd-1 mice. int j cancer 2005;113:423-33. 16. czyz m, lesiak-mieczkowska k, kopro wska k, et al. cell context-dependent activ article figure 3. expression of nf-κβ after ea treatment. a plasmid containing a luciferase reporter gene under the control of nf-κβ was transfected into wm852c (a) and 1205lu cells (b) and measured after 24 hours incubation. figure 4. expression of il-1β and il-8 cytokines after ea treatment. metastatic melanoma cells were seeded and incubated for 24 h. cells were then treated with 0 or 50 mm ea for 48 h. rna was extracted from treated and untreated cells and measured by qrt-pcr. gapdh was used as a control. *p <0.05 a b no nco mm er cia l u se on ly [page 80] [dermatology reports 2011; 3:e36] ities of parthenolide in primary and metastatic melanoma cells. br j pharmacol 2010;160:1144-57. 17. karst am, gao k, nelson cc, li g. nuclear factor kappa b subunit p50 promotes melanoma angiogenesis by upregulating interleukin-6 expression. int j cancer 2009;124:494-501. 18. wu fh, yuan y, li d, et al. endothelial cellexpressed tim-3 facilitates metastasis of melanoma cells by activating the nfkappab pathway. oncol rep 2010;24:693-9. 19. kim a, kim mj, yang y, et al. suppression of nf-kappab activity by ndrg2 expression attenuates the invasive potential of highly malignant tumor cells. carcinogenesis 2009;30:927-36. 20. yang j, splittgerber r, yull fe, et al. conditional ablation of ikkb inhibits melanoma tumor development in mice. j clin invest 2010;120:2563-74. 21. amschler k, schon mp, pletz n, et al. nfkappab inhibition through proteasome inhibition or ikkbeta blockade increases the susceptibility of melanoma cells to cytostatic treatment through distinct pathways. j invest dermatol 2010;130: 1073-86. 22. rasmussen mk, iversen l, johansen c, et al. il-8 and p53 are inversely regulated through jnk, p38 and nf-kappab p65 in hepg2 cells during an inflammatory response. inflamm res 2008;57:329-39. 23. mertens-talcott su, jilma-stohlawetz p, rios j, et al. absorption, metabolism, and antioxidant effects of pomegranate (punica granatum l.) polyphenols after ingestion of a standardized extract in healthy human volunteers. j agric food chem 2006;54:8956-61. 24. seeram np, lee r, heber d. bioavailability of ellagic acid in human plasma after consumption of ellagitannins from pomegranate (punica granatum l.) juice. clin chim acta 2004;348:63-8. article no nco mm er cia l u se on ly dr [dermatology reports 2011; 3:e44] [page 99] wegener´s granulomatosis in a young patient preceded by localized cutaneous manifestations jesper smit,1 jakob lykke poulsen,2 jakob sølling,3 carsten sauer mikkelsen4 1department of infectious diseases, aalborg hospital, aarhus university hospital, aalborg; 2department of internal medicine, lillebaelt hospital, vejle; 3department of nephrology, aalborg hospital, aarhus university hospital, aalborg; 4private practice, bredgade 13, broenderslev, denmark abstract wegener’s granulomatosis (wg) is a rare, systemic vasculitis involving multiple organs. the clinical presentation is highly diverse, and there is considerable risk of mortality if diagnosis and treatment are delayed. we present a case illustrating that patients with wg may initially present with localized cutaneous symptoms and signs. introduction wegener’s granulomatosis (wg) is an uncommon necrotizing vasculitis that most commonly affects the upper airways, lungs and kidneys, but can involve any other organ.1,2 the disease presents with varying symptoms and signs and early recognition and initiation of adequate immunomodulatory therapy are essential in limiting the potentially life-threatening aspects of the disorder.1,3-4 we report a case illustrating that wg may present with localized, cutaneous manifestations preceding systemic disease. case report an 18-year old caucasian man presented with a painful rash on the truncus that had developed over the course of a few weeks. the patient was known to have type-1 diabetes mellitus since the age of 8, but was otherwise healthy and reported no recent travel activity or antecedent trauma to the affected area. objective examination of the skin revealed inflamed cystic and nodular lesions confined to the chest and left shoulder, but there was no significant suppuration or other apparent signs of infection. the condition resembled a case of severe acne, and initial histopathological examination of a skin biopsy supported this preliminary clinical diagnosis. a few weeks later the patient developed a sore throat and signs of upper respiratory tract infection including cough, dyspnoea and mild chest pain. the skin changes remained limited to the chest and shoulder but had clearly progressed and now appeared as deep vasculitic ulcerations, including multiple elements more than 0.5 cm deep (figure 1). these findings and symptoms were accompanied by several weeks of fever (up to 39.6°c), malaise and substantial unilateral facial pain, and the patient was admitted to a department of nephrology for further investigation and treatment. the blood leukocyte and thrombocyte counts were normal as were liver and renal function tests, but c-reactive protein (crp) was 300 mg/l (normal range, less than 10 mg/l) and anti-neutrophil cytoplasmic antibodies including specific identification of proteinase 3 (canca/pr3-anca) was 223 ku/l (normal range, less than 7 ku/l). during hospitalization the patient’s kidney function was continually assessed and monitored, but levels of creatinine and urea remained within normal ranges and examination of urine including microbiological analysis revealed no abnormalities. chest x-ray examination was performed and several lung infiltrates with caverns were noted. a subsequent ct guided lung biopsy demonstrated no sign of infection, but significant inflammation of the tissue was observed, and a diagnosis of wg with concomitant mononeuritis multiplex involving the trigeminal nerve was established. the patient received systemic methylprednisolone and cyclofosfamide pulse therapy, which resulted in prompt improvement of the clinical condition and skin lesions as well as a decrease in the crp and anca titers. shortly after, however, the patient developed fever and renewed elevation of the c-anca/pr3-anca, and treatment was supplemented with rituximab leading to immediate resolution of symptoms and no residual pulmonary or cutaneous sequelae on recent follow-up. discussion our patient initially presented with a localized rash on the truncus, but his condition was insidiously complicated by malaise, fever and progression of the cutaneous lesions, and ultimately a diagnosis of systemic wg was established. the etiology of the disease remains unknown, however, several studies suggest that infectious antigens and especially s. aureus may contribute to the pathogenesis of vasculitis in susceptible hosts.1,5 the clinical presentation of wg is complex and found to be dependent on the number of organs affected and the duration of the disease. as in our case, the clinical course of wg is characterized by an initial or localized phase which may affect any organ followed by a generalized or systemic phase in approximately 80% of cases.1,3 however, in most patients specific cutaneous findings develop concurrently or after the onset of systemic involvement and affect the head or extremities,5 but in our case they were confined to the truncus and preceded systemic symptoms and signs, which has only seldomly been described.6 in wg specific cutaneous lesions are seen in approximately 15% of cases,5,6 and are usually associated with renal disease and musculoskeletal affection, but this was not noted in our patient. patients may develop more than one type of cutaneous lesion and these may change over time or with treatment, but several studies have identified palpable purpura as the most characteristic cutaneous lesion, and nodules, papules, ulcerations and deep erythema nodusum-like subcutaneous nodules complete the clinical spectrum.6-8 oral involvement is not uncommon in wg,5,7 but this was not observed in our patient during the course of the disease. in this present case the level of c-a nca/pr3-anca was markedly elevated, and anca positivity has been found to occur in 9095% of cases with active wg.1,6 however, as levels correlate with disease activity and relapses dermatology reports 2011; volume 3:e44 correspondence: jesper smit, department of infectious diseases, aalborg hospital, aarhus university hospital, mølleparkvej 4, p.o. box 365, dk-9000 aalborg, denmark. tel: +45.26241332. e-mail: jesm@rn.dk key words: wegener’s granulomatosis, cutaneous findings, case report, vasculitis, diabetes. contributions: js, jlp, js, csm, manuscript writing and text reviewing. conflict of interest: the authors have no conflict of interest. the manuscript has not been published and is not being considered for publication elsewhere. received for publication: 14 september 2011. accepted for publication: 22 september 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright j. smit et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e44 doi:10.4081/dr.2011.e44 no nco mm er cia l u se on ly [page 100] [dermatology reports 2011; 3:e44] in the absence of anca are rare, repeat testing and evaluation of blood biochemistry in order to follow the course of the disease is highly recommended. as illustrated by our case the diagnosis of wg represents a challenge and is based on anamnestic information closely correlated with clinical features, pathologic findings and anca testing.9 relevant differential diagnoses are numerous and include leukocytoclastic vasculitis, henoch-schönlein purpura, pyoderma gangrenosum, lymphoma, erythema nodosum, rheumatoid arthritis, drug reactions, and a variety of infectious conditions.5 however, like wg, these conditions often present with varying and uncharacteristic symptoms and signs and, as in our case, dermatological evaluation may provide valuable diagnostic information. if untreated, systemic wg leads to more than 90% mortality in the first two years, hence early recognition and initiation of adequate immunomodulatory treatment are essential and associated with significantly decreased morbidity and mortality.1,4,10 high dose corticosteoroids and pulsed intravenous cyclofosfamide remain the mainstay of initial therapy,4 but relapse and refractory wg still represent therapeutic challenges. however, data from recent studies evaluating biological therapies, including tnf-α blockers (infliximab) and monoclonal antibodies (rituximab) are promising1,4 and future treatment regimes will hopefully further improve the outcome of this patient group.4 we report a case illustrating that patients with wg may initially present with localized cutaneous symptoms and signs preceding serious systemic disease. prompt recognition of the condition and initiation of early and adequate immunomodulatory therapy is crucial in order to reduce mortality and morbidity. dermatologists therefore need to be aware of wg as a possible differential diagnosis, especially in patients presenting with characteristic skin manifestations and accompanying systemic symptoms and signs. references 1. schilder am. wegener´s granulomatosis vasculitis and granuloma. autoimmun rev 2010;9:483-7. 2. koldingsnes w, nossent h. epidemiology of wegener´s granulomatosis in northern norway. arthritis rheum 2000;43:2481-7. 3. rodrigues ce, callado mr, nobre ca, et al. wegener´s granulomatosis: prevalence of the initial clinical manifestations – report of six cases and review of the literature. rev bras reumatol 2010;50:150-64. 4. carruthers d, sherlock j. evidence-based management of anca vasculitis. best pract res clin rheumatol 2009;23:367-78. 5. gibson le, specks u, homburger h. clinical utility of anca tests for the dermatologist. int j dermatol 2003;42:859-69. 6. comfere ni, macaron nc, gibson le. cutaneous manifestations of wegener´s granulomatosis: a clinicopathologic study of 17 patients and correlation to antineutrophil cytoplasmic antibody status. j cutan pathol 2007;34:739-47. 7. marzano av, fanoni d, berti e. oral and cutaneous findings are valuable diagnostic aids in wegener´s granulomatosis. eur j intern med 2010;21:49. 8. barksdale sk, hallahan cw, kerr gs, et al. cutaneous pathology in wegener´s granulomatosis. a clinicopathologic study of 75 biopsies in 46 patients. am j surg pathol 1995;19:161-72. 9. leavitt ry, fauci as, bloch da, et al. the american college of rheumatology 1990 criteria for the classification of wegener´s granulomatosis. arthritis rheum 1990;33: 1101-7. 10. takala jh, kautiainen h, leirisalo-repo m. survival of patients with wegener´s granulomatosis diagnosed in finland in 1981-2000. scand j rheumatol 2010;39:716. case report figure 1. cystic and nodular lesions on the chest, notice necrotic wounds with element size ranging from a few millimeters up to 2 cm. in consistence with vasculitis the elements are inflamed and do not blanch on pressure. no nco mm er cia l u se on ly dr [page 130] [dermatology reports 2011; 3:e57] combined cetuximab and volumetric modulated arc-radiotherapy in advanced recurrent squamous cell carcinoma of the scalp uwe wollina,1 andreas schreiber,2 knut merla,2 gunter haroske3 1department of dermatology and allergology, 2department of radiology, and 3institute of pathology georg schmorl, academic teaching hospital dresden-friedrichstadt, dresden, germany abstract a 77-year old male patient presented with an ulcerated exophytic tumor (t2, n0, m0) with three macroscopically visible satellite metastases in the right temporo-occipital region. mohs surgery could not control the disease due to lymphangiosis carcinomatosa and perineural infiltration, and recurrence of satellite skin metastases. re-staging demonstrated a t2, n1, m0 profile (stage iii, ajcc). chemotherapy was limited by the patient’s co-morbidities. therefore, we used targeted therapy with monoclonal anti-epidermal growth factor receptor antibody cetuximab in combination with volumetric modulated arcradiotherapy (vmat). cetuximab was well tolerated except for the loading dose when the patient developed fever chills. to verify the correct application of vmat, it was applied to a 3-dimensional measuring phantom prior to the patient’s first treatment session. to minimize these tolerances, patient set-up was checked and corrected by orthogonal fluoroscopic images recorded daily by the on-board imager used in our varian accelerator. the average daily beam time was 6 min (6 arcs, 767 monitor units); the total treatment time including patient set-up and set-up correction was less than 20 min. combined therapy was well tolerated and complete remission was achieved. introduction squamous cell carcinoma (scc) is one of the most important non-melanoma skin cancers (nmsc) because of its frequency and because it has a more aggressive course than basal cell carcinoma (bcc), the most common nmsc. scc development has been linked to chronic uv exposure with an odds ratio of 1.77.1 patient related incidence rates for cutaneous scc in germany has been estimated at 9.7 for females and 17.4 for males.2 higher incidence rates in europe have been reported for scotland (34.7)3 and spain.4 diagnosis of scc depends on clinical data and histopathology. tumor staging is dependent on tumor diameter, invasion into cranial bone, tumor thickness and invasion level, differentiation, perineural invasion and anatomic location. furthermore, regional lymph nodes and distant metastases have to be considered.5 the standard treatment of scc of the head and neck area is mohs surgery or delayed mohs. for advanced scc, radiation therapy is another therapeutic option.6,7 since conventional chemotherapy in head and neck scc (hnscc) of the mucous membranes is associated with significant toxicity, alternatives for cutaneous scc have emerged. a phase iii trial with bleomycin versus other chemotherapy protocols, and prospective observational studies using bleomycin, cisplatin, doxorubicin or oral 5-fluorouracil (5fu), had low rates of complete responses (033%) but significant adverse effects.8 interferon in combination with capecitabine (an oral prodrug of 5-fu) is effective in scc of the head and neck region9 and in the reduction of scc developing in transplant recipients.10 response rates of 100% and complete responses of up to 50% have been reported.9,10 advanced scc shows numerical aberrations in the epidermal growth factor-receptor (egfr) gene and overexpression of egf/egfr.11-14 therefore, targeted therapy against egf-receptor (egfr) would be another option. recently, monoclonal antibodies against egfr have become available, including gefitinib, erlotinib, cetuximab and panitumumab.15 cetuximab is a 152 kda chimeric igg1 monoclonal antibody of 65% human and 35% murine origin. it specifically binds to egfr at an extracellular epitope in the ligand-binding domain.16 pharmacokinetics of single and multiple doses have been extensively evaluated. the drug half-life is 70-100 h.17 there are encouraging data from hnscc using cetuximab in the treatment of recurrent or metastatic tumors, either alone or in combination with radiation or chemotherapy. response rates vary between 10-71%. since 2006, cetuximab is approved for use in combination with radiotherapy in patients with locally advanced hnscc.18-22 there are limited data available for cetuximab therapy in advanced cutaneous scc of the head and neck region.23-27 we present a patient who was successfully treated by cetuximab combined with radiation for locally advanced cutaneous scc of the scalp. case report a 77-year old male patient presented with a large tumor of the scalp that had grown over a period of more than 24 months. he suffered from arterial hypertonia, hyperlipidemia, hyperuricemia, and liver cirrhosis. on examination, we observed an ulcerated exophytic tumor (approx. 4 cm in diameter) with three macroscopically visible satellite metastases in the right temporo-occipital region (figure 1). we performed delayed mohs surgery for both the tumor and the metastases. the defect was covered by large transposition flaps leaving a central area that was closed with a full thickness skin graft. healing was unremarkable and complete (figure 2). histological examination of the species revealed a moderately differentiated scc (t2, n0, m0; stage ii, american joint committee on cancer (ajcc)) with lymphangiosis carcinomatosa, and perineural infiltration and satellitosis (figure 3). because of the age of the patient and his co-morbidities, we decided against further surgery but initiated a closer follow up. eight weeks later, the patient presented with ulcerated satellitosis in the frontal and right fronto-temporal area of the scalp. restaging demonstrated a t2, n1, m0 profile (stage iii, ajcc). the situation was not controllable by surgery. chemotherapy was limited by the patient’s co-morbidities. therefore, we decided to use targeted therapy with monoclonal anti-epidermal growth factor receptor (egfr) antibody cetuximab (erbitux®; bristol-meyers sqibb) in combination with radiotherapy. after the loading dose of 400 mg/m2, the patient dermatology reports 2011; volume 3:e57 correspondence: uwe wollina, department of dermatology and allergology, academic teaching hospital dresden-friedrichstadt, friedri chstrasse 41, 01067 dresden, germany. e-mail: wollina-uw@khdf.de. key words: advanced squamous cell carcinoma, cetuximab, volumetric modulated arc-therapy conflict of interest: the authors have no conflict of interest. received for publication: 20 october 2011. accepted for publication: 22 october 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright u. wollina et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e57 doi:10.4081/dr.2011.e57 no nco mm er cia l u se on ly [dermatology reports 2011; 3:e57] [page 131] received 250 mg/m2 once a week for six weeks. pre-medication consisted of 100 mg prednisolone i.v., 4 mg dimetindene maleate i.v., 50 mg ranitidine i.v. and 8 mg ondansetron p.o. cetuximab was well tolerated except for the loading dose when the patient developed fever chills. we gave him dimetinden maleate intravenously and lowered the infusion speed. there was a fast recovery within a couple of hours. from the second infusion onwards, no further adverse effects of this kind were observed. within the first week of monoclonal antibody treatment, the patient developed rosacea-like pustules on facial and neck skin. the reaction was scored grade ii according to the nci-ctc scoring system.28 these cutaneous lesions were treated with metronidazole gel and there was a marked improvement within two weeks. the tumor response was visible within the first two weeks of treatment. nodules became flat and no new nodules developed. the lymph node swelling disappeared. there was an almost complete clinical response at the end of cetuximab therapy. after two weeks of monotherapy, radiotherapy was added. irradiation was realized by volumetric modulated arc-therapy (vmat). in this irradiation technique, the gantry of the accelerator moves 360° around the patient. due to the use of a dynamic multileaf collimator, variable dose rates and variable gantry speeds, this technique allows the generation of a very complex dose distribution in one or two optimized arcs around the patient. through continuously modulating the applied dose, high doses to the entire tumor volume can be delivered while at the same time sparing normal healthy tissue. another major advantage of vmat is the dramatically shorter treatment time compared to all existing methods, including tomotherapy. in the application of this technique, the exact and reproducible set-up of the patient during every treatment session is of crucial importance. we used a custom-formed 1 cm thick thermoplastic head-mask for immobilization and fixation. this mask was lined inside with bolus material to shift the dose maximum in the superficial treatment area. the physical treatment plan was designed according to a proposal of skinner29 consisting of 3 non-coplanar arcs. this technique provides homogeneous dose distribution and target coverage but still results in a relevant dose to brain (mean dose 28 gy) and eyes. we modified this approach in order to improve the protection of brain and eyes: both article figure 1. initial presentation of cutaneous squamous cell carcinoma of the scalp with satellitosis. figure 2. clinical presentation nine days after after mohs surgery. figure 3. histological evaluation demonstrates (a) lymphatic and (b) perineural invasion (hematoxylin-eosin, x20). figure 4. improved treatment technique is based on 2 coplanar and 4 non-coplanar arcs. figure 5. image of one partial non-coplanar arc demonstrating the dose deposition mainly in a tangential direction to the target volume. a b figure 6. image of one partial non-coplanar arc demonstrating the dose deposition mainly in a tangential direction to the target volume. no nco mm er cia l u se on ly [page 132] [dermatology reports 2011; 3:e57] the non-coplanar arcs were divided into two partial arcs (figure 4). in summary, the dose deposition in the target volume is built up mainly by tangential irradiation (figure 5) and optimal sparing of all organs at risk is achieved (table 1, figure 6). to verify the correct application of this treatment plan, it was applied to a 3-dimensional measuring phantom (arccheck, sun nuclear corp., melbourne/fl, usa) prior to the patient’s first treatment session. this showed good agreement between calculated and measured dose distributions [gamma (3%, 3 mm) = 95.4]. additional checks were carried out to investigate influences of deviations in daily patient set-up or bolus attachment on the dose distribution, in target volume and organs at risk. all results demonstrated that a safe application of this treatment plan is guaranteed, taking account of the tolerance levels achievable in daily routine clinical practce. to minimize these tolerances, patient set-up was checked and corrected by orthogonal fluoroscopic images recorded daily by the on-board imager (obi) used in our varian accelerator. average daily beam time was 6 min (6 arcs, 767 monitor units). total treatment time, including patient set-up and set-up correction, was less than 20 min. radiotherapy was well tolerated and the patient achieved complete remission (figure 7). discussion advanced cutaneous scc has a risk of metastases and relapse. in a prospective analysis of 653 patients, tumor thickness more than 2mm and tumor size more than 6 mm are the major risk factors for these phenomena. other features characterizing high-risk cutaneous scc include poor differentiation, perineural or lympho-vascular infiltration, and bone invasion.5,30,31 article table 1. main values characterizing dose distribution in planning target volume and organs of risk. ptv volume > 95 % dose 92% brain maximum dose 17.2 gy spinal cord maximum dose 34.3 gy optic nerves (left/right) maximum dose 16.4/22.0 gy chiasma maximum dose 7.3 gy eyes (left/right) maximum dose 11.1/28.2 gy eye lenses (left/right) maximum dose 4.1/9.0 gy table 2. case reports of cutaneous squamous cell carcinoma treated with cetuximab. patients tumor site treatment outcome references 1. 92 yrs, male forehead cetuximab weekly cr for at least kim et al. 201123 for 3 months 10 months 2. 79 yrs, male back 3 cycles of cetuximab cr for at least miller et al. 201024 weekly for 4 weeks 26 months 3. 73 yrs, male scalp weekly cetuximab cr baumann et al. 200725 4. 71 yrs, female nose weekly cetuximab almost cleared 5. 67 yrs, male ear 7 weeks cetuximab cr, 3 months giacchero et al. 201127 and radiotherapy 6. 69 yrs, female nose 32 weeks cetuximab pr, > 18 months and radiotherapy 7. 72 yrs, male ear 7 weeks cetuximab cr, 5 months and radiotherapy 8. 79 yrs, male scalp 16 weeks cetuximab cr, >21 months and radiotherapy 9. 82 yrs, female infra-orbital 46 weeks cetuximab sd, 11 months 9. 69 yrs, male temple 11 weeks cetuximab pd 10. 57 yrs, male sacrum 9 weeks cetuximab pr, 6 months and radiotherapy 11. 78 yrs, male scalp 7 weeks cetuximab pr, not reported and radiotherapy 12. 24 yrs, female arm 12 weeks cetuximab pr; > 3 months arnold et al. 200926 12. 77 yrs, male scalp 6 weeks cetuximab cr, > 3 months present and radiotherapy figure 7. treatment course with cetuximab and radiotherapy. (a) relapse with multiple ulcerated satellites eight weeks after mohs surgery. (b) at the end of radiotherapy. ulcers were tumor free. (c) after three months. a b c no nco mm er cia l u se on ly [dermatology reports 2011; 3:e57] [page 133] we report a successful treatment of advanced cutaneous scc with regional lymphnode involvement of the scalp with the antiegfr drug cetuximab and radiation after primary surgery. there are limited data available in this indication for cutaneous scc despite approval for hnscc23-27 (table 2). a single phase ii trial performed in france has only been published as an abstract. thirty-six patients with advanced cutaneous scc were involved. cetuximab therapy alone was able to control the disease in 69% of patients making this well tolerated treatment of interest for elderly patients with scc.32 hnscc and cutaneous scc over-express egfr, a 170 kda transmembrane protein, linked to tumor progression and autonomous tumor cell growth. egfr signaling in the cell is mediated by three major pathways: ras-map kinases, pi3k-aktc, and scr-stat. response to cetuximab in these tumors has been associated to overexpression of signal transducers and activators of transcription (stat) gene stat5a and ephrin receptor gene epha2.33 cetuximab demonstrated in vitro antiproliferative activity, direct cytotoxicity, and the potentiation of chemoor radiotherapy18,19 in hnscc. in vitro studies using cell lines derived from cutaneous scc further substantiated these results. xenograft tumor models gave evidence for the anti-angiogenic, apoptotic and anti-proliferative activity of cetuximab.34 a great advantage of cetuximab compared to traditional chemotherapy is the fact that there is no additional hepatotoxicity.35 egfrinhibitors can induce skin reactions like papulopustular rash or periungual inflammation, compromised hair growth, skin dryness and itching. these types of adverse effects have been linked to better outcome in patients with colorectal cancer and targeted therapy against egfr.36 in a recent investigation, 49% of patients with hnscc developed a grade iii to iv radiation dermatitis with concurrent cetuximab.37 a possible explanation is the reduction of a major anti-oxidant enzyme, i.e. glucose-6phosphate dehydrogenase by cetuximab.38 in the present case, however, severe radiation dermatitis was not observed. other egfr inhibitors have been developed, such as erlotinib and gefitinib, but there are limited reports of experience with these drugs in cutaneous scc.8,33 radiotherapy was added with intention to cure. given this, a total dose of at least 60 gy in six weeks based on daily doses of 2.0 gy is necessary when using percutaneous irradiation.27 traditionally these lesions were treated by two different methods:39 by afterloaded iridium-192 skin moulds. unfortunately, this technique is very timeconsuming in terms of preparation, planning, quality assurance and implementation. additionally, it results in high doses to brain and optical structures, and the actually delivered dose may vary from the planned dose; most commonly combined photon-electron plans are used. this is technically very complex due to necessary shiftings of matchlines between different fields during the treatment course, and results in less conformal plans with large dose gradients in the target volume. therefore, studies using the application of helical tomotherapy were initiated to overcome these problems.40 in recent publications, volumetric modulated arc-therapy (vmat) has also been demonstrated to be an alternative option; it is clinically acceptable and comparable to tomotherapy.41 it provides significantly more homogeneous dose distribution and reduces high-dose regions in the brain to a larger degree than all conventional methods. an additional advantage is the short treatment time. in conclusion, the present case report and other reports from the literature (table 2) suggest that the combination of monoclonal egfr antibody and radiotherapy is effective in controlling advanced cutaneous scc with or without metastases in analogy to hnscc. the recent advances in radiotherapy offer an effective and well tolerated treatment option. in summary, vmat is an excellent method for total scalp irradiation comparable to helical tomotherapy. the treatment achieved a complete stable remission without major toxicities. references 1. schmitt j, seidler a, diepgen tl, bauer a. occupational ultraviolet light exposure increases the risk for the development of cutaneous squamous cell carcinoma: a systematic review and meta-analysis. br j dermatol 2011;164:291-307. 2. stang a, ziegler s, büchner u, et al. malignant melanoma and nonmelanoma skin cancers in northrhine-westphalia, germany: a patientvs. diagnosis-based incidence approach. int j dermatol 2007; 46:564-570. 3. brewster dh, bhatti lh, inglis jh, et al. recent trends in incidence of nonmelanoma skin cancer in the east of scotland, 1992-2003. br j dermatol 2007; 156:1295-300. 4. revenga arranz f, paricio rubio jf, mar vásquez salvado m, del villar sordo v. decriptive epidemiology of basal cell carcinoma and cutaneous squamous cell carcinoma in soria (north-east spain) 19982000: a hospital-based survey. j eur acad dermatol venereol 2004;18:137-41. 5. farasat s, yu ss, neel va, et al. a new american joint committee on cancer staging system for cutaneous squamous cell carcinoma: creation and rationale for inclusion of tumor (t) characteristics. j am acad dermatol 2011;64:1051-9. 6. ho t, byrne pj. evaluation and initial management of the patient with facial skin cancer. facial plast surg clin north am 2009;17:301-7. 7. jambusaria-pahlajani a, miller cj, quon h, et al. surgical monotherapy versus surgery plus adjuvant radiotherapy in highrisk cutaneous squamous cell carcinoma: a systematic review of outcomes. dermatol surg 2009;35:574-85. 8. cranmer ld, engelhardt c, morgan ss. treatment of unresectable and metastatic cutaneous squamous cell carcinoma. oncologist 2010;15:1320-8. 9. wollina u, hansel g, koch a, köstler e. oral capecitabine plus subcutaneous interferon alpha in advanced squamous cell carcinoma of the skin. j cancer res clin oncol 2005;131:300-4. 10. jirakulaporn t, endrizzi b, lindgren b, et al. capecitabine for skin cancer prevention in solid organ-transplanted recipients. clin transplant 2010;doi:10.1111/j. 1399-0012.2010.01348.x. 11. wollina u, prochnau d, hoffmann a, et al. vasoactive intestinal peptide and epidermal growth factor: co-mitogens or inhibitors of keratinocyte proliferation in vitro? int j mol med 1998;2:725-30. 12. maubec e, duvillard p, velasco v, et al. immunohistochemical analysis of egfr and her-2 in patients with metastatic squamous cell carcinoma of the skin. anticancer res 2005;25:1205-10. 13. schlauder sm, calder kb, moodyp, morgan mp. her2 and egfr expression in cutaneous spindle squamous cell carcinoma. am j dermatopathol 2007;29:559-63. 14. toll a, salgado r, yèbenes m, et al. epidermal growth factor receptor gene numerical aberrations are frequent in actinic keratoses and invasive cutaneous squamous cell carcinoma. exp dermatol 2010;19:151-3. 15. amini s, viera mh, valins w, berman b. nonsurgical innovations in the treatment of nonmelanoma skin cancer. j clin aesthetic dermatol 2010;3:20-34. 16. goldstein ni, prewett m, zuklys k, et al. biological efficacy of a chimeric antibody to the epidermal growth factor receptor in a human tumor xenograft model. clin cancer res 1995;1:1311-8. 17. humbert y. cetuximab: an igg1 monoclonal antibody for the treatment of epidermal growth factor receptor-expressing tumours. expert opin pharmacother 2004; article no nco mm er cia l u se on ly [page 134] [dermatology reports 2011; 3:e57] 5:1621-33. 18. specenier p, vermorken jb. cetuximab in the treatment of squamous cell carcinoma of the head and neck. expert rev anticancer ther 2011;11:511-4. 19. harrington kj, kazi r, bhide sa, et al. novel therapeutic approaches to squamous cell carcinoma of the head and neck using biologically targeted agents. indian j cancer 2010;47:248-59. 20. tejani ma, cohen rb, mehra r. the contribution of cetuximab in the treatment of recurrent and/or metastatic head and neck cancer. biologics targets therapy 2010;4:173-85. 21. dequanter d, shala m, paulus p, lothaire p. cetuximab in the treatment of head and neck cancer: preliminary results outside clinical trials. cancer management res 2010;2:165-8. 22. ho c. cetuximab in locally advanced headand-neck cancer: defining the population. curr oncol 2010;17:48-51. 23. kim s, eleff m, nicolaou n. cetuximab as primary treatment for cutaneous squamous cell carcinoma to the neck. head neck 2011;33:286-8. 24. miller k, sherman w, ratner d. complete clinical response to cetuximab in a patient with metastatic cutaneous squamous cell carcinoma. dermatol surg 2010;36:206974. 25. bauman je, eaton kd, martins rg. treatment of recurrent squamous cell carcinoma of the skin with cetuximab. arch dermatol 2007;143:889-92. 26. arnold aw, bruckner-tuderman i, zuger c, itin ph. cetuximab therapy of metastasizing cutaneous squamous cell carcinoma in a patients with severe recessive dystrophic epidermolysis bullosa. dermatology 2009;219:80-3. 27. giacchero d, barrière j, benezery k, et al. efficacy of cetuximab for unresectable or advanced cutaneous squamous cell carcinoma a report of eight cases.clin oncol (r coll radiol) 2011; 23: 716-8. 28. national cancer institute common terminology criteria for adverse events version 4.0. available at: http://evs.nci.nih.gov/ftp1/ctcae/ctcae_ 4 . 0 2 _ 2 0 0 9 0 9 1 5 _ q u i c k reference_8.5x11.pdf pages 73-74. 29. skinner m. 2010. available at: http://my.varian.com/files/varian%20aapm % 2 0 u s e r s % 2 0 m e e t i n g % 2 0 2 0 1 0 % 2 0 %20skinner.pdf 30. brantsch kd, meisner c, schönfisch b, et al. analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study. lancet oncol 2008;9:713-20. 31. jennings l, schmults cd. management of high-risk cutaneous squamous cell carcinoma. j clin aesthet dermatol 2010;3:3948. 32. maubec e, petrow p, duvillard p, et al. cetuximab as first-line monotherapy in patients with unresectable squamous cell carcinoma: final results of a phase ii mutlicenter study [abstract]. j clin oncol 2010;28:8510. 33. kotoula v, lambaki s, televantou d, et al. stat-related profiles are associated with patient response to targeted treatments in locally advanced scchn. translation oncol 2011;4:47-58. 34. galer ce, corey cl, wang z, et al. dual inhibition of epidermal growth factor receptor and insulin-like growth factor receptor i: reduction of angiogenesis and tumor growth in cutaneous squamous cell carcinoma. head neck 2011;33:189-98. 35. pessaux p, panaro f, casnedi s, et al. targeted molecular therapies (cetuximab and bevacicumab) do not induce additional hepatotoxicity: preliminary results of a case-control study. eur j surg oncol 2010:36:575-82. 36. lacouture me, melosky bl. cutaneous reactions to anticancer agents targeting the epidermal growth factor receptor: a dermatology-oncology perspective. skin therapy lett 2007;12:1-5. 37. giro c, berger b, bölke e, et al. high rate of severe radiation dermatitis during radiation therapy with concurrent cetuximab in head and neck cancer: results of a survey in eortc institutes. radiother oncol 2009;90:166-71. 38. skvortsova i. oxidative damage and cutaneous reactions during radiotherapy in combination with cetuximab. radiother oncol 2009;90:281-2. 39. wojcicka jb, lasher de, mcafee ss, fortier ga. dosimetric comparison of three different techniques in extensive scalp lesion irradiation. radiother oncol 2009;91:255-60. 40. mallik s, master z, gupta t, et al. brain sparing whole skull/scalp radiotherapy: unique application of helical tomotherapy [abstract]. int j radiation oncol biol physics 2009;75:729. 41. agazaryan n, tenn s, chow p, et al. total scalp irradiation: comparison between volumetric modulated arc therapy, helical tomotherapy and conventional electron and photon field combination. med physics 2010;37:3319. article no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. dr [page 28] [dermatology reports 2012; 4:e10] dermatofibrosarcoma protuberans diagnosed by a single biopsy kristian bakke arvesen,1 carsten sauer mikkelsen,1 torben steiniche,2 birgitte stausbøl-grøn3 1dermatology clinic, brønderslev; 2department of pathology and 3dermatology, aarhus university hospital, denmark abstract this brief report is about a 9 year old girl presenting with a 2.5 cm circular blue to violet discoloration on the anterolateral upper left thigh. the first biopsy taken revealed the diagnosis dermatofibrosarcoma protuberans. the patient underwent surgery at a specialized sarcoma center with post operative histology showing free wide resection margin. preoperative chest x-ray showed no sign of metastasis. this brief report emphasizes the significance of the use of biopsy when cutaneous elements look suspicious and diagnosis is unclear. case report a 9 year old, previously healthy girl, presented with a 2.5 cm circular, blue to violet, slightly elevated discoloration on the upper anterolateral left thigh (figure 1). two years prior to the consultation she had a minor trauma against the area and the described cutaneous changes developed shortly after. her general physician suspected a foreign body and conducted an ultrasound of the thigh. all findings were normal except for a 6 mm fluid accumulation. in addition, the patient’s own gp tried treatment with topical steroid without success. the patient was then advised to seek further dermatological investigation. dermatological examination revealed the earlier described intumescens at the thigh. except for minor tenderness when palpating the discoloration, the examination was normal. a skin biopsy was taken and histologically, the dermis was replaced by a tumor composed of interwoven bundles of rather uniform, small spindle-cells (figure 2). staining with cd34 showed that the tumor cells characteristically expressed cd34 (figure 3). thus, histology revealed the diagnosis dermatofibrosarcoma protuberans grade i. the patient was referred to the specialized sarcoma center to the further treatment starting with a preoperative chest x-ray. the x-ray showed no signs of metastasis. the tumor was removed using wide local excision, with postoperative histology showing wide free resection margin. the patient is now set up to annual clinical controls during the next 5 years to detect any recurrence. discussion dermatofibrosarcoma protuberans (dfsp) is a relatively rare tumor with only 0.8-5 cases per million/year.1 the localization of this type of cancer is 50% on the thorax, 40% on the limbs, 10% head/neck area.1 the clinical presentation of dfsps are in the early stages plaque like areas of cutaneous thickening with violet/blue or red discoloration. when the tumor slowly enlarges it becomes raised, firm and nodular and the surrounding skin may become teleangieactatic. dfsp is low malignant and a locally aggressive growing cancer, only 1-4% disseminates.1 the dissemination is hematogenic to lungs and bones.2 sentinel node biopsy is not recommended because of dermatology reports 2012; volume 4:e10 correspondence: kristian bakke arvesen, skt.joergensgade 11, 7-5, 9000 aalborg, denmark. tel. +47.9263.7999. e-mail: kristian.bakke.arvesen@gmail.com key words: dermatofibrosarcoma protuberans, thigh, biopsy. contributions: kba, csm are the main authors; bsg, author, clinical photo, connecting work between departments; ts, histology. conflict of interests: the authors report no potential conflict of interests. received for publication: 14 may 2012. revision received: 7 june 2012. accepted for publication: 15 june 2012. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright k.b. arvesen et al., 2012 licensee pagepress, italy dermatology reports 2012; 4:e10 doi:10.4081/dr.2012.e10 figure 1. the clinical presentation of the cutaneous thickening with violet discoloration on the anterolateral upper left thigh, just before the biopsy was taken. figure 2. the dermis is replaced by a tumor composed of interwoven bundles of rather uniform, small spindle-cells. the tumor cells insinuate between fat cells in the subcutis (hematoxylin and eosin). figure 3. the tumor cells characteristically express cd34. no nco mm er cia l u se on ly [dermatology reports 2012; 4:e10] [page 29] the seldom lymph node involvement (<1%). the mortality is high with metastasis, the majority of patients die within the 2 first years.1 without metastasis and with total surgical tumor resection, the prognosis is good with 5 year survival rate of 93-100%.1-4 the recurrence rate is up to 50-75%, most of them within 3 years.1-3 the treatment for dfsp is tumor resection with pathologically negative margins. the preferred margin is 3-4 cm.1-4 this is called wide resection. for the surgeon, mohs surgery was not in consideration, since en bloc resection is preferred in sarcomas. furthermore, the dfsp has infiltrating elements that are hard to detect during histology. so margins have to be large, at least some centimetres. conclusions a new kind of treatment using imatinib, an abl-kinase inhibitor, has been approved for adult patients with unresectable, recurrent or metastatic dfsp who are not eligible for surgery. the imatinib results on patients with locally advanced or metastatic disease show variable response, but there are cases with successful results. in particular two cases; a man with dfsp on the thigh and metastasis of the spine and a woman with metastasis in the lungs and axilla show the successful use of imatinib. they were treated with imatinib for 4 and 3 months, respectively. a tumor size reduction of 75% was seen in the first case, permitting this patient to surgical resection. in the second case, a ct-scan 3 months after treatment start showed nearly resolution of the lung metastasis. adjuvant radiotherapy is not commonly preferred, because of reported cases with growth of aggressive fibrosarcomas in areas with dfsp that were treated with radiation therapy.1 references 1. gloster hm jr. dermatofibrsarcoma protuberance. j am acad dermatol 1995;35:355-76. 2. bague s, folpe al. dermatofibrosarcoma protuberance presenting as a subcutaneous mass: a clinicopathological study of 15 cases with exclusive or near exclusive subcutaneous involvement. am j dermatopathol 2008; 30:327-32. 3. barnes l, coleman ja, johnson jt. dermatofibrosarcoma protuberance of the head and neck. arch otolaryngol 1984;110: 398-404. 4. rockley pf, robinson jk, magid m, et al. dermatofibrosarcoma of the scalp: a series of cases. j am acad dermatol 1989;21:278-83. case report no nco mm er cia l u se on ly dr [page 8] [dermatology reports 2012; 4:e3] psoralen plus ultraviolet a (puva) soaks and uvb tl01 treatment for chronic hand dermatoses lisbeth jensen, anette stensgaard, klaus ejner andersen department of dermatology and allergy centre, odense university hospital, university of southern denmark abstract chronic eczematous hand dermatoses with and without contact allergies are complex diseases, which makes it a challenge to select the best treatment and obtain an optimal patient experience and a satisfactory treatment result. the aim of this study was to evaluate retrospectively the clinical effect and patient experience of local treatment with psoralen plus ultraviolet a (puva) soaks and tl01 phototherapy for severe chronic hand dermatoses, and also to evaluate the quality of life for the subgroup of patients with allergic contact dermatitis including compositae allergy. a retrospective evaluation of results for 94 consecutive patients having received a total of 121 treatment courses with local puva soaks or tl01 phototherapy for one of the following diagnoses (n=number of treatment courses): psoriasis (n=19), hyperkeratotic hand eczema (n=27), pustulosis palmoplantaris (ppp) (n=22), vesicular eczema (n=16), compositae dermatitis (n=24), and allergic contact dermatitis (n=13). moreover, semi-structured interviews with 6 selected patients having multiple contact allergies including compositae allergy were used to evaluate quality of life. as a result, we found that puva soaks has good effect in patients with psoriasis and hyperkeratotic hand eczema and local phototherapy for chronic hand dermatoses is a useful treatment option in selected cases. introduction chronic hand dermatoses, including eczema, psoriasis and palmar pustulosis are common, difficult to treat, and have a high impact on patients’ quality of life. in scandinavia the 1 year prevalence of hand eczema is 10-14%.1,2 in spite of this only few and small treatment studies have been performed to document treatment effect. one explanation for the limited number of high quality treatment studies is the lack of agreement on classification of hand dermatoses and the fluctuation of disease severity.1 photo therapy is one treatment option used with questionable results. sezer and co-workers evaluated local (psoralen plus ultraviolet a) puva (administered as paint) compared to tl01 in patients with chronic hand dermatoses. the results showed that puva worked best in patients with ppp, and in patients with chronic hand eczema (dry and dyshidrotic) both treatment modalities had beneficial effect. patients were assessed at week 0, 3, 6, 9 and 10 weeks after the last treatment, and 21 of 25 and 12 of 15 patients completed the studies respectively.3,4 in an older study puva soaks (8-methoxypsoralen) were given to 80 patients over a 5 year period; 56 patients completed the study, of these 16 (29%) cleared more than 90%.5 for nine years uvb tl01 and puva soaks (trioxysalen) have been available as treatment modalities at the department of dermatology, odense university hospital for severe hand dermatoses. the treatment modalities were options for patients with difficult to treat dermatoses at the discretion of the dermatologist. according to the danish contact dermatitis group hand eczema may turn into a chronic disease, if the patient is not offered examination, guidance and treatment within the first 3 months.6 a study by lerbaek et al. found that 68% (96/142) still suffer from hand eczema at a follow up study 8 years later.7 other studies show if the patient has got one contact allergy, his risk of getting more contact allergies, a more severe hand eczema and a worse prognosis is increased.8,9 agner et al. found that patients allergic to compositae and rubber chemicals had the most severe hand eczema, and patients allergic to compositae, cobolt or paraphenylendiamine (ppd) had the lowest quality of life.9 this suggested that patients allergic to compositae had the worst hand eczema and their life quality is severely affected. in another study, 2 patients allergic to compositae were treated with puva (systemic) together with systemic prednisolone to be able to tolerate the phototherapy and both needed maintenance treatment to prevent flares.10 hand eczema can have a great influence on patients’ life and quality of life because of the physical, psychological and social consequences.11,12 this study evaluated retrospectively the experience and effect of puva soaks and tl01 phototherapy for the treatment of severe chronic hand dermatoses with the purpose to reveal the beneficial effects in balance with the duration of effect and resources involved in performance of the treatment. further, a subgroup of patients suffering from multiple contact allergies and compositae allergy was interviewed to explore how their quality of life was influenced by the allergies and hand eczema in order to optimize the service provided by health professionals (table 1). materials and methods a retrospective quantitative evaluation of the records of patients who in the years 20082010 had received a minimum of 10 treatments in one course13 for treatment of one of the following diagnoses: psoriasis, hyperkeratotic eczema, ppp, vesicular eczema, compositae dermatitis, and allergic contact dermatitis. all patients also received topical treatment with varying amounts of topical corticosteroids and moisturisers with inadequate effect, therefore phototherapy was added as supplement. psoralen plus ultraviolet a soak the patient placed hands for 10 min in 2 l water of 37°c mixed with 1.0 ml tripsor 0.5 mg/ml (trioxysalen). the patient then placed hands on uva unit (waldmann puva 180), body and face covered. initially was given 0.10 joule/cm2, dose was raised 0.05 joule/cm2 at each treatment if tolerated by the patient. max dose was 1.20 joule/cm2. tl01 the patient placed hands on tl01 unit (waldmann uv 181 bl), body and face covered. initially was given 0.1 joule/cm2 dermatology reports 2012; volume 4:e3 correspondence: lisbeth jensen, department of dermatology, odense university hospital, sdr. boulevard 29, 5000 odense c, denmark. e-mail: l.jensen@ouh.regionsyddanmark.dk key words: puva soaks, hand eczema, quality of life, compositae allergy. contributions: lj, data collection, analyses, writing drafts of article; as, supervisor of qualitative part of study, revising article; kea, supervisor of quantitative part of study, revising article. conflict of interest: the authors have no conflict of interest. aknowledgement: expenses covered by department of dermatology, odense university hospital, denmark. received for publication: 14 november 2011. accepted for publication: 14 november 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright l. jensen et al., 2012 licensee pagepress, italy dermatology reports 2012; 4:e3 doi:10.4081/dr.2012.e3 no nco mm er cia l u se on ly [dermatology reports 2012; 4:e3] [page 9] (eczema) 0.2 joule/cm2 (psoriasis), dose was raised 0.10 joule/cm2 (eczema) 0.20 joule/cm2 (psoriasis) at each treatment if tolerated by the patient. max dose was 2.90 joule/cm2. the observation period after a treatment course was 24 weeks, or until the patient was discharged. the treatment effect was evaluated at the end of a treatment course by clinical evaluation of the severity of the hand dermatosis in relation to the severity prior to treatment. good effect was defined as healing of the dermatosis (effect 4) or at least 75% improvement (effect 3). inadequate treatment effect was defined as clinical improvement less than 75%. the effect was evaluated again at the end of the observation period (24 weeks) or before if the patient had a relapse. some patients had more than one diagnosis and were included once with the most prominent diagnosis. semi structured interviews were done with a subgroup of 6 patients with multiple contact allergies (3 or more positive patch tests) and compositae allergy. the informants were 49-67 years of age (mean age 56.5 years), and they had hand eczema for 12-42 years (mean number of years 38.5). an interview guide was developed for this investigation with questions about daily life events in relation to the contact allergies and hand eczema e.g. handling work, daily activities, leisure time, and patients’ perspectives on these matters, and patients’ experiences and views on relationship with family, colleagues, friends, and other people.14 patients’ signed informed consents before the interviews, which were conducted in a neutral office in the ward or in patients’ home according to their preference. patients’ were offered compensation for transport expenses in due course. the interviews were tape-recorded (26-50 min, mean number of min 40), transcribed word-for-word and then analysed and interpreted according to steinar kvale’s concepts.14 at the time of transcription each patient was given a fictive name. interviews were rewritten into a shorter exact language easier to read with respect to meaning and the patients’ ways of expressing themselves. the text of each interview was then categorised in topics and subtopics and reorganized according to this. the patients’ statements were translated from danish into english by the author. interpretation was done by reporting patients’ statements, rewriting them as the author understood them, and then compare them with the chosen theory by heggdal.15 patients go through four stages from the first symptoms and until they have accepted their chronic disease: uncertainty, loss, learning, and living with the disease. results a total of 107 patients received 138 treatment courses of puva soaks or tl01 treatment, and 94 (81%) had ≥10 treatments in one course and a total of 121 courses. figures 1 and 2 show that in 45/121 (37%) courses of puva soaks or tl01 the treatment was given with a good result, and in 76/121 (63%) the effect was inadequate. side effects in 10 courses of puva soaks 8 patients experienced erythema and/or a burning sensation and 5 complained of pruritus and/or pain. in 2 courses of tl01 the patients had erythema and pruritus. in all cases the duration of side effects was short. patients having less than 10 treatments in one course in 18 courses 16 patients had less than 10 treatments. in 9 courses treatment was discontinued because of side effects/exacerbation, and in 9 courses treatment was discontinued because of no effect or because the patient decided to stop. five patients had vesicular hand eczema, 4 patients had ppp, 4 had hyperkeratotic hand eczema, 2 had compositae allergy and 1 had psoriasis. in 3 cases patients tolerated phototherapy in earlier courses, which meant they were not excluded from the study. discussion local phototherapy is often chosen as a supplement to patients’ treatment with topical steroids, and to make it possible for patients to stop using steroids for a period in order to minimize possible side effects, for instance atrophy of the skin. local phototherapy can also be used as a supplement to or instead of systemic therapies if the patient does not tolerate or wish to use systemic therapies. patients suffering from psoriasis and hyperkeratotic eczema had the best effect of puva soaks and tl01 (figure 3). the effect was good for psoriasis in half of the treatment courses concerning puva soaks, and in one third of the courses with tl01. the effect of puva soaks are in accordance with results published by o’kane and coworkers16 and schempp and coworkers.17 among patients with ppp and a total of 21 courses of puva soaks the effect was of questionable value as it only lasted in more than 3 article table 1. patient distribution regarding sex, age, number of treatments in one course, single, and cumulative doses of uva for each diagnosis. (j=joule/cm2) psoriasis hyperkeratotic pustulosis vesicular compositae allergic eczema palmoplantaris eczema dermatitis contact dermatitis sex women 5 10 16 9 18 7 men 8 15 5 5 2 2 age range 29-82 34-74 39-76 29-57 46-79 33-69 median 57 52 59 46.5 54.5 51 number of treatments range 13-35 10-33 14-33 10-46 10-37 10-33 median 21 23 22 22 15 20 max single uva dose range 0.65-1.20 j 0.35-1.20 j 0.65-1.20 j 0.40-1.20 j 0.35-1.20 j 0.45-1.10 j median 1.05 j 1.10 j 0.90 j 0.83 j 0.65 j 0.85 j cumulative uva dose range 4.85-23.70j 2.35-26.40j 5.95-19.85j 2.07-39.20j 2.70-28.48j 3.85-13.45j median 13.45 j 13.70 j 12.30 j 10.45 j 5.53 j 10.76 j no nco mm er cia l u se on ly [page 10] [dermatology reports 2012; 4:e3] months in 4 patients. the effect could therefore be spontaneous remission. layton et al.18 conducted a placebo-controlled study, in which puva soaks (8-mop emulsion) or placebo were used in 18 patients and there was no convincing effect of active treatment. concerning vesicular eczema, one study reported that puva soaks (8-mop solution) had good effect in 9/12 patients.19 the behrens et al. study might be influenced by the exclusion criteria, as patients treated with systemic medication within the last 8 weeks and topical medication within the last 4 weeks were excluded, implying that patients included might have less severe hand eczema. in this study 5/14 (36%) of the patients obtained good effect. when evaluating the effect of puva soaks in patients with compositae dermatitis, it is necessary to take into consideration that one patient accounted for 4 courses of good effect (effect 4) and the treatment was combined with systemic steroid which might amplify the effect. tl01 also worked well in the patient but the effect did not last. if this patient was left out, only one patient had good effect of the treatment, meaning 1/15 (7%). in 14 courses (93%) the treatment was given with inadequate effect (effect 2, 1, 0). in 3/9 (33%) patients with allergic contact dermatitis puva soaks were given with good effect. the effect lasts for the observation period in 2 patients. no direct relationship was found between effect and number of treatments given. the treatment effect often began after 10-12 treatments, and patients who do not experience effect after 1 month seldom do so later,13 it seems reasonable to discontinue the treatment after 15 treatments if the patients have no effect. this corresponds to the scottish treatment protocol from photonet in which treatment is recommended discontinued if the patient does not experience more progress for 4 treatments in a row.20 in patients, who had more courses of puva soaks and tl01 phototherapy, the pattern of effect might differ from course to course. several factors might influence this e.g. the fluctuation of disease severity, the time of year and environmental exposures at work and at home. a weakness in the study is the retrospective nature of data collection based on patient records with sometimes inadequate information. some patients were treated with systemic treatments e.g. methotrexate or neotigason before, during or after phototherapy. most of the patients were treated with topical steroids (group 3 or 4), and all patients used moisturizers. the present results cannot be compared with the outcome of other studies due to characteristics of the selected patients material and possible differences in treatment protocols. however, the data are valuable as an audit for our department. reservations must also be taken due to the low number of patients included. it was not possible to compare the effect of puva soaks and tl01 as only few patients received tl01. and as only few patients in the study had tl01 it was not possible to comment on the effect of the treatment to the included diagnoses. to be able to judge the effect of the treatment it is recommended to document patients’ symptoms at the 1st treatment and after 4 weeks. if the patients have no effect the treatment can be discontinued. if the patients have little effect treatment continues and the patients’ symptoms and thereby effect are judged every 2 weeks. when no further progress is observed the treatment is discontinued. uncertainty and escaping the sick body the informants did not understand why they got hand eczema. the hand eczema had great impact on them and their self esteem. at first they ignored the eczema, it got worse, and eventually they had to deal with it. one saw a doctor after 2 years. i thought: it will disappear. it did, but then it got worse and worse... i have no idea what started it. (woman, 67 years old) reduced life, sorrow and sadness realizing having the eczema the informants felt depressed and tired. they needed to retreat to acquire peace and time to cope with the situation. the following topics were found to be of significance: affected state of mind, lack of energy, retreat from other people, and the importance of close relatives. afffected state of mind especially as the last allergy was compositae, i almost ran from here crying. i dreaded this most. no, it is definitely not funny. (woman, 50 years old) the garden was important to some informants. working in the garden, being surrounded by plants and flowers, staying in the garden with friends and family, and participating in outdoor activities gave them quality of life. the worst of my diseases is the eczema. it influences my quality of life the most. i feel i am no good. i can do nothing. (woman, 67 years old) the informants felt sad and restricted by the hand eczema, and they felt less worthy as human beings. they were troubled by symptoms like severe itching, pain and bleeding. lack of energy i am happy when it is not there. honestly, i get much more energy. (woman, 59 years old) when i get home from work there is no energy left to do anything, because it takes up so much room. it hurts, and i am finally at home and can relax a little. at such times not much is being done. (woman, 56 years old) at times with severe hand eczema the informants only managed to carry out the most important duties. with those at work, the job was their priority, and with those at home likewise only the most important jobs were done. article figure 1. good effect (effect 4, 3) and inadequate effect (effect 2, 1, 0) of puva soaks, tl01, and both treatment modalities together. number of treatment courses stated. no nco mm er cia l u se on ly [dermatology reports 2012; 4:e3] [page 11] retreat from other people i did not have any social contacts, and i didn’t want to be with my girlfriend either looking like this. (man, 49 years old) the informant retreated from colleagues, friends, and girlfriend because he could not stand his symptoms and the way he looked. he also retreated to avoid further confrontation with the situation and thereby protected himself from any more pain. if we were going to a party and i had to say hello to many people, i kept my gloves on, and that was hard on me to begin with. i wondered if people thought i was contagious. but in the end i realized that i had to think of myself, otherwise i could go nowhere. (woman, 57 years old) keeping up social activities took consideration and coming to terms with the situation before the informants could do so without strain e.g. using gloves and clothes also in warm weather. when the informants have come further in the process of living with hand eczema, they retreated from other people to protect themselves and because other people retreated from them. e.g. staying indoors or staying at home, explaining to people when they switched to another queue or ignoring them. the significance of close relatives bent (husband) does not do housework, but he can peel onions for me and shape hamburgers. (woman, 56 years old) i have a good family and a very good husband, he has been there for me the whole time. he is worth his weight in gold. he helps at home. he often says: leave that. (woman, 67 years old) the informants indicated how their close relatives helped to do practical housework, work in the garden, and offered support. two informants described good support and help by relatives. with the other informants my impression was that they had to ask for help, which could be difficult. bodily learning and strengthened hope the informants were eager to learn, but they also found it difficult to gather information on which plants and food were compositae. every time of success was a victory because they then knew more about how to prevent the eczema. they learnt to take care of their hands by using moisturizers and glove protection. they also learnt to be aware of limits in relation to skin tolerance e.g. in relation to housework, the use of gloves and staying outside. the informants were vulnerable in respect to the way they were met by people e.g. informants who could see no pattern in their way of living, flares, and recovery gave up on it, their feeling of not being taken serious by health professionals accentuated this. it is a science to find out, which plants are compositae, you cannot look them up in a book, you can, but you will only find a few. (woman, 50 years old) i get happy every time i find something that is no good for me. (woman, 67 years old) i wrote a note, and when i could do no more... i continued the next day...i knew if i did too much, my hands would hurt. (woman, 57 years old) lately, especially after having phototherapy (tl01), it (the eczema) has changed, the itching has become different. (woman, 57 years old) almost all the time i think of and remember that i have to take care of my hands. (woman, 57 years old) if only… but i can find no system. that is why i stopped coming here (dermatological clinic). i felt that i wasted my time, and i saw different doctors every time. (woman, 56 years old) embedded bodily knowledge, living with hand eczema the informants indicated that they lived their lives with hand eczema and contact dermatitis in the way they wanted to in spite of limitations. they succeeded doing so by taking into account the knowledge and experience they had acquired and by being constantly alert. limitations were of more or less nuisance according to the informants’ individual interests. in cases of flares they knew what to do, they were able to begin treatment or to ask for help e.g. in the department of dermatology. they were worried about the long-term effect of systemic steroid, but at the same time they were aware that they could not do without it in cases of severe flares. i live with it in the way that i always try to be alert. i think of what i eat, what i do... if i don’t, i know i will start flaring and i don’t want that. (woman, 50 years old) i feel it starting, my hands get rough. then i start using ... (a topical steroid), i sleep with gloves on and so forth. (woman, 67 years old) (puva soaks) is probably the best thing happened to me. i feel completely different after treatments. (woman, 59 years old) i am a little worried that i get so many tablets (steroid). i am afraid they will damage me inside. i don’t like that. (woman, 59 years old) conclusions the informants agreed that hand eczema fiercely intruded their lives as it affected them physically, psychologically, socially, and existentially and thereby had great influence on their daily living and quality of life. e.g. the informants stated they had a lot of pain, they were very bothered by itching, they constantly had to be alert and perseverant in looking after and treating their hands, they were noticed by other people, they looked different and were different to touch, and other people kept a distance. this corresponds with diepgen stating that patients are not satisfied if health professionals only focus on treating visible signs of disease as the burden of disease is even more important.21 this is in accordance with fowler who states that hand eczema is to be regarded as an impor article figure 2. effect of both treatment modalities divided on diagnoses. good effect (effect 4, 3) and inadequate effect (effect 2, 1, 0). number of treatment courses stated. no nco mm er cia l u se on ly [page 12] [dermatology reports 2012; 4:e3] tant challenge in the health services.22 as reported by cvetkovski other studies reveal that patients’ quality of life improve when patch tested and positive reactions are found,23 in this study the informants were relieved to know what they did not tolerate. with knowledge they were able to act in order to ease their eczema and regain control of their lives. having a chronic disease includes the risk of recurrent relapses, which is trying for both patients and health professionals.22,24 in such situations the informants might benefit from the self esteem and confidence gained when the eczema was at ease, situations with feelings of having knowledge and control. in the study one informant chose to be discharged from the clinic because of the lack of feeling in control. motivation and perseverance are important qualities having a chronic disease like hand eczema.25 the informants living best with their hand eczema described this very well. all the time they were alert, taking care, beginning treatment and taking extra precautions as soon as they sensed a flare was on its way. e.g. they all used a moisturizer of a high content of fat, and one used different moisturizers according to the eczema and the informant’s activities. all informants were worried about possible side effects to local or systemic steroid treatment. this is also referred to in niemeier’s study.25 all the informants used gloves to varying degrees. they considered whether the gloves made them sweat, as this made their eczema worse, and they considered their activities. more studies emphasize the use of moisturizers and gloves as being the most important factors in the prevention of hand eczema, and also as important factors in the treatment of flares together with local steroids.26,24 concerning phototherapy two informants were very satisfied with the effect of this, one had recurrent good effect of puva soaks, and one experienced that treatment with tl01 made the eczema change into being milder. another factor which is emphasised concerning allergic contact hand dermatitis is the importance of avoiding the allergen.26,27 this may be extremely difficult with compositae allergy as the plants in the family are widespread both as cultivated plants, weeds, and vegetables as well as the allergen being airborne.28 the informants did their best to avoid compositae taking their own experiences into account. they wore clothes, stayed indoors, and converted their gardens, which restricted their interests, activities, and social lives. having to beware of their diet bothered them the least, as it was of no importance to them avoiding cosmetics containing compositae. concerning work one informant was able to keep the job, one was able to make arrangements to stay employed, one found a new job, and three had pension. this contradicts to a study mentioned by diepgen in which 15% leave work because of hand eczema.21 it might have been of some importance that all the informants in this study had wet work, which could have made it more difficult for them to take necessary precautions. recommendation to be able to help future patients in carrying and possibly ease their burden of living with chronic hand eczema and allergic contact dermatitis health professionals are suggested to support patients in finding joy and experiencing victory of finding out what they do not tolerate and what works in their situation. this means helping them to find their individual limits and solutions according to limits and preferences. our task as health professionals is to make our theoretical and experience based knowledge available to the patient, e.g. about hand eczema, allergy, treatment, and prevention. the information must be adapted to the patient’s capability at the time. the patient’s task is to transform the knowledge presented into practical knowledge in the patient’s current life situation. health professionals must continuously be ready to offer more knowledge or to challenge the patient to consider the situation. in order to optimize the learning situation it is proposed that the patient is connected with a team of doctors and nurses having the necessary knowledge, also as the patient might be coming back over some time. health professionals are also suggested to visit patient’s home and work in order to gather more information and inspiration for the education of this and other patients.29 references 1. coevorden amv, coenraads pj, svensson a, et al. overview of studies of treatments for hand eczema the eden hand eczema survey. br j dermatol 2004;151:446-51. 2. hald m, berg nd, elberling j, johansen jd. medical consultations in relation to severity of hand eczema in the general population. br j dermatol 2008;158:773-7. 3. sezer e, erbil ah, kurumlu z, et al. comparison of the efficacy of local narrowband ultraviolet b (nb-uvb) phototherapy article figure 3. good and inadequate effect of puva soaks and tl01 shown for each diagnosis. number of treatment courses stated. no nco mm er cia l u se on ly [dermatology reports 2012; 4:e3] [page 13] versus psoralen plus ultraviolet a (puva) paint for palmoplantar psoriasis. j dermatol 2007;34:435-40. 4. sezer e, etikan i. local narrowband uvb phototherapy vs. local puva in the treatment of chronic hand eczema. photo-dermatol photoimmunol photomed 2007;23: 10-4. 5. taylor cr, baron ed. hand and foot puva soaks: an audit of the massachusetts general hospital's experience from 1994 to 1998. photodermatol photoimmunol photomed 1999;15:188-92. 6. menné t, veien n, sommerlund m, jet al. operationelle retningslinier for udredning og behandling. dansk kontakt dermatitis gruppe 2009;1-39. 7. lerbaek a, kyvik ko, ravn h, et al. clinical characteristics and consequences of hand eczema an 8-year follow-up study of a population-based twin cohort. contact dermatitis 2008;58:210-6. 8. carlsen bc, andersen ke, menné t, johansen jd. sites of dermatitis in a patch test population: hand dermatitis is associated with polysensitization. br j dermatol 2009;161:808-13. 9. agner t, andersen ke, brandao fm, et al. contact sensitisation in hand eczema patients relation to subdiagnosis, severity and quality of life: a multi-center study. contact dermatitis 2009;61:291-6. 10. burke da, corey g, storrs fj. psoralen plus uva protocol for compositae photosensitivity. am j contact dermatitis 1996;7;171-6. 11. skoet r, zachariae r, agner t. contact dermatitis and quality of life: a structured review of the literature. br j dermatol 2003;149:452-6. 12. diepgen tl. chronisches handekzem. epidemiologie und therapeutische evidenz. hautarzt 2008;59:683-9. 13. shephard se, schregenberger n, dummer r, panizzon rg. comparison of 8-mop aqueous bath and 8-mop ethanolic lotion (meladinine) in local puva therapy. dermatology 1998;197:25-30. 14. kvale s. interview. en introduktion til det kvalitative forskningsinterview. københavn: hans reitzels forlag; 1997. 15. heggdal k. kroppskunnskaping. pasienten som ekspert i helsefremmende prosesser. oslo: gyldendal norsk forlag as; 2008. 16. o´kane d, mcloone nm, jenkinson h, et al. efficacy of topical puva soaks for palmoplantar dermatoses: an audit. photodermatol photoimmunol photomed 2008; 24:279-84. 17. schempp cm, müller h, czech w, et al. treatment of chronic palmoplantar eczema with local bath-puva therapy. j am acad dermatol 1997;36:733-7. 18. layton am, sheehan-dare r, cunliffe wj. a double-blind, placebo-controlled trial of topical puva in persistent palmoplantar pustulosis. br j dermatol 1991;124:581-4. 19. behrens s, von kobyletzki g, gruss g, et al. puva-bath photochemotherapy (puvasoak therapy) of recalcitrant dermatoses of the palms and soles. photodermatol photoimmunol photomed 1999;15:47-51. 20. nhs scotland photonet (national managed clinical network for photo-therapy). treatment protocols. 2010. available from: http://www.photonet.scot.nhs.uk/ documents%20on%20professionals%20pa ge/photonet%20treatment%20protocols% 202010%20.pdf 21. diepgen t, agner t, aberer w, et al. management of chronic hand eczema. contact dermatitis 2007;57:203-10. 22. fowler j. chronic hand eczema: a prevalent and challenging skin condition. cutis 2008;82suppl4:3-8. 23. cvetkovski rs, zachariae r, jensen h, et al. quality of life and depression in a population of occupational hand eczema patients. contact dermatitis 2006;54:10611. 24. bikowski jb. hand eczema: diagnosis and management. cutis 2008;82suppl4:9-15. 25. niemeier v, nippesen m, kupfer j, et al. psychological factors associated with hand dermatoses: which subgroup needs additional psychological care? br j dermatol 2002;146:1031-7. 26. bourke j, coulson i, english j. guidelines for the management of contact dermatitis: an update. br j dermatol 2009;160:946-54. 27. smith mc, nedorost st. hand dermatitis: nursing support in the plan of care. dermatol nurs 2008;20:121-5. 28. gordon la. compositae dermatitis. australas j dermatol 1999;40:123-30. 29. van gils rf, van der valk pgm, bruynzeel d, et al. integrated, multidisciplinary care for hand eczema: design of a randomized controlled trial and cost-effectiveness study. biomed central public health 2009;9. article no nco mm er cia l u se on ly dr [dermatology reports 2013; 5:e2] [page 3] late reaction to ustekinumab infusion marina resener morais, luana pizarro meneghello, carina flores de oliveira, andré vicente esteves carvalho irmandade santa casa de misericórdia de porto alegre, brazil abstract psoriasis is a chronic inflammatory disease that directly affects the quality of life. biologics are prescribed for patients unresponsive to conventional treatments and with severe forms of the disease. ustekinumab is a fully human monoclonal antibody against the p40 subunit of interleukins 12/23 that is being used with satisfactory responses, achieving an improvement in the baseline psoriasis area and severity index of approximately 75% after 12 weeks of treatment. it has few side effects, including grater susceptibility to infections and development of reactions to the drug. our report discusses a case of a cutaneous reaction to the use of ustekinumab in a 27 year-old male patient after the third dose of the medication. no similar case has been reported in the literature. introduction psoriasis is a chronic inflammatory skin disease with courses of remission and worsening, which can have great impact on quality of life. patients with moderate-to-severe psoriasis usually require continuous treatment with higher chances of toxicity. the biologics are used in patients whose condition could not be controlled with conventional treatments, or had to discontinue it due to side effects or toxicity.1,2 ustekinumab is a human monoclonal antibody indicated for the treatment of moderate-to-severe psoriasis. its mechanism of action is based on the inactivation of interleukins 12 and 23 p40 subunit. patients treated with this medication are being monitored for a better definition of long-term effectiveness and side effects.2,3 this paper describes a case of late onset reactions to ustekinumab infusion. case report a 27-year-old man, diagnosed with psoriasis since he was 15, had been treated with acitretin, methotrexate, cyclosporine and phototherapy. however, since his symptoms became refractory to treatment, ustekinumab has been indicated. baseline psoriasis area and severity index (pasi) was 11.2, bsa>10%, and a dlqi>10. he was administered one subcutaneous injection of 45 mg of ustekinumab on week 0 and a subsequent injection of 45 mg after 4 weeks, which led to the complete resolution of the lesions. as public supply of the medication was restrained, the patient only received the first maintenance dose 11 months after the last infusion. a week after reintroduction of ustekinumab, pruritic and erythematous annular eruptions occurred on the patient’s trunk and limbs (figures 1 and 2). blood test shows eosinophilia. dexchlorphe niramine was prescribed. the patient returned after two weeks showing complete improvement of lesions. discussion and conclusions psoriasis is the most common immunemediated chronic inflammatory disease affecting approximately 2% to 3% of the world’s population.1-6 around 80% of patients present localized plaque psoriasis, while the generalized forms comprise less than 20%. the disease has a major impact on the quality of life and can be compared to diabetes mellitus, rheumatoid arthritis, depression and cancer. typically, psoriasis patients will usually cycle through therapies and sometimes will require indefinite treatment.1 in the psoriasis pathophysiology, il-12 activates cd4 t cells and natural killer cells that induce the production of type 1 cytokines (tnf interferon alpha), while il-23 stimulates the proliferation and increases the half-life of t cells, which produce il-17. the il-2 and il-23 are secreted after the activation of antigenpresenting cells and both present p40 sub-unit in their molecules.5 ustekinumab is a fully human monoclonal antibody that binds to the p40 subunit of the interleukins 12 and 23. three randomized controlled trials have demonstrated that both 45 mg and 90 mg doses showed a high efficacy in the treatment of psoriasis with 67% to 72% of patients achieving a pasi response of 75 at week 12. ustekinumab presents few sideeffects.7-9 in the phoenix 1 study, the most common adverse reactions were upper respiratory tract infection, nasopharyngitis, headache and arthralgia, affecting 0.8% of patients who were taking 45 mg, and 1.6% of those who used 90 mg.8 in phoenix 2, rates of serious infections were low in all treatment groups. the occurrence of injection site reactions was 1% of 5632 injections of ustekinumab and 0,4% of 14,919 placebo injections, which could in part dermatology reports 2013; volume 5:e2 correspondence: marina resener morais, irmandade santa casa de misericórdia de porto alegre, rua prof. annes dias 285 1 andar, porto alegre, rs 90020-090, brazil. tel./fax: +55.513.2148008. e-mail: mariresener@hotmail.com key words: psoriasis, ustekinumab, late adverse skin reactions. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 8 july 2013. accepted for publication: 22 july 2013. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright m.r. morais et al., 2013 licensee pagepress, italy dermatology reports 2013; 5:e2 doi:10.4081/dr.2013.e2 figure 1. macular eruption after the treatment. figure 2. exanthematous eruptions after the treatment. no nco mm er cia l u se on ly [page 4] [dermatology reports 2013; 5:e2] be related to the infrequent dosing interval.9 the acute reactions occurs during the infusion or in the first 24 hours. the majority can be classified as mild or moderate reactions and only few are severe. late reactions occur between 24 hours and 14 days after an infusion, in most cases symptoms include arthralgia, myalgia, influenza-like symptoms, headache and rash or urticaria.10 in patients with crohn’s disease treated with infliximab 61% patients had detectable antibodies against infliximab after the fifth infusion. they found a strong relation between the concentration of antibodies against the infliximab and the occurrence of an infusion reaction. the study showed a cumulative incidence of infusion reactions of 27%, no one occurred during the first infusion and the incidence increased during the subsequent infusions.11 in phoenix 1 and 2 the immunogenicity rates were low, with approximately 5% patients developing anti-ustekinumab antibodies and these were not associated with injection site reactions.8,9 our patient have presented late reaction to ustekinumab when the treatment was discontinued and antibodies were probably produced. no report on this type of reaction during the use of ustekinumab was found in the literature. more studies are necessary to understand the relation between antibodies against ustekinumab and infusion reactions. references 1. smith ch, anstey av, barker jn, et al. british association of dermatologists' guidelines for biologic interventions for psoriasis 2009. br j dermatol 2009;161: 987-1019. 2. lebwohl m, leonardi c, griffiths ce, et al. long-term safety experience of ustekinumab in patients with moderate-tosevere psoriasis (part i of ii): results from analyses of general safety parameters from pooled phase 2 and 3 clinical trials. j am acad dermatol 2012;66:731-41. 3. gordon kb, papp ka, langley rg, et al. long-term safety experience of ustekinumab in patients with moderate to severe psoriasis (part ii of ii): results from analyses of infections and malignancy from pooled phase ii and iii clinical trials. j am acad dermatol 2012;66:742-51. 4. scherl ej, kumar s, warren ru. review of the safety and efficacy of ustekinumab. therap adv gastroenterol 2010;3:321-8. 5. famenini s, wu jj. the safety of ustekinumab in psoriasis. j drugs dermatol 2012; 11:907-10. 6. yeilding n, szapary p, brodmerkel c, et al. development of the il-12/23 antagonist ustekinumab in psoriasis: past, present, and future perspectives. ann ny acad sci 2011;1222:30-9. 7. yeilding n, szapary p, brodmerkel c, et al. development of the il-12/23 antagonist ustekinumab in psoriasis: past, present, and future perspectives--an update. ann ny acad sci 2012;1263:1-12. 8. leonardi cl, kimball ab, papp ka, et al. efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (phoenix 1). lancet 2008;371:1665-74. 9. papp ka, langley rg, lebwohl m, et al. efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 52-week results from a randomised, double-blind, placebo-controlled trial (phoenix 2). lancet 2008;371:1675-84. 10. lecluse lla, piskin g, mekkes jr, et al. review and expert opinion on prevention and treatment of infliximab-related infusion reactions. br j dermatol 2008;159: 527-36. 11. baert f, noman m, vermeire s, et al. influence of immunogenicity on the longterm efficacy of infliximab in crohn’s disease. n engl j med 2003;348:601-8. case report no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. dr [page 10] [dermatology reports 2014; 6:5113] verrucous lichen planus: a rare presentation of a common condition moutusi audhya, jenny s. varughese, yuti c. nakhwa department of dermatology, venereology and leprosy, mahatma gandhi medical college and research institute, pondicherry, india abstract lichen planus is a chronic papulosquamous dermatoses in which both skin and mucosae are involved. there are various morphological forms of lichen planus. hypertrophic lichen planus is one of the rare clinical variants. herein, we report a very unusual presentation of hypertrophic lichen planus. a similar presentation has not been reported in literature yet, to the best of our knowledge. introduction the dermatosis, lichen planus was first described by erasmus wilson in 1869 and is characterized by purple, polygonal, pruritic, papular eruption of unknown etiology affecting the skin and can also involve the mucous membranes and the nails.1 lichen refers to the dry and undulating lichen-like appearance affecting skin. it is associated with oxidative stress, certain medications and diseases, however the underlying pathology is not exactly known.2 lichen planus may be divided morphologically into the following types: annular lichen planus, linear lichen planus, hypertrophic lichen planus, atrophic lichen planus, vesiculobullous lichen planus, ulcerative lichen planus, follicular lichen planus, actinic lichen planus and lichen planus pigmentosus.3 according to the site of involvement there is lichen planus of the palms and soles (palmoplantar lichen planus), mucosal lichen planus, lichen planus of the nails, lichen planus of the scalp (leading to cicatricial alopecia), inverse lichen planus.3 hypertrophic lichen planus/verrucosa is one of the relatively rare clinical variants. it occurs as a thick, elevated, purplish hypertrophic lesion seen mainly over the extremities, shin and interphalangeal joints. the development of hypertrophic lesions greatly lengthens the course of the disease.4 here we present the report of an elderly female who came with a very unusual presentation of hypertrophic lichen planus. case report a 70-year-old woman presented to the outpatient department with multiple raised, warty lesions over lower legs and dorsa of feet bilaterally for the last 1 year (figure 1a). the lesions were extremely pruritic. they initially started as small papules and gradually increased to attain the present size. she had received treatment previously in the form of certain topical ointments without any relief. on examination, she was found to have multiple well defined hyperpigmented verrucous plaques with follicular prominence, of varying sizes seen bilaterally over the lower legs and the dorsa of feet (figure 1b,c). she had no nail changes and the scalp and mucosae were normal. there was no evidence of koebnerization and wickham’s striae were not apparently visible. based on these findings a provisional clinical diagnosis of hypertrophic lichen planus was made. systemic examination did not reveal any abnormality. routine hematological and biochemical investigations were normal. a histopathological examination revealed basket weave type of hyperkeratotic, acanthotic squamous epithelium with elongation of the rete ridges. the sub epithelium showed pigment incontinence and dense bands of lymphohistocytic infiltration in papillary dermis hugging the epidermis (figure 2). based on the above findings a definite diagnosis of hypertrophic lichen planus was made. dermatology reports 2014; volume 6:5113 correspondence: moutusi audhya, department of dermatology, venereology and leprosy, mahatma gandhi medical college and research institute, pondicherry 607402, kirumampakkam, cuddalore, tn, india. tel. +91.0413.2615449 fax: +91.0413.2615457. e-mail: drmoutusiaudhya@gmail.com key words: verrucous, lichen planus, hypertrophic. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 8 october 2013. revision received: 18 january 2014. accepted for publication: 25 jnuary 2014. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright m. audhya et al., 2014 licensee pagepress, italy dermatology reports 2014; 6:5113 doi:10.4081/dr.2014.5113 figure 1. a) hyperpigmented verrucous follicular pitted plaque over the shin; b) dorsa of the feet; c) a clear view of the pits present over the verrucous plaque. figure 2. photomicrograph showing hyperkeratosis, papillomatosis, hypergranulosis with elongation of rete ridges and lymphocytic infiltration in the dermis (hematoxylin & eosin, ×40) no nco mm er cia l u se on ly [dermatology reports 2014; 6:5113] [page 11] discussion lichen planus (greek tree moss, latin planus flat) is a common inflammatory papulosquamous disorder that affects the skin, mucous membranes, nails and hair. the prevalence of disease is 1% of the general population.5 hypertrophic lichen planus (lichen planus hypertrophicus) occurs on the extremities especially the shins. it is the most pruritic variant of all lichen planus. lesions are thick, elevated, purplish in colour and hyperkeratotic. the variant heals with scar, hypopigmentation or hyperpigmentation.4 there are reports of metastatic squamous cell carcinoma and keratoacanthoma arising from long standing hypertrophic lesions of lichen planus.6,7 the morphology can be very varied ranging from hyperkeratotic papules to extremely thick plaque type of lesions. the histopathological appearance of hypertrophic lichen planus shows acanthosis, papillomatosis, hypergranulosis and hyperkeratosis,8 which correlated with the histopathological picture in our patient. hypertrophic lichen planus is a rare presentation, having a varying clinical picture which may pose a difficulty in diagnosis.6 conclusions hypertrophic lichen planus is one of the less commonly encountered variants of lichen planus. the resistance to treatment is a striking feature in this condition. though it has been mentioned in literature that the lesions in hypertrophic lichen planus can be extremely hyperkeratotic,4 however in our patient the morphology of the lesions was very unusual. the patient was started on treatment with topical high potent steroid under occlussion and was planned for intralesional steroid therapy. however she was lost to follow up and did not report back to us. we report the patient for the unusual presentation of a relatively common condition. references 1. kanwar aj, de d. lichen planus in children. indian j dermatol venereol leprol 2010;76:366-72 2. symcat. lichen planus. what you need to know. available from: http://www. symcat.com/conditions/lichen-planus. accessed on: january 2014. 3. usatine rp, tinitigan m. diagnosis and treatment of lichen planus. am fam physician 2011;84:53-60. 4. breathnach sm, black mm. lichen planus and lichenoid disorders. in: burns t, breathnach s, cox n, griffiths c, eds. rook’s text book of dermatology. 8th ed. oxford: blackwell science; 2010. pp 10-42. 5. sripathi h, kudur mh, prabhu s, pai sb. punctate keratotic papules and plaques over palm. diagnosis: hypertrophic lichen planus of palm. indian j dermatol venereol leprol 2010;76:449. 6. sharma vk, achar a, ramam m, singh mk. multiple cutaneous horns overlying lichen planus hypertrophicus. br j dermatol 2001;144:424-5. 7. fried tk, flaig mj, ruzicka t, rupec ra. [verrucous squamous cell carcinoma complicating hypertrophic lichen planus. three case reports and review of the literature]. hautarzt 2011;62:40-5. [article in german]. 8. garg vk, nangia a, logani k, sharma rc. lichen planus: a clinico-histopathological. indian j dermatol venereol leprol 2000; 66:193. case report no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. dr [dermatology reports 2014; 6:5282] [page 5] angina bullosa hemorrhagica: report of 11 cases julieta ruiz beguerie,1 silvina gonzalez2 1dermatology department, austral university hospital, austral university, buenos aires; 2dermatology department, stomatology clinic, hospital de clinicas jose de san martin, buenos aires, argentina abstract angina bullosa hemorrhagica is a rare and benign disorder, usually localized in the subepithelial layer of the oral, pharyngeal and esophageal mucosa. the lesions are characterized by their sudden onset. they appear as a painless, tense, dark red and blood-filled blister in the mouth that rapidly expand and rupture spontaneously in 24-48 hours. the underlying etiopathology remains ill defined, although it may be a multifactorial phenomenon including diabetes, and steroid inhalers. the condition is not attributable to blood dyscrasias, nor other vesicular-bullous disorders. in this study, eleven patients with such blisters are described. physical examination of the patients revealed a single blister with hemorrhagic content localized in the oral mucosa. biopsy of the lesions showed sub epithelial blisters with a mild infiltrate. in general practice, dermatologists could face a blood-filled bullous lesion of the oral mucosa. recognition is, therefore, of great importance for dermatologists. introduction in 1967 badham was the first to introduce the term angina bullosa hemorrhagica (abh), a bullous disorder in which recurrent oral blood blisters appear in the absence of any identifiable systemic disorder, which heal uneventfully within 1 week.1,2 other names that have been given to this disorder are benign hemorrhagic bullous stomatitis and recurrent or traumatic oral hemophlyctenosis.3,4 it can be one or more blood-filled blisters occurring at the same time and it is usually not painful, occurring in adults between 50-70 years old. there is no strong predilection for either male or female. they all heal spontaneously without scarring.4,5 case report we studied 11 patients (4 males and 7 females) with abh. the mean age was 65 (range 46-86 years). all cases presented with a similar history of a single, localized blood-filled blister, which measured 4 to 7 mm in diameter (figure 1). the blister spontaneously burst in 2-4 days, leaving a hemorrhagic content flow and erosion for 7 to 10 days. on examination, the nikolsky sign was negative. recurrences were seen in 2 patients. eight of the 11 patients had the blister localized to the palate. the remaining three subjects had one lesion each localized to the lateral anterior third of the tongue, the gums and the jugal mucosa (figure 2). sixty four percent (7/11) had an associated systemic disease at the time of their initial visit. four of these 7 individuals had arterial hypertension and 2 others had well-controlled niddm (non-insulin dependent dm) (table 1). trauma by sharp edges of adjacent teeth and metal crowns were identified as etiological factors in 4 cases. lesions healed after removal of the metal crown and rounding of the sharp-edged teeth. patients did not report a tendency to bleed at other sites. laboratory evaluation failed to disclose any underlying illness. platelet counts and coagulation tests were within normal limits in all patients. the histopathology report in all cases reported a sub epithelial bulla filled with blood. additionally there was an underlying mild to moderate nonspecific mononuclear inflammatory cell infiltrate, which was generally limited to the region of the lamina propria. occasionally, neutrophils were seen. performing a biopsy of an intact bulla is difficult because of the short duration in which the lesion stays intact (24-72 hours). otherwise, a biopsy of a ruptured bulla only exhibits a nonspecific ulceration. direct immunostaining for immunoglobulin g, a, or c3 are consistently noncontributory. these patients were safely monitored with regular follow-ups due to minimal risk of complications. discussion abh presents clinically with blood-filled blisters that occur predominantly on the soft palate. they generally reach a diameter of 2±3 cm.6 they tend to burst spontaneously, leaving a ragged ulcer that heals without scarring. approximately 30% of patients may have a recurrence.4 occasionally patients may present clinically with hoarseness, or even blood-tinged sialorrhea. following the rupture of the blister, painful ulcers may be present. the incidence is similar in both sexes (women, 52%; men, 48%).4 laboratory evaluation, including cbc and coagulation profile, usually fails to disclose an underlying illness. its etiology remains obscure. abh has been associated with a constitutional predisposition, such as loose cohesion between the epithelium and the corium of the mucosa, or a weak anchorage of mucosal vessels. this may predispose to sub-epithelial hemorrhages. as potential etiological factors, it has also been linked to arterial hypertension, diabetes mellitus and the long-term use of inhaled steroids.4,7,8 grinspan et al., noted an association with diabetes mellitus, hyperglycemia, and/or a family history of diabetes in 44.4% of the 54 cases they studied with abh.4 stephenson published a large series of 30 patients, not finding a clear precipitating factor in 47% of the cases.6 there have been many precipitating factors described: trauma by a sharp cusp or edge of an adjacent tooth or metal crown, masticatory trauma, hot drinks, use of steroids, as well as dental or anesthetic procedures.6,9,10 the differential diagnosis is broad, including pemphigus, mucosal pemphigoid, cicatricial pemphigoid, epidermolysis bullosa acquisita, linear iga dermatosis, toxidermia, bullous lichen planus, erythema multiforme, oral amyloidosis and fixed drug eruption. haemorrhagic blisters can also appear in the setting of leukemia, vasculitis and other haematological and haemostatic disorders.11 dermatology reports 2014; volume 6:5282 correspondence: julieta ruiz beguerie, dermatology department, austral university hospital, av. juan domingo perón 1500, buenos aires 1629, argentina. tel.: +54.1230.448.2000 e-mail: jruiz@cas.austral.edu.ar key words: angina bullosa haemorrhagica, bullous hemorrhagica, oral mucosa blisters. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 2 january 2014. revision received: 6 february 2014. accepted for publication: 15 march 2014. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright j.r.beguerie and s.gonzalez, 2014 licensee pagepress, italy dermatology reports 2014; 6:5282 doi:10.4081/dr.2014.5282 no nco mm er cia l u se on ly [page 6] [dermatology reports 2014; 6:5282] the histopathology reveals haemorrhagic subepithelial bullae, non-specific ulceration and a chronic inflammatory cell infiltrate in the lamina propria.6 in 1990, edward was the first to document a case of an intradermal blister. this had not been described previously in the literature.9 direct immunofluorescence is usually negative, but equivocal immunostaining for igg and c3 has been previously reported.6,12 although the risk of asphyxia is probably remote, palatal or pharyngeal blisters should be ruptured in order to prevent upper airway obstruction. in rare occasions, the size of the bulla and the free blood in the larynx requires intubation of the trachea by either fibreoptic endoscopy or direct laryngoscopy, or securing the airway by surgical tracheostomy.12 treatment is symptomatic. lesions can be treated successfully with topical steroids. some lesions may heal after removal of the metal crown and rounding of the cusp preventing constant trauma.13-16 conclusions the aim of this paper is to report the clinical features and describe the management of 11 cases of abh. we feel it is extremely important to distinguish this benign disorder from other more serious blistering diseases of the oral mucosa with similar presenting features. this disorder is likely under-reported. the lack of knowledge of this entity makes it very likely to be under-diagnosed. the recognition of the lesion is of great importance to avoid misdiagnosis. the examination of the oral mucosa and the skin, together with the medical history are the keys to diagnosis. the prognosis is good and this should also be stressed when advising patients. in general practice, the dermatologist can be confronted with a blood-filled bullous lesion of the oral mucosa. recognition is, therefore, of great importance for dermatologists. case report table 1. characteristics of the patients with angina bullosa haemorrhagica. patient age gender associated disease location 1 73 f htn palate 2 86 f htn palate 3 65 m dbt, mi palate 4 57 m palate 5 46 f palate 6 66 f colon cancer palate 7 70 f prostate cancer palate 8 63 m alcoholism palate 9 48 m gums 10 84 f htn, breast cancer tongue 11 52 f jugal mucosa htn, hypertension; mi, myocardial infarction; dbt, diabetes. figure 1. single localized blood-filled blister of the oral mucosa (case 1). figure 2. blister in oral mucosa (other cases). no nco mm er cia l u se on ly [dermatology reports 2014; 6:5282] [page 7] references 1. badham nj. blood blisters and oesophageal casts. j laryngol otol 1967;81:791-803. 2. kirtschig g, happle r. stomatopompholyx haemorrhagica. j am acad dermatol 1994;31:804-5. 3. antoni-bach n, couilliet d, garnier j, et al. case for diagnosis. benign hemorrhagic bullous stomatitis. ann dermatol venereol 1999;126:525-6. 4. grinspan d, abulafia j, lanfranchi h. angina bullosa hemorrhagica. int j dermatol 1999;38:525-8. 5. deblauwe bm, van der waal i. blood blisters of the oral mucosa (angina bullosa haemorrhagica). j am acad dermatol 1994;31:341-4. 6. stephenson p, lamey pj, scully c, prime ss. angina bullosa haemorrhagica: clinical and laboratory features of 30 patients. oral surg oral med oral pathol 1987; 63:560-5. 7. horie n, kawano r, inaba j, et al. angina bullosa hemorrhagica of the soft palate: a clinical study of 16 cases. j oral sci 2008;50:33-6. 8. high as, main dmg. angina bullosa haemorrhagica: a complication of long-term steroid inhaler use. br dent j 1988;165: 176-9. 9. edwards s, wilkinson jd, wojnarowska f. angina bullosa haemorrhagica: a report of three cases and review of the literature. clin exp dermatol 1990;15:422-4. 10. guillot b. skin reactions to inhaled corticosteroids. clinical aspects, incidence, avoidance and management. am j clin dermatol 2000;1:107-11. 11. vaillant l, fontès v. bullous diseases of the oral mucosa. rev prat 2002;52:385-8. 12. pahl c, yarrow s, steventon n, et al. angina bullosa haemorrhagica presenting as acute upper airway obstruction. br j anaesth 2004;92:283-6. 13. yip hk. angina bullosa haemorrhagica: a case report and a concise review. gen dent 2004;52:162-4. 14. petruzzi m. angina bullosa haemorrhagica: a case report. j biol regul homeost agents 2009;23:125. 15. giuliani m, favia gf, lajolo c, miani cm. angina bullosa haemorrhagica: presentation of eight new cases and a review of the literature. oral dis 2002;8:54-8. 16. de las heras me, moreno r, núñez m, et al. angina bullosa hemorrhagica. j dermatol 1996;23:507-9. case report no nco mm er cia l u se on ly dr [dermatology reports 2011; 3:e47] [page 105] pseudolymphoma tattoo-induced giorgio pasolini,1 patrizia ghidini1, mariachiara arisi,1 alessandra pedretti,1 marco ungari2 piergiacomo calzavara pinton1 1department of dermatology and 2department of pathology, spedali civili di brescia, university of brescia, italy abstract tattooing has become more and more popular in today’s society. the most common dermatological tattoo complications are represented by hypersensitivity reaction to tattoo pigments like irritant and allergical contact dermatitis, development of lichenoid areas and granulomatous responses, such as sarcoid granulomas or foreign body granulomas. less frequently patients developing discoid lupus erythematous have been reported. pseudolymphoma is an uncommon reactive lymphocytic proliferation mimicking the histological and clinical features of a malignant skin lymphoma. we herein report a pseuldoymphoma limited to the red area of a multicolour tattoo of the leg. case report a 34-year-old man presented with a six months history of mildly itching plaque of the left leg that he developed two months after the injection of a tattoo (figure 1). the patient was otherwise in good health and he had no personal or family history of allergic diseases or contact dermatitis. at dermatological examination, we observed a 12 square centimeters persistent swelling of the red area of a multicolour (red, black, green, yellow and blue) tattoo of the left leg. there was no involvement of the regional lymphonodes. a 4 mm punch skin biopsy was performed and histopathological examination showed acanthosis, enlarged interpapillary ridges and compact ortho-hyperkeratosis overlying a dense dermal infiltrate of lymphocytes of small and moderate size without nuclear atypia, sometimes grouped in clusters and with exocitosis. scattered macrophages with small intracytoplasmic granules of brown pigment, fibrous reaction and focal erythrocyte extravasations were seen as well (figure 2). on immunohistochemical analysis the lymphoid infiltrate showed a cd3 + cd4 + phenotype, with scattered cd20 + b lymphoid cells (figure 3). cd30 + large cells were not detected. the plasma cell population showed a polytypical pattern of immunoglobulin lightchains. the histological architectural pattern suggested a diagnosis of t-cell pseudolymphoma. patch tests with the standard series recommended by the italian society of occupational and environmental allergological dermatology (sidapa) and with substances often present into tattoo dyes (ammonium chloride mercury, sulphate mercury (cinnabar), cadmium, copper, titanium, iron, chromium sulphate, chromium chloride, 2-[ethyl[4-[(4-nitrophenyl)azo]phenyl]amino],4-(4-nitrophen ylazo)aniline, ethyl (2-mercaptobenzoato-s) mercury sodium salt, paraphenylendiamine ) showed a strong erythematous vesicular reaction (3+) to ammonium chloride mercury, cinnabar and thimerosal after 48 hours. the patient refused the surgical removal of the tattoo. a topical therapy with clobetasol dipropionate twice daily was prescribed and at a three months follow-up visit the lesion appeared unchanged. discussion tattoing has become a common custom all over the world. complications deriving from body tattoos are relatively uncommon if we think to the whole number of persons that recurs to this technique; they can consist in irritant and allergic contact dermatitis to tattoo dyes, development of lichenoid reactions and granulomatous responses such as sarcoid granulomas or foreign body granulomas.1,2 also cases of discoid lupus erithematous have been reported.3 skin pseudolymphoma is a reactive proliferation of benign lymphocytes mimicking the histological and clinical features of a malignant lymphoma.2 the pathogenetic mechanisms are unclear. pseudolymphomas can be secondary to medications, arhtropod bites, borrelia infections, vaccines, uv light and tattoo dyes and they may be caused by persistent allergic contact dermatitis or to the subcutaneous injection of allergens.4 tattoo-induced pseudolymphomas are rare with fifteen cases reported so far.1,2,5 in these cases dye pigments in the dermis act as an antigen stimulus determining a proliferation of lymphoid cells;5 they can appear from few months to 6 years after a tattoo placement.5 the most cases were described following red tattoos in patients with delayed contact sensitivity to cinnabar (mercuric sulphate) but pseudolymphomas can occur also in blue (mainly cobalt salts) or green (mainly chrome salts) areas of tattoos.6 in the present case, a strong reaction to cinnabar has been found together with positivities to other red pigments (e.g. red one disperse, ammonium chlo dermatology reports 2011; volume 3:e47 correspondence: mariachiara arisi, department of dermatology, spedali civili di brescia, p.le spedali civili 1, 25123 brescia, italy. tel. +39.030.399.5300 fax. +39.030.399.53015. e-mail: mariachiara.arisi@gmail.com key words: pseudolymphoma, tattoo, allergic contact dermatitis. received for publication: 18 july 2011. revision received: 14 october 2011. accepted for publication: 24 october 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright g. pasolini et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e47 doi:10.4081/dr.2011.e47 figure 2. scattered macrophages with small intracytoplasmic granules of brown pigment, fibrous reaction and focal erythrocyte extravasations. figure 1. mildly itching plaque of the left leg. no nco mm er cia l u se on ly [page 106] [dermatology reports 2011; 3:e47] ride mercury) and thimerosal as preservative. tattoo pseudolymphomas have been traeted with topical or intralesional corticosteroids, surgical excision or laser treatment.7 a complete regression of the skin lesions has been described also after the assumption of hydroxycloroquine sulphate6 and a spontaneous remission of the disease has also been reported.5 in our case, at three months follow up skin lesions remained substantially unchanged despite a topical corticosteroid therapy and the patient was lost at follow-up. altought pseudolymphoma is considered a benign disease7 a prolonged follow up is mandatory because of the reported hazard of progression of cutaneous pseudolymphoma to lymphoma. sangueza et al. described the progression of a tattooinduced t-pseudolymphoma, with 10-20% b-cells and characteristics of benign hystology, into a malignant monoclonal b-cell large lymphoma.8 references 1. sowden jm, byrne jp, smith ag, et al. red tattoo reactions: x-ray microanalysis and patch-test studies. br j dermatol 1991; 124:576-80. 2. shin jb, seo sh, kim bk, kim ih. delayed cutaneous t cell pseudolymphoma at the site of a semipermanent lip-liner tattoo. dermatology 2009;218:75-8. 3. kazandjieva j, tsankov n. tattoos: dermatological complications. clin dermatol 2007;25:375-82. 4. kuo we, richwine ee, sheehan dj. pseudolymphomatous and lichenoid reaction to a red tattoo: a case report. cutis 2011;87:89-92. 5. gutermuth j, hein r, fend f, ring j. cutaneous pseudolymphoma arising after tattoo placement. j eur acad dermatol venereol 2007;21:536-78. 6. patrizi a, raone b, savoia f, et al. tattooinduced psudolymphomatous reaction and its successful treatment with hydroxychloroquine. acta derm venereol 2009; 89:327-8. 7. chiang c, romero l. cutaneous lymphoid hyperplasia (pseudolymphoma) in a tattoo after far infrared light. dermatologic surg 2009;35:1434-8. 8. sangueza op, yadav s, white cr jr. evolution of b-cell lymphoma from pseudolymphoma. a multidisciplinary approach using histology, immunohistochemistry, and southern blot analysis. am j dermatopathol 1992;14:408-13. case report figure 3. immunohistochemical analysis showed a cd3+ and cd4+ lymphoid phenotype no nco mm er cia l u se on ly dr [page 12] [dermatology reports 2014; 6:5498] mucinous eccrine carcinoma of the eyelid: re-emphasizing the need for awareness of rare lesions kiran krishne gowda, parimal agarwal, amanjit bal department of histopathology, post graduate institute of medical education and research, chandigarh, india abstract we report here the case of a man presenting with mucinous eccrine carcinoma (mec) involving eyelid. this is a rare adencocarcinoma of the skin that originates from the deepest portion of eccrine sweat duct. the aim of our paper is to underline the importance of distinguishing mec from metastatic carcinomas of the skin, making clinicians aware that what seems to be a harmless benign lesion may be a malignant one. introduction mucinous eccrine carcinoma (mec) is a rare form of adenocarcinoma of skin, first described by mendoza and helwigin 1971.1 the clinical appearance of this lesion is varied and can be in form slow-growing, solitary, asymptomatic, flesh-colored nodule or can have ulcerated lesion. due to varied clinical appearance, the differential diagnoses ranges from benign to malignant lesions, thus requiring histopathological examination for diagnosis. case report a 56 year old man presented with a 10×15 mm smooth, bluish-red nodule over the right lower eyelid of 2 months duration. there was no extension into adjacent bony structures. his vision was intact. his physical examination did not reveal any lymphadenopathy and systemic examination was unremarkable. imaging studies did not reveal any lesions in other organs of the body. with clinical diagnosis of benign adnexal tumor of eyelid, wide local excision of the lesion was performed with 5 mm margins. histopathological examination showed a circumscribed tumor within the dermis, divided into numerous compartments by fibrous strands. the compartments showed tumor cells in nests, cords and few tubules with pools of extracellular mucin in the background (figure 1). the tumor cells showed mild nuclear atypia with abundant amount of cytoplasmic mucin. the mucin (intra and extra-cellular) showed positive reactions with periodic acid schiff and was resistant to diastase. alcian blue staining of mucinous material revealed strong positivity at ph 2.5 and weak positivity at ph 0.4 indicating that mucin is non-sulfated and represents sialomucin which represents epithelial mucin, suggesting an eccrine origin.2 immunohistochemistry for cytokeratin 7 was positive while, cytokeratin 20 and thyroid transcription factor-1 (ttf-1) were negative. thus a diagnosis of mucinous eccrine carcinoma of the right eyelid was made. on 6 months follow up, patient does not have recurrence, any regional or distant metastasis. he is currently on annual control for early detection of recurrence, metastasisregional or distal. discussion and conclusions mucinous eccrine carcinoma generally affects patients in their 60s, with a male:female ratio of 2:1. it is considered a proliferation of cells that originates from deepest portion of eccrine sweat duct. it is most commonly found on eyelid (38%) but can also occur on face (20.3%) and scalp (16%).3 the clinical appearance is varied and can be in form of slow-growing, solitary, asymptomatic, flesh-colored nodule, similar to the present case or can have ulcerated lesion. the clinical differential diagnosis ranges from benign lesions like lipoma, neuroma and cutaneous cysts to malignant tumors like basal cell carcinoma, sebaceous carcinoma, melanoma and metastatic adenocarcinoma. although clinical presentation is heterogeneous, histology of mec is quite characteristic and distinct from above mentioned lesions aiding in its diagnosis. its characteristic feature includes large pools of extracellular basophilic mucin, containing tumor cells with focal tubule formation indicating eccrine differentiation.2 the tumor cells are more atypical in metastatic type, which invade between collagen bundles at the margin of the nodule. however, its definitive diagnosis requires exclusion of metastatic visceral malignancy, especially from mucinous carcinoma breast, lung and colorectal tumors. it is important to differentiate this tumor from a metastatic mucinous adenocarcinoma which can be done by tissue-specific special stains and immunostains. mec stains positive for periodic acid-schiff, alcian blue at ph 2.5 and is negative at ph 0.4 differentiating mec from other sweat gland tumors and gastrointestinal neoplasms which contain sulfomucin rather than sialomucin. mucinous eccrine carcinomas may be positive for cytokeratins (ck7, cam5.2), carcinoembryonic antigen (cea), epithelial membrane antigen (ema), estrogen receptor (er), progesterone receptor (pr), p63, mucous-associated peptides of the trefoil factor family (tff1 and 3), tumor-associated glycoprotein (tag-72).4-6 cytokeratin 20 stains most colorectal carcinomas while it is absent in mec. metastatic breast carcinomas also share staining characters with mec making it difficult to rely solely on immunohistochemical stains. adenocarcinomas of lung stain positively with ttf-1 while mec do not stain with the antibody. although immunohistochemical staining pattern can help differentiate mec from metastatic tumors, it cannot be used with 100% certainty. a final diagnosis can be made by thorough clinical investigation and systemic imaging, which excludes presence of a more common primary mucinous carcinoma of lung, gastrointestinal tract and other sites, which was done in present case. other important feature that helps in making diagnosis of mec is its characteristic histology and histochemical staining as seen in current case. because of rarity of mec, there is neither a definite staging method nor standard guidelines for treatment. surgery is the treatment of choice as mucinous eccrine carcinoma is resistant to radiotherapy and chemotherapy. wide local excision with 5 mm margins is preferred. the high recurrence rate reported in literature is attributed to incomplete excision dermatology reports 2014; volume 6:5498 correspondence: amanjit bal, department of histopathology, post graduate institute of medical education and research, sector 12, chandigarh, 160012, india. tel.: +91.172.2747.585. e-mail: docaman5@hotmail.com key words: eyelid, mucinous eccrine carcinoma. contributions: kkg, pa, participated in writing the manuscript along with photography; ab, participated in writing and editing the manuscript. conflict of interests: the authors declare no potential conflict of interests. received for publication: 29 may 2014. revision received: 2 august 2014. accepted for publication: 11 august 2014. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright k.k. gowda et al., 2014 licensee pagepress, italy dermatology reports 2014; 6:5498 doi:10.4081/dr.2014.5498 no nco mm er cia l u se on ly [dermatology reports 2014; 6:5498] [page 13] of the tumor. in recurrent cases and sites such as eyelid, moh’s micrographic surgery (with 2 mm margins) is preferred as it ensures the complete removal of the tumor along with its margins, and is tissue preserving. due to the rarity of this entity, the usefulness of sentinel lymph node biopsy and regional lymphadenectomy is not proven.6 however rarity of this tumor precludes comparative evaluation of treatment. local recurrence rate of mec varies from 0-33% in the literature.7,8 metastasis to regional lymph node is rare (10%) with distant metastasis in 3% of cases. mortality has also been reported to be low (<2%) in previous published studies.7 in summary, it is important to distinguish mec from metastatic carcinomas to skin. the high degree of differentiation, intercellular cohesion, limited angiogenesis and extensive mucin production, which shields tumor antigens are factors which prevent loco-regional and systemic metastasis. the clinicians should be aware that what appears to be a harmless benign lesion may be a malignant. though indolent tumor it requires concerted effort from clinician, radiologist and pathologist in combination to make a definitive diagnosis of mec. references 1. lennox b, pearse ag, richards hg. mucin secreting tumors of the skin with special reference to the so-called mixed-salivary tumor of the skin and its relation to hidroadenoma. j pathol bacteriol 1952;64: 865-80. 2. headington jt. primary mucinous carcinoma of skin: histochemistry and electron microscopy. cancer 1977;39:1055-63. 3. snow sn, reizner gt. mucinous eccrine carcinoma of the eyelid. cancer 1992;70:2099-104. 4. carson hj, gattuso p, raslan wf, reddy v. muinous carcinoma of the eyelid. an immunohistochemical study. am j dermatopathol 1995;17:494-8. 5. zhang q1, wojno th, fitch sd, grossniklaus he. mucinous eccrine adenocarcinoma of the eyelid: report of 6 cases. can j ophthalmol 2010;45:76-8. 6. coan eb1, doan a, allen c. mucinous eccrine carcinoma: a rare case of recurrence with lacrimal gland extension. ophthal plast reconstr surg 2012;28:e10910. 7. breiting l, christensen l, dahlstrøm k, et al. primary mucinous carcinoma of the skin: a population-based study. int j dermatol 2008;47:242-5. 8. wright j, font rl. mucinous sweat gland adenocarcinoma of the eyelid: a clinicopathologic study of 21 cases with histochemical and electron microscopic observations. cancer 1979;44:1757 case report figure 1. a well circumscribed tumor in the dermis, divided into numerous compartments by fibrous strands. each compartment consists of tumor cells surrounded by abundant mucin (hematoxylin & eosin: a, 10×; b, 20×). focal tubules with lumen can also be noted (hematoxylin & eosin: c, 40×). alcian blue stain at ph 2.5 highlighting the mucin (d, 40×). no nco mm er cia l u se on ly dr [dermatology reports 2015; 7:5712] [page 25] two episodes of cutaneous non-tuberculous mycobacterial infection in a patient with psoriasis wai sze agnes chan,1 shang-ian tee,1 nisha su yien chandran,2 jiun yit pan1 1department of dermatology, national skin centre; 2department of dermatology, national university hospital, singapore abstract non-tuberculous mycobacteria (ntm) are a group of environmental pathogens, which cause a broad spectrum of disease. the incidence of ntm infection is increasing, especially in immunocompromized patients. the past three decades also saw a rapid increase in the incidence of ntm infection involving otherwise healthy subjects. we report a case of cutaneous ntm infection in a 79-year-old chinese woman, who was receiving methotrexate for psoriasis. mycobacterial culture grew mycobacterium abscessus, and the lesions cleared with a combination of oral clarithromycin, ciprofloxacin and doxycycline. interestingly, she then developed a second episode of cutaneous ntm infection with mycobacterium haemophilum over the same body region, five years after stoppage of methotrexate. both episodes were separated in time and involved different species, indicating that they were independent from each other. we further discuss the risk factors for cutaneous ntm infection, treatment, and highlight the need for diagnostic vigilance. case report a 79-year-old chinese female has been on follow-up at a specialist dermatological center in singapore for psoriasis vulgaris. following a pustular flare in october 2004, she was commenced on oral methotrexate (mtx) 2.5-7.5 mg weekly. a year later after having consumed a cumulative mtx dose of 390 mg, she noted the appearance of a new rash on the right antecubital fossa. she did not recall any preceding trauma at that region, including acupuncture or tattoos. physical examination showed a 17×10 cm erythematous coalescent ulcerated plaque studded with pustules. she was treated initially as for irritant contact dermatitis and erysipelas; however, there was no improvement despite six months of therapy with topical steroids and beta-lactam antibiotics. a skin biopsy was then performed, which revealed a suppurative granulomatous infiltrate consisting of neutrophils, histiocytes and langhans giant cells within the dermis (figure 1). acid-fast bacilli were not demonstrated on ziehl-neelsen stain; however tissue culture was positive for non-tuberculous mycobacteria (ntm), which was identified as mycobacterium abscessus on polymerase chain reaction (pcr). mtx was stopped and she was prescribed a combination of oral clarithromycin 500 mg, ciprofloxacin 500 mg and doxycycline 100 mg twice daily for six months with complete resolution of the lesion. there were no further infective episodes until august 2011, when she presented with another erythematous papulopustular rash over her right forearm and elbow (figure 2). she had not received systemic immunosuppressive therapy in the past five years and she did not report any local trauma. there were no findings on history and physical examination to suggest an underlying immunodeficiency disorder. laboratory tests including fasting blood glucose levels and hiv serology were normal, while total white cell count and differentials were within normal limits. skin biopsy revealed a dermal granulomatous dermatitis (figure 3). tissue culture confirmed the presence of ntm, identified as mycobacterium haemophilum on pcr. she was treated with clarithromycin 500 mg and ciprofloxacin 500mg twice daily with complete clearance of the lesion after ten months. she remains well on her last follow-up visit with us. discussion non-tuberculous mycobacteria are free living, fastidious aerobic acid fast bacilli organisms widely distributed in the environment. six clinical syndromes account for most infections caused by ntm including pulmonary disease, lymphadenitis, skin or soft tissue infections, skeletal (bone, joint, tendon), foreign body and central venous catheter infection, and disseminated diseases.1 infection is more common in patients who are immunocompromized. runyon identified and divided ntm into slow growing groups, basing on their ability to produce pigment, and rapidly growing groups (rgm) such as m. abcessus, m. fortuitum, and m. chelonae.2 the most common ntm species to cause cutaneous disease are m. marinum and rgm.3 recent epidemiological studies have confirmed that the incidence of cutaneous ntm infection is increasing worldwide, highlighting the importance of recognizing this entity.4,3 the rising incidence has been attributed to improved diagnostic techniques as well as the popularity of cosmetic and medical procedures, which carry a risk of contamination. cutaneous infection presents with myriad clinical signs ranging from erythematous plaques, papules or pustules to subcutaneous nodules, abscesses and ulcers. direct inoculation via penetrating injury is an important route of infection,4 and most cases involve the extremities. unfortunately a history of antecedent trauma is not always elicited or may be missed, especially given the long incubation period of certain organisms (up to 12 months for m. abscessus).5 this was the case of our patient, whose disease was picked up on skin biopsy only after six months of empirical treatment. afb staining has a low yield of 36.2%,2 and identification of ntm species may require pcr testing. indeed, misdiagnosis occurs in up to 82% of cases,6 emphasizing the need for a high index of suspicion, requesting for mycobacterial culture, and repeating biopsies in clinical scenarios where a patient may be at risk. immunosuppression is an important risk factor for ntm infection and is likely to have contributed to our patient’s initial episode, having occurred after 14 months of therapy with mtx. although her cumulative dose was only 390 mg, it has been noted that even low doses of mtx may induce b cell suppression and inhibit differentiation, leading to susceptibility to infection.7 opportunistic infections such as pneumocystis carinii pneumonia, mycobacterium avium-intracellulare pneumonia and disseminated histoplasmosis have been reported after mtx therapy as short as 11 weeks to 17 years duration.8 in immunocompromized hosts, cutaneous ntm infection dermatology reports 2015; volume 7:5712 correspondence: wai sze agnes chan, department of dermatology, national skin centre, 1 mandalay road, 308205 singapore. tel.: +65.9364.7239 fax: +65.6352.3225. e-mail: agneschan@nsc.gov.sg key words: mycobacterium abscessus; mycobacterium hemophilum; cutaneous; non tuberculous mycobacteria; psoriasis. contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. received for publication: 10 november 2014. revision received: 30 march 2015. accepted for publication: 26 april 2015. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright w.s.a. chan et al., 2015 licensee pagepress, italy dermatology reports 2015; 7:5712 doi:10.4081/dr.2015.5712 no n c om me rci al us e o nly [page 26] [dermatology reports 2015; 7:5712] presents more frequently, sometimes without associated inciting skin injury, and often involving multiple sites and/or deeper tissues. our patient was infected with a second episode of cutaneous ntm with a different species with m. haemophilum; hence the two episodes are distinct and not due to re-activation of latent infection. an inciting factor for the second episode is less obvious given the absence of trauma or drug-induced immunosuppression. moreover, patients with psoriasis usually do not carry an increased risk of skin infection, due to up-regulation of antimicrobial peptides and cathelicidins, compared to patients with eczema or those with normal skin.9 an underlying immunodeficiency syndrome, previously reported in other families susceptible to mycobacteria,10,11 seems unlikely in our patient given the absence of other recurrent infections to suggest defects in her cellular immune response. we instead postulate that her advanced age, along with the presence of dry and fissured psoriatic plaques, has led to skin barrier problems causing an increase in skin fragility, thereby compromising the innate immunity of skin and facilitating entry of mycobacteria with consequent infection. the importance of diagnostic vigilance is crucial, as a delay of up to 7.1 months from initial clinical presentation to commencement of treatment has been reported.6 the choice of antimicrobial treatment depends on species identification and the outcome of susceptibility testing. most studies recommend clarithromycin alone or in combination with fluoroquinolones or tetracyclines for 4 to 6 months to treat rapid-growing mycobacteria such as m. abscessus, with a curative rate of 87%.12 m. haemophilum is resistant to isoniazid and ethambutol in vitro, and experts recommend a combination of clarithromycin, ciprofloxacin and a rifamycin antibiotic. optimal duration of therapy is not known, and common recommendation is to continue treatment for 4 to 6 weeks upon resolution of cutaneous lesion.4,13 immunocompromized patients have cutaneous lesions which lasts several months longer than immunocompetent patients and are at higher risk of complications such as deep tissue infections;14 duration of treatment should therefore be longer with evaluation for surgical intervention including incision and drainage. conclusions non tuberculous mycobacterium organisms are widespread in the environment, and exposure is common. we have encountered a patient with psoriasis who was treated for two separate episodes of cutaneous ntm infection; first while she was receiving immunosuppres case report figure 1. this is composed of suppurative granulomas containing aggregates of neutrophils surrounded by histiocytes and lymphocytes (hematoxylin and eosin, 200×). figure 2. erythematous papulopustular plaque at flexor surface of the right forearm. figure 3. higher power reveals an infiltrate of histiocytes admixed with langhans-type giant cells and surrounded by numerous lymphocytes, plasma cells and neutrophils (hematoxylin and eosin, 100×). no n c om me rci al us e o nly [dermatology reports 2015; 7:5712] [page 27] sive therapy, and second, much later on, when she was apparently healthy with no known predisposing factors, with m. abscessus and m. haemophilum respectively. we propose that she was susceptible to cutaneous ntm infection due to advanced age and defective skin barrier, leading to implantation of ntm organism to the skin. immuno suppressive therapy was an additional risk factor in the first episode. with the rise in incidence of cutaneous ntm infection, physicians must have a high index of suspicion, especially in patients with non-resolving lesions of the upper distal extremities with a history of antecedent trauma, including acupuncture or medical procedures. references 1. no authors listed. diagnosis and treatment of disease caused by nontuberculous mycobacteria: this official statement of the american thoracic society was approved by the board of directors, march 1997. medical section of the american lung association. am j respir crit care med 1997;156:s1-25. 2. runyon eh. anonymous mycobacteria in pulmonary disease. med clin north am 1959;43:273-304. 3. hsiao ch, tsai tf, hsueh pr. characteristics of skin and soft tissue infection caused by non-tuberculous mycobacteria in taiwan. int j tuberc lung dis 2011;15:811-7. 4. wentworth ab, drage la, wengnack nl, et al. increased incidence of cutaneous nontubeculous mycobacterial infection, 1980 to 2009: a populationbased study. mayo clin proc 2013;88:38-45. 5. fitzgerald da, smith ag, lees a, et al. cutaneous infection with mycobacterium abscessus. br j dermatol 1995;132:800-4. 6. dodiuk-gad r, dyachenko p, ziv m, et al. nontuberculous mycobacterial infections of the skin: a retrospective study of 25 cases. j am acad dermatol 2007;57:413-20. 7. olsen nj, callahan lf, pincus t. immunologic studies of rheumatoid arthritis patients treated with methotrexate. arthritis rheum 1987;30:481-8. 8. lemense gp, sahn sa. opportunistic infection during treatment with low dose methotrexate. am j respir crit care med 1994;150:258-60. 9. morizane s, gallo rl. antimicrobial peptides in the pathogenesis of psoriasis. j dermatol 2012;39:225-30. 10. newport mj, huxley cm, huston s, et al. a mutation in the interferon gamma receptor gene and susceptibility to mycobacterial infection. n engl j med 1996;335:1941-9. 11. chetchotisakd p, mootsikapun p, anunnatisiri s, et al. disseminated infection due to rapidly growing mycobacteria in immunocompetent hosts presenting with chronic lymphadenopathy: a previous unrecognized clinical entity. clin infect dis 2000;30:29-34. 12. kothavade rj, dhurat rs, mishra sn, et al. clinical and laboratory aspects of the diagnosis and management of cutaneous and subcutaneous infections caused by rapidly growing mycobacteria. eur j clin microbiol infect dis 2013;32:161-88. 13. wagner d, young ls. nontuberculous mycobacterial infections: a clinical review. infection 2004;32:257-70. 14. lee wj, kang sm, sung h, et al. nontuberculous mycobacterial infections of the skin: a retrospective study of 29 cases. j dermatol 2010;37:965-72. case report no n c om me rci al us e o nly dr [dermatology reports 2011; 3:e51] [page 113] cutaneous lesions as presentation form of mantle cell lymphoma nayra merino de paz,1 marina rodríguez-martín,1 patricia contreras ferrer,1 sonia garcía-hernández,2 nieves hernández-león,2 antonio martín-herrera,2 antonio noda-cabrera1 1dermatology and 2pathology department, hospital universitario de canarias, university of la laguna, la laguna, tenerife, spain abstract mantle cell lymphoma is a type of nonhodgkin lymphoma that affects extranodal areas, especially, bone narrow, digestive tract and waldeyer ring. here we report a case of mantle cell lymphoma iv ann arbor stage with cutaneous lesions on nasal dorsum and glans penis as the first manifestations. skin involvement is a very rare manifestation and less than 20 cases have been reported in the literature. the importance of establishing multidisciplinary relationships for a global approach has been shown by this clinical case. introduction mantle cell lymphoma (mcl) is a type of non-hodgkin lymphoma that frequently affects extranodal areas, especially, bone narrow, digestive tract and waldeyer ring. other areas can also be affected too, however skin involvement is very rare.1,2 mcl is characterized by specific morphologic, inmunophenotypic and cytogenetic features [t(11;14)(q13;q32)] and cyclin d1 overexpression.3 case report we report a 73-years-old man with a personal history of bilateral cataracts, facial right paralysis, vertiginous syndrome treated with trimetazidin and teleangiectasic rosacea without treatment. he was referred to our department from otolaryngology (orl) where he was assessed for presenting nasal obstruction three months ago. no fever, asthenia or anorexia were reported. physical examination revealed: i) papular erythematous, infiltrated, 2.5 ¥ 2 cm of diameter lesion on nasal dorsum; ii) exulcerative, exudative lesion with an erythematous edge about 3¥4 cm of diameter in glans penis were observed (figure 1). blood test and cutaneous biopsies were performed. histological examination of cutaneous lesions on face and penis showed diffuse lymphocytic proliferation with middle size cells with irregular and clefted nucleous (figure 2). moderate mitotic activity was observed. immunochemistry was positive for cd-20 and d1-cyclin and negative for cd3 and cd10. ki67 showed a high proliferation rate (figure 3). these results were consistent with mantle cell lymphoma (mcl). blood tests, including hemogram, biochemistry and hepatic profile were in normal ranges. orl study included a turbinate biopsy. diffuse lymphocytic tumoral proliferation infiltrates with middle size tumoral cells were observed. tumoral cells showed clefted and irregular nucleous with granular chromatin, moderate mitotic rate and apoptotic bodies. bone narrow biopsy, thorax rx, ct scan, mri, pet and cytogenetic study were performed. limphocytic infiltrates showing features of mcl were observed in bone narrow. multiple adenopathies and heterogeneous high intensity sings in both lungs were observed in pet studies (figure 4). cytogenetic studies were performed and t(11;14) was observed by fish. after hematologic and dermatologic assessment mcl iva ann arbor stage and intermediate-high ipi diagnosis was established. four cycles of r-chop were administered every 21 days. a clear improvement after two cycles was observed (figure 3). two years later, the patient is still alive with hematological, orl and dermatological periodical controls. discussion the mcl represents around 10% of nonhodgkin lymphomas (nhl). it usually affects medium or elder people. skin involvement is rare, nevertheless, it can be the first manifestation of mcl. only 19 cases of cutaneous mcl have been reported in the literature. it represents 2-6% of all nhl and the 17% are in stage iv. men are more frequently affected than women (13:4) with a mean age of 63years-old. lesions usually appear in trunk, in contrast with our patient that presented the lesions first in face and genital area. a high variety in clinical appearence has been described. nodular lesions are the most frequent clinical presentation, but macules, papules or plaques have been described too. our patient presented two diferent clinical forms; nasal dorsum with papular presentation and ulcerative clinical appearence in glans penis. genital ulcerative form of cutaneous mcl is uncommon. up to 82% of patients with skin lesions present coexisting extracutaneous involvement, so extension studies are necessary to find other affected organs including blood tests, rx, ct scan, mri and pet. mcl has a median survival of 35 years, with a better prognosis in patients with non-nodal disease. mcl is associated to a poor prognosis.3,4 the median survival time dermatology reports 2011; volume 3:e51 correspondence: nayra merino de paz, servicio de dermatología, hospital universitario de canarias, ofra s/n. la laguna, santa cruz de tenerife, 38320 canary islands, spain. tel. +34.22.678.492 fax: +34.22.319.293. e-mail: nayradepazhotmail.com key words: cutaneous lymphoma, non-hodgkin, mantle cell. contributions: nmdp, nrm, and, manuscript writing; sgh, nhl, amh, pathology studing; nmdp, pcf, sgh, nhl, amh, data collecting and analyzing; mrm, pcf, anc, manuscript reviewing. conflict of interest disclosure: any author have a perceived or actual conflict of interest. received for publication: 21 july 2011. revision received: 7 october 2011. accepted for publication: 9 november 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright n. merino de paz et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e51 doi:10.4081/dr.2011.e51 figure 1. clinical appearance of cutaneous lesions on face and glans penis. no nco mm er cia l u se on ly [page 114] [dermatology reports 2011; 3:e51] is aproximately 3 years (range 2-5 years). the ten year survival rate is only 5-10%. younger age and limited diseases are favorable prognostic features. survival behavior of patients with cutaneous involvement is showed in table 1. the skin involvement is considerer as independent prognostic factor, but it is uncertain.3,5,6 treatment is difficult. first-line treatments for solitary lesions include surgical excision, antibiotics, and radiotherapy. systemic involvement needs an aggressive management. only 30% of patients experienced a complete response. it is based in single akylating agents, cvp (cyclophosphamide, vincristine and prednisone) and chop (cyclophosphamide, doxorubicin, vincristine and prednisone) regimens, hyper-cvad (hyperfractionated cyclophosphamide, doxorubicin, vincristine, and dexamethasone) with or without rituximab, r-chop (chop plus rituximab) or hyper-cvad with autologous stem cell transplantation. our patient was treated with r-chop with a complete response. r-chop have showed a higher complete response rate than chop. complications from chemotherapy may include infection, neutropenia, anemia, and thrombocytopenia, fatigue, neuropathy, dehydration after diarrhea or vomiting and cardiac toxicity from doxorubicin.6,7 only orl area involvement is also rare. so, our patient presented with a very unique clinical picture. in fact, sinonasal lymphomas are relatively uncommon and represent less than 1% of all head and neck malignancies. t/nk cell lymphoma is the most frequent in nasal cavity, however b-cell lymphoma is the main type in paranasal sinuses.8,9 so, here we present a rare case of mcl with cutaneous and nasal cavity lesions as presentation signs. the role of dermatologists is very important, in establishing an early diagnosis. we have to consider this entity in the dermatologic differential diagnosis of tumours and we have to be aware about the importance of multidisciplinary approach. case report figure 3. clinical appearance after treatment. table 1. skin manifestation of mantle cell lymphoma. n author age/gender extracutaneous stage prognosis involvement 1 ellison 66m yes iv d (55 days after hospitalizazion) 2 geerts 65f yes iva d (1.5 years after diagnosis) 3 geerts 77f yes iva 4 bertero 51m yes iva a (17 years after diagnosis) 5 bertero 78f no ie d (3 years after diagnosis) 6 bertero 43m yes iva a 7 bertero 22m no ie a 8 marti 61f yes iva d (15 months after diagnosis) 9 moody 47m yes iva a (3 years after onset) 10 dubus 56m yes iva d (1 year after treatment) 11 dubus 89m yes iva d (5 days after diagnosis) 12 dubus 72m yes iva a (1 year after treatment) 13 sen 85m yes ivb d (20 months after onset) 14 sen 76m no ie a (30 months after onset) 15 sen 56m yes iva a (21 months after onset) 16 sen 57m yes ivb d (19 months after onset) 17 sen 61m yes ivb d (17 months after onset) 18 motegi 62m yes a (4 months after diagnosis) 19 estrozi 72m yes iva a (6 months after diagnosis) 20 merino 73m yes iva a (2 years after diagnosis) most of data adapted from motegi s, okada e, nagai y, tamura a, ishikawa o. skin manifestation of mantle cell lymphoma. eur j dermatol. 2006 jul-aug; 16(4):435-8. d, dead; a, alive. figure 2. histological finding: a, b) hema-toxylin and eosin; c) cd20; d) cd3; e) cd10 and f ) d1-cyclin stains. no nco mm er cia l u se on ly [dermatology reports 2011; 3:e51] [page 115] references 1. estrozi b, sanches ja jr, varela pc, bacchi ce. primary cutaneous blastoid mantle cell lymphoma-case report. am j dermatopathol 2009;31:398-400. 2. sen f, medeiros lj, lu d, et al. mantle cell lymphoma involving skin: cutaneous lesions may be the first manifestation of disease and tumors often have blastoid cytologic features. am j surg pathol 2002 26:1312-8. 3. motegi s, okada e, nagai y, e al. skin manifestation of mantle cell lymphoma. eur j dermatol 2006;16:435-8. 4. lai r, medeiros lj. pathologic diagnosis of mantle cell lymphoma. clin lymphoma 2000;1:197-208. 5. bosch f, lopez-guillermo a, campo e, et al. mantle cell lymphoma: presenting features, response to therapy, and prognostic factors. cancer 1998;1:567-75. 6. swerdlow sh, kurrer m, bernengo m, buchner s. cutaneous involvement in primary extracutaneous b-cell lymphoma. in: weedon d, leboit p, burg g, sarasin a, eds. pathology and genetics of tumors of the skin: who classification of tumors. lyon: iarc, 2005. pp 204-6. 7. weigert o, unterhalt m, hiddemann w, dreyling m. mantle cell lymphoma: stateof-the-art management and future perspective. leuk lymphoma 2009;50:193750. 8. van prooyen keyzer s, eloy p, delos m, et al. sinonasal lymphomas. case report. acta otorhinolaryngol belg 2000;54:45-51. 9. vidal rw, devaney k, ferlito a, et al. sinonasal malignant lymphomas: a distinct clinicopathological category.ann otol rhinol laryngol 1999;108:411-9. case report figure 4. upper side: preauricular, retroauricular, occipital, submandibular, subcarinal, right hilum and groin lymphadenopathies, heterogeneuos. lower side: high intesity sings in both lungs were observed in pet studies. no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. dr [dermatology reports 2011; 3:e55] [page 125] long-term safety, tolerability, and efficacy of vismodegib in two patients with metastatic basal cell carcinoma and basal cell nevus syndrome glen j. weiss,1 raoul tibes,1 lisa blaydorn,1 gayle jameson,1 molly downhour,1 erica white,1 ivor caro,2 daniel d. von hoff1 1virginia g. piper cancer center at scottsdale healthcare, scottsdale, az, 2genentech, south san francisco, ca, usa abstract tumor responses in advanced basal cell carcinoma (bcc) have been observed in clinical trials with vismodegib, a smo antagonist. the result of smo antagonism is inhibition hedgehog signaling pathway (hhsp) downstream target genes. hhsp inhibition has been shown to affect stem cells responsible for blood, mammary, and neural development. we report on our experience of treating two patients with advanced bcc participating. these two patients have had no new bccs develop for at least 2.25 years. both patients have been receiving ongoing daily treatment with vismodegib for greater than 2.75 years without experiencing any significant side effects. after prolonged continuous daily dosing with a smo antagonist, we have not observed a significant alteration in hematologic parameters or physical abnormalities of the pectoral regions of two patients with advanced bcc. introduction the hedgehog signaling pathway (hhsp) is an important pathway for growth and development, including promotion of primitive hematopoietic,1 neural,2 and mammary3 stem cells. it is also required to bring the hair follicle from the resting to the growth phase.4 loss of heterozygosity and inactivation mutations in ptch1 and smo have been implicated in the development of the majority of basal cell carcinomas (bccs)5-7 and in patients with basal cell nevus syndrome (bcns).7,8 vismodegib (gdc-0449) is a synthetic small molecule inhibitor of smo that blocks downstream hhsp target genes; it has favorable pharmaceutical properties and greater potency than cyclopamine.9,10 a phase i dose-finding, safety, and tolerability study of vismodegib in patients with advanced bcc and solid tumors was conducted, demonstrating primarily mild to moderate side effects.6,7 here we report on our experience of treating two patients with advanced bcc participating in the phase i study6,7 who have received ongoing daily treatment for 2.75–>3 years without experiencing any significant side effects that might be anticipated with chronic hhsp inhibition. case report #1 a 49-year-old caucasian man presented to our clinic with bcc metastatic to the lung and lymph nodes of the left neck. eight years earlier he had been treated with cryotherapy and imiquimod cream for bccs on the neck. approximately 6.5 years later, he underwent his first surgical excision of cutaneous bcc of the neck and margins were reportedly positive. subsequently, he was found to have multifocal metastatic bcc in the lungs, confirmed by video-assisted thoracic surgery (vats) removal of a 1.5 cm left lower lung mass 1 month before evaluation at our clinic. his medical history was otherwise unremarkable except for approximately 2 years of heavy drinking; he had since abstained for over 2 years. physical examination was significant for healed left flank scar from vats, several hard, fixed palpable lymph nodes in the left posterior cervical chain measuring 1-3 cm, and a 3.1 cm hard fixed left supraclavicular lymph node. there were small cutaneous bccs in the left supraclavicular region, left neck (figure 1a), and left forearm (one each). computed tomography (ct) imaging revealed multiple pulmonary nodules (~20, the largest was 1.4 cm) (figure 1b) and multiple left neck (figure 1c) and supraclavicular lymph node involvement (size ranging from 1.4 to 3.1 cm). fluorine-18-2-fluoro-2-deoxy-d-glucose positron-emission tomography (pet)/ct imaging identified 3-5 hypermetabolic foci in the right and left lung (peak standardized uptake value [suv] 12.3) and 10-15 hypermetabolic foci in the left neck and supraclavicular fossa (peak suv 14.8). the patient started receiving oral vismodegib 270 mg daily in october 2008. by january 2009, the patient had a confirmed partial response on ct by response evaluation criteria in solid tumors (recist11) and a complete response on pet/ct (absence of hypermetabolic foci). by april 2009, only a 0.8 cm pulmonary nodule could be measured on ct scan. in december 2009, his vismodegib dose was increased to 300 mg daily when he transitioned from the phase i protocol to the extension study; with the transition to the extension study, the 270 mg dose was no longer available. he maintained a continuing partial response until january 2011 (figures 2a and 2b), when a left axilla metastasis (non-target progression by recist11) was identified and excised. as of october 2011, he continues on vismodegib 300 mg daily without evidence of progression or disease recurrence elsewhere with continued resolution of cutaneous bcc (figure 2c). his only drugassociated adverse events (aes) according to the national cancer institute common toxicity criteria (version 3.0) have been grade 2 dysgeusia, intermittent grade 1 muscle cramps and fatigue (diminished in frequency by calcium and magnesium supplementation), and grade 2 alopecia. during the phase i study this patient also reported drugrelated grade 1 intermittent heartburn and grade 1 weight loss. dermatology reports 2011; volume 3:e55 correspondence: glen j. weiss, virginia g. piper cancer center at scottsdale healthcare 10510 n. 92nd st., ste 200, scottsdale, az 85238, usa. tel. +1 480 323-1350 fax: +1 480 323-1359. e-mail: gweiss@tgen.org key words: basal cell carcinoma, vismodegib, basal cell nevus syndrome, hedgehog signaling pathway. funding: this study was supported in part by genentech. acknowledgments: we thank the patients and their families, jody emery, vickie marsh, and lisa rumble, and clinical staff for their assistance. support for third-party writing assistance for this manuscript was provided by genentech inc. through the genentech-curis collaboration, vismodegib was discovered by genentech and was jointly validated by the parties through a series of preclinical studies. genentech and roche collaborate on the clinical development and commercialization of vismodegib. disclosures: genentech provided funding for the clinical trial involving vismodegib. gjw and ddvh are investigators on trials involving hedgehog signaling pathway inhibitors. ic is an employee of genentech. received for publication: 11 october 2011. accepted for publication: 9 september 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright g.j. weiss et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e55 doi:10.4081/dr.2011.e55 no nco mm er cia l u se on ly [page 126] [dermatology reports 2011; 3:e55] case report #2 a 49-year-old caucasian man with bcns and active multifocal cutaneous bccs was referred to our clinic. he underwent multiple therapies for bcc beginning in his 30s including mohs surgeries, some requiring skin grafting, and cryosurgeries. he had recently averaged 5-10 surgeries for bcc annually. pertinent medical history included several family members with bcns. physical examination was significant for healed surgical scars, and several bccs of approximately 0.5 cm on the left cheek and the right and periorbital region. on high-resolution ultrasound (hru), six sonographic abnormalities were identified, the largest measuring 0.5 cm in the longest dimension. the patient started receiving oral vismodegib 270 mg daily in march 2008. by december 2008, the patient had complete resolution of all six skin lesions on his face. in november 2009, his vismodegib dose was increased to 300 mg daily when he transitioned from the phase i protocol to the extension study. after more than 3 years of continuous daily dosing with vismodegib, his only drug-associated aes are grade 1 dysgeusia, intermittent grade 1 muscle cramps (diminished with exercise), and grade 1 alopecia. grade 1 fatigue was also reported during the phase i study. the patient continues to receive vismodegib 300 mg daily. discussion inhibition of the hhsp has been shown to affect stem cells responsible for blood, mammary, and neural development. after at least 3 years of continuous daily dosing, these two patients have not experienced significant alteration in hematologic parameters, nor physical abnormalities of their pectoral regions. the drug-related aes observed in these two patients are all grade 1 or 2, with dysgeusia, possibly due to an effect on taste bud papillae.12 since our initial report on results treating advanced bcc >18 months ago,6 these two patients have had no new bccs develop for at least 2.25 and 3+ years, respectively, and are tolerating therapy well. based on the pharmacokinetic and pharmacodynamic profile of vismodegib, a dose of 150 mg daily is under evaluation in further studies.7 overall, based on data from these two patients, it appears that long-term vismodegib use in adults with advanced bcc can be an effective therapy with manageable aes. references 1. bhardwaj g, murdoch b, wu d, et al. sonic hedgehog induces the proliferation of primitive human hematopoietic cells via bmp regulation. nat immunol 2001;2:17280. 2. liu s, dontu g, mantle id, et al. hedgehog signaling and bmi-1 regulate self-renewal of normal and malignant human mammary stem cells. cancer res 2006;66:6063-71. 3. ahn s, joyner al. in vivo analysis of quiescent adult neural stem cells responding to sonic hedgehog. nature 2005;437:894-7. 4. paladini rd, saleh j, qian c, et al. modulation of hair growth with small molecule agonists of the hedgehog signaling pathway. j invest dermatol 2005;125:638-46. 5. weiss gj, von hoff dd. hunting the hedgehog pathway. clin pharmacol ther 2010;87:743-7. 6. von hoff dd, lorusso pm, rudin cm, et al. inhibition of the hedgehog pathway in advanced basal-cell carcinoma. n engl j med 2009;361:1164-72. 7. lorusso pm, rudin cm, reddy jc, et al. phase i trial of hedgehog pathway inhibitor gdc-0449 in patients with refractory, locally-advanced or metastatic solid tumors. clin cancer res 2011;17: case report figure 1. baseline photograph and computed tomography (ct) images of patient 1: a) photograph of left neck area at baseline; b) ct scan at baseline showing multifocal pulmonary nodules several of which were >1 cm; c) ct scan at baseline showing left neck adenopathy >1 cm. figure 2. response photograph and computed tomography (ct) images of patient 1: a) ct scan after approximately 28 months of treatment with vismodegib showing near complete resolution of all pulmonary nodules; b) ct scan after approximately 28 months of treatment with vismodegib showing resolution of left neck adenopathy.; c) recent photograph of left neck area following 31 months of treatment with vismodegib. a a b b c c no nco mm er cia l u se on ly [dermatology reports 2011; 3:e55] [page 127] 2502-11. 8. hahn h, wicking c, zaphiropoulous pg, et al. mutations of the human homolog of drosophila patched in the nevoid basal cell carcinoma syndrome. cell 1996;85:841-51. 9. binns a, james lf, shupe jl, everett g. congenital cyclopian-type malformation in lambs induced by maternal ingestion of a range plant, veratrum californicum. am j vet res 1963;24:1164-75. 10. chen jk, taipale j, cooper mk, beachy pa. inhibition of hedgehog signaling by direct binding of cyclopamine to smoothened. genes dev 2002;16:2743-8. 11. therasse p, arbuck sg, eisenhauer ea et al. new guidelines to evaluate the response to treatment in solid tumors. european organization for research and treatment of cancer, national cancer institute of the united states, national cancer institute of canada. j natl cancer inst 2000;92:205-16. 12. mistretta cm, liu hx, gaffield w, maccallum dk. cyclopamine and jervine in embryonic rat tongue cultures demonstrate a role for shh signaling in taste papilla development and patterning: fungiform papillae double in number and form in novel locations in dorsal lingual epithelium. dev biol 2003;254:1-18. case report no nco mm er cia l u se on ly dr [dermatology reports 2011; 3:e22] [page 49] the appearance of angiolipomatosis after using laptop computer on the thighs: a relationship? marie caucanas,1 gebhard müller,2 olivier vanhooteghem1 1department of dermatology, clinique sainte elisabeth, namur; 2institute of pathology and genetics, gosselies, belgium abstract a 56-year-old patient developed angiolipomatosis of the anterior part of the thighs after repeated laptop contact localisation. histological findings exhibit an unusual inflammatory infiltrate. we postulate that the computer could favour lipoma development by a physiopathological mechanism that remains to be clarified. case report a 56-year-old woman gradually developed subcutaneous nodules on the thighs over the course of two years. the patient has no medical or familial history and does not take any medication. she is a speech specialist and admits working several times a week for a couple of hours with her laptop over her thighs. clinical examination shows the existence of approximately ten nodules strictly localised on the anterior part of the thighs (figure 1), suggesting clinical lipomatosis. an excisional biopsy of a nodule shows angiolipomatosis with mild to moderate inflammatory infiltrate with cd68-positive macrophages and t lymphocytes (figure 2). the patient stopped putting her laptop on her thighs for one year and observed stabilisation of nodule count number, but no regression was noted. discussion this is the first description of a secondary lipomatosis of the thighs with the regular use of a laptop computer on this specific location. histological examination shows angiolipomatosis associated with an inflammatory infiltrate of histiocytes and t lymphocytes. according to the imputability criteria,1 it is highly plausible that the use of the laptop in contact with the thighs caused the development of underlying lipomas, as the rapid onset of nodules was observed with the use of the laptop, and the stabilisation of the lesions was observed after the laptop was no longer used at that location. this suggests a symmetric semiology and parallel evolution, and the absence of any other explanation for the condition after full examination supports this conclusion despite the absence of any reliable specific complementary examination proving the link of causality to the histological findings. we think that the laptop is responsible for the development of the lipomas. the inflammation found upon histological examination could have been provoked by the computer through an unknown mechanism and could involve the influence of the heat emitted by the battery and/or the electromagnetic waves emanating from the device. after changing her working habits, the number of lipomas stabilised but did not regress. the use of new technologies, which continue to development and become more accessible, were recently associated with unsuspected pathologies. the semicircular lipoatrophy of the thighs, described by a series of hundreds of patients in companies equipped with the most recent models of fixed computers, is secondary to electromagnetic lipolysis, which is facilitated by local circumstances such as the conductivity of the material of the desks, the ambient humidity and the inappropriate insulation of computer wiring.2-6 five cases of erythema ab igne dermatitis developed after regular use of a laptop on the thighs have been described since 2004.7-14 as suggested by the case of our patient, the development of lipoma could be a consequence of the extensive usage of the computer with immediate contact on the body. the exact physiopathological mechanism behind this pathology remains to be clarified. references 1. bégaud b, evreux jc, jouglard j, lagier g. imputabilité des effets inattendus ou toxiques des médicaments. actualisation de la méthode utilisée en france. therapie 1985;40:111-8. 2. flagothier c, quatresooz p, pierard g-e. electrolipolysis and semicircular lipoatrophy of the thighs. ann dermatol venereol 2006;133:577-80. 3. panella h, juanola e, de peray jl, artazcoz l. semicircular lipoatrophy : a new occupational disease. gac sanit 2008;22:73-5. 4. lachapelle jm, tennstedt d. nouvelles dermatoses de l’environnement. progrès en dermato-allergologie. dijon 2002. ed. e. collet. john libbey eurotext, montrouge 2002,pp.157-65. 5. hermans v, hautekiet m, haex b, spaepen aj, van der perre g. lipoatrophia semicircularis and the relation with office work. applied ergonomics 1999;30:319-24. 6. curvers b, maes a. lipoatrophia semicircularis: a new office disease? 900 cases reported in belgium. www.next-up.org dermatology reports 2011; volume 3:e22 correspondence: olivier vanhooteghem, sainte elisabeth hospital, dermatology unit, namur, belgium. e-mail: ovanhooteghem@hotmail.com key words: lipoma, angiolipomatosis, laptop computer, electromagnetic waves, thighs, nodules. conflict of interest: all authors certified that they have no conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject of this manuscript. received for publication: 6 august 2011. accepted for publication: 9 august 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright m. caucanas et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e22 doi:10.4081/dr.2011.e22 figure 1. lipomatosis of the anterior part of the thigh. figure 2. inflammatory infiltrate associated with angiolipomatosis. no nco mm er cia l u se on ly [page 50] [dermatology reports 2011; 3:e22] 7. bilic m, adams bb. erythema ab igne induced by a laptop computer. j am acad dermatol 2004;50:973-4. 8. jagtman ba. erythema ab igne due to a laptop computer. contact dermatitis 2004;50:105. 9. maalouf e, simantov a, rosenbaum f, chosidow o. erythema ab igne as an unexpected computer side-effect. dermatology 2006;212:392-3. 10. mohr mr, scott ka, pariser rm, hood af. laptop computer-induced erythema ab igne: a case report. cutis 2007;79: 59-60. 11. levinbook ws, mallett j, grant-kels jm. laptop computer associated erythema ab igne. cutis 2007;80:319-20. 12. bachmeyer c, bensaid p, bégon e. laptop computer as a modern cause of erythema ab igne. j eur acad dermatol venereol 2009;23:736-7. 13. fite c, bouscarat f. laptop computer-induced erythema ab igne. presse med 2009; 38:1164-5. 14. gohar a. comment on the letter by bachmeyer, bensaid and bégon on laptop computer as a modern cause of erythema ab igne. j eur acad dermatol venereol 2009;23:1221-2. case report no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. dr [page 26] [dermatology reports 2012; 4:e9] zosteriform metastases from colon carcinoma: an unusual pattern paula maio,1 cristina amaro,1 ana rodrigues,1 adelaide milheiro,2 jorge cardoso1 1department of dermalology and venereology and 2department of pathology, hospital de curry cabral, lisbon, portugal abstract cutaneous metastases of internal malignancies occur infrequently and the zosteriform spread of the skin lesions represents a rare entity. we report here a case of cutaneous metastases from a colon carcinoma clinically mimicked herpes varicella-zoster. the literature is also reviewed. introduction cutaneous metastases of internal malignancies occur infrequently and the zosteriform spread of the skin lesions represents a rare entity with only a few cases reported in the literature. skin metastases are more frequently seen as papules or nodules overlaying the skin that can show ulceration in later stages. the zosteriform pattern of distribution of these lesions is a particular and an even rarer form of presentation. the authors report a case in which cutaneous metastases from a colon carcinoma clinically mimicked herpes varicella-zoster. the corresponding literature is also reviewed. case report a 72-year-old-man presented with a six-week history of small papules and plaques limited to the inframammary region and left flank denying pruritus or pain with respect to this specific lesions. he had been previously diagnosed with a herpes varicella-zoster infection by a general practitioner and was treated with oral valacyclovir, 1000 mg three times a day. after the third day of therapy, he described clinical worsening and the additional appearance of multiple papules with similar morphology. the patient had a known medical history of hemicolectomy for adenocarcinoma of the colon 5 years before and was being followed up regularly for known loco-regional lymph node metastasis (modified dukes staging system c2 and t3n1m0). he had been treated with adjuvant chemotherapy with 5-fluourouracil and folinic acid until two months before the time of evaluation at our clinic. clinical examination revealed patches, papules and small nodules limited to the skin on a background of erythema. the lesions had a zosteriform distribution pattern (figure 1). the histopathological examination revealed infiltration by adenocarcinoma that was consistent with colorectal origin, showing an immunostaining that was ck 20 positive and ck7 negative (figures 2 and 3). the search for varicella zoster virus dna was negative. regarding treatment and follow-up, the area was too extensive to excise and the concomitant existence of multiple lesions was not suitable for surgical removal. the patient returned for systemic chemotherapy with capecitabine with slight improvement of the preexisting lesions. this partial remission was maintained for nine months until progression of the systemic disease, resulting from the patient death. discussion and conclusions the pattern of presentation of zosteriform cutaneous metastasis is rare and should be included in the differential diagnosis of zosteriform eruptions in immunocompromised patients.1,2 the common clinical characteristics are mainly of a topographic nature, with lesion distribution along dermatomes. the skin lesions can be heterogeneous, including papular, nodular or vesicobullous forms.3,4 cutaneous metastasis is defined as cancer spreading through the blood stream or lymphatic system to involve the skin.5,6 cutaneous involvement by direct extension of the tumor or iatrogenic implantation is normally excluded from this specific definition. the mechanisms that might predispose certain types of internal malignancies to give rise to cutaneous metastasis have rarely been discussed in the literature. in recent years, chemokines and their receptors have been shown to mediate tumorigenesis and the metastasis spreading process.7 one proposal mechanism for cutaneous metastization is the expression of the chemokine receptor ccr10, which is involved in cutaneous metastasis of melanomas by mediating the survival, migration and growth of melanoma cells. the ligand ccl27/ctack is a skin-specific chemokine that is expressed by epidermal keratinocytes. these interactions (ccr10 on tumor cells and ccl27/ctack on the epidermis) may mediate the colonization by melanoma cells of non-primary cutaneous sites.7,8 other potentially implicated chemokines include cxcr4, which has been shown to be of major importance on not only the growth, angiogenesis and invasion of cutaneous basal cell carcinomas but also in the skinhoming mechanisms of sézary cells.7,9 the molecular mechanisms by which tumor metastasis occurs, are complex and incompletely understood. because the majority of cutaneous metastasis is found in the dermis, it is probable that the interaction between tumor cells and dermal and epidermal factors may play a crucial role in the skin-homing mechanism of metastatic cells.7 different internal malignancies metastasize to the skin with different frequencies.10,11 the dermis may provide a favorable environment for the colonization and survival of metastatic breast carcinoma, as cutaneous adnexa and lactiferous ducts share similar embryonic origins. this may provide at least a partial explanation for the occurrence of a higher rate of skin metastasis of breast adenocarcinoma compared with adenocarcinomas of the gastrointestinal tract. usually, the median survival after diagnosis is approximately six months although it was slightly higher in the case of our patient.12,13 the vast majority of cases exhibit a poor prognosis and an upgrading of the tumor staging. we found that most of the reported cases in the literature (about one third) had previous been medicated with antiviral therapy before the correct diagnosis was made.12-14 the high degree of clinical suspicion and the histopathological examination are therefore essential for diagnosis and the correct therapeutic approach. dermatology reports 2012; volume 4:e9 correspondence: paula maio, department of dermalology and venereology, hospital de curry cabral, lisbon, portugal. e-mail: paulamaio@gmail.com key words: cutaneous metastases, zosteriform, skin-homing mechanisms. conflict of interests: the authors report no potential conflict of interests. received for publication: 29 october 2011. revision received: 19 november 2011. accepted for publication: 7 december 2011 this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright p. maio et al., 2012 licensee pagepress, italy dermatology reports 2012; 4:e9 doi:10.4081/dr.2012.e9 no nco mm er cia l u se on ly [dermatology reports 2012; 4:e9] [page 27] several theories have been proposed to explain the pathogenic mechanism by which zosteriform dissemination occurs, but none was adequately proven to date.12,14 additional studies and proper biological profiling of the tumor cells may allow for better understanding of this pathogenesis and for the also proposal of new biological therapeutic targets. references 1. lookingbill dp, spangler n, sexton fm. skin involvement as the presenting sign of internal carcinoma: a retrospective study of 7316 cancer patients. j am acad dermatol 1990;22:1926. 2. white jw jr. evaluating cancer metastatic to the skin. geriatrics 1985;40:67-73. 3. augustin g, kekez t, bodgdaria b. abdominal popular zosteriform cutaneous metastasis from endometrial carcinoma. int j gynaecol obstet 2010;110:74. 4. manteaux a, cohen pr, rapini rp. zosteriform and epidermotropic metastasis. report of two cases. j dermatol surg oncol 1992;18:97-100. 5. ahmed i, holley kj, charles-holmes r. zosteriform metastasis of colonic carcinoma. br j dermatol 2000;142:182-3. 6. bauzá a, redondo p, idoate ma. cutaneous zosteriform squamous cell carcinoma metastasis arising in an imunocompetent patient. clin exp dermatol 2002;27:199-201. 7. murakami t, cardones ar, finkelstein se, et al. immune evasion by murine melanoma mediated through ccr10 chemokine receptor. j exp med 2003;198:1337-47. 8. cuerda e, sanchez f, mansilla i, et al. malignant melanoma with zosteriorm metastases. cutis 2000:312-4. 9. blanchi l, orlandi a, carboni i, et al. zoateriform metastasis of occult bronchogenic carcinoma. acta derm venereol 2000;80:391-2. 10. werchau s, hartschuh w, hartmenn m. zosteriform metastasis of endometrial cancer. eur j dermatol 2009;19:401-2. 11. shafqat a, viehman ge, myers sa. cuatneous squamous cell carcinoma with zosteriform metastasis in a transplant recipient. j am acad dermatol 1997;37:1008-9. 12. savoia p, fava p, deboli t, et al. zosteriform cutaneous metastases: a literature meta-analysis and a clinical report of three melanoma cases. dermatol surg 2009;35:1355-63. 13. hu sc, chen gs, wu cs, et al. rates of cutaneous metastases from different internal malignancies: experience from a taiwanese medical center. j am acad dermatol 2009;60:379-87. 14. niiyama s, satoh k, kaneko s, et al. zosteriform skin involvement of nodal t-cell lymphoma: a review of the published work of cutaneous malignancies mimicking herpes zoster. j dermatol 2007;34:68-73. brief report figure 1. clinical presentation with zosteriform pattern distribution. figure 2. histhopatology (hematoxylin and eosin 10¥). figure 3. immunohisthopatology showing cd20 positivity. no nco mm er cia l u se on ly dr [dermatology reports 2012; 4:e1] [page 1] atopic dermatitis in adolescence giampaolo ricci,1 federica bellini,1 arianna dondi,1,2 annalisa patrizi,2 andrea pession1 1pediatric unit, department of gynecologic, obstetric and pediatric sciences; 2dermatology unit, department of internal medicine, aging and nephrological diseases, university of bologna, italy abstract atopic dermatitis (ad) is a chronic inflammatory skin disorder that typically occurs during childhood especially in the first year of life, with a variable frequency from 10% to 30%. recent studies have shown that in europe among 10-20% of children with ad suffer from this disorder also in adolescence. ad is a chronic inflammatory skin disease with a typical onset in the first years of life and with a 1030% prevalence among young children. ad prevalence in adolescence has been estimated around 5-15% in european countries. ad persists from childhood through adolescence in around 40% of cases and some risk factors have been identified: female sex, sensitization to inhalant and food allergens, allergic asthma and/or rhinoconjunctivitis, the practice of certain jobs. during adolescence, ad mainly appears on the face and neck, often associated with overinfection by malassezia, and on the palms and soles. ad persistence during adolescence is correlated with psychological diseases such as anxiety; moreover, adolescents affected by ad might have problems in the relationship with their peers. stress and the psychological problems represent a serious burden for adolescents with ad and cause a significant worsening of the patients’ quality of life (qol). the pharmacological treatment is similar to other age groups. educational and psychological approaches should be considered in the most severe cases. introduction atopic dermatitis (ad) is a chronic inflammatory skin disease which typically affects children during the first years of life, with a prevalence around 10-30%.1,2 recent studies have shown that in 10-20% of children with ad, the disease persists through adolescence.3,4 in particular, few years ago the international study isaac phase iii estimated that, among adolescents, ad is present in 5-10% in most european countries, 15-20% in uk and south america and in 0-5% in asia.5 peters and colleagues4 evaluated the course of ad in a group of german adolescents, who had been enrolled for the isaac phase ii, and were able to recognize several risk factors: family history for allergic rhinitis (or=1.6) and/or ad (or=2.7), allergic sensitization during the first years of life (or=1.8), jobs at risk for allergen exposure (hairdresser, nurse and health care professionals, cleaning staff, baker) (or=1.4). adolescents with ad are rarely affected by animal protein food allergy (only 7.4% have a cow’s milk or hen’s egg allergy), but often show sensitization to inhalant allergens such as grass and birch pollens (44.4% and 55.6% respectively) and oral allergy syndrome (22%) against plant foods. the sex gender also influences the prevalence of ad: during the first 2 years of life ad more often affects males,6-8 but in the pubertal age and in adulthood the female sex has a higher prevalence;9 no significant differences are reported during the school age. ziyab and colleagues10 performed a longitudinal study in order to evaluate a relationship between variations in ad prevalence, gender and allergic sensitization during the first 18 years of life. puberty seems to represent a very important period, during which a change in the disease prevalence happens (16.3% of females and 8.3% of males, p<0.001); the study results indicate that this difference might be due to an increase in girls affected by intrinsic ad (5.9% females and 1.5% males, p=0.002) and to a higher number of healed males (65.4% of males and 50% of females, p=0.04). no differences were highlighted in the disease severity during puberty between males and females. several studies evidenced that up to 30-40% of children affected by asthma, eczema and rhinitis during childhood were allergic children; the paper by ziyab et al.10 indicates a higher prevalence of allergic sensitization for inhalant allergens (grass pollens, alternaria alternata, cladosporium, dog’s and cat’s dander) at 4, 10 and 18 years of age among male patients than in girls (p=0.024, p=0.003 and p<0.001 respectively). mohrenschlager e coll.11 performed a study on a population of 5-7 year-old patients and showed that girls have a higher skin ph and a lower hydration of the stratum corneum than boys, independently of being affected by ad; this might cause female patients to have a higher risk of developing eczema. several authors highlighted that female ad patients have an important worsening of the skin condition during the pre-menstrual period, menstruations and pregnancy, suggesting that an association exists between hormonal levels and ad lesions.12,13 about 52% of patients with ad show a worsening during pregnancy, usually in the first 2 weeks of gestation; however, the mechanisms are not yet completely understood. during pregnancy a t cell switch towards a th2-type response occurs; this phenomenon is probably due to a reduction in deidroepiandrosterone (dhea) and deidroepiandrosterone-solfato (dhea-s) levels. an increase in th2 activity might explain the eczema worsening; it is unclear whether changes in the filaggrin expression also happen.14 pincus et al.15 also showed the existence of an inverse association between progesterone levels during the first months of pregnancy and the risk of developing ad during adolescence in girls but not in boys. no association has been highlighted between maternal levels of estradiole during pregnancy and the risk of developing ad. experiments on mice speculate on a possible stimulating effect of estrogens on mast cell activation. dhea might antagonize the th2 cytokines release, but the role of testosterone and other androgens has not been clarified yet.16 dhea-s levels in the peripheral blood increase in response to stress, chronic inflammation and immunomediated processes, but the actual role of this phenomenon has not been elucidated and no changes in the peripheral blood levels of this hormone have been detected in women affected by severe ad. in most cases, patients with ad improve or recover during childhood. however, in some cases ad persists through adulthood and is associated with the onset of allergic rhinitis and/or asthma. the risk of developing asthma in children affected by ad varies from 25% to 80%.17 dermatology reports 2012; volume 4:e1 correspondence: giampaolo ricci, department of pediatrics, university of bologna, via massarenti 11, bologna, italy tel. +39.051.6363075. e-mail:giampaolo.ricci@unibo.it key words: atopic dermatitis, adolescence, quality of life. conflict of interest: the authors have no conflict of interest. received for publication: 31 august 2011. revision received: 24 october 2011. accepted for publication: 24 october 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright g. ricci et al., 2012 licensee pagepress, italy dermatology reports 2012; 4:e1 doi:10.4081/dr.2012.e1 no nco mm er cia l u se on ly [page 2] [dermatology reports 2012; 4:e1] clinical features the typical eczematous lesions appear mainly during the first two years of life with a different distribution depending on the age of the patients. during the first months of life lesions are exudative and mainly localized in the head, face (in particular forehead, cheeks, chin, with the central-face saving) and in the extensor surfaces of limbs. in older children the lesions are mainly concentrated on the flexural surfaces of the limbs, the popliteal and antecubital folds, back of hands and feet. the skin is commonly dry with lichenification and intense itch; the lips are frequently dry brittle, chapped and develop fissures. a post-inflammatory hyperpigmentation is frequently found in the region around the eyes. the evolution of the clinical feature is characterized by phases of remission of symptoms, which occur mostly during the summer months, alternating with periods of exacerbation, particularly during the autumn-winter.18 clinical features typical of adolescence are represented by eyelid dermatitis, and the palmar and plantar juvenil dermatitis; the eczematous lesions are often localized to the neck, and in are often associated with infection by malassezia.19 the lesions are also localized in forehead, perioral region, neck, upper chest and shoulder girdle, flexor surfaces of the legs and backs of hands. quality of life the early onset, the severity of the framework, frequent relapses and chronic course make a disease with important psychological consequences that affect the quality of life (qol) of the children and their families.20 these discomforts are accentuated if the persistence of symptoms progresses through adolescence. affected children often present behavioral problems, mainly characterized by increased emotional dependency, anxiety, and sleep disturbances. the itching, which is one of the main symptoms of the disease, affects mood and sleep quality of patients and consequently of their family. the chronic course characterized by remission and exacerbation and the long-term treatments, negatively affects the quality of family life, both economically and psychologically, producing anxieties, frustrations, creating feelings of guilt and anger. adolescents with ad exhibit greater vulnerability, anger, anxiety, insecurity, but few studies have been done about it. a recent study21 study of 367 american adolescents suffering from atopic diseases has highlighted the existence of a significant association between increased levels of anxiety and the presence of allergic respiratory diseases (asthma and rc) but not with the ad; in this study it seems that ad affects the qol in general terms of itching, and sleep disturbance, but it is subjectively experienced by patients as less severe than respiratory diseases. a study by brenninkmeijer et al.22 considered a group of 165 patients aged between 18 and 30 years who had ad during childhood. ad had a highly negative impact on patient qol in the 48.7% of patients, with significant correlation between disease severity and qol (r=0.518, p<0.001). among the problems identified, patients had experienced the need to receive clearer information about the treatment of the disease (87%), greater empathy with the doctor (85%), the need to deal with other patients with ad (52%) and the need of a psychological support (68%). furthermore, adolescents with moderate/ severe ad had shown a significant delay in development of social relationships (lower number of friends, reducing output in a group) compared to healthy ones and those with mild ad. during high school, 70% of patients reported to be ashamed of their skin, 49.1% avoided intimate situations, 43.2% abstained from sport, 90% reported intense itching, 69.2% sleep disturbance, fatigue 60.2% and 74.1% physical deterioration of the lesions with stress. a study by saunes et al.23 of norwegian adolescents with ad showed a correlation between the severity of clinical feature and increased levels of psychological stress. in particular, the prevalence of psychological distress was highest in the largest age group (17-19 years). although females were more affected by psychological stress than males, the association between ad and psychological distress was higher in males than females (or=2.1 or=1.3). sang ho et al.24 evaluated the psychological characteristics of 34 patients with ad (age 1341 years) by the following questionnaire: back depression inventory (bdi), state trait anxiety index (stai), interaction anxiousness scale (ias), private body consciousness (pbc) and the dermatology life quality index (dlqi) and found a significant increase of all parameters of the questionnaires and a significant correlation between the parameters of the questionnaires covered and the dlqi (p<0.001). among the clinical parameters the itch was significantly correlated with levels of anxiety (r=0.525, p<0.05). atopic dermatitis management the basis of therapy for the management of ad in adolescents are similar to those of younger child. it may be noted that the adherence to therapy, which often must be at least daily for prolonged periods, is certainly more difficult for the adolescents. to encourage this therapeutic compliance in adolescents, a recent study25 conducted in the u.s. used short message service (sms) to the mobile phone to remember to patients the need of a daily therapy. the study showed that daily sending sms to mobile patients, led to significant improvements in patient compliance (p≤0.001), their self-care (p=0.002), severity (p<0.001) and qol (p=0.014). the need to create an educational and training program to educate, inform and support families with children affected by ad in the management of this disease originates the concept of the school of atopy, on the model of the first educational program initiated in germany: the berlin parental education programme26 based on a series of meetings between specialists and family. the schools of atopy are differently structured, depending on different countries, although in general the standard provides, in addition to a coordinator or leader, a dermatologist, a pediatrician, an allergist and a clinical psychologist, to which other figures can be added. a study by ricci et al.27 on a group of children with ad and their parents, who had joined this educational program for 3 years, showed a significant reduction in anxiety levels in parents mostly. conclusions ad in adolescents remains a condition in which is need to investigate several aspects: while the clinical feature is well characterized, there are also risk factors that promote the persistence of ad from the first years of life. it is also necessary to investigate better the relationship with psychological problems, the disturbing presence of ad in adolescence can become, through a vicious circle, the cause of worsening of the same. references 1. girolomoni g, abeni d, masini c, et al. the epidemiology of atopic dermatitis in italian schoolchildren. allergy 2003:58: 420-5. 2. the international study of asthma and allergy in childhood (isaac) steering committee. worldwide variation in the prevalence of symptoms of asthma, allergic rhinitis, and atopic eczema: isaac. lancet 1998;351:1125-32. 3. buggiani g, ricceri f, lotti t. atopic dermatitis. dermatolo ther 2008;21:96-100. 4. peters as, kellbergere j, vogelberg c, et al. prediction of the incidence, recurrence and persistence of stopic dermatitis in adolescence: a prospective cohort study. jaci 2010;126:590-5. 5. williams hc. eczema across the world: the missing piece of the jigsaw revealed. j inves dermatol 2011;131:12-4. 6. asher mi,montefort s, bjorksten b, on behalf of the isaac phase three study group. worldwide time trends in the review no nco mm er cia l u se on ly [dermatology reports 2012; 4:e1] [page 3] prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: isaac phases one and three repeat multicountry cross-sectional surveys. lancet 2006;368:733-43. 7. smidesang i, saunes m, storrø o, et al.atopic dermatitis among 2-year olds; high prevalence, but predominantly mild disease – the pact study, norway. pediatr dermatol 2008;25:13-8. 8. dirven-meijer pc, glazenburg ej, mulder pg, et al. prevalence of atopic dermatitis in children younger than 4 years in a demarcated area in central netherlands: the west veluwe study group. br j dermatol 2008;158:846-7. 9. chen w, mempel m, schober w, et al. gender difference, sex hormones, and immediate type hypersensitivity reactions. allergy 2008;63:1418-27. 10. ziyab ah, raza a, karmaus w, et al. trends in eczema in the first 18 years of life: results from the isle of wight 1989 birth cohort study. clin exp allergy 2010; 40.1776-84. 11. mohrenschlager m, schafer t, huss-marp j, et al. the course of eczema in children aged 5-7 years and its relation to atopy: differences between boys and girls. br j dermatol 2006;154:505-13. 12. suhyun cho, hee jung kim, sang ho, et al. the influence of pregnancy and menstruation on the deterioration of atopic dermatitis symptoms. ann dermatol 2010;22:180-5. 13. kemmet d, tidman mj. the influence of the menstrual cycle and pregnancy on atopic dermatitis. br j dermatol 1991;125: 59-61. 14. weatherhead s, robson sc, reynolds nj. eczema in pregnancy. bmj 2007;335:1524. 15. pincus m, keil t, rucke m, et al. fetal origin of atopic dermatitis. j allergy clin immunol 2009;125:273-5. 16. ebata t, itamura r, aizawa h, et al. serum sex hormone levels in adult patients with atopic dermatitis. j dermatol 1996;23:6035. 17. ricci g, patrizi a, giannetti a, et al. does improvement management of atopic dermatitis influence the appearance of respiratory allergic diseases? a follow-up study. clin mol allergy 2010;8:8. 18. braun-falco o, plewig g, wolf hh, et al. dermatology 2002;501:504. 19. darabi k, grim hostetler s, bechtel ma. the role of malassezia in atopic dermatitis affected the head and the neck of adults. j am acad dermatol 2009;60:125-36. 20. ricci g, bendandi b, bellini f, et al. atopic dermatitis: quality of life of young italian children and their families and correlation with severity score. pediatr allergy immunol 2007;18:245-9. 21. slattery mj, essex mj. specificity in the association of anxiety, depression and atopic disorders in a community sample of adolescents. j psychiat resh 2011;45:78895. 22. brenninkmeijer ee, legierse cm, sillevis smitt jh, et al. the course of life of patients with childhood atopic dermatitis. pediatr dermatol 2009;26:14-22. 23. saunes m, smidesang i, holmen tl, et al. atopic dermatitis in adolescent boys is associated with greater psychological morbidity compared with girls of the same age: the young-hunt study. br j dermatol 2007;156:283-8. 24. sang ho oh, byung gi bae, chang ook park, et al. association of stress with symptoms of atopic dermatitis. acta derm venereol 2010;90:582-8. 25. pena-robichaux v, kvedar jc, watson aj. text messages as a reminder aid and educational tool in adults and adolescents with atopic dermatitis: a pilot study. dermatol res pract. 2010; 2010: 894258. 26. wenninger k, khert r, von rueden u, et al. structured parent education in the management of childhood atopic dermatitis: the berlin model. patient educ couns 2000;40:253-61. 27. ricci g, bendandi b, aiazzi r. three years of italian experience of an educational program for parents of young children affected by atopic dermatitis: improving knowledge produces lower anxiety levels in parents of children with atopic dermatitis. pediatr dermatol 2009;26:1-5. review no nco mm er cia l u se on ly dr [page 62] [dermatology reports 2011; 3:e28] laser therapy for hailey-hailey disease: review of the literature and a case report arisa e. ortiz, christopher b. zachary department of dermatology, university of california, irvine, irvine, ca, usa abstract medical therapy for hailey-hailey disease (hhd) generally only provides temporary suppression. surgical intervention has been shown to prolong remission, but may lead to significant morbidity. laser therapy is becoming the preferred method of treatment because of its successful results and lower risk of complications compared to surgical modalities. we report a case of fractional ablative carbon dioxide (co2) laser treatment for hhd and review the relevant literature. fractional co2 laser therapy was performed in our patient with a 14-year history of hhd. no recurrence was observed 5 months after laser therapy in right inframammary and axillary regions. symptomatic recurrence was noted after treatment of inguinal areas. in conclusion, traditional laser ablation remains the treatment of choice for prolonged remission of recalcitrant plaques in hhd. introduction familial benign chronic pemphigus, also known as hailey-hailey disease (hhd), is a rare autosomal dominant disease characterized by crusted erosions with marked predilection for intertriginous areas, especially the axillae, submammary and groin regions.1 the onset of clinical lesions is typically during the second or third decade of life, and may present as late as the fifth decade.2 the course of the disease is often variable with periods of exacerbation and spontaneous remission. lesions generally heal without scarring, but may be complicated by malodorous vegetations and painful fissures. environmental factors, such as heat, sweating, secondary infections, and allergic contact allergens found in topical treatments, can exacerbate disease severity.1,3 friction can also induce new lesions due to defects in cell-cell adhesion within the epidermis. suprabasilar acantholysis, which causes the characteristic “dilapidated brick wall” appearance, is due to mutations in the golgi-associated calcium transporter atp2c1 located on chromosome 3q21-24.2,4 first-line therapies for hhd include topical corticosteroids, topical and/or systemic antibiotics, and antifungals. anecdotal reports have shown some benefit with retinoids,5 dapsone,6 cyclosporine,7 topical vitamin d analogs,8 and topical immunomodulators9 in recalcitrant cases. medical therapies may be beneficial short-term, but generally do not induce prolonged remissions. they are also limited by their long-term use. therefore, there is a need for more definitive care. surgical modalities, such as wide excision with split-thickness grafting,10 primary closure11 or healing by secondary intention12 have been reported to achieve prolonged remission and cure in some cases. however, these techniques are cosmetically disfiguring and may be associated with great morbidity such as scar contractures, limited mobility, thromboembolic events, graft failure, or infection.13,14 more superficial ablative techniques, such as dermabrasion and laser ablation are now favored compared to older more aggressive surgical approaches. dermabrasion has been reported to achieve extended remission, but is limited to treatment areas that can be immobilized or flattened and is not suitable for genital and mucosal lesions. several treatments are generally required and hypertrophic scarring has been reported.15 laser therapy of hhd is a more advanced technique that can be used in sites where dermabrasion is not feasible. traditional ablative lasers such as carbon dioxide lasers and erbium:yag laser devices have been well documented as options for treatment of recalcitrant plaques in hhd. to our knowledge, we are the first to report a case of hhd treated with a fractionated ablative laser. fractionated ablative lasers are becoming more commonly used for resurfacing procedures due to their excellent results, better safety profile, and decrease in downtime compared to traditional ablative devices. however, in the authors’ opinion, fractionated ablative devices are not particularly effective for treatment of hhd. carbon dioxide lasers the most well documented laser therapy in the treatment of hhd is the carbon dioxide laser (co2) (table 1). don et al.16 reported the first case of hhd successfully treated with co2 laser abrasion. the patient was a 50-year-old male who had failed conventional therapeutic regimens. after co2 laser treatment, the patient remained free of disease in treated areas 8 months after therapy. although, the patient was kept on oral prednisone and oral antibiotics during laser therapy, only untreated areas flared. the authors suggested that the sparing of underlying adnexae contributed to the reepithelialization of normal epidermis.16 this report led to several other cases of localized, recalcitrant plaques in patients with hhd that have been successfully treated with co2 laser vaporization. kartamaa et al.17 reported the largest case series of 8 patients with hhd treated with co2 laser vaporization (sharplan 1020, laser industries ltd., tel aviv, israel). six of the 8 patients had symmetrical skin lesions of which one side was left untreated for an internal control. five of these 6 patients showed considerable improvement in the treated side compared to control. notably, 2 of the patients also had spontaneous resolution in untreated lesions. of the 2 patients without internal controls, both patients showed improvement. at follow-up visits ranging from 10 to 27 months, only 2 of the patients had recurrent lesions in the treated sites. hypertrophic scarring was noted in the axillary region of 1 patient. the authors speculated that improvement in skin lesions was secondary to fibrosis of upper dermal tissues which led to increased support of diseased epidermis. touma et al.18 reported a case of a 38-yearold woman with hhd treated with a pulsed co2 laser (ultrapulse 5000, coherent medical group, palo alto, ca, usa) to unresponsive lesions of the chest and axilla. these areas showed clearing in 1 to 2 weeks. they also investigated the effects of treating uninvolved skin for prophylaxis. the uninvolved area only had a minor asymptomatic recurrence 18 months after treatment. minor scarring was noted on the chest. christian et al.19 treated a 26-year-old woman with refractory hhd of the axillary regions with a short dwell time co2 laser. she received additional treatments with a short pulsed co2 laser to foci of persistent blistering. this resulted in prolonged resolution of disease in the right axilla and periodic blistering in the left axilla at 3 years following laser therapy. the authors later mention that because the right axilla was initially treated with a con dermatology reports 2011; volume 3:e28 correspondence: arisa e. ortiz, department of dermatology, university of california, irvine c340 med sci i, irvine, ca 92697, usa. tel. +1.949.824.5515 fax: +1.949.824.7454. e-mail: arisao@uci.edu key words: fractional resurfacing, familial benign chronic pemphigus, ablative laser. received for publication: 24 august 2011. accepted for publication: 24 august 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright a.e. ortiz and c.b. zachary, 2011 licensee pagepress, italy dermatology reports 2011; 3:e28 doi:10.4081/dr.2011.e28 no nco mm er cia l u se on ly [dermatology reports 2011; 3:e28] [page 63] tinuous co2 laser and the left axilla was treated with fewer passes and a lower fluence, the thermal damage may have been insufficient to provide adequate disease control. therefore, the authors proposed that short pulsed co2 lasers may not be as effective as continuous co2 lasers in treating hhd due to their lower fluences. mcelroy et al.20 reported a 56-year-old female with hhd treated with a co2 laser (weck 525, weck instruments, princeton, nj, usa) to the inguinal and perivaginal areas and a 38-yearold male treated similarly on the scrotum. both patients remained disease free at 4 months and 1 year, respectively, following treatment. kruppa et al.21 reported 2 patients with hhd that were successfully treated with a co2 laser (silktouch flashscanner, laser industries ltd., tel aviv, israel). they did not report any complications and remained without recurrence in treated skin at 6 months and 1 year following laser therapy. the authors suggested that perhaps the flash scanner may decrease the risk of scarring due to rapid energy delivery. this report reaffirmed that co2 laser ablation is an effective treatment modality for hhd. erbium: yag lasers beier et al.22 reported the first cases of hhd treated with an erbium:yag 2940-nm laser (mcl 29 dermablate, asclepion-meditec, jena, germany) (table 1). two male patients with hhd were treated for malodorous lesions of the groin, scrotum, and axillae. one of the patients showed complete regression in treated areas 1 year following laser therapy. the other patient had recurrence of a lesion at the periphery of the treated area, which required an additional treatment. there were no reported side effects in these patients. the authors concluded that erbium: yag laser ablation is very effective in treating hhd and perhaps superior to co2 laser ablation because it produces less residual thermal injury and therefore, has a lower risk of scar formation.23 they also hypothesized that the key to improvement is related to the critical depth of tissue removal. konrad et al.24 compared erbium:yag laser ablation (mcl 29 dermablate, asclepionmeditec, jena, germany) to dermabrasion and botulinum toxin a (btxa) injections (botox, allergan, irvine, ca, usa) in the treatment of a 62-year-old woman with hhd. since it is well known that sweating can exacerbate disease,1 this patient was treated with 100 iu of btxa to the submammary regions to control hyperhidrosis. after cessation of sweating, the patient was treated with dermabrasion on one side and a pulsed erbium: yag laser on the other. designated areas were left unablated to assess the efficacy of btxa alone. all treated areas were free of disease 12 months after treatment. however, the patient reported an review table 1. laser therapy for hailey-hailey disease. author laser used/parameters n. results co2 lasers don et al.16 co2 laser 1 no recurrence in treated areas at 8 (power of 8 w, irradiance of 1020 months after treatment. w/cm2, 1-mm spot, defocused mode, continuous wave) kartamaa et al.17 sharplan 1020, laser industries ltd. 8 at follow-up visit (10-27 months), (power of 5 w, irradiance ranging160 no recurrence of lesions in 5 of 8 635 w/cm2, 1-2 mm spot, continuous patients wave) touma et al.18 ultrapulse 5000, coherent medical 1 treated lesional skin showed group clearing in 1-2 weeks. at 18 months (settings not provided) following therapy, prophylactically treated skin had a minor asymptomatic recurrence. minimal scarring was reported. christian et al.19 short dwell time co2 laser 1 nearly complete resolution of (396 �msec dwell time, energy of 25-28 lesions treated with continuous co2 j/cm2, 2-3 passes) laser and short dwell time co2 laser short pulsed co2 laser 3 years after treatment. periodic (90 �msec pulse duration, energy of 15 blistering in lesions treated with j/cm2) short dwell time co2 laser only. continuous co2 laser (396 �msec pulse duration, energy of 28 j/cm2, 3 passes) mcelroy et al.20 weck 525, weck instruments 2 lesions treated remained without (power of 5-15 w, 2.0 mm spot, recurrence at 4 months and 1 year. defocused mode, 2 passes) kruppa et al.21 silktouch flashscanner, laser 2 patients remained without industries ltd. recurrence in treated skin at 6 (power of 6 w, 3 mm spot, 0.2 sec scan months and 1 year. time, 3 passes) erbium:yag lasers beier et al.22 mcl 29 dermablate, asclepion2 one patient showed no recurrence meditec and the other patient had (1.6-5.0 mm spot, 5-10 hz, 300-1000 recurrence at the periphery of mg, energy of 5-8.5 j/cm2, and 350 treated lesions 1 year after therapy. microseconds, 30% overlap) konrad et al.24 mcl 29 dermablate, asclepion1 sites treated with dermabrasion, meditec, laser ablation and btxa alone (3 mm spot, 450 mj, 8 hz,) remained relapse free dermabrasion, and botox, allergan 100 for 12 months. increased healing iu time with laser treatment compared to dermabrasion. btxa was as effective as ablation. radiofrequency ablation nandini et al.25 surgitron ffpf emc, ellman 1 treated lesions remained clear 16 international, inc. weeks after therapy. (3.8 mhz, 140 watt +/20%, continuous mode) vascular lasers fisher et al.26 v-beam, candela corporation 1 the patient had continuous (595 nm, 10-mm spot, 1.5 ms, and remission over 20 months. energy of 7.5 j/cm2) diode lasers downs27 smoothbeam, candela corporation 1 after 3 treatments, no improvement (6 mm spot, energy of 14 j/cm2, dcd in lesions. marked reduction in 50 ms) sweating and malodour. no nco mm er cia l u se on ly [page 64] [dermatology reports 2011; 3:e28] extended healing time in the laser treated area compared to the area treated with dermabrasion. in this case, the authors reported that btxa alone was as effective as ablation. radiofrequency ablation although, radiofrequency is not considered a laser, it is included in this review for interest due to its ability to cause tissue ablation (table 1). nandini et al.25 reported a case of a 35-yearold male with hhd with a 20-year history of recurrent axillary erosions that were successfully treated with radiofrequency ablation (surgitron ffpf emc, ellman international, inc., new york, ny, usa). the authors ablated one axilla to the level of mid-dermis with clearance of the lesions 16 weeks after therapy. the opposite side was left untreated as the internal control and was reported to have flared several times compared to the ablated side. radiofrequency was determined to be a cheap, effective and easily administered treatment for hhd. vascular lasers fisher et al.26 treated a 35-year-old female with persistent hhd for steroid induced striaerubrae of the entire axillary and inframammary regions with a pulsed-dye laser (pdl) (v-beam, candela corporation, wayland, ma, usa) (table 1). after the fourth treatment, the patient reported incidental improvement in the axillary and inframammary regions, while she continued to flare in the untreated inguinal area. the patient continued to have remission of her disease over the next 20 months with additional pdl treatments at purpuragenic settings approximately 1 month apart. the rationale they offered for improvement was in relation to a vascular effect or some unknown effect of pdl on keratinocytes. the authors did not investigate the efficacy of nonpurpuragenic settings, but suggest pdl as a potential treatment in all skin types with a good safety profile. diode lasers downs27 reported the only case of hhd treated with a 1450-nm diode laser (smoothbeam, candela corporation, wayland, ma, usa) (table 1). the author reported no improvement in the lesions regardless of a marked reduction in sweating. the mechanism of decreased sweat production was not explored. the author concluded that subsurfacing laser treatment is not an effective treatment for hhd. fractional ablative lasers: case report a 49-year-old female presented to our clinic with a 14 year history of hhd with recalcitrant, symptomatic, hyperkeratotic, fissured plaques in the axillary, inframammary and groin areas. her father was similarly affected. she failed conservative medical therapy with topical and oral antibiotics, topical antifungals and topical corticosteroids. she had good improvement with oral corticosteroids, but did not want to be on long-term therapy due to their potential side effects. she also responded well to dapsone, but was discontinued secondary to an adverse reaction. the patient continued to flare with strenuous exercise and was interested in a more definitive treatment, but did not want to undergo radical surgery. given that there is a better safety profile and less downtime associated with fractional ablative laser therapy compared to traditional ablative devices, we decided to treat our patient with a fractionated ablative co2 laser (fraxel re:pair, solta medical, inc., hayward, ca, usa). a 4x2 cm test site on the left submammary region was treated with 4 passes at a fluence of 70 mj and 30% coverage. two months after therapy, the test site was much improved clinically and symptomatically. she then underwent treatment to her right axillary, inframammary and inguinal regions in the same manner using tumescent anesthesia. the patient received antiviral prophylaxis and standard postoperative care with vinegar soaks and petroleum jelly applications. the opposite side was left untreated as an internal control. the patient was kept on topical steroids and topical antibiotics during the course of laser therapy in order to maintain control of the untreated sites. one month following treatment, the right axilla (figure 1) and right groin were improved, but the right submammary region was slow to heal and still mildly tender with residual ulceration. overall, the patient was very happy with the results and requested additional therapy for the eroded, grey, hyperkeratotic plaques on the left groin. the left groin region was treated with similar settings, but did not respond as well as previously treated areas. the patient returned to the clinic several months later with persistent painful, erosive, hyperkeratotic plaques on bilateral inguinal folds. given the failed response to fractionated co2 laser therapy, the patient was treated with a traditional erbium:yag 2940-nm laser (profile, sciton, inc., palo alto, ca, usa) with 2 passes at an ablation depth of 50 mm and a coagulation of 25. she returned one month later with tremendous symptomatic improvement and only residual erosions and hyperkeratosis. discussion hhd is a frustrating disease with chronic recalcitrant erosive plaques that can be very debilitating. although, first line therapy is generally medical, these options only provide temporary suppression. surgical options can lead to prolonged remissions, but are not without complications. the more recent trend in therapy has been in using superficial ablative techniques. dermabrasion has been effective, but is limited by the treatment sites and risk of complications. this has led to laser therapy as the preferred modality for treating recalcitrant plaques in hhd. however, our experience is limited to anecdotal reports. the exact mechanism of action of laser ablation for the treatment of hhd remains unclear. one theory is that the epidermis and keratinocytes that express the molecular defect are ablated, while leaving adnexae intact to regenerate normal epidermis lacking the adhesion defect. another theory is that dermal fibrosis leads to better support of the diseased epidermis and decreases risk of ulceration and fissuring. this hypothesis supports the improvement seen in non-ablative laser therapy. fractionated technology only ablates microthermal zones and therefore, leaves untreated areas of epidermis expressing the review figure 1 a) right axilla prior to laser treatment. b) right axilla 1 month after treatment with fractional co2 laser therapy. a) b) no nco mm er cia l u se on ly [dermatology reports 2011; 3:e28] [page 65] molecular defect. perhaps with several treatments, eventually the entire diseased epidermis would be completely ablated and would lead to some improvement. however, this is only speculation. at this time, the authors do not recommend fractional ablative lasers in the treatment of hhd since traditional ablative devices seem to provide more consistent results than seen in our patient. further studies are needed to determine optimal devices and laser parameters for treatment of hhd. references 1. hailey h, hailey h. familial benign chronic pemphigus. arch dermatol syphilol 1939;39:679-85. 2. hu z, bonifas jm, beech j, et al. mutations in atp2c1, encoding a calcium pump, cause hailey-hailey disease. nat genet 2000;24:61-5. 3. reitamo s, remitz a, lauerma ai, forstrom l. contact allergies in patients with familial benign chronic pemphigus (hailey-hailey disease). j am acad dermatol 1989;21:506-10. 4. sudbrak r, brown j, dobson-stone c, et al. hailey-hailey disease is caused by mutations in atp2c1 encoding a novel ca(2+) pump. hum mol genet 2000;9:1131-40. 5. hunt mj, salisbury el, painter dm, lee s. vesiculobullous hailey-hailey disease: successful treatment with oral retinoids. australas j dermatol 1996;37:196-8. 6. sire dj, johnson bl. benign familial chronic pemphigus treated with dapsone. arch dermatol 1971;103:262-5. 7. berth-jones j, smith sg, graham-brown ra. benign familial chronic pemphigus (hailey-hailey disease) responds to cyclosporin. clin exp dermatol 1995;20:70-2. 8. bianchi l, chimenti ms, giunta a. treatment of hailey-hailey disease with topical calcitriol. j am acad dermatol 2004;51:475-6. 9. rabeni ej, cunningham nm. effective treatment of hailey-hailey disease with topical tacrolimus. j am acad dermatol 2002;47:797-8. 10. thorne fl, hall jh, mladick ra. surgical treatment of familial chronic pemphigus (hailey-hailey disease). report of a case. arch dermatol 1968;98:522-4. 11. kauten jr, zook eg, kumar aa, kinkead lr. surgical management of familial benign chronic pemphigus by excision and primary closure. ann plast surg 1982; 9:337-43. 12. shons ar. wide excision of perineal hailey-hailey disease with healing by secondary intention. br j plast surg 1989; 42:230-2. 13. crotty cp, scheen sr 3rd, masson jk, winkelmann rk. surgical treatment of familial benign chronic pemphigus. arch dermatol 1981;117:540-2. 14. berger rs, lynch pj. familial benign chronic pemphigus. surgical treatment and pathogenesis. arch dermatol 1971; 104:380-4. 15. hamm h, metze d, brocker eb. haileyhailey disease. eradication by dermabrasion. arch dermatol 1994;130:1143-9. 16. don pc, carney ps, lynch ws, et al. carbon dioxide laserabrasion: a new approach to management of familial benign chronic pemphigus (hailey-hailey disease). j dermatol surg oncol 1987; 13:1187-94. 17. kartamaa m, reitamo s. familial benign chronic pemphigus (hailey-hailey disease). treatment with carbon dioxide laser vaporization. arch dermatol 1992; 128:646-8. 18. touma dj, krauss m, feingold ds, kaminer ms. benign familial pemphigus (hailey-hailey disease). treatment with the pulsed carbon dioxide laser. dermatol surg 1998;24:1411-4. 19. christian mm, moy rl. treatment of hailey-hailey disease (or benign familial pemphigus) using short pulsed and short dwell time carbon dioxide lasers. dermatol surg 1999;25:661-3. 20. mcelroy ja, mehregan da, roenigk rk. carbon dioxide laser vaporization of recalcitrant symptomatic plaques of haileyhailey disease and darier's disease. j am acad dermatol 1990;23:893-7. 21. kruppa a, korge b, lasch j, et al. successful treatment of hailey-hailey disease with a scanned carbon dioxide laser. acta derm venereol 2000;80:53-4. 22. beier c, kaufmann r. efficacy of erbium:yag laser ablation in darier disease and hailey-hailey disease. arch dermatol 1999;135:423-7. 23. kaufmann r, hibst r. pulsed erbium:yag laser ablation in cutaneous surgery. lasers surg med 1996;19:324-30. 24. konrad h, karamfilov t, wollina u. intracutaneous botulinum toxin a versus ablative therapy of hailey-hailey disease-a case report. j cosmet laser ther 2001; 3:181-4. 25. nandini as, mysore v. hailey-hailey disease: a novel method of management by radiofrequency surgery. j cutan aesthet surg 2008;1:92-3. 26. fisher gh, geronemus rg. improvement of familial benign pemphigus after treatment with pulsed-dye laser: a case report. dermatol surg 2006;32:966-8. 27. downs a. smoothbeam laser treatment may help improve hidradenitis suppurativa but not hailey-hailey disease. j cosmet laser ther 2004;6:163-4. review no nco mm er cia l u se on ly dr [page 14] [dermatology reports 2012; 4:e4] plantar pitted keratolysis: a study from non-risk groups asli feride kaptanoglu,1 ozlem yuksel,2 selcuk ozyurt3 1near east university, lefkosa-north cyprus, turkey; 2bayindir hospital kavaklidere, ankara, turkey; 3i̇zmir ataturk research and education hospital, i̇zmir,turkey abstract pitted keratolysis is an acquired, superficial bacterial infection of the skin which is characterized by typical malodor and pits in the hyperkeratotic areas of the soles. it is more common in barefooted people in tropical areas, or those who have to wear occlusive shoes, such as soldiers, sailors and athletes. in this study, we evaluated 41 patients who had been diagnosed with plantar pitted keratolysis. the patients were of high socioeconomic status, were office-workers, and most had a university degree. malodor and plantar hyperhydrosis were the most frequently reported symptoms. the weight-bearing metatarsal parts of the feet were those most affected. almost half the women in the study gave a history of regular pedicure and foot care in a spa salon. mean treatment duration was 19 days. all patients were informed about the etiology of the disease, predisposing factors and preventive methods. recurrences were observed in only 17% of patients during the one year follow-up period. this study emphasizes that even malodorous feet among non-risk city dwellers may be a sign of plantar pitted keratolysis. a study of the real incidence of the disease in a large population-based series is needed. introduction pitted keratolysis is an acquired, superficial bacterial infection of the skin. the characteristic features of the diseaseare multiple crateriform pits (usually in the weight-bearing areas of the soles), maceration (mostly because of hyperhydrosis), a typical unpleasant smell, and sliminess of the feet. pitted keratolysis has a worldwide distribution, but the disease is more common among barefooted people living in tropical regions. no race or sex predilection has been reported.1-3 in this study, we documented clinical and demographic data of 41 plantar-pitted keratolysis patients who were admitted to a private hospital in ankara, turkey. materials and methods the study included all patients diagnosed with plantar-pitted keratolysis in a 2-year period among the patients of the dermatology department of a private hospital in ankara. an unproblematic clinical diagnosis of pitted keratolysis was made in almost all of the 41 patients with the help of the unique malodor of the disease. in 11 of the patients, gram’s staining was performed to show the rod like organisms confirming the diagnosis of pitted keratolysis. however, mycotic investigations and wood light examination were carried out in every patient to exclude tinea pedis and erythrasma. in some suspected patients, bacteriological cultures or histopathological examinations were carried out to exclude other bacteriological infections and some keratodermas. patients with a diagnosis other than pitted keratolysis were excluded from the study, but 4 of the patients who concomitantly had both tinea pedis and pitted keratolysis were included. patients were investigated with a special emphasis on the triggering factors and the results were recorded. results of the 41 pitted keratolysis patients included in this study, 24 were male (58.6%) and 17 were female (41.4%). patients were between 18-56 years of age (mean 38.95 years). most of the patients were office workers of a high socioeconomic status and had a university degree (n=24, 58.6%). thirteen patients (31.7%) had a high school degree and reported prolonged use of occlusive footwear for work. three patients were students (7.3%) and one was not educated (2.4%). patients mostly complained about malodor (n=41, 100%), wet feet (n=27, 66%), sliminess of the feet (n=11, 26.8%), pain and burning sensation in the feet (n=11, 26.8%) and pruritus (n=1, 2.4%). none of the patients reported a seasonal change in their condition. none of the patients reported involvement of the palms of their hands. weight-bearing metatarsal regions of the feet were most commonly involved areas (n=39, 95.1%). physical examination mostly revealed malodor (100%) and hyperkeratosis (58.6%) of the soles. maceration due to hyperhydrosis was found in 31.7% of patients, whereas fissures and erythema were seen in 14.6% and 2.4% of cases, respectively. four of the patients had concomitant tinea pedis (9.7%). plantar warts and corns were observed in 7.3% and 2.4% of cases, respectively. no corynebacterial triad (pitted keratolysis, erythrasma and trichomycosis) was seen in any of the patients in the present study. as there is no system for scoring the severity of plantar pitted keratolysis, treatment was planned according to the clinical appearence of lesions, depending on the anatomic extension of lesions, the hyperkeratosis and depth of the pits. only topical treatment with 4% erythromycin gel was applied in 9 patients (21.9%) who had malodor and slight pits. patients (n=32, 78.1%) with more severe clinical appearance (malodor, hyperkeratosis deep pitted lesions and maceration) needed both systemic and topical treatment. roxytromycine 300 mg/day was used as a systemic antibiotic. patients (n=19, 46.4%) who had malodor, hyperkeratosis and deeper pitted lesions were treated with 10% salicylic acid, including creams in addition to erythromycine gel. in patients with severe maceration, 0.01% kmno4 solution was also used for its astringent and drying properties (table 1). patients were controlled weekly and topical treatments were continued until symptoms had completely disappeared. all patients reported strict adherence to treatment and kept their checkup appointments. treatment lasted between one and eight weeks (mean 19 days). during the treatment period, patients used cotton socks and followed suggestions for changes in their daily habits. they did not wear the same shoes for two consecutive days. during the 1-year follow up, recurrence was observed in 7 (17%) patients. time to recurrence was 4-12 months. the common feature of these patients was the highly hyperkeratotic tissue of the sole; one was in severe depression and one was deeply immunosupressed. discussion pitted keratolysis is a skin disorder charac dermatology reports 2012; volume 4:e4 correspondence: asli feride kaptanoglu, near east university, ankara, turkey. e-mail: dr.aslikaptanoglu@gmail.com key words: plantar pitted keratolysis; foot odour; risk groups. received for publication: 25 july 2011. revision received: 21 november 2011. accepted for publication: 1 december 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright a.f. kaptanoglu et al., 2012 licensee pagepress srl, italy dermatology reports 2012; 4:e4 doi:10.4081/dr.2012.e4 no nco mm er cia l u se on ly [dermatology reports 2012; 4:e4] [page 15] terized by crateriform pits that primarily affect the pressure-bearing parts of the plantar surfaces of the feet and occasionally the palms of the hands. the manifestations are due to a superficial cutaneous bacterial infection. the causavite agents are corynebacterium species, kytococus sedentarius and dermatophilus congolensis.2-5 pitted keratolysis was first reported by castellani in a ceylonese patient in 1910, and was confirmed as a unique separate clinical entity in the 1930s. the current name, plantar pitted keratolysis, was used to define the clinical presentation.1 diagnosis can easily be made by means of visual examination and recognition of the characteristic odor.2 in our study, patients were aged between 18-56 years (mean 38.95 years), which correlated with the other reports.6 pitted keratolysis is observed in males more than females.6-9 in our study, the male to female ratio was 6:4, showing an almost equal predilection. pitted keratolysis is reported to be more common among barefooted laborers/ farmers, sailors, soldiers and industrial workers wearing occluded wet shoes for prolonged periods.1 ramsey reported pitted keratolysis as a common infection of active feet as sporting activity makes the feet hot and wet.10 in our study, there were no barefoot laborers, farmers, sailors or soldiers. most of our cases were office workers and well-educated people who take care of their personal hygiene. prolonged use of footwear could be the common factor in these subjects. interestingly, more than the half of the female patients (58.8%) had a history of regular pedicure and foot care in a spa salon. moisture and inappropriate hygiene may be the predisposing factors in such patients. pitted keratolysis is usually asymptomatic but patients may complain of hyperhydrosis, sliminess, malodor and occasionally soreness, itching and pain while walking.11,12 in our study, malodor (100%) was the most commonly reported symptom. in one series, naik and singh reported malodor in 70% of patients.6 malodor could be the most important indication of disease because of its negative impact in office-working conditions. pain and a burning sensation were reported by almost a quarter of the patients (26.8%). sliminess of the skin was also a common complaint (26.8%). pruritus was present in only one patient (2.4%). interdigital intertrigo and paronychia may coexist with pitted keratolysis but these are reported to have no influence on the onset or course of the disease.11 associated dermatophyte infections were also evident in 17.1% of our patients. associated plantar warts and corn was observed in 7.3 and 2.4% of the cases, respectively. corynebacterial triad (pitted keratolysis, erythrasma and trichomycosis ) was not seen in any of the patients in the present study. the other associated diseases were diabetes mellitus (9.75%), depression (2.4%), and immunosuppression (7.31%) due to chemo therapy for ovarian carcinoma, and interferon treatment for hepatitis b and c. the predisposing factors are known to be a humid climate, poor hygiene, hyperhydrosis, obesity, diabetes, advanced age and immunocompromised host.2 in contrast with the literature, the city where the study took place does not have a hot and humid climate and patients showed a good standard of personal hygene. however, the associated disorders, such as diabetes or immunosuppression, were correlated with the other reports. pitted keratolysis has been reported to have an excellent prognosis; effective treatment clears both the lesions and the odor in 3-4 weeks time. topical antibiotics are reported to be effective, easy to use and acceptable by the patients. recommendations include twicedaily application of erythromycin solution or gel, 1% clindamycin hydrochloride solution, fusidic acid cream and mupirocin cream. use of systemic antiobiotic may shorten the treatment period.1-3 koc et al. reported topically applied clindamycin and erytromycin to be both safe and effective.13 in a case of ertam et al., three weeks of oral erythromycin treatment was reported to be effective.14 in our study, only topical treatments were applied in 9 cases whereas 32 patients needed both topical and systemic treatments. treatment duration was 1-8 weeks (mean 19 days) which was almost twice that reported by koc et al.13 during the follow-up period, recurrence was observed in 7 (17%) of the patients after one year. most of the patients (83%) had no recurrence after one year. this might be because of the increased awareness in avoiding the predisposing factors, as well as applying the treatments correctly. the common feature of the 7 recurrent cases was the highly hyperkeratotic tissue of the soles. patients should be warned about the importance of plantar hyperkeratosis in disease development, as under suitable conditions, like prolonged occlusion, hyperhydrosis, and increased skin surface ph, bacterias that cause the disease may proliferate and produce proteinases which in turn destroy the hyperkeratotic stratum corneum, creating pits and causing malodor. maintenance treatment may be suggested to these high-risk patients. preventive measures, such as avoiding occlusive footwear, not sharing shoes or towels with others, using absorbent cotton socks, and drying feet properly after washing should be recommended. most of our patients maintained a good standard of personal hygiene and were careful about using shoes, socks or towels but they all prolonged use of occlusive footwear. conclusions plantar pitted keratolysis is a disease mostly affecting the soles of the feet. it is a bacterial infection and usually occurs because of prolonged use of occlusive footwear. although a lot of people have smelly feet there are not many reports about the real incidence of plantar pitted keratolysis. the only reports concern highrisk groups. our study showed that the incidence of pitted keratolysis might be more common than suspected. instead of seeking medical help, people with foot odor might be using over the counter products which mostly contain anti-fungals and anti-perspirants or sometimes ointments which may aggrevate maceration. references 1. singh g, naik cl. pitted keratolysis. indian j dermatol venereol leprol 2005; 71:213-15. 2. martin ag, kobayashi gs. bacterial diseases with cutaneous involvement. in: freedberg im, eisen az, wolff k, et al. dermatology in general medicine. new article table 1. treatment modalities according to clinical appearance. symptom n (%) topical treatment systemic treatment malodor-pits 9 (21.9) erythromycine gel malodor-hyperkeratosis-deeper pits 19 (46.4) erythromycine gel roxytromycine 10% salicylic acid cream 300 mg/day malodor-hyperkeratosis-deeper pits-maceration 13 (31.7) erythromycine gel roxytromycine 10% salicylic acid cream 300 mg/day 0.01% kmno4 solution no nco mm er cia l u se on ly [page 16] [dermatology reports 2012; 4:e4] york: mcgraw hill inc, 5 th edi; 1999. pp 2203-2204. 3. english jc. pitted keratolysis. emedicine j 2003;11:1-7. 4. woodgyer aj, baxter m, rush-munro fm. isolation of dermatophilus congolensis from two new zealand cases of pitted keratolysis. aust j dermatol 1985;26:29-35. 5. longshawcm, wright jd, farrel am, holland kt. kytococcus sedentarius the organism associated with pitted keratolysis,produces keratin-degrading enzymes. j appl microbiol 2002;93:810-6. 6. naik cl, singh g. clinico epidemiological study of pitted keratolysis. ind j dermatol 2007;52:35-8. 7. schissel dj. aydelotte j, keller r. road rash with a rotten odor. mil med 1999;164:65-7. 8. gill ka, buckels lj. pitted keratolysis. arch dermatol 1968;98:7-11. 9. morse jm. when a patient presents with malodorus, macerated feet. podiatry today 2008;12:26-32. 10. ramsey ml. pitted keratolysis. a common infection of active feet. phys sport med 1996;24:1-4. 11. takama h, tamada y, yano k, et al. pitted keratolysis. clinical manifestations in 53 cases. br j dermatol 1997;137:282-5. 12. narayani k, gopinathan t, ipe pt. pitted keratolysis. indıan j dermatol venereol leprol 1981;47:151-4. 13. koc e, arca e, akar a, gür ar. comparison of topical clindamycine solution with erytromycin gel treatment in pitted keratolysis. dermatose 2004;4:37-41. 14. ertam i, aytimur d, yuksel se. isolation of kytococcus sedentarius from a case of pitted keratolysis. ege tip dergisi 2005; 44:117-8. article no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. dr [page 22] [dermatology reports 2012; 4:e7] polymorphic eruption of pregnancy developing postpartum: 2 case reports ellen cathrine pritzier, carsten sauer mikkelsen department of dermato-venerology, stavanger university hospital, stavanger, norway abstract polymorphic eruption of pregnancy (pep), also known as pruritic urticarial papules and plaques of pregnancy, is a common benign dermatosis of pregnancy mainly affecting primigravidae and multiple pregnancies. we report here two cases of pep with typical clinical and histological features presenting in the postpartum period. introduction polymorphic eruption of pregnancy (pep), also known as pruritic urticarial papules and plaques of pregnancy (puppp) is a common benign dermatosis of pregnancy mainly affecting primigravidae and multiple pregnancies. pep usually evolves in the third trimester and resolves rapidly postpartum (table 1). we describe two cases of pep with typical clinical and histological features presenting in the postpartum period. only few cases of pep developing postpartum have been described in the literature. however, a rash appearing in the mother shortly after delivery still can be a specific dermatosis of pregnancy. case report #1 a 21-year-old woman was referred to our department of dermatology complaining of an intense pruritic rash starting 12 days postpartum. the eruption initially developed in and around the abdominal striae distensae with a periumbilical sparing (figure 1). the urticarial plaques and erythematous papules spread to the buttocks, thighs and lower lumbar region. on the abdomen tiny vesicles were observed. no facial involvement or hand and foot lesions were observed. the patient was successfully treated with prednisolone 20 mg daily for five days combined with high potency topical corticosteroids tapered over four weeks. a punch biopsy showed slight dermal edema and a predominantly perivascular infiltrate of lymphocytes and eosinophilic granulocytes (figure 2). there were no epidermal alterations, no blisters and no vasculitis. direct immunfluorescens study was negative. case report #2 a 26-year old primigravida woman was referred 5 days after giving birth with an itchy rash on the abdomen spreading to the proximal thighs. in the last week of her pregnancy, she had noticed some itchiness on her abdomen but no visible changes besides wellmarked striae gravidarum. objectively erythematous urticarial plaques and confluent papules were seen with a periumbilical sparing. high potency topical corticosteroids were initiated in combination with oral antihistamines and the itchy eruption subsided in the following 3 weeks. a 4 mm punch biopsy from the skin of the buttock showed a slight dermal edema and perivascular lymphocytic infiltrates with scattered perivascular and interstitial eosinophils. the patient was otherwise healthy apart from a tendency to depression treated with citalopram. discussion in pregnancy, complex endocrinologic, immunologic, metabolic and vascular changes influence the skin in various ways. the multiple alterations of the skin during pregnancy can be classified as physiological skin changes, alterations in pre-existing skin diseases and specific dermatoses of pregnancy.1 the specific dermatoses of pregnancy represent a unique group of disease processes caused or exacerbated by the pregnancy state and include gestational pemphigoid (herpes gestationis), prurigo of pregnancy, intrahepatic cholestasis of pregnancy, impetigo herpetiformis and pep/puppp. pep is a common distinct clinical entity with an estimated incidence in a single pregnancy of one in 130-300 pregnancies.2-4 it is generally considered as a benign dermatosis almost exclusive in primigravidae. the condition is more common in multiple pregnancies, where both earlier presentation and recurrence in second pregnancy are seen.5-7 the etiology is still unknown. it has been postulated that excessive abdominal distension and weight gain may act as a trigger for the skin changes due to connective tissue damage caused by overstretching.1,4 rudolph et al. found a high frequency of atopy (55%) among their patients, especially in those with longer disease duration. pep usually evolves in the third trimester at the average gestational week of 35 and resolves rapidly postpartum and only exceptionally does it appear in the postpartum period.2,4 the lesions start in the abdominal striae in two thirds of the patients with a periumbilical sparing distinguishing pep from other common rashes of pregnancy.8 the rash consists of very itchy small erythematous papules in the stretch marks which can coalesce to form larger urticarial abdominal plaques often surrounded by blanched halos. occasionally eczematous, polycyclic and target lesions can be seen or vesicles (but never bullae) eventually in an acral dyshidrosiform pattern.4,5,6 over days, the rash can spread over the thighs, buttocks, breasts, and arms with infrequent facial, hand and foot lesions.4 in spite of the severe pruritus, the absence of excoriations on the skin is a striking feature in contrast to excoriations related to cholestasis of pregnancy. the condition is harmless to the mother but can be very annoying because of the severe itching.4,6 the average duration of healing is 46 weeks. there are no cutaneous manifestations in the newborn and the fetal prognosis is excellent.1 the diagnosis of pep can be made clinically in typical cases based on the appearance of the rash. there are no specific laboratory abnormalities and only nonspecific histopathology with a perivascular lymphohistiocytic infiltrate with some edema and eosinophils in the dermis.4 direct immunofluorescence studies of the skin are by definition negative.4 skin biopsies are only performed to rule out other differential diagnoses such as pemphigoid gestationis, atopic dermatitis, contact dermatitis, drug eruptions, viral eruptions and scabies. pep is a self-limiting disor dermatology reports 2012; volume 4:e7 correspondence: ellen cathrine pritzier, deparment of dermato-venerology, stavanger university hospital, postboks 8100, 4068 stavanger, norway. tel. +47.515.130.10. e-mail: elnc@sus.no key words: pruritic urticarial papules and plaques of pregnancy, polymorphic eruption of pregnancy, dermatosis conflict of interests: the authors report no potential conflict of interests. received for publication: 16 april 2012. accepted for publication: 16 april 2012. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright e.c. pritzier and c.s. mikkelsen, 2012 licensee pagepress, italy dermatology reports 2012; 4:e7 doi:10.4081/dr.2012.e7 no nco mm er cia l u se on ly [dermatology reports 2012; 4:e7] [page 23] der with resolution shortly after parturition and the treatment is symptomatic.4,6 general measures, such as mild to potent topical steroids can be helpful in treating symptoms from the disease together with systemic antihistamines. furthermore application of emollients is basic in the treatment.4 in the most severe cases, as seen in one of the cases above, oral steroids may be necessary to control itching.4,5 if systemic corticosteroid treatment is necessary during pregnancy non-halogenated glucocorticosteroids (e.g. prednisolone) which are inactivated enzymatically in placenta should be administered as a short time therapy in a dosage of 0.5-2 mg/kg/day depending of the severity of symptoms.1 conclusions pep is a frequently occurring pruritic, selflimited inflammatory dermatosis, most often seen in primiparous women and in the last trimester of pregnancy.1 if a rash develops after delivery, specific dermatoses of pregnancy still remains a possible diagnosis. references 1. ambros-rudolph cm. dermatoses of pregnancy. j dtsch dermatol ges 2006;9:74859. 2. holmes rc, black mm, dann j, et al. a comparative study of toxic erythema of pregnancy and herpes gestations. br j dermatol 1982;106:499-510. 3. roger d, vaillant l, fignon a, et al. specific pruritic diseases of pregnancy. a prospective study of 3192 pregnant women. arch dermatol 1994;130:734-9. 4. rudolph cm, al-fares s, vaughan-jones sa, et al. polymorphic eruption of pregnancy: clinicopathology and potential trigger factors in 181 patients. br j dermatol 2006;154:54-60. 5. powell fc. pruritic urticarial papules and plaques of pregnancy and multiple pregnancies. j am acad dermatol 2000;43:7301. 6. cohen lm. capeless el, krusinski pa, maloney me. pruritic urticarial papules and plaques of pregnancy and its relationship to maternal-fetal weight gain and twin pregnancy. arch dernatol 1989;125:1534-6. 7. elling sv, mckenna p, powell fc. pruritic urticarial papules and plaques of pregnancy in twin and triplet pregnancies. j eur acad dermatol venereol 2000;14:378-81. 8. matz h, orion e, wolf r. pruritic urticarial papules and plaques of pregnancy: polymorphic eruption of pregnancy (puppp). clin dermatol 2006;24:105-8. case report table 1. clinical features of two patients with postpartum polymorphic eruption of pregnancy. patient maternal primagravida delivery outcome onset duration of distribution morphology treatment age gestational polymorphic age eruption of pregnancy a 21 12 days abdomen, urticarial postpartum thighs plaques b 26 yes caesarean healthy 5 days 3 weeks abdomen, urticarial topical section boy postpartum thighs plaques steroids, ....... antihistamines figure 2. skin biopsy showing a predominantly perivascular infiltrate of lymphocytes and eosinophilic granulocytes. typical, but not diagnostic for polymorphic eruption of pregnancy. figure 1. erythematous papules and urticarial plaques with periumbilical sparing and accentuation in striae in a 21-year old woman with polymorphic eruption of pregnancy. no nco mm er cia l u se on ly dr [dermatology reports 2011; 3:e23] [page 51] patient with giant becker’s nevus and epidermal nevus george issa, travis w. blalock, jack l. lesher medical college of georgia, division of dermatology, augusta, ga, usa abstract becker’s nevus is a cutaneous hamartoma that may be present at birth, but more commonly is noticed during puberty. it classically manifests unilaterally on the shoulder and upper trunk as a tan to brown patch or thin plaque. "it typically has an irregular margin, breaks up into islands at the periphery, and has an average size of 125 square centimeters. numerous skin, soft-tissue, and bony anomalies have been reported in association with becker’s nevus. we describe a patient with becker’s nevus of considerable size who has a concurrent epidermal nevus. case report a 70 year old black male presents with a lesion on his left lower extremity and one on his trunk that he has had since adolescence. the lesion on his lower extremity is a hyperpigmented scaly plaque extending along his left lateral thigh, knee, and leg (figure 1a), biopsy of which demonstrates hyperkeratosis with acanthosis and increased pigmentation at the basal layer, consistent with an epidermal nevus (figure 1b). the lesion on his trunk is a hyperpigmented patch with irregular borders and satellite macules extending bilaterally to his medial arms across his left shoulder and onto his lower neck (figure 1c/1d). biopsy demonstrates acanthosis, hyperkeratosis with regular elongation of rete ridges, increased basal layer pigmentation with a normal number of melanocytes, and an increase in smooth muscle bundles in the dermis (figure 1e/1f), consistent with a becker’s nevus.1,2 the patient is otherwise healthy with no clinically significant medical history, developmental anomalies, or family history of similar lesions. discussion the pathogenesis of becker’s nevus remains uncertain. there is a male to female ratio of 5:1.1 this, along with the increased number of terminal hairs seen within many lesions, and reports of acne vulgaris confined to becker’s nevi, has raised the suspicion of androgenic stimulation as an underlying factor.1 hypertrichosis is present in approximately one-half of cases and there is often an associated smooth muscle hamartoma.1 epidermal nevi are congenital hamartomas that arise from pluripotential germinative cells of the basal layer of the embryonic epidermis.3 they appear as patches, plaques, or nodules that may be bilateral and most commonly affect the face, trunk, and proximal extremities.4,5 an estimated one third of affected individuals have involvement of other organs, which is called epidermal nevus syndrome.5 this sporadic neurocutaneous linkage of congenital ecdermatology reports 2011; volume 3:e23 correspondence: travis w. blalock, md, medical college of georgia, division of dermatology, 1004 chafee ave., augusta, ga 30904, usa. tel. +1.706.721.6231 fax: +1.706.721.6220. e-mail: tblalock@mcg.edu key words: epidermal nevus, becker's nevus, epidermal nevus syndrome. contributions: all authors have contributed significantly and are in agreement with the content of the manuscript. funding/support: there were no funding sponsors in the collection, analysis, and interpretation of data; or in the preparation, review, or approval of the manuscript. received for publication: 9 august 2011. accepted for publication: 9 august 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright g. issa et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e23 doi:10.4081/dr.2011.e23 figure 1. hyperpigmented scaly plaque on left lower extremity consistent with epidermal nevus (a). biopsy of (a) showing increased basilar pigmentation, acanthosis, and hyperkeratosis(b, h&e 5x). large hyperpigmented patch with irregular borders and satellite macules (c & d) consistent with becker’s nevus. increased basilar pigmentation (e, h&e 10x) and smooth muscle proliferation (f, h&e 20x) in biopsies from lesion (c). no nco mm er cia l u se on ly [page 52] [dermatology reports 2011; 3:e23] todermal defects can affect the skin, brain, eyes, and/or skeleton.5 as some authors regard becker’s nevi as a subclass of epidermal nevi, patients with becker’s nevi should be examined for associated soft tissue, neurologic, ophthalmologic, and bony abnormalities. the becker’s nevus in our patient is remarkable due to its large size and co-existence with an epidermal nevus. a study of french men estimated the prevalence of becker’s nevi to be approximately 0.5%, while epidermal nevi have an incidence of approximately 0.1% of newborns.1, 6 there is considerable debate in the literature regarding these two entities, some regarding both lesions as cutaneous hamartomas while others consider them each to be versions of epidermal nevi.6 regardless of the classification, the presence of both lesions in a single patient is very unusual, and to our knowledge, simultaneous expression of these two lesions has not been previously reported. references  1. grande sarpa h, harris r, hansen cd, callis duffin kp, florell sr, hadley ml. androgen receptor expression patterns in becker’s nevi: an immunohistochemical study. j am acad dermatol 2008;59:834-8. 2. person, jr, longcope, c. becker’s nevus: an androgen-mediated hyperplasia with increased androgen receptors. j am acad dermatol 1984;10:235-238. 3. copeman pw, jones ew. pigmented hairy epidermal nevus (becker). arch dermatol sep 1965;92:249-51. 4. rogers m, mccrossin i, commens c. epidermal nevi and the epidermal nevus syndrome. a review of 131 cases. j am acad dermatol mar 1989;20:476-88. 5. vidaurri-de la cruz h, tamayo-sanchez l, duran-mckinster c, de la luz orozco-covarrubias m, ruiz-maldonado r. epidermal nevus syndromes: clinical findings in 35 patients. pediatr dermatol 2004;21:432-9. 6. kose o, caliskan c, kurumlu, z. three different epidermal naevi with no organ involvement: sebaceous naevus, naevus comedonicus and becker’s nevus. acta derm venereol 2008;88:67-9. case report no nco mm er cia l u se on ly dr dr [dermatology reports 2013; 5:e1] [page 1] erythema annulare centrifugum-like eruption associated with pegylated interferon treatment for hepatitis c mark naccarato,1 deborah yoong,1 robert solomon,2 mario ostrowski1,3 1department of infectious diseases and hiv, st. michael’s hospital, toronto, ontario; 2department of dermatology, st. michael’s hospital, toronto, ontario; 3faculty of medicine, university of toronto, 1 king’s college circle, toronto, ontario, canada abstract current standard of treatment for chronic hepatitis c virus infection requires the use of pegylated interferon plus ribavirin. treatment with these two agents has been associated with numerous side effects, which frequently include dermatologic eruptions. we report a cutaneous eruption associated with interferon having clinical presentation of erythema annulare centrifugum. the eruption occurred within days of the first interferon injection and repeatedly flared following subsequent injections. our patient was able to continue therapy without interruption, while managing the reaction with topical corticosteroid and oral antihistamine. we conclude that this is a benign cutaneous eruption associated with interferon which can be managed without discontinuing treatment for hepatitis c. case report a 48-year-old male was referred to our clinic for assessment of hepatitis c (hcv). his past medical history included mild chronic obstructive pulmonary disease, spinal surgery, remote eczema, and past alcohol, cigarette and intravenous drug use. he reported an allergy to penicillin and was taking naproxen daily for back pain. treatment for hcv, genotype 1, was initiated with pegylated interferon alfa-2a 180 mcg subcutaneously once per week and oral ribavirin 1000 mg per day. on the fourth day of treatment he experienced an intermittently pruritic and enlarging rash localized to his arms and legs. he described these painless lesions as migrating cloud-like rings, which eventually became confluent with nearby lesions. dermatologic exam one week after starting therapy showed multiple large annular erythematous lesions, each with a non-scaly peripheral red border (figure 1). the patient denied any fevers or chills, the eruption was not localized to the injection site, there was no presence of bullae, erosions, or mucous membrane involvement. punch biopsy was obtained; however, due to the absence of alarming symptoms we elected to continue treatment at the same dosages and manage the reaction with betamethasone valerate 0.1% cream applied twice daily along with oral hydroxyzine 25 mg as needed for pruritus. histopathology of the skin biopsy (figure 2) revealed a sparse superficial perivascular infiltrate of lymphocytes and eosinophils. the epidermis was unremarkable, there was no evidence of vasculitis, and the periodic acidschiff (pas) stain was negative for fungi. as well, labs at this time did not show any eosinophilia. following the second interferon injection, the eruption flared at the same sites and had the same migratory nature as observed the prior week. the rash again improved over the next several days with topical steroids while continuing on ribavirin, yet re-emerged following the third interferon injection. the rash then completely resolved by the fourth week of interferon with no further dermatologic reactions. diagnosis based on clinicopathology was an annular erythematous drug reaction, however the patient successfully completed 48 weeks of uninterrupted therapy and achieved cure of his hepatitis c. as well, investigations for internal malignancy have thus far been negative. discussion various cutaneous conditions have been associated with hcv infection and its treatment (table 1).1,2 interferon and ribavirin therapy have been reported to cause dermatologic reactions in approximately 13-23% of hcv patients.2 however annular erythematous eruptions associated with interferon appear rare as only one case of granuloma annulare and two cases of erythema gyratum repens have been reported in literature.3,4 the administration of exogenous interferon alfa is thought to up-regulate hundreds of genes involved in inflammatory cell responses, along with having immunomodulating effects.5 therefore a cutaneous eruption following initiation of interferon is consistent with its proinflammatory properties. the term erythema annulare centrifugum (eac) was first introduced by darier in 1916 to describe an eruption of annular lesions that enlarged rapidly then disappeared in 1 to 2 weeks while new lesions continued to develop.6 eac lesions usually present as erythematous macules or urticarial papules, which enlarge centrifugally and clear centrally, thereby creating an annular appearance.7 as the edges of lesions advance, they may become confluent with adjacent lesions developing arciform segments.7 darier described the classical histopathologic feature as a dense perivascular sleeve-like lymphocytic infiltrate throughout the thickness of the dermis.6 however since that time, the term eac has grown to include similar presentations which have an entirely superficial histology lacking the classic sleeve-like arrangement.6 lesions of superficial eac, unlike the deep-type, often include scaling along with nonspecific histologic findings of mild spongiosis and perakeratosis.6 the etiology of eac is not known, however it has been associated with a variety of etiologic factors including neoplasms, infectious agents, and several different medications.6 given the myriad of histologic findings and association to a variety of etiologic agents, eac likely represents a clinical reaction pattern whose diagnosis cannot be made on pathology alone. our patient experienced a new migratory annular dermatologic eruption within four days of starting pegylated interferon, which was clinically indistinguishable from eac. the lesions initially waned over the next few days while he continued taking twice daily ribavirin; however, again flared following each of the next two weekly doses of interferon. based on the clinical presentation of his migrating lesions following interferon, distribution limited to his extremities, lack of scaling or eosinophilia, non-specific histopathology, and the resolution of symptoms without any target dermatology reports 2013; volume 5:e1 correspondence: mark naccarato, department of infectious diseases and hiv, st. michael’s hospital, 30 bond street, 4ccn, 4-177, toronto, ontario, m5b 1w8, canada. e-mail: naccaratom@smh.ca key words: interferon, ribavirin, hepatitis c, erythema annulare centrifugum, drug eruption. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 11 june 2013. revision received: 5 july 2013. accepted for publication: 8 july 2013. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright m. naccarato et al., 2013 licensee pagepress, italy dermatology reports 2013; 5:e1 doi:10.4081/dr.2013.e1 no nco mm er cia l u se on ly [page 2] [dermatology reports 2013; 5:e1] ed therapy; other causes of annular lesions or migrating erythemas were excluded.7 a primary differential diagnosis of this eruption includes a similar reactive erythema, erythema gyratum repens (egr), which has been previously reported in association with interferon.4 histopathologically both egr and superficial eac have nonspecific perivascular lymphocytic or eosinophilic infiltrates as shown in our case. clinically however, egr is characterized by its wood-grain appearance, presents with multiple or a generalized pattern of lesions, and is associated with intense pruritus and scaling which was absent,8 making eac the most likely diagnosis. therefore, we propose that interferon caused an eac-like eruption in our patient given the clinical presentation. although, the classical sleeve-like finding of deep-eac was absent, the lymphocytic infiltrate involving eosinophils was consistent with a drug etiology. it is unclear why despite continued treatment with interferon, the lesions did not return after resolution. interferon is noted to promote memory t-cell proliferation, stimulate natural-killer-cell activation and dendritic-cell maturation,5 thus it is possible the eac-like eruption represents an up-regulated immune response to an unknown skin pathogen in our case. as well, it is possible that the etiologic agent or stimulus that induced eac may have been eliminated. given that the etiology of eac has not been fully elucidated, it is difficult to speculate why continued interferon therapy did not incite more lesions, however the observations highlight that development of eac is not a contraindication to continuing interferon treatment. noteworthy to the clinician is that psoriatic, eczematoid and lichenoid eruptions associated with interferon therapy can also be successfully managed using corticosteroids without discontinuation of interferon.2 as well, some reactive annular erythemas are associated with an underlying malignancy,9 however all screening tests in our patient have remained negative. using the naranjo probability scale to evaluate a potential adverse drug reaction,10 our proposed causal relationship of interferon producing this dermatologic eruption was calculated as probable. conclusions annular erythematous drug eruptions associated with interferon appear to be rare, however this report adds to the literature on this subject. in this case, recognizing the benign nature of the reaction and continuing with hcv therapy were factors enabling the patient to complete treatment and achieve cure of his hepatitis c. we conclude that in the treatment of hcv, clinicians need to distinguish benign from life-threatening dermatologic conditions in order to avoid unnecessary treatment interruption risking therapeutic failure. references 1. crowson an, nuovo g, ferri c, magro c. the dermatopathologic manifestations of hepatitis c infection: a clinical, histological, and molecular assessment of 35 cases. human pathol 2003;34:573-9. 2. mistry n, shapero j, crawford ri. a review of adverse cutaneous drug reactions resulting from the use of interferon and ribavirin. can j gastroenterol 2009;23: 677-83. 3. kluger n, moguelet p, chaslin-ferbus d, et al. generalized interstitial granuloma annulare induced by pegylated interferonalpha. dermatology 2006;213:248-9. 4. rongioletti f, fausti v, parodi a. erythema gyratum repens induced by pegylated interferon alfa for chronic hepatitis c. arch dermatol 2012;148:1213-4. 5. feld j, hoofnagle j. mechanism of action of interferon and ribavirin in treatment of hepatitis c. nature 2005;436:967-72. 6. weyers w, diaz-cascajo c, weyers i. erythema annulare centrifugum: results of a clinicopathologic study of 73 patients. am j dermatopathol 2003;25:451-62. 7. burgdorf w. erythema annulare centrifugum and other figurate erythemas. in: fitzpatrick’s dermatology in general medicine. 7th ed. wolff k, goldsmith l, katz s, et al, eds. new york: mcgraw-hill; 2008. pp 366-9. 8. tyring sk. reactive erythemas: erythema annulare centrifugum and erythema gyratum repens. clin dermatol 1993;11:135-9 9. abreu velez am, howard m. diagnosis and treatment of cutaneous paraneoplastic disorders. dermatol ther 2010;23:662-75. 10. naranjo ca, busto u, sellers em, et al. a method for estimating the probability of adverse drug reactions. clin pharmacol ther 1981;30:239-45. case report table 1. dermatologic manifestations of hepatitis c virus and cutaneous reactions to interferon and ribavirin. dermatologic manifestations of hcv cutaneous reactions to interferon and ribavirin pruritus, vasculitis, urticaria, lichen planus, cryoglubulinemia, injection-site reactions, pruritus, psoriasis, alopecia, sarcoidosis, eczematoid, porphyria cutanea tarda, pityriasis rubra pilaris, lichenoid, lupus, fixed-drug eruptions, pigmentation disorders, skin necrosis, graft-versus-host disease, polyarteritis nodosa, meyerson nevi erythema nodosum, erythema multiforme, pyoderma gangrenosum, granuloma annulare, perniosis-like lesions, lichenoid, follicular-based purpura hcv, hepatitis c virus figure 2. histopathology showing a dermal infiltrate in superficial dermis; at 50× magnification. figure 1. patient presenting with erythematous, annular, maculo-papular lesions. no nco mm er cia l u se on ly dr [dermatology reports 2014; 6:5604] [page 21] combined therapeutic use of oral alitretinoin and narrowband ultraviolet-b therapy in the treatment of hailey-hailey disease kaitlin a. vanderbeck,1 lyne giroux,2 nirosha j. murugan,3,4 lukasz m. karbowski3,4 1department of medicine, northern ontario school of medicine, greater sudbury; 2department of medicine, university of ottawa; 3behavioural neuroscience program and 4department of biomolecular sciences, laurentian university, greater sudbury, canada abstract hailey-hailey disease (hhd) is a chronic familial bullous disease characterized by recurrent blisters and erosions typically at friction-prone areas of the body accompanied by acantholysis upon histologic examination. there are a number of therapies used in the management of hhd. its symptoms have been effectively treated with antimicrobial therapies, corticosteroids and other agents such as cyclosporine and prednisone. however, such treatments are not always effective. therefore, there is a need for new treatments for the management of hhd. in this report, a patient with long-standing hhd responsive only to high levels of prednisone is described. after the successful tapering and cessation of oral prednisone the patient began a new combination therapy of complementary doses of oral alitretinoin, and narrowband uvb therapy, which yielded a favorable response within 2-3 weeks. after 6 weeks, a mono-therapy of daily (30 mg) oral alitretinoin was sufficient to maintain successful near-complete remission of the disease. introduction hailey-hailey disease (hhd), otherwise known as familial benign chronic pemphigus is a rare autosomal dominant, acantholytic disease with incomplete penetrance that is characterized by recurrent blisters, plaques, and erosions often accompanied by a burning or pruritic sensation.1-3 patients typically experience a relapsing-remitting course of the disease.4 it is caused by a mutation in the atp2c1 gene on chromosome 3q21-q24, which encodes a disrupted golgi associated ca2+ atpase.5 this mutation induces abnormal intracellular ca2+ signaling which promotes premature keratinocyte proliferation leading to inappropriate desmosomal protein production causing failed keratinocyte adhesion and acantholysis, typically at flexural regions and friction prone sites.1-3,5,6 we report a 64-year-old female with a 37year history of severe hailey-hailey disease involving her whole body. most recently, hhd lesions have appeared on her pubic region and middle back. the patient’s hhd has been unresponsive to common therapies used in the management of hhd. case report in 2005, a then 55-year-old caucasian female presented with clinical signs and symptoms of hhd, which had been active for 32 years. the patient initially developed symptoms of hailey-hailey disease in 1973 in her axillae and inframammary folds as well as her pubic region (namely her labia). a biopsy performed confirmed the hhd diagnosis. the patient reported a family history of the disease. she also reported that hhd lesions have previously appeared on her arms, neck, back, abdomen, popliteal regions, and oral mucosa. the presence of white bands on her fingernails, a rare manifestation of the disease, has also been documented.2,4 in 2003, the severity of the hhd lesions within her inframammary folds necessitated a double mastectomy. a second biopsy was performed and confirmed that the inframammary lesions were in fact hhd lesions. most recently, the patient presented with erythematous and crusted erosions and erupted bullae on her pubic region and middle back (figure 1). since the patient’s initial presentation and diagnosis, several different treatments have been administered for the management of the disease and its symptoms including: steroid and non-steroidal anti-inflammatory treatments (systemic, topical and intra-lesional), cyclosporin, methotrexate, dapsone, botulinum toxin a, fraxelated co2 laser to affected regions, and a variety of oral and topical antimicrobial therapies with minimal relief. of the treatments given the patient’s disease and symptoms were best controlled by oral doses of prednisone during times of exacerbated symptoms with doses of 30-50 mg per os. however, attempts to taper the prednisone to doses less than 10 mg were met with the recurrence of symptoms of the disease. recent studies have reported the use of narrowband uvb or alitretinoin as successful independent therapeutic options in the treatment of hhd.6,7 considering the persistent nature of the patient’s disease a combination therapy of alitretinoin, an oral retinoid agent known as toctino (30 mg per os daily), and narrowband uvb therapy was started.3,6,7 the narrowband uvb therapeutic dose range was determined by the patient’s skin type.8 for our patient, the narrowband uvb range began at 0.200 j/cm2 with an initial exposure time of 30 seconds. uvb therapy was administered twice weekly and was to be continued until a total of 30 treatments (approximately 4 months) had been reached. treatment was administered using the professional full body unit by ultralite enterprises (ultralite enterprises, lawrenceville, ga, usa). based on the patient’s positive response to the treatment, the uvb dose was increased by increments of 0.020 j/cm2 each visit until a dose of 0.294 j/cm2 was reached. the treatment doses administered throughout the patient’s treatment were within a safe range as the minimum erythematous dose described by hamada et al.7 was 0.300 j/cm2. the course of treatment undertaken in this case is unique because existing literature describes the treatment of hhd with oral alitretinoin while the patient was tapering prednisone.6,9 the patient described in this report began the combination alitretinoin-narrowband uvb treatment within days of prednisone cessation. the patient reported that the lesions found on her pubic region and middle back improved within the first 2-3 weeks of starting this new combination alitretinoin and narrowband uvb treatment. upon follow-up 6 weeks after beginning this new treatment course, a marked increase in healing bullae and tissue on the patient’s back were noted. residual rubor from dermatology reports 2014; volume 6:5604 correspondence: kaitlin vanderbeck, department of medicine, northern ontario school of medicine, ramsey lake rd, greater sudbury, on p0m, canada. tel.: +1.705.662.2294. e-mail: kvanderbeck@nosm.ca key words: hailey-hailey disease, pemphigus, alitretinoin, narrowband uvb. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 26 august 2014. accepted for publication: 26 october 2014. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright k.a. vanderbeck et al., 2014 licensee pagepress, italy dermatology reports 2014; 6:5604 doi:10.4081/dr.2014.5604 no n c om me rci al us e o nly [page 22] [dermatology reports 2014; 6:5604] uvb burns experienced during the fourth uvb session were also noted. only after the fourth uvb treatment did the patient present with rubor from uvb burns, which led to the cessation of the uvb treatment, but continued use of oral alitretinoin as a mono-therapy. healing hhd lesions could also be seen in the patient’s pubic area at this time with no new lesions noted (figure 2). no other topical or systemic treatments were used throughout this treatment period. currently, a mono-therapy of oral alitretinoin has maintained remission of the disease for 14 weeks since the beginning of the initial combination alitretinoin and narrowband uvb treatment course. no other treatments or interventions have been used, and no new lesions have been experienced with the alitretinoin mono-therapy. discussion hailey-hailey disease was first described by brothers hailey and hailey in 1939.10 familial benign chronic pemphigus is an inherited, autosomal dominant bullous disease.1,2,4 hhd presents with recurrent bullae, vesicles, and erythematous patches and erosions. patients usually experience a relapsing-remitting course of the disease.1,2,4,8 for many patients, a family history of hhd is present with lesions manifesting after adolescence.1,2 lesions favoring the axillae, chest, neck, genital areas, and other flexural regions are usually noted.1,2 eruptions are sometimes accompanied by a burning or pruritic sensation.2 secondary infection with candida and/or staphylococcus is often noted and considered to be a common complication of the disease.1,3 several white bands on the fingernails have also been described in some cases. involvement of the vulva, conjunctiva, and mucosae are considered rare manifestation of the disease.2,3 this disease affects a patient’s quality of life and can be quite distressing. the management of hhd can be challenging.1,3,4,11 there is currently no cure for hhd, however, treatment for managing the symptoms are available.3,6,7 in some cases, antibiotics, antifungal agents, as well as systemic, topical, and intralesional corticosteroids have proven effective for the management of hhd.1-3 furthermore, other agents such as cyclosporine, retinoids, botulinum toxin a, and dapsone have also proven to be effective in some cases, and ineffective in others.1-3 according to sardy and ruzicka,6 there is a need for new treatments. the patient, whose case is described, presented with a severe manifestation of hhd with recurrent bullae, erythematous patches, and erosions.4 the patient has experienced hhd lesions on many different areas of her body including her genital region, neck, back, and oral mucosa, to name a few. for this patient, hhd has been a part of her life for almost 40 years. finding an effective treatment for her hhd has been challenging. recently, the successful remission of hhd with narrowband uvb has been discussed.7 in this patient’s case narrowband uvb was ceased after only four sessions due to uvb burns. this may be attributed to the oral alitretinoin, a retinoid agent that has been shown to induce photosensitivity.3,7,8,12 the case report by sardy and ruzicka showed successful treatment with alitretinoin in a patient with hhd.6 the treatment was accompanied by a continued course of oral prednisone, which was later tapered while treatment with oral alitretinoin persisted.6 conversely, in our patient’s case, the combination daily oral alitretinoin (30 mg) and narrowband uvb therapy described, which resulted in the successful remission of the patient’s hhd, was started after the tapering and complete cessation of prednisone use. further, considerable and sustained clinical improvement of the patient’s hhd lesions has been noted with the administration of the daily oral alitretinoin therapy alone. presently there has been no need for any treatment with further uvb, prednisone, or any other systemic or topical agents as the patient’s disease appears to be in remission. for the first time in almost 40 years the patient has found relief and an effective treatment for her hhd. conclusions in conclusion, we suggest that conjunctive therapy of oral alitretinoin with narrowband uvb therapy be considered as a therapeutic option for the treatment of hhd to be followed by a mono-therapy of alitretinoin. the use of oral alitretinoin and narrowband uvb therapy should be explored further. in addition, the efficacy of oral alitretinoin as a mono-therapy for hhd should be explored. case report figure 1. erythematous hailey-hailey lesions on the patient’s midback (a); healing hailey-hailey lesions with some residual rubour and erupted bullae on the patient’s midback 6 weeks after combination alitretinoin and narrowband uvb course initiated (b). figure 2. erythematous hailey-hailey lesions on the patient’s left groin (a); healing hailey-hailey lesions on patient’s left groin 6 weeks after starting combination alitretinoin and narrowband uvb treatment (b). no n c om me rci al us e o nly [dermatology reports 2014; 6:5604] [page 23] references 1. james wd, berger tg, elston dm, eds. familial benign chronic pemphigus (hailey-hailey disease). in: andrews' diseases of the skin clinical dermatology. 10th ed. toronto: elsevier inc; 2006. pp 559-560. 2. helm tm. familial benign pemphigus (hailey-hailey disease). avallabile from: http://emedicine.medscape.com/article/10 63224-overview. accessed on: july 17, 2014. 3. d'errico a, bonciani db, bonciolini v, et al. hailey-hailey disease treated with methotrexate. j dermatol case rep 2012;6:49-51. 4. hunt r, o'reilly k, ralston j, et al. familial benign chronic pemphigus (hailey-hailey disease). dermatol online j 2010;16:14. 5. hu z, bonifas jm, beech j, et al. mutations in atp2c1, encoding a calcium pump, cause hailey-hailey disease. nat genet 2000;24:61-5. 6. sardy m, ruzicka t. successful therapy of refractory hailey-hailey disease with oral alitretinoin. br j dermatol 2014;170:20911. 7. hamada t, umemura h, aoyama y, iwatsuki k. successful therapeutic use of targeted narrow-band ultraviolet b therapy for refractory hailey-hailey disease. acta derm venereol 2012;93:110-1. 8. do an, koo jym. initiating narrow-band uvb for the treatment of psoriasis. psoriasis forum. available from: https://www.natbiocorp.com/pdf/do-koonpf.pdf 9. berth-jones j, smith sg, graham-brown rac. benign familial chronic pemphigus (hailey-hailey disease) responds to cyclosporin. clin exp dermatol 1995;20:702. 10. hailey h, hailey h. familial benign chronic pemphigus. arch dermatol 1982;118: 774-80. 11. ikeda s, suga y, ogawa h. successful management of hailey-hailey disease with potent topical steroid ointment. j dermatol sci 1993;5:205-11. 12. mukherjee s, date a, patravale v, et al. retinoids in the treatment of skin aging: an overview of clinical efficacy and safety. clin interv aging 2006;1:27-348. case report no n c om me rci al us e o nly dr [dermatology reports 2014; 6:5039] [page 3] orofacial granulomatosis in children can be the initial manifestation of systemic disease: a presentation of two cases anne birgitte simonsen, mette deleuran department of dermatology, aarhus university hospital, aarhus, denmark abstract orofacial granulomatosis is a chronic granulomatous condition characterized by relapsing and remitting lip swelling and oral involvement that may include deep ulcers, tags and cobblestone formation. it occurs as an independent entity but also in conjunction with systemic diseases such as tuberculosis, sarcoidosis and crohn’s disease. the clinical presentation is not indicative of concomitant systemic disease. to highlight the importance of thorough examination to rule out systemic disease, we present two childhood cases of orofacial granulomatosis, one of which was associated to crohn’s disease. introduction orofacial granulomatosis (ofg) is a chronic granulomatous condition characterized by relapsing and remitting lip swelling and oral involvement affecting the buccal mucosa, gingivae and floor of the mouth.1,2 histologically, the condition is characterized by non-caseating granulomas that block lymphatics causing lymphoedema. eventually, fibrosis may develop, making the swelling permanent.3 differential diagnoses include granulomatous cheilitis, where lesions are limited to the lips, and melkersson-rosenthal syndrome, which consists of the triad of persistent lip or facial swelling, recurrent facial paralysis and fissured tongue (table 1).4 the precise etiology of ofg is unknown, although allergies, infections, genetic predisposition and immunological mechanisms have been suggested as causative agents.5-7 furthermore, ofg is seen as an independent entity, but also in conjunction with systemic conditions such as tuberculosis, sarcoidosis and crohn’s disease.8-10 to highlight the association between childhood ofg and systemic disease, we present two cases of ofg in children. case report #1 case 1 was a 12-year old boy referred to us because of persistent swelling of the lips and gingivae, along with an uncharacteristic facial rash (figure 1). he had a history of atopic dermatitis, but was otherwise previously healthy and had no predisposition to skinor gastrointestinal disease. he presented with pronounced perioral edema, severe fissuring of the lips, angular cheilitis, gingival edema, and cobblestone formation of the buccal mucosa. during flare-ups the boy experienced severe abdominal pain. suspecting inflammatory bowel disease, the patient was thoroughly examined with blood tests, biopsies from the gingival and buccal mucosa, and endoscopy of the gastrointestinal tract. the histopathological examination of the mucosal biopsies revealed chronic granulomatous inflammation consistent with ofg and oral crohn’s disease. serum calprotectin was elevated to 409 mg/kg. crp and blood sedimentation rate were normal. gastroscopy showed duodenal inflammation and by subsequent endoscopy ileac aphtous ulcers were detected. the patient was diagnosed with crohn’s disease. infliximab treatment was initiated with a good clinical response on both abdominal symptoms and mucosal lesions. case report #2 case 2 was a 9-year old boy who presented chronic swelling of the upper lip, redness, swelling and hypertrophy of the gingivae, and cobblestone formation of the buccal mucosa (figure 2). this patient had ige-mediated allergy to grass, birch, and alternaria, but was otherwise healthy and was not predisposed to any skin or systemic diseases. he had no history of abdominal pain or stool alteration and no respiratory symptoms. as in case 1, the mucosal biopsy from the upper-lip revealed granulomatous inflammation. all blood tests were normal. the patient was further conferred with a pediatric gastroenterologist. serum and fecal calprotectin were normal. as this patient had no history of abdominal problems, no further examination was indicated at the time. the oral lesions were treated with topical fluticasone propionate 50 �g/dose. the initial dosage was 1 spray unit twice daily. after 6 weeks this was reduced to once daily for another 6 weeks, after which the treatment was given pro necessitate. the lesions responded well to this treatment and after 12 weeks only mild infiltration and swelling of the gingivae remained without noticeable inflammatory activity. regular check-ups every 3 months ensure that the condition is stable, and that possible gastrointestinal symptoms are detected. discussion whether ofg should be considered a separate entity or a manifestation of systemic disease remains a topic of discussion.4 in particular, several case reports have suggested an association to crohn’s disease. the two entities share a number of clinical and histological features, but the exact relationship has not yet been established.4 some authors suggest that patients with ofg may have subclinical crohn’s disease.1,11 furthermore, several authors have observed that children are more likely to have onset of ofg preceding symptoms of crohn’s disease,3,11-13 and speculate that childhood onset carries a higher risk of developing crohn’s disease. the prevalence of crohn’s disease in children with ofg is not well-established and could be underestimated since our current knowledge is based on case reports and case studies.3 the clinical presentation of the two patients presented here was almost identical. the history revealed that one of the patients had intermittent abdominal pain, which led to further examination, revealing an underlying crohn’s disease. this illustrates an important point, to be remembered when encountering children with ofg. the clinical presentation is not indicative of concomitant systemic disease and symptoms of this may be few. regardless of the clinical presentation, systemic disease should always be ruled out. ofg has been reported to be a manifestation of tuberculosis and sarcoidosis,8-10 however, the vast majority of the literature focuses on the possible link dermatology reports 2014; volume 6:5039 correspondence: anne birgitte simonsen, department of dermatology, aarhus university hospital, norrebrogade 44, 8000 aarhus c, denmark. tel. +45.784.50000 e-mail: anbsim@rm.dk key words: orofacial granulomatosis, children, chron's disease. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 20 august 2013. revision received: 17 november 2013. accepted for publication: 20 december 2013. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright a.b. simonsen and m. deleuran, 2014 licensee pagepress, italy dermatology reports 2014; 6:5039 doi:10.4081/dr.2014.5039 no nco mm er cia l u se on ly [page 4] [dermatology reports 2014; 6:5039] between ofg and crohn’s disease (supplementary table 1).3,11,12,14-20 in our opinion, the caring for pediatric patients with ofg should focus mainly on monitoring for signs, symptoms, and laboratory evidence of crohn’s disease. a thorough patient history and clinical examination is necessary and we recommend blood screening including crp, blood sedimentation rate, complete blood count, and serum calprotectin. if serum calprotectin is elevated, the patient should be referred to a pediatric gastroenterologist. any specific symptoms or abnormal blood screening should lead to further examination of relevance, i.e. a history of pulmonary symptoms should lead to x-ray examination of the chest and further blood tests depending on the symptoms and patient history. we recommend that patients be followed closely until the oral symptoms stabilize. when the condition is stable follow up at regular intervals ensures that the condition remains stable and any new symptom of systemic disease is detected. references 1. sanderson j, nunes c, escudier m, et al. oro-facial granulomatosis: crohn’s disease or a new inflammatory bowel disease? inflamm bowel dis 2005;11:840-6. 2. campbell h, escudier m, patel p, et al. distinguishing orofacial granulomatosis from crohn’s disease: two separate disease entities? inflamm bowel dis 2011;17:210915. 3. tuxen aj, orchard d. childhood and adolescent orofacial granulomatosis is strongly associated with crohn’s disease and responds to intralesional corticosteroids. australas j dermatol 2010;51:124-7. 4. tilakaratne wm, freysdottir j, fortune f. orofacial granulomatosis: review on aetiology and pathogenesis. j oral pathol med 2008;37:191-5. 5. kemmler n, pfannschmidt n, strohal r. orofacial granulomatosis as first manifestation of crohn’s disease: successful treatment of both conditions with a combination of infliximab and dapsone. acta derm venereol 2012;92:406-7. 6. grave b, mccullough m, wiesenfeld d. orofacial granulomatosis a 20-year review. oral dis 2009;15:46-51. 7. campbell he, escudier mp, patel p, et al. review article: cinnamonand benzoatefree diet as a primary treatment for orofacial granulomatosis. aliment pharmacol ther 2011;34:687-701. 8. al-azri ar, logan rm, goss an. oral lesion as the first clinical presentation in sarcoidosis: a case report. oman med j 2012;27:243-5. 9. ramesh v. orofacial granulomatosis due to tuberculosis. pediatr dermatol 2009;26:108-9. 10. kruschinski c, welkoborsky hj. tuberculosis of the larynx associated with orofacial granulomatosis in childhood. otolaryngol head neck surg 2005;132:9679. 11. saalman r, mattsson u, jontell m. orofacial granulomatosis in childhood-a clinical entity that may indicate crohn’s disease as well as food allergy. acta paediatr 2009;98:1162-7. 12. khouri jm, bohane td, day as. is orofacial granulomatosis in children a feature of crohn’s disease? acta paediatr 2005;94:501-4. 13. sainsbury cp, dodge ja, walker dm, aldred mj. orofacial granulomatosis in childhood. br dent j 1987;163:154-7. 14. rana ap. orofacial granulomatosis: a case report with review of literature. j indian soc periodontol 2012;16:469-74. 15. smith vm, murphy r. orofacial granulomatosis: three case reports illustrating the spectrum of disease and overlap with crohn’s disease. clin exp dermatol 2013;38:33-5. 16. girlich c, bogenrieder t, palitzsch kd, et al. orofacial granulomatosis as initial manifestation of crohn’s disease: a report of two cases. eur j gastroenterol hepatol 2002;14:873-6. 17. kolho kl, heiskanen k, verkasalo m, pitkaranta a. orofacial granulomatosis in children: a challenge for diagnosis and treatment. int j pediatr otorhinolaryngol 2011;75:864-7. 18. singhal p, chandan gd, das um, singhal a. a rare case report of orofacial granulomatosis in a pediatric patient. j indian soc pedod prev dent 2012;30:262-6. 19. kaarthikeyan g, arvind m, jayakumar n, khakar m. idiopathic orofacial granulomatosis in a young patient: a rare entity. j oral maxillofac pathol 2012;16:432-4. 20. howell jl, bussell rm, hegarty am, zaitoun h. service evaluation of patients with orofacial granulomatosis and patients with oral crohn’s disease attending a paediatric oral medicine clinic. eur arch paediatr dent 2012;13:191-6. case report table 1. differential diagnoses of orofacial granulomatosis. granulomatous cobblestone formation mucosal oral facial nerve plicated swelling of lips of oral mucosa swelling ulcers paralysis tongue orofacial granulomatosis + + + (+) granulomatous cheilitis + melkersson-rosenthal syndrome + + + figure 1. perioral edema, severe fissuring of the lips, angular cheilitis, gingival edema, and cobblestone formation of the mucosa. figure 2. chronic swelling of the upper lip. redness, swelling and hypertrophy of the gingivae. no nco mm er cia l u se on ly 502 bad gateway the server returned an invalid or incomplete response. 502 bad gateway the server returned an invalid or incomplete response. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. dr [dermatology reports 2011; 3:e37] [page 81] vulvar basal cell carcinoma: report of a case involving the mucosa and review of the literature marie caucanas,1 gebhard müller,2 olivier vanhooteghem1 1department of dermatology, sainte elisabeth hospital, namur; 2department of anatomopathology, ipg, gosselies, belgium abstract we report the case of woman who presented a vulvar basal cell carcinoma (bcc) on the inner part of the labium majus, treated with local resection. vulvar bcc is a rare cancer but can be long misdiagnosed due to a non-specific presentation. though even rarer, bcc involving the mucosal side of the labium majus has to be considered in the differential diagnosis of the vulvar tumors. a complete excision with free margins is the treatment most recommended. other recommendations include the early identification of aggressive subtypes, which carry a greater risk of recurrence and spreading potential as well as a long-term follow-up with exhaustive muco-cutaneous examination. case report a 57-year-old woman presented with an asymptomatic genital eroded mucosal lesion that she had noticed two years earlier (figure 1). physical examination showed a papillomatous lesion of 2.2x1.5 cm, located on the mucosal surface of the left labium majus. there was visible pigmentation and bleeding. lymph nodes areas remained free. the patient’s medical history was unremarkable. differential diagnosis was to be made between pemphigus vegetans and tumors of the vulvar area. a resection-biopsy was performed under local anesthesia and revealed a basal cell carcinoma of compact, nodular and pigmented type, with erosion on surface. all margins of excision were free of disease. follow-up to date showed no evidence of recurrent or metastatic carcinoma. discussion basal cell carcinoma (bcc) of the vulva represents 2-3 % of the vulvar cancers and less than 1% of all bcc. out of around 250 cases published so far, only twenty cases of bcc of the clitoris, the labia minora or the medial non-hair bearing aspect of the labia majora have been described.1 review of the literature shows that, considering other mucosas, four cases related to the buccal mucosa have been published.2-5 to our knowledge, no case involving the glans is reported. in the literature, vulvar bcc is commonly reported to affect white women, mostly in the post-menopausal period6 though some cases affecting younger women have been described.1 diagnosis is difficult as presentation and clinical manifestations are unspecific. as a result, the delay for diagnosis reaches 5 to 6 years on average.1 complaints mostly range from the discovery of an asymptomatic labial lesion to the evaluation of pruritus, pain or bleeding. clinical manifestations are diverse and do not usually suggest bcc, lacking characteristic pearly and telangectasic aspects.1 they are showing an exophytic, ulcerated, pedunculate, infiltrating, nodular or pigmented lesion, mostly located on the nonmucosal surface of the labia majora.7 differential diagnosis has to be made between pemphigus vegetans and tumors of the vulva (table 1).1,6,8-15 bcc of the vulva is not located on a surface exposed to uv and therefore other risk factors need to be determined. to date, there hasn’t been any evidence of clearly identified risk factors, especially for bcc involving mucosa. possible associations remain prior radiation therapy1,16 and previous trauma such as a burn or a scar.16 common risk factors to cutaneous bcc have to be considered: gorlin syndrome,17,18 chronic radiation,1,16,19 chronic arsenic exposure20, mutations in p5321, xeroderma pigmentosum.11 immunosuppressive medication has been suggested.16 a few cases have been reported in association with preexisting lesion: lichen sclerosis et atrophicus,22 paget’s disease,23 multiple tumors of the follicular infundibulum.1 biopsy of any suspect lesion is widely recommended.7,16,24 once diagnosis is confirmed, conservative surgery is most indicated, with free margins resection.1,25-27 some cases of relapses have been reported and are possibly due to inadequate margins. local recurrence varies from 0-25% in published reports1 with an average of 10-20%.7 the aggressiveness and recurrence of bcc vary according to histological pattern.7 tumors of the morphea-like (nodular, sclerosing), metatypical (basosquamous), adenocystic or infiltrative types are more aggressive, leading to a higher rate of recurrences. an aggressive bcc is associated with often deep local infiltration and occasional perineural extension.7 several cases of metastazing bcc have been reported with an incidence of 0.0028-0.1% and with a mean time from initial presentation reaching 9 years.7 these cases raise a challenging differential diagnosis in which it can be difficult to distinguish bcc from adnexal tumors. eventually, bcc may be associated with another vulvar tumor, such as melanoma or epidermoid carcinoma.1 most reported associated cancer with bcc of the vulva is uterine neck cancer (unc).1 considering the role of hpv in the genesis of unc, a few studies have assessed the presence of hpv in genital bcc on small dermatology reports 2011; volume 3:e37 correspondence: olivier vanhooteghem, department of dermatology, sainte elisabeth hospital, b 5000, namur, belgium. e-mail: ovanhooteghem@hotmail.com key words: vulvar basal cell carcinoma. received for publication: 3 august 2011. accepted for publication: 31 august 2011 this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright m. caucanas, g. müller and o. vanhooteghem, 2011 licensee pagepress, italy dermatology reports 2011; 3:e37 doi:10.4081/dr.2011.e37 figure 1. eroded and pigmented papillomatous lesion located on the mucosal surface of the left labium majus. table 1. vulvar cancers. squamous-cell cancers 90% non-squamous tumors 10% malignant melanoma bartholin’s gland carcinoma verrucous carcinoma paget’s disease adenosquamous carcinoma basal-cell carcinoma sarcoma leiomyosarcoma malignant fibrous histiocytoma dermatofibrosarcoma protuberans kaposi’s sarcoma metastatic malignant disease lymphoma of the vulva merckel-cell cancer no nco mm er cia l u se on ly [page 82] [dermatology reports 2011; 3:e37] series of patients and with uneven results.1,28,29 yet the implication of hpv in the bcc pathogenesis has not been proved. most authors underline the fact that there is a possible significant morbidity and occasional mortality if a lesion such as bcc is neglected or improperly treated.19 considering the rates of relapse and possible aggressiveness of bcc, a close long-term follow-up is essential in order to decrease skin cancer morbidity through early detection and treatment.17 references 1. mateus c, fortier-beaulieu m, lhomme c, et al. basal-cell carcinoma of the vulva: 21 cases. ann dermatol venereol 2001;128: 11-5. 2. del rosario rn, barr rj, jensen jl, cantos ka. basal cell carcinoma of the buccal mucosa. am j dermatopathol 2001; 23:203-5. 3. samit am. intraoral basal cell carcinoma. j surg oncol 1978;10:27-32. 4. keen rr, elzay rp. basal cell carcinoma from mucosal surface of lower lip: report of case. j oral surg anesth hosp dent serv 1964;22:453-5. 5. liroff kp, zeff s. basal cell carcinoma of the palatal mucosa. j oral surg 1972;30: 730-3. 6. finan ma, barre g. bartholin’s gland carcinoma, malignant melanoma and other rare tumors of the vulva. best pract res clin obstet gynaecol 2003;17:609-33. 7. pisani c, poggiali s, de padova l, et al. basal cell carcinoma of the vulva. j eur acad dermatol venereol 2006;20:446-8. 8. eliezri yd. the toluidine blue test: an aid in the diagnosis and treatment of early squamous cell carcinomas of mucous membranes. j am acad dermatol 1988; 18:1339-49. 9. lotem m, anteby s, peretz t, et al. mucosal melanoma of the female genital tract is a multifocal disorder. gynecol oncol 2003; 88:45-50. 10. wood wg, giustini fg, sohn s, aranda rr. verrrucous carcinoma of the vagina. south med j 1978;71:368-71. 11. powell fc, bjornsson j, doyle ja, cooper aj. genital paget’s disease and urinary tract malignancy. j am acad dermatol 1985; 13:84-90. 12. aartsen ej, albus-lutter ce. vulvar carcinoma: clinical implications. eur j obst gynecol reprod biol 1994;56:181-9. 13. giordano g, gnetti l, melpignano m. endometrial carcinoma metastatic to the vulva : a case report and review of the literature. pathol res pract 2005;201:751-6. 14. iczkowski ka, han ac, edelson mi, rosenblum ng. primary, localized vulvar b-cell lymphoma expressing cd44 variant 6 but not cadherins. a case report. j reprod med 2000;45:853-6. 15. waibel m, richter k, von lengerken w, niedobitek f. merkel cell tumor (neuroendocrine carcinoma of the skin) in an unusual location. immunohistochemical and lectin histochemical findings. zentralbl pathol 1991;137:140-50. 16. gillian eg, iftikhar a. perianal and genital basal cell carcinoma: a clinicopathologic review of 51 cases. j am acad dermatol 2001;45:68-71. 17. perrone t, twiggs lb, adcock ll, dehner lp. vulvar basal cell carcinoma: an infrequently metastasizing neoplasm. int j gynecol pathol 1987;6:152-65. 18. giuliani m, di stefano l, zoccali g, et al. gorlin syndrome associated with basal cell carcinoma of the vulva: a case report. eur j gynaecol oncol 2006;27:519-22. 19. mulayim n, foster silver d, tolgay ocal i, babalola e. vulvar basal cell carcinoma: two unusual presentations and review of the literature. gynecol oncol 2002;85:5327. 20. cabrera hn, cuda g, lopez m, costa ja. basal cell epithelioma of the vulva in chronic endemic regional arsenic poisoning. med cutan ibero lat am 1984;12:81-5. 21. barrett tl, smith kj, hodge jj, et al. immunohistochemical nuclear staining for p53, pcna, and ki-67 in different histologic variants of basal cell carcinoma. j am acad dermatol 1997;37:430-7. 22. meyrick thomas rh, mcgibbon dh, munro dd. basal cell carcinoma of the vulva in association with vulval lichen sclerosus et atrophicus. j r soc med 1985; 78 suppl 11:16-8. 23. ishizawa t, mitsuhashi y, sugiki h, et al. basal cell carcinoma within vulvar paget’s disease. dermatology 1998;197:388-90. 24. de giorgi v, salvini c, massi d, et al. vulvar basal cell carcinoma: retrospective study and review of the literature. gynecol oncol 2005;97:192-4. 25. ambrosini a, becagli l, resta p, et al. basal cell carcinoma of the vulva. eur j gynaecol oncol 1980;1:126-8. 26. simonsen e, johnsson je, tropé c, alm p. basal cell carcinoma of the vulva. acta obstet gynecol scand 1985;64:231-4. 27. piura b, rabinovitch a, dgani r. basal cell carcinoma of the vulva. j surg oncol 1999; 70:172-6. 28. nehal ks, levine vj, ashinoff r. basal cell carcinoma of the genitalia. dermatol surg 1998;24:1361-3. 29. santos m, montagut c, mellado b, et al. immunohistochemical staining for p16 and p53 in premalignant and malignant epithelial lesions of the vulva. int j gynecol pathol 2004;23:206-14. case report no nco mm er cia l u se on ly dr [dermatology reports 2011; 3:e21] [page 47] flagellate dermatitis following consumption of shiitake mushroom hui voon loo, hazel h. oon national skin centre, singapore abstract japanese dermatologists were the first to describe the very characteristic flagellate dermatitis following consumption of undercooked or raw shiitake mushroom (lentinus edodes). these similar eruptions were also reported in patients treated with bleomycin, in dermatomyositis and adult onset still’s disease. we report a case where a 40 year old chinese female developed flagellate dermatitis following ingestion of a bun containing shiitake mushroom. introduction flagellate literally means to whip (someone), either as a religious discipline or for sexual gratification according to oxford dictionary. flagellate dermatitis or toxicoderma presents with very characteristic linear wheal like skin manifestations and is often associated with shiitake mushroom (lentinus edodes). it was first described by nakamura in 1985.1 we report a 40 year old lady who developed flagellate dermatitis following ingestion of a bun containing shiitake mushroom. case report a 40 year old lady complained of acute onset of unusual rashes on her neck, body and limbs for 2 days. she reported feeling itchy on her arms and kept scratching, but denied scratching her trunk. she denied taking any medications. physical examination revealed extensive flagellate dermatitis on arms, trunk, legs, neck, forehead and some pinpoint petechiae on arms (figure 1). on further questioning, patient recalled eating portobello mushroom from an italian restaurant 5 days ago and a mushroom bun from a bakery shop 3 days ago, but could not recall taking shiitake mushroom. she recalled having itch when she ate mushroom in the past but no rash. her full blood counts, liver function tests, creatine kinase and creatinine were normal. her ana was a low titre at 1:100 (speckled). she received oral prednisolone and antihistamines. on further clarification with the bakery shop, the mushroom bun that she ate 3 days prior to the onset of rash contained shiitake mushroom. she was advised to avoid shiitake mushroom in future. her rash improved subsequently. discussion flagellate dermatitis typically presents with multiple intensely pruritic, erythematous linear plaques and papules on the trunk and extremities.2 such cutaneous reactions often occurred 48 hours following ingestion of under-cooked or raw shiitake mushroom.3 the average duration of involvement was 8.5 days and improvement was generally noticed within 2 to 14 days.4 people involved in cultivating and marketing shiitake mushrooms may develop allergic alveolitis on inhalation of mushroom spores and contact dermatitis upon contact with the mushroom. they may have positive patch tests and specific ige antibodies. however, in shiitake dermatitis, skin prick and patch tests were mostly negative except for a few cases report by lipper.3 there was a suggestion of possibility of uva photodermatosis by hanada during which 47% of patients with shiitake dermatitis had reproducible skin lesions to uva on phototesting but not with uvb.5 histology findings are nonspecific. acutely, the skin biopsy shows spongiosis, elongated rete ridges with infiltrates of degenerative epidermal cells, lymphocytes, eosinophils and dermal oedema with perivascular infiltrates of lymphocytes, neutrophils, and eosinophils.4 the exact underlying pathogenesis is still uncertain. koebnerisation was postulated by nakamura, although scratching did not reproduce the eruptions.4 lentinan, a polysaccharide found in shiitake has been implicated by a direct toxic effect, leading to interleukin-1 secretion, causing vasodilation, haemorrhage and the eruption.5 heat may play a role in denaturing the toxin as flagellate dermatitis mostly only occurs in patients who consumed the under-cooked mushroom.4 flagellate dermatitis was also reported in patients treated with bleomycin, in dermatomyositis6 and hiv patients.7 in bleomycin-induced flagellate dermatitis, patients developed linear pruritic pigmented lesions between 1 day and 9 weeks after the administration and may recur upon rechallenge of the drug. it was reported to occur, in a dose dependent manner, in about 8 to 66% of patients treated with bleomycin. some patients may develop such eruptions even with a very low dose of bleomycin.8 three cases of aids patient with kaposi’s sarcoma treated with relatively low dose of bleomycin were also reported to develop pruritic flagellate dermatitis.6 during the acute phase of bleomycin-induced flagellate dermatitis, the histological findings are similar to fixed drug eruption. this includes basal vaculolar alteration, pigmentary incontinence, dyskeratotic keratinocytes and perivascular dermal infiltrates of lymphocytes and eosinophils. ultrastructurally, there is increased contact time between melanocytes and keratinocytes from the decrease in epidermal turnover, with the melanocytes being arrested in a pigment-producing state. some authors suggested that since the skin lacks hydrolase which inactivates bleomycin, the local accumulation of bleomycin in skin could result in inflammatory reactions, similar to that of a fixed drug eruption. the hyperpigmentation may be postinflammatory rather than a primary sign. nevertheless, the dermatitis resolves with cessation of bleomycin but hyperpigmentation can persist up to eight months.9 previously, it was thought that this was class specific to bleomycin. in 2007, there was a case report of a patient developing flagellate erythema after three days treatment with docetaxel for metastatic breast cancer. her pruritus and erythema resolved spontaneously with resolution of pigmentation gradually over weeks.10 rarely, patients with dermatomyositis present with centripetal flagellate erythema on the trunk and proximal extremities. the histological findings showed interface dermatitis. such unusual eruptions have not been reported in other types of connective tissues dis dermatology reports 2011; volume 3:e21 correspondence: hazel h. oon, national skin centre 1, mandalay road, singapore 308205. tel. 65.62534455 fax: 65.62533225. e-mail: hazeloon@nsc.gov.sg key words: flagellate dermatitis, shiitake mushroom, lentinan poisoning. this paper has not been published or submitted for publication elsewhere. all authors have contributed significantly and are in agreement with the content of the manuscript. conflict of interest: the authors have no conflict of interest. there are no financial or personal relationship between the authors and others that could bias the work set out in the manuscript. received for publication: 23 july 2011. accepted for publication: 10 august 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright h.v. oon et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e21 doi:10.4081/dr.2011.e21 no nco mm er cia l u se on ly [page 48] [dermatology reports 2011; 3:e21] ease except for adult onset still’s disease. the intensity of the flagellate dermatitis purportedly mirrors the disease severity of dermatomyositis and may indicate a more complicated course of disease in adult onset still’s disease.6,11 even less commonly, hiv patients with hypereosinophilic syndrome were also reported to present with unusual cutaneous manifestations of linear flagellate plaques.7 conclusions flagellate erythema was initially described in patients who consumed raw or undercooked shiitake mushroom. however, such eruptions are also characteristic of several diseases, each having their own distinguishing clinical features. shiitake mushroom is the second most cultivated mushroom in the world and was reported to have immunomodulatory effects.4 perhaps a wise move would be to consume the thoroughly cooked mushroom so that this delicious delicacy could be savoured without adverse effects. references 1. nakamura t, kobayashi a. toxicodermia cause by the edible mushroom shiitake (lentinus edodes). hautarzt 1985;36:591-3. 2. arseculeratne g, berroeta l, meiklejohn d, et al. bleomycin-induced flagellate dermatitis. arch dermatol 2007;143:1461-2. 3. lippert u, martin v, schwertfeger c, et al. shiitake dermatitis. br j dermatol 2003; 148:178-9. 4. nakamura t. shiitake (lentinus edodes) dermatitis. contact dermatitis 1992;27: 65-70. 5. hanada k, hashimoto i. flagellate mushroom (shiitake) dermatitis and photosensitivity. dermatology 1998;197:255-7. 6. nousari hc, ha vt, laman sd, et al. centripetal flagellate erythema: a cutaneous manifestation associated with dermatomyositis. j rheumatol 1999;26:692-5. 7. may lp, kelly j, sanchez m. hypereosinophilic syndrome with unusual cutaneous manifestations in two men with hiv infection. j am acad dermatol 1990;23 (2 pt 1):202-4 8. nandwania r, money-kyrle j, hawkins da, et al. bleomycin-induced flagellate dermatitis in aids patients with kaposi’s sarcoma. j eur acad dermatol venerol 1995; 4:89-95. 9. vuerstaek j.d, frank j, poblete-gutiérrez p. bleomycin-induced flagellate dermatitis. intern j of dermatol 2007;46:3-5. 10. tallon b, lamb s. flagellate erythema induced by docetaxel. clin exp dermatol 2007;33:276-7. 11. yamamoto t, nishioka k. flagellate erythema. int j dermatol 2006;45:627-31. case report table 1. characteristics of flagellate erythema found in different conditions. shiitake flagellate bleomycin-induced dermatomyositis adult onset still’s disease hiv associated dermatitis flagellate erythema associated flagellate associated flagellate flagellate erythema4 erythema erythema10 clinical features 1. pruritic erythematous 1. hyperpigmented brownish 1. centripetal reddish linear 1. persistent plaques with 1. linear flagellate plaques linear papules, sparing linear streaks streaks with erythematous linear pigmentation with accompanying fever the inaccessible areas 2. occurs 1 day to 9 weeks plaques or without coalescent and eosinophilia to scratching on the back post administration 2. mirrors the disease erythematous plaques 2. hiv patients with 2. triggered by of bleomycin in a severity 2. presence could indicate hypereosinophilic under-cooked/raw shiitake dose-dependant manner 3. pruritus present, a worse prognosis with syndrome mushroom, commonly 48 hrs 3. pruritus maybe absent, usually no pigmentation increased risk of systemic after ingestion pigmentation present complications and longer 3. intense pruritus, time to remission usually no pigmentation 3. pruritus and pigmentation may be present histology non-specific similar to fixed drug eruption interface dermatitis dyskeratotic cells in the mixed perivascular infiltrate (spongiosis, elongated rete in the acute phase epidermis and dermal with eosinophils, ridges, eosinophils post-inflammatory infiltrates of neutrophils histiocytes, lymphocytes and lymphocytes infiltrates, hyperpigmentation in late and eosinophils dermal oedema) lesions presence of flame bodies treatment topical and oral discontinue bleomycin topical /oral corticosteroids main aim is to treat the oral and topical corticosteroids, short course of oral/ potent and immunosuppresants underlying systemic disease corticosteroids, antihistamines topical corticosteroids (topical calcineurin inhibitors, oral corticosteroids and puva self-limiting self-limiting hydroxychloroquine) immunosuppressants thoroughly cooked shiitake responds well to (methothrexate, cyclosporin) for future consumption conventional therapy may persist even after fever has subsided figure 1. linear grouped erythematous papules on lower limbs (a) and abdomen (b). a b no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. dr [dermatology reports 2011; 3:e32] [page 71] eczema herpeticum in pregnancy grigoriy e. gurvits,1 jill a. nord2 1new york university school of medicine, langone medical center; 2st. vincent’s medical center/ new york medical college, new york, ny, usa abstract eczema herpeticum (eh), or kaposi’s varicelliform eruption, is a skin infection with herpes simplex type i virus (hsv-1) that occurs in patients with compromised skin integrity, such as atopic dermatitis (ad). unrecognized, it may be fatal and viremia in pregnancy may lead to fetal demise and miscarriage. we describe a rare case of eh in pregnancy, eczema herpeticum gravidarum (ehg), which is the third published report in the literature to date. case report a 22-year-old gravida two para one woman in her 23rd week of pregnancy presented with a painful papular eruption on her face and neck of one week’s duration. she had prior history of ad, but has recently stopped topical corticosteroids. she denied history of sick contacts, sun exposure, or sexually transmitted diseases. on examination, her temperature was 37.8°c, heart rate 120 beats per minute, and blood pressure 127/72 mmhg. there were multiple hyperpigmented plaquelike lesions covering 80% of her body surface, and tender umbilicated vesiculo-papular lesions on her face, neck and upper torso in different stages of development. pus was expressed from several lesions. shotty cervical lymphadenopathy was noted. her fundal height was appropriate for stated length of pregnancy and gynecological examination was unremarkable. laboratory analysis showed white blood cell count of 8.3x103/l. she tested negative for serum rapid plasma reagin and human immunodeficiency virus. she was diagnosed with severe impetiginized eh with underlying severe ad. intravenous acyclovir 5 mg/kg per dose three times daily and intravenous cefazolin one gram every six hours were administered. local corticosteroid cream was applied for her severe ad. on day 3, no new lesions were noted, and herpetic rash cleared by tenth day of therapy. subsequently, viral and bacterial cultures from lesions isolated hsv-1 and methicillin sensitive staphylococcus aureus, which was also present in her bloodstream. she completed two weeks of intravenous therapy and delivered healthy baby at term. first described by dr. kaposi in 1887, eh is a disseminated herpetic infection of inflamed skin that may complicate ad, darier-white disease, pemphigus foliaceus, mycosis fungoides, sezary syndrome, ichthyosis vulgaris, and burns.1 several theories have been proposed to explain pathogenesis of eh, including decreased skin integrity, impaired plasmacytoid dendritic cell recruitment and local interferon production.2 associated findings may include fever, malaise, lymphadenopathy, elevated serum ige levels, and relative lymphopenia.1 failure of early recognition and prompt treatment with intravenous acyclovir and concomitant antibiotics may carry risk of multiorgan failure and death.1,2 use of corticostroids has not been shown to cause eh,1 and treatment of the underlying ad is warranted. to date, only two cases of ehg have been published in english literature.3,4 acyclovir appears to be safe in pregnancy5 and early therapy of ehg is indicated. overall, ehg is rare but serious condition that may complicate pregnancy in patients with ad and requires prompt recognition. references 1. wollenberg a, zoch c, wetzel s, et al. predisposing factors and clinical features of eczema herpeticum: a retrospective analysis of 100 cases. j am acad dermatol 2003;49:198-205. 2. wollenberg a, wetzel s, burgdorf whc, haas j. viral infections in atopic dermatitis: pathogenic aspects and clinical management. j allegy clin immunol 2003;112: 667-74. 3. rekant si. eczema herpeticum and pregnancy. obstet gynecol 1973;41:387-91. 4. garland sm, hill pj. eczema herpeticum in pregnancy successfully treated with acyclovir. aus n z j obstet gynaecol 1994;34: 214-5. 5. stone km, reiff-eldridge r, white ad, et al. pregnancy outcomes following systemic prenatal acyclovir exposure: conclusions from the international acyclovir pregnancy registry, 1984-1999. birth def res a clin mol teratol 2004;70:201-7. dermatology reports 2011; volume 3:e32 correspondence: grigoriy e. gurvits, 530 first ave, ski-9n, new york, ny 10016, usa. tel. +1.212.263.3095 e-mail: g_gurvits@hotmail.com key words: eczema herpeticum, pregnancy, herpes simplex virus, acyclovir, impetigo. received for publication: 11 august 2011. accepted for publication: 16 august 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright g.e. gurvits and j.a. nord, 2011 licensee pagepress, italy dermatology reports 2011; 3:e32 doi:10.4081/dr.2011.e32 no nco mm er cia l u se on ly dr [page 90] [dermatology reports 2011; 3:e40] infliximab-induced intertriginous psoriasis in patient with crohn’s disease federica mola, alberico motolese department of dermatology, circolo hospital and macchi foundation, varese, italy abstract tumor necrosis factor-α (tnfα) inhibition is an effective treatment of moderate-to-severe psoriasis and other diseases (rheumatoid arthritis, ankylosing spondylitis, psoriasis or crohn’s disease). we report a case of a 32years-old patient affected by crohn’s disease since the age of 25 who started infliximab infusion after four years of treatment with prednisone and azathioprine per os without improvement. after the fifth infusion of infliximab, he developed a form of intertriginous psoriasis which was approached with topical steroid cream. the patient never presented psoriasis in the past. new onset of psoriasis in patients without history for skin diseases (as in our case) is a quite uncommon complication of tnfα inhibitor therapy. the increased production of ifnα during tnfα inhibitor therapy is a possible pathophysiologic explanation for this paradoxical effect of the anti-tnfα. introduction tumor necrosis factor-α (tnfα) is a proinflammatory cytokine produced by different cell types (activated t lymphocytes, keratinocytes, langerhans cells, endothelial cells, cardiac myocytes, adipose tissue etc.) and is involved in the pathogenesis of psoriatic skin lesions. tnfα inhibitors have become established agents in the treatment of inflammatory diseases and have shown to be of great benefit in many inflammatory diseases (rheumatoid arthritis, ankylosing spondylitis, psoriasis or crohn’s disease).1 case report we report a case of unexpected induction of psoriasis due to the use of intravenous tnfα inhibitor. a 32-years-old male patient with recalcitrant crohn’s disease of the ileum and descending colon (treated without improvement with prednisone, mesalazine and azathioprine per os) started treatment with infliximab at the dose of 5 mg/kg at the week 0, 2, 6 and afterwards every 14 weeks. after the fifth infusion he developed erythematous patches with peripheral scaling in the axillary folds and inguinal areas, suggesting the diagnosis of flexural psoriasis (figure 1). the face and the neck also presented a form of sebopsoriasis (figure 2). the patient never had psoriasis in the past, and he did not have a familiar history of any skin disease. no signs of infection were shown. the skin biopsy showed psoriasiform hyperplasia, papillary dermal edema with parakeratosis and intracorneal microabscesses of neutrophils (figure 3). the infliximab infusion was continued (seeing the good response of crohn’s disease) and a clinical skin improvement was achieved after 40 days of topical steroid treatment. an expanding literature of experience with anti tnfα associated psoriasis is providing abundant information about this paradoxical effect. many cases are described. the first published report of this association appeared in 2004 and concerned the development of symmetrical psoriasiform plaques in a patient treated with infliximab for crohn’s disease.2 subsequently plaque, guttate, and pustolar psoriasis have all been noted, and palmoplantar pustolar disease appears to be more common than idiopathic psoriasis, accounting for up to the 50% of reported cases. flexural psoriasis and sebopsoriasis are a rare form of presentation. in fact, to our knowledge, ther are only two articles describing cases of flexural psoriasis during infliximab treatment for crohn’s disease.3,4 dermatology reports 2011; volume 3:e40 correspondence: federica mola, department of dermatology, circolo hospital and macchi foundation, viale borri 75, varese, italy. tel. +39.349.2611869. e-mail: federicamola@yahoo.it key words: tumor necrosis factor−α, psoriasis, crohn’s disease. received for publication: 6 june 2011. accepted for publication: 12 september 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright f. mola and a. motolese, 2011 licensee pagepress, italy dermatology reports 2011; 3:e40 doi:10.4081/dr.2011.e40 figure 3. histologic evaluation demonstrates psoriasiform hyperplasia, papillary dermal edema with parakeratosis and intracorneal microabscesses of neutrophils. figure 1. erythematous patches with peripheral scaling in the axillary folds, suggestive for the diagnosis of flexural psoriasis figure 2. typical erithemato-desquamative patches on the face and neck in sebopsoriasis. no nco mm er cia l u se on ly [dermatology reports 2011; 3:e40] [page 91] it is well recognized that blocking tnfα may actually favour specific autoimmune phenomena and may activate autoreactive t cells. in addition, with particular relevance to the skin, it may upregulate interferon (ifn)-α activity.5 immunologically this is not unexpected because tnfα is known to negatively regulate the maturation and function of plasmocytoid dendritic cells, which are the major source of ifn-α. therapeutic inhibition of tnfα signaling would increase ifnα activity and could trigger psoriasis in genetically susceptible individuals.5 on the other hand, some cases can be diagnosed as an adverse drug reaction and may contribute to stop the treatment. in literature two-thirds of patiens who simply continue anti tnfα therapy improve or resolve the skin disease with steroid treatment. the decisions need to be based on individual circumstances as the extent and severity of the disease, the efficacy of the anti tnfα in treating the condition for which it was initiated and the availability of realistic therapeutic alternatives.5 references 1. wollina u, hansel g, koch a, et al. tumor necrosis factor-alpha inhibitor-induced psoriasis or psoriasiform exanthemata: first 120 cases from the literature including a series of six new patients.am j clin dermatol 2008;9:1-14. 2. baeten d, kruithof e, van den bosch f, et al. systematic safety follow up in a cohort of 107 patients with spondyloarthropathy treated with infliximab: a new perspective on the role of host defence in the pathogenesis of the disease? ann rheum dis 2003; 62:829-34 3. peramiquel l, puig l, dalmau jricart e, et al. onset of flexural psoriasis during infliximab treatment for crohn's disease. clin exp dermatol 2005; 30:713-4. 4. avila alvarez a, garcia-alonso l, solar boga a, garcia-silva j. flexural psoriasis induced by infliximab and adalimumab in a patient with crohn's disease. an pediatr (barc) 2009; 70:278-81. 5. shale m, ghosh s. learning the lessons of antitumour necrosis factor therapy-associated psoriasis. can j gastroenterol 2009; 23:674-6. case report no nco mm er cia l u se on ly dr [dermatology reports 2011; 3:e25] [page 55] benign lichenoid keratosis: an off-center fold case ashley hamstra, michael messina, abel torres department of dermatology, loma linda university medical center, ca, usa abstract this off-center fold case depicts the difficult differential diagnosis for benign lichenoid keratosis. it is challenging to diagnosis this benign lesion through clinical exam, dermoscopy, and even dermatopathology. given its similar appearance to regressed melanoma, it is important to be cognizant of both and up to date on the dermatopathology clues. case report a 53-year-old caucasian female presented with an asymptomatic, changing pigmented lesion on her right forearm, first noticed two years earlier. three months ago, one half had grown rapidly to 3.8 cm in diameter. it had initially become raised and scaly, before transitioning to flat and violaceous. the other half was brown and unchanged with central pink papules. she had not experienced pruritis, bleeding or burning throughout this progression. her past medical history was significant for a meningioma in 1998. an enlarged right cervical lymph node was noted on physical exam at time of presentation to our office. the diagnosis was benign lichenoid keratosis. microscopic findings and clinical course an excisional biopsy showed focal parakeratosis, epidermal thinning, dyskeratosis without atypia, irregular acanthosis, epidermal necrotic keratinocytes, vacuolar alterations of the basal layer, solar elastosis of the dermis, increased numbers of dilated blood vessels, a dense lichenoid infiltrate of lymphocytes at the dermoepidermal junction, numerous melanophages, pigment incontinence and a solar lentigo adjacent to the lesion. the s-100, melan-a and hmb-45 immunohistiochemical stains were negative for melanocytes. the ki17 stain showed equivocal active cells in the basal layer. this was suggestive of benign lichenoid keratosis vs. regressed melanoma. further pathological review was sought from three dermatopathologists, who all interpreted the slides as benign lichenoid keratosis (figures 1, 2, 3). discussion benign lichenoid keratosis (blk), also known as lichen planus-like keratosis, is a common skin entity that typically presents as a solitary asymptomatic lesion on the trunk or distal upper extremities. there is an increased prevalence among women and caucasians.1 it may be rough or scaly in texture and often transitions from pink to violaceous to hyperpigmented as its regression progresses. multiple regression phases may be simultaneously present within a lesion.2,3 it is thought that blk’s may arise from a regressing seborrhoeic keratosis or a regressing solar lentigines.1,4-6 this particular case had remnants of a lentigo. while t-lymphocytes and cell-mediated immunity are predominant throughout regression, as inflammation advances the ratio of cd3 to cd20 diminishes. this indicates a relative increase in the percentage of b-lymphocytes and in humoral immunity. autoantibodies may be produced by the multiplying b-lymphocytes.2 clinically, a blk resembles basal cell carcinoma, bowen’s disease, lentigo, seborrheic keratosis, actinic keratosis and, most importantly, melanoma,6 in addition to their clinical similarity, melanoma in situ may be dermoscopically indistinguishable from blk in all stages of regression, especially if on the face, due to the face’s unique epidermal structure.3 furthermore if the regression is advanced, the remaining lesion may be insufficient to make a definitive diagnosis using dermoscopy, regardless of the site, due to pathological and procedural disruption of the lesion and distortion of much needed diagnostic attributes.6,7,8 the blue-white structures that are strongly associated with melanoma may be present in many other regressing lesions.4,9 histological-ly, blk’s typically demonstrate epidermal acanthosis, parakeratosis and a band-like lichenoid lymphocyte infiltrate. additionally there are clinical subtypes (classic, bullous, atypical, early and late) that further contribute to confusion and misdiagnosis.1 distinguishing blk from melanoma remains difficult. many have noted certain findings that raise the suspicion of melanoma, such as proliferations of junctional melanocyte nests and starburst giant cells. also fish may reveal altered melanocytes with an absent dna copy number of chromosome 9p21. if any of these findings are present, taking a deeper section to rule out regressed melanoma is advised.8 dermatology reports 2011; volume 3:e25 correspondence: abel torres, loma linda university medical center, department of dermatology, 11370 anderson street, suite 2600, loma linda, ca 92354, usa. tel. +1.909.558.2890 fax: +1.909.558.2891. e-mail: abelt@aol.com key words: benign lichenoid keratosis, melanoma, dermoscopy. received for publication: 10 august 2011. accepted for publication: 11 august 2011. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright a. hamstra et al., 2011 licensee pagepress, italy dermatology reports 2011; 3:e25 doi:10.4081/dr.2011.e25 figure 1. dermoscopy. figure 2. ki67 stain. figure 3. 20x slide. no nco mm er cia l u se on ly [page 56] [dermatology reports 2011; 3:e25] references 1. morgan m, stevens g, switlyk s. benign lichenoid keratosis: a clinical and pathologic reappraisal of 1040 cases. am j dermatopathol 2005;27:387-92. 2. bayer-garner i, ivan d, schwartz m, tschen j. the immunopathology of regression in benign lichenoid keratosis, keratoacanthoma and halo nevus. clin med res 2004;2:89-97. 3. raptoulis g, spencer r, einstein b, et al. lichen planus-like keratosis of the face: a simulator of melanoma in situ. dermatol surg 2007;33:854-6. 4. zaballos p, rodero j, pastor l, et al. dermoscopy of lichenoid regressing solar lentigines. archiv dermatol 2008;144: 284. 5. zaballos p, marti e, cuéllar f, et al. dermoscopy of lichenoid regressing seborrheic keratosis. archiv dermatol 2006;142: 410. 6. bugatti l, filosa g. dermoscopy of lichen planus-like keratosis: a model of inflammatory regression. j eur acad dermatol venereol 2007;21:1392-7. 7. giorgi v, massi d, salvini c, et al. features of regression in dermoscopic diagnosis: a confounding fact? two clinical, dermoscopic-pathologic case studies. dermatol surg 2006;32:282-6. 8. dalton s, fillman e, altman c, et al. atypical junctional melanocytic proliferations in benign lichenoid keratosis. hum pathol 2003;34:706-9. 9. zalaudek i, argenziano g, ferrara g, et al. clinically equivocal melanocytic skin lesions with features of regression: a dermoscopic-pathological study. br j dermatol 2004;150:64-71. case report no nco mm er cia l u se on ly 502 bad gateway the server returned an invalid or incomplete response. dr [dermatology reports 2015; 7:5816] [page 9] severe scratcher-reaction: an unknown health hazard? carsten sauer mikkelsen,1 helene ringe holmgren,2 kristian bakke arvesen,3 reem dina jarjis,4 gudjon leifur gunnarsson5 1private practice, broenderslev, denmark; 2private practice, frederikshavn, denmark; 3department of dermatovenereology, aarhus university hospital, denmark; 4department of plastic surgery, aalborg university hospital, denmark; 5department of plastic surgery, telemark hospital, skien, norway abstract tattoos are well known to cause skin problems and the number of reported adverse reactions after tattooing has increased. illegally imported tattoo ink is unrestrained and can contain unknown ingredients and contamination thereby posing a serious health hazard. we present a case illustrating the risk of pronounced phototoxic allergic reaction and other severe complications after using home kit tattoo ink. introduction a 48-year-old caucasian male developed an impetigonous rash followed by exfoliative dermatitis occurring after the use of a home kit tattoo ink imported from china via the internet. we suggest that a sudden severe phototoxic tattoo ink reaction ignited a cascade of interesting events that we feel obliged to report since we were unable to find any similar cases in the literature. case report this case concerned a man in his late 40’s, otherwise healthy with no previously known illnesses or skin diseases. his medical history revealed earlier urticarial reaction to penicillin. a few weeks after being sun burned on his arms, the patient developed multiple bullae and itchiness on his left forearm. a few days later he developed an exuding erythema rash with crustations. the rash spread the next day to the other arm developing edema, redness and heat. eventually the same rash spread to the neck and abdomen. the patient contacted his general practitioner 14 days after the onset of symptoms and was then referred to the local hospital under suspicion of severe impetigo. upon his admission he was relatively unaffected, sub-febrile (38°c) with extreme edema of his arms, generalized erythema and multiple fissures with pus formation and some areas with dry crustations (figure 1). lab results showed slight leukocytosis 12 (3.5-10.0) with neutrofiles 9 (2.0-7.0) and marginally raised crp 22 (<8 mg/l) .the initial diagnosis was impetigo and erysipelas and he was treated with intravenous cefuroxim 750 mg × 4 daily. the itchiness was treated with fexofenadin 180 mg × 1. the patient responded to the treatment and his condition improved rapidly. the cultivated swab taken from the forearm was positive for staphylococcus aureus. due to the severity of skin symptoms a dermatologist was consulted and it became apparent that the patient had 2 months earlier had a tattoo on his left forearm. for this purpose the patient had ordered tattoo needles and ink over the internet from china. it was in this precise tattooed area that the symptoms with bullae development and impetigo arose. the consultant dermatologist diagnosed the patient with staphylococcal scalded skin syndrome (ssss), and began a 7 day treatment with prednisolone 37.5 mg × 1 daily and a group iii topical cortisone cream. the skin became smooth after a few days. the treatment was founded on the probable phototoxic reaction to the tattoo ink followed by a break in the skin barrier due to itching and resulting in staphylococcus aureus infection and later ssss. there was also a speculation of the probability of contaminated tattoo ink but further investigations of other ink bottles from the same batch tested negative to microbes when cultured. a few days after the completed prednisolone treatment, the patient developed universal exfoliative dermatitis, with exaggerated hyperkeratosis changes to the palms of the hands and soles of the feet (figure 1). the patient was retreated with high dosage prednisolone, a group iv hormone cream and in addition ciclosporin 100 mg × 2 daily. the response to this treatment was striking. the patient’s symptoms were most likely due to allergic contact dermatitis reaction with some contents of the tattoo ink. the biopsises concluded with photo-allergic dermatitis in early and late phase. further investigations with light tests (uva and uvb) and photopatch test were all negative. the patient is still followed by the dermatology department, 6 months after the onset of symptoms and continues a ciclosporin treatment. at the latest control there were only minor dermatitis changes found in the palms of the hands. the patient therefore has a good prognosis. a patch test with the ink contents would be ideal to study and maybe find which ingredients the patient reacted to but unfortunately we haven’t been able to acquire such a sample. discussion the number of tattooed people has substantially increased in the past years. surveys in different countries reveal this to be up to 24% of the population.1 no reports are found about the number of people using home kit tattoo ink. tattoos are well known to cause skin problems and the number of reported adverse reactions after tattooing has increased. this includes transient acute inflammatory reaction due to trauma of the skin with needles and medical complications such as superficial and deep local infections, systemic infections, allergic contact dermatitis, photodermatitis, granulomatous and lichenoid reactions and skin diseases localized on tattooed area (eczema, psoriasis, lichen rubor, and morphea).2 tattoo colors consist of inorganic pigments, organic dyes, or a combination of both. in the past, it appears that heavy metals, that were the backbone of tattooing for decades, have been largely replaced by organic colorants.3 the reactions to tattoos are reported more often where the colors red and yellow give a serious allergic reaction and acute tattoo reactions are most commonly associated dermatology reports 2015; volume 7:5816 correspondence: carsten sauer mikkelsen, private practice, bredgade 13, 9700 broenderslev, denmark. tel.: +45.201.00198. e-mail: c.s.mikkelsen@hotmail.com key words: tattoo, ink, home kit, exfoliative dermatitis, impetigo. contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. received for publication: 17 january 2015. revision received: 19 march 2015. accepted for publication: 19 march 2015. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright c.s. mikkelsen et al., 2015 licensee pagepress, italy dermatology reports 2015; 7:5816 doi:10.4081/dr.2015.5816 no n c om me rci al us e o nly [page 10] [dermatology reports 2015; 7:5816] with red pigments.4,5 reports on severe reactions to green pigments (especially due to chromium) is also described in the literature.6 the etiology is still uncertain but it is generally considered to be a delayed-type hypersensitivity reaction to either the pigment itself or its carrier solution.7 in our case both the light and photo-patch test wee negative. this is also the findings in a newer published study.8 after patch-testing patients with tattoo reactions, the study indicates that the putative allergen(s) causing tattoo reactions are formed inside the dermis and external factors like sunlightproduce photochemical cleavage of tattoo pigments in vivo in the skin and may contribute to allergen formation. this means that regular patch-testing will not reproduce the reaction due to inadequate penetration of the skin, and will therefore be negative. photoinduced reactions, principally associated with yellow pigments, are generally present as erythematous, pruriginous nodules that appear following sun exposure.9 very few reports describe phototoxic reaction to the green pigment as described in our case-story. recent analyses of a wide range of commercially available tattoo inks demonstrated surprisingly high rates of bacterial contamination in both open and unopened ink bottles.10,11 it wasn’t possible to test the green ink bottle used by the patient in this case. but the rest of the imported inkbottles were tested for bacterial contamination without any positive findings. our patient represents a pronounced phototoxic allergic reaction to the green ink in the home kit tattoos activated by sunburn. in this case we suggest that the staphylococcus aureus infection and subsequent ssss were self-induced based on scratching of the affected skin-area where the green tattoo was present on his forearm. following remission of the bacterial infection our patient was strained by the chronic systematic allergic reaction which indicated the need for a long term oral immune suppression for over 6 months. the effect of tattoo colors on the skin immune system is unknown. the tattoo colors are known to have a possible contamination of nanoparticles that are known to invade the lymphatic system and further into the center of the cells where they might affect cellular function.12 a large concentration of tattoo colors has been discovered in the lymph-node biopsies of tattooed patients in a project led by professor jørgen serup at the dermatology department in bispebjerg hospital in denmark. no one knows the long term effects of the accumulation of tattoo colors in the lymphatic system. could it in any way hinder its normal function or by chronic inflammation increase the risk of later cancer developer other late complications? the potentially harmful ingredients in such substances, especially uncontrolled and illegally imported tattoo inks are completely unknown. stock bottles of tattoo ink may contain environmental bacteria and bacteria pathogenic to humans and packaging, labeling and preservation of inks have been shown to be inadequate.11-14 we fear the lack of safety and risk of cutaneous inoculation of dangerous bacteria and toxic allergens. even the possibility of resistant nontuberculous mycobacteria or methicillin resistant staphylococcus aureus strains and long term consequences of such practice. we have searched the literature and were unable to find other cases of ssss and chronic systemic allergic reactions arising from home kit tattoos. conclusions illegally imported tattoo ink is uncontrolled and can contain practically anything and thereby pose serious health hazard as described in this case. awareness needs to be raised of the risks involved. references 1. wenzel sm, rittmann i, landthaler m, et al. adverse reactions after tattooing: review of the literature and comparison to results of a survey. dermatology 2013:226:138-47. 2. bassi a, campolmi p, cannarozzo g, et al. tattoo-associated skin reaction: the importance of an early diagnosis and proper treatment. biomed res int 2014;2014:354608. 3. sanghavi sa, dongre am, khopkar us. tattoo reactions an epidemic on the surge: a report of 3 cases. indian j dermatol venereol leprol 2013;79:231-4. 4. champman g, thoroton-hildyard ca. two decades later: a delayed red ink tattoo reaction. bmj case rep 2014;2014:bcr2013201726. 5. cui y, spann ap, couch lh, et al. photodecomposition of pigment yellow 74, a pigment used in tattoo inks. photochem photobiol 2004:80:175-84. 6. kaur rr, kirby w, maibach h. cutaneous allergic reactions to tattoo inj. j cosmet dermatol 2009;8:295-300. 7. sweeney sa, hicks ld, ranallo n, et al. perforating granulomatous dermatitis reaction to exogenous tattoo pigment: a case report and review of the literature. am j dermatopathol 2013;35:754-6. 8. serup j, hutton carlsen k. patch test study of 90 patients with tattoo reactions: negative outcome of allergy patch test to baseline batteries and culprit inks suggests allergen(s) in the skin trough haptenization. contact dermatitis 2014;70:255-63. 9. adams dr, eid mp, badreschia s, et al. self assessment examination of the american academy of dermatology. a violaceus plaque. j am acad dermatol 2006;54:185-7. 10. baumgartner a, gautsch s. hygienicmicrobiological quality of tattoo and per case report figure 1. images showing patient’s edema of arms, generalized erythema and multiple fissures with pus formation and some areas with dry crustations. no n c om me rci al us e o nly [dermatology reports 2015; 7:5816] [page 11] manent make-up colours. j verbrauch lebensm 2011:6:319-25. 11. høgsbjerg t, saunte dm, serup j, et al. microbial status and product labeling of 58 original tattoo inks. j eur acad dermatol venereol 2013;27:73-80. 12. høgsberg t, loeschner k, serup j, et al. tattoo inks in general usage contain nanoparticles. br j dermatol 2011;165:1210-8. 13. falsey rr, kinzer mh, hurst s, et al. cutaneous inoculation of nontuberculous mycobacteria during professional tattooing: a case series and epidemiologic study. clin infect dis 2013;57:e143-7. 14. centers for disease control and prevention. tattoo-associated nontuberculous skin infections: multiple states, 20112012. mmwr morb mortal wkly rep 2012;61:653-6. case report no n c om me rci al us e o nly dr [dermatology reports 2015; 7:5888] [page 1] treatment of primary cutaneous anaplastic large cell lymphoma with superficial x-rays malene e. jepsen,1 robert gniadecki1,2 1department of dermatology, bispebjerg hospital; 2faculty of health sciences, copenhagen university, denmark abstract the optimal radiation schedule for primary cutaneous anaplastic lymphoma (pcalcl) has not been investigated. we report here satisfactory outcomes of low-dose (16-20 gy, 3-5 fractions), superficial x-ray radiation (40-50 kv) in a series of 10 patients with pcalcl. only 1 patient developed a local relapse during the median observation time of 25 months; complete remission was recorded in the other patients. this observation indicates that superficial, low dose x-ray therapy may provide a cost-effective alternative to the traditional 35-45 gy schedules. introduction primary cutaneous anaplastic large cell lymphoma (pcalcl) is a rare indolent cancer with a favorable prognosis and the 5-year specific disease survival of 90%.1-5 the patients often present with solitary or localized nodules or tumors, sometimes with ulceration.3 treatment in most cases comprises surgery or radiotherapy, sometimes in combination.1,5-8 however, due to rarity of this disease the evidence for the efficacy of these modalities is very low. here we report the excellent outcome of pcalcl treatment with superficial radiotherapy in a small cohort of 11 patients. materials and methods patients with the diagnosis pcalcl were identified from the clinical lymphoma registry in our institution between september 2007 and october 2014. among 277 patients with cutaneous t-cell lymphomas, 36 patients had a cd30+ lymphoproliferative disorder, and of these 13 were registered as having pcalcl. we have excluded one patient had spontaneous remission before treatment, one patient died of other causes before the outcome of the radiation therapy was registered and one patient who received electron beam radiation therapy (40 gy) to multiple tumors in the scalp. the remaining 11 patients (table 1) were treated with superficial radiotherapy using gulmay d3100 x-ray unit (gulmay ltd., surrey, uk). results the male:female ratio was 2.67:1 (8 men, 3 women) which is compatible with the 2-3:1 ratio reported in the literature.3 the median age at diagnosis was 62 years. the median-follow-up time after radiation therapy was 26 months. five patients had an associated malignancy: lymphomatoid papulosis (lyp) or mycosis fungoides (mf). the patients were treated with the dose 1620 gy given in 3-5 daily fractions (40-50 kv). all patients were evaluated after 3 months when complete response was observed in 8/10 patients and partial response (pr) in 3/10 patients (in patient 1 one of the tumors had a cr and one tumor had a pr). on a long-term observation one patient (patient 9) had a local relapse and patient 1 progressed and developed new lesions (but not within the irradiated site). no adverse effects were registered except for local hyperpigmentation and mild scarring within the irradiated site. discussion and conclusions our data document satisfactory effect of superficial x-ray treatment of pcalcl tumors, using the doses 16-20 gy and photon energy 40-50 kv. theoretically, 50% of the radiation of this energy is absorbed within the most superficial 10 mm of the skin,9 which is less that the estimated thickness of some tumors. dermatology reports 2015; volume 7:5888 correspondence: robert gniadecki, department of dermatology, bispebjerg hospital, bispebjerg bakke 23, dk-2400 copenhagen, denmark. e-mail: r.gniadecki@gmail.com key words: radiotherapy, cutaneous lymphoma. contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. received for publication: 25 february 2014. accepted for publication: 25 february 2014. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright m.e. jepsen and r. gniadecki, 2015 licensee pagepress, italy dermatology reports 2015; 7:5888 doi:10.4081/dr.2015.5888 table 1. patients’ characteristics, treatments and outcomes. patient sex age at clinical size of location secondary radiation response at 3 follow-up, relapse follow up diagnosis lesion(s) lesions, cm lymphoma dose months months 1 m 46 2 tumors 3 left thigh and crus 50 kv 4 gyx5 cr + pr (crus) 56 local pd 2 f 35 1 tumor 2.5 left crus lyp 50 kv 6 gyx3 cr 85 new cr 3 m 78 1 tumor 1.5 right forearm lyp 50 kv 4 gyx5 cr 13 none cr 4 m 70 multiple tumors 35×20 upper back 50 kv4 gyx5 cr 41 none cr 5 m 72 1 tumor 2×0.5 right flank 40 kv 4 gyx4 cr 5 none cr 6 f 65 1 plaque 2×3 behind right ear 40kv 4 gyx5 cr 14 none cr 7 f 48 3 tumors 7×5, 5×5.5, 1.5 left upper arm, mf 50 kv 4 gyx5 pr 13 none cr right foot, left first finger 8 m 67 1 tumor 4×3×0.5 left foot 50kv 4 gyx5 cr 11 new cr 9 m 68 1 plaque 10, 3.5 right calf, left hand lyp 50 kv 4gyx5 pr 8 none pr 10 m 78 1 tumor 1.5 right upper arm lyp, mf 40kv 4 gyx5 cr 6 none cr lyp, lymphomatoid papulosis; mf, mycosis fungoides; cr, complete response; pr, partial response; pd, progressive disease. no n c om me rci al us e o nly [page 2] [dermatology reports 2015; 7:5888] nevertheless, the clinical outcome of the superficial therapy has been excellent with 90% long-term cr. this indicates the high radio-sensitivity of pcalcl and possibly involvement of secondary anti-tumor mechanism such as bystander effect.10 studies reporting outcome of radiotherapy in pcalcl are scarce.2-5,7,10 the yale center records from 2008 is the only study involving radiation therapy exclusively using the dose of 34-44 gy given in 2-gy fractions.7 all eight reported patients achieved cr after 12 months median-follow-up. we propose here that the number of fractions and total radiation dose can be reduced to 16-20 gy, without a significant loss of long-term efficacy. the modified, low-dose schedule can be delivered as superficial radiotherapy which is more cost-effective and will probably reduce the risk of sideeffects. references 1. kadin me. current management of primary cutaneous cd30+ t-cell lymphoproliferative disorders. oncology 2009;23: 1158-64. 2. benner mf, willemze r. applicability and prognostic value of the new tnm classification system in 135 patients with primary cutaneous anaplastic large cell lymphoma. arch dermatol 2009;145:1399-404. 3. willemze r, jaffe es, burg g, et al. whoeortc classification for cutaneous lymphomas. blood 2005;105:3768-85. 4. woo dk, jones cr, vanoli-storz mn, et al. prognostic factors in primary cutaneous anaplastic large cell lymphoma: characterization of clinical subset with worse outcome. arch dermatol 2009;145:667-74. 5. booken n, goerdt s, klemke cd. clinical spectrum of primary cutaneous cd30-positive anaplastic large cell lymphoma: an analysis of the mannheim cutaneous lymphoma registry. j dtsch dermatol ges 2012;10:331-9. 6. willemze r, hodak e, zinzani pl, et al. primary cutaneous lymphomas: esmo clinical practice guidelines for diagnosis, treatment and follow-up. ann oncol 2013;24:149-54. 7. yu jb, mcniff jm, lund mw, wilson ld. treatment of primary cutaneous cd30+ anaplastic large-cell lymphoma with radiation therapy. int j radiat oncol biol physics 2008;70:1542-5. 8. kempf w, pfaltz k, vermeer mh, et al. eortc, iscl, and usclc consensus recommendations for the treatment of primary cutaneous cd30-positive lymphoproliferative disorders: lymphomatoid papulosis and primary cutaneous anaplastic large-cell lymphoma. blood 2011;118:402435. 9. goldschmidt h, panizzon rg. modern dermatologic radiation therapy. new york: springer-verlag; 1991. 10. nagasawa h, little jb. induction of sister chromatid exchanges by extremely low doses of alpha-particles. cancer res 1992;52:6394-6. article no n c om me rci al us e o nly dr subclinical onychomycosis in patients with type ii diabetes amira elbendary,1,2 amira el tawdy,1 naglaa zaki,1 mostafa alfishawy,3,4 amr rateb1 1department of dermatology, kasr al ainy faculty of medicine, cairo university, egypt; 2ackerman academy of dermatopathology, new york, ny, usa; 3department of internal medicine, kasr al ainy faculty of medicine, cairo university, egypt; 4department of medicine, queens hospital center/ichan school of medicine at mount sinai, new york, ny, usa abstract fungal organisms could be present in the nail without any clinical manifestations. as onychomycosis in diabetics has more serious complications, early detection of such infection could be helpful to prevent them. we aim in this study to assess the possibility of detecting subclinical onychomycosis in type ii diabetic patients and addressing possible associated neuropathy. a cross sectional, observational study included patients with type ii diabetes with normal big toe nail. all were subjected to nail clipping of the big toe nail, followed by staining with hematoxylin and eosin and periodic-acid-schiff (pas) stains and examined microscopically. a total of 106 patients were included, fungal infection was identified in eight specimens, all were uncontrolled diabetes, and six had neuropathy. using the nail clipping and microscopic examination with pas stain to detect such subclinical infection could be an applicable screening test for diabetic patients, for early detection and management of onychomycosis. introduction reports about fungi that could be present in the nail without any clinical manifestations have been documented,1-4 and this was referred to as subclinical onychomycosis.3 evidence that these fungi could change from the passive form to induce superficial fungal infection in case there is defect in the immune system of the patient was reported.5 onychomycosis is a well known complication of diabetes mellitus. about one third of diabetic patients are affected.6 although onychomycosis doesn’t represent a serious infection in most people, its risk is increased in diabetics, due to its limb threatening infection that could progress to ulcers and amputation as a result of the comorbidities present in diabetics, namely peripheral neuropathy, macro and microvascular diseases and impaired immunity in addition to foot deformities,7 and thus it is critical to manage onychomycosis properly in such patients. the approach to diagnose onychomycosis could be painful, prolonged and complicated. nail clipping is an easy doing procedure, painless, cheap and reasonable.8 accordingly, the aim of our study was to investigate the presence of subclinical onychomycosis in diabetic patients using nail clipping as a diagnostic tool, and addressing possible association of neuropathy with the occurrence of subclinical infection. materials and methods a cross sectional, observational study included participants with type ii diabetes mellitus following up in endocrinology clinics presented to the clinic by issues unrelated to onychomycosis. patients with any clinical nail dystrophy including discoloration, subungual debris, thickening, onycholysis, or patients with previous diagnosis of onychomycosis at least one year before the study were excluded. age, sex and history of associated medical condition, diabetes related factors including type of diabetes, duration, associated peripheral neuropathic symptoms (numbness, burning, tingling or loss of sensation) were recorded. diabetic neuropathy was tested by testing the vibratory sensation by using a 128 hz tuning fork on the interphalangeal joint of the right hallux comparing it to the dorsal wrist. patients with lost vibration sense on the dorsal foot or feel stronger vibration on the wrist were considered having diabetic neuropathy. this method of detection of neuropathy was chosen due to its utility in clinical practice being simple and reliable.9 heamoglobin a1c (hba1c) was assessed for every patient; hba1c level below 7.0% was considered as controlled diabetic patients.10 nail clipping was done from a normal big toenail for each patient. the clippings were subjected for hematoxylin and eosin stain (h&e) and periodic-acid-schiff (pas) staining according to standard protocol. the histopathologic criteria to diagnose onychomycosis included the presence of parakeratosis, serous lakes, hyperkeratosis and inflammatory cells (neutrophils) that may suggest the possibility of onychomycosis in h&e stained specimens and the presence of hyphae invading the plate in pas stained sections. a total of 106 patients with type ii diabetes were included in the current study, 20 males (18.9%), and 86 females (81.1%). the duration of diabetes ranged from 2 months to 20 years with mean duration (7.9) years. the patients’ age ranged from 25 to 75 years and a mean age dermatology reports 2015; volume 7:6099 correspondence: amira elbendary, ackerman academy of dermatopathology, 45e 32nd street #9, new york, ny 10016, usa. tel.: +1.212.889.6225. e-mail: aelbendary@residents.kasralainy.edu.eg key words: diabetes mellitus type ii; onychomycosis: nail clipping: neuropathy: subclinical disease. contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. received for publication: 5 july 2015. accepted for publication: 7 july 2015. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright a. elbendary et al., 2015 licensee pagepress, italy dermatology reports 2015; 7:6099 doi:10.4081/dr.2015.6099 table 1. factors associated with patients found to be positive for subclinical onychomycosis. factors, variables total patients with percentage of these patients patients subclinical onychomycosis within same group disease duration more than 10 years 42 5 7.8 less than 10 years 64 3 7.1 glycemic control controlled 7 0 0 uncontrolled 99 8 8.1 neuropathy present 48 6 12.5 absent 58 2 3.4 [page 34] [dermatology reports 2015; 7:6099] no n c om me rci al us e o nly [dermatology reports 2015; 7:6099] [page 35] 51.2 (±9.2) years, 49 patients were less than 50 years. 99 patients were uncontrolled diabetes (hbalc�7) (93.4%), while the controlled were seven patients (6.6%). 43 patients were on oral hypoglycemic drugs (40.6%), and 63 were on insulin therapy (59.4%). forty eight patients had neuropathy (45.30%) as revealed by absence or weak vibration sense using the tuning fork test. pas stained specimens revealed eight cases positive for fungal infection, in which uniform septate hyphae were found. this accounts 7.5% of the total patients. these pas positive eight cases were five females and three males, with age ranged from 40 to 70 with mean age 51.6 (±8.7). four patients were on oral hypoglycemic drugs (9.3% of patients on oral hypoglycemic drugs), and the other four patients were on insulin (6.3% of patients taking insulin). factors that were found to be associated with patients with subclinical onychomycosis are demonstrated in table 1. although follow up was not intended in our study, we found that five out of the eight patients had associated tinea pedis and two patients developed clinical onychomycosis after two and three months respectively during their visit to dermatology clinic. discussion and conclusions the microscopic findings were not correlated with culture, as the objective of this study was to search for subclinical infection in diabetics, and addressing associated possible risk factors for it, regardless of the causative agent, and using the most accurate method reported in the literature (finding hyphae in pas stained specimens obtained by nail clipping). larger population of type ii diabetic patients is needed to be investigated in further studies in order to answer the question: do we need to recommend screening diabetics for subclinical onychomycosis using nail clipping as a diagnostic tool in their routine checkup? scant data about subclinical onychomycosis were reported (table 2) and might be a finding in a percent of type ii diabetic patients especially the uncontrolled ones which can be associated with tinea pedis and neuropathy. using the nail clipping and microscopic examination with pas stain to detect such subclinical infection could be an applicable screening test for diabetic patients, being non painful, reasonable, and simple test, aiming for early detection and management of onychomycosis and hence decreasing the incidence of its possible serious complications in diabetics and perhaps the serious side effects of prolonged systemic antifungal treatment. references 1. davies rr. mycological tests and onychomycosis. j clin pathol 1968;21:729-30. 2. baran r, badillet g. primary onycholysis of the big toenails: a review of 113 cases. br j dermatol 1982;106:529-34. 3. walling hw. subclinical onychomycosis is associated with tinea pedis. br j dermatol 2009;161:746-9. 4. shemer a1, gupta ak, farhi r, et al. when is onychomycosis onychomycosis? a crosssectional study of fungi in normal-appearing nails.br j dermatol 2015;172:380-3. 5. baran r, badillet g. is an ungual dermatophyte necessarily pathogenic?. ann dermatol venereol 1983;110:629-31. 6. gupta ak, konnikov n, macdonald p, et al. prevalence and epidemiology of toenail onychomycosis in diabetic subjects: a multicenter survey. br j dermatol 1998;139: 665-71. 7. nather a, bee cs, huak cy, et al. epidemiology of diabetic foot problems and predictive factors for limb loss. j diabetes complications 2008;22:77-82. 8. fillus neto j, tchornobay am. how the nail clipping helps the dermatologist. ann bras dermatol 2009;84:173-6. 9. meijer jw, smit aj, lefrandt jd, et al. back to basics in diagnosing diabetic polyneuropathy with the tuning fork! diabetes care 2005;28:2201. 10. american diabetes association. standards of medical care in diabetes 2014. diabetes care 2014;37:s14. brief report table 2. previous studies reporting fungal infection in apparently normal nail. authors patients patients with method used to diagnose associated included subclinical infection fungal infection findings davis1 1954 170 (8.7%) direct microscopy (koh) or culture active onychomycosis in other toenails baran and badillet2 46 with normal toenails 7 (15%) koh, pas staining where established t. rubrum toenail from total of 113 with onycholysis appropriate; fungal culture infection baran and badillet2 52 2 (4%) koh, pas staining where appropriate; fungal culture none walling3 101 7 (1.5%) out of 66 nail clipping with pas staining none 6 out of 35 (17%) confirmed tinea pedis shemer et al.4 585 54 (9.2%) koh none 23 (3.9%) culture none 18 (3.1%) koh and culture none our study 106 8 (7.5%) nail clipping with pas staining diabetes mellitus type ii no n c om me rci al us e o nly dr [page 6] [dermatology reports 2016; 8:6386] digit-length ratios (2d:4d) as a phenotypic indicator of in utero androgen exposure is not prognostic for androgenic alopecia: a descriptive-analytic study of 1200 iranian men. amir feily,1 masoomeh hosseinpoor,1 ali bakhti,1 mohamad nekuyi,1 saeed sobhanian,2 zahra fathinezhad,3 reza sahraei,4 marigdalia k. ramirez-fort5 1department of dermatology, jahrom university of medical sciences, jahrom, iran; 2hormozgan university of medical sciences, bandarabas, iran; 3department of community health, jahrom university of medical sciences, jahrom, iran; 4department of anesthesiology, jahrom university of medical sciences, jahrom iran; 5department of dermatology, tufts medical center, boston, ma, usa abstract the etiology of androgenic alopecia (aga) involves several factors, including genetics, androgens, age and nutrition. digit-length ratio of the index and ring finger (2d:4d) is an indicator of prenatal exposure to sex hormones. there is a paucity of studies that systemically review the possible positive predictive value of 2d:4d in the development of aga. we performed a single-site, descriptive-analytical study among a racially homogeneous population. our results revealed that no significant association was determined between right 2d:4d and aga severity within our entire population (p=0.384, r=0.025), however a positive correlation coefficient was identified in subjects above the age of 40. based on the receiver operating characteristic curve analysis, 2d:4d does not predict the development of aga. aga is truly a multifactorial disease. further, our findings suggest that increased in utero exposure to androgens as a fetus does not predispose men to develop aga. introduction androgenic alopecia (aga) is the most common type of progressive hair loss. the etiology of aga involves several factors, including genetics, androgens, age and nutrition.1-4 some evidence suggests that the digit-length ratio of the index and ring finger (2d:4d) is an indicator of prenatal exposure to sex hormones, with a lower 2d:4d being suggestive of a greater androgen exposure.5-8 digit-length ratios have been utilized to determine the effects of prenatal androgen exposure a variety of phenotypic expressions.5,6,8 however, there is a paucity of studies that systemically review the possible positive predictive value of 2d:4d in the development of aga. materials and methods the study was initiated after approval by the research and ethics committee of jahrom university of medical sciences, approval id: jums.rec.1393.017. all participants signed an informed consent prior to participating in the study. we performed a single-site, descriptiveanalytical study between june 2013 and february 2014 among a racially homogeneous population that they were selected by stratified and randomized sampling. participants did not have a significant history of other types of alopecia (e.g. iatrogenic scarring alopecia, alopecia areata, etc.). a trained team performed digit-length measurements of both hands with vernier calipers and subsequently calculated the 2d:4d. a single trained technician graded baldness using the hamiltonnorwood classification scale; for simplicity these grades were further divided into four stages: no baldness (i), mild (ii, iii), moderate (iv, v) and severe baldness (vi, vii). associations between 2d:4d and aga were determined with spss version 16. the quantitative results are presented as a mean±standard deviation (sd). a pearson linear correlation was performed to assess relationships between 2d:4d and age; a spearman linear correlation to assess relationships between 2d:4d and aga severity, and rocs mode was used to measure the validity of 2d:4d as a predictive test for aga. statistical significance was assigned at p<0.05. results a total of 1200 men between 20 to 60 years of age with a mean age of 33.2 (sd: 0.28), enrolled in the study. the prevalence of aga among the study population was 45.4%. a total of 53.4% of the participants had normal hair distribution (aged 29.95±8.4 years), 26.16% had mild hair loss (aged 34.97±10.11 years), 15.19% had moderate (aged 40.35±9.43 years) and 4.32% had severe hair loss (aged 42.28±9.92 years). the mean ratio of the right 2d:4d was 0.992 (sd: 0.0024), while the left was 0.982 (sd: 0.0017). no significant differences were identified between left and right hand 2d:4d per subject (table 1). there was significant association between age and aga(r=-0.426, p=0.001). no significant association was determined between right 2d:4d and aga severity within our entire population (p=0.384, r=0.025), also there was no significant association between left 2d:4d and aga severity (p=0.495, r=0.028), however a correlation coefficient was identified in subjects above the age of 40. the receiver operating characteristic (roc) analysis of subjects age 40 and above demonstrated the area under curve (auc) as 0.502 (95%ci 0.391 to 0.613) and 0.480 (95% ci 0.371 to 0.590) for right and left 2d:4d, respectively, as a predictive test for aga (figure 1). dermatology reports 2016; volume 8:6386 correspondence: masoomeh hosseinpoor, department of dermatology, jahrom university of medical sciences, shahid motahhari blvd, jahrom, iran. tel.: +98.937.6925988. e-mail: masoomehosseinpoor@yahoo.com key words: androgenic alopecia; hair loss; digitlength ratio; predictive value. contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. received for publication: 24 december 2015. accepted for publication: 4 april 2016. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright amir feily et al., 2016 licensee pagepress, italy dermatology reports 2016; 8:6386 doi:10.4081/dr.2016.6386 figure 1. receiver operating characteristic curve analysis of right and left 2d:4d with androgenetic alopecia gold standard. no n c om me rci al us e o nly [dermatology reports 2016; 8:6386] [page 7] discussion and conclusions herein, is the largest study to date aimed to explore the utility of a phenotypic expression of in utero androgen exposure in predicting the development of aga. the prevalence of aga was 45.4%, similar to worldwide reports.9,10 the prevalence of aga trended upwards as participant age increased. although there was no significant association between right 2d:4d and aga (p=0.384, r=0.025), there was a correlation coefficient identified in subjects above the age of 40. with increasing of age the aga severity increases especially in participants above the age of 40. in clinical practice, most patients generally express aga by age 40. therefore, we attempted to evaluate the utility of 2d:4d as a predictive test for aga. based on the roc curve analysis, 2d:4d does not predict the development of aga. aga is truly a multifactorial disease. further, our findings suggest that increased in utero exposure to androgens does not predispose men to develop aga. references 1. trueb rm. molecular mechanisms of androgenetic alopecia. exp gerontol 2002;37:981-90. 2. stárka l, cermáková i, dusková m, et al. hormonal profile of men with premature balding. exp clin endocrinol diabetes 2004;112:24-8. 3. chumlea wc, rhodes t, girman cj, et al. family history and risk of hair loss. dermatology 2004;209:33-9. 4. inui s, itami s. androgen actions on the human hair follicle: perspectives. exp dermatol 2012;22:168-71. 5. honekopp j, manning tj, muller c. digit ratio (2d:4d) and physical fitness in males and females: evidence for effects of prenatal androgens on sexually selected traits. horm behav 2006;49:545-9. 6. honekopp j, voracek m, manning jt. 2nd to 4th digit ratio (2d:4d) and number of sex partners: evidence for effects of prenatal testosterone in men. psychoneuroen docrinology 2006;31:30-7. 7. manning jt, wood s, vang e, et al. second to fourth digit ratio (2d:4d) and testosterone in men. asian j androl 2004;6:2115. 8. rivas mp, moreira lm, santo ld, et al. new studies of second and fourth digit ratio as a morphogenetic trait in subjects with congenital adrenal hyperplasia. am j hum biol 2014;26:559-61. 9 . severi g, sinclair r, hopper jl, et al. androgenetic alopecia in men aged 40-69 years: revalence and risk factors. br j dermatol 2003;149:1207-13. 10. yeo ik, jang ws, min pk, et al. an epidemiological study of androgenic alopecia in 3114 korean patients. clin exp dermatol 2014;39:25-9. article table 1. mean of 2d:4d ratio compared to androgenetic alopecia stage severity. aa stages mean sd 95% ci sum of squares df mean square f sig. right ratio 0.009 3 0.003 0.409 0.747 normal 0.9919 0.08179 0.9855-0.9982 mild 0.9952 0.06994 0.9874-1.0030 moderate 0.9913 0.09576 0.9770-1.0057 severe 0.9810 0.13942 0.9391-1.0229 left ratio 0.012 3 0.004 1.127 0.337 normal 0.9853 0.06019 0.9806-0.9899 mild 0.9781 0.04175 0.9735-0.9828 moderate 0.9795 0.09040 0.9659-0.9931 severe 0.9812 0.03508 0.9707-0.9918 aa, androgenetic alopecia; sd; standard deviation; ci, confidence interval. no n c om me rci al us e o nly dr [dermatology reports 2016; 8:6819] [page 15] signet-ring cells in the skin: a case of late-onset cutaneous metastasis of gastric carcinoma and a brief review of histological approach özgür gündüz,1 mehmet can emeksiz,2 pınar atasoy,3 mehtap kıdır,4 selim yalçın,5 serkan demirkan1 1department of dermatology and venerology, kırıkkale university; 2department of dermatology, özel keçiören hospital; 3department of pathology kırıkkale university; 4department of dermatology and venerology, dumlupınar university, evliya çelebi teaching hospital; 5department of oncology, kırıkkale university, turkey abstract up to 10% of patients with visceral malignancies develop skin metastases during their clinical course and these metastases constitute about 2% of all skin cancers. skin metastasis may be the first sign of a clinically silent visceral cancer or represent recurrence of an internal malignancy. in both situations, they are associated with poor prognosis, which can partly be attributed to underdiagnosis. in this paper, a case of relapsing gastric adenocarcinoma, which manifested itself as asymptomatic cutaneous papules and nodules on a patient’s head and neck, is reported and histopathological approach to the cutaneous lesions containing signet-ring cell is briefly reviewed. introduction metastatic skin cancers (msc) are relatively rare dermatological malignancies.1 they constitute 2% of all skin tumors and reported incidence rates differ from 0.7% to 9.0%.1,2 msc originate most commonly from breast, lung and gastrointestinal tissues, and are recognized as a poor prognostic factor.2 in this paper, we present a case of relapsing gastric adenocarcinoma with signet-ring cell (src) morphology, which presented itself as cutaneous nodular lesions about 4 months after the cessation of chemotherapy. case report a 57-year-old woman presented with a 2month history of asymptomatic, steadily growing lesions on her face, neck and shoulders. her medical history revealed that she was diagnosed with stage iiia (t3n2m0) gastric src adenocarcinoma (srcc) 12 months prior in an oncology clinic. at that time, she had underwent total gastrectomy and splenectomy. her surgical pathology reports revealed cancer-free margins and surgery was followed by adjuvant chemotherapy [infusional folinic acid + 5-fluorouracil (fufa)] and radiotherapy directed to the gastric lodge. about four months later after the end of the combined chemotherapy and radiotherapy, the patient had noticed several small lumps on her face and shoulders. since then, these lesions had been consistently growing. at the time of physical examination, multiple asymptomatic skin lesions consisting of two erythematous papules on her forehead, one solitary nodule on the right preauricular area, another one on her right shoulder and two prominent bright red, fleshy nodules on her neck ranging from 1.0×1.0 to 3.0×4.0 cm (figure 1a-c) were found. an incisonal biopsy was performed from the papule located on the frontal hairline. histopa thological sections showed diffuse dermal infiltration of cells with signet-ring morphology. immunohistochemical staining were negative for hmb45, cd45, er, pr, gcdfp-15 stains, lowering the possiblity of an melanoma, a metastatic tumor of hematopoietic origin and a metastatic breast cancer, respectivelyand positive for ae1/ae3 and mucicarmine indicating a glandular epithelial origin for the srcs (figure 2). since the patient was operated in another clinic, original resection material was unavailable to us for a comperative histological and immunohistochemical staining. a working diagnosis for metastatic signet-ring cell carcinoma was made on the basis of the last skin biopsises and patient’s medical history, and the patient was referred to the oncology department for further evaluation. tests performed by the oncology department, including complete blood count, urea and electrolytes, liver function tests, plasma proteins, tumor markers, chest x-ray, breast, abdominal and suprapelvic ultrasound, bilateral mammography, complete abdominal magnetic resonance imaging, bilateral mammography, upper gastrointestinal endoscopy and colonoscopy, revealed no other internal focus, from which the skin lesions could originate. after the completion of the oncological examination and tests, diagnosis of the patient was established as metastatic cutaneous signet-ring cell carcinoma and she was scheduled for a second round of chemotherapy (figure 1d-f). discussion signet-ring pattern defines a specific cell shape change, during which the nucleus of the cell is pushed to the periphery due to the cytoplasmic accumulation of mucin, vacuoles or inclusion bodies, causing the cell to bear a resemblance of a signet-ring. although srcs are usually associated with malignancies (i.e., gastric, prostatic, breast cancers, melanoma, etc),3 and accepted as a poor prognostic factor, they can also be observed in various nonneoplastic conditions (e.g., pseudomembranous colitis, cystic fibrosis, ulcerative colitis),4 or after formalin fixation as a cytoplasmic shrinkage artifact.5 in cases without an apparent source for cutaneous srcs, first step in the differential diagnosis should be to determine whether the cells are neoplastic or not. wang et al. indicated that even in the setting of a previously diagnosed nonneoplastic disease, benign src change can be easily confused with malignant transformation and proposed that lack of the infiltration of lamina propria, rare mitosis and apoptosis and certain histochemical and immunohistochemical staining patterns (positive for e-cadherin and negative for p53 and ki-67) may be in favor of a nonneoplastic origin for the said srcs.4 other studies about src pathogenesis have shown that malign srcs posses particular qualities, which may be helpful in developing new diagnostic techniques and treatment modalities. kobayashi et al. found out that highly differentiated colon adenocarcinoma cells were transformed into srcs, when phosphatidylinositol 3-kinase (pi3k) was activated.6 they also showed that the activation of pi3k was induced by the activation of erbb2/erbb3 complex (a member of cell surface receptor family for epidermal growth factor).7 at the further steps of dermatology reports 2016; volume 8:6819 correspondence: özgür gündüz, kirikkale universitesi tip fakültesi, deri ve zührevi hastalıkları ad, yenisehir mah., tahsin duru cad., no:14, yahsihan, kirikkale, turkey. tel.: +90.4404071.5408 fax: +90.318.2444697. e-mail: gunduzozgur@windowslive.com key words: signet-ring cell, metastatic skin cancer, immunohistochemistry. contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. received for publication: 4 august 2016. accepted for publication: 24 november 2016. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright ö. gündüz et al., 2016 licensee pagepress, italy dermatology reports 2016; 8:6819 doi:10.4081/dr.2016.6819 no n c om me rci al us e o nly [page 16] [dermatology reports 2016; 8:6819] the erbb2/erbb3 – pi3k cascade, p38 mitogen activated protein kinase (mapk) is activated, resulting in the loss of intercellular tight junctions.8 activation of pi3k is also known to enhance the mucin secretion (muc4),9 and transcriptional upregulation of muc4 is recognized to have antiapopitotic and mitogenic effects in various tumors.10,11 pik3 activation and muc4 overexpression have also been found in gastric adenocarcinomas,12,13 which further supports the role of erbb2/erbb3 – pi3k cascade activation in the formation of mucin-laden neoplastic srcs. as mentioned above, reported incidence rates of metastatic skin cancers from internal malignancies vary between 0.7-9.0%.2 a metaanalysis including 22,297 patients with visceral malignancies by krathen et al.14 revealed the incidence of skin metastases as 5.3%. according to this study, the most common primary visceral cancers to metastasize to skin were breast cancers (24.0%), renal cancers (4.0%), ovarian cancers (3.8%), bladder cancers (3.6%), lung cancers (3.4%), colorectal cancers (3.4%) and prostate cancers (0.7%) respectively.14 gastric cancers, despite being one of the most common cancers in the world, (ranking 5th in worldwide frequency and 3th in the leading causes of cancer relateddeaths),15 do not develop skin metastases frequently. most common sites for metastatic spread of the gastric cancers were found to be liver, peritoneoum, lung and bone.16 rare skin metastases of gastric cancers are usually observed as umbilical or periumbilical papules or nodules.2 signet-ring cell carcinoma (srcc) is a histologic subtype of gastric cancers which accounts for 8-30% of all stomach cancers and is usually associated with advanced stage cancer and recognized as poor prognostic factor.14 srcc has a similar metastatic spread pattern like the other gastric cancers and tends to metastasize particularly to peritoneum and intraabdominal organs (liver, ovaries, etc.). cutaneous metastases of srcc are also very rare and may present as nodular lesions, such as in this case, mimick benign other nonneoplastic or benign entities such as erysipelas,17 scars18 or contact dermatitis,19 complicating the diagnostic process in the absence of an known primary tumor. due to their mucin content and epithelial origin, malignant cells of srcc can be identified with certain stains. mucicarmine, periodic acid-schiff stains (pas) are helpful in identifying the mucin content and ae1/ae3 pancytokeratin antibody can be used to confirm the epithelial origin of the srcs and to distinguish normal, metaplastic and neoplastic cells. since adenocarcinomas originating from tissues other than gastric mucosa may also present with srcs, other immunohistochemical investigations may be case report table 1. practical histological and immunohistochemical stains for the differential diagnosis of cutaneous signet-ring cells of unknown origin. origin of the malign signet-ring cells histopathological and immunohistochemical clues stomach intracytoplasmic mucin (+) stains positive for mucicarmine and ae1/ae3, alcian blue, ema colon and rectum intracytoplasmic mucin (+) stains positive for mucicarmine, ae1/ae3,ck20, cdx2, muc2, muc5ac prostate intracytoplasmic mucin (+) stains positive psa, ae1/ae3, mucicarmine, alcian blue breast intracytoplasmic mucin (+) stains positive for muc1, er, pr, gcdfp-15, ck7, cea lung intracytoplasmic mucin (+) ttf-1, ck7, napsina, mucicarmine, ema, cea ae1/ae3: immunohistochemical stain which detects ck1-8, 10, 14-16 and 19, in adenocarcinomas alcian-blue: common stain for mucin cdx2: immunohistochemical stain for a nuclear homeobox transcription factor that belongs to the caudal-related family of cdx homeobox genes and considered specific for enterocytes cea (carcinoembriyogenic antigen): found in the normal fetal epithelial cells, also can be detected in metastatic adenocarcinomas. ck (cytokeratin) 7: cytokeratin of nonkeratinizing epithelia (breast, lung) ck20: epithelial marker (positive staining in colon, small intestine and stomach) ema (epithelial membrane antigen): expressed frequently in adenocarcinomas and menengiomas er (estrogen receptor): immunohistochemical stain for estrogen receptor, relatively specific for breast cancer, nuclear staining(+) gcdfp15 (gross cystic disease fluid protein-15, prolactin-induced protein): can be stained immunohistochemically and is considered as a marker of benign and malignant apocrine metaplasia, usually positive in lobular carcinomas with signet ring cells muc (mucin): mucins are a family of high molecular weight, glycosylated proteins produced by epithelial tissues. there are two main families of muc genes: 1) genes encoding gel forming /secreted mucins (muc2, muc5ac, muc5b, muc6) 2) genes coding membrane bound mucins (muc1, muc3a, muc3b, muc4, muc12, muc13, muc17) mucicarmine: very specific stain for epithelial mucins and adenocarcinomas napsin-a: napsin-a is a protein that in humans is encoded by the napsa gene and expressed in lung and kidneys. pr (progesterone receptor): can be identified by immunohistochemical staining and is relatively specific for metastatic tumors from breast. psa (prostate specific antigen, kallikrein-3): glycoprotein enzyme secreted by the epithelial cells of the prostate gland. serum levels are elevated in benign and malign prostate diseases. ttf (thyroid transcription factor) 1: is a protein which is encoded by the nkx2-1 gene and regulates transcription of genes particularly in thyroid and lungs. figure 1. (a,b,c) numerous asymptomatic fleshy appearing papules and nodules with an elastic texture on the forehead, neck and right shoulder of the patient (d,e,f) shriveling of the skin nodules, 3 months later after the start of dosetaxel + cisplatin + infusional 5fluorouracil chemotherapy. no n c om me rci al us e o nly [dermatology reports 2016; 8:6819] [page 17] required in the differential diagnosis. immunohistochemical staining can be particularly helpful, if malignant cells of the primary tumor have conserved adequate level of differentiation, these cells will continue to synthesize tissue specific proteins, which can be identified by immunohistochemcial staining [i.e., thyroid transcription factor (tff-1) is heavily expressed in lungs and gross cystic disease fluid protein-15 (gcdfp-15) may be found in well-differentiated breast cancers]. identification of the tumoral cytokeratin and mucin expression profiles may also help particularly to distinguish adenocarcinomas [i.e., mucin5a (muc5a), muc2 and cytokeratin 20 (ck20) are commonly expressed in colorectal carcinomas, muc1 and ck7 can be found in breast cancers] (table 1). conclusions signet-ring cell may be seen in various neoplastic and nonneoplastic diseases, but these uncommon cells are frequently associated with malignancies and usually develop due to increased intracellular mucin content. when srcs are found in a skin biopsy, a high level of suspicion for a cancer should be aroused. since skin metastases can be observed as the first sign of a clinically-silent malignancy, a detailed medical history should be taken and a thorough physical examination must be conducted for a possible tumor. appropriate tests should be ordered considering the age and sex specific risk factors for the patient. in case of a cancer of unknown primary origin, histological and immunohistological staining methods would be useful to determine the primary tumor. in very rare instances, when the common histological staining methods are inadequate to distinguish a benign signet-ring change from a malign signet-ring cell transformation, observation invasion of lamina propria and a high intracellular pi3k activity may favor a malign cellular transformation. actually, mapk and pi3k signaling pathways are now considered as possible therapeutic targets in various cancers and various methods including western blotting, phospho-flow cytometry and immunofluorescence staining have been proposed for measuring mapk and pi3k activity.20 unfortunately, there isn’t yet an established and universally accepted method and the proposed methods require specific laboratory equipment and medical laboratory technicians with certain qualifications, preventing the widespread routine use. for similar reasons, we also could not measure the pi3k activity in our specimen. but, despite these facts, mapk and pi3k pathways seem to be as promising targets for future diagnostic and therapeutic interventions. case report figure 2. serial histological sections of the biopsy specimen. a) signet-ring cells among an eosinophilic dermal infiltrate. part of an hair follicle can be seen on the right (h&e, 100x) b) a typical cell with signet-ring morphology (arrow) (h&e, 200x) c) cellular mucin content in the cells near a pilosebeaceous unit indicating glandular origin of epithelial cells (mucicarmine, 100x) d) a close-up of signet-ring cells stained positive for mucin (mucicarmine, 200x) e) positive staining for cytokeratin indicating an epidermal or epithelial origin (ae1/ae3, 40x) f) srcs (positive for pancytokeratin) in higher magnification (ae1/ae3, 100x). no n c om me rci al us e o nly [page 18] [dermatology reports 2016; 8:6819] references 1. nashan d, müler ml, braun-falco m, et al. cutaneous metastases of visceral tumours: a review. j cancer res clin oncol 2009;135:1-14. 2. hu sc, chen gs, lu yw, et al. cutaneous metastases from different internal malignancies: a clinical and prognostic appraisal. j eur acad dermatol 2008;22:735-40. 3. fukui y. mechanisms behind signet ring cell carcinoma formation. biochem biophys res commun 2014;450:1231-3. 4. wang k, weinrach d, lal aseem, et al. signet-ring cell change versus signet-ring cell carcinoma: a comperative analysis. am j surg pathol 2003;27:1429-33. 5. arista-nasr j, romero-lagarza p, pichardo-bahena r. artifactual signetring-like cells in endoscopic biopsy of gastric lymphoma. arch pathol lab med 1997;121:623-5. 6. kobayashi m, nagata s, iwasaki t, et al. dedifferentiation of adenocarcinomas by activation of phosphatidylinositol 3-kinase. proc natl acad sci usa 1999 27;96:4874-9. 7. kobayashi m, iwamatsu a, shinoharakanda a, et al, activation of erbb3-pi3kinase pathway is correlated with malignant phenotypes of adenocarcinomas. oncogene 2003;22:1294-301. 8. xu q, karouji y, kobayashi m, et al. the pi3-kinaserac-p38 map kinase pathway is involved in the formation of signet-ring cell carcinoma. oncogene 2003;22:553744. 9. el homsi m, ducroc r, claustre j, et al. leptin modulates the expression of secreted and membrane-associated mucins in colonic epithelial cells by targeting pkc, pi3k, and mapk pathways. am j physiol gastrointest liver physiol 2007;293:g36573. 10. zhang jj, zhu y, xie kl, et al. yin yang-1 suppresses invasion and metastasis of pancreatic ductal adenocarcinoma by downregulating mmp10 in a muc4/erbb2/p38/mef2c-dependent mechanism. mol cancer 2014;13:130. 11. miyahara n, shoda j, kawamoto t, et al. interaction of muc4 and erbb2 in a transgenic mouse model of gallbladder carcinoma: potential pathobiological implications. oncol rep 2014;32:1796-802. 12. tapia o, riquelme i, leal p, et al the pi3k/akt/mtor pathway is activated in gastric cancer with potential prognostic and predictive significance. virchows arch 2014;465:25-33. 13. tamura y, higashi m, kitamoto s, et al. muc4 and muc1 expression in adenocarcinoma of the stomach correlates with vessel invasion and lymph node metastasis: an immunohistochemical study of early gastric cancer. plos one 2012;7:e49251. 14. krathen ra, orengo if, rosen t. cutaneous metastasis: a meta-analysis of data. south med j 2003;96:164-7. 15. pernot s, voron t, perkins g, et al. signetring cell carcinoma of the stomach: impact on prognosis and specific therapeutic challenge. world j gastroenterol 2015;21: 11428-38. 16. riihimäki m, hemminki a, sundquist k, et al. metastatic spread in patients with gastric cancer. oncotarget doi:10.18632/ oncotarget.10740 17. müller csl, pföhler c, reichrath j, tilgen w. erysipelas carcinomatosum der abdominalhaut. hautarzt 2008;59:992-4. 18. aneiros-fernandez j, husein-elahmed h, arias-santiago s, et al cutaneous metastasis as first clinical manifestation of signet ring cell gastric carcinoma. dermatol online j 2010;16:9. 19. ahn sj, oh sh, chang se, et al. cutaneous metastasis of gastric signet ring cell carcinoma masquerading as allergic contact dermatitis. j eur acad dermatol venereol 2007;21:123-4. 20. paraiso kh, van der kooi k, messina jl, smalley ks. measurement of constitutive mapk and pi3k/akt signaling activity in human cancer cell lines. methods enzymol 2010;484:549-67. case report no n c om me rci al us e o nly 429 too many requests you have sent too many requests in a given amount of time. dr [dermatology reports 2017; 9:6976] [page 5] ibrutinib-associated skin toxicity: a case of maculopapular rash in a 79-year old caucasian male patient with relapsed waldenstrom’s macroglobulinemia and review of the literature anders bisgaard jensen,1 birgitte stausbøl-grøn,2 rikke riber-hansen,3 francesco d’amore1 1department of hematology; 2department of dermatology; 3department of pathology, aarhus university hospital, aarhus, denmark abstract waldenstrom's macroglobulinamia (wm) is a rare malignant lymphoproliferative disorder, characterized by monoclonal igm paraproteinemia and neoplastic proliferation of malignant lymphoplasmacytoid cells in the bone marrow. traditionally, wm has been treated with modalities similar to those used in the management of other indolent lymphomas. just recently, based on impressive clinical trial results in heavily pretreated wm patients, a new bruton tyrosine kinase-inhibitor, ibrutinib, has been approved for the treatment of this disorder. as the use of ibrutinib in wm outside clinical trials is still limited, only few clinical reports illustrating treatment side effects are currently available. here we review the current literature specific on ibrutinib-associated rash in hematologic patients, and report on an elderly patient with wm, who developed a red maculopapular non-pruritic rash 12 weeks after starting ibrutinib therapy. without modifications of the ongoing ibrutinib schedule, the rash regressed within two weeks of treatment with topical steroidcontaining dermatological compounds. introduction as in other indolent lymphoproliferative malignancies, not all wm patients require treatment at the time of diagnosis. most often these patients’ disease status will be followed and cytoreductive intervention suggested if clinically indicated. in patients where therapeutic intervention is deemed necessary rituximab-based combination therapy regimens currently remains the therapy of choice. monotherapy with rituximab is only moderately effective with overall response rates (orr) of 40-50% in previously untreated patients.1 combinations of rituximab with conventional cytotoxic agents, such as cyclophosphamide and dexamethasone (rcd) or bendamustine (br), increase orr up to 8095% and median progression-free survival (pfs) values to 35-70 months.2,3 a growing number of novel drugs are currently undergoing clinical trials in wm. one of these is the bruton’s tyrosine kinase (btk) inhibitor ibrutinib, recently approved for the treatment of wm. in wm, a myd88l265p mutation has been proven in 93-97% of patients.4 this gain-of-function mutation activates the btk pathway, which in turn increases nf-κb signaling.5 ibrutinib interferes with this b-cell proliferation signal by inhibiting the bcr, btk pathway, ultimately leading to increased apoptosis as demonstrated in chronic lymphatic leukemia (cll) cells.6 several clinical trials with ibrutinib have proven the drug to be effective in bcell malignancies such as mantle-cell lymphoma (mcl) and cll. a recent clinical trial has shown ibrutinib treatment to be highly effective in wm as well, inducing durable responses in a group of 63 pretreated wm patients, with an orr of 90.5% along with 2 year pfs and os of 69.1% and 95.2%, respectively.7 overall the current results of ibrutinib treatment are looking very promising when compared to previously used regimens of rituximab as monotherapy or regimens of rituximab combined with conventional cytotoxic agents.8 the recent clinical ibrutinib trial found grade ≥3 adverse events to be neutropenia (14%) and thrombocytopenia (13%). less frequent (≤5%) were cardiac (e.g., arrhythmia), gastrointestinal (diarrhea) and hemorrhagic side effects. skin events including pruritus, rash and skin exfoliation were observed in 2% of patients. case reports specifically focusing on skin reactions to ibrutinib treatment are described in cll and mcl patients.9,10 more recently, iberri et al. reported on ibrutinib-related skin rashes in cll and mcl patients. the authors describe two types of rash presentations: a non-palpable, largely asymptomatic rash, and a palpable, pruritic type.11 no detailed clinical descriptions of ibrutinib associated skin rash have yet been reported in patients with wm. case report a 79-year-old man with wm diagnosed in 2002 presented to our out-patient clinic for evaluation of increasing pancytopenia (total white blood cell count 2.9x109/l, absolute neutrophil count 1.61x109/l; hemoglobin 10.63 g/dl, platelet count 146x109/l) and igm paraproteinemia (3500 mg/dl) associated with fatigue, drenching night sweats, recurrent bacterial and viral infections and hypogammaglobinemia. a bone marrow biopsy revealed marrow compartments heavily infiltrated (approximately 90% of the evaluated marrow cellularity) by a homogeneous population of lymphoplasmacytoid cells morphologically and immunohistochemically (cd2+, cd79a+, intracytoplasmic κ-light chain restriction) compatible with wm. the patient had previously been treated with a number of regimens including a combination of rituximab + cyclophosphamide + vincristine + prednisone (r-cvp) in 2004, as well as fludarabine (r-fc) in 2009, rituximab + bendamustine (br) in 2012, bortezumib + rituximab + dexamethasone (bdr) in 2015, dermatology reports 2017; volume 9:6976 correspondence: anders bisgaard jensen, department of hematology, aarhus university hospital, aaparken 1, 0-15, 8000 aarhus c, denmark. tel: +45.25566176. e-mail: ajensen@biomed.au.dk key words: waldenstrom's macroglobulinamia; ibrutinib; rash; adverse effects; minireview. contributions: abj and fda, collected data along with patient case information and interpreted these, reviewed the literature on the subject. bs-g produced clinical images and assisted with dermatological expertise, interpretation and description of this. rr-h produced, interpreted and described the histological samples. drafting, critical revision and final approval of the manuscript was undertaken by all authors. conflict of interest: the authors declare no potential conflict of interest. received for publication: 17 november 2016. accepted for publication: 31 march 2017. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright a.b. jensen et al., 2017 licensee pagepress, italy dermatology reports 2017; 9:6976 doi:10.4081/dr.2017.6976 no n c om me rci al us e o nly with the most recent therapy given 5 months prior to his out-patient clinic visit. he was started on ibrutinib 420 mg po daily. the patient continued with two medications he had been receiving over several months prior to ibrutinib, i.e. human igg immunoglobulin (sc) and allopurinol 300mg (po) once daily. twelve weeks after starting ibrutinib treatment, the patient developed a painless, slightly pruritic rash starting from the groins and wrists and subsequently spreading to trunk, extremities and with single elements also in the facial area (figure 1). the rash was characterized by a diffuse distribution of bright red edematous maculopapular elements, ranging from 0.5 to 1 cm in diameter, with sparing of his palms and soles (grade 3 according to nci-ctc). never before had the patient experienced a similar rash, nor had any of his family members or close relations similar symptoms concomitant to the time of onset in the patient. with regard to wm, the patient had a good clinical response to ibrutinib, with igm values gradually dropping to normal levels within the first twothree months from treatment start. absolute eosinophil count at the time of rash onset was within normal range (0.20.5x109/l). blood work showed no significant elevation of liver enzymes or signs of impaired kidney function, which would suggest a more systemic reaction to the drug. after an initial clinical assessment, the patient was referred to the department of dermatology, where a punch biopsy from a relevant rash area was obtained for histological evaluation. this biopsy showed lymphocytic infiltration with numerous eosinophil granulocytes, mainly in the superficial dermal layer, but also in the perivascularand interstitial tissue (figure 2a). a pas staining of the sample was negative for fungi (figure 2b). these findings, integrated with the clinical picture and the therapeutic history, led to the diagnosis of drug-induced rash. topical steroid treatment was initiated under dermatological supervision. while effective in eliminating the pruritus symptoms, topical treatment did not lead to a rapid resolution of the maculopapular elements. tapering of ibrutinib dose was considered, but not implemented in the absence of systemic and cutaneous clinical progression. at subsequent clinical evaluations, under persistent topical treatment, the rash gradually subsided and eventually resolved approximately 3 months after its onset. at last follow-up, 6 months after rash resolution, the patient is still on ibrutinib and has not experienced reoccurrence of the cutaneous manifestations. written consent from the patient has been obtained. discussion ibrutinib (imbruvica, janssen biotech), an oral btk inhibitor is approved for use in refractory cll and mcl. in 2015, ibrutinib was also approved for use in pre-treated adult wm patients, or previously untreated wm patients not eligible for chemotherapy. ibrutinib has been shown to have good clinical and paraclinical effect in these patients, and is generally very well tolerated with a low frequency of severe adverse events.12-14 in recently published results, from early phase clinical trials testing ibrutinib as monotherapy in mcl, cll and small lymphocytic lymphoma (sll), rash occurred at a frequency of 13-27%.9,10,13-15 a recent study reporting the stanford university experience with ibrutinib-associated rash development in mcl and cll patients described two different types of clinical pic case report figure 1. pruritic rash in waldenstrom's patient developed 12 weeks after beginning ibrutinib therapy. a) upper back; b) back thighs and calves; c and d) close-up of rash papules seen in panels a and b. figure 2. a slightly spongiotic reaction with predominantly perivascular infiltrates of lymphocytes and eosinophils with a negative reaction for fungi were seen in the histopathological examination of the punch biopsy of the skin (a: hematoxylin eosin, x200; b: periodic acid-schiff, x200). [page 6] [dermatology reports 2017; 9:6976] no n c om me rci al us e o nly tures: i) a non-palpable, late-onset mild cutaneous eruption not requiring skindirected therapy or ibrutinib tapering; and ii) a palpable purpuric rash, with earlier onset, generally more severe, requiring skin-directed intervention with topical therapy and oral antihistamines.11 in half of the patients with grade 3 rashes, ibrutinib was either tapered or temporarily halted. all patients were able to resume ibrutinib treatment at full dose or (in two patients) at a permanently dose reduced level. another group reported of an igg lpl patient who developed a rash consistent with schnitzler’s syndrome. however rash onset, look and symptoms in our patient shared only few similar characteristics with the typical presentation of schnitzlers, and thus the rash was not suspected a part of this specific syndrome. apart from being a btkinhibitor, ibrutinib has been shown to effectively inhibit the epidermal growth factor receptor (egfr) in a dose dependent manner.16 inhibition of egfr is known to stimulate apoptosis, inflammation, enhance apoptosis and inhibit cell cycle progression.17 cutaneous eruptions are a well-known adverse effect to egfr inhibition by other tyrosine kinase inhibitors (tki),18 and similarly ibrutinib-induced rash may in part be a result of egfr inhibition. the time of onset, and the general appearance of the rash could resemble a late-phase ige-mediated reaction. the histological sample with lymphocytic and eosoniphile infiltration supports this theory, although the patient had not experienced any immediate reaction to the compound, and had not previously experienced atopic reactions to other drugs. another possible explanation is that the rash represents a viral reactivation as a result of the patient’s immunocompromised state. if this were the case, it would be the first time the patient experienced viral reactivation during treatment since diagnosed in 2002. no further investigation of the underlying mechanism was made, as the rash gradually resolved on topical steroid treatment. data on skinbased toxicity in wm patients are largely lacking, and as of now only a small amount of detailed clinical characteristics of rash in this group of patients have been described. it is therefore only possible to compare this presentation to other patient groups. ibrutinib-induced rashes have been described in mcl, cml and cll patients, all receiving 400-600 mg of ibrutinib (figure 3).9,11,19,20 as can be seen from these reports, the time of rash onset is highly variable, with onset as late as 300-400 days after starting treatment, in some patients. the rash and pruritus symptoms in our patient are comparable to the symptoms described in the mcl/cll group ii. compared to this group, rash onset is delayed in our patient (84 days compared to median 15 days), and no ibrutinib tapering or pausing was deemed necessary. conclusions here we report of an elderly wm patient who developed a rash 84 days after initiating ibrutinib therapy. this is, to our knowledge the first case description of an ibrutinib-associated rash in a wm patient. the possible mechanism could be attributed to either egfr action of the compound, ige mediated allergic reaction or more simply, a viral reactivation caused by immunocomprimisation. in comparison to the other patient groups, rash onset was delayed and symptoms were milder when compared to the other cases presented with pruritic symptoms, and comparable cll/mcl type ii rash group of the stanford study. due to the novelty of the drug in the wm setting, detailed, and disease-specific clinical descriptions of toxicity profiles in general, and skin-based in particular, are valuable information for daily clinical practice. by providing a detailed report on the clinical manifestation and subsequent management of ibrutinib-associated skin-toxicity in a wm patient, our case report contributes in generating a shared clinical experience useful for recognition and management of ibrutinib-associated rash. the relevance of this data is underscored by the increasing use of ibrutinib in wm, after its recent approval. references 1. treon sp, emmanouilides c, kimby e, et al. extended rituximab therapy in waldenstrom’s macroglobulinemia. ann oncol 2005;16:132-8. 2. rummel mj, niederle n, maschmeyer g, et al. bendamustine plus rituximab versus chop plus rituximab as firstline treatment for patients with indolent and mantle-cell lymphomas: an openlabel, multicentre, randomised, phase 3 non-inferiority trial. lancet 2013;381: 1203-10. 3. dimopoulos ma, anagnostopoulos a, kyrtsonis mc, et al. primary treatment of waldenstrom macroglobulinemia with dexamethasone, rituximab, and cyclophosphamide. j clin oncol 2007; 25:3344-9. 4. treon sp, xu l, hunter z. myd88 mutations and response to ibrutinib in waldenstrom’s macroglobulinemia. n engl j med 2015;373:584-6. case report figure 3. an overview of rash onset from previously published studies and case reports regarding ibrutinib-associated rashes in cml, cll and mcl patients. references refer to reference list. [dermatology reports 2017; 9:6976] [page 7] no n c om me rci al us e o nly [page 8] [dermatology reports 2017; 9:6976] 5. treon sp, xu l, yang g, et al. myd88 l265p somatic mutation in waldenstrom’s macroglobulinemia. n engl j med 2012;367:826-33. 6. herman se, gordon al, hertlein e, et al. bruton tyrosine kinase represents a promising therapeutic target for treatment of chronic lymphocytic leukemia and is effectively targeted by pci32765. blood 2011;117:6287-96. 7. treon sp, tripsas ck, meid k, et al. ibrutinib in previously treated waldenstrom’s macroglobulinemia. n engl j med 2015;372:1430-40. 8. castillo jj, palomba ml, advani r, treon sp. ibrutinib in waldenstrom macroglobulinemia: latest evidence and clinical experience. ther adv hematol 2016;7:179-86. 9. mannis g, wu d, dea t, et al. ibrutinib rash in a patient with 17p del chronic lymphocytic leukemia. am j hematol 2015;90:179. 10. tobinai k, ogura m, ishizawa k, et al. safety and tolerability of ibrutinib monotherapy in japanese patients with relapsed/refractory b cell malignancies. int j hematol 2016;103:86-94. 11. iberri dj, kwong by, stevens la, et al. ibrutinib-associated rash: a single-centre experience of clinicopathological features and management. br j haematol 2016 [epub ahead of print]. 12. advani rh, buggy jj, sharman jp, et al. bruton tyrosine kinase inhibitor ibrutinib (pci-32765) has significant activity in patients with relapsed/refractory b-cell malignancies. j clin oncol 2013;31:88-94. 13. byrd jc, furman rr, coutre se, et al. targeting btk with ibrutinib in relapsed chronic lymphocytic leukemia. n engl j med 2013;369:32-42. 14. o’brien s, furman rr, coutre se, et al. ibrutinib as initial therapy for elderly patients with chronic lymphocytic leukaemia or small lymphocytic lymphoma: an open-label, multicentre, phase 1b/2 trial. lancet oncol 2014; 15:48-58. 15. wang ml, rule s, martin p, et al. targeting btk with ibrutinib in relapsed or refractory mantle-cell lymphoma. n engl j med 2013;369:50716. 16. chen j, kinoshita t, sukbuntherng j, et al. ibrutinib inhibits erbb receptor tyrosine kinases and her2-amplified breast cancer cell growth. endocr relat cancer 2016;15:689-708. 17. woodworth cd, michael e, marker d, et al. inhibition of the epidermal growth factor receptor increases expression of genes that stimulate inflammation, apoptosis, and cell attachment. mol cancer ther 2005;4:650-8. 18. perez-soler r, van cutsem e. clinical research of egfr inhibitors and related dermatologic toxicities. oncology (williston park) 2007;21:10-6. 19. milojkovic d, short k, salisbury jr, et al. dose-limiting dermatological toxicity secondary to imatinib mesylate (sti571) in chronic myeloid leukaemia. leukemia 2003;17:1414-6. 20. rule sa, o’brien sg, crossman lc. managing cutaneous reactions to imatinib therapy. blood 2002;100:3434-5. case report no n c om me rci al us e o nly 429 too many requests you have sent too many requests in a given amount of time. dr [page 34] [dermatology reports 2017; 9:7050] actinic prurigo in scandinavian adolescent successfully treated with cyclosporine a jan c. sitek department of dermatology, oslo university hospital, norway abstract actinic prurigo is a pruritic sun-induced dermatosis classified among the immunologically mediated photodermatoses. the disease is a well-known entity among native americans and in central and south america, however rare in caucasians with only a few reports from australia, britain and france. we report the first case of actinic prurigo in a scandinavian patient, responding favorably to systemic treatment with cyclosporine a. case report an 11-year old norwegian girl presented with a long-standing itchy rash resistant to topical and systemic steroids. she was otherwise healthy. physical examination revealed a centro-facial rash consisting of erythematous papules, excoriations and crusts on an erythematous basis (figure 1a) and excoriated papules on her upper extremities and chest. cheilitis and conjunctivitis were absent. standard laboratory investigations, complement factors and autoantibodies were all within normal range. porphyrin screening was negative. phototesting showed reduced and normal med for uva and uvb, respectively. skin biopsy showed focal paraand hyperkeratosis, mild acanthosis and a perivascular predominantly mononuclear infiltrate (figure 2). direct immunofluorescence staining for iga, igg, igm and c3 were negative. human leucocyte antigen (hla) typing detected the drb1*0407 subtype. clinical presentation and additional investigations strongly indicated actinic prurigo (ap). sunblocks, potent steroids and antihistamines were ineffective. uv desensitization therapy was considered but not feasible for practical reasons. treatment with hydroxychloroquine and subsequently tetracyclines, both for several months, yielded no improvement. cyclosporine a was initiated, bringing the disease in partial remission within a few weeks. after 4 months followup itch and non-facial lesions were practically absent, with the exception of hypopigmented scars to her arms (figure 1c). facial involvement was considerably milder (figure 1b). the mother of the patient has given her written informed consent for publication of all material in this manuscript, including the photographs. discussion and conclusions ap is an immunologically mediated photodermatosis primarily described in amerindians and people of central and south american descent with frequent familial occurrence and early-childhood onset.1 in caucasians ap occurs sporadically, typically starts in adolescence and to a lesser extent present conjunctivitis and cheilitis.2-4 the disease has previously not been described in scandinavian patients. ap normally manifests in spring as an itchy papular dermatitis in sun-exposed areas. coalescing patches, with vesicular and erosive areas may develop and non-exposed skin may be affected. hla drb1*0407 subtype is strongly associated with ap in populations of both caucasian3 and centraland south-american descent.5 the dermatology reports 2017; volume 9:7050 correspondence: jan cezary sitek, department of dermatology, oslo university hospital, post box 4950 nydalen, 0424 oslo, norway. tel.: +4723072430. e-mail: jsitek@ous-hf.no key words: photodermatosis; immunosuppression; pediatric dermatology. contributions: jcs has had full access to all patient data, made all contributions to the conception of this case report and drafted and approved the version to be published. conflict of interest: the author declares no conflict of interest. received for publication: 16 january 2017. accepted for publication: 16 may 2017. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright j.c. sitek, 2017 licensee pagepress, italy dermatology reports 2017; 9:7050 doi:10.4081/dr.2017.7050 figure 1. actinic prurigo: a) facial rash before cyclosporine a treatment; b) facial rash at 4 months follow-up with cyclosporine a treatment showing significant improvement; c) upper extremity at 4 months follow-up with cyclosporine a treatment showing remission of activity and post-inflammatory hypopigmented scars. a b cno nco mm er cia l u se on ly [dermatology reports 2017; 9:7050] [page 35] drb1*0407 subtype is not associated with polymorphic light eruption (ple) and may aid in the distinction between ple and ap.3 treatment of ap includes sun-protective measures, topical steroids, antihistamines and preventive uvb therapy. systemic therapies, including antimalarials, tetracyclines and systemic steroids, are often ineffective or not suitable for longterm treatment. thalidomide is generally recommended as the treatment of choice in recalcitrant cases, however the risk of peripheral neuropathy and teratogenesity limit its usage.1 cyclosporine a is an immunosuppressive drug exerting anti-pruritogenic effects, possibly through inhibition of t-cell activity and proliferation, and migration of eosinophilic granulocytes to the skin.6 uvexposed skin normally exhibits a decrease of epidermal langerhans cells. in ap the number of langerhans cells is maintained, referred to as uv resistance. partial decrease in epidermal langerhans cells in ap patients treated with cyclosporine a has been observed. whether these observations indicate a direct effect on the migration of langerhans cells or suppression of the uv resistance remains elusive.7 our patient is the first ethnic scandinavian reported with ap. she had no atopy, which is frequently recorded in caucasians with ap. she carried the hla drb1*0407 subtype, present in only 1% of the norwegian population (t. egeland, 2016, personal communication) as compared to frequencies of 18-60% in amerindians and colombian sub-populations.5 cyclosporine a is generally omitted as a therapy option for ap in publications on photodermatoses, including a recent review paper regarding photodermatoses in children.1 we advocate cyclosporine a as a suitable treatment alternative in ap patients demanding systemic intervention. references 1. chantorn r, lim hw, shwayder ta. photosensitivity disorders in children: part i. j am acad dermatol 2012;67:1093.e1-18. 2. crouch r, foley p, baker c. actinic prurigo: a retrospective analysis of 21 cases referred to an australian photobiology clinic. australas j dermatol 2002;43:128-32. 3. grabczynska sa, mcgregor jm, hawk jl, et al. actinic prurigo and polymorphic light eruption: common pathogenesis and the importance of hladr4/drb1*0407. br j dermatol 1999;140:232-6. 4. batard ml, bonnevalle a, thomas p, et al. caucasian actinic prurigo: 8 cases observed in france. br j dermatol 2001;144:194-6. 5. suárez a, valbuena mc, de porras quintana l, et al. association of hla subtype drb10407 in colombian patients with actinic prurigo. photodermatol photoimmunol photomed 2006;22:55-8. 6. sonkoly e, muller a, homey b, et al. il31: a new link between t cells and pruritus in atopic skin inflammation. j allergy clin immunol 2006;117:411-7. 7. umaña a, gómez a, porras l, et al. lymphocyte subtypes and adhesion molecules in actinic prurigo: observations with cyclosporin a. int j dermatol 2002;41:139-45. case report figure 2. histopathology (h&e) from upper arm/elbow. focal paraand hyperkeratosis, mild acanthosis and a perivascular, predominantly lymphocytic infiltrate. no nco mm er cia l u se on ly dr [page 14] [dermatology reports 2017; 9:7117] a study case in photoepilation, the hppl™ and ifl™ technologies alessandro martella,1 mauro raichi2 1former senior consultant in dermatology, university of modena and reggio emilia medical school, tiggiano (le); 2clinical pharmacology and biophysics consultant, milan, italy abstract the high power pulsed light™ [hppl™] and incoherent fast light™ technologies [ifl™, novavision group s.p.a., 20826 misinto (mb), italy] are recent innovations in the field of unwanted hair removal with intense pulsed light devices. ifl™ is a further improvement over the already advanced characteristics of the hppl™ technology. a selection of photoepilation case histories with the hppl™ and ifl™ technologies is presented; a short introduction highlights the main features of the two technologies. all study materials were appropriately peer-reviewed for ethical problems. the development of intense pulsed light photoepilation selective photothermolysis, meaning selective damage to pigmented structures, cells, and organelles in vivo with suitably brief pulses of selectively absorbed radiation is the goal of any application of pulsed light sources to unwanted hair removal.1 all technologies developed since the mid-eighties after the introduction of the selective photothermolysis concept have aimed to a single goal: establishing the most efficient dermatology reports 2017; volume 9:7117 correspondence: mauro raichi, e-mail: mraichi@gmail.com key words: photoepilation; intense pulsed light; selective photothermolysis. sponsor: novavision group s.p.a., misinto (mb), italy. conflict of interest: the authors declare no potential conflict of interest. received for publication: 6 march 2017. accepted for publication: 9 may 2017. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright a. martella and m. raichi 2017 licensee pagepress, italy dermatology reports 2017; 9:7117 doi:10.4081/dr.2017.7117 figure 1. light absorption spectra of skin chromophores (melanin and oxyhemoglobin) and water in visible and infrared wavelengths with evidence (shaded areas) of the ipl xenon flash lamp wavelengths eliminated by the built-in water filter and the movable 650-nm cut-off one. no n c om me rci al us e o nly [dermatology reports 2017; 9:7117] [page 15] compromise between skin penetration and energy absorption by melanin leading to thermal destruction of the hair shaft, hair follicle and matrix. all that with minimum energy absorption and thermal damage to other skin chromophores like oxyhemoglobin and water.2 second-generation devices for unwanted hair removal based on high-intensity pulsed flashes of multi-chromatic light (intense pulsed light, ipl) are equipped with closed-loop cooling systems with ultra-transparent water bi-distilled to less than 0.0001% particulate residue. the cooling system acts as a water filter that absorbs most infrared radiation, especially wavelengths longer than 900 nanometers (nm), thus minimizing the risk of infrared-related local side effects. in the most advanced second-generation ipl technologies like high power pulsed light™ (hppl™) and incoherent fast light™ (ifl™), the ultratransparent cerium-supplemented borosilicate glass of the xenon flash lamp also filters off the ultraviolet radiation below 380 nm. a pre-installed 420-nm cut-off filter reinforces the suppression of ultraviolet wavelengths. the residual operating range of wavelengths in second-generation ipl devices article figure 2. short-term efficacy of photoepilation vs wax epilation, intra-individual evaluation. clear evidence of recent folliculitis in the right armpit treated with a depilatory wax. before treatment six weeks after treatment left armpit, hppl ™ photoepilation right armpit, depilatory wax no n c om me rci al us e o nly like hppl™ and ifl™ (i.e., between about 420 and 900 nm) includes the three energy emission peaks of xenon flash lamps at 700, 810 and 890 nm. movable filters cutting off all radiation below the 520/550/590/ 650/720 nm orange-red or 650-nm red wavelengths allow to concentrate all the emitted light energy in a narrow window of highly penetrating wavelengths. the visible and near-infrared radiation in this narrow waveband is able to reach the lower dermis and includes the three major energy emission peaks (figure 1). ipl devices based on the hppl™ and ifl™ technologies have been extensively used and tested by the main author in his everyday hospital and plastic dermatology private practice. a collection of photoepilation case histories, collected over the last several years, is herein presented. clinical outcomes of second-generation intense pulsed light technologies the application of pulsed light sources for long-term epilation was a definite progress over previously available techniques. the most recent refinement of the hppl™ technology, known as ifl™, allows to focus the energy on three wavelengths corresponding to the three energy emission peaks, 700, 810 and 890 nm. the number of spots is also increased up to 210,000 and there is no contact of the photoepilation device with the skin. figure 2 illustrates the higher efficacy 6 weeks after treatment with a novavision group hsl 120 ifl device compared with wax epilation. much less hair is growing again in the light-epilated left armpit and, differently from the wax-epilated right armpit, there is no evidence of folliculitis. ipl-treated skin areas should overlap by about 10% to avoid leaving non-epilated areas that will give a very unpleasant zebra effect (figure 3). the safety of the technology allows for multiple treatments in the same individual in the same session, as shown by the very good results reached in groin, leg and face with 7 photoepilation sessions over 5 months with the hsl 120 ifl device (figure 4). higher levels of fluence allow a lower number of photoepilation sessions (figure 5). frank hirsutism associated with endocrine disorders is a reliable test for the effectiveness of the new ifl™ technology in a condition that is both challenging and discriminating. figures 6 and 7 illustrate the striking improvement of facial hirsutism associated with an increased function of the adrenal cortical tissue 6 weeks after a single session of hppl™/ifl™ photoepilation; figure 8 bears witness to the dramatic aesthetic improvement over 17 hppl™/ifl™ photoepilation sessions every 6-7 weeks in a young woman with hormone disorders and a really severe clinical presentation of facial hirsutism. in this woman the unwanted hair growth was so severe to demand the daily use of a razor. figures 9 to 11 confirm the hair removal efficacy of the new ifl™ technology as the most recent step in the still on-going history towards ever more efficient photoepilation. references 1. anderson rr, parrish ja. selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. science 1983;220:524-7. 2. haedersdal m, beerwerth f, nash jf. laser and intense pulsed light hair removal technologies: from professional to home use. br j dermatol 2011;165:31-6. [page 16] [dermatology reports 2017; 9:7117] article figure 3. zebra effect between contiguous skin areas of the thigh in a 30-year old woman 4 weeks after single-flash hppl™/ifl™ photoepilation (settings: 50 msec, 60 j, cut-off filter 590 nm). before treatment after 4 weeks no n c om me rci al us e o nly [dermatology reports 2017; 9:7117] [page 17] article figure 4. multi-site hppl™/ifl™ photoepilation (face, groin, leg; settings: 50 msec, 80-100 j, cut-off filter 650 nm); 7 sessions over 5 months. before treatment final outcome before treatment final outcome before treatment final outcome no n c om me rci al us e o nly [page 18] [dermatology reports 2017; 9:7117] article figure 5. repeated-passage groin hppl™/ifl™ photoepilation in a phototype-iii woman, 4 sessions every 6 weeks (settings: 60-65 j; 2 sessions: 30-msec flash, 650-nm cut-off filter; 2 sessions: 30-msec flash, 590-nm cut-off filter). before treatment final outcome figure 6. a-c) facial hirsutism as symptom of hyperactivity of the adrenal cortex in a 18-year old woman; d) dermoscope evidence of the abnormal facial hair growth before hppl™/ifl™ photoepilation (microphotograph, 20x). before treatment a b c dno n c om me rci al us e o nly [dermatology reports 2017; 9:7117] [page 19] article before treatment (a) overall clinical and aesthetic outcome (b) higher-detail outcome final outcome figure 7. a) clinical and aesthetic efficacy 6 weeks after a single session of hppl™/ifl™ photoepilation in a 18-year old woman with severe facial hirsutism due to hypercorticosurrenalism; b) very sparse growth of pale, thin and rudimentary hair 6 weeks after treatment (dermoscope image, 20x). settings: 50-msec single flash, 50 j, cut-off filter 590 nm.no n c om me rci al us e o nly [page 20] [dermatology reports 2017; 9:7117] article figure 8. time course of improvement over 17 hppl™/ifl™ photoepilation sessions every 6-7 weeks in a young woman with severe facial hirsutism. before treatment after 10 treatments figure 9. ifl™ photoepilation, armpit, 3 sessions. before treatment after 3 sessions after 17 treatmentsafter 15 treatments no n c om me rci al us e o nly [dermatology reports 2017; 9:7117] [page 21] article figure 10. ifl™ photoepilation, armpit, 2 sessions. before treatment after 2 sessions figure 11. ifl™ photoepilation, back and shoulder, 4 sessions. before treatment after 4 sessions no n c om me rci al us e o nly 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. dr [page 36] [dermatology reports 2017; 9:7198] eyelid dermatitis caused by allergic contact to acrylates in artificial nails jorge moreira, rita gonçalves, pedro coelho, tiago maio department of ophthalmology, hospital pedro hispano, porto, portugal abstract over the past few years, there has been an increase in cases of allergic contact dermatitis caused by acrylates, because of the growing popularity of artificial nails. pathological reactions to artificial nails typically occur on or around the nail area. eyelid contact dermatitis due to artificial nails is rarely seen, especially in a nonoccupational setting. the authors report the case of a 45-year-old female accountant who developed eyelid dermatitis due to artificial nails. introduction the eyelid is one of the most sensitive areas of the body as the skin of the eyelid is extremely thin and is exposed to an extraordinary number of substances. for this reason, eyelid dermatitis is a common disease, and a variety of factors, including primary skin diseases and external insults may cause eyelid erythema. determining the underlying etiology may prove especially challenging, because eyelid rashes, regardless of the cause, look very similar. allergic contact dermatitis (acd) is considered the most common cause of eyelid dermatitis, and its prevalence ranges from 46% to 74%.1,2 acute acd often presents with intense pruritus and a well-demarcated erythema of the eyelids whereas subacute and chronic forms are less erythematous, and are characterized by dry, scaly and lichenified skin.3 the list of allergens that are potentially associated is extensive, and it includes topical pharmaceutical products, cosmetics, metals, rubber derivatives, and plants.4 the causal contact allergens may be of occupational or non-occupational origin and may come into contact with the eyelid skin in several ways. most often, eyelid contact dermatitis is the result not from direct periocular exposure, but rather due to ectopic reactions, caused by substances applied to the hair, face, scalp or fingernails.5 the eyelid is also particularly susceptible to acd from airborne allergens.5 due to its exceptional vulnerability, eyelid skin may be the initial or only area that demonstrates signs of contact dermatitis, while other areas of the body remain unaffected by the same exposure.5 here, we present the case of a woman who developed eyelid dermatitis due to acrylates in artificial nails. case report a 45-year-old female accountant presented with a one-week history of a pruritic and symmetric redness of the eyelids. examination showed edema and a welldefined erythema of both eyelids (figure 1). at the slit lamp exam, eye examination was normal. there was no personal or family history of atopy. a detailed history of her exposures revealed that she wore photobonded acrylic gel nails. she had no skin lesions elsewhere, namely on the hands, periungual area or nails. patch tests with the portuguese standard and acrylates series (chemotechnique® diagnostics, vellinge, sweden) applied using finn® chambers on scanpor® tape (epitest ltd oy, tuusula, finland) were performed and readings at d2 and d4 revealed positive reactions to ethylacrylate 1% (++), methyl metacrylate monomer 10% (+), and 2-hydroxyethylmethacrylate (++). the results were consistent with the diagnosis of allergic contact dermatitis to artificial nails containing acrylates. the eyelid dermatitis resolved following application of topical corticosteroid and removal of the artificial nails. discussion acrylates are plastic materials that are formed by the polymerization of monomers derived from acrylic or methacrylic acid. they can be found in a wide variety of products, including adhesives, glues, paints, and artificial nails. acrylates are well-known for their sensitizing potential, and for causing acd in those exposed to the monomers. classically, acd caused by acrylates was considered primarily an occupational disease, affecting mainly dentists, prosthesis technicians, painters, and workers in the fiberglass and graphic printing industries.6 in the last few years, with the widespread use of artificial nails, an increasing number of cases of allergic contact dermatitis caused by acrylates have been reported particularly in nail technicians, but also among artificial nail users.7-9 exposure to acrylates in artificial nails may induce a wide variety of clinical manifestations. reactions in nail users, most commonly, occur on or around the nail area, and include paronychia, onychodystrophy, onycholysis, nail bed hyperkeratosis, painful nails, and occasionally, paresthesia.10,11 in the case of the nail technicians, the most frequent adverse reaction is hand dermatitis, through manipulation of unpolymerized acrylates.7 unlike what happens with traditional nail varnishes, acd caused by the acrylates present in the artificial nails usually produces lesions at the site of application to the nail itself, and only very rarely affects distant areas, such as the face and eyelids.7,8,12 distant acd can be explained by hand transportation or airborne dissemination of the allergen.13 the acrylate monomer is a powerful sensitizer, whereas the polymer is significantly weaker or non-sensitizing, and because of this feature, distant allergic reactions to acrylate-containing artificial nails dermatology reports 2017; volume 9:7198 correspondence: jorge moreira, department of ophthalmology, hospital pedro hispano, rua dr. eduardo torres, 4464-513, senhora da hora, porto, portugal. tel.: +351.229391000. e-mail: jorgemoreira.fm@gmail.com key words: eyelid; contact dermatitis; artificial nails; acrylates. acknowledgments: we thank the department of dermatology for all the help in this clinical case. contributions: jm, conception of the work; data collection, and interpretation; drafting and revising the manuscript; literature review; final approval of the manuscript to be published. rg, pc, tm, analysis and interpretation of data; manuscript review; literature review; final approval of the manuscript to be published. conflict of interest: the authors declare no potential conflict of interest. received for publication: 23 april 2017. accepted for publication: 22 may 2017. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright j. moreira et al., 2017 licensee pagepress, italy dermatology reports 2017; 9:7198 doi:10.4081/dr.2017.7198 no n c om me rci al us e o nly [dermatology reports 2017; 9:7198] [page 37] are uncommon.5,6 in our case, contact with monomer might have occurred before polymerization, or small amounts of monomer might have remained unpolymerized, or the filling process of completely polymerized resins might have released the monomer.11,14 conclusions contact dermatitis is the most common cause of eyelid dermatitis, therefore, a detailed exposure history is essential for an accurate diagnosis and successfull management. this report highlights a hypersensitivity reaction to artificial nails involving an unusual location, particularly in a non-occupational setting, and stresses the importance of considering nail cosmetics in the evaluation of eyelid dermatitis. references 1. nethercott jr, nield g, holness dl. a review of 79 cases of eyelid dermatitis. j am acad dermatol 1989;21:223-30. 2. guin jd. eyelid dermatitis: experience in 203 cases. j am acad dermatol 2002;47:755-65. 3. peralejo b, beltrani v, bielory l. dermatologic and allergic conditions of the eyelid. immunol allergy clin north am 2008;28:137-68. 4. goossens a. contact allergic reactions on the eyes and eyelids. bull soc belge ophtalmol 2004;292:11-7. 5. rietschel rl, fowler jf jr. fisher’s contact dermatitis, 6th ed. hamilton, on: bc decker; 2008. pp 1-7; 731-741. 6. geukens, goossens a. occupational contact allergy to (meth)acrylates. contact dermatitis 2001;44:153-9. 7. roche e, de la cuadra j, alegre v. sensitization to acrylates caused by artificial acrylic nails: review of 15 cases. actas dermosifiliogr 2008;99:788-94. 8. ramos l, cabral r, gonçalo m. allergic contact dermatitis caused by acrylates and methacrylates a 7-year study. contact dermatitis 2014;71:1027. 9. montgomery r, stocks sj, wilkinson sm. contact allergy resulting from the use of acrylate nails is increasing in both users and those who are occupationally exposed. contact dermatitis 2016;74:120-2. 10. cruz mj, baudrier t, cunha ap, et al. severe onychodystrophy caused by allergic contact dermatitis to acrylates in artificial nails. cutan ocul toxicol 2011;30:323-4. 11. freeman s, lee ms, gudmundsen k. adverse contact reactions to sculptured acrylic nails: 4 case reports and a literature review. contact dermatitis 1995;33:381-5. 12. baran r. nail beauty therapy: an attractive enhancement or a potential hazard? j cosmet dermatol 2002;1:24-9. 13. lazarov a. sensitization to acrylates is a common adverse reaction to artificial fingernails. j eur acad dermatol venereol 2007;21:169-74. 14. maio p, carvalho r, amaro c, et al. allergic contact dermatitis from sculptured acrylic nails: special presentation with an airborne pattern. dermatol reports 2012;4:e6. case report figure 1. periorbital eczema. no n c om me rci al us e o nly dr [page 46] [dermatology reports 2017; 9:7340] quality of life in patients with melasma in turkish women hacer uyanikoglu,1 mustafa aksoy2 1department of obstetrics and gynecology; 2department of dermatology, harran university medical faculty, sanliurfa, turkey abstract the aim of this study was to determine the impact of melasma on quality of life (qol) using the dermatology life quality index (dlqi) questionnaire in a group of outpatients. this study is questionnairebased. a total of 101 turkish women suffering from melasma, who themselves were able to understand and complete the turkish version of the dlqi questionnaire, were enrolled. this questionnaire included 10 questions; each of each was scored on a scale of 0-3, with a maximum score of 30. the data were analyzed after the results had been collated and the higher the dlqi score, the poorer the qol. the participants’ mean age was 29.53±6.87 years, and mean dlqi score was 6.02±4.94. when we divided the participants into two subgroups according to age, the dlqi scores for younger and older individuals were 7.44±4.99 and 4.33±4.36, respectively (p=0.001). when the melasma area and severity index (masi) score was used, participants with mild and moderate disease had mean dlqi scores of 5.80±4.72 and 7.11±5.90, respectively. no patient had severe disease. melasma might affect the participants’ qol, especially that of the younger individuals, in our study population. introduction melasma is a common disorder of acquired hyperpigmentation. it is characterized by irregular macules on sun-exposed areas of the face mainly the cheeks, forehead, upper lip, nose, and chin.1 although the clinical and histological features of melasma are similar in both genders, the disorder is more commonly observed in females of reproductive age than in males of the same age (90% vs 10%).2 the precise etiology of melasma is not well known, and statistical data regarding its incidence are lacking.3 however, it has been shown that various risk factors, such as ultraviolet (uv) light, genetic predisposition, pregnancies, oral contraceptives (oc), hormonal therapies, thyroid autoimmunity, cosmetics ingredients, and phototoxic drugs are involved.4 melasma is more common in locations that experience high-intensity uv radiation, such as asia and latin america, and it occurs in up to 10.7% of pregnant women.5,6 the measurement of quality of life (qol) is increasingly becoming part of the total assessment of a patient’s health, in both the clinical and the research settings. it is defined as the capacity to perform daily activities, and provides a more detailed knowledge of the health of the patient.7 our city, sanliurfa, is in the southeast region of turkey, where exposure to the sunlight is excessive. at the same time, the number of pregnancies is higher in this region than in the rest of turkey.8 nevertheless, there was no study researching impact of melasma on turkish women. therefore, we investigated the clinical factors associated with melasma and used the dlqi questionnaire7 to assess its impact on the qol of turkish women living in the southeast region of the country. compliance with ethical standards all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. informed consent was obtained from all individual participants included in the study. materials and methods this questionnaire-based study was performed in 101 melasma patients at the departments of gynecology and dermatology, harran university medical faculty, sanliurfa, turkey, between january 2016 and december 2016. the study protocol was approved by the hospital ethical committee, and informed consent was obtained from all participants. the data collected included demographic and clinical parameters, such as age, family history, duration of melasma, number of pregnancies, and the use of hormonal contraceptives. the clinical distribution of melasma was scored as fitzpatrick phototypes [type i, always burns, never tans; type ii, always burns, tans minimally; type iii, burns moderately, tans gradually (light brown); type iv, burns minimally, tans well (moderate brown); type v, rarely burns, tans darkly (black brown); type vi, never burns, tans dark black (black)].9 melasma area and severity index (masi) score was calculated by subjective assessment of the following three factors: area (a) of involvement, darkness (d), and homogeneity (h), and rated on a scale of 0 4 (0=absent; 1=slight; 2=mild; 3=marked; and 4=maximum). the masi score was recorded according to the literature (total masi score: forehead 0.3 (d+h) a + right malar 0.3 (d+h) a + left malar 0.3 (d+h) a + chin 0.1(d+h) a).10 the total score ranged from 0 48, with higher scores indicating more severe disease. the inclusion criteria were clinical diagnosis of melasma, sufficient physical and mental capacity, age of at least 18 years, and the ability to speak and read turkish. the exclusion criteria were male gender, pregnant women, age of below 18 years, systemic disorders (such as adrenal or thyroid disorders), and other dermatological disorders that could hinder the evaluation of melasma lesions, such as systemic lupus erythematosus and post-inflammatory hyperpigmentation. all the participants were instructed to complete a dlqi questionnaire that consisted of 10 questions, and were asked to score all of these questions on a scale from 0-3, with 0=not at all, 1=a little, 2=a lot, and 3=very much.11 the total score ranged from 0-30. the higher score, the poorer the qol. dermatology reports 2017; volume 9:7340 correspondence: hacer uyanikoglu, harran university, school of medicine, department of obstetrics and gynecology, yenisehir campus, 63300, sanliurfa, turkey. tel.: +94.143183097 fax: +94.0414.318319. e-mail: huoglu@hotmail.com key words: quality of life; turkish women; melasma. acknowledgments: we would like to thank all the subjects who participated in this questionnaire. also we thank professor tevfik sabuncu for his supporting to statistical analyses. conflict of interest: the authors declare no potential conflict of interest. received for publication: 3 august 2017. accepted for publication: 18 september 2017. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright h. uyanikoglu and m. aksoy, 2017 licensee pagepress, italy dermatology reports 2017; 9:7340 doi:10.4081/dr.2017.7340 no n c om me rci al us e o nly statistical analysis the data were analyzed with spss version 20. mean and standard deviation (sd) were used for quantitative variables (e.g., age, gravidity, dlqi scores). for qualitative variables like frequency and percentage were calculated. data were stratified for severity of melasma (masi score=0-16, 17-32, 33-48). a p value of <0.05 was considered significant. results a total of 111 patients participated in this questionnaire-based study. ten individuals with melasma were excluded because of lower age (<18 years), pregnancy, and other systemic disorders. ultimately, 101 individuals with melasma completed the questionnaire and were enrolled in the analyses. the mean age of the study population was 29.53±6.87 years, and all participants were female. the most common fitzpatrick skin phototypes were iii and iv (50.5% and 38.6%, respectively). the mean duration of disease was 18.74±10.2 months. the demographic and clinical characteristics of the study participants are presented in tables 1 and 2. according to melasma severity, 81 patients had mild disease, having a masi score from 0-16, and 20 patients had moderate disease, having a masi score of 17-32 (the mean scores were 7.65±3.47 and 17.9±2.15, respectively). no patient had severe disease (a masi score of 33-48). the mean dlqi score of all patients was 6.02±4.94. a comparison of the mean dlqi scores between those aged <30 years and those aged ≥30 years was made, and a significant difference between the younger and older age groups was observed (7.44±4.99 and 4.33±4.36, respectively; p=0.001; figure 1). the participants with a mild masi score had a mean dlqi score of 5.80±4.72, and those with a moderate masi score had a mean dlqi score of 7.11±5.90. this indicates a slight but statistically insignificant increase in dlqi score in the participants with more severe disease (p>0.05; table 3). in the correlation analysis, the dlqi score was significantly negatively correlated with age and parity (r: –0.28, p=0.005; r: –0.22, p=0.03, respectively; figure 2). similarly, a positive correlation between dlqi score and duration of disease was observed (r: 0.28, p=0.004; figure 3). however, no correlation between the masi score and age, gravida, dlqi, family history, oc use, and duration of disease was identified (all p>0.05). discussion and conclusions it has been shown that melasma is a chronic, recurrent skin disorder that may result in deteriorations in patients’ qol in different populations.6,12,13 we firstly reported an assesment of qol in turkish women article table 1. demographic and clinical characteristics of the study participants. n=101 (mean±sd) age (year) 38.43±6.75 gravida (n) 3.44±1.56 parity (n) 2.45±1.43 duration of disease (month) 18.74±10.2 masi 0-16 7.65±3.47 17-32 17.9±2.15 33-48 0 dlqi score 6.02±4.94 sd, standard deviation; masi, melasma area and severity index; dlqi, dermatology life quality index. table 2. demographic and clinical characteristics of the study participants. n=101 (%) age (year) <30 y 54.5 ≥30 y 45.5 marital status single 3.03 married 98.9 fitzpatrick skin phototypes 2 10.9 3 50.5 4 38.6 oc use 26.7 family history 78.2 oc, oral contraceptive. table 3. the mean dlqi score according to severity of disorder (using masi). severity dlqi p of disease (mean±sd) mild 5.80±4.72 ns moderate 7.11±5.90 ns severe total sample 6.02±4.94 masi, melasma area and severity index; sd, standard deviation; dlqi, dermatology life quality index. figure 1. dlqi scores between the younger and older age groups. figure 2. negative correlations between dlqi score and age and parity. figure 3. a positive correlation between dlqi score and duration of disease. [dermatology reports 2017; 9:7340] [page 47] no n c om me rci al us e o nly [page 48] [dermatology reports 2017; 9:7340] with melasma. several studies have shown that the mean age of people with melasma is 36-40 years.11,12 in the present study, the mean age of the participants was 29.53±6.87 years, this difference may be due to racial, cultural, and social variations in different countries. in our population, the qol of older women was less affected by melasma than that of the younger group. this was consistent with the findings of ali et al. and balkrishnan et al., who observed that melasma patients aged 20-30 years were more affected than patients aged 46-55 years.11,14 therefore, we believe that younger patients with melasma might need more intensive medical care. however, unnecessary tests and intensive medical care are not recommended for pregnant women with melasma, in order to avoid further stress for these patients and because of the transient character of gestational melasma.15 the hormonal link to melasma has not been clearly defined; some studies have noted the onset or worsening of disease with pregnancy or oc use.16,17 we observed oc use in 26.7% of our patients, which was consistent with previous studies that showed a prevalence of 8-29% with regard to oc use in melasma patients. although we did not assess the relationship between oc use and the onset of melasma, we observed that oc use was not associated with melasma severity. however, these data may be insufficient as a result of some limitations of the study design, such as a low patient number and low duration of use of oc. although several quantitative measurements (e.g., mexameter, chromameter) may be used to evaluate melasma severity, we used only masi scoring in the present study because there is no significant difference between these methods.13 our city (sanliurfa) is in the southeast region of turkey and the number of sunny-days and the rate of pregnancies are higher than in the rest of the country.8,18 nevertheless, we observed mild melasma severity and a low dlqi score in most of our participants, which may be explained by the fact that almost all of them were protected from the sun, because they wore a traditional headscarf and stayed at home (i.e., they were housewives). some studies have shown that working women have more stress-related disorders than housewives.19,20 therefore, we believe that our participants might have been less exposed to stres, affecting their qol results. the mean dlqi score is 6.02±4.94 in the present study, which was compatible with the findings of farag et al. from egypt and with harumi et al. from singapore (5.8±3.8, 4.5±5, respectively), but opposite to those of ikino et al. from brazil (34.4±13.5).12,13,21 the present study revealed that people suffering from more advanced disease had a slightly higher, but statistically insignificant, mean dlqi score, which was also observed by farag et al. and balkrishnan et al.11,12 however, arellano et al. and ali et al. showed a strong correlation between dlql score and severity of melasma.14,22 previous studies have shown that melasma that is related to a family history, might affect melasma appearance time in some populations.23 a multicenter study indicated that patients with a family history of melasma were younger at melasma onset than those without a family history of the disorder.24 in contrast, ikino et al. found no familial relationship in the patients they studied.21 the majority of participants (78.2%) in the present study had a familial history of melasma. although we did not assess the relationship between time of melasma onset and family history, we observed no correlation between family history and masi and dlqi scores. in conclusion, the present study showed that melasma at a lower age, and with a longer duration, was associated with a greater reduction in qol in turkish women. further comprehensive studies are required to better understand the effect of this frequent skin disorder on qol. references 1. sheth vm, pandya ag. melasma: a comprehensive update: part i. j am acad dermatol 2011;65:689-97. 2. sarkar r, puri p, jain rk, et al. melasma in men: a clinical, aetiological and histological study. j eur acad dermatol venereol 2010;24:768-72. 3. knott l. chloasma (melasma) [online] 2009 [cited 2009 may 31]. available from: http://www.patient.co.uk/showdoc/4000215 2/ 4. grimes pe, yamada n, bhawan j. light microscopic, immunohistochemical and ultrastructural alterations in patients with melasma. am j dermatopathol 2005;27:96-101. 5. perez m, luke j, rossi a. melasma in latin americans. j drugs dermatol 2011;10:517-23. 6. hexsel d, rodrigues tc, dal’forno t, et al. melasma and pregnancy in southern brazil. j eur acad dermatol venereol 2009;23:367-8. 7. dogramaci ac, havlucu dy, inandi t, et al. validation of a melasma quality of life questionnaire for the turkish language: the melasqol-tr study. j dermatolog treat 2009;20:95-9. 8. uyanikoglu h, karahan ma, turp ab, et al. are multiple repeated cesarean sections really as safe? j matern fetal neonatal med 2017;30:482-5. 9. pathak m, nghiem p, fitzpatrick th. acute and chronic effects of the sun. in: fitzpatrick th, ed. fitzpatrick’s dermatology in general medicine, 5th edn. new york: mcgraw-hill; 1999. pp 1598-1607. 10. kimbrough-green ck, griffiths ce, finkel lj, et al. topical retinoic acid (tretinoin) for melasma in black patients. a vehicle-controlled clinical trial. arch dermatol 1994;130:727-33. 11. balkrishnan r, mcmichael a, camacho f, et al. development and validation of a health related quality of life instrument for women with melasma. br j dermatol 2003;149:572-7. 12. farag a, sabry h, alam m. melasma and its impact on health related quality of life (hrqol) in egyptian women before and after treatment with a quadruple combination serum (hydroquinone 4%, kojic acid 1%, lycolic acid 6% and ascorbic acid 2%). j pan arab league dermatol 2007;18:17-30. 13. harumi o, goh cl. the effect of melasma on the quality of life in a sample of women living in singapore. j clin aesthet dermatol 2016;9:21-4. 14. ali r, aman s, nadeem m, et al. quality of life in patients of melasma. j pakistan assoc dermatol 2013;23:1438. 15. tyler kh. physiological skin changes during pregnancy. clin obstet gynecol 2015;58:119-24. 16. lieberman r, moy l. estrogen receptor expression in melasma: results from facial skin of affected patients. j drugs dermatol 2008;7:463-5. 17. maeda k, naganuma m, fukuda m, et al. effect of pituitary and ovarian hormones on human melanocytes in vitro. pigment cell res 1996;9:204-12. 18. demirkan s, gündüz ö, sayan cd. retrospective analysis of endemic melasma patients. dermatol rep 2017;9:7027. 19. nyberg a, peristera p, westerlund h, et al. does job promotion affect men’s and women’s health differently? dynamic panel models with fixed effects. int j epidemiol 2016 [epub ahead of print]. 20. bener a, gerber lm, sheikh j. prevalence of psychiatric disorders and associated risk factors in women during their postpartum period: a major public article no n c om me rci al us e o nly [dermatology reports 2017; 9:7340] [page 49] health problem and global comparison. int j womens health 2012;4:191-200. 21. ikino jk, nunes dh, silva vp, et al. melasma and assessment of the quality of life in brazilian women. an bras dermatol 2015;90:196-200. 22. arellano i, leon g, luna c. quality of life in mexican patients with melasma. cosmet dermatol 2006;5:343-5. 23. misery l, schmitt am, boussetta s, et al. melasma: measure of the impact on quality of life using the french version of melasqol after cross-cultural adaptation. acta derm venereol 2010;90:331-2. 24. hexsel d, lacerda da, cavalcante as, et al. epidemiology of melasma in brazilian patients: a multicenter study. int j dermatol 2014;53:440-4. article no n c om me rci al us e o nly dr [dermatology reports 2018; 10:7445] [page 1] a case of chronic ulcer due to subcutaneous arteriolosclerosis in an obese patient mimicking pyoderma gangrenosum sezin fıçıcıoğlu,1 nuray can,2 busem tutuğ2 1department of dermatology; and 2department of pathology, trakya university faculty of medicine, edirne, turkey abstract the differential diagnosis of chronic ulcers covers a wide range of diseases and poses a diagnostic challenge. subcutaneous ischemic arteriolosclerosis can lead to local ischaemia and ulceration as a result of arteriolar narrowing and reduction of tissue perfusion. this pathophysiological feature can be seen in eutrophication (nonuremic calciphylaxis) in morbid obesity, hypertensive ischemic leg ulcer (martorell ulcer) and calciphylaxis in chronic renal insufficiency. all of the ulcers happened in this way can be wrongly diagnosed as pyoderma gangrenosum because of clinical similarity and inadequate biopsies. we report a case of chronic ulcer due to subcutaneous arteriolosclerosis in morbid obesity, wrongly diagnosed as pyoderma gangrenosum. it can be detrimental to misdiagnose the ulcers due to subcutaneous arteriolosclerosis as pyoderma gangrenosum since they need a diametrically different approach. introduction the differential diagnosis of chronic ulcers covers a wide range of diseases and poses a diagnostic challenge.1,2 the clinical presentations, underlying etiology, and pathological manifestations of the ulcers are major clues to make the diagnosis. hafner reviewed four diseases: i) calciphylaxis (distal patern); ii) calciphylaxis (proximal patern); iii) martorell hypertensive ischemic leg ulcer; iv) calciphylaxis with normal renal and parathyroid function (eutrophication) all having the same clinical features as necrotizing livedo, skin infarctions and ulcerations at typical locations. hafner stated that these four diseases largely share the same risk factors including arterial hypertension, diabetes mellitus (types 1 and 2), secondary or tertiary hyperparathyroidism (in end-stage kidney disease) and oral anticoagulation with vitamin k antagonists.3 also a shared histopathology has been stated in these diseases: subcutaneous ischemic arteriolosclerosis characterized by a medial calcinosis and stenosis due to thickening of the vessel wall (hyperplasia of the smooth muscle layer) and/or intimal hyperplasia.2-4 hafner et al.5 suggested the term uremic small artery disease with medial calcification and intimal hyperplasia instead of the customary denomination calciphylaxis. in 1992 ramsey-stewart reported a case of progressive dermatoliponecrosis in a morbidly obese patient and suggested the term eutrophication for. even though he did not investigate the existance of subcutaneous arteriolosclerosis he claimed that in obese people inadequate peripheral tissue perfusion affects the apex of grossly dependent adipose folds and leads patchy gangrenous changes and skin infartions.6 case report a 44-year-old man who had nissen fundoplication and incisional hernia repair operation one year and three months ago respectively, referred to our hospital for a linear necrotic ulcer 15 cm in length 5 cm in width at the anterior abdomen, on incision line. he had type 2 diabetes mellitus for five years, no hypertension or renal insufficiency and he was obese as his body mass index was 31.1 kg/m². the ulcer first appeared after removing the sutures of incisional hernia repair and rapidly enlarged. after surgical debridement of necrotic tissues and three sessions of negative pressure wound therapy with vacuum dressings, a prominent effect was not observed. the ulcer kept on growing, reached 15×10 cm dimensions with raised and rolled undermining margins (figure 1a). by the way the incisional biopsy taken from the edge of the ulcer concluded as pyoderma gangrenosum. after taking 80 mg/day methylprednisolone for one week the ulcer got worse, enlarged and deepened (figure 1b). systemic steroid treatment stopped and a second biopsy was taken in a large elliptical shape starting from healthy skin at the ulcer edge extending into the fascia. histological examination revealed subcutaneous arteriolosclerosis with thickened arteriole walls and narrowed lumens and von kossa staining also displayed the calcification in the vessel walls (figure 2). serum concentration of urea was 14 mg/dl [normal range (nr): 19-50], creatinine was 0.73 mg/dl (nr: 0.72-1.25), parathyroid hormone was 32.5 pg/ml (nr: 11-88), calcium was 10.1 mg/ml (nr: 8.810.6) and phosphate was 3.3 mg/ml (nr: 2.5-4.5), alanine aminotransferase was 5 u/l (nr: 0-50), aspartate aminotransferase was 15 u/l (nr: 0-50), gamma-glutamyl transferase was 27 u/l (nr: 0-55), total bilirubin was 0.2 mg/dl (nr: 0.3-1.2), direct bilirubin was 0.1 mg/dl (nr: 0-0.2). his other liver function parameters including prothrombin time test, serum protein electrophoresis and abdominal ultrasonography were in normal limits. also he had no history of weight loss, pain, fever, fatique, persistent cough or hoarseness, no change in bowel habits and no finding of lymphadenopathy in physical examination. with these clinical and laboratory findings we ruled out uremic calciphylaxis, liver failure, neoplasia and made the diagnosis of eutrophication (nonuremic calciphylaxis). after six more sessions of negative pressure wound therapy with vacuum dressings, split thickness skin grafting was done successfully. discussion eutrophication or nonuremic calciphylaxis or calciphylaxis in normal renal function affects morbidly obese people who has also arterial hypertension and type 2 diabe dermatology reports 2018; volume 10:7445 correspondence: sezin fıçıcıoğlu, trakya üniversitesi tıp fakültesi, dermatoloji anabilim dalı, balkan yerleşkesi, 22030 edirne, turkey. tel.: +90.284.2357641 extension: 1282. e-mail: sezinkuru@hotmail.com key words: arteriolosclerosis; eutrophication; pyoderma gangrenosum; calciphylaxis. authors’ contributions: sf had participated in the study, in conception and design, analysis and interpretation of data, drafting the article and final approval of the version. nc and bt had participated in the study in analysis and interpretation of data, revising it critically for important intellectual content and final approval of the version. conflict of interest: the authors declare no potential conflict of interest. received for publication: 13 october 2017. accepted for publication: 16 march 2018. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright s. fıçıcıoğlu et al., 2018 licensee pagepress, italy dermatology reports 2018; 10:7445 doi:10.4081/dr.2018.7445 no nco mm er cia l u se on ly tes mellitus. it is characterized by rapid appearance of progressive skin infarctions in places where fatty tissue is particularly thick such as inner thigh, fatty abdominal apron, breasts or outer upper arms.3,4 the skin infarction begins with a painful livedoid area and becomes necrotic with progressive livid margins. histologically arterioles show massive thickening of the vessel wall (hyperplasia of the smooth muscle layer) leaving a narrow lumen which is often thrombosed. this subcutaneous ischemic arteriolosclerosis is a common pathophysiological feature also in martorell hypertensive ischemic leg ulcer, calciphylaxis in chronic renal insufficiency. all of them can lead to local ischaemia and ulceration as a result of arteriolar narrowing and reduction of tissue perfusion.2,3,7 on the other hand, pyoderma gangrenosum (pg) is a rare neutrophilic inflammatory skin disease presenting with painful sterile ulcerations. its etiology remains unknown however it is commonly associated with inflammatory bowel disease, rheumatoid arthritis, hematologic malignancies and disorders.8,9 also it may occur in areas of trauma or surgery; a phenomenon called pathergy.10 jockenhöfer et al.11 also suggested an association of obesity and pg. our patient was a confusing case as he did not have a disorder like inflammatory bowel disease, rheumatoid artritis or hematologic malignancy but he was obese, had a surgery before the ulceration, his ulcer with livid margins and undermining edges enlarged progressively directing us to the diagnosis of pg. after the pathological confirmation of pyoderma gangrenosum we decided to start systemic steroids which are often the first choice drugs for pg along with other immunosuppressive treatments. but he did not benefit from steroid treatment and even it aggravated the ulcer. the ulcers mentioned above whose shared histopathology was subcutaneous ischemic arteriolosclerosis can be wrongly diagnosed as pyoderma gangrenosum because of clinical similarity and inadequate biopsies.3,4,12 moreover, superficial biopsy samples taken from many types of chronic wound base can be misdiagnosed as pyoderma gangrenosum because necrotic dermis with sheets of neutrophil granulocytes can be found. in a study by hafner et al.4 50% of 31 cases of martorell ulcers were misdiagnosed as pyoderma gangrenosum and 20% as necrotizing vasculitis. so in the suspicion of eutrophication and other ulcers caused by subcutaneous arteriolosclerosis, biopsies should be of sufficient depth extending into the subcutis. our case’s not the first but the second biopsy which was taken in a large elliptical shape starting from healthy skin at the ulcer edge extending into the fascia yielded the subcutaneous arterioles with hyperplasia of the smooth muscle layer and narrowing of the lumen. our patient’s ulcer did not begin spontaneously but occured after the surgery on the incision line but it is not contradictory to the eutrophication (nonuremic calciphylaxis) theory as the subcutaneous arteriolosclerosis and decreased tissue perfusion did not allow the cutt to heal and enlarged the ulcer. it can be detrimental to misdiagnose eutrophication (nonuremic calciphylaxis) and other subcutaneous arteriolosclerotic ulcers as pyoderma gangrenosum since they need a diametrically different approach. pyoderma gangrenosum needs systemic steroid treatment and surgical approaches are not recommended.3,4,9 however treatment of skin infarctions from subcutaneous ischemic arteriolosclerosis includes surgical debridement, negative pressure wound therapy and split thickness skin grafting and systemic medication for analgesia and infection.1,3,7 systemic steroids can cause exacerbation as in our case, sepsis and even death in subcutaneous arteriolosclerosis. conclusions according to hafner3, eutrophication (nonuremic calciphylaxis) and other entities showing subcutaneous ischemic arteriolosclerosis are not known very well and familia[page 2] [dermatology reports 2018; 10:7445] case report figure 1. the ulcer on the incision line at the anterior abdomen had livid undermined margins resembling pyoderma gangrenosum, before steroid treatment (a) and after taking 80 mg/day methylprednisolone for one week the ulser enlarged and deepened (b). figure 2. a) subcutaneous arteriole (black arrow) shows hyperplasia of smooth muscle layer, narrowing of the lumen and increased wall-to-lumen ratio resulting in skin infarction leading to ulceration (hematoxylin-eosin, original magnification ×10). b) von kossa staining (×20) shows vessel calcification (yellow arrow) in addition to narrowing of the lumen. a b a b no nco mm er cia l u se on ly [dermatology reports 2018; 10:7445] [page 3] rity with these disorders should be improved especially because of the risk of confusion with pyoderma gangrenosum. and our case demonstrates that he is wright. references 1. novinscak t, filipovic m, edita j, et al. surgical approach to atypical wounds (clinical cases). subcutaneous ischemic arteriolosclerosis (martorell ulcer, calciphylaxis, eutrophication). acta med croatica 2012;66:139-45. 2. alavi a, hafner j, sibbald rg. martorell hypertensive ischemic leg ulcer: an underdiagnosed entity. adv skin wound care 2012;25:563-72. 3. hafner j. calciphylaxis and martorell hypertensive ischemic leg ulcer: same pattern one pathophysiology. dermatology 2016;232:523-33. 4. hafner j, nobbe s, partsch h, et al. martorell hypertensive ischemic leg ulcer: a model of ischemic subcutaneous arteriolosclerosis. arch dermatol 2010;146:961-8. 5. hafner j, keusch g, wahl c, et al. uremic small-artery disease with medial calcification and intimal hyperplasia (so-called calciphylaxis): a complication of chronic renal failure and benefit from parathyroidectomy. j am acad dermatol 1995;33:954-62. 6. ramsey-stewart g. eutrophication: spontaneous progressive dermatoliponecrosis. a fatal complication of gross morbid obesity. obes surg 1992;2:263-4. 7. vuerstaek jdd rs, henquet cjm, neumann ham. arteriolosclerotic ulcer of martorell. jeadv 2010;24:867-74. 8. al ghazal p, korber a, klode j, dissemond j. investigation of new cofactors in 49 patients with pyoderma gangrenosum. j dtsch dermatol ges 2012;10:251-7. 9. vallini v, andreini r, bonadio a. pyoderma gangrenosum: a current problem as much as an unknown one. int j low extrem wounds 2017; 16:191-201. 10. urman co, ashby-richardson h, thakker ps. pyoderma gangrenosum following gastric bypass surgery. cutis 2014;93:261-3. 11. jockenhofer f, herberger k, schaller j, et al. tricenter analysis of cofactors and comorbidity in patients with pyoderma gangrenosum. j dtsch dermatol ges 2016;14:1023-30. 12. kolios aga, hafner j, luder c, et al. comparison of pyoderma gangrenosum and hypertensive ischemic leg ulcer martorell in a swiss cohort. br j dermatol 2017 [epub ahead of print]. case report no nco mm er cia l u se on ly dr [page 4] [dermatology reports 2018; 10:7660] clinical evaluation of morgellons disease in a cohort of north american patients melissa c. fesler,1 marianne j. middelveen,2 raphael b. stricker1 1union square medical associates, san francisco, ca, usa; 2atkins veterinary services, calgary, ab, canada abstract morgellons disease (md) is a dermatological condition characterized by aberrant production of keratin and collagen fibers in skin. although infection with borrelia burgdorferi, the causative agent of lyme disease (ld), has been associated with md, relatively few studies have hitherto provided epidemiological evidence regarding this association. a cohort of 1000 seropositive north american ld patients was evaluated for the presence of md. patients were diagnosed with md based on detection of microscopic fibers in skin lesions or under unbroken skin. demographic and clinical features of md patients were analyzed, and laboratory testing for tickborne coinfections and other infectious agents, was performed. subjective and objective features of md were analyzed using statistical methods. of 1000 seropositive ld patients, 60 (6%) were diagnosed with md. of these 60 patients, 75% were female and 78% presented in the late disseminated stage of md. all 60 patients (100%) were seropositive for b. burgdorferi infection. tickborne coinfections in these patients included babesia spp (62%), bartonella and rickettsia (25% each), ehrlichia (15%) and anaplasma (10%). helicobacter pylori was detected in 12% of md patients. in all, 77% of md patients had one or more coinfections. this study confirms recent findings that md occurs in a limited subset of ld patients. the clinical and genetic determinants of md in ld patients require further study. introduction morgellons disease (md) is a dermatological condition characterized clinically by the presence of multicolored microscopic fibers in skin lesions or lying under unbroken skin.1-7 the disease is associated with overproduction of keratin and collagen in cutaneous tissue. historically, md has been misclassified as a delusional disorder due to its sometimes bizarre symptomatology in patients who present with claims of colorful fibers or parasites protruding from or crawling within the dermis. in contrast, recent peer reviewed publications demonstrate that md is a true somatic illness associated with borrelia infection, and not a delusional disorder.1-7 other studies have shown that a similar dermopathy occurs in cattle and dogs, providing further evidence that md is a dermatological condition associated with spirochetal infection.8,9 the spirochete borrelia burgdorferi is the etiologic agent of lyme disease (ld). according to the centers for disease control and prevention (cdc), there are more than 300,000 newly diagnosed cases of ld each year in the usa,10 making it the fastest growing epidemic of our time.11 ld is twice as common as breast cancer,12 six times more common than hiv/aids,13 20 times more common than hepatitis c virus (hcv) infection,14 and 30 times more common than tuberculosis in the usa.15 unfortunately, a large number of ld cases go either undiagnosed or misdiagnosed, resulting in chronic infection and potential complications associated with the tickborne disease, including md.6,16 although previous studies have shown a strong clinical association between ld and md,2,3,5-7 few studies have provided epidemiological data for md. recently, mayne evaluated a cohort of australian patients and found that 6% of seropositive lyme patients were positive for md based on skin microscopy.17 this publication was the first to provide an epidemiological assessment of md as related to ld. to date, there are no similar studies regarding the prevalence of md in north america. other studies have implicated tickborne coinfections and helicobacter pylori infection in the etiology of md.18,19 the present study is the first to analyze the prevalence and clinical characteristics of md in a cohort of north american patients with ld drawn from a single medical practice. materials and methods patients and data collection patients were recruited from a medical practice located in san francisco, ca, specializing in the diagnosis and treatment of tickborne diseases. all patients were residents of north america. informed consent for data collection was obtained from each patient, and the anonymous data collection protocol was approved by the western institutional review board (wirb), puyallup, wa. patients were included in the study if they met the diagnostic criteria for md through identification of fibers visible in skin lesions or under unbroken skin using a hand-held microscope, as previously described.1-6 md classification based on the duration of disease (early versus late) and the extent of skin involvement (localized versus disseminated) was performed as previously described.5 all subjects were required to have ld testing and tickborne coinfection testing through a single laboratory, and they were required to have repeat testing to confirm the diagnosis of ld. prior antibiotic treatment was not an excluding factor. subjective data including a thorough history was obtained during the initial patient encounter. objective data including physical findings and laboratory testing was collected during each patient visit and through various laboratories. laboratory assessment testing for tickborne diseases was performed through igenex laboratory in palo alto, ca. igenex is a high-complexity testing laboratory that has clinical laboratory improvement amendments (clia) certification. seropositivity for ld and tickborne coinfections was based on dermatology reports 2018; volume 10:7660 correspondence: raphael b. stricker, 450 sutter street, suite 1504, san francisco, ca 94108 usa. tel.: 415.399.1035 fax: 415.399.1057. e-mail: rstricker@usmamed.com key words: morgellons disease; lyme disease; borrelia burgdorferi; spirochetes; dermopathy; borrelial dermatitis. acknowledgements: the authors thank our patients for participating in the study. we also thank dr. jae brodsky for statistical analysis. funding: supported in part by a grant from the lindorf family foundation, newark, oh, usa. conflict of interests: the authors declare no conflict of interests. received for publication: 27 february 2018. accepted for publication: 16 march 2018. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright m.c. fesler et al., 2018 licensee pagepress, italy dermatology reports 2018; 10:7660 doi:10.4081/dr.2018.7660 no nco mm er cia l u se on ly [dermatology reports 2018; 10:7660] [page 5] standard laboratory interpretation criteria, as previously described.20 serological testing for helicobacter pylori infection was performed through various laboratories using standard assays.21 to evaluate companion diagnostic features of tickborne diseases, cd57 natural killer (nk) cell subset testing was performed by bioreference laboratories (elmwood park, nj) or labcorp, inc. (burlington, nc).22 testing for complement protein c4a, a marker of inflammation, was performed by national jewish health laboratory in denver, co.23 low cd57 nk cells and elevated c4a levels are common in ld patients.22,23 statistical analysis was performed using r statistical software version 3.2.5 (r foundation for statistical computing, vienna, austria). the student t-test was used for parametric variables and the pearson correlation coefficient r was used for non-parametric variables. results a total of 1000 patients (665 females and 335 males) who were residents of north america and seropositive for ld were screened for the study. patients ranged in age from 22 months to 93 years. of this total, 62 were diagnosed with md. two patients were excluded from the study. one subject never returned after the first visit and the other never received follow-up testing, although the subject tested positive for tickborne coinfections. a total of 60 patients were included for data analysis. md tended to be more common in women, with a 3:1 female-to-male ratio (p=0.001), as shown in table 1. the median age of md patients was 52 years, with an age range of 26-75 years, as shown in figure 1, and there was no statistical difference in age between men and women (p=0.2), as shown in figure 2. more than three-quarters of md patients (78%) were diagnosed with late disseminated md at presentation, as shown in table 2, and the most common patient symptoms are shown in table 3. the three most common symptoms were musculoskeletal pain, fatigue and insomnia; the next most common were cognitive impairment and depression, followed by hypothyroidism, anxiety and neuropathy. coinfection testing to evaluate other article table 1. sex of md patients. md was more common in women with a 3:1 female-tomale ratio (p=0.001). sex number (n) percent (%) female 45 75 male 15 25 table 2. clinical classification of md patients based on reference 5. md number percent classification (n) (%) early localized md 5 8 early disseminated md 4 7 late localized md 4 7 late disseminated md 47 78 table 3. symptoms noted in md patients. symptoms number percent (n) (%) musculoskeletal symptoms 56 93 fatigue 53 88 insomnia 48 80 cognitive impairment 30 50 depression 30 50 hypothyroidism 20 33 anxiety 20 33 neuropathy 20 33 figure 1. age of md patient cohort. each bar represents a two-year span. frequency represents the number of individuals who fall within the reported two-year span. the median age was 52 years with a range of 26 to 75 years. figure 2. sex versus age in md patient cohort. wings represent the age range for men and women. each box represents the standard deviation for each sex. bars represent the mean age for each sex. there was no statistical difference in age between men and women (p=0.2). the female patients (mean: 51.2 years) had a tendency to be slightly older than the male patients (47.9 years). the standard deviations of the two groups were similar (12.2 years and 14.4 years) and the shape of their distributions were of similar symmetry. a two-sample t-test with an alternative hypothesis of the male mean less than the female mean had a t-statistic of 0.7942 and p-value of 0.218 (21 degrees of freedom). no nco mm er cia l u se on ly infectious agents in the etiology of md was performed on all patients, and the documented coinfections are listed in table 4. in our 60 md patients, 30 (50%) were seropositive for babesia duncani, 7 (12%) for babesia microti, 15 (25%) for bartonella henselae, 15 (25%) for rickettsia spp., 9 (15%) for ehrlichia, 6 (10%) for anaplasma, and 7 (12%) were seropositive for helicobacter pylori. while 23% of md patients had no coinfection, 33% had a single coinfection and 44% had multiple coinfections (table 5). examination of companion diagnostic tickborne disease testing in the md cohort revealed that 66% had decreased cd57 nk cells and 33% had increased c4a levels. a lower cd57 nk level correlated with a higher c4a inflammatory marker level in a non-linear manner (r=0.02), as shown in figure 3. discussion according to the cdc, approximately 329,000 cases of ld are diagnosed each year in the usa (10). in our cohort of north american ld patients, we found that 6% had md (table 1). based on these numbers, there may be at least 19,740 annual cases of md in the usa (md prevalence = 6%; md incidence =19,740). considering cumulative rates of ld over the past 20 years, there may be approximately 5,304,500 total cases of ld in the usa, corresponding to a total of at least 318,270 cases of md. at this rate, and as a reference, md is slightly more common than hcv infection, 1.5 times more common than pediatric cancer and almost three times more common than amyotrophic lateral sclerosis in the usa.14,24,25 patients were more likely to present with late disseminated md in our cohort (table 2), and systemic symptoms that often accompany ld were common (table 3). many of these symptoms tended to precede the onset of md skin lesions. tickborne coinfections including babesia spp (62%), bartonella and rickettsia (25% each), ehrlichia (15%) and anaplasma (10%) were found in patients with md (table 4), and helicobacter pylori infection was detected in 12% of md patients. more than three-quarters of patients had at least one coinfection (table 5), and it is unclear if these coinfections serve as a trigger or exacerbate the condition. studies have found helicobacter pylori and bartonella in tissue biopsies of md patients,18,19 and further studies are needed to investigate the role of coinfections in md severity and presentation. our study confirms that there is a greater tendency for women to develop md, and the 3:1 female predominance exceeds the 2:1 female predominance of ld in our cohort.2,26 savely and stricker2 previously showed that women are more likely to develop this dermopathy in conjunction with ld, reflecting the fact that certain disease processes may be recognized more frequently in women due to an exaggerated response to infection.26 women also tend to be more meticulous with dermatologic care, and increased awareness of skin changes could account for a female predominance of the disease. genetic factors may also play a role in md. preliminary genetic studies have demonstrated nine genes with significant sequence variation in md patients (sapi e, university of new haven, unpublished observation 2017). there was no difference in age at presentation between men and women, although men tended to present at a slightly younger age (figures 1 and 2). as noted above, patients were more likely to present with late disseminated md (table 2). since md apparently represents a dermatopathological spectrum associated with ld, it is possible that many individuals do not realize they have the dermatological condition until later in its course, when more symptoms are present and/or more skin lesions appear. as in the case of ld, few practitioners diagnose and treat md, and patients may have a difficult time obtaining treatment during the early stages of the disease.27 consequently, there may be a greater tendency to seek medical care only after the disease worsens. future studies are required to evaluate and confirm md epidemiological data obtained in this study. larger sample sizes should be examined and direct methodology such as culture, immunohistochemistry and molecular testing, should be performed to confirm the tickborne disease etiology of article figure 3. cd57 nk versus c4a levels in md patient cohort. established normal range for the cd57 nk subset is 60-360 cells/ul. established normal c4a level is <2830 ng/ml. a lower cd57 nk level correlated with a higher c4a inflammatory marker level in a nonlinear manner (r=0.02) for this cohort. table 4. variety of coinfections found in md patients. infection number percent (n) (%) borrelia burgdorferi 60 100 babesia duncani 30 50 babesia microti 7 12 bartonella henselae 15 25 rickettsia spp. 15 25 ehrlichia 9 15 anaplasma 6 10 helicobacter pylori 7 12 table 5. number of coinfections in md patients. coinfections number percent (n) (%) 0 14 23 1 20 33 2 18 30 3 4 7 4 4 7 [page 6] [dermatology reports 2018; 10:7660] no nco mm er cia l u se on ly [dermatology reports 2018; 10:7660] [page 7] md. furthermore, genetic susceptibility for md should be evaluated, and additional animal studies in dogs, cattle and other models should be conducted to determine the prevalence of md in association with spirochetal infection and genetic factors in animal and human populations. conclusions to our knowledge, this is the first study that documents the prevalence and clinical characteristics of md in north american patients. the study confirms recent findings that md occurs in a limited subset of ld patients, and other tickborne coinfections were inconsistently associated with md. the clinical and genetic determinants of md in ld patients require further study. references 1. savely vr, leitao mm, stricker rb. the mystery of morgellons disease: infection or delusion. am j clin dermatol 2006;7:1-5. 2. savely vr, stricker rb. morgellons disease: analysis of a population with clinically confirmed microscopic subcutaneous fibers of unknown etiology. clin cosmet investig dermatol 2010;3:67-78. 3. middelveen mj, burugu d, poruri a, et. al. association of spirochetal infection with morgellons disease. f1000res 2013;2:25. 4. harvey wt, bransfield rc, mercer de, et al. morgellons disease, illuminating an undefined illness: a case series. j med case rep 2009;3:8243. 5. middelveen mj, bandoski c, burke j, et. al. exploring the association between morgellons disease and lyme disease: identification of borrelia burgdorferi in morgellons disease patients. bmc dermatol 2015;15:1. 6. middelveen mj, stricker rb. morgellons disease: a filamentous borrelial dermatitis. int j gen med 2016;9:349-54. 7. middelveen mj, fesler mc, stricker rb. history of morgellons disease: from delusion to definition. clin cosmet investig dermatol 2018;11:7190. 8. middelveen mj, stricker rb. filament formation associated with spirochetal infection: a comparative approach to morgellons disease. clin cosmet investig dermatol 2011;4:167-77. 9. middelveen mj, rotaru gm, mcmurray jl, et al. canine filamentous dermatitis associated with borrelia infection. j vet sci med diagn 2016;5:6. 10. cdc. how many people get lyme disease? available from: https://www.cdc.gov/lyme/stats/humancases.html accessed: march 30, 2017. 11. stricker rb, middelveen mj. sexual transmission of lyme disease: challenging the tickborne disease paradigm. expert rev anti ther 2015;13:1303-6. 12. cdc. breast cancer statistics. available from: https://www.cdc.gov/ cancer/breast/statistics/ accessed: march 30, 2017. 13. cdc. hiv in the united states: at a glance. available from: https://www.cdc.gov/hiv/statistics/over view/ataglance.html accessed: march 30, 2017. 14. cdc. viral hepatitis: statistics & surveillance. available from: https://www.cdc.gov/hepatitis/statistics/. accessed: march 30, 2017. 15. cdc. tuberculosis (tb). available from: https://www.cdc.gov/tb/statistics/ accessed: march 30, 2017. 16. stricker rb, johnson l. lyme disease: the promise of big data, companion diagnostics and precision medicine. infect drug resist 2016;9:215-9. 17. mayne pj. clinical determinants of lyme borreliosis, babesiosis, bartonellosis, anaplasmosis and ehrlichiosis in an australian cohort. int j gen med 2014;8:15. 18. bandoski c. evidence for the presence of human pathogens borrelia and helicobacter in morgellons patients’ skin samples. presented at: 7th annual medical-scientific conference on morgellons disease; march 29-30, 2014; austin, tx. available from: http://www.thecehf. org/cheryl-bandoski.html accessed: september 30, 2016. 19. allen l, saylor-hefley c. morgellons under investigation: identification of associated microorganisms by molecular analysis of epithelial samples. presented at: 7th annual medicalscientific conference on morgellons disease; march 29–30, 2014; austin, tx. available from: http://www.thecehf.org/resources/osu%20_2015%20_ research.pdf accessed: september 30, 2016. 20. shah js, du cruz i, narciso w, lo w, harris ns. improved sensitivity of lyme disease western blots prepared with a mixture of borrelia burgdorferi strains 297 and b31. chronic dis int 2014;1:7. 21. she rc, wilson ar, litwin cm. evaluation of helicobacter pylori immunoglobulin g (igg), iga, and igm serologic testing compared to stool antigen testing. clin vaccine immunol 2009;16:1253-5. 22. stricker rb, winger ee. decreased cd57 lymphocyte subset in patients with chronic lyme disease. immunol lett 2001;76:43-8. 23. stricker rb, savely vr, motanya nc, giclas pc. complement split products c3a and c4a in chronic lyme disease. scand j immunol 2009;69:64-9. 24. national cancer institute. childhood cancers. available from: https://www.cancer.gov/types/childhood-cancers accessed: october 30, 2017. 25. cdc. prevalence of amyotrophic lateral sclerosis — united states, 2012–2013. surveillance summaries 2016; 65:1–12. available from: https://www.cdc.gov/mmwr/volumes/6 5/ss/ss6508a1.htm. accessed october 30, 2017. 26. stricker rb, johnson l. gender bias in chronic lyme disease. j womens health (larchmt). 2009;18:1717-8. 27. johnson l, aylward a, stricker rb. health care access and burden of care for patients with lyme disease: a large united states survey. health policy. 2011;102:64–71. article no nco mm er cia l u se on ly dr [dermatology reports 2018; 10:7686] [page 35] cephalexin-induced acute generalized exanthematous pustulosis matthew dacunha, sarah moore, david kaplan university of kansas medical center, kansas city, kansas, usa abstract cephalexin is a cephalosporin antibiotic that is commonly used in the treatment of infectious diseases. we report a patient exhibiting a rare adverse effect of cephalexin: drug-induced acute generalized exanthematous pustulosis (agep). we present this case because of the scarcity of reports associating cephalexin with agep in hopes that clinicians will consider agep in their differential diagnosis in the appropriate clinical setting. case report a 35-year-old female presented with a 10-day history of rash, starting on her left forearm, clinically diagnosed as a staphylococcal infection. the patient was started on cephalexin 500 mg three times a day by her primary care physician. she now presents with flat 2.0 cm superficially eroded plaques on her left forearm, which was the initial presenting lesion, as well as new erythematous eroding papules on the antecubital and popliteal fossa (figure 1). she describes the new lesions as both itchy and tender. she has stopped the antibiotics two days prior to this presentation. an initial bacterial culture taken by her primary care physician showed no growth. a repeat bacterial culture was obtained during this visit while starting a one-week course of trimethoprim/sulfamethoxazole. mupirocin was also added to all affected areas. she returned four days later with more lesions appearing on the extremities (figure 2). a skin biopsy was obtained along with a cbc and chemistry panel as culture results again showed no growth. the histology was non-diagnostic, showing a neutrophilic inflammation within the epidermis and areas of confluent parakeratosis. she was again seen three days later as the rash continued to spread on the extremities. she complained of flu like symptoms including fever, sweats, and malaise. her bloodwork was unremarkable. skin biopsy was repeated since the previous was non-diagnostic. histology now showed intracorneal neutrophils and neutrophilic spongiosis along with pustule formation (figure 3) consistent with acute generalized exanthematous pustulosis (agep), which correlated clinically. she was started on prednisone and resolved uneventfully over the next 2 weeks. discussion agep is a rare adverse reaction with only 3-5 cases per million per year.1-3 though agep is rare, more than 90% of agep cases are drug-induced with the most common offenders being beta-lactam antibiotics.1-4 cephalexin-induced agep, however, has only been reported in 3 case reports to our knowledge, making this case a probable 4th case supporting the connection between cephalexin and agep.5 cephalexin is an oral 1st-generation cephalosporin beta-lactam antibiotic that has been shown to have bactericidal activity via the inhibition penicillin-binding proteins.6 in comparison to 2nd and 3rd generation cephalosporins, cephalexin has more activity against gram-positive organisms, with less activity against gramnegatives.1,2,7 common side effects of cephalexin include dyspepsia, gastritis, diarrhea, abdominal pain, and urticarial,1,2,7,8 with agep being much rarer. despite these adverse effects, cephalexin is a well-tolerated and effective bactericidal antibiotic used to treat gram-positive infections, making it a reasonable option in the treatment of common streptococcal and staphylococcal conditions including otitis media and pharyngitis.8 agep is a severe cutaneous reaction which is part of a group of pustular drug eruptions that commonly has a delayed diagnosis due to mimicking other rashes. typically, the rash starts locally on flexor surfaces such as the groin and axilla, as in this case, before spreading into a more generalized distribution. agep presents as erythematous eruptions of pustules and papules. although extremely uncommon, agep can present with signs of fever or malaise. onset of rash usually occurs within 2 days of exposure to the offending agent, and typically resolves over the course of 12 weeks after discontinuation of the causative drug as the skin sheds and regenerates itself.1,9,10 although biopsy can be used as a supportive measure in diagnosis, agep is often diagnosed clinically.1 treatment includes the discontinuation of the offending agent and infection prevention with topical antibiotics. additionally, topical corticosteroids are beneficial in the treatment of agep.9 conclusions we present the challenges of diagnosing agep as its presentation can mimic other pustular eruptions. it can be difficult for the clinician to make an accurate and timely diagnosis. clinical clues to diagnosis include flexural involvement of the rash, negative bacterial cultures, a recent exacerbation of symptoms while on appropriate antibiotic therapy. clinical assessment diagnosis can be supported by histology with a skin biopsy.10 we present this particular case because of the paucity of reports associating cephalexin with agep in hopes of having clinicians consider agep in their differential diagnosis in the appropriate clinical setting. to our knowledge, cephalexin-induced agep has only been reported in 3 previous case reports.5 although this case cannot conclusively say that agep was directly caused by cephalexin due to the delay in diagnosis, agep is the most likely diagnosis with cephalexin being the most probable cause. this would be the 4th probable case of cephalexin-induced agep. it is imperative for dermatologists to recognize the signs and symptoms of dermatology reports 2018; volume 10:7686 correspondence: david kaplan, university of kansas medical center, 4601 w 109th st., suite 116, overland park, ks 66211, usa. e-mail: dookdoc@gmail.com acknowledgements: the authors would like to acknowledge dr. allison lisle cargnel for the histology image. key words: tender; erythematous; pustular eruption; drug reaction; antibiotic. contributions:the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. funding: none. received for publication: 18 march 2018. revision received: 7 july 2018. accepted for publication: 19 july 2018. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright m. dacunha et al., 2018 licensee pagepress, italy dermatology reports 2018; 10:7686 doi:10.4081/dr.2018.7686 no nco mm er cia l u se on ly agep, as it may require the discontinuation of antibiotics such as cephalexin and prompt the use of alternative medications.1,9 it is also important to communicate to the patient and interdisciplinary team members that the condition may be resolved more rapidly with the use of topical corticosteroids in addition to discontinuation of the offending agent.9,10 references 1. sidoroff a. acute generalized exanthematous pustulosis. hautarzt 2014;65:430-5. 2. sidoroff a, halevy s, bavinck jn, et al. acute generalized exanthematous pustulosis (agep)-a clinical reaction pattern. j cutan pathol 2001;28:113-9. 3. cranga ta, simpson ma, featherstone p. acute generalised exanthematous pustulosis (agep)-a potential pitfall for the acute physician. acute med 2016;15:140-4. 4. roujeau jc, bioulac-sage p, bourseau c, et al. acute generalized exanthematous pustulosis. analysis of 63 cases. arch dermatol 1991;127:1333-8. 5. holscher cm, mauck sk, armstrong l, buchanan ja. man with rash and nausea. acute generalized exanthematous pustulosis after cephalexin use. ann emerg med 2011;58:508-16. 6. williamson r, collatz e, gutmann l. mechanisms of action of beta-lactam antibiotics and mechanisms of nonenzymatic resistance. presse med 1986;15:2282-9. 7. gerald r, donowitz md, gerald l, mandell md. beta-lactam antibiotics. n engl j med 1988;318:490-500. 8. thienvibul c, vachiramon v, chanprapaph k. five-year retrospective review of acute generalized exanthematous pustulosis. dermatol res pract 2015;2015:260928. 9. kley c, murer c, maul jt, et al. rapid involution of pustules during topical steroid treatment of acute generalized exanthematous pustulosis. case rep dermatol 2017;9:135-9. 10. speeckaert mm, speeckaert r, lambert j, brochez l. acute generalized exanthematous pustulosis: an overview of the clinical, immunological and diagnostic concepts. eur j dermatol 2010;20:425-33. case report figure 1. tender erythematous eroding papules on the antecubital fossa. figure 2. tender erythematous papulopustular eruption of the proximal lower extremity. figure 3. intracorneal neutrophils and neutrophilic spongiosis with subcorneal neutrophils forming pustule. [page 36] [dermatology reports 2018; 10:7686] no nco mm er cia l u se on ly dr [dermatology reports 2017; 9:7116] [page 9] photoepilation and skin photorejuvenation: an update alessandro martella,1 mauro raichi2 1former senior consultant in dermatology, university of modena and reggio emilia medical school, tiggiano (le); 2clinical pharmacology and biophysics consultant, milan, italy abstract the effectiveness of intense pulsed light (ipl) and laser devices is widely accepted in aesthetic dermatology for unwanted hair removal and treatment of a variety of cutaneous conditions. overall, most comparative trials have demonstrated similar effectiveness for ipl and laser devices. literature studies alternatively favor the ipl and laser concepts, but the incidence of severe local pain and side effects were generally lower with ipl. ipl phototherapy, already established as a sound option in photoepilation and treatment of photoaging, hyperpigmentation and other skin conditions, is also considered first choice in the phototherapy of skin vascular malformations. when treating large areas, as often required in photoepilation and many aesthetic dermatology indications, ipl technologies show advantages over laser-based devices because of their high skin coverage rate. compared to lasers, the wide range of selectable treatment settings, though a strong advantage of ipl, may also imply some more risk of local thermal side effects, but almost only in the hands of poorly trained operators. overall, the strongest advantages of the ipl technologies are robust technology, versatility, lower purchase price, and the negligible risk of serious adverse effects in the hands of skilled and experienced operators. how the photoepilation story began two landmark dates mark the history of photoepilation and, generally, the application of pulsed light sources in dermatology and aesthetic dermatology. the introduction of the selective photothermolysis concept in 1984 was the first landmark event. it was a crucial step that deserved a science paper and opened the way to major advances in photoepilation technology over the past quarter of a century. in the words of the authors, selective damage to pigmented structures, cells, and organelles in vivo with suitably brief pulses of selectively absorbed radiation overcomes the need of precise aiming because inherent optical and thermal properties provide target selectivity.1 proper selection of wavelength in the recommended visible to near-infrared region up to about 1100-1200 nanometers (nm), pulse duration, and the energy density administered over the exposure time or fluence are the three paramount parameters. compromise among these three parameters is crucial to ensure deep dermal penetration, maximum thermal damage to the melanin chromophore, and minimum absorption by oxyhemoglobin and water.2,3 the second landmark date was 1996. in that year the american food and drug administration approved the first ruby-laser device for hair removal. it was so feasible to overcome at least the most severe risks of scarring or hyperpigmentation inherent to electrolysis, performed since 1875 and the only other technology then available for long-term destruction of follicles.4 today light-based hair removal technologies are based either on narrow-waveband lasers or high-intensity incoherent and multi-chromatic pulsed light (intense pulsed light, ipl). long-term unwanted hair removal has become one of the fastest growing, nonsurgical aesthetic procedures in europe and all over the world.2 specifically as regards broad-spectrum ipl epilation based on noncoherent 590-1200 nm light sources typically xenon flash lamps emitting energy in short bursts and operated with cut-off filters already in 2014 it had become the seventh most popular procedure among plastic surgeons and related specialists, according to the american society for aesthetic plastic surgery.5 the relative merits and liabilities of intense pulsed light and laser systems any chromophore-based photoepilation technology should be an efficient compromise between dermal penetration and targeting of the endogenous melanin in the hair shaft, the outer sheath of the hair follicle infundibulum and the matrix areas (figure 1). the hair bulb and the germinal matrix are rich in amelanotic stem cells that are most efficiently targeted during the anagen phase of development, when the nonpigmented germinal matrix is closest to pigmented structures.2,6-8 ipl and laser devices that operate in the red or near-infrared wavelength region like the long-pulsed 755nm alexandrite laser, the long-pulsed 800, 810-nm diode laser and the long-pulsed 1064-nm neodymium:yttrium-aluminiumgarnet (nd:yag) laser allow for the overall best compromise.6,9 the nd:yag laser, less effective in light-skinned subjects, could find a somewhat limited but elective niche in dark-skin individuals (fitzpatrick skin type iv-vi), especially with pseudofolliculitis barbae.8,10 the nd:yag has the least overall hair removal efficiency while the alexandrite and diode lasers are the best for extensive use. however, post-laser pigmentation may be troublesome with alexandrite devices whilst the need for high levels of fluence increase the risk of complications with diode systems in darker skin types.11 ipl systems are possibly more technique-dependent to limit the risk of local pain and irritation. however, they offer the benefit to be highly versatile due to the wide range of emitted wavelengths when hair or skin colors are not ideal for laser photoepilation.8 the hair removal benefits of ipl technologies are most significant in individuals with dark hair and light skin, a common caucasian phenotype and the dominant phenotype in east asia. hair that is growing after epilation is also thinner and lighter in color, and thus often another ideal candidate for ipl re-treatment several months after the first ipl or laser procedure.8 a decade ago, there had been some isolated criticism of ipl, related to the need for early ipl devices to be very highly powered to destroy hair.12 yet, a decade ago is much time in this rapidly evolving field. some recent intra-patient-controlled split dermatology reports 2017; volume 9:7116 correspondence: mauro raichi, e-mail: mraichi@gmail.com key words: photoepilation; photorejuvenation; intense pulsed light; dermal remodeling. sponsor: novavision group s.p.a., misinto (mb), italy. conflict of interest: the authors declare no potential conflict of interest. received for publication: 6 march 2017. accepted for publication: 2 may 2017. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright a. martella and m. raichi 2017 licensee pagepress, italy dermatology reports 2017; 9:7116 doi:10.4081/dr.2017.7116 no n c om me rci al us e o nly [page 10] [dermatology reports 2017; 9:7116] face comparisons seem to indicate that ipl could offer some benefits compared with laser devices in terms of hair reduction, patient satisfaction, and local pain. a 2013 left-to-right split-face assessor-blinded study compared a ipl (λem=600-950 nm) and a diode laser device for removal of unwanted axillary hair (6 sessions at 4week intervals in 30 subjects with skin type ii-iii; hair counts assessed with close-up photographs).13 the 3and 12-month mean hair reduction was slightly higher with the diode laser system (59.7% vs 42.4% and 69.2% vs 52.7% from baseline for laser and ipl treatments, respectively), but at significantly higher pain cost compared with the almost pain-free ipl technology (3.7±2.1 vs 1.6±1.4, respectively; 10-cm visual analogue scale).13 similar results were seen in a double-blind, intra-patient-controlled randomized study of axillary hair removal in 21 women after application (6 sessions) of a diode laser on one axilla and ipl on the other one. the number of hair shafts was lastingly and similarly reduced with both hair reduction systems, but local pain was significantly more disturbing with the diode laser.14 ultra-refining the chromophore targeting process some advanced ipl systems are being introduced that allow to concentrate almost all emitted energy in very narrow wavelengths selected within the ample waveband of ipl xenon flash lamps. for instance, an advanced italian ipl-derived technology [ifl™ (incoherent fast light), novavision group s.p.a., 20826 misinto (mb), italy], when used in photoepilation mode at up to 3.3 light pulses per second, allows an extremely high selection of the wide xenon lamp waveband by focusing the energy emission on 700, 810 and 890 nm wavelengths. ultraviolet emissions are preliminary filtered away by default by the ultratransparent cerium-supplemented borosilicate glass of the ifl™ light emitter acting together with a permanently installed 420nm cut-off filter. the local safety allowed by wavelength selection is further improved by avoiding all contacts of the device with the skin. at the same time, the technological improvements of the system allow to increase the number of spots up to 210,000. summarizing, the photoepilation story that began in 1984 with a landmark science paper is still going on and technology is still making strong headways; and not only in photoepilation. the expanding scope for intense pulsed light beyond photoepilation in 1990, a high-intensity flash lamp was first described as a new tool for treating vascular lesions; the first ipl medical device aimed to benign vascular lesions was commercially launched in 1994.15 since those years, many features of first-generation ipl devices have undergone technological refinements, with special reference to the xenon gas-discharge flash lamp and the electronic control of the capacitor banks. such capacitors store and discharge the electrical energy that generates the pulsed polychromatic high-intensity light. the computer-assisted selection of article figure 1. a) relationship between intense pulsed light (ipl) and laser wavelength and depth of penetration into the epidermis and dermis. at wavelengths within the low absorption index of water (400 to 1000 nm, visible and near-infrared spectrum), dispersal within the dermis decreases with increasing wavelengths whilst penetration deepens and photothermolytic effects become stronger. the ipl wavelength window is about 590 to 1,200 nm. the 694-nm ruby laser is no longer used in photoepilation because of strong absorption by melanin and high risk of adverse effects in tanned and darker skin types and hypopigmented areas observed even in skin type ii. nd:yag: neodymium:yttriumaluminium-garnet.6,11 b) diagram illustrating the overall relationship between wavelengths in the visible and near-infrared spectrum and electromagnetic energy absorption by melanin. energy absorption by the chromophore and thermal biological effects are high in the low visible spectrum and decrease with increasing wavelengths. in spite of high dermal penetration, wavelengths higher than 1,100 nanometers (nm) are less useful for selective photothermolysis.8 a b no n c om me rci al us e o nly [dermatology reports 2017; 9:7116] [page 11] treatment settings is also being steadily improved and water filters have been developed to absorb most infrared radiation. the ifl™ technology previously discussed is an example of such engineering improvements. beyond photoepilation, the versatile range of ipl wavelengths (figure 2) has been applied to a wide spectrum of dermatological conditions, such as photodamaged skin, acne vulgaris, epidermal and dermal pigmented and vascular lesions, angiokeratoma, and hypertrophic scars and keloids. available evidences suggest ipl might be the treatment of choice in at least some of such cutaneous disorders.16,17 the range of cutaneous disorders amenable to ipl treatment continues to widen. a recent evidence-based set of recommendations, based on the highest level of evidence available to guide physicians in the ipl treatment of dermatologic diseases, found level 1 evidence for melasma, acne vulgaris, and telangiectasia; level 2 evidence for lentiginous disease, acne rosacea, capillary malformations, actinic keratoses, and sebaceous gland hyperplasia; level 3 or lower evidence for poikiloderma of civatte, venous malformations, infantile hemangiomas, hypertrophic scars and keloids, superficial basal cell carcinoma, and bowen’s disease.18 other dermatological disorders have also been treated with ipl with satisfactory results: port-wine stains, a common congenital vascular malformation occurring in up to 25% of individuals since infancy, becker’s nevus, a male-predominant benign hypermelanotic birthmark on the shoulders, chest or lower back, and pilonidal or sacro-coccygeal cysts containing hair and skin debris.19 disseminated porokeratosis, presenting as asymptomatic or mildly itching atrophic plaques surrounded by an hyperkeratotic border histologically known as cornoid lamella, and the soft warty or squamous crusted, yellow-brown surface of seborrheic keratosis have also been treated quite successfully with ipl.19 biological mechanisms of intense pulsed light phototherapy and photorejuvenation findings in photoaging due to chronic exposure to uv sunlight include wrinkling and rough skin texture, altered pigmentation and loss of elasticity. even with first-generation ipl devices, improved texture and telangiectasias were reported 4 years after ipl treatment (median, 3 sessions) by, respectively, 83% and 82% of individuals with skin types i-iv; improvements in mottled pigmentation persisted in 79% of treated subjects.20 as regards the biological mechanisms underlying ipl photorejuvenation, epithelial and dermal structures appear to be preserved in the weeks following the ipl procedure with no further lesion to the sun-damaged skin.21 cosmetic benefits are thus most probably unrelated to destruction of pre-existing dermal structures. conversely, increased collagen deposition in the upper papillary and upper reticular dermis and a more neat arrangement of elastin fibers have long been known to have a role in the clinical and aesthetic improvements.21,22 dermal dendritic cells are likely to be the biological target in ipl photorejuvenation, as suggested by the expression of the heat-induced protein hsp70 (heat shock protein 70 kilodaltons) and procollagen 1 by these cells as markers of their activation. activation of dermal dendritic cells might be the underlying event that ultimately leads to collagen deposition by dermal fibroblasts.21 advanced ipl developments are being devised to activate such cellular photorejuvenation mechanisms. a most recent example is the photoactivating system (phas™) program of the ifl™ technology, which produces a long continuous pulse, adjustable from 2 to 4 seconds, of very low energy to maximize efficiency of action on dermal cells. some examples of the intense pulsed light efficacy in dermatological disorders as regards phototherapy of dyschromia, improvements were similar in a samepatient, spit-face study of treatment of dark and light lentigines and vessels less and greater than 0.6 mm with pulsed dye laser and ipl, three sessions at 3to 4-week intervals (responder patients, 86.5, 65, 85 and 38% vs 82, 62.5, 78.5 and 32.5%, respectively, with pulsed dye laser and ipl). however, treatment times and assessment of local pain significantly favored ipl (mean third session times; pulsed dye laser 7.7 minutes, ipl 4.6 minutes, p=0.005; mean pain ratings, pulsed dye laser 5.8 minutes, ipl 3.1 minutes, p=0.007).23 in another study with benign pigmented lesions, 96% of patients with lentigo solaris and melanocytic nevi showed pigment article figure 2. light absorption spectra of skin chromophores (melanin and oxyhemoglobin) and water in visible and infrared wavelengths with evidence of the strongest energy emission peaks of ipl flash-lamp devices within their operating visible and near-infrared wavelengths. in advanced ipl devices like incoherent fast light™ (ifl™), the emitted light energy is selectively concentrated within these energy-emission peaks whilst the ultra-transparent low-residue water in the closed-loop cooling system extensively filters away infrared wavelengths longer than 900 nanometers. no n c om me rci al us e o nly [page 12] [dermatology reports 2017; 9:7116] reduction with an average clearance of 74.2% and 66.3% of lesions, respectively. superficial crusting and ulceration (average diameter on day 5, 3.7 mm) followed by some degree of erythema were observed in most treated lesions, but healing was complete within 30 days.24 figure 3 illustrates the ipl and ifl™ wavelength range ideally suited to phototherapy of cutaneous dyschromia. skin vascular lesions such as facial telangiectasia and port-wine stains have traditionally been treated with the pulsed dye laser. such lesions are another indications where ipl is at least as effective as the gold standard. ipl may even be considered first choice because it is often successful when the pulsed dye laser fails. the mechanism of action is related to selective absorption of ipl energy by hemoglobin within target blood vessels.25,26 in patients with port-wine stains resistant to multiple pulsed dye laser treatments, almost half of the patients (46.7%) responded to four ipl sessions with a more than 50% reduction of lesions. the average clearance for the responders was 83.9±9.5%. most of such ipl responders (85.7%) obtained reductions between 75% and 100% of their basal stains; only lesions in the central part of the v2 face dermatome failed to respond. preference for ipl over multiple pulsed dye laser was expressed by 93.5% of the patients.26 ipl technologies have also been long used in the treatment of acne vulgaris. ipl seems to act by targeting both inflammation and sebaceous glands. with a few treatment sessions, ipl reduces the density of the inflammatory cell infiltrate and the surface area of sebaceous glands, especially in more inflammatory acne variants, in parallel with reduction of the cardiff acne disability index or other scores of clinical impact.27 the molecular mechanism of such powerful anti-inflammatory action could be a novel anti-tumor necrosis factor-α effect independent of interleukin-10 up-regulation.28 selective photothermolysis of blood vessels that supply sebaceous glands could also contribute to the acne-suppressing efficacy by reducing the sebum secretion rate. such photodynamic effect could be mediated by energy absorption by coproporphyrins produced by propionibacterium acnes (absorption peaks: 400, 510, 542, 578, 630, 665 nm) with generation of bacteridical reactive oxygen species.29 all light-based therapies, including ipl, are especially effective in treating inflammatory acne vulgaris with minimal side effects. this was most recently confirmed in a 2016 single-blind, split-face clinical trial that compared the clinical efficacy of 3 sessions of ipl on the right side of the face and 1,064-nm nd:yag laser on the left side at 4-weeks intervals in 74 individuals with mild to severe facial acne. the reduction of inflammatory papules, pustules, nodules and cysts was similar with both phototherapy strategies (−67.1% and −70.2%, respectively, with ipl and nd:yag laser) while response of non-inflammatory comedones was equally modest (−18.3% and −19.3%, respectively).30 summarizing versatility in treating many dermatological conditions as well as lower commercial costs and more robust technology are strong advantages for ipl technologies compared to laser devices. this may be true for both photoepilation and treatment of several skin disorders, for which ipl is often the firstchoice option. the large spot sizes allowed by ipl shorten the time needed for photorejuvenation sessions while the troublesome need to apply an optical coupling gel has been eliminated with the most advanced pulsed light devices.29 ipl technologies developed over the very last years like ifl™ have also eliminated the emission of sigmoidal-shaped pulses, another weak point of older ipl devices. shifts in spectral and fluence distribution within the pulse are unavoidable with non-square-shaped pulses. thanks to the large capacitor banks in advanced ipl devices, variable current are no longer delivered to the xenon flash lamp and roughly square-shaped pulses are dependably emitted. some minor difficulties with handling and the weight of the handpiece incorporating both the lamp and the lampcooling system are a little price that has still to be paid for all the benefits of the most advanced ipl technologies.29 it does not seem a heavy price to pay. references 1. anderson rr, parrish ja. selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. science 1983;220:524-7. 2. haedersdal m, beerwerth f, nash jf. laser and intense pulsed light hair removal technologies: from professional to home use. br j dermatol 2011;165:31-6. 3. dierickx cc. hair removal by lasers and intense pulsed light sources. dermatol clin 2002;20:135-46. 4. richards rn, meharg ga. electrolysis: observations from 13 years and 140,000 hours of experience. j am acad dermatol 1995;33:662-6. 5. dibernardo be, pozner jn. intense pulsed light therapy for skin rejuvena article figure 3. light absorption spectra of skin chromophores (melanin and oxyhemoglobin) and water in visible and infrared wavelengths with evidence of the useful range of wavelengths in the ipl phototherapy of disorders of cutaneous pigmentation. no n c om me rci al us e o nly [dermatology reports 2017; 9:7116] [page 13] tion. clin plast surg 2016;43:535-40. 6. drosner m, adatto m; european society for laser dermatology. photoepilation: guidelines for care from the european society for laser dermatology (esld). j cosmet laser ther 2005;7:33-8. 7. serrano-grau p, campo-voegeli a, romero d. photodepilation. actas dermosifiliogr 2009;100:351-61. 8. mandt n, troilius a, drosner m. epilation today: physiology of the hair follicle and clinical photo-epilation. j investig dermatol symp proc 2005;10:271-4. 9. casey as, goldberg d. guidelines for laser hair removal. j cosmet laser ther 2008;10:24-33. 10. schulze r, meehan kj, lopez a, et al. low-fluence 1,064-nm laser hair reduction for pseudofolliculitis barbae in skin types iv, v, and vi. dermatol surg 2009;35:98-107. 11. sadighha a, mohaghegh zahed g. meta-analysis of hair removal laser trials. lasers med sci 2009;24:21-5. 12. mcgill dj, hutchison c, mckenzie e, et al. a randomised, split-face comparison of facial hair removal with the alexandrite laser and intense pulsed light system. lasers surg med 2007;39:767-72. 13. klein a, steinert s, baeumler w, et al. photoepilation with a diode laser vs. intense pulsed light: a randomized, intrapatient left-to-right trial. br j dermatol 2013;168:1287-93. 14. ormiga p, ishida ce, boechat a, ramos-e-silva m. comparison of the effect of diode laser versus intense pulsed light in axillary hair removal. dermatol surg 2014;40:1061-9. 15. goldman mp. treatment of benign vascular lesions with the photoderm vl high-intensity pulsed light source. adv dermatol 1997;13:503-21. 16. erol oo, gurlek a, agaoglu g, et al. treatment of hypertrophic scars and keloids using intense pulsed light (ipl). aesthetic plast surg 2008;32:902-9. 17. morais p, santos al, baudrier t, et al. angiokeratomas of fabry successfully treated with intense pulsed light. j cosmet laser ther 2008;10:218-22. 18. wat h, wu dc, rao j, goldman mp. application of intense pulsed light in the treatment of dermatologic disease: a systematic review. dermatol surg 2014;40:359-77. 19. piccolo d, di marcantonio d, crisman g, et al. unconventional use of intense pulsed light. biomed res int 2014; 2014:618206. 20. weiss ra, weiss ma, beasley kl. rejuvenation of photoaged skin: 5 years results with intense pulsed light of the face, neck, and chest. dermatol surg 2002;28:1115-9. 21. prieto vg, diwan ah, shea cr, et al. effects of intense pulsed light and the 1,064 nm nd:yag laser on sun-damaged human skin: histologic and immunohistochemical analysis. dermatol surg 2005;31:522-5. 22. goldberg dj. new collagen formation after dermal remodeling with an intense pulsed light source. j cutan laser ther 2000;2:59-61. 23. galeckas kj, collins m, ross ev, uebelhoer ns. split-face treatment of facial dyschromia: pulsed dye laser with a compression handpiece versus intense pulsed light. dermatol surg 2008;34:672-80. 24. bjerring p, christiansen k. intense pulsed light source for treatment of small melanocytic nevi and solar lentigines. j cutan laser ther 2000;2:177-81. 25. tanghetti ea. split-face randomized treatment of facial telangiectasia comparing pulsed dye laser and an intense pulsed light handpiece. lasers surg med 2012;44:97-102. 26. bjerring p, christiansen k, troilius a. intense pulsed light source for the treatment of dye laser resistant port-wine stains. j cosmet laser ther 2003;5:713. 27. barakat mt, moftah nh, el khayyat ma, abdelhakim za. significant reduction of inflammation and sebaceous glands size in acne vulgaris lesions after intense pulsed light treatment. dermatol ther 2017 [epub ahead of print]. 28. taylor m, porter r, gonzalez m. intense pulsed light may improve inflammatory acne through tnf-α down-regulation. j cosmet laser ther 2014;16:96-103. 29. babilas p, schreml s, szeimies rm, landthaler m. intense pulsed light (ipl): a review. lasers surg med 2010;42:93-104. 30. mohamed ee, tawfik k, elsaie m. intense pulsed light versus 1,064 longpulsed neodymium:yttrium-aluminumgarnet laser in the treatment of facial acne vulgaris. j clin diagn res 2016; 10:wc01-3. article no n c om me rci al us e o nly 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. dr unilateral demodicidosis of face mimicking hansens disease deepak vashisht,1 jatinder singh,1 sukriti baveja,1 rohit tiwari,2 anuj bhatnagar1 departments of 1dermatology and 2pathology, armed forces medical college, pune, india abstract demodicosis is a common parasitic infection of the hair follicles and the pilosebaceous unit by the demodex mites viz. demodex folliculorum and demodex brevis. infection by this parasite is common among immunocompromised and elderly. we report a case of facial demodicosis which presented like atypical rosacea with a gradually progressing swelling and redness on right side of face which was initially diagnosed as a case of hansen’s disease. skin biopsy revealed follicular dilatation with presence of demodex mite along with intense perifollicular lymphomononuclear infiltrate. patient was treated with oral tab ivermectin 12 mg stat along with topical gel metronidazole twice daily to which he responded favourably. introduction mite demodex is an ectoparasite infesting the areas of face rich in pilo-sebaceous units and less commonly other seborrheic sites like upper and medial region of chest and back are also involved.1,2 majority of the patients are immune-compromised though immunocompetent are not spared, nevertheless atypical presention in immunocompetent individuals is a rarity. we report a case with atypical presentation which posed diagnostic dilemma due to confusing clinical picture. case report a 32-year-old male presented with gradual onset swelling and redness on right side of face associated with minimal itching for past six months. it started as a pea-sized red raised flat lesion, which increased in size to involve 1/3 rd of right cheek, adjoining nasolabial fold and lower eye-lid. there was modest increase in redness and pruritus of the lesions on sunexposure, however hot spicy meals, alcohol or emotional stress did not aggravate his symptoms. there was no history of cough, chest pain, fever, weight loss or any constitutional or systemic symptoms. patient denied using any local or systemic medication. there was no history of pets in the house. patient reported to a dermatologist about a month back, where he was diagnosed as hansen’s disease in view of equivocal hypoaesthesia and solitary indurated plaque on face. he underwent skin biopsy which revealed non-specific inflammation. he was empirically started on multi drug treatment (mdt) multi bacillary for hansens disease. after about four weeks of mdt, patient reported to our hospital with no clinical improvement and persistence of symptoms. his general physical and systemic examinations were within normal limits. dermatological examination revealed involvement of right malar region, nasolabial fold and adjacent parts of nasal bridge and lower eyelid in the form of edema, erythema and follicular dilatation (figure 1). there was no hypoesthesia or thickened peripheral nerves. laboratory investigations revealed complete blood count, erythrocyte sedimentation rate (esr), liver and renal function tests, serum ace levels, were normal. screening for hepatitis b, hepatitis c and human immunodeficiency virus, as well as serology for antinuclear antibodies (ana) were negative. chest x-ray showed no abnormality and koh mount of scrapings did not reveal any pathology. repeat skin biopsy from medial end of the swelling along nasolabial fold showed mild epidermal orthohyperkeratosis. the dermis showed intense follicular and perifollicular lymphocytic inflammatory infiltrate along with dense lichenoid lymphomononuclear infiltrate. there was follicular dilatation with presence of demodex sp.mite with surrounding homogenous eosinophilic material (figure 2). patient was managed with oral ivermectin 12 mg stat and topical metronidazole gel locally twice a day. the eryhthema and swelling started regressing within few days and after 03 weeks had near complete resolution of symptoms (figure 3). discussion and conclusions demodex are parasitic mites that live in hair follicles and pilosebaceous units, accordingly maximum density is found in seborrheic sites. besides humans they also cause significant infestation in canines and felines.3 human infestation is very common and varies between 23-100% as per different authors.4,5 this infestation is usually asymptomatic, but when and how it becomes pathogenic is poorly understood.6 primary or secondary suppression in immunity plays a major role in demodex proliferation and resultant dermatoses. cutaneous disorders attributed to this mite include, rosacea, pustular folliculitis, perioral dermatitis, lupus miliaris disseminatus faciei, madarosis, non-specific facial dermatitis etc.7 our patient presented with nonspecific facial dermatitis affecting only right dermatology reports 2016; volume 8:6891 correspondence: deepak vashisht, department of dermatology, armed forces medical college, pune, maharasthra, 411040 india. tel.: +91.9419021643. e-mail: deepak3975@gmail.com key words: demodicosis, atypical rosacea, hansen’s disease. contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. received for publication: 16 september 2016. accepted for publication: 18 november 2016. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright d. vashisht et al., 2016 licensee pagepress, italy dermatology reports 2016; 8:6891 doi:10.4081/dr.2016.6891 figure 1. a) partially defined edematous and erythematous plaque on right malar region, nasolabial fold and lower eyelid with follicular dilatation. b) comparisson of the lesion with contralateral normal site. [dermatology reports 2016; 8:6891] [page 13] a b no n c om me rci al us e o nly [page 14] [dermatology reports 2016; 8:6891] side of the face. patient had no evidence of primary or secondary immune suppression. there was no local or systemic risk factor suggestive of demodex infestation. unilateral, indurated, erythematous plaque on face with equivocal hypoaesthesia resulted in initial misdiagnoses. earlier it has also been reported to present with facial sclera-oedema and blepharoedema which mimicked cutaneous lymphoma.8 this case is being reported for its unilateral atypical presentation. further demodicidosis should also be considered in patients presenting even with unilateral lesions in seborrheic areas. references 1. aylesworth r, vance c.demodex folliculorum and demodex brevis in cutaneous biopsies. j am acad dermatol 1982;7:583-9. 2. bastajuzbasic a, subic js, ljubojevic s. demodex folliculorum in development of dermatitis rosaceiformis steroidica and rosacea-related diseases. clin dermatol 2002;20:135-40. 3. gross tl, ihrke pj, walder ej, affolter vk. skin diseases of the dog and cat: clinical and histopathologic diagnosis. oxford: blackwell science ltd; 2008. pp 932 4. norn ms. demodex folliculorum. incidence, regional distribution, pathogenicity. dan med bull 1971;18:14-7. 5. rufli t, mumcuoglu y. the hair follicle mites demodex folliculorum and demodex brevis: biology and medical importance. a review. dermatologica 1981;162:1-11. 6. temnikov ve. the peculiarity of immune status in rosacea. nigniy novgorod 1991;1:86-8. 7. rather pa, hassan i. human demodex mite: the versatile mite of dermatological importance. indian j dermatol 2014;59:606. 8. kito y, hashizume h, tokura y. rosacealike demodicosis mimicking cutaneous lymphoma. acta derm venereol 2012;92:169-70. case report figure 2. section through skin biopsy showing multiple follicular infundibula showing demodex mites (horizontal arrow). the perifollicular tissue shows lymphomononuclear inflammation (h&e, 100×). inset: demodex mite in the infundibulum(horizontal arrow) (h&e, 400×). figure 3. almost completed resolution of the plaque on right malar region. no n c om me rci al us e o nly 429 too many requests you have sent too many requests in a given amount of time. dr [page 8] [dermatology reports 2019; 11:7853] trps1-deficient transplanted skin gave rise to a substantial amount of hair: trps1 is unnecessary for hair development yingzhe zhang,1 tomoyuki nakamura,2 fukumi furukawa,2 yasuteru muragaki1 1department of pathology; 2department of dermatology, wakayama medical university school of medicine, japan abstract trps1 is considered as an important gene involved in the interactions between the epithelial and mesenchymal cells during hair follicle morphogenesis. the number of hair follicles in trps1 knockout (ko) newborn mouse skin was significantly lower than that in wild-type (wt) newborn skin. to gain insight into the functional role of trps1 in hair development, we transplanted trps1 ko newborn mouse skin on the backs of nude mice and examined hair growth at day 42 after transplantation. surprisingly, transplanted skin from trps1 ko newborn mice gave rise to a substantial amount of hair, although the hair was softer than that of wt mice. histological examination revealed that the diameter of both hair follicles and hair shafts were significantly lower, whereas the density of hair follicles showed no significant difference between the trps1 ko and wt mice. we introduce mouse hair follicles as a fascinating model to study the functions of trps1 in mouse hair growth and pathology. this model suggests that the function of trps1 is unnecessary for the development of normal hair follicles and hair shafts, although the loss of trps1 affects the diameters of hair follicles and hair shaft. introduction it has been reported that heterozygous germ line mutations in tricho-rhino-phalangeal syndrome (trps1) on chromosome 8q23 in humans result in autosomal dominant inheritance of tricho-rhino-phalangeal syndrome type i (trpsi) and iii (trpsiii), characterized by sparse and slow growing scalp hair, as well as craniofacial and skeletal abnormalities.1,2 trps1 knockout (ko; it is a genetically modified mouse, musmusculus, in which researchers have inactivated, or knocked out, an existing gene by disrupting it with an artificial piece of dna) mice were reported to have fewer hair follicles, with craniofacial and skeletal defects that mirror the phenotypic characteristics of human patients. patients with trps i have an orbicular nose, a long and even philtrum, a thin upper lip, sparse scalp hair that grows slowly, and protruding ears.3,4 these findings proved that trps1 was required for specific aspects of hair growth regulation. in addition to the apparent defects in facial soft tissues, male patients were particularly affected by hair loss, with many being nearly or completely bald soon after puberty. some children with this disease have loose skin, although the skin becomes tighter over time. individuals with trps i may experience excessive sweating, although the clinical description is often incomplete.5-8 skin development is a complex dynamic process that includes formation of epidermis, a layered self-renewing epithelium, and several skin auxiliaries such as hair follicles (hf), hair nails and sweat glands. hf morphogenesis is driven by bidirectional ectodermal-mesenchymal interactions between epidermal keratinocytes and a specialized population of dermal fibroblasts, resulting in formation of the hair bulb, in which epithelial progenitor cells proliferate and differentiate into cell lineages to form hair shafts and their supporting layers in the inner root sheath. hf morphogenesis is governed by a well-balanced mutual effect among cell proliferation, differentiation, and apoptosis, all of which are controlled at several levels including signalling/transcription factor-mediated and epigenetic regulatory mechanisms.9,10 we previously demonstrated that transcription factor trps1 played an important role in the morphogenesis of secondary hfs via an interaction with the bmp inhibitor noggin.11 we found that development of secondary hair follicles in mutant trps1 embryos was inhibited compared to their wide-type counterparts. additional analysis revealed that trps1 activated wnt inhibitors and other transcription factors essential for follicle morphogenesis in mice.12 while this study demonstrated a requirement for trps1 during early hf formation, it did not address the mechanisms underlying hair follicle degeneration in subsequent stages after birth. in addition, since trps1 ko mice die within a few hours due to respiratory failure, we do not know whether or not hair grows with total loss of trps1. in this study, to observe hair follicle growth after birth, we transplanted trps1 ko newborn mouse skin to the back of nude mice. materials and methods trps1 knockout mice and tissue preparation trps1 ko mice were generated as previously described.13 the principles of animal care and use were followed as directed by the committee of wakayama university. we crossed male and female heterozygous mice to obtain wild-type and homozygous newborns.11 when newborn mice were harvested, genotyping was performed. dorsal skin was carefully peeled off newborn mice and skin (6-mm in diameter) was taken with a tissue puncher and transplanted to the back of nude mice. 40 skin grafts from wild-type, heterozygous, and homozygous newborn, respectively, were transplanted to 20 nude mice (6 skin grafts per nude mouse). the skin graft was affixed to the recipient skin by adding aron alfa (konishi, japan) at the margin. preparation of histological sections and immunohistochemistry at day 42 after transplantation, transplanted skin tissue was obtained and fixed with 4% paraformaldehyde overnight. the dermatology reports 2019; volume 11:7853 correspondence: yasuteru muragaki, department of pathology, wakayama medical university school of medicine, 811-1 kimiidera, wakayama 641-0012, japan. tel.: 073.447.2300 fax: 073.447.2300. e-mail: ymuragak@wakayama-med.ac.jp key words: hair follicle; trps1; hair development; hair shaft. contributions: yz, tn, ff data collecting and analyzing; yz, manuscript writing and references search. conflict of interest: the authors declare no potential conflict of interest. funding: this work was supported in part by a grant-in-aid for scientific research (15k08430) from the ministry of education, science, sports, and culture of japan (to y.m.). it was also supported by csc scholarship (no. 201406220175). received for publication: 28 august 2018. revision received: 18 december 2018. accepted for publication: 18 december 2018. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright y. zhang et al., 2019 licensee pagepress, italy dermatology reports 2019; 11:7853 doi:10.4081/dr.2019.7853 no nco mm er cia l u se on ly [dermatology reports 2019; 11:7853] [page 9] next day, it was embedded in paraffin blocks. the skin was sectioned longitudinally into 5-μm sections for he staining or immunostaining. statistical analysis the data were analyzed by student’s ttest with a student-newman-keuls test (spss, 13.0). p<0.05 was considered to be statistically significant. results abnormalities in appearance and morphogenesis of hair follicles in newborn trps1 knockout mice as we reported in a previous paper, newborn trps1 ko mice showed a decreased size of the maxillary region compared with that of wild-type (wt; it refers to the phenotype of the typical form of a species as it occurs in nature) mice.11 hair follicles in trps1 ko mice were present at postnatal day1, but were reduced in number, irregularly spaced and smaller than those of wt mice (figure 1). trps1 knockout mice showed distinct appearance differences at day 42 after transplantation to investigate whether or not hair follicles develop and give rise to hair, and if trps1 ko mice could survive, we transplanted newborn mouse skin to nude mice. surprisingly, at day 42 after transplantation, transplanted skin from trps1 ko newborn mice produced hairs with the same length and density as those of wt mice although they were softer than those of wt mice (figure 2). comparison between trps1 knockout and wild-type mice at day 42 after transplantation histological examination revealed that hair follicles and hairs were thinner in the transplanted skin from trps1 ko newborn mice than those from wt mice (figure 3a). diameters of both hair follicles and hair shafts were significantly smaller in transplanted skin from trps1 ko mice than those from wt mice (figure 3b-d). discussion and conclusions in this study, we investigated whether hair could develop in a condition of trps1deficient hair follicles. we expected that few hairs would emerge from transplanted article figure 2. appearance comparison of wt and trps1 ko mice after 42 days of transplantation. (a) -/shows the ko mouse transplanted skin, +/shows the wt mouse transplanted skin; (b) appearance of wt (left) and ko (right) mouse skin sample at 42 days after transplantation by naked-eye observing. trps1 ko mouse sample showed a thinner and softer hair. figure 1. h&e staining showing wild-type (wt) and trps1 knockout (ko) mice display differences during hair growth. 20× magnification. histology of newborn dorsal skin got from wt and ko newborn mice. note that trps1 ko mice lack a number of hair follicles in newborn mice. no nco mm er cia l u se on ly [page 10] [dermatology reports 2019; 11:7853] skin from trps1 ko newborn mice, because hair follicles in trps1 ko newborn mice showed decreased number and diameter compared to those of wt mice. at day 42 after transplant, however, transplanted skin from trps1 ko newborn mice produced soft, otherwise comparable amounts of hair as that of wt mice. histological examination revealed smaller diameter of a hair follicle in trps1 ko mice than that of wt mice. in our previous papers, we provided evidence that trps1 expression was essential for normal hair follicle growth using trps1 ko mice.11 trps1 ko mice die shortly after birth due to respiratory insufficiency. these developmental abnormalities may be related to disrupted wnt signalling.14 how disrupted wnt signalling caused this abnormality led us to investigate the function of trps1in hair follicle growth. the extensive phenotypic outcomes in trps1 ko mice suggested that the structure of trps1 protein might be required in the embryonic development of complex organ systems. in addition, a recent study of comprehensive transcriptome profiling of balding and non-balding scalps in trps i patients demonstrated that trps1 indeed plays a vital role in human hair loss.6 specifically, we found that trps1 controls gene expression and plays a fundamental role in the interaction between epithelial and dermal papilla cells during hair follicle morphogenesis. we sought to identify alteration of the target genes of trps1, focusing on wnt and androgen/androgen receptor signalling in hf development. wnt signalling is required for crosstalk between follicular keratinocytes and dermal papilla cells during hair follicle development. activation of the wnt signalling pathway requires accumulation of β-catenin that translocates into the nucleus, where it acts as a coactivator of t cell-factor proteins to regulate gene expression. a number of recent studies demonstrated that androgen is essential for hair follicle morphogenesis; paracrine secretion is involved in this crosstalk at various hair cycle stages and some signaling pathways are affected.15,16 these findings demonstrate that the processes required for hair follicle growth are complicated. wnt/β-catenin signalling is essential for the initiation and maintenance of hair morphogenesis.17 in promoting dermal papilla cells properties to maintain hf regeneration, wnt signalling through the βcatenin pathway played an important role.18 trps1 may maintain mouse hfs through inhibition of canonical wnt signalling and may operate as a major molecular regulator of hf regression. remarkably, wnt inhibitors, wif1, apcdd1 and dkk4, were down-regulated in trps1 ko mouse skin according to microarray hybridization analysis, suggesting that trps1 may repress the wnt signalling pathway to develop normal hair growth.12 therefore, we hypothesized that the miniaturization of hair follicles and hair shafts seen in trps1 ko mice may be directly caused by inhibition of wnt signalling. nevertheless, to date, we have failed to detect any significant alteration in gene expression of wnt inhibitors such as wifi, apcdd1 and dkk4. on the other hand, androgen (dihydrotestosterone: dht) is believed to have an important role in transformation of scalp hair to vellus hair through dermal papilla morphogenesis. it has been reported that the dermal papilla from hf of a balding scalp contains higher levels of dht than those from non-balding scalp.19 in addition, it has been shown that dht disturbs the balance of wnt agonist/antagonist in dermal papilla cells, down regulating wnt10b mrna.20 it is possible that trps1 may act as a regulator of hair shaft formation. trps1 functions in the normal hair cycle as a key molecule of hf regression by inhibiting wnt signalling via androgen expression. this is in line with a previous report in which dht abrogated the ability of dp cells to induce hf stem cells differentiation into a hair follicle lineage via inhibition of wnt signaling.21 although we could not show any significant change in androgen receptor expression in the transplanted skin from trps1 ko mice compared with wt mice skin by immunofluorescence, it is possible that ar expression may be up regulated in trps1 ko skin. we have reported that trps1 plays an important role in the morphogenesis of secondary but not primary hfs via an interaction with the bmp inhibitor noggin. however, there was no significant difference in the density of hair follicles in the transplanted skin. to date, although we cannot explain the discrepancy clearly, it is possible that the interaction of the transplanted skin with normal dermal tissue in article figure 3. hair follicles are attenuated in trps1 ko mice skin compared with those of wt mice at day 42 after transplantation. (a) h&e staining of p42 wt and ko dorsal skin after transplant. compared with wt (left), ko (right) displayed thinner hair shaft and shrunken hair follicles. 20× magnification. (b) comparative analysis of diameter of hair follicles (n=3 per group, error bars represent sd; *p<0.001. **p<0.005) trps1 ko (right) mice showed significantly reduced diameter of hair follicles compared with those of wt mice (p=0.001). (c) comparative analysis of diameter of hair shafts (n=3 per group, error bars represent sd; *p<0.001. **p<0.005) trps1 ko (right) mice showed significantly reduced diameters of hair shaft compared with those of wt (left) mice (p=0.005). (d) comparative analysis of density of hair follicles (n=3 per group, error bars represent sd; *p<0.001. **p<0.005) density of hair follicles in wt (left) and trps1 ko mice were not significantly different. no nco mm er cia l u se on ly [dermatology reports 2019; 11:7853] [page 11] nude mice might have increased the hair follicle density. injury to the recipient mouse skin could cause an upregulation in wnt, resulting in signaling that promotes hair growth in the ko skin. another possibility would be a mechanism by which ambras syndrome is caused. koa mice, a mouse model of as, display hypertrichosis, which is an opposite phenotype of trps1 ko mice although trps1 expression levels are reduced.22 this molecular mechanism might explain the discrepancy between trps1 ko and the transplanted skin. to further study the mechanism of how trps1 regulates hair follicle growth after birth, we ought to investigate follicle growth using trps1 conditional ko mice where trps1 is specifically deficient in the skin. in conclusion, soft hairs grew out of the transplanted skin from trps1-deficient newborn mice. these hairs were thin, but were otherwise comparable with normal hairs, suggesting that trps1 is unnecessary for hair growth itself, perhaps regulating only the diameter of hair shaft. further study should be undertaken to elucidate the precise function of trps1 on hair development. references 1. canún s, guevara-sanginés eg, elviramorales a, et al. hypertrichosisterminalis, gingival hyperplasia, and a characteristic face: a new distinct entity. am j med genet a 2003;116:278-83. 2. gai z, gui t, muragaki y. the function of trps1 in the development and differentiation of bone, kidney, and hair follicles. histol histopathol 2011;26: 915-21. 3. merjaneh l, parks js, muir ab, fadoju d. a novel trps1 gene mutation causing trichorhinophalangeal syndrome with growth hormone responsive short stature: a case report and review of the literature. int j pediatr endocrinol 2014;16. 4. trippella g, lionetti p, naldini s, et al. an early diagnosis of trichorhinophalangeal syndrome type 1: a case report and a review of literature. ital j pediatr 2018;44:138. 5. vaccaro m, tchernev g, wollina u, et al. trichorhinophalangeal syndrome. open access maced j med sci 2017;5:486-9. 6. kim yj, yoon b, han k, park bc. comprehensive transcriptome profiling of balding and non-balding scalps in trichorhinophalangeal syndrome type i patient. ann dermatol 2017;29:597601. 7. lüdecke hj, schaper j, meinecke p, et al. genotypic and phenotypic spectrumin tricho-rhino-phalangeal syndrome types i and iii. am j hum genet 2001;68:81-91. 8. malik th, von stechow d, bronson rt, et al. deletion of the gata domain of trps1 causes an absence of facial hair and provides new insights into the bone disorder in inherited tricho-rhinophalangeal syndromes. mol cell biol 2002;22:8592-600. 9. wen tc, li ys, rajamani k, et al. effect of cinnamomum osmophloeum kanehira leaf aqueous extract on dermal papilla cell proliferation and hair growth. cell transplant 2018;27:25663. 10. chen d, jarrell a, guo c, et al. dermal β-catenin activity in response to epidermal wnt ligands is required for fibroblast proliferation and hair follicle initiation. development 2012;139:1522-33. 11. sun y, nakanishi m, sato f, et al. trps1 deficiency inhibits the morphogenesis of secondary hair follicles via decreased noggin expression. biochem biophys res commun 2015;456:721-6. 12. fantauzzo ka, christiano am. trps1 activates a network of secreted wnt inhibitors and transcription factors crucial tovibrissa follicle morphogenesis. development 2012;139:203-14. 13. suemoto h, muragaki y, nishioka k, et al. trps1 regulates proliferation and apoptosis of chondrocytes through stat3 signaling. dev biol 2007;312: 572-81. 14. zhu k, xu c, liu m, et al. hairless controls hair fate decision via wnt/βcatenin signaling. biochem biophys res commun 2017;491:567-70. 15. botchkarev va, kishimoto j. molecular control of epithelial-mesenchymal interactions during hair follicle cycling. j investig dermatol symp proc 2003;8:46-55. 16. roh c, tao q, lyle s. dermal papillainduced hair differentiation of adult epithelial stem cells from human skin. physiol genom 2004;19:207-17. 17. millar se. molecular mechanisms regulating hair follicle development. j invest dermatol 2002;118:216-25. 18. xiong y, liu y, song z, et al. identification of wnt/β-catenin signaling pathway in dermal papilla cells of human scalp hair follicles: tcf4 regulates the proliferation and secretory activity of dermal papilla cell. j dermatol 2014;41:84-91. 19. lai jj, chang p, lai kp, et al. the role of androgen and androgen receptor in skin-related disorders. arch dermatol res 2012;304:499-510. 20. leirós gj, ceruti jm, castellanos ml, et al. androgens modify wnt agonists/antagonists expression balance in dermal papilla cells preventing hair follicle stem cell differentiation in androgenetic alopecia. mol cell endocrinol 2017;439:26-34. 21. xu z, wang w, jiang k, et al. embryonic attenuated wnt/β-catenin signaling defines niche location and long-term stem cell fate in hair follicle. elife 2015;4:e10567. 22. fantauzzo ka, tadin-strapps m, you y, et al. a position effect on trps1 is associated with ambras syndrome in humans and the koala phenotype in mice. hum mol genet 2008;17:353951. article no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. dr [dermatology reports 2015; 7:5880] [page 15] article the use of chemotherapeutics for the treatment of keloid scars christopher david jones,1 luke guiot,2 mike samy,3 mark gorman,1 hamid tehrani4 1glasgow royal infirmary; 2university hospital ayr; 3st. bartholomew’s and the london school of medicine and dentistry; 4whiston hospital, merseyside, uk abstract keloid scars are pathological scars, which develop as a result of exaggerated dermal tissue proliferation following cutaneous injury and often cause physical, psychological and cosmetic problems. various theories regarding keloidogenesis exist, however the precise pathophysiological events remain unclear. many different treatment modalities have been implicated in their management, but currently there is no entirely satisfactory method for treating all keloid lesions. we review a number of different chemotherapeutic agents which have been proposed for the treatment of keloid and hypertrophic scars while giving insight into some of the novel chemotherapeutic drugs which are currently being investigated. non-randomized trials evaluating the influence of different chemotherapeutic agents, such as 5-fluorouracil (5-fu); mitomycin c; bleomycin and steroid injection, either alone or in combination with other chemotherapeutic agents or alternative treatment modalities, for the treatment of keloids were identified using a predefined pubmed search strategy. twenty seven papers were identified. scar improvement ≥50% was found in the majority of cases treated with 5-fu, with similar results found for mitomycin c, bleomycin and steroid injection. combined intralesional 5-fu and steroid injection produced statistically significant improvements when compared to monotherapy. monotherapy recurrence rates ranged from 0-47% for 5-fu, 015% for bleomycin and 0-50% for steroid injection. however, combined therapy in the form of surgical excision and adjuvant 5-fu or steroid injections demonstrated lower recurrence rates; 19% and 6% respectively. currently, most of the literature supports the use of combination therapy (usually surgery and adjuvant chemotherapy) as the mainstay treatment of keloids, however further investigation is necessary to determine success rates over longer time frames. furthermore, there is the potential for novel therapies, but further investigation is required to elucidate their true efficacy. introduction keloid scars have afflicted humans for many centuries, described as far back as 3000 bc in the edwin smith papyrus.1 keloids are proliferative scars, defined as benign mesenchymal tumors that extend beyond the wound margin, that do not regress spontaneously and tend to recur following excision.2,3 they are characterized by extensive intradermal collagen and glycosaminoglycan deposition.4,5 keloids are a common manifestation following abnormal wound healing, with an incidence of 5% to 16% in high-risk populations, which includes africans, asians and hispanics.5,6 although benign, keloid lesions can cause pain, paresthesia and pruritus, as well as functional and aesthetic impairment. consequently, patients may be burdened with marked physical and psychosocial sequelae.7 many studies have examined the pathophysiology of keloid scarring at the cellular level, but at present the exact underlying mechanisms are yet to be comprehensively understood. many factors such as wound tension, skin pigmentation, genetic predisposition, immunoregulation and skin injury have been implicated in the etiology of keloidogenesis.3,8,9 research into epithelial-mesenchymal interactions between keloid keratinocytes and fibroblasts has suggested that the overproduction of numerous growth factors and cytokines, such as transforming growth factor beta (tgf-β), platelet-derived growth factor, vascular endothelial growth factor (vegf), insulin-like growth factor (igf), interleukin 1 and 6 (il-1 and il-6), interferon beta (inf-β) and tumor necrosis factor alpha (tnf-α) are involved in keloid pathology.4,5,10 in addition, it has also been proposed that abnormalities in the apoptosis pathway may also be linked to keloid genesis; in normal wound healing, apoptosis mediates a reduction in cellularity between granulation tissue and normal scarring.9 mutations in key apoptosis regulator genes, such as p53, bcl-2 and fas, have been demonstrated in keloid fibroblasts, which resulted in lower rates of apoptosis compared to normal controls.3,9,11 on histopathological examination, keloid scars are composed of thick bundles of closely packed type i, iii, iv and v collagen and dilated vessels, both of which are arranged in a haphazardous manner.9,12 in addition to excessive collagen production, keloid fibroblasts also synthesize more elastin, fibronectin and proteoglycan and show abnormal responses to cytokine stimulation compared to normal fibroblasts.3,4 with little known regarding the exact pathophysiological events underlying this condition, the management of a keloid scar is clinically challenging. many treatments have been advocated either alone or in combination, including surgical excision, intralesional chemotherapeutic injection, radiotherapy, laser therapy, cryotherapy, topical silicone, systemic chemotherapy and pressure therapy, most of which have had varying and transient success.10,13,14 in addition, adverse effects from the different treatments may significantly limit any benefits.15 despite the wide range of available treatments, recurrence rates are typically 50-70%.10 at present the most commonly used treatment is intralesional corticosteroid injection, isolated or in association.3,5,16-18 this review will focus on the use of chemotherapeutics for the treatment of keloids and hypertrophic scars. chemotherapeutic drugs it has been well established that through production of ground substance components, collagen synthesis and wound edge tension, fibroblasts are important in the wound healing response.19 at present the main classes of chemotherapeutic drugs which are used in pathological scar treatment are the antitumor/antimetabolite drugs and steroid drugs which include 5fluorouracil, mitomycin c, bleomycin and corticosteroid. these drugs work by halting mitosis in different phases of the cell cycle and consequently inducing suppression of fibroblast proliferation.15 5-fluorouracil dermatology reports 2015; volume 7:5880 correspondence: christopher david jones, glasgow royal infirmary, 84 castle street, glasgow, g4 0sf, uk. tel.: +44.1292.610555. e-mail: cdj9lfc@gmail.com key words: keloid; hypertrophic scar; chemotherapeutic agents. contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. received for publication: 19 february 20115. accepted for publication: 23 march 2015. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright c.d. jones et al., 2015 licensee pagepress, italy dermatology reports 2015; 7:5880 doi:10.4081/dr.2015.5880 no n c om me rci al us e o nly [page 16] [dermatology reports 2015; 7:5880] 5-fluorouracil (5-fu) is a fluorinated pyrimidine analogue with antimetabolite activity. it disrupts the interconversion of uridine into thymidine through inhibiting thymidylate synthase.20,21 it was originally used in the 1980’s as an adjuvant to glaucoma filtering surgery and in recent years for the treatment of a variety of malignancies.2,20 both in vitro and in vivo experiments have shown that 5-fu can inhibit fibroblast proliferation.19,22 in addition, it also has an inhibitory effect on tgf-β induced expression of the type i collagen gene.16 consequently, several studies have investigated the potential application of intralesional 5fu, either as an adjunct to conventional therapy or as an alternative to it, in preventing keloid development and promoting keloid scar resolution.23,24 following positive evidence regarding 5fu’s safety and efficacy in preventing scar formation after trabeculectomy surgery, fitzpatrick began to investigate its use in hypertrophic and keloid scar therapy. over a 9year period, he was able to demonstrated the efficacy of intralesional 5-fu (50 mg/ml) injected into the scars of over 1000 patients as a single agent and as combined with triamcinolone acetate (tac) (1 mg/ml), with and without concomitant use of a pulsed-dye laser.2,24 most patients responded favorably to the 5-fu injections. the most significant responses were obtained with scars that were symptomatic and inflamed, whereas the older, non-inflamed, asymptomatic scars responded less. similar findings have also been reported in another study.25 it has been demonstrated that keloid and hypertrophic scars respond most effectively to intralesional 5-fu when it is given either once weekly or once every 2 weeks.7,16 this correlates well with the other findings of fitzpatrick in that scar response was dramatically improved with more frequent injections.2 nanda and reddy treated the keloid scars of 28 patients with intralesional 5-fu (50 mg/ml) at weekly intervals for a period of 12 weeks. in 78.5% of the patients, improvement (with respect to keloid size, height, induration and associated symptoms) was more than 50%, with no patient showing failure to therapy and no signs of recurrence during a 24-week follow-up period.22 similar findings for small keloids were reported by gupta and kalra.26 kontochristopoulos et al. did a similar study whereby they treated 20 patients once weekly for on average 7 weeks with intralesional 5-fu (50 mg/ml) injections. in 85.0% of the patients, the improvement was more than 50%. in contrast to nanda and reddy, one of their patients did not respond to therapy. of the 19 patients who did, there was a 47.4% recurrence rate within 1 year. they also reported that recurrence correlated directly to keloid duration following successful treatment with 5-fu.25 manuskiatti and fitzpatrick compared the treatment response of keloids and hypertrophic sternotomy scars to intralesional triamcinolone alone or combined with 5-fu, 5-fu single therapy and the 585-nm flashlamppumped pulsed-dye laser (pdl).19 all of the methods produced a statistically significant clinical improvement, however no method was found to be significantly superior.19 in contrast, zhang et al. reported that the effectiveness rate of 5-fu injection alone is 62.5%, whereas the efficacy of combined 5-fu and glucocorticoids was significantly better at 92%. other authors also reported positive effects using similar methods.15,21 in a recent study, haurani et al. showed that surgical excision combined with monthly intralesional 5-fu (50 mg/ml) injections, was an effective way to treat keloid scars in patients who had previously been unresponsive to corticosteroid injections. the recurrence rate was 19% at 1 year follow up.20 intralesional 5-fu is generally well tolerated, commonly encountered adverse effects include: pain at the injection site, ulceration, burning and hyperpigmentation.2,16,19,22,23,25 regarding the aforementioned studies, no systemic complications of 5-fu, such as anemia, leucopenia and thrombocytopenia were reported.16,23 mitomycin c mitomycin c is an antibiotic that was first isolated from streptomyces cespitosus by wakaki in 1958.27 it has both antineoplastic and antiproliferative properties and was initially used in 1963 by kunitomo and mori for the treatment of pterygium.28 since the 1980’s, it has been used as an antiscarring agent in ophthalmologic, airway and sinonasal surgery, as well as for the treatment of tumors of the oral cavity, lungs, pancreas, stomach and bladder.10,27-29 mitomycin c alkylates and cross-links dna at the adenosine and guanine nucleotides, therefore inhibiting dna, rna and protein synthesis.27-29 it has been shown to inhibit fibroblast proliferation and decrease scar formation both in vivo and in vitro.28,29 in addition, mitomycin c has been shown to reduce dna synthesis and decrease the density of cultured keloid fibroblasts.10 furthermore, sewall et al. demonstrated that topical application of mitomycin c to full thickness skin lesions in mice resulted in significantly smaller rates of wound contraction.29 these properties have contributed to its interest in recent years as a potential agent for the treatment of keloid scars. in one study, stewart and kim treated 10 patients with topical mitomycin c (0.4 mg/5 ml) for 4 minutes following the excision of head and neck keloids. at mean follow up of 8 months (range, 6 to 14 months), there was a 10% recurrence rate.10 in contrast, when saunders et al. treated post excisional keloid wound beds with topical mitomycin c (0.4 mg/ml) for 5 minutes the recurrence rate at 9 months was 28.6%. however, there was no significant difference in outcome between treated and untreated keloids (p>0.99) thus the authors concluded that topical mitomycin c made no difference in the prevention of keloid recurrence following surgical excision.30 recently, ribeiro et al. demonstrated that when mitomycin c was topically applied to rats it caused delayed wound healing in the first four weeks following treatment. however, after twelve weeks both the treated and untreated wounds showed the same histological characteristics.27 the authors suggested that this drug delays, but does not inhibit, the final degree of fibrosis.27 similar results were found by simman et al. following application of mitomycin c (0.1 mg/ml) to human keloid fibroblasts in vitro.31 when used topically, mitomycin c appears to be a relatively safe and well tolerated agent, however further studies should be undertaken to determine effective dosages and application intervals.10,27 bleomycin bleomycin is a cytotoxic antibiotic derived from streptomyces verticellus. it has antineoplastic, antibacterial and antiviral properties and has been used for many years in dermatological practice for treating recalcitrant plantar warts, cutaneous neurofibromas and keratoacanthomas.4,14,32 in addition, it is frequently used for treating various malignancies.32 more recently, its use has been focused in the treatment of keloid and hypertrophic scars. the exact mechanism of action by which bleomycin resolves keloids and hypertrophic scars is unclear but several possible explanations have been proposed.14 it has been shown that cultured human dermal fibroblasts treated with bleomycin have diminished collagen synthesis, even when tgf-β1 is applied.14,33 similarly, administration of bleomycin to cultured fibroblasts has been found to cause a reduction in lysyl-oxidase levels.34 lysyl-oxidase is a crosslinking enzyme involved in collagen maturation.14 its concentration may be normal or raised in keloid and hypertrophic scars.4 furthermore, it has also been reported that bleomycin induces apoptosis.14 in 1996, bodokh and brun were the first to report the use of bleomycin for scar therapy. they treated 31 keloids and 5 hypertrophic scars with 3 to 5 intralesional infiltrations of review no n c om me rci al us e o nly [dermatology reports 2015; 7:5880] [page 17] bleomycin within a 1-month period. total regression was obtained in 84% of scars.32 in another study, espana et al. injected 1.5 u/ml bleomycin into keloid and hypertrophic scars of 13 patients using a multiple needle puncture approach. patients received between 1-5 treatments, each session held 1-4 months apart. all patients were relieved of pruritus after the first session. complete flattening of the scar was achieved in 53.8% of patients and in the other 46.2% of patients there was a >75% resolution in scar thickness. at 12 months follow up, there was a 15.4% recurrence rate.32 using a different approach, saray and gulec administered monthly intralesional bleomycin (1.5 u/ml) into 15 keloid and hypertrophic scars using a jet injector. here, 73.3% of scars became completely flat and in the other 26.7% there was >50% reduction in thickness. during the mean follow up period of 19 months, there were no reported recurrences.14 more recently, naeini et al. compared the efficacy of bleomycin tattoo monotherapy with that of cryotherapy combined with intralesional triamcinolone (tac) injection. in the cryotherapy combined with tac group, lesions less than 100 mm2 showed a significantly better response than larger lesions (p=0.007), whereas in the bleomycin group, the size of lesion did not affect the rate of resolution. there was no statistical difference between the two groups in lesions less than 100 mm2. however in larger lesions, the therapeutic response to bleomycin was significantly better.4 in contrast to the study by espana et al., 22% of patients in the bleomycin group remained symptomatic. the most commonly encountered side effects include: pain, superficial ulceration and crusting at the sites of injection, transient hyperpigmentation (seen in skin phototypes iii and iv) and dermal atrophy.4,14,32 it is known that systemic administration of high dose bleomycin can cause pulmonary, renal and cutaneous fibrosis, hepatotoxicity and bone marrow suppression. at present, no systemic toxicity has been reported with low doses of this drug.14 corticosteroids corticosteroids have been used for the treatment of keloid and hypertrophic scars since 1960.35 many different corticosteroids are used clinically, with intralesional triamcinolone acetonide (tac) being the most common, whether alone as a monotherapy or combined with another type of treatment.17,35 all the literature relating to the role of tac in keloid and hypertrophic scar therapy suggests that a dose of 10-40 mg/ml is required to be effective.7 the recommended treatment interval has arbitrarily varied from intervals of 4 to 6 weeks; given for a period of several months or until the scar is flattened.16 intralesional corticosteroid administration has shown a clinical efficacy of 50-100% and a recurrence rate ranging between 9% and 50%.16,35 there are numerous reported mechanisms by which corticosteroids influence scar formation. some of the described modes of action include: reduction in fibroblast proliferation, suppression of components involved in the inflammatory response, attenuation of pro-collagen and ground substance synthesis and decreased endothelial budding.17,35-37 in addition, many studies have demonstrated that corticosteroids regulate the expression of numerous growth factors that are involved in wound healing, such as tgf-β, insulin-like growth factor-1, vegf and alpha-globulins.17,35,38 caroll et al. found that application of tac to in vitro human dermal fibroblasts obtained from normal skin and keloid scars caused the production of basic fibroblast growth factor (bfgf) and tgf-β1 to increase and decrease respectively.35 recently, wu et al. found that dexamethasone retarded keloid fibroblast proliferation and suppressed endogenous vegf-a mrna expression.5 vegf is a proangiogenic cytokine which promotes neo-vascularization and cell growth during wound healing. in vitro studies have indicated that vegf expression is higher in keloid fibroblasts compared to controls.5,39 corticosteroids exert their effects through binding to a glucocorticoid cytoplasmic receptor, which ultimately influences the transcription of various genes. in studies where intralesional tac has been used as a monotherapy, it has been shown to cause a statistically significant decrease in keloid height, length, width, associated pruritus and erythema, and improves pliability.7,16 in addition, subjective and objective improvements in keloid appearance have also been noted in patients treated with intralesional tac.7,16 however, in studies where corticosteroids have been used in combination with other modes of therapy, such as 5-fu, ifn-α2b and 585-nm flashlamp-pumped pulsed-dye laser (pdl), the measured parameters, which included scar height, length, width, volume, pliability, associated erythema and pruitus, and subjective and objective assessment of improvements in keloid appearance, all showed statistically significant improvements compared to patients treated with tac monotherapy.7,16,35 tac has also been found to show efficacy when used as an adjunct to surgical excision.36 using this method, recurrence rates are on average less than 50%.35 it has been suggested that surgical excision with intraoperative injection of intralesional tca followed by weekly injections over a 2 to 5 week period and then monthly injections for 4 to 6 months may produce optimal results.35 using a similar approach, hamrick et al. reported a 6% recurrence rate at 6 months follow up when they treated paediatric earlobe keloids with intralesional tac preoperatively, intraoperatively and at 4 weeks post-operatively.40 donkor described a technique of injecting intralesional tac (40 mg/ml) into head and neck keloid scars at 10-14 days post-operative and then at 4-week intervals on 2 additional occasions. at 2 years follow up, there was no recurrence.36 despite the benefits of intralesional corticosteroids, several adverse side effects have been reported, which include altered pigmentation, telangiectasia, skin atrophy, injection pain, ulceration and cushingoid habitus.4,7,16,35 it has been suggested that the combined use of intralesional 5-fu and low-dose corticosteroid may yield fewer undesirable side effects compared with intralesional corticosteroid monotherapy.23 furthermore, lignocaine anesthesia may be co-administered with intralesional tac to reduce injection pain.35 on account of their side effect profile, the use of topical steroids was proposed as an alternative to intralesional steroids. however, recently it was demonstrated that topically applied steroids failed to diminish scar formation.15 potential therapies in addition to the aforementioned chemotherapeutic agents, there are numerous alternative pharmacological agents that are currently being investigated for the management of hypertrophic scars and keloids. these include imiquimod, colchicine, botulinum toxin, tamoxifen citrate, and angiotensin converting enzyme (ace) inhibitors.41 imiquimod is a topical therapeutic agent that acts as an immune-response modulator by inducing expression of interferon alpha and gamma (ifn-α,g), tissue necrosis factor alpha and interleukins -1, -6, -8 and -12.6,9 jacob et al. found that imiquimod significantly altered proapoptotic gene expression in keloid tissue.9 from its ability to induce ifn-α and g expression, which in turn inhibits human fibroblast collagen production, studies have been undertaken to see if it could be used as an adjuvant to surgical excision. the results have been variable, with some studies reporting low rates of recurrence, while others report high rates.13,42 colchicine is an antimitotic agent commonly used for cancer therapy because of its ability to inhibit collagen synthesis, cause microtubu review no n c om me rci al us e o nly [page 18] [dermatology reports 2015; 7:5880] lar disruption and increase the activity of collagenase.21,41 peacock et al. studied the effects of colchicine in 10 patients with scars and reported positive results. however, because of its narrow therapeutic window its application is restricted.21 through its ability to reduce wound edge tension, there has been recent interest in the potential role of botulinum toxin type a as a therapeutic agent for reducing scar tissue formation.41 zhibo and miaobo carried out a twelve patient study whereby they administered intralesional botulinum toxin type a (35 u/ml) at 3-month intervals for a maximum of 9 months. good results were obtained in all of the patients and there were no serious adverse sequelae. keloids of long duration and large size were responsive to botulinum toxin type a and after one year follow up there was no evidence of recurrence.43 transforming growth factor (tgf) β1 is a key cytokine involved in wound repair. it has been demonstrated that both tgf-β1 and β2 are overproduced by keloid fibroblasts compared with normal fibroblasts.44,45 tamoxifen citrate is a synthetic anti-estrogen, which through its ability to modulate the synthesis of multiple growth factors has been shown to inhibit keloid fibroblast proliferation and decrease collagen production.46 recent keloid fibroblast culture studies have shown that tamoxifen causes a dose-dependent reduction in the production of tgf-β in these cells.44,47 the local renin-angiotensin system is also known to play a role in the control of collagen biosynthesis and wound healing. when ardekani et al. topically applied captopril, a ace inhibitor, to new zealand white rabbits, they effectively prevented hypertrophic scar formation. recently, they reported the first successfully treated human case.48 in addition to the above, research evaluating the use of camptothecin and dhmeq as antiscarring treatments has been conducted.3,37 zhang et al. studied the effects of camptothecin (cpt), a topoisomerase i inhibitor, on collagen synthesis in cultured dermal fibroblasts obtained from normal skin and keloid scars. here, the keloid fibroblasts showed a dose-dependent reduction in synthesis of type i collagen without significant cellular toxicity.3 makino et al. found that dehydroxymethylepoxyquinomicin (dhmeq), a nf-kb inhibitor, markedly reduced keloid fibroblast proliferation and type i collagen expression in vitro.37 nuclear factor kappa b (nf-kb) is a transcription factor involved in the regulation of genes associated with the immune and inflammatory pathway, cellular proliferation and apoptosis. recently, it has been reported that the nf-kb pathway is also involved in keloid pathogenesis. further investigation of these two novel therapies is required to elucidate their true efficacy. conclusions although the exact mechanisms which underlie the physiopathogenesis of keloid scars are yet to be fully understood, a variety of therapies have been tested in an attempt to combat the characteristic aggressive and expansive nature of these benign cutaneous tumours.4,19 many of the chemotherapeutic agents that have been used in the treatment of keloid scars, work by modulating tissue repair. through direct and indirect effects on dermal fibroblast proliferation and collagen synthesis, many of these agents have proved quite effective at preventing recurrence and improving the aesthetic features of the scar. however, at present no one single agent has demonstrated the ability to cause complete scar resolution and thus the treatment of keloid scars and hypertrophic scars still presents a major therapeutic dilemma.15 in addition to problems with drug efficacy, intolerance and side effects, many of the studies themselves have limitations. for example, there is a significant variation in study design, size and methods of classifying the groups, with many combining both hypertrophic scars and keloids when describing the treatment regimens.18 many of the studies treat all scars with the same regimens even though they vary according to size and age; potentially a standardized grading system would allow for more objective treatment comparisons. the criteria used for patient selfassessment and observer assessment of scar improvement needs to be more clearly clarified. furthermore, there has been considerable variation in the follow-up period post treatment and many studies have problems with patient compliance during this period.18 at present, since there is no optimal treatment modality, all potential adverse effects should be explained to the patient when deciding on the most appropriate therapy so that compliance is improved. currently, the majority of the literature supports the use of combination therapy as the mainstay treatment of keloids.40 many of the combination therapies, such as surgical excision combined with adjuvant intralesional tac, or combined 5-fu, tac and 585 nm-pdl have shown greater efficacy and fewer side effects when compared to controls. however, further investigation will be necessary to determine success rates over longer timeframes.49 references 1. cheng et, nowak kc, koch rj. effect of blended carbon dioxide and erbium: yag laser energy on preauricular and ear lobule keloid fibroblast secretion of growth factors. arch facial plast surg 2001;3:2527. 2. fitzpatrick re. treatment of inflamed hypertrophic scars using intralesional 5fu. dermatol surg 1999;25:224-32. 3. zhang gy, gao wy, li x, et al. effect of camptothecin on collagen synthesis in fibroblasts from patients with keloid. ann plast surg 2009;63:94-9. 4. naeini f, najafian j, ahmadpour k. bleomycin tattooing as a promising therapeutic modality in large keloids and hypertrophic scars. dermatol surg 2006;32: 1023-30. 5. wu w, wang f, yang k et al. dexamethasone induction of keloid regression through effective suppression of vegf expression and keloid fibroblast proliferation. j invest dermatol 2006;126: 1264-71. 6. berman b, villa a. imiquimod 5% cream for keloid management. dermatol surg 2003;29:1050-1. 7. asilian a, darougheh a, shariati f. new combination of triamcinolone, 5fluorouracil, and pulsed-dye laser for treatment of keloid and hypertrophic scars. dermatol surg 2006;32:907-15. 8. he s, liu x, yang y, et al. mechanisms of transforming growth factor β1/smad signalling mediated by mitogen-activated protein kinase pathways in keloid fibroblasts. br j dermatol 2009;162:538-46. 9. jacob s, berman b, nassiri m, et al. topical application of imiquimod 5% cream to keloids alters expression genes associated with apoptosis. br j dermatol 2003;149:62-5. 10. stewart iv ce, kim jy. application of mitomycin-c for head and neck keloids. otolaryngol head neck surg 2006;135:94650. 11. ladin da, hou z, patel d, et al. p53 and apoptosis alterations in keloids and keloid fibroblasts. wound repair regen 1998;6:28-37. 12. rusciani l, paradisi a, alfano c, et al. cryotherapy in the treatment of keloids. j drugs dermatol 2006;5:591-5. 13. cação f, tanaka v, messina m. failure of imiquimod 5% cream to prevent recurrence of surgically excised trunk keloids. dermatol surg 2009;35:629-33. 14. saray y, güleç a. treatment of keloids and hypertrophic scars with dermojet injections of bleomycin: a preliminary study. int j dermatol 2005;44:777-84. 15. xi-qiao w, ying-kai l, chun q, et al. a review of the effectiveness of antimitotic drug injections for hypertrophic scars and review no n c om me rci al us e o nly [dermatology reports 2015; 7:5880] [page 19] keloids. ann plastic surg 2009;63:688-92. 16. darougheh a, asilian a, shariati f. intralesional triamcinolone alone or in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars. clin exp dermatol 2007;34:219-23. 17. hochman b, locali rf, matsuoka pk, et al. intralesional triamcinolone acetonide for keloid treatment: a systematic review. aesth plast surg 2008;32:705-9. 18. hom db. treating the elusive keloid. arch otolaryngol head neck surg 2001;127:1140-3. 19. manuskiatti w, fitzpatrick r. treatment response of keloidal and hypertrophic sternotomy scars: comparison among intralesional corticosteroid, 5-fluorouracil, and 585-nm flashlamp-pumped pulsed-dye laser treatments. arch dermatol 2002;138:1149-55. 20. haurani m, foreman k, yang j, et al. 5fluorouracil treatment of problematic scars. plast reconstr surg 2009;123:13948. 21. wang x, liu y, wang z, et al. antimitotic drug injections and radiotherapy: a review of the effectiveness of treatment for hypertrophic scars and keloids. int j low extrem wounds 2008;7:151-9. 22. nanda s, reddy b. intralesional 5-fluorouracil as a treatment modality of keloids. dermatol surg 2004;30:54-7. 23. apikian m, goodman g. intralesional 5-fluorouracil in the treatment of keloid scars. australas j dermatol 2004;45:140-3. 24. goldan o, weissman o, regev e, et al. treatment of postdermabrasion facial hypertrophic and keloid scars with intralesional 5-fluorouracil injections. aesthetic plast surg 2008;32:389-92. 25. kontochristopoulos g, stefanaki c, panagiotopoulos a, et al. intralesional 5fluorouracil in the treatment of keloids: an open clinical and histopathologic study. j am acad dermatol 2005;52:474-9. 26. gupta s, kalra a. efficacy and safety of intralesional 5fluorouracil in the treatment of keloids. dermatology 2002;204:130-2. 27. ribeiro fa, guaraldo l, borges jp, et al. clinical and histological healing of surgical wounds treated with mitomycin c. laryngoscope 2004;114:148-52. 28. rahbar r, jones dt, nuss rc, et al. the role of mitomycin in the prevention and treatment of scar formation in the pediatric aerodigestive tract. arch otolaryngol head neck surg 2002;128:401-6. 29. sewall gk, robertson km, connor np, et al. effect of topical mitomycin on skin wound contraction. arch facial plast surg 2003;5:59-62. 30. sanders kw, gage-white l, stucker fj. topical mitomycin c in the prevention of keloid scar recurrence. arch facial plast surg 2005;7:172-5. 31. simman r, alani h, williams f. effect of mitomycin c on keloid fibroblasts: an in vitro study. ann plast surg 2003;50:71-6. 32. espana a, solano t, quintanilla e. bleomycin in the treatment of keloids and hypertrophic scars by multiple needle punctures. dermatol surg 2001;27:23-7. 33. hendricks t, martens mf, huyben cm, et al. inhibition of basal and tgf betainduced fibroblast collagen synthesis by antineoplastic agents. implications for wound healing. br j cancer 1993;67:54550. 34. yeowell hn, marshall mk, walker lc, et al. regulation of lysly oxidase mrna in dermal fibroblasts from normal donors and patients with inherited connective tissue disorders. arch biochem biophys 1994;308: 299-305. 35. roques c, téot l. the use of corticosteroids to treat keloids: a review. int j lower extremity wounds 2008;7:137-45. 36. donkor p. head and neck keloid: treatment by core excision and delayed intralesional injection of steroid. j oral maxillofac surg 2007;65:1292-6. 37. makino s, mitsutake n, nakashima m, et al. dhmeq, a novel nf-kappab inhibitor, suppresses growth and type i collagen accumulation in keloid fibroblasts. j dermatol sci 2008;51:171-80. 38. diegelmann rf, bryant cp, cohen ik. tissue alpha-globulins in keloid formation. plast reconstr surg 1977;59:418-24. 39. gira ak, brown lf, washington cv, et al. keloids demonstrate high-level epidermal expression of vascular endothelial growth factor. j am acad dermatol 2004;50:850-3. 40. hamrick m, boswell w, carney d. successful treatment of earlobe keloids in the pediatric population. j pediatr surg 2009;44:286-8. 41. leventhal d, furr m, reiter d. treatment of keloids and hypertrophic scars: a metaanalysis and review of the literature. arch facial plast surg 2006;8:362-8. 42. kaufman j, berman b. topical application of imiquimod 5% cream to excision sites is safe and effective in reducing keloid recurrences. j am acad dermatol 2002;47:20911. 43. zhibo x, miaobo z. view points: intralesional botulinum toxin type a injection as a new treatment measure for keloids. plast reconstr surg 2009;124:253-79. 44. mikulec a, hanasono m, lum j, et al. effect of tamoxifen on transforming growth factor beta1 production by keloid and fetal fibroblasts. arch facial plast surg 2001;3:111-4. 45. lee ty, chin gs, kim wjh, et al. expression of transforming growth factorβ 1, 2 and 3 proteins in keloids. ann plast surg 1999;43:179-84. 46. mancoll js, macauley rl, phillips lg. the inhibitory effect of tamoxifen on keloid fibroblasts. surg forum 1996;47:718-20. 47. chau d, mancoll js, lee s, et al. tamoxifen downregulates tgf-b production in keloid fibroblasts. ann plast surg 1998;40:490-3. 48. ardekani gs, aghaie s, nemati mh et al. treatment of a postburn keloid scar with topical captopril: report of the first case. plast reconstr surg 2009;123:108-27. 49. dinh q, veness m, richards s. role of adjuvant radiotherapy in recurrent earlobe keloids. australas j dermatol 2004;45:1626. review no n c om me rci al us e o nly dr [page 36] [dermatology reports 2015; 7:6063] severity of depression and anxiety in patients with alopecia areata in bandar abbas, iran shahram baghestani,1 shahram zare,2 seyed hamzeh seddigh3 departments of 1dermatology, 2community medicine, 3psychiatry, school of medicine, hormozgan university of medical sciences, bandar abbas, iran abstract alopecia areata (aa) is a chronic disease which esthetic outcomes may result in deep effects on mental disorders of patients. in this case-control study, we compared the mental health of 68 patients diagnosed with aa with 68 healthy individuals using hamilton anxiety and depression rating scales. there were significant differences between the case and control groups regarding the prevalence of anxiety and depression. the means of anxiety scores in cases and control group were 12.76±7.21 vs 8.54±6.37, p=0.003. likewise, the means of depression scores for the groups were 12.84±4.03 vs 6.22±4.95, p=0.001. further more, patients with aa were exposed to depression approximately five times and to anxiety about three times more than normal people. our study revealed a high prevalence of anxiety and depression in aa patients. dermatologists should pay more attention on psychological effect of the disease on the patients. introduction alopecia areata (aa) is considered as a chronic and common inflammatory disease that affects mostly hair follicles along with nails involvement in few cases. this disorder, which is characterized by the sudden hair loss on the scalp or other hair bearing areas, is seen in both sexes, at all ages. various factors, including genetic, endocrine, immunologic, infectious, spiritual, and psychological factors are supposed to have a role in its pathogenesis.1 the role that psychological factors play in the pathogenesis of aa has been the subject of discussion for decades. numerous studies have been done in relation to this matter that has resulted in controversial outcomes.2-14 the objective of our study was to investigate the severity of anxiety and depression in patient with aa. materials and methods this case-control study, was carried out on 68 confirmed patients (>18 years old) suffering from aa (on scalp) referred to the skin clinic, affiliated to hormozgan university of medical sciences (bandar abbas, iran). sixty eight healthy people from general population selected as control, matched with the case group by age, sex and the level of education. informed consent was obtained, and according to severity of disease on scalp, patients were divided into five groups (s1: 0-25%, s2: 2649%, s3: 50-74%, s4: 75-99% and s5: 100%) based on olsen/canfield criteria.14 according to the location of the disease onset, the patients were classified into four groups as follow: temporal, occipital, frontal and multifocal. finally, from the view point of education level, the participants were grouped as primary, secondary and higher education. severity of anxiety and depression were assessed respectively by the use of persian versions of hamilton anxiety rating scale (hama) and hamilton depression rating scale (ham-d).15,16 all statistical analyses were performed by means of spss-16 (spss inc. chicago, il, usa). t-student, analysis of variance and chisquare tests were used to compare the groups. logistic regression was applied to estimate odds ratios of the disease for each of the outcome variables. p-value<0.05 was considered as significant. results seventy-two percent of both cases and controls were male. the age range for the cases was from 19 to 64 with average of 35.4±7.6 years and for the control group was 20 to 63 with average of 33.8±8.1 years. when compared the two groups, no significant difference regarding age and sex could be observed. the mean of disease duration in men and women was 22.7 and 20.8 months, respectively. based on ham-a, there were 32 cases (47%) suffering from anxiety. the mean of anxiety scale in case group was significantly more than that of the control group (12.76±7.21 vs 8.54±6.37; p=0.003). moreover, according to ham-d, there were 38 cases (56%) suffering from a degree of depression. the mean of depression scale in case group was significantly more than the control group (12.84±4.03 vs 6.22±4.95; p=0.001). table 1 demonstrates the frequency of anxiety and depression severity in case and control groups based on sex. the severity of anxiety and depression was significant in both the groups (p<0.05). odds ratios (or) were calculated using a bivariate logistic regression model in order to measure the strength of the relationship between the disease and depression or anxiety. results show that, patients with aa are exposed to depression approximately five times more than normal people (or=4.48; 95%ci: 2.12-9.44). however, the odds ratio of anxiety originated from aa was 2.72 (95%ci: 1.30-5.68). table 1 shows the severity of anxiety and depression in the case and control groups based on sex. a degree of anxiety was observed in 44.9% of men and 52.7% of women in case group compared with 16.3% of men and 42.1% of women in control group. moreover, 53.1% of men and 63.2% of women in case group and 18.4% of men and 31.6% of women in control group were suffering from depression. mean scores for anxiety and depression were significantly different in the case and control groups (p=0.003). in this study, comparison of prevalence, severity of anxiety, and severity of depression between the two groups revealed no significant difference with respect to age, whereas a dermatology reports 2015; volume 7:6063 correspondence: shahram zare, department of community medicine, hormozgan university of medical sciences, jomhoori blvd. mohammadi hospital, education department, 7919915519 bandar abbas, iran tel.: +98.917.161.3924 fax: +98.763.333.7618. e-mail: shzare159@gmail.com key words: alopecia areata; depression; anxiety; iran. acknowledgements: the authors would like to thank the research and information technology department of hormozgan university of medical sciences for funding the research. contributions: sb, sz, references search, manuscript writing; shs, data collecting; sz, data analyzing; sb, sz, shs, manuscript reviewing. conflict of interest: the authors declare no potential conflict of interest. funding: the study was financially supported by vice-chancellor for research and information technology, hormozgan university of medical sciences. received for publication: 7 june 2015. revision received: 1 october 2015. accepted for publication: 2 october 2015. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright s. baghestani et al., 2015 licensee pagepress, italy dermatology reports 2015; 7:6063 doi:10.4081/dr.2015.6063 no n c om me rci al us e o nly [dermatology reports 2015; 7:6063] [page 37] highly significant difference was observed from the education level’s point of view. table 2 shows the prevalence of anxiety of case and control groups based on education level. the prevalence of anxiety and depression was significantly different between the case and control groups considering the education level in two levels of primary and secondary education (p-values<0.05) (table 2). regarding the means of anxiety and depression when it comes to the level of severity of the disease (table 3), the results showed that there was significant difference in anxiety and depression mean scores based on the severity of disease (p-values<0.05). no significant relationship was observed concerning the mean of anxiety and depression and the onset location of the disease. likewise, there was no significant correlation between duration of the disease, and the severity of anxiety or the severity of depression. discussion the purpose of this paper is to investigate the psychological effects of alopecia areata. alopecia areata, which can be considered as a triggering factor in psychological disorders such as anxiety and depression, have been the subject of many previous studies, with contradictory results.5-12 the present study revealed that psychological disorders are prevalent in patients with aa; this is in accordance with the results of other studies carried out on adults with aa.8-10,13,14 however, yasemi and colon in their studies had observed no difference between case and control groups.6,11 despite the fact that aa patients compared to the general population are more suffering from anxiety and depression, the disorder may not confirm the etiological role of psychological factors, it suggests that anxiety and depression are named as comorbid mental disorders. this aspect is matched with the perspective of sadock et al.17 about the role of psychological factors involved in this disease. they stated that, although the role of stressful events in onset and aggravation of aa is not clear, still comorbid mental disorders have been seen. psychological diagnoses such as substantial depression, generalized anxiety disorder and paranoid disorders have been reported in article table 1. frequency of anxiety and depression in case and control groups based on sex. mental disorder case (n=68), n (%) control (n=68), n (%) p-value anxiety mean±sd 12.76±4.21 8.54±3.37 0.003 male 22 (44.9) 8 (16.3) 0.001 weak 11 (22.4) 5 (10.2) mild 9 (18.4) 3 (6.1) severe 2 (4.1) 0 (0.0) female 10 (52.7) 8 (42.1) 0.022 weak 3 (15.8) 5 (26.3) mild 4 (21.1) 2 (10.5) severe 3 (15.8) 1 (5.3) depression mean±sd 12.84±4.03 6.22±1.95 0.003 male 26 (53.0) 9 (18.4) 0.001 weak 6 (16.3) 2 (4.1) mild 7 (14.3) 0 (0.0) severe 11 (22.4) 7 (14.3) female 12 (63.2) 6 (31.3) 0.001 weak 3 (15.8) 3 (15.8) mild 4 (21.1) 0 (0.0) severe 5 (26.3) 3 (15.8) sd, standard deviation. table 2. prevalence of anxiety and depression in the patients based on education level. case (n=68) control (n=68) primary, n (%) secondary, n (%) higher, n (%) primary, n (%) secondary, n (%) higher, n (%) anxiety no 16 (44.4) 19 (52.8) 1 (2.8) 22 (42.3) 23 (55.8) 1 (1.9) yes 10 (31.3)a 20 (62.5)a 2 (6.2) 7 (43.8)b 8 (50.0)b 1 (6.2) depression no 10 (33.3) 18 (60.0) 2 (6.7) 21 (39.6) 30 (56.6) 2 (3.8) yes 17 (44.8)c 20 (52.6)c 1 (2.6) 8 (53.3)d 6 (40.0)d 1 (6.6) ap=0.012, bp=0.038, cp=0.023, dp=0.028. table 3. mean of anxiety and depression scores of the patients based on severity of the disease. severity of the disease n (%) anxiety,a mean±sd depression,b mean±sd s1 25 (36.8) 11.45±4.07 11.55±5.35 s2 22 (32.3) 12.89±4.33 11.86±6.41 s3 10 (14.7) 14.15±5.27 12.98±4.32 s4 6 (8.8) 14.21±3.51 14.17±2.42 s5 5 (7.4) 15.19±3.35 13.14±3.12 total 68 (100) 12.76±4.21 12.84±4.03 sd, standard deviation. ap=0.038,bp=0.041. no n c om me rci al us e o nly [page 38] [dermatology reports 2015; 7:6063] many cases.17 in our study, like firooz who reported no relationship between the concerns of patients about their disease and their age,18 there was no significant difference between prevalence, severity of anxiety and severity of depression in aa patients and the control group when discussing the age. whereas, safa reported that the number of severe cases of depression in 16-25 age-group was more than other agegroups.9 this difference might be due to differences in age groups or lack of control group in safa study.9 in our study, females were differentiated with males by higher prevalence of anxiety and depression. these findings are in accordance with results of other studies that indicated a higher prevalence of psychiatric disorders among females with aa.1,9 the researcher suggested that it was due to higher rate of aesthetic stress for women. nevertheless, firooz found no relationship between patients’ concerns about the outcomes of the disease and sex.18 definitely, to study the role of sex in development of mental disorders in aa patients, considerable number of cases is required to be studied and investigated. our findings also showed a significant statistical difference between those with primary and secondary education level concerning the prevalence of anxiety and depression. nevertheless, safa and firooz showed that there was not a significant relationship between education level and psychological disorders in the patients.9,18 in line with many published studies, our findings revealed a significant difference in average anxiety and depression scores based on extent of the disease.1,19 this finding may confirm that stressful events in life can be considered as an accelerating factor for the onset of aa, as manolache in a study on 114 aa patients concluded that trauma and acute anxiety were the most common causes of aa.20 no significant relationship was observed between neither the onsite location of the disease and anxiety nor the onsite location and depression. safa also reported the same results.9 in our patients, there was not a significant relationship between average anxiety and depression scores and duration of the disease. safa also did not find relationship between psychological disorders and duration of disease.9 however, firooz pointed out the direct relationship between increased patient’s concerns with that of the increased duration of disease.18 conclusions although the fact that aa patients compared to the general population are more suffering from anxiety and depression disorders, but it may not confirm the etiological role of psychological factors, it suggests anxiety and depression as comorbid mental disorders. references 1. sellami r, masmoudi j, ouali u, et al. the relationship between alopecia areata and alexithymia, anxiety and depression: a case-control study. indian j dermatol 2014;59:421-8. 2. chu sy, chen yj, tseng wc, et al. psychiatric comorbidities in patients with alopecia areata in taiwan: a case control study. br j dermatol 2012;166:525-31. 3. ghanizadeh a, ayoobzadeh a. a review of psychiatric disorders comorbidities in patients with alopecia areata. int j trichology 2014;6:2-4. 4. alfani s, antinone v, mozzetta a, et al, psychological status of patients with alopecia areata. acta derm venereol 2012;92:304-6. 5. schmitt jv, riberio cf, souza fh, at al. hair loss perception and symptoms of depression in female outpatients attending a general dermatology clinic. an bras dermatol 2012;87:412-7. 6. yasemi mt, mansouri p, personal characteristics and anxiety severity in patients with regional hair loss. kerm med sci j 1994;2:65-70. 7. gulec at, tanriverdi n, duru c, et al. the role of psychological factors in alopecia areata and the impact of the disease on the quality of life. int j dermatol 2004;43:352-6. 8. kose o, sayar k, ebrinc s. psychometric assessment of alopecia areata patients before and after dermatological treatment. bull clin psychopharmacol 2000;10:21-5. 9. safa m, jabreili r, moamen-nasab m. depression and anxiety frequency in patients with alopecia areata, referred to dermatology and psychology clinics of khorram abad. yafteh 2007;9:33-7. 10. kalafi y, mousavi-nasab m, tobaei s, et al. the role of psychiatric disorder in paitient with alopecia areata. iran j med sci 1993;18:21-5. 11. colón ea, popkin mk, callies al, et al. lifetime prevalence of psychiatric disorders in patients with alopecia areata. compr psychiatry 1991;32:245-51. 12. sayar k, köse o, ebrinç s, cetin m. hopelessness, depression and alexithymia in young turkish soldiers suffering from alopecia areata. dermatol psychosomat 2001;2:12-5. 13. diaz-atienza f, gurpegui m. environ mental stress but not subjective distress in children or adolescents with alopecia areata. j psychosom res 2011;71:102-7. 14. olsen ea, hordinsky mk, price vh, et al. alopecia areata investigational assessment guidelines-part ii. national alopecia areata foundation. j am acad dermatol 2004;51:440-7. 15. hamilton m. the assessment of anxiety states by rating. br j med psychol 1959;32:50-5. 16. williams jbw. a structured interview guide for the hamilton depression rating scale. arch gen psychiatry 1988;45:742-7. 17. sadock bj, sadock va, kaplan hi. comprehensive textbook of psychiatry. 8th ed. vol. 3. philadelphia: williams & wilkins; 2005. 18. firooz a, firoozabadi mr, ghazisaidi b, dowlati y. concepts of patients with alopecia areata about their disease. bmc dermatol 2005;5. 19. ruiz-doblado s, carrizosa a, garciahernandez mj. alopecia areata: psychiatric comorbidity and adjustment to illness. int j dermatol 2003;42:434-7. 20. manolache l, benea v. stress in patients with alopecia areata and vitiligo. j eur acad dermatol venereol 2007;21:921-8. article no n c om me rci al us e o nly 429 too many requests you have sent too many requests in a given amount of time. dr [dermatology reports 2015; 7:6246] [page 39] exploring valrubicin’s effect on propionibacterium acnes-induced skin inflammation in vitro and in vivo louise rottboell,1 sarah de foenss,1 kenneth thomsen,2 helle christiansen,1 stine m. andersen,1 tomas n. dam,3 cecilia rosada,1 karin stenderup1 1department of dermatology, aarhus university hospital; 2department of biomedicine, aarhus university; 3department of dermatology, roskilde hospital, denmark abstract acne is a common skin disease involving colonization with propionibacterium acnes (p. acnes), hyperproliferation of the follicular epithelium and inflammatory events. valrubicin is a second-generation anthracycline, non-toxic upon contact, and available in a topical formulation. valrubicin’s predecessor doxorubicin possesses antibacterial effects and previously we demonstrated that valrubicin inhibits keratinocyte proliferation and skin inflammation suggesting beneficial topical treatment of acne with valrubicin. this study aims to investigate valrubicin’s possible use in acne treatment by testing valrubicin’s antibacterial effects against p. acnes and p. acnes-induced skin inflammation in vitro and in vivo. valrubicin was demonstrated not to possess antibacterial effects against p. acnes. additionally, valrubicin was demonstrated not to reduce mrna and protein expression levels of the inflammatory markers interleukin (il)1β, il-8, and tumor necrosis factor (tnf)-α in vitro in human keratinocytes co-cultured with p. acnes. moreover, in vivo, valrubicin, applied both topically and intra-dermally, was not able to reduce signs of inflammation in mouse ears intra-dermally injected with p. acnes. taken together, this study does not support beneficial antibacterial and anti inflammatory effects of topical valrubicin treatment of acne. introduction acne vulgaris is one of the most common skin diseases worldwide affecting more than 85% of all adolescents.1 the disease presents a significant clinical problem with severe social and psychological implications. the pathogenesis of acne is multifactorial and usually implicates follicular colonization with the gram-positive anaerobe propionibacterium acnes (p. acnes) and inflammation upon manifestation.2,3 p. acnes has previously been shown to stimulate secretion of pro-inflammatory cytokines such as interleukin (il)-1β, il-8 and tumor necrosis factor (tnf)-α.4 current acne treatments present side effects such as skin irritation, bacterial resistance, teratogen effects, and chronicity rendering acne as a disease with persistent need for new and improved treatment modalities.1 valrubicin (n-trifluoroacetyladriamycin-14valerate) is a second-generation anthracycline currently fda-approved for intra-vesical treatment of bacillus calmette-guérin-refractory bladder cancer.5 valrubicin is derived from doxorubicin, which exhibits both antibiotic and antineoplastic activities.5,6 valrubicin excels by lacking contact and cardiac toxicity.6 valrubicin’s improved safety profile and excellent tissue penetration5,6 has led to the development of a cream formulation facilitating topical application and possible treatment of hyperproliferative skin diseases as demonstrated by alleviation of psoriasis and prevention of skin tumor development in mouse models;7,8 an effect ascribed to valrubicin’s ability to inhibit keratinocyte proliferation and skin inflammation.7-9 in this study, we aim to investigate whether topical valrubicin treatment may play a future role in acne treatment, thus valrubicin’s antibacterial effect against p. acnes is tested together with valrubicin’s anti-inflammatory effect on p. acnes-induced inflammation in vitro and in vivo. valrubicin did not demonstrate antibacterial effects nor did it reduce expression levels of il1β, il-8, and tnf-α, in vitro, or reduce signs of inflammation in vivo. in conclusion, this study does not support beneficial antibacterial and anti-inflammatory effects of topical valrubicin treatment of p. acnes-associated acne. the submitted manuscript includes primary normal human epidermal keratinocytes (nheks), isolated from healthy donors undergoing skin reductive surgery. all donors have signed a donor consent letter and the project is approved by the regional ethical committee (den videnskabsetiske komité for århus amt) with journal number 20030125. the submitted manuscript also includes animal experimentation which is approved by the danish animal experiments inspectorate (dyreforsøgstil synet) with journal number 2011/561-1958. materials and methods p. acnes bacteria three different p. acnes strains: 1.4.l1, 12.1.l1 and 30.2.l1, were included in this study. 1.4.l1 and 12.1.l1 are sequence type (st)18 and strongly associated with moderate to severe acne while 30.2.l1 is st27 and associated with healthy skin. strains were kindly provided by professor mogens kilian, institute of biomedicine, aarhus university, denmark, and isolated from acne patients as previously described.10-12 p. acnes were inoculated on 5% blood agar or reinforced clostridium agar and incubated under anaerobic conditions at 37°c. further growth was accomplished by inoculation on dialysis membranes (3500 dalton, 3 spectra/por® no.: 132725, spectrum laboratories, breda, the netherlands) on 5% blood agar for four days or by re-suspension in brain heart infusion broth until reaching log phase growth. bacteria were harvested, washed and re-suspended in isotonic saline water and used immediately. dermatology reports 2015; volume 7:6246 correspondence: karin stenderup, research centre s., department of dermatology, aarhus university hospital, p.p. oerumsgade 11, bldg. 15b, dk-8000 aarhus c, denmark. phone: +45.7846.1838 fax: +45.7846.1850. e-mail: karin.stenderup@clin.au.dk key words: propionibacterium acnes; valrubicin; acne; skin inflammation; mouse model. acknowledgements: the authors thank annette blak rasmussen, winnie heidemann and tove findahl for their excellent technical assistance, lars iversen and mogens kilian for making available laboratory facilities, and mogens kilian and holger brüggemann for guidance. we thank elisabeth de darkó from valderm aps for supplying valrubicin. contributions: lr, tnd, cr, ks, conception of the work; lr, sdf, kt, hc, sma, acquisition of data for the work; lr, tnd, cr, ks, analysis and interpretation of data for the work; lr, sdf, kt, hc, sma, tnd, cr, ks, drafting the work and critically revising it for important intellectual content and final approval of the manuscript version to be published. conflict of interest: lr, sdf, kt, hc, sma, cr, declare no conflict of interest; ks received funding for operating expenses from valderm aps; tnd is a consultant at valderm aps. funding: this work was financially supported by valderm aps; institute of clinical medicine, aarhus university; aage bang’s foundation. received for publication: 19 october 2015. accepted for publication: 29 november 2015. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright l. rottboell et al., 2015 licensee pagepress, italy dermatology reports 2015; 7:6246 doi:10.4081/dr.2015.6246 no n c om me rci al us e o nly [page 40] [dermatology reports 2015; 7:6246] antibacterial assay tyeg agar supplemented with 2 μg/ml of furazolidone to inhibit growth of staphylo cocci,13 was used to test the antibacterial activity of valrubicin against p. acnes. valrubicin in different concentrations and formulations were loaded onto sterile filter discs and placed on the surface of inoculated agar plates. valrubicin 250 mg/ml in acetone (kindly provided by valderm aps, lyngby, denmark), 25 mg/ml in acetone/dmso [1:10], 5 μg/ml in acetone/sterile water [1:10,000], 40 mg/ml (valstar®) in cremophor/ethanol [1:1], (kindly provided by valderm aps), 10 mg/ml (valstar®) in cremophor/ethanol/sterile water [1:1:4], 10 mg/ml in cream (1% batch 7077/001, kindly provided by valderm aps), 10 mg/ml in cream gel (1% batch 7078/001, kindly provided by valderm aps) and the vehicles: acetone, acetone/dmso [1:10], acetone/sterile water [1:10,000], cremophor® l (c5135, sigma-aldrich, broendby, denmark)/ethanol [1:1], cremophor® l (c5135, sigmaaldrich)/ethanol/sterile water [1:1:4], cream and gel vehicles (kindly provided by valderm aps) were tested. discs with penicillin (5 μg, roscolab ltd., london, uk) were added as positive control. plates were incubated under anaerobic conditions at 37°c for three days. antibacterial potential was determined as growth inhibition of the bacterial layer. keratinocyte cell cultures primary normal human epidermal keratinocytes (nheks) were isolated from four healthy donors undergoing skin reductive surgery. informed consent was obtained and the study was approved by the central ethical committee and conducted in accordance with the declaration of helsinki protocols. nheks were grown in keratinocyte serum-free medium (k-sfm, invitrogen) containing the supplements for keratinocyte growth (epidermal growth factor and pituitary extract; invitrogen), at standard conditions (37°c, 5% co2, and 90% humidity) as previously described.14 24 hrs prior to co-culturing nheks with p. acnes, medium was removed, cells washed in pbs (invitrogen), and new medium without antibiotics added. p. acnes were resuspended in dulbecco’s modified eagle’s medium (dmem, invitrogen, carlsbad, ca, usa) containing 10% fbs without antibiotics prior to co-culture. the p. acnes strain 1.4.l1, associated with acne, was used. in house, unpublished results, demonstrated that freshly prepared p. acnes, harvested in log phase growth, stimulated a greater inflammatory response compared with thawed p. acnes, thus freshly prepared p. acnes were used throughout the study. the effect of valrubicin on p. acnes-induced expression levels of inflammatory cytokines in nheks was determined by assessing five different treatment groups. group 1 was not cocultured with p. acnes, and served as negative control. groups 2, 3, and 4 were co-cultured with p. acnes (strain 1.4.l1, 103 freshly prepared p. acnes/nhek). 30 minutes post p. acnes challenge, group 3 and 4 were furthermore treated with valrubicin (5.0 μg/ml, diluted 1:5,000 in acetone) or vehicle (acetone diluted 1:5,000). group 5 was treated with valrubicin (5.0 μg/ml diluted 1:5,000 in acetone) alone. each treatment group was performed in triplicate from each of the four donors. measurement of inflammatory cytokine mrna and protein expression levels to analyze mrna expression levels, cells were harvested 2.5 hrs post p. acnes co-culture (2 hrs post valrubicin or vehicle treatment) by transferring cells to ice, washing in ice-cold pbs (invitrogen) and adding rna-lysis-buffer including β-mercaptoethanol (sv 96 total rna isolation system, promega, madison, wi, usa). lysed cell samples were stored at −80°c until processed for rna purification. rna was isolated according to the sv total rna isolation system vacuum protocol (promega) and cdna and quantitative real-time reverse transcription-polymerase chain reaction (pcr) was performed as previously described.9 expression of il-1β, il-8 and tnf-α was determined by taqman® gene expression assays (assay id: il-1β: hs00174097_m1, il-8: hs00174103_m1, tnf-α: hs01113624_g1, applied biosystems, san francisco, ca, usa). rplp0 was used as internal reference (assay id: rplp0: hs99999902_m1, applied biosystems). the expression of each gene was analyzed in triplicate. to analyze expression levels of secreted proteins, cell supernatants were removed 12.5 hrs post p. acnes stimulation (12 hrs post valrubicin or vehicle treatment), snap-frozen in liquid nitrogen and stored at −80°c until processed in the enzymelinked immunosorbent assay (elisa) as previously described by use of duoset® elisa development kits (il-1β/il-1f2: dy201, cxcl8/il-8: dy208, and tnf-α: dy210; r&d systems, abingdon, uk).9 the expression of each protein was analyzed in triplicate. p. acnes-induced ear inflammation mouse model c57bl/6j female mice (6-10 weeks old) (taconic, ry, denmark) were housed under standard conditions with a 12 hrs light/dark cycle and controlled temperature. animals were fed a standard rodent laboratory diet and given water ad libitum. during intra-dermal injection of p. acnes, measurement of ear thickness, and topical and intra-dermal injection treatment with valrubicin or vehicle, mice were anaesthetized in isoflurane (2-3.75%). at the end of the experiment, mice were sacrificed by cervical dislocation. animal experiments were approved by the danish experimental animal inspectorate. ear inflammation was induced in mouse ears by challenging ears with intra-dermal injections of 10 µl (6×107) or 15 µl (9×107) freshly prepared p. acnes (strain 1.4.l1) re-suspended in isotonic saline water. no ear inflammation was observed in control mice intradermally injected with only isotonic saline water after 24 hrs (data not shown). to test the effect of valrubicin as topical treatment a short term (1 day) and a long term (2 weeks) experiment was performed. valrubicin (10 μg/μl dissolved in acetone) and vehicle (acetone) was administered in a volume of 10 μl per dorsal and 10 μl per ventral surface of each ear. in the short term experiment mouse ears were treated once topically, 30 minutes post challenge, with valrubicin (group 1, n=9) or vehicle (acetone, group 2, n=16) and ear thickness was measured before (0 hrs) and 24 hrs after challenge. in the long-term experiment, mouse ears were divided into five groups where groups 1 and 2, and groups 3 and 4 were challenged with 6×107 or 9×107 freshly prepared p. acnes, respectively. 30 minutes post challenge and daily hereafter throughout the study, ears were treated topically with valrubicin (group 1, n=7 and group 3, n=8) or vehicle (acetone, group 2, n=4 and group 4, n=8). as control, an additional group of mouse ears (group 5, n=8) was left unchallenged but treated daily with valrubicin throughout the study. to test the effect of intra-dermal valrubicin treatment, 2 weeks post challenge, mouse ears were treated daily for 3 days with intra-dermal injections of valrubicin (valstar®, 10 μl, group 1, n=12) or vehicle (cremophor/ethanol [1:1], 10 μl, group 2, n=11). as control, an additional group of challenged mouse ears were left untreated (group 3, n=9). ear thickness was measured by a mitutoyo digimatic indicator (mitutoyo, kawasaki, japan) prior to and at indicated time points after ear challenge. statistics for statistical analysis the two-tailed student’s t-test was employed. p<0.05 was considered significant. results valrubicin’s antibacterial effect against p. acnes valrubicin’s antibacterial effect against p. acnes was tested by employing different concentrations and formulations of valrubicin article no n c om me rci al us e o nly [dermatology reports 2015; 7:6246] [page 41] (table 1). three p. acnes strains: clinical isolates 1.4.l1, 12.1.l1, and 30.2.l1 were inoculated on agar plates but no signs of bacterial clearing were demonstrated. valrubicin’s effect on p. acnes-induced inflammation in keratinocytes in vitro valrubicin’s effect on p. acnes-induced inflammation in keratinocytes in vitro was tested in nheks co-cultured with freshly prepared p. acnes. p. acnes only significantly induced an increase in the mrna expression level of il-1β (figure 1a) but not il-8 (figure 1b) and tnf-α (figure 1c). the observed increased mrna expression level of il-1β and the existing expression levels of il-8 and tnfα were not affected by valrubicin treatment (p=0.98 for il-1β, ��p=0.52 for il-8, and p=0.88 for tnf-α). p. acnes significantly increased protein expression levels of both il-1β (figure 1d), il-8 (figure 1e) and tnf-α (figure 1f), however, valrubicin treatment was demonstrated not to reduce the p. acnes-induced expression levels of il-1β (p=0.54), il-8 (p=0.94), and tnf-α (p=0.76). valrubicin’s effect on p. acnesinduced skin inflammation in vivo valrubicin’s effect on p. acnes-induced skin inflammation in vivo was tested by treating mouse ears, challenged by injection of p. acnes. short term (1 day) topical valrubicin treatment demonstrated no reduction in ear thickness (figure 2a); ear thickness in both valrubicin and vehicle treated mouse ears was increased approximately 2-fold after 24 hrs. long term (2 weeks) daily topical valrubicin treatment was tested in repeated experiments where mouse ears were injected with the same amount of p. acnes (figure 2b) or 30% fewer p. acnes (figure 2c). no reduction in ear thickness was seen in valrubicin treated mouse ears compared with vehicle treated ears, at any time point during the 2 weeks. ear thickness, in both the valrubicin and vehicle treated mouse ears, increased approximately 3-fold (figure 2b) and 2-fold (figure 2c) after 24 hrs. mouse ears treated with valrubicin alone, demonstrated no change in ear thickness during the 2 weeks. repeated acetone-applications have previously been demonstrated, by our group, not to affect ear thickness.9 in a final experiment, to facilitate the ability of valrubicin to locate directly into the site of inflammation, valrubicin was injected intra-dermally into the mouse ears (figure 2d). no effect of valrubicin as compared with vehicle, on ear thickness, was observed. article figure 1. valrubicin’s effect on p. acnes-induced mrna and protein expression levels of inflammatory cytokines by nheks. nheks from four healthy donors, were cultured in the presence of freshly prepared p. acnes. the effect of valrubicin on p. acnes-induced mrna expression levels of il-1β (a), il-8 (b), and tnf-α (c) was evaluated after 2 hrs of stimulation. mrna expression levels were normalized to the expression levels of the housekeeping gene, ribosomal protein large p0 (rplp0) and to the untreated control (no p. acnes bacteria added). the effect of valrubicin on p. acnes-induced protein expression levels of il-1β (d), il-8 (e), and tnf-α (f) was evaluated after 12 hrs of stimulation. protein expression levels were determined by elisa and normalized to the untreated control (no p. acnes bacteria added). values are presented as mean + standard deviation (nheks, n=4 donors, cultured in triplicate). table 1. valrubicin’s antibacterial effect on p. acnes. valrubicin concentration and formulation 1.4.l1 12.1.l1 30.2.l1 250 mg/ml in acetone * * * 25 mg/ml in acetone/dmso (1:10) * * * 5 μg/ml in acetone/sterile water (1:10,000) * * * 40 mg/ml (valstar®) in cremophor/ethanol (1:1) * * * 10 mg/ml (valstar®) in cremophor/ethanol/sterile water (1:1:4) * * * 10 mg/ml in cream (1% batch) * * * 10 mg/ml in cream gel (1% batch) * * * * indicates no clearing of the bacterial layer. vehicles alone demonstrated no antibacterial effect and penicillin, used as positive control, showed strong bacterial clearing in all three p. acnes strains. no n c om me rci al us e o nly [page 42] [dermatology reports 2015; 7:6246] discussion several treatment modalities exist for acne, however, some may be associated with adverse side effects and therapeutic failure.1 thus, research is focused on discovering new and improved treatments to expand the current treatment palette. the role of p. acnes in the pathogenesis of acne has been discussed, as p. acnes is also a commensal of healthy skin.2 recent findings, by multi-locus sequence typing (mlst), however, have shown that p. acnes can be divided into different strains associated with either moderate to severe acne, healthy skin or opportunistic infections.10,12 nevertheless, the majority of acne treatments, currently available, are associated with anti-inflammatory effects and not necessarily antibacterial effects. interestingly, prolonged antibiotic treatment, associated with high degree of p. acnes resistance, often alleviates acne lesions; a fact explained by anti-inflammatory effects of the antibiotics.15,16 valrubicin did not demonstrate anti-inflammatory effects on primary keratinocytes co-cultured with p. acnes, as measured by mrna and protein expression levels of il-1β, il-8, and tnf-α. these findings were surprising as we previously demonstrated that 2 hrs of valrubicin treatment significantly reduced mrna expression levels of il-1β and il-6 in 12-otetradecanoylphorbol 13-acetate (tpa) treated mouse ears,9 and because 2 hrs of valrubicin treatment demonstrated to significantly reduce mrna expression levels of il-1β, il-8 and tnf-α in stimulated keratinocytes and immune cells (unpublished results). moreover, we previously demonstrated that 8 hrs and 24 hrs of valrubicin treatment significantly reduced protein expression levels of il-1β and il-6 in tpa treated mouse ears.9 also, we previously reported that the employed concentration of valrubicin (5.0 μg/ml) was able to inhibit proliferation of nheks in cell culture.7 why valrubicin reduces tpa-induced inflammation and not p. acnes-induced inflammation is unclear. il-1β, il-8 and tnf-α are expressed in human acne lesions,17-20 and p. acnes has previously been demonstrated to stimulate secretion of these pro-inflammatory cytokines in keratinocytes.21-25 the fact that il-1β is up-regulated in acne skin17 has proposed beneficial effects of il-1β-targeted therapy which was recently shown to be the case, in patients suffering from auto-inflammatory syndromes including acne-lesions.26-28 topical valrubicin treatment did not reduce p. acnes-induced ear inflammation following short and long term treatments. in a similar study, by our group, hauge et al. induced both acute and chronic inflammation in the same mouse strain by stimulating mouse ears topically with tpa.9 in this study, topical valrubicin treatment significantly reduced tpa-induced ear inflammation in both the acute and the chronic model. in both studies, topical valrubicin was applied in equal amounts and concentrations. again, why valrubicin reduces tpa-induced inflammation and not p. acnesinduced inflammation is unclear. previous studies have successfully demonstrated anti-inflammatory effects in the employed p. acnes injected ear-inflammation model.17,29 similar numbers of p. acnes were injected, however different p. acnes strains were employed. these studies demonstrated a similar 2-4 fold increase in ear thickness upon p. acnes injection which then decreased upon article figure 2. effect of valrubicin treatment on p. acnes-induced ear inflammation. ear inflammation was induced in mouse ears by challenging ears with intra-dermal injection of 15 μl (9×107; a and b) or 10 μl (6×107; c and d) freshly prepared p. acnes (clinical strain 1.4.l1). short term (1 day) topical valrubicin treatment (a): 30 minutes post challenge, ears were treated topically with valrubicin (group 1, n=9) or vehicle (acetone, group 2, n=16). long term (2 weeks) topical valrubicin treatment (b, c): 30 minutes post challenge and daily hereafter throughout the study, ears were treated topically with valrubicin group 1 (n=7) and group 3 (n=8) or vehicle (acetone) group 2 (n=4) and group 4 (n=8). as control, an additional group of mouse ears (group 5, n=8) was left unchallenged but treated daily with valrubicin throughout the study. intra-dermal valrubicin treatment (d): 2 weeks post challenge, ears were treated daily for 3 days with central intra-dermal injections of valrubicin (valstar®) group 1 (n=12) or vehicle (cremophor/ethanol [1:1]) group 2 (n=11). as control, an additional group of challenged ears were left untreated group 3 (n=9). ear thickness was measured at indicated time points. values are presented as mean ± standard deviation. no n c om me rci al us e o nly [dermatology reports 2015; 7:6246] [page 43] treatment. decreased levels of il-1β, il-8 and tnf-α��in this model, upon treatment, have also been demonstrated.29 conclusions taken together, valrubicin did not demonstrate antibacterial effects against p. acnes nor did it reduce p. acnes-induced inflammation in vitro and in vivo. acne is, however, a multifactorial disease, and valrubicin may, despite the lack of antibacterial and anti-inflammatory effects, demonstrate beneficial effects on other aspects of the disease. references 1. james wd. clinical practice. acne. n engl j med 2005;352:1463-72. 2. gollnick h, cunliffe w, berson d, et al. management of acne: a report from a global alliance to improve outcomes in acne. j am acad dermatol 2003;49:s1-37. 3. ayer j, burrows n. acne: more than skin deep. postgrad med j 2006;82:500-6. 4. vowels br, yang s, leyden jj. induction of proinflammatory cytokines by a soluble factor of propionibacterium acnes: implications for chronic inflammatory acne. infect immun 1995;63:3158-65. 5. kuznetsov dd, alsikafi nf, o’connor rc, et al. intravesical valrubicin in the treatment of carcinoma in situ of the bladder. expert opin pharmacother 2001;2:100913. 6. krishan a, dutt k, israel m, et al. comparative effects of adriamycin and ntrifluoroacetyladriamycin-14-valerate on cell kinetics, chromosomal damage, and macromolecular synthesis in vitro. cancer res 1981;41:2745-50. 7. rosada c, stenderup k, de darkó e, et al. valrubicin in a topical formulation treats psoriasis in a xenograft transplantation model. j invest dermatol 2010;130:455-63. 8. andersen sm, rosada c, dagnaes-hansen f, et al. topical application of valrubicin has a beneficial effect on developing skin tumors. carcinogenesis 2010;31:1483-90. 9. hauge e, christiansen h, rosada c, et al. topical valrubicin application reduces skin inflammation in murine models. br j dermatol 2012;167:288-95. 10. lomholt hb, kilian m. population genetic analysis of propionibacterium acnes identifies a subpopulation and epidemic clones associated with acne. plos one 2010;5:e12277. 11. bruggemann h, lomholt hb, tettelin h, et al. crispr/cas loci of type ii propionibacterium acnes confer immunity against acquisition of mobile elements present in type i p. acnes. plos one 2012;7:e34171. 12. kilian m, scholz cf, lomholt hb. multilocus sequence typing and phylogenetic analysis of propionibacterium acnes. j clin microbiol 2012;50:1158-65. 13. ross ji, snelling am, carnegie e, et al. antibiotic-resistant acne: lessons from europe. br j dermatol 2003;148:467-78. 14. kragballe k, desjarlais l, voorhees jj. leukotrienes b4, c4 and d4 stimulate dna synthesis in cultured human epidermal keratinocytes. br j dermatol 1985;113:4352. 15. esterly nb, furey nl, flanagan le. the effect of antimicrobial agents on leukocyte chemotaxis. j invest dermatol 1978;70:515. 16. webster gf, leyden jj, mcginley kj, et al. suppression of polymorphonuclear leukocyte chemotactic factor production in propionibacterium acnes by subminimal inhibitory concentrations of tetracycline, ampicillin, minocycline, and erythromycin. antimicrob agents chemother 1982;21: 770-2. 17. kistowska m, gehrke s, jankovic d, et al. il-1beta drives inflammatory responses to propionibacterium acnes in vitro and in vivo. j invest dermatol 2014;134:677-85. 18. ingham e, eady ea, goodwin ce, et al. proinflammatory levels of interleukin-1 alphalike bioactivity are present in the majority of open comedones in acne vulgaris. j invest dermatol 1992;98:895-901. 19. kang s, cho s, chung jh, et al. inflammation and extracellular matrix degradation mediated by activated transcription factors nuclear factor-kappab and activator protein-1 in inflammatory acne lesions in vivo. am j pathol 2005;166:16919. 20. trivedi nr, gilliland kl, zhao w, et al. gene array expression profiling in acne lesions reveals marked upregulation of genes involved in inflammation and matrix remodeling. j invest dermatol 2006;126:1071-9. 21. akaza n, akamatsu h, kishi m, et al. effects of propionibacterium acnes on various mrna expression levels in normal human epidermal keratinocytes in vitro. j dermatol 2009;36:213-23. 22. graham gm, farrar md, cruse-sawyer je, et al. proinflammatory cytokine production by human keratinocytes stimulated with propionibacterium acnes and p. acnes groel. br j dermatol 2004;150:421-8. 23. nagy i, pivarcsi a, koreck a, et al. distinct strains of propionibacterium acnes induce selective human beta-defensin-2 and interleukin-8 expression in human keratinocytes through toll-like receptors. j invest dermatol 2005;124:931-8. 24. akaza n, akamatsu h, kishi m, et al. normal human epidermal keratinocytes react differently than hacat keratinocyte cell line on exposure to propionibacterium acnes. j dermatol 2011;38:499-502. 25. isard o, leveque m, knol ac, et al. antiinflammatory properties of a new undecylrhamnoside (aprc11) against p. acnes. arch dermatol res 2011;303:707-13. 26. brenner m, ruzicka t, plewig g, et al. targeted treatment of pyoderma gangrenosum in papa (pyogenic arthritis, pyoderma gangrenosum and acne) syndrome with the recombinant human interleukin1 receptor antagonist anakinra. br j dermatol 2009;161:1199-201. 27. braun-falco m, kovnerystyy o, lohse p, et al. pyoderma gangrenosum, acne, and suppurative hidradenitis (pash)—a new autoinflammatory syndrome distinct from papa syndrome. j am acad dermatol 2012;66:409-15. 28. wendling d, prati c, aubin f. anakinra treatment of sapho syndrome: short-term results of an open study. annals of the rheumatic diseases 2012;71:1098-100. 29. lee wr, kim kh, an hj, et al. the protective effects of melittin on propionibacterium acnes-induced inflammatory responses in vitro and in vivo. j invest dermatol 2014;134:1922-30. article no n c om me rci al us e o nly dr [page 20] [dermatology reports 2012; 4:e6] allergic contact dermatitis from sculptured acrylic nails: special presentation with an airborne pattern paula maio, rodrigo carvalho, cristina amaro, raquel santos, jorge cardoso contact dermatitis unit, dermatology and venereology department, curry cabral hospital, lisbon, portugal abstract methylmethacrylate was first reported in 1941 as a cause of contact dermatitis. since then, occupational contact allergies to acrylates in dentistry, orthopedic surgery, printing industry and industry have been reported, but few reports are found in the literature as a consequence of the contact with sculptured artificial acrylic nails which are increasingly popular. we describe here 3 patients with contact allergy to acrylates in artificial sculptured nails. patch tests were performed with the portuguese baseline series of contact allergens and an extended series of acrylates were applied. in particular, we tested three female patients with allergic contact dermatitis from sculptured acrylic nails. two of these patients were both customers and also technical nail beauticians. two patients developed periungual eczema; one presented only with face and eyelid dermatitis had no other lesions. the tests showed positive reaction to 2-hydroxyethylmethacrylate (2-hema) and 2-hydroxypropylmethacrylate (2-hpma) in all the three patients. our cases demonstrate the variety of clinical presentations of allergic contact dermatitis from acrylic sculptured nails. they show the need to warn patients of persistent and sometimes permanent side effects of these products. they also emphasize the importance of cosmetic ingredient labeling. introduction sculptured artificial acrylic nails, have gained popularity over recent years. they can cause allergic contact dermatitis both in occupational and non-occupational settings. acrylates are known allergens and also irritants.1 methylmethacrylate was the first reported in 1941 as a cause of contact dermatitis.2 since then, occupational contact allergies to acrylates in dentistry, orthopedic surgery, printing industry and industry have been reported in the literature.3,4 polymerization of acrylate occurs when the polymer and the monomer are mixed together in the presence of an organic peroxide catalyst and accelerator. hardening occurs at room temperature. however with photobonded sculptured acrylate nails, polymerization requires exposure to uv radiation.4 in this study, we describe 3 patients with distinct clinical presentations of contact allergy to acrylates present in artificial nails. the patients were observed in a contact dermatitis unit. case report epicutaneous tests were applied on the upper back using finn chambers®, and a positive patch test reaction was defined according to the international contact dermatitis research group guidelines. all patients were tested with the european baseline series (with additions recommended by the portuguese contact dermatitis study group) and personal products. an extended series of acrylates were applied. results we observed three female patients aged 3550 years old (mean 41.5) with allergic contact dermatitis from sculptured acrylic nails. two of these patients were both customers and also professional nail beauticians. two patients (one customer and the other both customer and professional nail beautician) developed periungual eczema two and four months respectively after the first application of acrylic gel (figure 1); one of them had clinically an airborne pattern. the third patient only presented with dermatitis localized to the face and eyelid that was noted four months after the first contact with sculptured acrylic nails. this patient had no hand/periungual or any other cutaneous lesions at distant sites. the tests showed positive reactions to 2-hydroxyethylmethacrylate (2-hema) and 2-hydroxypropylmethacrylate (2-hpma) in three patients. positive reactions to other acrylates were also found: in all our patients 2-hydroxypropyl methacrylate and triethylene glycol diacrylate; two of our patients tested positive for 2hydroxyethyl methacrylate, ethylacrylate and hydroxyethyl acrylate, showing how allergic sensitization induced by one acrylic compound extends to one or more other acrylic compounds. one patient tested also positive to nickel with probable relevance to jewelry and to metallic pigment nail polisher. dermatitis resolved in all patients after having their acrylic gel nails removed and in those with occupational setting, after they stop working with as manicurists. discussion nowadays are available three distinct types of sculptured acrylic nails: acrylate monomers and polymers that polymerize at room temperature in the presence of an organic peroxide and accelerator; photobonded sculptured acrylate nails in which polymerization of the acrylate requires exposure to uv radiation; and, cyanoacrylates nail preparations. our cases only used sculptured acrylic nails. initial formulations contained methyl methacrylate monomer, which caused severe contact dermatitis, paronychia and nail dystrophy. since 1974, the food and drug administration banned the use of this monomer in artificial nails.6 currently marketed artificial nails contain various methacrylate ester monomers such as ethyl, butyl and isobutyl methacrylate monomers; dimethacrylates and trimethacrylates. dermatology reports 2012; volume 4:e6 correspondence: paula maio, contact dermatitis unit, dermatology and venereology department, curry cabral hospital, rua da beneficência, 8, 1069-166. lisbon, portugal. tel. +351.963018082. e-mail: paulamaio@gmail.com key words: contact allergy dermatitis, acrylates, airborne dermatitis. conflict of interests: the authors report no conflict of interests. received for publication: 18 august 2011. revision received: 7 march 2012. accepted for publication: 12 march 2012. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright p. maio et al., 2012 licensee pagepress, italy dermatology reports 2012; 4:e6 doi:10.4081/dr.2012.e6 figure 1. clinical aspect of periungueal dermatitis. no nco mm er cia l u se on ly [dermatology reports 2012; 4:e6] [page 21] conclusions the reported cases demonstrate the heterogeneous clinical presentation of allergic contact dermatitis from sculptured acrylic nails. clinical manifestation in sensitized patients includes: contact dermatitis at contact areas and at sites distant to the contact; transient or permanent nail dystrophies and paronychia.6,7 eyelid and face dermatitis can be caused by airborne dusts of completely polymerized resins that have become depolymerized by the filing process or by exposure to organic vapors and polymethacrylate dusts. the particular clinical presentation with an airborne pattern following exposure to methacrylate ester monomers has been reported in the english literature in dentistry, orthopedic surgery and printing industry but never in patients with sculptured artificial acrylic nails thus far as we know. references 1. lazarov a. sensitization to acrylates is a common adverse reaction to artificial fingernails. j eur acad dermatol venereol 2007:21:169-74. 2. stevenson wj. methyl methacrylate dermatitis. contact point 1941:18:171. 3. farli m, gasperini m, francalanci s, et al. occupational contact dermatitis in 2 dental technicians. contact dermatitis 1990:22:282-7. 4. hemmer w, focke m, jarish r. allergic contact dermatitis to artificial fingernails prepared from uv light-cured acrylates. j am acad dermatol 1996:35:377-80. 5. constandnt l, hecke ev, naeyaert jm, goosens a. screening for contat allergy to artificial nails. contact dermatitis 2005; 52:73-7. 6. fisher a. adverse nail reactions and paraesthesia from photobonded acrylate sculptured acrylic nails. cutis 1990:45:2934. 7. andersen sl, rastogi sc, andersen ke. occupational allergic contact dermatitis to hydroxyethyl methacrylate (2-hema) in a manicurist. contact dermatitis 2009;61: 48-50. case report no nco mm er cia l u se on ly dr [page 22] [dermatology reports 2019; 11:7965] evaluation of the glycemic effect of methotrexate in psoriatic arthritis patients with metabolic syndrome: a pilot study tannaz dehpouri,1 ghasem rahmatpour rokni,2 nematollah ahangar narenjbon,3 mohamad goldust,2 paul s. yamauchi,4,5 uwe wollina,6 torello lotti,7 leon kircik,8 vito giuseppe di lernia,9 sidharth sonthalia,10,11 aleksandra vojvodic,12 jacek szepietowski,13 philippe bahadoran,14 enzo errichetti,15 carmen cantisani,16 laura atzori,17 elham rezaee,18 zekayi kutlubay,19 burhan engin,19 steven nisticò,20 giovanni damiani,21,22 rosalynn r.z. conic,23 andy goren,7 leo čabrijan,24 georgi tchernev25 1student research committee, mazandaran university of medical sciences, ramsar international branch, ramsar, iran; 2department of dermatology, mazandaran university of medical sciences, sari, iran; 3department of pharmacology, faculty of pharmacy, mazandaran university of medical sciences, sari, iran; 4dermatology institute and skin care center, santa monica, california, usa; 5division of dermatology, david geffen school of medicine at university of california, los angeles, california, usa; 6department of dermatology and allergology, städtisches klinikum dresden, academic teaching hospital of the technical university of dresden, dresden, germany; 7department of dermatology, “guglielmo marconi” university, rome, italy; 8icahn school of medicine at mount sinai, new york, ny, usa; 9dermatology unit, santa maria nuova-irccs hospital, reggio emilia, italy; 10skinnocence: the skin clinic & research center, gurugram, haryana, india; 11dermasource india, gurugram, haryana, india; 12department of dermatology and venereology, military medical academy, belgrade, serbia; 13department of dermatology, venereology and allergology, wroclaw medical university, wroclaw, poland; 14department of dermatology, university hospital of nice, nice, france; 15department of experimental and clinical medicine, institute of dermatology, university of udine, udine, italy; 16department of dermatology, “umberto i” hospital, “sapienza” university of rome, rome, italy; 17dermatology clinic, department medical sciences and public health, university of cagliari, cagliari, italy; 18department of pharmaceutical chemistry, school of pharmacy, shahid beheshti university of medical sciences, tehran, iran; 19department of dermatology, cerrahpasa faculty of medicine, university of istanbul, istanbul, turkey; 20department of health sciences, “magna graecia” university of catanzaro, catanzaro, italy; 21department of medical and surgical pathophysiology and transplantation, university of milan, dermatology unit, irccs ca’ granda foundation, ospedale maggiore policlinico, milan, italy; 22young dermatologists italian network (ydin), centro studi gised, bergamo, italy; 23department of dermatology, case western reserve university, cleveland, oh, usa; 24department of dermatovenereology, rijeka clinical hospital center, rijeka, croatia; 25medical institute of ministry of interior (mvr), department of dermatology, venereology and dermatologic surgery, sofia, bulgaria abstract methotrexate (mtx) is a systemic immunosuppressant drug used for the treatment of psoriasis and psoriatic arthritis. previous studies demonstrated a potential association between psoriasis and diabetes mellitus, obesity, atherosclerosis, hypertension, eventuating into metabolic syndrome. this study aimed at exploring the glycemic effects of mtx in psoriatic arthritis (psa) patients. in this prospective cross-sectional study, 27 patients with psa were evaluated. the status of psa and presence of accompanying metabolic syndrome was determined by standard criteria and indices. blood indicators including hba1c, erythrocyte sedimentation rate, fasting blood sugar, total cholesterol, high-density lipoprotein, triglycerides, and c-reactive protein were examined before and 12 weeks after mtx therapy. there were no significant changes between hba1c levels before and after mtx therapy in both genders (men: p=0.131, women: p=0.803). in addition, hba1c levels in psa patients with metabolic syndrome were not different before and after treatment (p=0.250). finally, hba1c levels did not change in psa patients without metabolic syndrome before and after therapy (p=0.506). mtx in psa patients does not appear to have hyperglycaemic effects in the short-term and can be safely used in patients with metabolic syndrome and diabetes. introduction psoriasis (pso) is defined as a systemic, inflammatory dermatologic disease which affects approximately 2-3% of the global population.1,2 furthermore, psoriatic arthritis (psa) can develop in 7-48% of all pso subjects.3,4 patients with pso and/or psa are at a higher risk for development of other chronic pathologic diseases, which can complicate the management of these patients.5-7 previous studies have proved that metabolic syndrome is related to a state of chronic low-grade inflammation.8,9 the underlying mechanism is partially unknown, but a group of cytokines, including tumor necrosis factor-α (tnf-α), have been evidenced to reduce the activity of insulin, contributing to insulin resistance.9-11 unfortunately, there is limited data on association between metabolic syndrome and rheumatological disorders, even though a dermatology reports 2019; volume 11:7965 correspondence: ghasem rahmatpour rokni, department of dermatology, mazandaran university of medical sciences, sari, iran. tel.: +989125443956 fax: +981133261248. e-mail: dr.rokni@yahoo.com key words: psoriatic arthritis; metabolic syndrome; hba1c; methotrexate. contributions: the manuscript has been read and approved by all the authors. conflict of interest: the authors declare no potential conflict of interest. funding: none. received for publication: 4 december 2018. accepted for publication: 18 january 2019. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright t. dehpouri et al., 2019 licensee pagepress, italy dermatology reports 2019; 11:7965 doi:10.4081/dr.2019.7965 no nco mm er cia l u se on ly [dermatology reports 2019; 11:7965] [page 23] few studies have reported an increased incidence of metabolic syndrome in patients with rheumatologic disease.12-14 besides, a few previous studies have indicated that there is an association between the metabolic syndrome and pso.15,16 additionally, epidemiological evidence has proposed that systemic anti-inflammatory therapy might be helpful to decrease the risk of cardiovascular disease (cvd) in patients suffering from psoriasis.17,18 methotrexate (mtx) is an anti-rheumatic drug with its cytotoxic, anti-inflammatory and immune modulatory activities often used in psoriasis treatment. however, despite its use for the last 60 years, a close evaluation of its adverse effects and related risk factors has not been performed.19 in spite of growing concerns about cumulative toxicity, there are no detailed data for complications associated with an increased cumulative dose of mtx.20 studies have demonstrated significant reductions in cvd-related mortality in patients treated with methotrexate.21 this finding has been attributed to the potent anti-inflammatory properties of methotrexate.21,22 the aim of this study was to explore the effects of short-term methotrexate therapy on the blood levels of glucose and hba1c in patients having psoriasis. materials and methods subjects in this multicenter cross-sectional study, 27 patients (aged 30-60 years) with psa from february 2016 to february 2018 were enrolled. the evaluation subjects included the evidence of lifestyle factors including smoking behavior, medical history, taking medications, presence of diabetes mellitus, hypertension, duration of disease, comorbidities, and clinical examinations which were obtained to discover the presence of psa. also, physical examination included recording the number of tender and swollen joints. to confirm the suspect of psa we also performed joints radiogram and enthesis sonography. the diagnosis of psa was established by standard criteria for psoriatic arthritis (caspar) with a score >3 points.18 additionally, other parameters such as weight, height and waist circumference, body mass index (bmi) (kg/m2) and blood pressure were also measured. the status of psa was determined by the following standard indexes: the bath ankylosing spondylitis disease activity index,23 disease activity score 2824 and the health assessment questionnaire.25 furthermore metabolic syndrome was determined via the international diabetes federation (idf) 2004 and the national cholesterol education program adult panel iii (ncep atp iii) (ncep atp iii) 2001.26,27 all patients were treated with oral methotrexate (7.5 mg/kg) weekly for three months. before the collection of samples a written informed consent was obtained from each participant and ethical approval was granted by the ethics committee of the mazandaran university of medical sciences, pardis unit, ramsar, iran. inclusion and exclusion criteria in this study, psa was diagnosed and confirmed by expert rheumatologists based on the caspar.28 subjects with other inflammatory rheumatic diseases, myocardial infarction (mi), stroke, hyper-glycaemic status different from diabetes mellitus type 2 e.g. hyperthyroidism and hyperglicaemic, renal insufficiency, lung or liver or retroperitoneal fibrosis as well as patients who took anti-inflammatory drugs (nsaids or corticosteroids) were excluded from the study. blood analysis following serum sampling, they were kept at -80ºc until further processing. the hba1c and erythrocyte sedimentation rate were primarily measured. also, the serum concentrations of fasting blood sugar (fbs), total cholesterol, high-density lipoprotein cholesterol (hdl), triglycerides and c-reactive protein were measured using an automated analyzer (model 912, hitachi, japan). all these parameters were examined before and after 12 weeks of treatment with methotrexate. statistical analysis data was expressed as mean ± standard deviation (sd). statistical analysis was conducted using spss version 18 (spss, inc, chicago, il, usa). differences were evaluated with the paired t test and chi-square test. the normality of data was checked using the one-sample kolmogorov– smirnov test. the significant level of differences was set at 0.05. results inclusion criteria were met by 35 patients. among these, 27 patients continued the study with the mean age of 43.22±8.9. nine (33.33%) patients were female and 18 (66.66%) were male. demographic data and clinical features of patients before and after treatment are shown in table 1. hyperlipidemia was present in 7 (25.93%) patients at baseline for article table 1. demographic and clinical features of the study patients. variation patients with psa before treatment n=27 patients with psa after treatment n=27 p value age (years) 43.22±8.9 gender men n (%) 18 (66.7) women n (%) 9 (33.3) history of diabetes n (%) 2 (10.0) history of stroke n (%) 10 (35.0) history of hyperlipidemia n (%) 7 (20.0) fbs (mg/dl) 103.2±30.2 101.3±22.8 0624 total cholesterol (mg/dl) 165.7±26.9 166.5±33.2 0.881 hdl (mg/dl) 39.6±7.7 42.8±6.2 0.005 ldl (mg/dl) 98.7±22.7 104.6±22.7 0.059 crp 100% negative 100% negative 0.21 esr (mm/hour) 24.2±17.9 23.5±17.6 0.722 psa, psoriatic arthritis patients; fbs, fasting blood sugar; hdl, high-density lipoprotein cholesterol; crp, c-reactive protein; esr, erythrocyte sedimentation rate. no nco mm er cia l u se on ly which 5 (18.52%) patients were using medications. family history of stroke was present in 10 (37%) patients. in this study, 7 (25.93%) patients had a normal weight, 10 (37%) patients were overweight, and the other 10 patients were obese. hba1c test was taken before and after using methotrexate. at baseline, 2 (7.41%) patients had diabetes while the rest were negative. there were no significant differences between hba1c levels among genders before and after treatment with methotrexate (men: p=0.131, women: p=0.803) (figure 1). according to the ncep, 20 (74.04%) patients had the signs of metabolic syndrome while the other 7 (25.93%) did not. however, according to idf, 19 (70.37%) patients showed the signs of metabolic syndrome and 8 (29.63%) patients didn’t. furthermore, based on the ncep index, hba1c levels in psa patients with metabolic syndrome were 5.7±0.9% before and 5.9±0.9% after methotrexate therapy (p=0.250). however, hba1c levels in psa patients without metabolic syndrome were 5.6±0.4 % and 5.7±0.5% before and after methotrexate therapy respectively (p=0.506) (figure 2). discussion several studies have proposed that patients with psa are at increased risk of cvd, obesity, diabetes and fatty liver disease.29-31additionally, previous reports have indicated that hba1c as the primary screening tool for glucose intolerance and the major predictive factor for cardiovascular events.32,33 in the present study, we prospectively examined the influence of short-term anti-psoriatic therapy with methotrexate on hba1c.the findings showed that there was no significant alteration in the hba1c levels after 12 weeks of continuous treatment. previously, derotte and perdan-pirkmajer et al. demonstrated that mtx reduced hba1c concentrations in patients with ra or psa.33,34 however, in a retrospective cohort study, wu et al. showed that pso, psa, and ra patients under treatment with tnf inhibitors associated with mtx displayed no significant differences in terms of the hba1c level.35 solomon et al. reported that there is a non-significantly lower risk of incident diabetes mellitus within patients suffering from psa, pso, or ra who were treated with methotrexate without tumor necrosis factor inhibitors or hydroxychloroquine. nonetheless, in contrast to our study, solomon et al. did not determine levels of hba1c and fbs in their research.36 furthermore, gisondi et al. conducted a survey of two groups of psoriasis patients who were newly treated with methotrexate and demonstrated that there was no detected changes in the fbs level.37 in a 24-week retrospective study comparing tnf inhibitor, efalizumab, and methotrexate there was no significant alterations in fbs in any of the groups.38 cuchacovich et al. examined 37 patients with ra treated with methotrexate (mean 34.7 months), and found no significant changes have been in fbs.39 all these reports are consistent with the results of our study. it appears that the administration of methotrexate for treatment of psa does not have hyperglycaemic effects and thus it can be used in psa patients with metabolic syndrome and diabetes. moreover, the most important part of controlling the chronic disorders is following a healthy lifestyle along with proper medication. in addition, regular screening of diabetes by monitoring bmi, fbs levels, blood pressure and cholesterol levels may help early detection and management of new-onset diabetes in psa patients being treated with methotrexate. conclusions to conclude, the use of methotrexate was not related to a significant alteration in hba1c or fbs levels in patients with psa. according to the data obtained in this study, methotrexate can be used in the treatment of psa patients without the risk of developing diabetes. article figure 1. the level of hba1c based on the gender of psoriatic arthritis patients. the results are presented as mean ± sem. statistically significant differences between control and patients (p<0.05). figure 2. the level of hba1c based on the national cholesterol education program adult panel index in psoriatic arthritis patients patients with and without metabolic syndrome. results are presented as mean ± sem. statistically significant differences between control and patients (p<0.05). [page 24] [dermatology reports 2019; 11:7965] no nco mm er cia l u se on ly [dermatology reports 2019; 11:7965] [page 25] references 1. puig l, strohal r, husni me, et al. cardiometabolic profile, clinical features, quality of life and treatment outcomes in patients with moderate-tosevere psoriasis and psoriatic arthritis. j dermatol treat 2015;26:7-15. 2. reich k. the concept of psoriasis as a systemic inflammation: implications for disease management. j eur acad dermatol venereol 2012;26:3-11. 3. sommer dm, jenisch s, suchan m, et al. increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis. archiv dermatol res 2007;298:321. 4. channual j, wu jj, dann fj. effects of tumor necrosis factor-α blockade on metabolic syndrome components in psoriasis and psoriatic arthritis and additional lessons learned from rheumatoid arthritis. dermatol ther 2009;22:61-73. 5. gladman dd. psoriatic arthritis from wright’s era until today. j rheumatol suppl 2009;83:4-8. 6. ahlehoff o, gislason gh, charlot m, et al. psoriasis is associated with clinically significant cardiovascular risk: a danish nationwide cohort study. j intern med 2011;270:147-57. 7. kwon o, kang sj, kang sh, et al. relationship between serum inflammatory marker levels and the dynamic changes in coronary plaque characteristics after statin therapy. circ cardiovasc imaging 2017;10:e005934. 8. boscarino ja. ptsd is a risk factor for cardiovascular disease: time for increased screening and clinical intervention. prevent med 2013;166:806-14. 9. jialal i. the role of the laboratory in the diagnosis of the metabolic syndrome. am j clin pathol 2009;132:161-2. 10. ruan h, lodish hf. insulin resistance in adipose tissue: direct and indirect effects of tumor necrosis factor-α. cytokine growth factor rev 2003;14:447-55. 11. chandalia m, cabo-chan jr av, devaraj s, et al. elevated plasma highsensitivity c-reactive protein concentrations in asian indians living in the united states. j clin endocrinol metabol 2003;88:377. 12. grundy sm, cleeman ji, daniels sr, et al. diagnosis and management of the metabolic syndrome. circulation 2005;112:2735-52. 13. johnson lw, weinstock rs. the metabolic syndrome: concepts and controversy. mayo clinic proceed 2006;81:1615-20. 14. pereira rmr, de carvalho jf, bonfá e. metabolic syndrome in rheumatological diseases. autoimmun revi 2009;8:415-9. 15. love tj, qureshi aa, karlson ew, et al. prevalence of the metabolic syndrome in psoriasis: results from the national health and nutrition examination survey, 2003-2006. archiv dermatol 2011;147:419-24. 16. armstrong aw, harskamp ct, armstrong ej. psoriasis and metabolic syndrome: a systematic review and meta-analysis of observational studies. j am acad dermatol 2013;68:654-62. 17. ahlehoff o, skov l, gislason g, et al. cardiovascular disease event rates in patients with severe psoriasis treated with systemic anti-inflammatory drugs: a danish real-world cohort study. j intern med 2013;273:197-204. 18. prodanowich s, ma f, taylor jr, et al. methotrexate reduces incidence of vascular diseases in veterans with psoriasis or rheumatoid arthritis. j am acad dermatol 2005;52:262-7. 19. nicola pj, maradit-kremers h, roger vl, et al. the risk of congestive heart failure in rheumatoid arthritis: a population-based study over 46 years. arthritis rheum 2005;52:412-2. 20. borja f, jury ec, mauri c, ehrenstein mr. defects in ctla-4 are associated with abnormal regulatory t cell function in rheumatoid arthritis. proceed nation acad sci 2008;105:19396-401. 21. choi hk, hernán ma, seegar jd, et al. methotrexate and mortality in patients with rheumatoid arthritis: a prospective study. lancet 2002;359:1173-7. 22. dessein ph, joffe bi, stanwix ae. effects of disease modifying agents and dietary intervention on insulin resistance and dyslipidemia in inflammatory arthritis – a pilot study. arthritis res 2002;4:12-8. 23. garrett s, jenkinson t, kennedy lg, et al. a new approach to defining disease status in ankylosing spondylitis: the bath ankylosing spondylitis disease activity index. j rheumatol 1994;21: 2286-91. 24. prevoo m, van’t hof m, kuper h, et al. modified disease activity scores that include twenty-eight-joint counts development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. arthritis rheumatol 1995;38:44-8. 25. marra ca, woolcott jc, kopec ja, et al. a comparision of generic, indirect utility measures (the hul2,hul3, sf6d , and the eq-5d) and disease-specific instruments (the raqol and the haq) in rheumatoid arthritis. soc sci med 2005;60:1571-82. 26. targher g, bertolini l, tessari r, et al. the international diabetes federation definition of the metabolic syndrome independently predicts future cardiovascular events in type 2 diabetic patients. the valpolicella heart diabetes study. diabetic med 2006;23:1270-1. 27. expert panel on detection, evaluation, and treatment of high blood cholesterol in adults. executive summary of the third report of the national cholesterol education program (ncep) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel iii). jama 2001;285:2486-97. 28. taylor w, gladman d, helliwell p, et al. classification criteria for psoriatic arthritis: development of new criteria from a large international study. arthritis rheumat 2006;54:2665-73. 29. cohen ad, gilutz h, henkin y, et al. psoriasis and the metabolic syndrome. acta dermato-venereol 2007;87:506-9. 30. johonsson h, mclnnes lb, sattar n, cardiovascular and metabolic risks in psoriasis and psoriatic arthritis: pragmatic clinical management based on available evidence. ann rheum dis 2012;71:480-3. 31. chin yy, yu hs, li wc, et al. arthritis as an important determinant for psoriatic patients to develop severe vascular events in taiwan: a nation-wide study. j eur acad dermatol venereol 2013;27:1262-8. 32. khaw k-t, wareham n, luben r, et al. glycated haemoglobin, diabetes, and mortality in men in norfolk cohort of european prospective investigation of cancer and nutrition (epic-norfolk). bmj 2001;322:15. 33. de rotte mc, de jong ph, den boer e, et al. effect of methotrexate use and erythrocyte methotrexate polyglutamate on glycosylated hemoglobin in rheumatoid arthritis. arthritis rheumatol 2014;66:2026-36. 34. perdan-pirkmajer k, pirkmajer s, thevis m, et al. methotrexate reduces hba1c concentration but does not produce chronic accumulation of zmp in patients with rheumatoid or psoriatic arthritis. scand j rheumatol 2016;45:347-55. 35. wu jj, rowan cg, bebchuk jd, anthony ms. no association between tnf inhibitor and methotrexate therapy article no nco mm er cia l u se on ly [page 26] [dermatology reports 2019; 11:7965] versus methotrexate in changes in hemoglobin a1c and fasting glucose among psoriasis, psoriatic arthritis, and rheumatoid arthritis patients. j drugs dermatol 2015;14:159-66. 36. solomon dh, massarotti e, garg r, et al. association between diseasemodifying antirheumatic drugs and diabetes risk in patients with rheumatoid arthritis and psoriasis. jama 2011;305:2525-31. 37. gisondi p, cotena c, tessari g, girolomoni g. anti–tumour necrosis factor-α therapy increases body weight in patients with chronic plaque psoriasis: a retrospective cohort study. j eur acad dermatol venereol 2008;22:341-4. 38. saraceno r, schipani c, mazzotta a, et al. effect of anti-tumor necrosis factorα therapies on body mass index in patients with psoriasis. pharmacol res 2008;57:290-5. 39. cuchacovich r, espinoza lr. does tnf-alpha blockade play any role in cardiovascular risk among rheumatoid arthritis (ra) patients? clin rheumatol 2009;28:1217-20. article no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. dr [dermatology reports 2015; 7:5804] [page 3] efficacy of intravenous immunoglobulin monotherapy in patients with cutaneous lupus erythematosus: results of proof-of-concept study christa ky,1 brian swasdibutra,1 shaadi khademi,1 sheetal desai,2 vivian laquer,1 sergei a. grando1,3,4 1department of dermatology, 2division of rheumatology, department of medicine, 3department of biological chemistry, 4institute for immunology, university of california, irvine, ca, usa abstract cutaneous lupus erythematosus (cle) is a chronic inflammatory autoimmune skin disease. evidence-based therapy for cle is lacking in the most part. intravenous immunoglobulin (ivig) is being increasingly utilized as off-label therapy for a variety of autoimmune and inflammatory conditions, especially in dermatology. the usefulness of ivig in cle is not well established. the goal of the present study was to obtain the proof-of-concept evidence that ivig can control acute cle and thus replace current systemic immunosuppressive therapy that causes severe side effects and adverse reactions. sixteen patients who tried and failed various systemic treatments for cle were screened and consented to use ivig as a monotherapy. the ivig was administered at 500 mg/kg/day on 4 consecutive days up to a total of 2 g/kg/month for 3 months, and the subjects were monitored for additional 6 months off any drug for a possible relapse. the cumulative results revealed an overall improvement, as evinced by a decrease of both objective and subjective measures of disease activity. the most sensitive and specific objective and subjective instruments for assessment of the therapeutic effect of ivig were clasi-a (cutaneous lupus erythematosus disease area and severity index) measuring disease activity and skindex-29 scores, respectively. the clasi-a score dropped down from the initial value taken as 100%, and remained in the range of approximately 70% until the last visit. three patients (18.8%) had a temporary flare of cle symptoms but recovered within a month from the relapse. no serious side effects and adverse reactions occurred. thus, ivig monotherapy in cle allowed to achieve: i) rapid and persistent decreased in disease activity; ii) steady improvement of patients’ quality of life assessed by skindex-29; iii) low relapse rate; and iv) mild nature and short duration of relapses. since healing was maintained for months after ivig treatment, it is possible that the ivigtriggered molecular events mediating the therapeutic action of ivig that continued to unfold after the end of therapy. introduction cutaneous lupus erythematosus (cle) is a chronic inflammatory autoimmune skin disease that may cause permanent scarring. discoid lupus erythematosus, subacute cutaneous lupus erythematosus, lupus panniculitis and lupus erythematosus tumidus all fall into the category of cle. face and scalp are most commonly affected by scarring in the discoid form of cle. the etiology and pathogenesis of cle are multifactorial with genetic and environmental factors playing a role. photosensitivity, polymorphisms of the major histocompatibility complex leading to increased immune response to self-antigens, deficiencies of complement components, gender, and autoantibodies are all thought to play a role. anti-ro, anti-la, anti-dsdna and antinucleosome antibodies are thought to play a role in skin disease by increased skin cell apoptosis. dysregulation of t cells may also play a role in the pathogenesis of cle.1,2 evidence-based therapy for cle is lacking. administration of systemic immunosuppressive and anti-inflammatory agents, such as corticosteroids, hydroxychloroquine, mepa crine, methotrexate, mycophenolate mofetil, cyclophosphamide and azathioprine, in many cases, leads to remission. nevertheless, many patients suffer from resistant cutaneous lesions despite therapy. alternative systemic (dapsone, thalidomide, retinoids, cyclosporine) and topical agents (thalidomide, intralesional steroids, retinoids, tacrolimus ointment) as well as laser therapy, phototherapy, photopheresis, and cryotherapy are used for resistant cutaneous lesions, but a positive outcome is not guaranteed.3-5 intravenous immunoglobulin (ivig) is a fractioned blood product consisting of pooled, polyvalent, igg antibody extracted from the plasma of over 10,000 blood donors per batch. historically, it was used to treat primary and secondary immune deficiencies, however, its use has expanded tremendously over the past several decades. today, it is being increasingly utilized as off-label therapy for a variety of autoimmune and inflammatory conditions, especially in dermatology. ivig exhibits several effects with the most well described being: i) complement blockade and degradation; ii) neonatal fc� receptor saturation; iii) induction of immunomodulatory fc receptors; iv) inhibition of b cells; and v) altering t cell function, cytokine production and migration.6 the increasing use of ivig has been associated with further understanding of its mechanisms of action, clinical manipulation and associated side effects, as well as the introduction of improved or new types of ivig products. ongoing research continues to elaborate and identify novel mechanisms. one area in which ivig is continuing to make dramatic improvements is the ability to treat derangements of immunity in immune-mediated diseases.7 although the usefulness of ivig in cle is not well established, ivig has been used to successfully treat cle, either as monotherapy or in conjunction with an immunosuppressant.8-13 the first report in 1997 described 7 female patients treated with ivig at a dosage of 300 mg/kg per day for 5 consecutive days each month for a 12-month period.14 although some clinical symptoms, such as asthenia, arthromyalgia, and fever, disappeared in some patients and immunologic parameters improved, ivig was not able to improve the cutaneous manifestations. moreover, skin lesions of cle worsened. the vast majority of subsequent reports, however, demonstrated an overall good efficacy of ivig in resistant cases.8,11-13,15 for instance, in the responding patients, the duration of the remission ranged from 2 months to more than 1 year, suggesting that repeated pulses of ivig could be used as maintenance therapy. for example, ivig showed beneficial effects in a 2-day course (1 g/kg per day) every 4 weeks in 5 patients with refractory extensive long-lasting discoid cle dermatology reports 2015; volume 7:5804 correspondence: sergei a. grando, university of california irvine, 134 sprague hall, irvine, ca 92697, usa. tel.: +1.949.824.2713 fax: +1.949.824.2993. e-mail: sgrando@uci.edu key words: cutaneous lupus erythematosus, ivig, case-series, clasi, skindex-29. acknowledgements: this work was supported by a research grant from grifols and a grant-in-aid from institute for clinical and translational science at university of california, irvine. contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. received for publication: 10 january 2015. accepted for publication: 12 january 2015. this work is licensed under a creative commons attribution noncommercial 3.0 license (cc bync 3.0). ©copyright c. ky et al., 2015 licensee pagepress, italy dermatology reports 2015; 7:5804 doi:10.4081/dr.2015.5804 no n c om me rci al us e o nly no n c om me rci al us e o nly [page 4] [dermatology reports 2015; 7:5804] with major face involvement. relapses occurred 2 to 10 months after ivig withdrawal and skin lesions were controlled again with ivig in one patient with discoid cle. in another case report, one patient with resistant cle was treated with ivig (2 g/kg per month) and showed dramatic improvement within 3 months and almost complete resolution after 6 months. three patients with cle unresponsive to previous therapy were treated with ivig, which achieved good response of their skin lesions. twelve patients with histologically confirmed cle were given ivig with starting doses of 1 g/kg per day on 2 consecutive days, followed by 400 mg/kg per month for 6 months or until disease resolution. five patients had complete or near complete clearing of their skin disease (>75% clearing), two had partial improvement (~50% clearing), and three had limited response (<50% clearing). others reported a female patient with highly recalcitrant cle who responded very well to treatment with ivig (1 g/kg per day on 3 consecutive days per month). amelioration was observed after the first cycle followed by an almost complete clearing. more recently, a case of cle successfully treated with ivig was reported after other therapy modalities failed. thus, the available data strongly suggest that patients with cle may benefit from a therapy with ivig. however, a recommended or defined protocol for patients with cle does not exist. the goal of the present study was to obtain the proof-of-concept evidence that ivig can control acute cle and thus replace current systemic immunosuppressive therapy that causes severe side effects and adverse reactions. from the review of literature, we postulated that: i) the beneficial effects of ivig for patients with cle should be prompt, with marked improvement within a few weeks; and ii) clinical improvement should last several weeks after the last infusion. materials and methods for this small scale exploratory consecutive case-series type of study, subjects were recruited from an outpatient cle patient population treated at the university of california, irvine. sixteen patients who received a standard therapy without a therapeutic response for a minimum of one month were screened and consented to use ivig as a monotherapy. our patients have tried and failed various systemic treatments for cle, such as prednisone, plaquenil and dapsone. topical treatment with clobetasol or tacrolimus, which was not effective either, was stopped at the beginning of ivig therapy. inclusion criteria: males and females ≥18 years of age; active cle (any subtype) established by standard clinical and histoand immunopathological criteria; understands and follows directions. exclusion criteria: subjects <18 years of age; cannot understand or follow directions; a pregnant, planning to get pregnant or breast feeding female; a female of child-bearing potential and unwilling to use a form of highly effective birth control; has one or more of the following problems: iga deficiency, hiv infection, organ transplant, severe anemia, jaundice, major organ failure, creatinine >1.5 mg/dl or hemoglobin <11.0 g/dl. all enrolled subjects received ivig treatment following the protocol that proved to be efficacious in the treatment of patients with autoimmune blistering diseases as well as previously treated patients with cle. the ivig (gamunex-c, grifols, los angeles, ca, usa) was administered at 500 mg/kg/day on 4 consecutive days up to a total of 2 g/kg/month for 3 months in the institute for clinical and translational science at university of california, irvine. after 3 months of treatment, ivig was discontinued and the subjects were monitored for additional 6 months off any drug for a possible relapse. upon entry into the study, the study subject’s severity of cle was evaluated using the following instruments: physician’s subjective assessment of severity (psas; mild, moderate or severe), physician’s subjective assessment of improvement (psai; improved, unchanged or worse), and cutaneous lupus erythematosus disease area and severity index (clasi) measuring both the activity of the disease (clasi-a) and the damage done by the disease (clasi-d). the higher scores indicated more severe skin disease.16 the subjects also evaluated their skin-specific quality of life with the skindex-29 − the questionnaire consisting of 29 items used to calculate three subscales: symptoms (pain, itch, burning, sensitivity), emotions (depression, anxiety, embarrassment, anger) and functioning (sleep, relationships with others).16 all assessments were repeated at all study visits. results we have enrolled and treated 15 female and 1 male cle patients aged 19-70 years with 3 monthly cycles of ivig monotherapy. the cumulative results of assessment of clinical efficacy of ivig in the enrolled patients revealed an overall improvement, as evinced by a decrease of both objective and subjective measures of disease activity. the most sensitive and specific objective and subjective instruments for assessment of the therapeutic effect of ivig were clasi-a and skindex-29 scores, respectively (table 1). the individual variations of clasi-a and skindex-29 scores are shown in figure 1. all other measured parameters, clasi-d, psas and psai, did not article table 1. the clinical response scores (%) in enrolled cutaneous lupus erythematosus patients treated by intravenous immunoglobulin monotherapy. clinical initial 1st visit 2nd visit 3rd visit 4th visit 5th visit 6th visit 7thvisit 8th visit 9th visit evaluation visit (n=16) (n=14) (n=14) (n=12) (n=9) (n=6) (n=6) (n=6) (n=5) (n=6) test clasi-a 100 94 84 94 86 85 72 68 81 71 clasi-d 100 100 100 100 100 100 100 100 100 100 psas 100 100 98 100 97 92 92 92 90 92 psai 100 100 100 136 104 105 117 133 15 100 skindex-29 100 97 94 92 90 81 79 83 99 92 clasi, cutaneous lupus erythematosus disease area and severity index; psas, physician’s subjective assessment of severity; psai, physician’s subjective assessment of improvement. results are expressed as a relative mean value determined for the entire group of cutaneous lupus erythematosus on a particular visit number, compared to the pre-treatment value for the corresponding test, taken as 100%. number of patients per each particular time-point (i.e., visit number), for who the mean value was calculated. no n c om me rci al us e o nly no n c om me rci al us e o nly [dermatology reports 2015; 7:5804] [page 5] correlate with clinical improvement. as seen in table 1, on the 7th visit after starting ivig treatment, the clasi-a score dropped down to 68% from the initial value taken as 100%, and remained in the range of approximately 70% until the last visit. skindex-29 was found to be an informative subjective measure, showing a drop to 79% from the initial 100% on the 6th visit (table 1). after that, skindex-29 has increased again. first dose response was indicated by a steady decrease in clasi-a between the baseline and the 1st month after starting ivig treatment. five patients had a decrease in clasi-a that persisted for the rest of the study. three patients (18.8%) had a temporary flare of cle symptoms categorized as a relapse of the disease. all patients recovered within a month from the relapse. in one patient, the clasi-a score increased from 7 to 10 but then dropped to 8. in a second patient, the clasi-a score increased from 2 to 5 and then decreased back to 2. in a third patient, the clasi-a score increased from 14 to 17 but then dropped to 9. no serious side effects and adverse reactions occurred. two patients developed mild anemia, 1 mild neutropenia, 5 headache, 1 back aches, 1 high blood pressure, 2 fever, 1 gastro-intestinal upset, 2 nausea/vomiting, and 1 herpes-associated erythema multiforme. these are commonly seen in patients with various medical conditions receiving ivig therapy. discussion the results of this proof-of-concept study of clinical efficacy of a short-term ivig monotherapy in cle produced very promising results, as evidenced by: i) rapid and persistent decreased in disease activity measured by clasi-a scores; ii) steady improvement of patients’ quality of life assessed by skindex-29; iii) low relapse rate; and iv) mild nature and short duration of relapses. since healing was maintained for months after ivig treatment, it is possible that the ivigtriggered molecular events mediating the therapeutic action of ivig that continued to unfold after the end of therapy. the results of this study thus provide the basis for hypotheses for the future multicenter randomized controlled studies to identify which cle subsets will benefit the most and which protocol will provide the optimal clinical outcome. the obtained results indicated that a minimum of 3 treatment cycles with ivig at 2 g/kg/month were needed to achieve clinical response. however, the fact that both clasi-a and skindex-29 scores showed a tendency to increase after reaching the minimal values strongly suggests that more cycles of ivig monotherapy are required to achieve a stable clinical remission off any drugs. this would be in keeping with duration of ivig therapy required to achieve stable remission in patients with autoimmune blistering dermatoses. for examples, an average number of ivig cycles (i.e., months) of treatment of patients with pemphigus and pemphigoid is equal to 38.6.17 thus, while the use of ivig allows achievement of rapid remission of cle, the maintenance therapy with repeated monthly pulses of ivig for an extended period of time should maintain the disease in remission. future clinical trials should determine the optimal number of cycles of treatment for patients with distinct cle forms by ivig monotherapy. in this study, clasi-a was the most sensitive measure of treatment efficacy. the obtained results are comparable to those reported by the others who tested the efficacy of cle treatment by pulsed dye laser treatment or vitamin d.18,19 overall, clasi score measurement shows good content validity, addresses the most relevant aspects of all subsets of cle, including individual lesions localized and generalized cle, and also has good inter-rater article figure 1. individual cutaneous lupus erythematosus disease area and severity index-total activity score (a) and skindex-29 (b) values in enrolled cutaneous lupus erythematosus patients. the vertical axis shows the score for each patient (blue dots), and the horizontal axis indicates the visit number, starting from initial visit before starting immunoglobulin monotherapy, i.e., visit #1. the red line depicts the best fit line relative to all data points. note: values for some individual patient overlay. visit 1: screening; visit 2: baseline; visit 3: month 1; visit 4: month 2; visit 5: month 3; visit 6: month 4; visit 7: month 5; visit 8: month 6; visit 9: month 7; visit 10: month 8. no n c om me rci al us e o nly no n c om me rci al us e o nly [page 6] [dermatology reports 2015; 7:5804] and intra-rater reliability when used by either dermatologists or rheumatologists.16,20-26 in marked contrast, clasi-d remained unchanged for all but 2 patients, as could be expected for such a short-term study, given the irreversible nature of skin damage in cle, e.g., scars. the clasi-d result is comparable to other cle studies that have been shown to treat cle. the relapses in the three of our patients, defined as an increase in clasi-a score, were mild, because within one month, their clasia became comparable to or even lower than that prior to the relapse. in our patients, the relapse rate was much lower, compared to that reported in the literature for cle patients. for comparison, in other clinical trials the relapse rate was reported at the range of 70-80%.27-29 conclusions we can conclude that: i) ivig monotherapy clearly alleviated symptoms in patients with different clinical forms of cle resistant to standard treatments, which should justify a multi-center clinical trial on a larger number of patients to ultimately establish the efficacy of ivig in each clinical form of cle; ii) three monthly cycles of 2 g/kg/month of ivig were sufficient to achieve a stable remission, but the symptoms may return, indicating the need for a more extended duration ivig monotherapy of cle, by analogy with other mucocutaneous autoimmune diseases; iii) clasi-a and skindex-29 appeared to be the most sensitive objective and subjective, respectively, instruments for analysis of clinical efficacy of ivig in patients with cle, and, therefore, should be employed for assessment of treatment efficacy in future clinical trials of ivig in cle; iv) treatment with ivig dramatically decreases 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ahmed ar. efficacy of various intravenous immunoglobulin therapy protocols in autoimmune and chronic inflammatory disorders. ann pharmacother 2007;41:812-23. 8. goodfield m, davison k, bowden k. intravenous immunoglobulin (ivig) for therapy-resistant cutaneous lupus erythematosus (le). j dermatolog treat 2004;15:46-50. 9. genereau t, chosidow o, danel c, et al. high-dose intravenous immunoglobulin in cutaneous lupus erythematosus. arch dermatol 1999;135:1124-5. 10. kreuter a, gaifullina r, tigges c, et al. lupus erythematosus tumidus: response to antimalarial treatment in 36 patients with emphasis on smoking. arch dermatol 2009;145:244-8. 11. kreuter a, hyun j, altmeyer p, gambichler t. intravenous immunoglobulin for recalcitrant subacute cutaneous lupus erythematosus. acta derm venereol 2005;85:5457. 12. espirito santo j, gomes mf, gomes mj, et al. intravenous immunoglobulin in lupus panniculitis. clin rev allergy immunol 2010;38:307-18. 13. lampropoulos ce, hughes gr, dp dc. intravenous immunoglobulin in the treatment of resistant subacute cutaneous lupus erythematosus: a possible alternative. clin rheumatol 2007;26:981-3. 14. de pita o, bellucci am, ruffelli m, et al. intravenous immunoglobulin therapy is not able to efficiently control cutaneous manifestations in patients with lupus erythematosus. lupus 1997;6:415-7. 15. levy y, sherer y, ahmed a, et al. a study of 20 sle patients with intravenous immunoglobulin-clinical and serologic response. lupus 1999;8:705-12. 16. klein r, moghadam-kia s, lomonico j, et al. development of the clasi as a tool to measure disease severity and responsiveness to therapy in cutaneous lupus erythematosus. arch dermatol 2011;147:203-8. 17. seidling v, hoffmann jh, enk ah, hadaschik en. analysis of high-dose intravenous immunoglobulin therapy in 16 patients with refractory autoimmune blistering skin disease: high efficacy and no serious adverse events. acta derm venereol 2013;93:346-9. 18. erceg a, bovenschen hj, van de kerkhof pc, et al. efficacy and safety of pulsed dye laser treatment for cutaneous discoid lupus erythematosus. j am acad dermatol 2009;60:626-32. 19. cutillas-marco e, marquina-vila a, grant w, et al. vitamin d and cutaneous lupus erythematosus: effect of vitamin d replacement on disease severity. lupus 2014. [epub ahead of print]. 20. albrecht j, taylor l, berlin ja, et al. the clasi (cutaneous lupus erythematosus disease area and severity index): an outcome instrument for cutaneous lupus erythematosus. j invest dermatol 2005;125: 889-94. 21. albrecht j, werth vp. development of the clasi as an outcome instrument for cutaneous lupus erythematosus. dermatol ther 2007;20:93-101. 22. bonilla-martinez zl, albrecht j, troxel ab, et al. the cutaneous lupus erythematosus disease area and severity index: a responsive instrument to measure activity and damage in patients with cutaneous lupus erythematosus. arch dermatol 2008;144: 173-80. 23. krathen ms, dunham j, gaines e, et al. the cutaneous lupus erythematosus disease activity and severity index: expansion for rheumatology and dermatology. arthritis rheum 2008;59:338-44. 24. salphale p, danda d, chandrashekar l, et al. the study of cutaneous lupus erythematosus disease area and severity index in indian patients with systemic lupus erythematosus. lupus 2011;20:1510-7. 25. piette ew, foering kp, chang ay, et al. impact of smoking in cutaneous lupus erythematosus. arch dermatol 2012;148:31722. 26. braunstein i, klein r, okawa j, werth vp. the ifn-regulated gene signature is elevated in scle and dle and correlates with clasi score. br j dermatol 2012;166:9715. 27. cortes-hernandez j, avila g, vilardelltarres m, ordi-ros j. efficacy and safety of lenalidomide for refractory cutaneous lupus erythematosus. arthritis res ther 2012;14:r265. 28. cortes-hernandez j, torres-salido m, castro-marrero j, et al. thalidomide in the treatment of refractory cutaneous lupus erythematosus: prognostic factors of clinical outcome. br j dermatol 2012;166:61623. 29. coelho a, souto mi, cardoso cr, et al. long term thalidomide use in refractory cutaneous lesions of lupus erythematosus: a 65 series of brazilian patients. lupus 2005;14:434-9. article no n c om me rci al us e o nly no n c om me rci al us e o nly dr [dermatology reports 2017; 9:7399] [page 55] a retrospective comparative study of the efficacy and safety of two regimens of diphenylcyclopropenone in the treatment of recalcitrant alopecia areata tueboon sriphojanart, saranya khunkhet, poonkiat suchonwanit division of dermatology, faculty of medicine, ramathibodi hospital, mahidol university, bangkok, thailand abstract diphenylcyclopropenone (dpcp) is an effective topical immunotherapy for recalcitrant alopecia areata (aa), which sometimes requires prolonged treatment. we developed a new treatment protocol to shorten the duration of therapy. this study aimed to compare the efficacy and safety of the new treatment protocol with the standard treatment protocol in the treatment of recalcitrant aa. we conducted a 6-year retrospective comparative study of patients with aa who received one of the dpcp treatment protocols at our institute. patients’ information was collected and subsequent statistically analyzed. thirtynine patients (16 in the new treatment group and 23 in the standard treatment group) were included. there were no statistically significant differences in area of hair regrowth. mean duration to initial hair regrowth and mean duration to significant hair regrowth in the new treatment group were significantly shorter than in the standard treatment group (p=0.002 and 0.01, respectively). adverse effects were slightly higher in the new treatment group. the present study reveals the effectiveness and safety of the new treatment protocol, which shortens the duration of dpcp treatment and could represent an alternative regimen. introduction alopecia areata (aa) is an autoimmune disease with a genetic basis presenting with non-scarring hair loss both on the scalp and non-scalp areas. the prevalence of aa is approximately 1-2% of the general population.1 the disease has no sexual and age prevalence. clinically, patients manifest with well-defined, asymptomatic, non-scarring areas of hair loss with characteristic exclamation mark hairs. the prognosis of the disease is quite variable. spontaneous improvement within 1 year was reported in 34-50% of patients. however, in 14-25%, aa can progress to total scalp hair loss (alopecia totalis; at) or even entire body hair loss (alopecia universalis; au), which shows spontaneous improvement in less than 10% of cases.2 even though aa is not a life threatening disease, it can greatly affect patients’ psychosocial status and quality of life. compared with the general population, psychological disorders, such as anxiety, depression, and phobias, are more common in patients with aa.3,4 the pathogenesis of aa remains to be determined. currently, a widely accepted theory is the autoimmune etiology. specific t-cell lymphocytes, autoantibodies against anagen follicles, and various cytokines such as interferon-γ, interleukins, and tumor necrosis factor-α have been found to play a major role in aa.5 in addition, the immune privilege theory has been recently introduced and suggested to play a role in the pathogenesis.6 therefore, the principle of treatment is to inhibit all the possible etiological pathways. there is currently no curative treatment for aa. treatment modalities include corticosteroids, anthralin, cyclosporine, biologic therapy, topical immunotherapy, photochemotherapy, and 308-nm excimer laser, among other.7 however, treatment is still very difficult, particularly in patients with chronic and extensive aa. currently, topical immunotherapy using diphenylcyclopropenone (dpcp) is one interesting treatment option for recalcitrant case. this treatment was first introduced by happle et al. in 1983.8 the principle of treatment is induction and repeated elicitation of an allergic contact dermatitis by application of contact allergen on affected areas. its mechanism of action is not fully understood, but antigenic competition from induction of contact dermatitis on the scalp is believed to be a possible mechanism.9 for almost 10 years, we have been performing dpcp treatment regularly in patients with aa who do not respond to other treatments within the first 6 months. the first step of treatment is sensitization of the patient to dpcp. after this is successfully completed, the lowest concentration of dpcp is initially applied to the affected area on the patient’s scalp. then, the concentration is gradually increased every week until the optimal reaction occurs. we observed that some patients took several weeks or even months to reach the optimal reaction, which could extend the overall treatment duration. we developed a new treatment protocol of topical immunotherapy for recalcitrant aa and have been using it in some patients since 2011. the purpose of developing the new protocol was to minimize the duration of dpcp treatment. after sensitization, multiple concentrations of dpcp were applied to the scalp in individual small areas at the same time. then, the optimal concentration that could cause mild contact dermatitis was selected to be the first concentration applied to the patient’s scalp. we believe that our new treatment protocol could reduce the treatment duration and also reduce the cumulative treatment cost compared to the standard protocol. therefore, to prove our hypothesis, we conducted a retrospective comparative study of patients with aa who received dpcp treatment at our institute. the objective of the study was to determine whether the new treatment protocol is superior to the standard protocol in the treatment of recalcitrant aa and to compare adverse events between the two treatment protocols. materials and methods study design this is a retrospective comparative study conducted at ramathibodi hospital, mahidol university. patients’ information from 2011 to 2016 was collected from medical records. the study was reviewed and dermatology reports 2017; volume 9:7399 correspondence: poonkiat suchonwanit, division of dermatology, ramathibodi hospital, 270 rama vi road, rajthevi, bangkok, thailand 10400. tel.: +662.201.1141 fax: +662.201.1211. e-mail: poonkiat@hotmail.com key words: alopecia; alopecia areata; diphencyprone; diphenylcyclopropenone; topical immunotherapy. contributions: ts, sk, ps, study conception and design; ts, sk, acquisition of data; ts, sk, ps, analysis and interpretation of data; ts, ps, drafting of manuscript; ps, critical revision. conflict of interest: the authors declare no conflict of interest. received for publication: 7 september 2017. accepted for publication: 6 november 2017. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright t. sriphojanart et al., 2017 licensee pagepress, italy dermatology reports 2017; 9:7399 doi:10.4081/dr.2017.7399 no n c om me rci al us e o nly [page 56] [dermatology reports 2017; 9:7399] approved by the mahidol university institutional review board for ethics in human research (protocol number 06-5952). patients patients with aa who received dpcp treatment using either the standard treatment protocol or the new treatment protocol in the outpatient dermatology clinic were included in the study. the diagnosis of aa in each patient was based on clinical and/or histological examination. the inclusion criteria were age greater than 18 years, unfavorable treatment outcomes with any other topical and systemic treatments for at least 6 months, scalp hair loss greater than 50%, and regular followed up in our clinic at least 6 months after discontinuation of dpcp treatment. the exclusion criteria were incomplete medical records and unsuccessful sensitization to dpcp. demographic data including the age of onset, duration of disease, medical history, family history of aa, type of aa, severity of disease measured using the severity of alopecia tool (salt) score,10 and nail abnormalities were collected for further analysis. sensitization to diphenylcyclopropenone dpcp solution was prepared by dissolving dpcp powder (fluka, sigmaaldrich corp, st. louis, mo, usa) in acetone at serial dilutions of 0.0001%, 0.0005%, 0.001%, 0.005%, 0.01%, 0.02%, 0.05%, 0.1%, 0.2%, 0.5%, 1.0%, and 2.0% and storing the dilution in dark glass vials to prevent degradation from ultraviolet light. at the first visit, the patient was sensitized by application of 2% dpcp at the inner aspect of the upper arm over a 4×4 cm2 area. dpcp was left on the sensitized area for 24 hours then washed off. after 72 h, patient was evaluated for an eczematous reaction to detect whether sensitization to dpcp had occurred. treatment with standard regimen two weeks after sensitization, dpcp treatment starting with the 0.0001% concentration was applied at the affected scalp area every week. first, dpcp was left on the scalp for 24 h and then washed off with gentle shampoo. each week, concentration of dpcp was titrated upward to reach a tolerable eczematous reaction, which was mild pruritus and mild erythema lasting not more than 48 h. the concentration that produced optimal eczematous reaction was maintained at subsequent treatments. if the concentration of dpcp used on the scalp revealed negative or below the optimal reaction, then the concentration of dpcp would be titrated upward. the concentration may be titrated upward or downward to maintain the optimal eczematous reaction. treatment with new treatment regimen two weeks after sensitization, the scalp was mapped for applying dpcp. then, six consecutive concentrations of dpcp (0.0001%, 0.001%, 0.01%, 0.05%, 0.1%, and 0.5%) were applied on the scalp over 3×3 cm2 areas separated by a distance of 4 cm. dpcp was left on the scalp for 24 h and then washed off with gentle shampoo. one week later, the concentration that created a mild eczematous reaction was chosen to be the first applied. the starting concentration was applied at the affected scalp area and left for 24 h and then washed off. the concentration of dpcp was adjusted every week to maintain a tolerable eczematous reaction. clinical assessment the patients were followed up weekly for evaluation of clinical responses and side effects. treatment was withdrawn if there were no signs of hair regrowth at 6 months. if there was any clinical response, treatment was continued until complete hair regrowth. for patients with incomplete hair regrowth at 1 year after treatment, percentage of hair regrowth at 1 year was recorded as their treatment outcome. all patients were followed up monthly for 6 months after discontinuation of treatment. the clinical assessment was divided into efficacy and safety. efficacy assessment included the treatment response reported as percentages of area of hair regrowth, change in salt score from baseline, and duration of clinical responses (initial response and significant response). the initial response was defined as appearance of any new regrowth hair within treated sites and significant response was defined as greater than 75% hair regrowth. failure of treatment was considered when hair regrowth was not observed after the first 6 months of treatment. relapse was defined as more than 25% hair loss after complete hair regrowth. safety information was collected from the adverse effects recorded. statistical analysis statistical analysis was performed using the spss statistics version 18.0 (spss inc., chicago, il, usa). chi-square test, fisher exact test, t-test, and wilcoxon rank-sum test were performed to compare demographic data, efficacy, and adverse effects. the results were considered statistically significant at p<0.05. results from a total of 65 patients with aa who received dpcp treatment during the last 5 years, 39 patients were eligible and were included in the study. sixteen patients were treated with the new treatment regimen and 23 patients were treated with the standard regimen. epidemiological data and baseline clinical characteristics of all patients are compared and summarized in table 1. the groups were comparable in terms of age, gender, duration of disease, underlying disease, scalp area involvement, and nail involvement. table 2 demonstrates the comparison of treatment outcomes between the 2 treatment groups. eight patients in the new treatment group and 12 patients in the standard group had >75% area of hair regrowth. seven patients in each group had complete hair regrowth. failure of treatment was reported in 2 and 3 patients in the new and standard treatment group, respectively. regarding area of hair regrowth, there were no statistically significant differences between the two groups. for treatment duration, mean duration to initial hair regrowth in the new treatment group was significantly shorter than that in the standard treatment group (10.5±2.6 weeks and 14.2±3.9 weeks, respectively; p=0.002). moreover, mean duration to >75% hair regrowth was 24.3±4.2 weeks in the new treatment group and 29.2±6.5 weeks in the standard treatment group, representing a statistically significant difference (p=0.01). regarding relapse of aa, there was no significant difference in both number of patients and median duration to relapse between the 2 groups (p=0.81 and 0.62, respectively). adverse effects were slightly higher in the new treatment group, without statistical significance. discussion topical immunotherapy using dpcp has been proven effective in the treatment of patients with recalcitrant aa. this method is recommended as first-line therapy in patients with aa who have more than 50% scalp area involvement.11 its efficacy, in terms of acceptable regrowth, has been reported in previous studies with variable response. a systematic review reported that the average response rate of dpcp treatment in 26 studies was 53.75%.12 our study reported a significant response rate of 50% in the new treatment group and 52.1% in the standard treatment group, which are comparable with the average response rate. article no n c om me rci al us e o nly previous studies reported response rates of dpcp ranging from 5 to 85%.8,13-20 the variability in clinical response rate between studies may be attributed to different study designs, treatment protocols, baseline disease severity, therapeutic response grading systems, and follow-up periods. to minimize this problem in future studies, clinical trials using a standardized method in clinical assessment is recommended. regarding percentage of hair regrowth, the present study found similar clinical response rates between the 2 groups. the data confirms that the efficacy of the new treatment protocol was not inferior in comparison with the standard treatment protocol. in addition, this retrospective study reveals the advantage of the multiple dpcp treatment protocol in shortening the duration of treatment. our study showed that mean duration to initial response and mean duration to >75% hair regrowth in the new treatment group were significantly shorter than in the standard treatment group, which was approximately 5 weeks. our results are comparable with a previous study using multiple concentrations of dpcp in patients with at or au, which revealed a benefit of shortened treatment duration.21 when comparing the treatment duration using data from the standard treatment group, the average duration to significant hair regrowth was comparable with previous studies. chiang et al.22 and el khoury et al.23 reported durations to significant hair regrowth of 28 and 31.74 weeks, respectively. therefore, the new treatment protocol could shorten the response time, which normally takes several months to reach a significant clinical response, and could be considered an alternative regimen to shorten the therapeutic period. application of multiple concentrations of dpcp at the first treatment assisted the physician in identifying the optimal concentration in a shorter period. reduction of the overall treatment duration could reduce the cost of treatment and other expenses such as transportation, accommodation, and income loss while undergoing dpcp treatment. the relapse rates in each treatment group in the present study were less than that reported in previous studies, which range between 45.1 and 70%.19,20,24-26 the difference in the relapse rate may be due to different definitions of relapse and the duration of follow-up. although the relapse rate of topical immunotherapy with dpcp is quite high, it is considered to be the most successful treatment for severe types of aa.27 common adverse effects of dpcp treatment described in the literature are severe eczematous reaction, wide spread eczema, urticarial reaction, severe dermographism, and cervical lymphadenopathy.28-30 the present study shows that adverse effects were slightly higher in the new treatment protocol group, without statistical significance. using a higher concentration during the early treatment period could increase the possibility of severe reactions. fortunately, the adverse effects were tolerable and rapidly disappeared within a few days after providing symptomatic treatment. none of the patient dropped out of the treatment. limitations of this study are the retrospective design and small number of patients. therefore, we were unable to assess patients’ history and clinical evaluation completely. the small sample size may account for the lack of statistically significant results. prospective clinical trials with a large number of patients could overcome this limitation. conclusions topical immunotherapy is an effective treatment option for patients with chronic article table 1. demographics and clinical characteristics of the patients in the 2 treatment groups. variables standard regimen new regimen p value number 23 16 n/a mean age (year) 35.5±5.2 32.9±4.6 0.11 sex (male:female) 9:14 6:10 0.91 mean age at onset (year) 26.9±5.6 23.5±5.8 0.07 mean duration of disease (week) 56.9±10.2 61.9±12.6 0.17 underlying diseases, n (%) atopic disease 3 (13) 1 (6.2) 0.49 autoimmune thyroid 1 (4.3) 1 (6.2) 0.79 family history of aa, n (%) 2 (8.6) 3 (18.8) 0.35 nail involvement, n (%) 8 (34.8) 9 (56.2) 0.18 type of alopecia areata, n (%) multiple patches 9 (39.2) 6 (37.4) 0.81 alopecia totalis 8 (34.8) 7 (43.7) alopecia universalis 6 (26) 3 (18.9) baseline area involvement, n (%) 51-75% 5 (21.7) 3 (18.9) 0.95 76-99% 5 (21.7) 4 (25) 100% 13 (56.6) 9 (56.1) aa, alopecia arata. table 2. response to treatments and adverse effects observed in patients in the 2 treatment groups. variables standard regimen new regimen p value area of hair regrowth, n (%) no hair regrowth 3 (13) 2 (12.5) 0.99 1-25% 2 (8.6) 2 (12.5) 26-50% 2 (8.6) 1 (6.2) 51-75% 4 (17.7) 3 (18.9) 76-99% 5 (21.7) 1 (6.2) 100% 7 (30.4) 7 (43.7) mean duration to initial response (week) 14.2±3.9 10.5±2.6 0.002* mean duration to >75% hair regrowth (week)# 29.2±6.5 24.3±4.2 0.01* relapse, n (%) 5 (21.7) 4 (25) 0.81 median duration to relapse (week) 14 (8-23) 11 (6-18) 0.62 adverse effects, n (%) blister formation 1 (4.3) 1 (6.2) 0.9 widespread eczema 3 (13) 6 (37.4) dyspigmentation 1 (4.3) 2 (12.5) lymphadenopathy 7 (30) 8 (50) *statistically significant; #data collected from patients with >75% hair regrowth. [dermatology reports 2017; 9:7399] [page 57] no n c om me rci al us e o nly [page 58] [dermatology reports 2017; 9:7399] and extensive aa. the present study shows that the new treatment protocol is effective and safe, and could shorten the duration of dpcp treatment. our new treatment protocol could be an alternative regimen for the treatment of aa. references 1. willemsen r, vanderlinden j, roseeuw d, haentjens p. increased history of childhood and lifetime traumatic events among adults with alopecia areata. j am acad dermatol 2009;60:388-93. 2. mcdonagh aj, messenger ag. the pathogenesis of alopecia areata. dermatol clin 1996;14:661-70. 3. rafique r, hunt n. experiences and coping behaviours of adolescents in pakistan with alopecia areata: an interpretative phenomenological analysis. int j qual stud health well-being 2015;10:26039. 4. hunt n, mchale s. the psychological impact of alopecia. bmj 2005;331:9513. 5. gregoriou s, papafragkaki d, kontochristopoulos g, et al. cytokines and other mediators in alopecia areata. mediators inflamm 2010;2010:928030. 6. kang h, wu wy, lo bk, et al. hair follicles from alopecia areata patients exhibit alterations in immune privilegeassociated gene expression in advance of hair loss. j invest dermatol 2010;130:2677-80. 7. delamere fm, sladden mm, dobbins hm, leonardi-bee j. interventions for alopecia areata. cochrane database syst rev 2008:cd004413. 8. happle r, hausen bm, wiesnermenzel l. diphencyprone in the treatment of alopecia areata. acta derm venereol 1983;63:49-52. 9. sutherland l, laschinger m, syed zu, gaspari a. treatment of alopecia areata with topical sensitizers. dermatitis 2015;26:26-31. 10. olsen ea, hordinsky mk, price vh, et al. alopecia areata investigational assessment guidelines—part ii. national alopecia areata foundation. j am acad dermatol 2004;51:440-7. 11. alkhalifah a, alsantali a, wang e, et al. alopecia areata update: part ii. treatment. j am acad dermatol 2010;62:191-202. 12. jang yh, jung hj, moon sy, et al. systematic review and quality analysis of studies on the efficacy of topical diphenylcyclopropenone treatment for alopecia areata. j am acad dermatol 2017;77:170-2. 13. hull sm, cunliffe wj. successful treatment of alopecia areata using the contact allergen diphencyprone. br j dermatol 1991;124:212-3. 14. van der steen ph, van baar hm, perret cm, happle r. treatment of alopecia areata with diphenylcyclopropenone. j am acad dermatol 1991;24:253-7. 15. van der steen ph, boezeman jb, happle r. topical immunotherapy for alopecia areata: re-evaluation of 139 cases after an additional follow-up period of 19 months. dermatology 1992;184:198-201. 16. cotellessa c, peris k, caracciolo e, et al. the use of topical diphenylcyclopropenone for the treatment of extensive alopecia areata. j am acad dermatol 2001;44:73-6. 17. aghaei s. topical immunotherapy of severe alopecia areata with diphenylcyclopropenone (dpcp): experience in an iranian population. bmc dermatol 2005;5:6. 18. firooz a, bouzari n, mojtahed f, et al. topical immunotherapy with diphencyprone in the treatment of extensive and/or long-lasting alopecia areata. j eur acad dermatol venereol 2005;19:393-4. 19. avgerinou g, gregoriou s, rigopoulos d, et al. alopecia areata: topical immunotherapy treatment with diphencyprone. j eur acad dermatol venereol 2008;22:320-3. 20. ohlmeier mc, traupe h, luger ta, bohm m. topical immunotherapy with diphenylcyclopropenone of patients with alopecia areata—a large retrospective study on 142 patients with a selfcontrolled design. j eur acad dermatol venereol 2012;26:503-7. 21. thuangtong r, varothai s, triwongwaranat d, rujitharanawong c. multi-concentration level patch test guided diphenyl cyclopropenone (dpcp) treatment in alopecia totalis or alopecia universalis, j med assoc thai 2017;100:86-92. 22. chiang ks, mesinkovska na, piliang mp, bergfeld wf. clinical efficacy of diphenylcyclopropenone in alopecia areata: retrospective data analysis of 50 patients. j investig dermatol symp proc 2015;17:50-5. 23. el khoury j, abd-el-baki j, succariah f, et al. topical immunomodulation with diphenylcyclopropenone for alopecia areata: the lebanese experience. int j dermatol 2013;52:1551-6. 24. bolduc c, shapiro j. dpcp for the treatment of alopecia areata. skin therapy lett 2000;5:3-4. 25. wiseman mc, shapiro j, macdonald n, lui h. predictive model for immunotherapy of alopecia areata with diphencyprone. arch dermatol 2001;137:1063-8. 26. luk nm, chiu ls, lee kc, et al. efficacy and safety of diphenylcyclopropenone among chinese patients with steroid resistant and extensive alopecia areata. j eur acad dermatol venereol 2013;27:e400-5. 27. hoffmann r, happle r. topical immunotherapy in alopecia areata. what, how, and why? dermatol clin 1996;14:739-44. 28. hull sm, cunliffe wj. treatment of alopecia areata with diphenylcyclopropenone. j am acad dermatol 1992;26:276-7. 29. alam m, gross ea, savin rc. severe urticarial reaction to diphenylcyclopropenone therapy for alopecia areata. j am acad dermatol 1999;40:110-2. 30. skrebova n, nameda y, takiwaki h, arase s. severe dermographism after topical therapy with diphenylcyclopropenone for alopecia universalis. contact dermatitis 2000;42:212-5. article no n c om me rci al us e o nly dr [dermatology reports 2017; 9:7044] [page 1] assessment effect of breast milk on diaper dermatitis bahar seifi,1 sheida jalali,2 mohammad heidari3 1department of nursing, tehran medical sciences branch, islamic azad university, tehran; 2department of midwifery, tehran medical sciences branch, islamic azad university, tehran; 3department of medical and surgical, school of nursing and midwifery, shahrekord university of medical sciences, shahrekord, iran abstract diaper dermatitis is the most common dermatological disease of infancy, which occurs and caused by the combined effect of irritants such as diaper, urine and faces. in this study, we intend to evaluate the effect of breast milk on the healing of diaper dermatitis. this study was a clinical trial of 30 infants between 0-12 months of age that were suffering from diaper dermatitis and referred to the health centers in tehran, iran. the subjects were selected by open study. infants were divided into two matched groups: case and control. datagathering tools were the questionnaire that contained two parts: the demographic characteristics of infants and the status of care and condition of the lesion. data analysis was performed using spss/18 software and mann-whitney and chi-square tests were used. the findings revealed a significant difference between the case and control groups in the number and lesion score of the rashes at the first and third day (p=0.013, p=0.005), these differences were more significant at the fifth day (p=0.004, p=0.001). because of positive effects of breast milk on healing of diaper dermatitis, it is proposed that educational programs in health centers should be considered by health officials, and the managers would play a key role in increasing knowledge behavior changes in mothers. introduction diaper dermatitis is the most common dermatological problem of infancy.1 the diagnosis is based on the clinical observation, characterized by an acute inflammatory eruption of the skin in the diaper area of an infant. although this condition is relatively common, it can cause considerable pain and stress for infants and could be troublesome for their caregivers.2,3 in the united states, the frequency of diaper dermatitis is substantial and accounts for a high number of health care visits. the three most common types of diaper dermatitis are: chafing dermatitis, irritant contact dermatitis and diaper candidacies.4 diaper dermatitis is also known as diaper rash or nappy rash, indicating inflammation of the skin in the area covered by diapers. diaper dermatitis commonly occurs in general pediatric practice, occurring in 16% of children with a primary or a secondary skin complaint.4 an estimated 7% to 35% of the infant population is affected at a given time, with the highest prevalence in infants 9 to 12 months of old. only 7% of diaper dermatitis cases seek medical advice. on the other hand, a group of skin disorders that result from attack of the skin by physical, chemical, enzymatic, and microbial factors result in the diaper environment.5 the integrity of healthy skin is compromised by the very nature of the diaper environment, and normal intact skin. therefore, remains an elusive goal of current diapering practices. moist occlusion promotes malaria, and causes an increase in the coefficient of skin friction.6 diapering is unquestionably an effective and convenient way of localizing an infant’s excreta. unfortunately, infant skin was not designed to operate continuously in the resulting environment, and is frequently unable to whether this assault.7 a diverse group of diseases can cause skin conditions in the diaper area, including those which are directly caused by diapers or the diaper environment, some which are not clearly due to, but are worsened by, the wearing of diapers, and those which are independent of the presence of the diaper or its resulting environment.8 many of these conditions are limited to this area of the skin, but others extend to skin outside this area, and some are signs of systemic disease. the most important factors in the development of diaper dermatitis are: water/moisture, friction, urine, feces, and microorganisms (sometimes).9 diaper rash affects the areas within the confines of the diaper. increased wetness in the diaper area makes the skin more susceptible to damage by physical, chemical, and enzymatic mechanisms. wet skin increases the penetration of irritant substances.10 however, breast milk does appear to have healing properties that can prove beneficial when it comes to treating minor illnesses and injuries. this is due to the antibodies that breast milk contains. it can kill off bacteria and viruses when applied topically to problematic areas because of antibacterial properties.11 it is important to distinguish diaper dermatitis from other dermatomes that may develop within the diaper area. considerable advances have occurred during recent years in the scientific knowledge regarding the benefits of breastfeeding, the mechanisms underlying these benefits, and in the clinical management of breastfeeding diaper.12 studies show human breast milk as a preventive measure and effective treatment of some sores and infections.13 these are all conditions that mother’s milk is cheap and readily available, side effects and contraindications, not even anti-bacterial and regenerative properties.14 in addition to feeding, such as greater use: conjunctivitis, sore nipples, ear infection, diaper rash that there is oriented to the milk as a topical antibacterial agent in the treatment and healing effect.15 for century’s breast milk as a natural substance used smooth skin. breast milk contains vitamin groups: a, e, d, k and b complex, vitamin e is that it is very effective.16 breastfeeding lead to skin cream. furthermore it is a natural substance that causes softness to the skin. research has shown that protein, calcium and vitamin b12 in milk play an important role in the prevention of complications such as dry skin, eczema and its fragility.17 the lactic acid in milk is used in most skin creams and dermatology reports 2017; volume 9:7044 correspondence: mohammad heidari, department of medical and surgical, school of nursing and midwifery, shahrekord university of medical sciences, shahrekord, iran. tel.: +98.9131850128. e-mail: heidari@skums.ac.ir key words: breast milk; dermatitis healing; diaper dermatitis. acknowledgments: this paper is the result of a research project supported by the tehran medical sciences branch, islamic azad university research project. contributions: bs, idea conceiving; bs, sj, mh, data collection; mh data interpretation. all authors contributed equally in drafting and editing the manuscript. conflict of interest: the authors declare no potential conflict of interest. received for publication: 11 january 2017. accepted for publication: 23 february 2017. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright b. seifi et al., 2017 licensee pagepress, italy dermatology reports 2017; 9:7044 doi:10.4081/dr.2017.7044 no n c om me rci al us e o nly [page 2] [dermatology reports 2017; 9:7044] lotions, face and softening effect upon the skin. there is some evidence that ingestion of breast milk protects the infant against certain infectious and non-infectious conditions.18 it is important that midwives are aware of current evidence to inform the advice they give to women on infant feeding.19 according to the above this study was conducted with the aim of assessing the effect of breast milk on diaper dermatitis. materials and methods this study was a clinical trial of 30 infants between 0-12 months of age that were suffering from diaper dermatitis and referred to the health centers in tehran, iran. ethical committee approval was obtained for this hipaa compliant clinical trial. thirty infants with diaper dermatitis sought medical advice at our health centers within three months. we planned that thirty infants were recruited for this study. after full explanation of the goals, informed consent was obtained from the caregivers. a through medical history was obtained and a complete physical examination was conducted to rule out any other possible cause of dermatitis. the exclusion criteria were presence of infection or candidacies. however we did not exclude any patient. infants were randomly assigned to case (n=15) and control (n=15) groups and were matched by age, sex, parent’s job, family income, number of diaper change per day, number of rashes and dermatitis score (lesion score). both groups were followed up for five days (visits on first, third and fifth days of the intervention). data were collected by a questionnaire, which contained two parts: demographic and state of care. demographic data were filled through an interview with mothers on the first day. the state of care included number of the lesions, location, and severity of erythema, which was scored according to al-waili study; a five-point scale rash severity: 0=none, 1=mild erythema, 2=moderate erythema, 3=moderate erythema + maceration, 4=sever erythema + pustules or ulceration.20 the second part of the questionnaire was filled by a research assistant on days 1, 3 and 5. during study, any new signs or symptoms were recorded. a positive therapeutic effect was described as score improvement such as when a moderate rash became mild or a mild rash disappeared. the mothers in the control group were asked to bath the infant following urination or defecation with only warm water, pat them dry and change diapers. they were asked not to apply any topical treatment or creams. in the case group, mothers were instructed to do the same in addition to applying breast milk three times a day on the affected area and let it air dry before putting a diaper back on. all mothers used the same brand of diapers before and during the study. lesions that did not improve within five days of the study were treated with conventional therapy, and the failure was recorded. no other topical products were used during the study period. data were analyzed using the spss package 18.0 for windows (spss, chicago, il, usa). chi-square test was used to assess the differences between case and control groups. results thirty number of infants were included in the study with the six months of mean age. all infants were breast feeder, used high-power absorbent cloths for diapering, and none used disposable diapers. infants’ demographic characteristics were shown on table 1. most of infants had the first birth seniority. all the mothers were housewives and 53.3% of the fathers had private jobs. the mean family salary was between 300450 dollars. about 30% mothers and 33.3% fathers had (a qualification of) diploma or higher. the mean ages of mothers were 25.44 years and mean ages of fathers were 30.5. all infants were breast feeder and all of them were used cloth diapers (high power absorbent material) for diapering and none of them used disposable diapers. nobody used soaps and powders. frequency of diaper changes in 60% cases was 6 times/day. no sexual difference was observed. diaper rashes were most common between 8-10 months old. about 73.3% infants have one site of diaper rash. the mean and standard deviation of number of dermatitis were shown in table 2. 60% of infants have moderate rash (according to al-waili study;20 a five-point scale rash severity). table 3 was shown number, location and score of lesions in case and control group. in the case group, 73.3% had two dermatitis with moderate erythema and 53.3% of the control group had one lesion with mild erythema. the mothers reported breast milk application as convenient. out of 15 infants with score 1or 2 (mild or moderate erythema) in case group, 80% improved during the study period in fifth day. in control group 26.1% infants showed improvement. in case group the mean of scores pre and post intervention showed a significant difference (p=0.006) while in control group no difference was detected. most common locations for dermatitis rash in days 1 and 3 were anal (66%), genitalia (10%) and perineum (6%) regions. the topical application of the breast milk has decreased the incidence of anal dermatitis rash (p=0.009). 80% of infants in case group have been none erythema and 20% failed to respond to breast milk application with mild erythema. 73.3% of infants in the control group placed on conventional therapy at the end of 5-day study (figure 1). discussion physical degradation of the epidermal barrier caused by exposure to excrement, moisture, and friction directly contributes to article table 1. demographics characteristics in infants. variations case (n=15) control (n=15) results age >6 months: 60% <6 months: 60% f=0.5 sex boys: 53.3% boys: 60% f=0.5 parents job mothers: 100% housewives mothers: 100% housewives p=0.229 fathers: 53.3 private jobs fathers 53.3 private jobs family income between 300-450 dollars/months between 300-450 dollars/months p=0.584 diapers 100% used cloth diapers 100% used cloth diapers (high power absorbent material) (high power absorbent material) p=0.00 number of diaper change per day 60% six times/day 60% six times/day p=0.00 no n c om me rci al us e o nly [dermatology reports 2017; 9:7044] [page 3] diaper dermatitis. furthermore, reduced skin acidity (of ph) is associated with a decrease in epidermal barrier integrity, reduced antimicrobial defenses, and increased inflammation.21 diaper dermatitis can cause significant discomfort for infants and distress for their parents and caregivers.22 ehretsmann et al. obtained similar results.23 these provide useful information regarding the comparative skin mildness of baby wipes and water. our findings showed a significant difference between the number of dermatitis rash and lesion score on the third day as a result of topical use of the breast milk. this result is consistent with the findings of al-waili.20 according to al-waili et al., olive oil, beeswax and honey are natural products, containing flavonoids, and antioxidant, antibacterial and antifungal compounds that affect the production of cytokines by skin cells when applied topically. on the fifth day there was still obvious differences between two groups by the number of rashes and lesion score; this was consistent with the findings of baldwin et al.24 visscher et al. noted that regular use of over the counter diaper ointments or pastes, and frequent diaper changes are required in any patient without a history of diaper dermatitis. topical corticosteroids are still recognized as a treatment option for diaper dermatitis, although it is increasingly discouraged.25 farahani et al. and gozen et al. described human breast milk as an effective and safe treatment for diaper dermatitis in infants,11,26 whereas spraker et al. recommended topical miconazole nitrate ointment for the treatment of diaper dermatitis.27 limitations however, regarding the results, limitation should be acknowledged. this article is limited by its emphasis on papers published in english in journal databases, so we may have missed potentially useful studies. conclusions diaper dermatitis is a stressful condition for affected infants and their caregivers. breast milk can be an effective, safe and convenient remedy. educational programs in primary health centers can target caregivers. references 1. brucker m, mcguire s, merrill l, et al. clinicians discuss diaper dermatitis. nurs women health 2015;19:422-9. 2. kayaoglu s, kivanc-altunay i, sarikaya s. diaper dermatitis in infants admitted to social pediatrics health center: role of socio-demographic factors and infant care. indian j pediatr 2015;82:904-8. 3. sheikhei ra, heydari m, shahbazi s. comparison of intra-abdominal pressure measurement and physical exam for diagnosis of surgery indication in patients with abdominal compartment syndrome due to blunt trauma. j kerman univ med sci 2011;18:271-8. 4. garcia bartels n, lünnemann l, stroux a, et al. effect of diaper cream and wet wipes on skin barrier properties in infants: a prospective randomized controlled trial. pediatr dermatol 2014;31: 683-91. 5. erasala g, merlay i, romain c. [evolution of disposable diapers and reduction of diaper dermatitis]. archiv pediatr 2007;14:495-500 [in french]. 6. al-faraidy na, al-natour sh. a forgotten complication of diaper dermatitis: granuloma gluteale infantum. j fam commun med 2010;17:107. 7. hoeger p, stark s, jost g. efficacy and safety of two different antifungal pastes in infants with diaper dermatitis: a randomized, controlled study. j eur acad dermatol venereol 2010;24:1094-8. 8. visscher mo, chatterjee r, ebel jp, et al. biomedical assessment and instrumental evaluation of healthy infant skin. pediatr dermatol 2002;19:473-81. article table 2. mean and standard deviation of the number of dermatitis rash, among the study subjects. local rash groups first day third day fifth day case mean 1.0667 0.6 0.2 total 15 15 15 standard deviation 0.2582 0.50709 0.41404 control mean 1.4667 1.4 1.2667 total 15 15 15 standard deviation 0.83381 0.91026 1.2228 table 3. compare the situation changes dermatitis rash, of study subjects in both groups. days diaper dermatitis first day third day fifth day number of local rash case 86.7% 46.7% 80% n=1 n=1 n=0 control 60% 53.3% 26.7% n=1 n=1 n=0 p-value p=0.09 p=0.013 p=0.004 lesion score case 73.3% 46.7% 80% moderate mild none control 53.3 60% 26.7% mild moderate none p-value p=0.132 p=0.005 p=0.001 figure 1. diaper dermatitis anal area before and after treatment with breast milk. no n c om me rci al us e o nly [page 4] [dermatology reports 2017; 9:7044] 9. ravanfar p, wallace js, pace nc. diaper dermatitis: a review and update. curr opin pediatr 2012;24:472-9. 10. stamatas gn, tierney nk. diaper dermatitis: etiology, manifestations, prevention, and management. pediatr dermatol 2014;31:1-7. 11. gozen d, caglar s, bayraktar s, atici f. diaper dermatitis care of newborns human breast milk or barrier cream. j clin nursing 2014;23:515-23. 12. atherton dj. a review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. curr med res opin 2004;20:645-9. 13. urbaniak c, angelini m, gloor gb, reid g. human milk microbiota profiles in relation to birthing method, gestation and infant gender. microbiome 2016;4:1-9. 14 giusti a. breastfeeding: health, prevention, and environment. epidemiol prevenz 2014;39:386-91. 15. zaheer k, akhtar mh. an updated review of dietary isoflavones: nutrition, processing, bioavailability and impacts on human health. crit rev food sci nutr 2015 [in press]. 16. gertosio c, meazza c, pagani s, bozzola m. breast feeding: gamut of benefits. minerva pediatr 2015 [in press]. 17. við streym s, højskov cs, møller uk, et al. vitamin d content in human breast milk: a 9-mo follow-up study. am j clin nutr 2016;103:107-14. 18. arnold ld, larson e. immunologic benefits of brest milk in relation to human milk banking. am j infect control 1993;21:235-42. 19. mehrparvar s, varzandeh m. investigation of decreasing causes of exclusive breastfeeding in children below six months old, in kerman city during 2008-2009. j fasa univ med sci 2011;1:45-52. 20. al-waili n. clinical and mycological benefits of topical application of honey, olive oil and beeswax in diaper dermatitis. clin microbiol infect 2005;11:1603. 21. markham t, kennedy f, collins p. topical sucralfate for erosive irritant diaper dermatitis. archiv dermatol 2000;136:1199-200. 22. austin ap, milligan mc, pennington k, tweito dh. a survey of factors associated with diaper dermatitis in thirty-six pediatric practices. j pediatr health care 1988;2:295-9. 23. ehretsmann c, schaefer p, adam r. cutaneous tolerance of baby wipes by infants with atopic dermatitis, and comparison of the mildness of baby wipe and water in infant skin. j eur acad dermatol venereol 2001;15:16-21. 24. baldwin s, odio m, haines s, et al. skin benefits from continuous topical administration of a zinc oxide/petrolatum formulation by a novel disposable diaper. j eur acad dermatol venereol 2001;15:5-11. 25. visscher mo, chatterjee r, munson ka, et al. development of diaper rash in the newborn. pediatr dermatol 2000;17:52-7. 26. farahani la, ghobadzadeh m, yousefi p. comparison of the effect of human milk and topical hydrocortisone 1% on diaper dermatitis. pediatr dermatol 2013;30:725-9. 27. spraker mk, gisoldi em, siegfried ec, et al. topical miconazole nitrate ointment in the treatment of diaper dermatitis complicated by candidiasis. cutis 2006;77:113-20. article no n c om me rci al us e o nly 429 too many requests you have sent too many requests in a given amount of time. dr [page 8] [dermatology reports 2016; 8:6599] erythrodermic psoriasis treated with apremilast john arcilla,1 daniel joe,1 johnathan kim,1 yohanan kim,1 vuanh n. truong,1 navin jaipaul1,2 1department of medicine, loma linda university school of medicine and 2department of medicine, va loma linda healthcare system, loma linda, ca, usa abstract erythroderma is a rare potentially deadly exfoliative dermatitis characterized by diffuse cutaneous erythema which may be associated with multi-organ dysfunction. therefore, it is imperative to recognize and treat it promptly. erythrodermic psoriasis is the most common form of erythroderma. management of this condition is largely based on aggressive supportive care and the use of anti-inflammatory immunosuppressive and biologic agents. we describe a case of psoriatic erythroderma which was triggered by withdrawal from systemic steroids and successfully treated with apremilast and cyclosporine. apremilast induced atrial fibrillation limited its continued use after the initial response period. introduction we report a case of a 79 year old man with erythrodermic psoriasis successfully treated during the initial response phase with the novel oral small-molecule phosphodiesterase-4 inhibitor apremilast. case report a 79-year-old man with hypertension and psoriasis was hospitalized for severe sepsis associated with a generalized and painful erythematous rash. he had been diagnosed with psoriasis affecting <1% body surface area (bsa) three months before this presentation and was treated with topical ketoconazole and fluocinolone. two weeks before hospitalization, he received a five day oral prednisone taper prescribed by a family physician for skin rash. following this, he developed a confluent, erythematous, scaling rash covering >50% bsa. methotrexate was started for presumed psoriatic erythroderma; however, his symptoms worsened to include progressive skin involvement, fever, and hypotension which led to hospitalization.physical exam revealed tender erythematous plaque with scale from head to toe, most prominently involving the head, neck, chest, back, upper arms, abdomen, buttocks, groin, and proximal thighs (figure 1). laboratory evaluation was remarkable for leukocytosis of 23.8×103/µl and pre-renalazotemia. intravenous fluids, empiric antibiotics, topical steroids, and emollient moisturizer were started. infectious work-up was negative; yet fevers, leukocytosis, and cutaneous pain symptoms persisted. dermatology performed a punch biopsy which demonstrated evolving pustular psoriasis (figure 2). apremilast was started for treatment of erythrodermic psoriasis. the patient’s rash and systemic features began to improve by day 10. though bsa involvement was essentially unchanged, psoriasis plaques demonstrated reduced erythema and scaling with marked improvement in cutaneous pain symptoms (figure 3). as a result, psoriasis area and severity index score improved from 44.0 on admission to 26.4 after initiating apremilast treatment. however, the patient subsequently developed new-onset atrial fibrillation attributed to apremilast which was discontinued and switched to cyclosporine. the patient continued to improve and was discharged on cyclosporine. dermatology reports 2016; volume 8:6599 correspondence: navin jaipaul, va loma linda healthcare system, 11201 benton st. 111n, loma linda, ca 92357, usa. tel.: +1.909.583.6090 fax: +1.909.777.3858. e-mail: navin.jaipaul@va.gov key words: erythroderma; psoriasis; erythrodermic psoriasis; apremilast. contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. received for publication: 13 may 2016. accepted for publication: 17 august 2016. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright j. arcilla et al., 2016 licensee pagepress, italy dermatology reports 2016; 8:6599 doi:10.4081/dr.2016.6599 figure 1. skin findings on day one of hospitalization demonstrating (a) well defined generalized erythema and scaling most prominently involving the head, neck, chest, back, upper arms, abdomen, buttocks, groin, and proximal thighs and (b) magnified view of the erythema and scaling. no n c om me rci al us e o nly [dermatology reports 2016; 8:6599] [page 9] discussion erythroderma is a rare potentially deadly exfoliative dermatitis which may result from systemic infection, drug hypersensitivity, malignancy (e.g. cutaneous t cell lymphoma), and inflammatory conditions such as stevens johnson syndrome, pityriasis rubra pilaris, and erythrodermic psoriasis.1 initial management for severe cases includes fluid resuscitation, empiric antibiotics, and diligent diagnostic evaluation. erythrodermic psoriasis is the most common form of erythroderma and accounts for 25% of all cases.2 when associated with psoriasis, the erythrodermic variant represents less than 1.5% of cases and manifests with welldefined erythematous plaques and overlying silvery scale.3 it generally affects the entire body and may be associated with life-threatening complications such as sepsis, hypovolemic shock, and acute kidney injury secondary to cutaneous fluid loss.2 erythrodermic psoriasis may result from uncontrolled dermatosis, abrupt withdrawal of anti-psoriatic drugs such as steroids or methotrexate, drug reaction, systemic infection, ultraviolet burns, alcoholism, and emotional stress.2 our patient’s withdrawal from oral steroids likely triggered his erythroderma. skin biopsy may be helpful in diagnosis as erythroderma may develop acutely or gradually from any variant of psoriasis.2 treatment is largely based on aggressive supportive care and the use of anti-inflammatory immunosuppressive and biologic agents. high quality evidence-based treatment recommendations for erythordermic psoriasis are lacking due to the rarity of the condition. most randomized clinical trials on psoriasis treatments have excluded less common variants such as the erythrodermic and pustular subtypes.4 in light of this, first-line agents that have been used with variable efficacy include cyclosporine, infliximab, acitretin, and methotrexate.5 etanercept and combination therapies are second-line alternatives.5 recently, biologics including ustekinumab and golimumab have also been used with reported efficacy in the treatment of erythrodermic psoriasis.6,7 systemic corticosteroids and ultraviolet light therapy are not recommended due to risks of disease exacerbation and photosensitivity.5 choice of therapy should be based on disease severity and patient comorbidities. for example, we chose to treat our patient with apremilast due to the presence of pre-renal acute kidney injury which is a relative contraindication to use of the other aforementioned first-line agents. apremilast is a novel small-molecule oral medication which selectively inhibits phosphodiesterase 4 and has been shown to downregulate the production of pro-inflammatory cytokines while upregulating anti-inflammatory cytokines.8 it is approved for treatment of psoriatic arthritris and moderate to severe plaque psoriasis. the efficacy of apremilast was demonstrated in a phase iii randomized controlled trial that showed a statistically and clinically significant reduction versus placebo in the baseline psoriasis area and severity index score in patients with moderate to severe plaque psoriasis.9 however, a search of the published literature resulted in no reports describing the use of apremilast in erythrodermic psoriasis. our case report figure 2. skin biopsy demonstrating mild psoriasiform hyperplasia and rare intracorneal pustules with mild superficial perivascular mixed inflammation consistent with evolving pustular psoriasis. figure 3. skin findings on day ten of hospitalization demonstrating reduced intensity of erythema and scaling in response to apremilast treatment. no n c om me rci al us e o nly [page 10] [dermatology reports 2016; 8:6599] patient improved on apremilast; however, he developed new-onset atrial fibrillation which was attributed to the medication so it was discontinued. when compared with placebo, apremilast treatment has been associated with an increased, albeit low, incidence of tachyarrhythmia, most frequently atrial fibrillation.9 once the patient’s renal function improved, he was started on cyclosporine and his erythroderma eventually resolved. conclusions erythroderma associated with psoriasis may be triggered by withdrawal from systemic steroids. it is a rare and potentially fatal exfoliative dermatitis which needs to be recognized and treated promptly. the mainstay of treatment is founded on aggressive supportive care and use of anti-inflammatory immunosuppressive drugs, including newer biologic agents. we also observed encouraging results in treating erythrodermic psoriasis using the novel oral small-molecule phosphodiesterase-4 inhibitor apremilast. its continued use in our patient, however, was limited after the initial response period by the development of atrial fibrillation which was attributed to the medication. references 1. rothe mj, bernstein ml, grant-kels jm. life-threatening erythroderma: diagnosing and treating the red man. clin dermatol 2005;23:206-17. 2. stinco g, errichetti e. erythrodermic psoriasis: current and future role of biologicals. bio drugs 2015;29:91-101. 3. raychaudhuri sk, maverakis e, raychaudhuri sp. diagnosis and classification of psoriasis. autoimmun rev 2014;13:490-5. 4. menter a, korman nj, elmets ca, et al. guidelines of care for the management of psoriasis and psoriatic arthritis: sections 1,3,4,5. overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. j am acad dermatol 2008;58:826-50. 5. rosenbach m, hsu s, korman nj, et al. treatment of erythrodermic psoriasis: from the medical board of the national psoriasis foundation. j am acad dermatol 2010;62:655-62. 6. kim ys, kim jh, lee s, et al. erythrodermic psoriasis improved by ustekinumab: a report of two cases. ann dermatol 2016;28:121-2. 7. lee wk, kim gw, cho hh, et al. erythrodermic psoriasis treated with golimumab: a case report. ann dermatol 2015;27:446-9. 8. kelly jb, foley p, strober be. current and future oral systemic therapies for psoriasis. dermatol clin 2015;33:91-109. 9. papp k, reich k, leonardi cl, et al. apremilast, an oral phosphodiesterase 4 (pde4) inhibitor, in patients with moderate to severe plaque psoriasis: results of a phase iii, randomized, controlled trial (efficacy and safety trial evaluating the effects of apremilast in psoriasis [esteem] 1). j am acad dermatol 2015;73:37-49.a) case report no n c om me rci al us e o nly 429 too many requests you have sent too many requests in a given amount of time. dr [page 20] [dermatology reports 2018; 10:7597] antioxidant properties of topical caulerpa sp. extract on uvb-induced photoaging in mice anak agung gde putra wiraguna,1 wimpie pangkahila,2 i. nyoman mantik astawa3 1dermatology department, faculty of medicine; 2anti-aging medicine department, faculty of medicine; 3virology laboratory, faculty of veterinary medicine, udayana university, indonesia abstract caulerpa sp., a genus of seaweed native to the indo-pacific region, has been known for its antioxidant properties and health benefits when consumed as food. previous studies have reported caulerpa sp.’s potential as a strong antioxidant, but its effects on the skin in a topical preparation, especially its role in ultraviolet (uv) protection, have not been studied extensively. our study investigated the protective effects of 0.2% and 0.4% caulerpa sp. extract gels on photoaging in the uvb-irradiated skin of wistar mice. the subjects were divided into naive control, vehicle control, and 3 treatment groups (0.2% caulerpa sp. extract gel, 0.4% caulerpa sp. extract gel, and 0.02% astaxanthin gel as a standard antioxidant). the groups, except the naive control group, received a total of 840 mj/cm2 of uvb irradiation in four weeks. protective effects of the extract were measured through the evaluation of collagen expression, matrix metalloproteinase (mmp)-1 expression and levels, and 8-ohdg expression. mice who received topical application of caulerpa sp. extract gel had higher collagen expression, better-preserved collagen structure, lower levels of mmp-1, and less mmp-1 and 8ohdg expressions compared to the vehicle control group. there was no difference between different concentrations of the extract. our findings demonstrated that topical application of caulerpa sp. extract gel significantly protected uvb-irradiated mice skin from photoaging. introduction ultraviolet (uv) radiation is an important external factor in skin aging due to its effects on the skin’s structures and functions,1 especially uv-b (290-320 nm), which delivers more energy than uva. due to its shorter wavelength, uvb is mostly absorbed in the epidermis, but is able to reach the papillary dermis.2 photoaging results in the degradation of collagen, elastin, and other components of the extracellular matrix (ecm), causing pigmentation, wrinkles, changes in skin texture, and histologic changes.3 uv exposure to the skin produces free radicals in the form of reactive oxygen species (ros). ros is known to damage dna through oxidation of c8 guanine base, creating 8-hydroxy-2deoxyguanosine (8-ohdg), which is a biomarker of oxidative dna damage.4 furthermore, free radicals will activate cytokine receptors and growth factors in keratinocytes and fibroblasts, which will activate nucleus transcription factors of activator protein-1 (ap-1) through the induction of mitogen-activated protein kinase (map kinase).5 ap-1 will induce the expression of matrix metalloproteinases (mmps), which are a group of matrixdegrading enzymes. mmp-1 will degrade type i, ii, and, iii collagen in the skin.3 photoaging is a prevalent problem, especially in tropical countries with yearlong sunshine. traditional sunscreens do not fully protect the skin from the formation of free radicals. thus, the addition of antioxidant agents in sunscreens is expected to strengthen the protective effects of sunscreens against uv rays.6 caulerpa sp. is a genus of algae native to the indo-pacific region. locally known as bulung boni, its succulent texture makes it a commonly found delicacy in the islands of indonesia. caulerpa sp. is found to contain many types of antioxidants and vitamins, such as astaxanthin, beta carotene, vitamin c, vitamin e, and polyphenols.7 in this study, we aim to investigate the protective effects of topical caulerpa sp. extract against ultraviolet-induced aging of the skin through the evaluation of collagen in the dermis, 8-ohdg expression, mmp-1 expression, and mmp-1 levels in mice. materials and methods materials caulerpa sp. from bali, indonesia, was extracted using ethanol and concentrated using a danke and kunkel rotary vacuum evaporator in the agriculture technology laboratory, udayana university. the extract was made into 0.2% and 0.4% gels by roi surya prima farma in surabaya, indonesia. the comparison gel, containing astaxanthin obtained from fuji chemical industry co ltd, was produced by roisurya prima farma. standard kits of mmp-1 antibody, 8ohdg antibody, formaldehyde, nah2po4, paraffin, xylol, sirius red, ethanol, avidinhrv, and dab were used in the analysis of samples. animals thirty male wistar (rattus norvegicus) mice (age 10-12 weeks) weighing 200-250 grams were obtained from the udayana university animal laboratory. the mice were divided into five groups of six mice, including one control group. the naive control (nc) group did not receive any treatment, the vehicle control group (vc) received a type of gel without any active ingredients, group 1 received 0.02% astaxanthin gel as standard antioxidant, group 2 received 0.2% caulerpa sp. extract gel, and group 3 received 0.4 caulerpa sp. extract gel. the vc group and group 1-3 received 0.05mg/cm2 of their respective gels. subjects grouping and treatments are shown in figure 1. uv irradiation the vc group and group 1-3 were irradiated with uvb light three times a week (on monday, wednesday, and friday), starting from 50 mj/cm2 in the first week, 70 mj/cm2 in the second week, and 80 mj/cm2 for the last two weeks, resulting in a sum of 840 mj/cm2 of uvb received in four weeks. the gels were applied on the mice’s skin twice a day: 20 minutes before uv irradiation to allow absorption of gel, and 4 hours dermatology reports 2018; volume 10:7597 correspondence: anak agung gde putra wiraguna, dermatology department, faculty of medicine, udayana university, indonesia. e-mail: wiraguna@unud.ac.id key words: caulerpa sp., photoaging, antioxidant, uvb radiation. conflict of interest: the authors declare no potential conflict of interest. received for publication: 21 january 2018. revision received: 18 july 2018. accepted for publication: 19 july 2018. this work is licensed under a creative commons attribution noncommercial 4.0 license (cc by-nc 4.0). ©copyright a.a.g.p. wiraguna et al., 2018 licensee pagepress, italy dermatology reports 2018; 10:7597 doi:10.4081/dr.2018.7597 no nco mm er cia l u se on ly [dermatology reports 2018; 10:7597] [page 21] after irradiation (ros formation starts 4 hours after uv exposure). gels were also applied on days when no irradiation was performed. to avoid the acute affects of irradiation, 48 hours after the last irradiation all mice are decapitated, and a sample of their back skin was taken. histological examination the tissue sample was submerged in 10% phosphate buffered formalin for 24 hours. to dehydrate the tissue, it was doused in different concentrations of alcohol from 70%, 80%, 90%, 96%, ethanol i, and ethanol ii, each for two hours. then, the tissue was inserted in clearing agents (toluene i and toluene ii) for two hours each. in the embedding phase, the tissue went through the infiltration process twice with liquid paraffin (56-58°c) and planted in liquid paraffin to set for 24 hours. the tissue was sliced into 6μ-thick sections using a microtome. the 5th, 10th, and 15th slices were stained with sirius red and for immunohistochemistry. evaluation of collagen collagen expression was measured through digital analysis. photographs of the tissue slides were taken using an lc evolution camera and olympus bx51 microscope with 40x objective magnification. then, adobe photoshop was used to measure the pixel area of collagen (stained bright red), which was divided by the pixel area of the entire slide.8,9 evaluation of matrix metalloproteinases-1 levels and expression elisa analysis was performed to determine the level of mmp-1 using the rat matrix metalloproteinase-1 kit produced by mybiosource, usa. mmp-1 expression was determined through the expression of mmp-1 by dermal fibroblasts, examined through immunohistochemistry staining. the number of fibroblasts was measured article figure 1. flowchart of subjects treatment. figure 2. profile of matrix metalloproteinase (mmp)-1 levels in wistar mice dermal tissue. the naive control group did not receive any treatment; the vehicle control received uv irradiation and gel with no active ingredients; group 2 received uv radiation and 0.02% astaxanthin gel; group 3 received uv radiation and 0.2% caulerpa sp. extract gel; group 4 received uv radiation and 0.4% caulerpa sp. extract gel. application of topical antioxidants significantly decreases mmp-1 levels. *p<0.05 compared to other treatment groups. †received uvb radiation. figure 3. profile of mmp-1 expression in wistar mice dermal tissue. the naive control group did not receive any treatment; the vehicle control received uv irradiation and gel with no active ingredients; group 2 received uv radiation and 0.02% astaxanthin gel; group 3 received uv radiation and 0.2% caulerpa sp. extract gel; group 4 received uv radiation and 0.4% caulerpa sp. extract gel. application of topical antioxidants significantly decreases mmp-1 expression. *p<0.05 compared to other treatment groups. †received uvb radiation. no nco mm er cia l u se on ly through 40x magnification on the olympus bx51 microscope. mmp-1 expression (%) was calculated as the number of fibroblasts expressing mmp-1 divided by the total amount of fibroblasts in 5 fields of view. evaluation of 8-ohdg expression of 8-ohdg was determined through its expression by dermal fibroblasts, examined through immunohistochemistry staining. the number of fibroblasts was measured through 40x magnification on the olympus bx51 microscope. 8-ohdg expression (%) was calculated as the number of fibroblasts expressing 8-ohdg divided by the total amount of fibroblasts in 5 fields of view. statistical analysis data analysis was performed using spss (version 20.0). comparison analyses were performed using one-way analysis of variance, followed by post-hoc tests to determine differences between groups. results effect of caulerpa sp. extract on mmp-1 levels and expression mmp-1 plays an important role in collagen degradation due to uvb irradiation. the profile of mmp-1 levels in our subjects is shown in figure 2; mmp-1 levels in the vc group is significantly higher than the nc group which did not receive uv radiation and the treatment groups. when given topical antioxidants in the form of astaxanthin gel and caulerpa sp. extract gel, mmp1 levels decreased significantly, although no differences were found between the three treatment groups. mmp-1 expression was measured through immunohistochemistry staining, and the profile can be found in figure 3. the vc group had the highest amount of mmp-1 expression, significantly higher than the nc group and group 1-3. histological examination of the stained slides is shown in figure 4. fibroblasts expressing mmp-1 are stained brown, the largest number of which is seen in the vc group. effect of caulerpa sp. extract on 8odhg expression expression of 8-ohdg indicates oxidative dna damage. our results show uv irradiation on mice who received no topical antioxidant (vc group) caused a significant increase in 8-ohdg expression, and application of topical antioxidants substantially inhibit 8-ohdg expression; there was no difference between the inhibition properties of astaxanthin gel and caulerpa sp. extract gel (figure 5). figure 6 shows immunohistochemistry staining, where in the vc group considerable fibroblast damage is seen. effect of caulerpa sp. extract on collagen expression degradation of collagen fibers is one of the hallmarks of photoaging in the skin, and sirius red-stained slides are able to clearly show the structure of collagen fibers. profile of collagen expression in the subjects is shown in figure 7. after being irradiated with uv-b, the vc group, which received no active ingredients, had the least amount of collagen expression (figure 7), significantly lower than group 1-3, and significant collagen fibers degradation (figure 8). the groups who received treatment with astaxanthin and caulerpa sp. extract as antioxidant showed higher collagen expression (figure 7) and well-preserved structure of collagen fibers (figure 8). discussion and conclusions uv exposure to the skin triggers processes of external aging called photoaging, which includes decreasing epidermal thickness, cellular dysplasia, infiltration of inflammatory cells, and increasing elastin and collagen degradation.10 fibroblasts in the dermis are the main producers of collagen fibers, elastin, and supporting tissue in the ecm; they also secrete mmp enzyme, whose role is protein degradation.11,12 internal aging causes an increase in mmp-1 and mmp-9, which leads to a decrease in the synthesis of collagen and other ecm proteins.13 the presence of uv irradiation further enhances this process, increasing mmp activity and protein degradation. several studies reported that mmp-1 is the main enzyme responsible for collagen degradation in human skin and it is induced by uv irradiation, especially uvb.14-16 uv irradiation induces the formation of ros, which contributes to oxidative damage of article figure 4. immunohistochemistry staining showing mmp-1 expression in wistar mice dermal tissue, 40x magnification. a: naive control group, showing non-mmp-1 expressing fibroblasts (red arrowhead) and mmp-1-expressing fibroblasts (black arrowhead) whose cytoplasm is stained brown with fragmented nucleus; b: vehicle control (vc) group, red arrowheads show more fibroblasts were expressing mmp-1 compared to fibroblasts that were not expressing mmp-1 (black arrowheads); c: group 1, the number of fibroblasts expressing mmp-1 (red arrowheads) was fewer than in the vc group; d: group 2, the number of fibroblasts expressing mmp-1 (red arrowheads) was fewer than in the vc group; e: group 3, the number of fibroblasts expressing mmp-1 (red arrowheads) was fewer than in the vc group. [page 22] [dermatology reports 2018; 10:7597] no nco mm er cia l u se on ly [dermatology reports 2018; 10:7597] [page 23] the dna. 8-ohdg is the marker for oxidative dna damage; it is a product of c8 oxidation in guanine, the main target of rosinduced oxidative damage in the dna.17 sunscreens are the standard topical agent used to avoid photoaging from uv irradiation. a study by haywood reported sunscreens only reduce free radical formation in the skin by 55%, thus addition of topical antioxidants is expected to improve photoaging prevention.6 caulerpa sp. is a type of seaweed widely available in the indo-pacific region, traditionally consumed as food. studies have shown various antioxidant agents are present in caulerpa sp, including vitamin a, vitamin c, vitamin e, astaxanthin, and polyphenols.18 we investigated caulerpa sp. extract’s potential protective properties against photoaging, and our results show this compound significantly reduces effects of photoaging. no side effects were observed during treatment of subjects with article figure 5. profile of 8-ohdg expression in wistar mice dermal tissue. the naive control group did not receive any treatment; the vehicle control (vc) received uv irradiation and gel with no active ingredients; group 2 received uv radiation and 0.02% astaxanthin gel; group 3 received uv radiation and 0.2% caulerpa sp. extract gel; group 4 received uv radiation and 0.4% caulerpa sp. extract gel. application of topical antioxidants significantly decreases 8-ohdg expression. *p<0.05 compared to other treatment groups. †received uvb radiation. figure 6. immunohistochemistry staining showing 8-ohdg expression in wistar mice dermal tissue, 40x magnification. a: naive control group, showing non-8-ohdg expressing fibroblasts (black arrowhead) and 8-ohdg-expressing fibroblasts (red arrowhead); b: vehicle control (vc) group, red arrowheads show damaged fibroblasts and an increase in 8-ohdg expression; c: group 1, the number of damaged fibroblasts (red arrowheads) was fewer than in the vc group, with a decrease in 8-ohdg expression; d: group 2, the number of damaged fibroblasts (red arrowheads) was fewer than in the vc group, with a decrease in 8-ohdg expression; e: group 3, the number of damaged fibroblasts (red arrowheads) was fewer than in the vc group, with a decrease in 8-ohdg expression. no nco mm er cia l u se on ly [page 24] [dermatology reports 2018; 10:7597] topical caulerpa sp. extract and astaxanthin gel. mmp-1 levels and expression in mice who received topical caulerpa sp. extract are significantly lower than mice in the vc group, and this decrease does not differ significantly from the decrease caused by astaxanthin gel, a known antioxidant. our results show the difference in caulerpa sp. extract concentrations did not cause significantly different antioxidant properties, which mean the properties are not dosedependent. this decrease in mmp-1 corresponds to the decrease in collagen degradation in groups receiving treatment, due to the inhibition of the enzymes responsible for collagen degradation. furthermore, we found caulerpa sp. extract inhibits oxidative dna damage, indicated by the low amount of 8-ohdg expression in treatment groups compared to the vc group. the antioxidant properties of caulerpa sp. extract are due to the various antioxidant article figure 7. profile of collagen expression in wistar mice dermal tissuethe naive control group did not receive any treatment; the vehicle control received uv irradiation and gel with no active ingredients; group 2 received uv radiation and 0.02% astaxanthin gel; group 3 received uv radiation and 0.2% caulerpa sp. extract gel; group 4 received uv radiation and 0.4% caulerpa sp. extract gel. application of topical antioxidants significantly increases collagen expression. *p<0.05 compared to other treatment groups. †received uvb radiation. figure 8. sirius red staining of collagen expression in wistar mice dermal tissue, 40x magnification. a: naive control group, showing wellorganized and dense collagen fibers (arrowheads: intact collagen fibers); b: vehicle control group, damage was present on the collagen fibers’ structure and organization (arrowheads: fragmented collagen fibers); c: group 1, collagen fibers are well-organized (arrowheads: intact collagen fibers); d: group 2, collagen fibers are well-organized (arrowheads: intact collagen fibers); e: group 3, collagen fibers are well-organized (arrowheads: intact collagen fibers). no nco mm er cia l u se on ly [dermatology reports 2018; 10:7597] [page 25] agents contained in the plant, such as vitamin a, c, e, and polyphenols. vitamin a in the form of carotenoids is known to inhibit mmp-1, preventing collagen degradation.19 vitamin c decreases ros activities and plays a role in collagen biosynthesis, while vitamin e prevents lipid peroxidation, guarding the structure of cell membrane. polyphenols in seaweed are reported as potent inhibitors of nf-kb and ap-1 activities, which lead to nhibition of mmp-1 expression.20 our results are corroborated by hantke et al.’s study, which found a compound containing a combination of vitamin c, e, and polyphenols decrease mmp-1 expression by 40%.21 our results show no difference between the effects of topical 0.2% and 0.4% caulerpa sp. extract and topical 0.2% astaxanthin. astaxanthin is a known naturally-occurring carotenoid with potent antioxidant properties, which is reported to be 550 times more potent than vitamin e and 40 times more potent than beta carotene in scavenging oxygen singlets.22 arakane’s study found adding astaxanthin to sunscreen formulas was beneficial in increasing uv protection. the non-significant difference between the effects of caulerpa sp. extract and astaxanthin in our study indicates caulerpa sp. extract has similar antioxidant potency to astaxanthin, and has the potential to be a beneficial addition to photoaging protection, due to its rich and varying antioxidant compounds. whether or not similar effects can be observed on the human skin remains a subject for future investigation. in conclusion, our study presents caulerpa sp. extract as a potential antioxidant agent for the prevention of photo-aging through its inhibitory activity of mmp-1 and prevention of oxidative dna damage. references 1. ichihashi m, ando h, yoshida m, et al. photoaging of the skin. j anti-aging med 2009;6:46-59. 2. cavinato m, jansen-durr p. molecular mechanisms of uvb-induced senescence of dermal fibroblasts and its relevance for photoaging of the human skin. exp gerontol 2017;94:78-82. 3. hwang e, lee dg, park sh, et al. coriander leaf extract exerts antioxidant activity and protects against uvbinduced photoaging of skin by regulation of procollagen type i and mmp-1 expression. j med food 2014;17:985-95. 4. valavanidis a, vlachogianni t, fiotakis c. 8-hydroxy-2’-deoxyguanosine (8ohdg): a critical biomarker of oxidative stress and carcinogenesis. j environm sci and health 2009;27:12039. 5. helfrich yr, sachs dl, voorhees jj. overview of skin aging and photoaging. dermatol nurs 2008;20:177-83. 6. haywood r, wardman p, sanders r, linge c. sunscreens inadequately protect against ultraviolet-a-induced free radicals in skin: implications for skin aging and melanoma? j invest dermatol 2003;121:862-8. 7. wiraguna aagp. photochemoprotection effect of active component of bulung boni (caulerpa spp.) on rats’ skin. int j biomed sci 2013 [in press]. 8. lehr ha, van der loos cm, teeling p, gown am. complete chromogen separation and analysis in double immunohistochemical stains using photoshop-based image analysis. j histochem cytochem 1999;47:119-26. 9. widodo y, dahlan i. the effect of narrow and broad band ultraviolet b onto keloid fibroblast-vegf expressions. berkala ilmu kedokteran 2007;39:82-7. 10. hong h, jung m, choe sj, et al. the effect of rhus verniciflua stokes extracts on photo-aged mouse skin. ann dermatol 2017;29:295-301. 11. chu dh. development and structure of the skin. in: wolff k, goldsmith la, katz sl, gilchrest ba, paller as, leffell dj, eds. fitzpatrick’s dermatology in general medicine. 7th ed. new york: mcgrawhill; 2008. pp 57-72. 12. jouni u, mon-li c, richard g, arthur ze. collagen, elastic fibers, and extracellular matrix of the dermis. in: wolff k, goldsmith la, katz sl, gilchrest ba, paller as, leffell dj, eds. fitzpatrick’s dermatology in general medicine. 7th ed. new york: mcgrawhill; 2008. pp 517-542. 13. varani j, dame mk, rittie l, et al. decreased collagen production in chronologically aged skin: roles of agedependent alteration in fibroblast function and defective mechanical stimulation. am j pathol 2006;168:1861-8. 14. quan t, qin z, xia w, et al. matrixdegrading metalloproteinases in photoaging. j investig dermatol symp proc 2009;14:20-4. 15. yulianto, i. the changes of fibroblast cells due to uvb irradiation in various doses: an in vitro experiment [dissertation]. surabaya: universitas airlangga; 2006. 16. lee yr, noh em, jeong ey, et al. cordycepin inhibits uvb-induced matrix metalloproteinase expression by suppressing the nf-κb pathway in human dermal fibroblasts. exp mol med 2009;41:548-54. 17. bruskov vi, malakhova lv, masalimov zk, chernikov av. heat-induced formation of reactive oxygen species and 8-oxoguanine, a biomarker of damage to dna. nucleic acids res 2002;30:1354-63. 18. julyasih ksm. ekstrak bulung boni (caulerpa spp.) dan bulung sangu (gracilaria spp) memperbaiki profil lipid, menurunkan kadar malonaldehid, dan enzim hmg-koa reduktase tikus wistar diberikan diet tinggi kolesterol [dissertation in indonesian]. denpasar: universitas udayana; 2011. 19. chen l, hu jy, wang sq. the role of antioxidants in photoprotection: a critical review. j am acad dermatol 2012;67:1013-24. 20. joe mj, kim sn, choi hy, et al. the inhibitory effects of eckol and dieckol from ecklonia stolonifera on the expression of matrix metalloproteinase1 in human dermal fibroblasts. biol pharm bull 2006;29:1735-9. 21. hantke b, lahmann c, venzke k, et al. influence of flavonoids and vitamins on the mmpand timp-expression of human dermal fibroblasts after uva irradiation. photochem photobiol sci 2002;1:826-33. 22. naguib ym. antioxidant activities of astaxanthin and related carotenoids. j agric food chem 2000;48:1150-4. article no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. dr [dermatology reports 2019; 11(s1):8012] [page 1] the role of protein-53 amyloid in determining the aggressiveness of basal cell carcinoma regulated by interleukin-6, myeloid cell leukemia-1 and basic fibroblast growth factor prasetyadi mawardi,1 handono kalim,2 kusworini handono kalim,3 loeki enggar fitri,4 karyono mintarjo,5 ambar mudigdo,6 oyong oyong,6 brian wasita6 1dermatovenereology department, medical faculty of sebelas maret university/dr. moewardi public hospital, surakarta; 2internal medicine department, faculty of medicine brawijaya university/dr. saiful anwar public hospital, malang; 3clinical pathology department, faculty of medicine brawijaya university/dr. saiful anwar public hospital, malang; 4parasitology department, faculty of medicine brawijaya university/dr. saiful anwar public hospital, malang; 5pathology department, faculty of medicine, brawijaya university/dr. saiful anwar public hospital, malang; 6pathology department, medical faculty of sebelas maret university/dr. moewardi public hospital, surakarta, indonesia abstract basal cell carcinoma (bcc) is a common malignant skin tumor that rarely metastasized, although it is often locally destructive and aggressive. the amyloid in bcc is resulted from degenerated epithelial cell through apoptosis caused by activation of p53. interleukin-6, mcl-1 and bfgf are inflammatory mediators which have important role in angiogenesis. to prove that high expression of p53 amyloid is related to aggressiveness of bcc via the regulation of il-6, mcl-1 and bfgf expression. archived specimens from 51 cases diagnosed with primary bcc. we performed immunohistochemical staining for il-6, mcl-1, bfgf expression and p53 amyloid deposit. there was a significant difference in the expression of p53 (p = 0.04), amyloid deposits (p = 0.015), p53 amyloid deposits (p = 0.038), il-6 (p = 0.040), mcl-1 (p = 0.032), bfgf (p = 0.044) in a bcc compared with na bcc. there were a significant association between mcl-1 and bfgf (p = 0.07) and p53 amyloid with bfgf (p = 0.051). p53 amyloid, il-6, mcl-1 and bfgf have an important role in bcc aggresivity. introduction basal cell carcinoma (bcc) is a very common malignant skin tumor that rarely metastasizes, even though is often locally aggressive. several factors, like a large size (more than 3 cm), face localization, exposure to ultraviolet rays, histological variants, infiltration level and perineural or perivascular invasion, are associated with a more aggressive clinical course.1 although it rarely metastasizes, bcc can cause significant damage due to its local and aggressive recurrences.2 p53 is activated upon the induction of dna damage to either arrest the cell cycle or to induce apoptosis. however, when mutated, p53 is no longer able to properly accomplish these functions. apparently, appropriate p53 functioning is crucial for the suppression of tumor development.3 the p53 gene is not reactive in cells where dna is undamaged. when there is dna damage, the gene suspends the cell cycle until the damage can be repaired. the p53 gene is not reactive in cells where dna is undamaged. when there is dna damage, the gene suspends the cell cycle until the damage can be repaired. if there is a mutation in p53, the cell cycle continues unrestrained and damaged dna is reproduced, leading to uncontrolled cell proliferation and cancerous tumors.4 the existence of amyloid deposits in bcc has been found in previous studies. the frequency of secondary amyloidosis in bcc varies from 50% to 75% in the literature. in the past, the origin of amyloid in bcc was thought to be derived from degenerated epithelial cells following apoptosis.5 this study aimed to investigate the differences in the immunohistochemical expression of p53, amyloid deposits, il-6, mcl-1 and bfgf in aggressive bcc. the expression of these markers was associated with clinicopathological features such as age, gender and anatomical sites of the lesions, as well as aggressive vs nonaggressive forms of bcc. materials and methods archived specimens from 51 cases diagnosed with primary bcc were collected from december 2014 to may 2016 at the dr. moewardi public hospital in surakarta, central java, indonesia. clinical findings such as age, gender and tumor localization were obtained from medical records. specimens were reevaluated independently by two expert pathologists who agreed on all specimens involved in the study. histopathological types of bcc were determined and histopathological classification of the lesions was performed according to the criteria proposed by dixon and jacobs et al.6,7 in order to detect p53 protein expression in bcc specimens, we performed immunohistochemical staining as follows. initially, we chose adequately represented bcc paraffin blocks, and then the blocks were deparaffinized and dehydrated. strongly positive control slides were used in each run of the immunochemical staining procedure for each protein, i.e. p53 (breast carcinoma), il-6 (tonsil) and bfgf (brain tissue). expression measurement of p53, il6, mcl-1, and bfgf and p53 amyloid used j-image (open access). amyloid deposite were assessed with the congo red staining procedure. statistical analyzed with kruskal wallis and mann whitney method for comparing data, and pearson’s chi square for correlation studied. results from the 51 bcc pathologic’s slides that underwent histopathological examinations, thirteen patients were excluded. in this study we found predominantly females than males (55.3%; 44.7%). the age range of the patients were 41-90 years old, with the most common occupation was farmer (53.6 %) and housewife (26.7 %). according to the duration of illness, most patients had symptom for more than 3 years dermatology reports 2019; volume 11(s1):8012 correspondence: prasetyadi mawardi, departement of dermatovenerology, dr. moewardi general hospital, surakarta, indonesia. tel.: +62271 634 848 fax: +62271 634 848. e-mail: prasetyadimawardi@yahoo.com key words: basal cell carcinoma, basic fibroblast growth factor, protein-53 amyloid, interleukin-6, myeloid cell leukimia-1 contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. received for publication: 1 february 2019. accepted for publication: 6 february 2019. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright p. mawardi et al., 2019 licensee pagepress, italy dermatology reports 2019; 11(s1):8012 doi:10.4081/dr.2019.8012 no nco mm er cia l u se on ly [page 2] [dermatology reports 2019; 11(s1):8012] and affect people over 50 years old. based on the biological aspect bcc, this study has found aggressive bcc (a bcc) is more dominant than nonaggressive bcc (na bcc) with 65.8% and 34.2 % respectively. all patients were divided based on site predilection according to the baker protocol (2007). about 73.7 % tumor site predominant in the midface followed by the upperface (15.8%) and the lowerface (10.5%). there was significant difference between aggressive bcc and nonaggressive bcc upon tumor site predilection (p = 0.033). based on histopathological features, this study found 6 (six) subtype of bcc, which are nodular, basosquamous, morpheaform, mixed, infiltrative and superficial subtype. nodular and morpheaform bcc were more dominant subtype than others. expression of p53 was found 76.3% in this study. this expression is higher in a bcc rather than in na bcc (47.4% vs 28.9%). there was a significant difference in the expression of p53 positive 1 and 2 a bcc compared with na bcc (p = 0.04). amyloid deposits was found in 89.4%, in which the amyloid deposits in a bcc is higher than na bcc (60.5% vs 28.9%). there was a significant difference in positive amyloid deposits 3 and 4 at a bcc compared to na bcc (p = 0.015). p53 amyloid deposits was found in 65.8%, in which p53 amyloid deposits in a bcc higher than that in na bcc (42.1% vs 23.7%), and it showed statistically significant difference between a bcc and na bcc (p = 0.038) (figure 1). expression of il-6 was found in 89.4% (table 1). expression of il6 in a bcc was twice higher than na bcc (65.7% vs 34.3%). the difference between expression of il-6 positive 2 and 3 in a bcc and na bcc was statistically significant (p = 0.040). the expression of mcl-1 was found in 65.8% sample, in which a bcc 44.7% and na bcc 21.1%. the differences between mcl-1 positive 2 and 3 in a bcc compared to na bcc was statistically significant (p = 0.032). while the expression of bfgf was found in 89.4% sample, in which a bcc 57.9% and na bcc 31.5%. the differences between expression of bfgf positive 2 and 3 in a bcc compared to na bcc was statistically significant (p = 0.044). the study also found a significant association between mcl-1 expression and bfgf (p = 0.07) and contigency coefficient (cc) 0.34 this study also found a close correlation between p53 amyloid with bfgf (p = 0.051) and contigency coefficient (cc) 0.45. discussion basal cell carcinoma is the most common cutaneous cancer, with increasing prevalence especially in lighter skinned individuals or in the caucasian population. several studies have shown that bcc is more often found in men compared to women. this may reflect a higher rate of sun exposure in males because of their employment pattern.8 however, in this study, bcc was found more often in women than in men, i.e. 55.3% vs. 44.7%, respectively. the incidence in women is increasing due to changing fashions in clothing and increased time spent outdoors for recreational or occupational reasons. based on occupation, this study found that farmers are more frequently affected bcc than others. uv radiation, especially uvb, is responsible for the majority of cutaneous damage and is believed to be the primary risk factor driving tumorigenesis in bcc.9 the present study found more bcc in the midface region than in the other areas; bcc in the midface region is more aggressive. as stated by baker (2007), the midface area covers the glabella to the sub-nasal area.10 according to the histological findings, the nodular, morpheic and basosquamous bcc subtypes were more frequent than the other subtypes in this study. the most common subtype (with an estimated 60%-75% prevalence overall) is the nodular (or nodulocystic) subtype, which is especially common in the head and neck area.11 in this study, the nodular and morpheic bcc subtypes comprised 52.6% of all samples. basal cell carcinoma is a multifactorial disease in which both environmental factors and host genetic factors are implicated in carcinogenesis. in this study, 47.4% nuclear positivity for p53 was found in all groups. khodaeilani et al. (2013) found a p53 expression rate of 67.7%, which was higher than in this study.12 the tumor suppressor p53 regulates genome integrity. it is frequently mutated in all types of human cancer, making p53 a main factor in cancer development.13 based on amyloid deposits, this study found that most bcc (92.1%) had amyloid deposits. several previous studies have found that secondary amyloidosis in bcc varies from 50% to 75%. in the present study, the origin of amyloid deposits in bcc is thought to be derived from degenerated epithelial cells via apoptosis. if the correlation between p53 expression and amyloid obtained a statistically article table 1. protein 53 expression, amyloid deposite, p53amyloid, il-6, mcl-1 and bfgf related bcc aggressivity. type n p53 amyloid p53amyloid il-6 mcl-1 bfgf a bcc 25 18 (47.4 %) 23 (60.5%) 16 (42.1%) 23 (60.5%) 17 (44.7%) 22 (57.9%) na bcc 13 11 (28.9%) 11 (28.9%) 9 (23.7%) 11 (28.9%) 8 (21.1%) 12 (31.5%) total 38 29 (76.3%) 34 (89.4%) 25 (65.8%) 34 (89.4%) 25 (65.8%) 34 (89.4%) figure 1. deposits value of p53 amyloid related to bcc aggressivity. no nco mm er cia l u se on ly [dermatology reports 2019; 11(s1):8012] [page 3] significant difference, it means there is a difference in the role of p53 in determining the aggressiveness of a bcc and na bcc (p<0.05). amyloid fibril deposition has been described in patients with malignant disease. it is more frequently seen in hematological neoplasms and has also been noted in patients with solid tumors. this study also found higher il-6, mcl-1 and bfgf expression in a bcc than in na bcc. proinflammatory cytokines induce angiogenesis. the bcl-2 protein family, including mcl-1, is critical to the regulation of the intrinsic apoptotic pathway and the elimination of cells affected by oncogenic mutations in various human tissues, including the epidermis.14 enhancing il-6 expression also induced mcl-1 expression. mcl-1 is an anti-apoptotic protein that is essential for the survival of multiple cell lineages and is highly amplified in human cancer. under physiological conditions, the mcl-1 expression is tightly regulated at multiple levels, involving transcriptional, post-transcriptional and post-translational processes. beta-fgf or fgf-type 2 is the most important angiogenic factor, along with vegf, and stimulates angiogenesis, which is a sequence of cellular events comprising vascular initiation, formation, maturation, remodeling, and regression, which are tightly controlled to meet tissue requirements. angiogenesis has an important role in the development and progression cancer.15 conclusions given the results of this study, a midface location of bcc is significantly more aggressive than bcc at other sites. this study also found bcc more frequently in females than in males. the expression of p53 amyloid was significantly different in a bcc and na bcc, but was associated with amyloid deposits; p53 amyloid role in determining aggressiveness between a bcc vs. na bcc was significantly different. the expression of mcl-1 and bfgf was significantly higher in a bcc than in na bcc. references 1. pilloni l, bianco p, manieli c, et al. immunoreactivity for alpha-smooth muscle actin characterizes a potentially aggressive subgroup of little basal cell carcinomas. eur j histochem 2009;53: 113-6. 2. epstein eh. basal cell carcinomas: attack of the hedgehog. nat rev cancer 2008;8:743-54. 3. ghaderi r, haghighi f. immuno histochemistry assessment of p53 protein in basal cell carcinoma. iran j allergy asthma immunol 2005;4:16771. 4. george p. p53 how crucial is its role in cancer?. int j curr pharm res 2011;3:19-25. 5. chen cc, chen cl. clinical and histopathologic findings of superficial basal cell carcinoma: a comparison with other basal cell carcinoma subtypes. j chin med assoc 2006;69:364-71. 6. dixon ay, lee sh, mcgregor dh. factors predictive of recurrence of basal cell carcinoma. am j dermatopathol 1989;11:222-32. 7. jacobs g, rippey j, altini m. prediction of aggressive behavior in basal cell carcinoma. cancer 1982; 49:533-7. 8. situm m, buljan m, bulat v, et al. the role of uv radiation in the development of basal cell carcinoma. coll antropol 2008;32:167-70. 9. avci g. an overview on basal cell carcinoma. 2011. in: skin cancer overview [internet]. intech. available from: https://http://www.intechopen. com/books/skin-cancer-overview/anoverview-on-basal-cell-carcinoma. 10. baker sr. reconstruction of the nose in: local flap in facial reconstruction. edisi ke2. michigan usa: mosby; 2007. 11. kraft s, granter sr. molecular pathology of skin neoplasms of the head and neck. arch pathol lab med 2014;138: 759-87. 12. khodaeiani e, fakhrjou a, amirnia m, et al. immunohistochemical evaluation of p53 and ki67 expression in skin epithelial tumors. indian j dermatol 2013;58:181-7. 13. lasagna-reeves ca, clos a, castillocarranza d, et al. dual role of p53 amyloid formation in cancer; loss of function and gain of toxicity. biochem biophys res commun. 2013;430:9638. 14. burke mt, morais c, oliver ka, et al. expression of bcl-xl and mcl-1 in the nonmelanoma skin cancers of renal transplant recipients. am j clin pathol. 2015;143:514-26. 15. spinelli fm, vitale dl, demarchi g, et al. the immunological effect of hyaluronan in tumor angiogenesis. clin transl immunology 2015;4:e52. article no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. dr [page 12] [dermatology reports 2018; 10:7749] foscarnet-induced genital lesions: an overview with a case report jonas a. adalsteinsson, michael pan, shivani kaushik, jonathan ungar department of dermatology, mount sinai, new york city, ny, usa abstract foscarnet is an important antiviral medication used mainly in the treatment of complicated herpes-simplex virus and cytomegalovirus (cmv) infections. reported first in the 1990’s, genital ulcers are a potential side effect in about 10% of cases. we report the case of a 29 year old man with acute myelogenous leukemia who was on ganciclovir for cmv prophylaxis. three weeks after being switched to foscarnet because of neutropenia, he developed two, painful symmetric ulcers on the inferior aspect of glans penis. viral and bacterial cultures were negative. two weeks after stopping the infusion of foscarnet, the ulcers subsided without any additional treatment. it is important that physicians be aware of this potentially disfiguring side effect of foscarnet so that methods of prevention can be implemented early in the treatment of these patients. introduction foscarnet usage has fallen out of favor given the better safety profile of other antiviral medictions. in cases of acyclovir or ganciclovir resistance, foscarnet has an important role to play in the treatment or prophylaxis of herpes-simplex virus (hsv) and cytomegalovirus (cmv) infections. foscarnet not only inhibits proliferation of all herpes viruses, but also of human immunodeficiency virus (hiv), influenza viruses and the hepatitis b virus. it has low oral bioavailability and thus must be administered intravenously and is excreted in over 90-95% unchanged form through the kidneys.1,2 in addition to genital ulcers, frequently reported serious adverse effects are nephrotoxicity, electrolyte disturbances, nausea and seizures.2,3 other side effects include arrhythmias or seizures that may be an effect of transient decreases in serum ionized calcium levels, which appear to occur in all patients during infusion of the drug.4 a less common complication of treatment seen in approximately 10% of cases is genital ulcerations.1,5 in 1990, the first cases were reported in aids patients being treated with foscarnet for cmv retinitis. the patients developed 1-5 cm tender lesions of the glans that were negative in the workup for any infectious disease process. this side effect of foscarnet was uncovered when most lesions healed in 12-14 days after discontinuing the drug.6,7 many similar cases were subsequently reported between 19901996, mostly in aids affected homosexual males.2,8-13 we report the case of a 29 year old man with acute myelogenous leukemia (aml) who developed penile ulcerations after being treated with foscarnet for cmv viremia. patient’s consent was obtained before writing this case report. case report a 29 year old hispanic man with aml complained of a sudden appearance of painful lesions on his penis. he was diagnosed with aml one year earlier and completed an allogenic stem cell transplatation one month prior to current admission. his posttransplant clinical course was complicated by neutropenic fever of unknown origin. he was treated empirically with vancomycin and aztreonam and prophylactically with acyclovir, posaconazole and tmp/smx. initial serum pcr studies for cmv dna showed low grade viremia at 376 iu/ml. repeat pcr one week later showed cmv reactivation at 1522 iu/ml. acyclovir was discontinued and foscarnet was started at 90 mg/kg every 12 h at this point to avoid bone marrow toxicity with ganciclovir. patient was pre-hydrated using 500 cc of normal saline with every foscarnet infusion. repeat cmv pcr studies continued to show viremia. on day 22 of foscarnet treatment, patient complained of painful lesions on his penis (figure 1). dermatology was consulted and physical examination revealed two symmetric erythematous shallow ulcers adjacent to the urethral meatus, oriented posteriorly toward the outward angle of the sub preputial space. the patient is uncircumcised. viral culture was negative for hsv. syphilis serology was negative. foscarnet was continued despite appearance of these lesions due to persistent viremia for a total treatment duration of thirty days, after which the patient was switched back to acyclovir. the ulcers were monitored after stopping foscarnet. nine days after cessation of foscarnet therapy the ulcers had notably improved (figure 2). after 16 days, the lesions had almost completely resolved without scarring (figure 3). no topical therapy was administered for the ulcers. discussion the reported incidence of foscarnetinduced genital lesions in males has been reported to be around 10%. in one study, foscarnet was given to 132 patients with aids. 15 patients developed penile ulcerations with twelve of them doing so during the initial period of high dose treatment. all patients were uncircumcised.5 the main theory behind the pathophysiology of foscarnet-induced ulcers and erosions is that the drug itself induces an acute irritant contact dermatitis. clinically the lesions can look similar to a fixed drug eruption but a biopsy will typically show a spongiotic dermatitis, rather than an interface dermatitis. topical preperations of 3% foscarnet cream have been found to induce a severe irritant dermatitis when applied to skin and mucosal surfaces. this, in combination with the fact that approximately 90-95% of the drug is excreted unchanged in the urine2 contributes to the unique morphology of the lesions (figure 1-3), which are often linearly distributed lesions outward from the urethral meatus. in uncircumcised men, urine that is eliminated through the urethral meatus has the potential to accumulate under the foreskin. it is in this population that most cases have been reported. retention of the drug in the sub-preputial space after urination may account for the tendency of ulceration to occur on the glans. our patient’s hygiene was noted as poor, dermatology reports 2018; volume 10:7749 correspondence: jonas a. adalsteinsson, department of dermatology, mount sinai, 5e 98th st, new york city, ny 10029, usa. e-mail: jonas.adalsteinn@gmail.com key words: foscarnet; ulcer; genital. conflicts of interest: the authors declare no potential conflicts of interest. received for publication: 20 may 2018. accepted for publication: 4 june 2018. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright j.a. adalsteinsson et al., 2018 licensee pagepress, italy dermatology reports 2018; 10:7749 doi:10.4081/dr.2018.7749 no nco mm er cia l u se on ly [dermatology reports 2018; 10:7749] [page 13] along with him being uncircumcised, which placed him at greater risk. lesions have also been reported, though less frequently, in women and circumcised men. a single case has been reported in a circumcised child. the fewer cases reported in women can be explained by the fact that between 19901996, foscarnet was mainly used in aids affected homosexual males.14-17 most cases of ulceration have been reported to occur early on in treatment, when high dose regimens are used.2 our patient is an exception given the sudden onset of the ulcers three weeks after initiation of foscarnet therapy. foscarnet-induced genital ulcers are best managed by stopping the infusion of the drug. preventative measures are important, paying careful attention to personal hygiene with delay retraction of the prepuce and saline washing after each micturition. washing genitals after each urination should be encouraged and probably helps reduce occurence.3,5,11 conclusions genital lesions are a relatively common inpatient problem for uncircumcised males as a result of foscarnet therapy. a careful physical examination along with a detailed history and the exclusion of an infectious disease processes should in most cases be enough to make a confident diagnosis. a biopsy should be unnecessary in most cases. it is important that physicians are not only able to correctly diagnose this potential complication of foscarnet, but most importantly, that they know how to prevent it. preventing it could save the patient from considerable morbidity which could necessitate stopping the drug. all uncircumcised patients receiving iv foscarnet therapy should be advised to wash their prepuce following each micturition. references 1. gerard l, salmon-ceron d. pharmacology and clinical use of foscarnet. int j antimicrob agents 1995;5:209-17. 2. torres t. foscarnet-induced penile ulceration. acta dermatovenerol alp pannonica adriat 2011;20:39-40. 3. jayaweera dt. minimising the dosagelimiting toxicities of foscarnet induction therapy. drug saf 1997;16:258-66. 4. jacobson ma. review of the toxicities of foscarnet. j acquir immune defic syndr 1992;5:s11-7. 5. moyle g, barton s, gazzard bg. penile ulceration with foscarnet therapy. aids 1993;7:140-1. 6. [no authors listed]. penile ulcerations with foscarnet. lancet 1990;335:547-8. 7. [no authors listed]. risk of ulceration from foscarnet. nurs stand 1990;4:16. 8. luelmo j. [genital ulcers from foscarnet: three cases]. med clin (barc) 1996;107:318. 9. papini m, bruni pl. [a case for diagnosis: penile ulcer induced by foscarnet]. ann dermatol venereol 1996;123:67980. 10. gross as, dretler rh. foscarnetinduced penile ulcer in an uncircumcised patient with aids. clin infect dis 1993;17:1076-7. 11. schiff ta, bodian ab, buchness mr. foscarnet-induced penile ulceration. int j dermatol 1993;32:526-7. 12. miguelez m. [foscarnet and genital lesions]. med clin (barc) 1993;100:717-8. 13. evans lm, grossman me. foscarnetinduced penile ulcer. j am acad dermatol 1992;27:124-6. 14. aguirrebengoa k. [foscarnet related vulvar ulcers. description of 2 aids patients]. enferm infecc microbiol clin 1995;13:315-6. 15. caumes e. foscarnet-induced vulvar erosion. j am acad dermatol 1993;28:799. case report figure 1. day 22 of foscarnet therapy (10/4). the patient had erythematous periurethral ulcers on his glans. figure 2. 9 days after stopping foscarnet the ulcers had partially healed (10/13). figure 3. 16 days after stopping foscarnet the lesions had almost completely resolved (10/20). no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. microsoft word dr 9613.docx eissn 2036-7406 publisher's disclaimer. e-publishing ahead of print is increasingly important for the rapid dissemination of science. dermatology reports is, therefore, e-publishing pdf files of an early version of manuscripts that undergone a regular peer review and have been accepted for publication, but have not been through the copyediting, typesetting, pagination and proofreading processes, which may lead to differences between this version and the final one. the final version of the manuscript will then appear on a regular issue of the journal. e-publishing of this pdf file has been approved by the authors. please cite this article as [epub ahead of print] with its assigned doi: 10.4081/dr.2023.9613 note: the publisher is not responsible for the content or functionality of any supporting information supplied by the authors. any queries should be directed to the corresponding author for the article. all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. dermatology reports https://www.pagepress.org/journals/index.php/dr/index real-world use of dimehtyl fumarate in patients with plaque psoriasis: a delphi-based expert consensus martina burlando1 elena campione2 aldo cuccia3 giovanna malara4 luigi naldi5 francesca prignano6 leonardo zichichi7 1dermatology unit, irccs san martino university hospital, genoa, italy 2dermatology unit, university of rome ‘tor vergata’, rome, italy 3dermatology unit, san donato hospital, arezzo, italy 4dermatology unit, metropolitan hospital ‘bianchi melacrino morelli’, reggio calabria, italy 5dermatology unit, san bortolo hospital, vicenza, italy 6 dermatology unit, department of health sciences, university of florence, florence, italy 7dermatology unit, sant’antonio abate hospital, trapani, italy correspondence: martina burlando department of dermatology irccs san martino polyclinic hospital largo rosanna benzi x, 16132, genoa, italy phone: +39 (0) 10 5555761 fax: +39 (0) 10 5556641 e-mail: martinaburlando@hotmail.com keywords: psoriasis treatment, dimethyl fumarate, long-term, consensus disclosure: m. b. served as consultant and received fees and speaker's honoraria from abbvie, almirall, amgen, eli lilly, janssen, leo pharma, novartis, and ucb. e. c. served as consultant for almirall, bms, amgen, and ucb. g. m. reports no conflict of interest. a. c. has been an advisor board member and/or consultant and/or received speakers’ honoraria and/or received grants and/or received research support and/or participated in clinical trials with the following pharmaceutical companies: almirall, amgen, eli lilly, janssen-cilag, novartis. l. n. has received honoraria as a scientific consultant for abbvie, almirall, boehringer ingelheim, bristol myers squibb, ibsa, janssen, leo, lilly, novartis, pfizer, and sanofi. f. p. served as advisory board member and consultant and received fees and speaker's honoraria or has participated in clinical trials for abbvie, almirall, biogen, boehringer-ingelheim, leo pharma, lilly, janssen, novartis, and sanofi genzyme. l. z. received honoraria as a scientific consultant for abbvie, almirall, leo, lilly, and novartis. funding this consensus document was sponsored by almirall s.p.a. editamed provided assistance with coordination of the delphi process and medical writing, with financial support by almirall s.p.a. availability of data and material: data and materials are available by the authors. informed consent: the manuscript does not contain any individual person’s data in any form. abstract dimethyl fumarate (dmf) was recently approved by the european medicines agency for systemic treatment of moderate-to-severe chronic plaque psoriasis. appropriate management of dmf treatment is required to achieve optimal clinical benefits. seven dermatology experts gathered online for three meetings to identify consensus on use of dmf in patient selection, drug dosage/titration, side effects management, and follow-up, with the aim to provide guidance on use of dmf for psoriasis in clinical dermatological practice based on literature data and expert opinion. twenty statements were discussed and voted on using a facilitator-mediated modified delphi methodology. strong consensus was reached for all statements (agreement level of 100%). dmf treatment is characterized by dosage flexibility, sustained efficacy, high rates of drug survival, and low potential for drug–drug interactions. it can be used in a broad range of patients, including the elderly or those with comorbidities. side effects (mainly gastrointestinal disorders, flushing, and lymphopenia) are frequently reported but are generally mild and transient and can be minimized by dosage adjustments and slow titration schedule. hematologic monitoring throughout treatment course is required to reduce the risk of lymphopenia. this consensus document provides clinical dermatologists with answers on optimal use of dmf to treat psoriasis. introduction psoriasis is a chronic, systemic, immune-mediated disease affecting approximately 2–4% of adults in europe and leading to a substantial physical and psychological burden.1,2 psoriasis pathogenesis appears to be driven by proinflammatory cytokines, and immunologic and genetic studies have identified interleukin (il)-17 and il-23 as key players in the disease process.1,3 among clinical presentations, plaque psoriasis is the most common subtype, and up to one-third of patients have moderate-to-severe psoriasis requiring systemic therapy with either conventional or biologic agents.2 the therapeutic options for moderate-to-severe plaque psoriasis have expanded rapidly in recent years, owing to the introduction of several new drugs and physical modalities with the potential to shift traditional treatment paradigms.4 in this rapidly evolving field, choosing the most appropriate treatment strategies based on disease characteristics and patient profiles is a challenge for both academic experts and practicing dermatologists. although fumaric acid esters (faes) have been used for decades in germany and other european countries as a systemic therapy for psoriasis, dimethyl fumarate (dmf) is the first drug in this class to be approved by the european medicines agency (ema) for the treatment of moderate-to-severe plaque psoriasis in adult patients in need of systemic therapy.5 after oral administration, dmf is rapidly converted to monomethyl fumarate (considered to be the active molecule), subsequently metabolized through the tricarboxylic acid cycle and excreted mainly through the respiratory system, with no known involvement of the cytochrome p450 system.6,7 although the mechanism of action of dmf and monomethyl fumarate in improving signs and symptoms of psoriasis has not been entirely elucidated, these molecules seem to promote a downregulation of inflammatory cytokines and an overall shift from a proinflammatory th1/th17 response to an anti-inflammatory th2 response, and may also extend their effects on granulocytes as well as non-immune cells, such as keratinocytes and endothelial cells.6,8 recent findings suggest that dmf may also display an anti-inflammatory effect through regulation of glutathione-s transferase.6,9 in the phase 3 randomized, double-blind, noninferiority bridge trial, dmf was found to be significantly superior to placebo in terms of the proportion of patients achieving a ≥75% improvement from baseline in the psoriasis area and severity index (pasi 75) and a physician global assessment (pga) score of 0 (clear) or 1 (almost clear) at week 16.2 dmf was also proven to be noninferior to a combination of faes containing dmf and monomethyl fumarate. furthermore, dmf-treated patients reported clinically meaningful improvements in health-related quality of life.2,10 dmf demonstrated a favorable safety profile, with most adverse events being classified as ‘mild’ in severity.2 observational studies confirm the efficacy and safety of dmf.11,12 although clinical data with dmf are still scarce, several studies (including real-life observational studies) suggest that long-term treatment with faes is safe and beneficial (both as monotherapy and in combination with other therapies) and is characterized by high drug survival rates.13-15 in the european s3-guidelines, faes are recommended for the induction and long-term treatment of psoriasis vulgaris.16 however, despite the overall favorable safety profile of faes/dmf, adverse events such as gastro intestinal (gi) disorders, flushing, and lymphopenia are common when starting treatment, requiring a careful titration schedule and hematologic monitoring.2,17 there is a need for guidance on the use of dmf, especially for clinicians who have not had previous experience with faes. in this article, we report a consensus document on real-world clinical use of dmf in moderate-to-severe psoriasis drafted by an expert panel of dermatologists using delphi methodology. material and methods this consensus document was prepared by an expert panel consisting of seven italian dermatologists with specific experience on the use of dmf in patients with psoriasis. the delphi technique, a structured group interaction based on a series of questionnaires, has been widely used to integrate expert opinions on various healthcare topics, mainly for development of consensus recommendations.18 a modified delphi technique, consisting of two online meetings (via zoom) and two rounds of questionnaires, was used to reach a consensus on dmf use by drafting and commenting on a series of statements in four main areas: (1) patient selection, (2) drug dosage and titration, (3) side effects management, and (4) follow-up. panel members were asked to rate each statement on a likert scale ranging from 0 (‘absolutely not approved’) to 9 (‘strongly approved’). consensus for each statement was defined as a median score ≥8. the statements were based on both literature data and expert opinion. selected literature articles on patient profile, dosing, management of side effects, and follow-up methods included dmf-related clinical studies (randomized and observational) as well as relevant reviews and previous consensus documents. supporting evidence for dmf use was also obtained from studies of faes, in particular the largest real-world observational studies and registry data-based reviews. the modified delphi process is outlined in figure 1. briefly, in the first meeting the participants discussed and modified a preliminary list of statements previously drafted by the delphi facilitator with the help of members of the expert panel. the amended set of statements was then sent by email to each participant for voting in the first questionnaire round. panel members were asked to vote on each statement, making comments if desired. the results of the first questionnaire and the anonymized comments were sent back to the panel members by the facilitator. during the second online meeting the expert panel discussed each statement and voted again (second questionnaire round). a third meeting was dedicated to a final discussion about the main issues related to dmf use and to the drafting of the first outline of the manuscript, which was written, revised, and finalized over the following month. figure 1. modified delphi process results the guidance on clinical use of dmf consisted of 20 statements. consensus among panelists was reached for all statements, with a level of agreement of 100% (median score of 9). statements and clinical queries are summarized in table 1. table 1. summary of statements patient selection which patients are potential candidates for dmf therapy? 1. dmf is one of the first-choice treatments to be considered in adult patients with mild-tomoderate plaque psoriasis for whom local therapy is ineffective or not applicable 2. dmf is not indicated in patients with non-stable or rapidly progressing disease, or those with psoriatic arthritis 3. dmf can be used in patients with comorbidities, elderly patients, and those with mild-tomoderate renal or hepatic impairment (provided renal/hepatic function is monitored) 4. dmf is a valid systemic option in young patients who refuse immunosuppressant therapies and/or in patients who prefer an oral treatment to an injectable one 5. dmf is a valid treatment option in patients with psoriasis involving areas that are difficult to treat with topical therapy (i.e. scalp, genitals and palmoplantar areas) 6. dmf is not contraindicated in: • patients with metabolic syndrome • patients with a cancer history • patients with latent tuberculosis • women of childbearing potential, provided they are using adequate contraception 7. dmf is a slow-acting drug that requires time to induce a clinical response. it is therefore not a first-line option in patients with expectations of an immediate response dosage and titration what is the dosage of dmf and how should it be titrated? 8. dmf treatment allows for dosage flexibility and dosage individualization based on patient characteristics and clinical response 9. to improve tolerability, a slow titration of dmf is recommended. dmf is usually started at 30 mg/day, with gradual increases up to a maximum dose of 720 mg/day 10. when the optimal therapeutic dose has been reached for each patient (clinical response → pasi <3), a gradual reduction of the daily dose should be considered until a maintenance dose is identified, which should be personalized based on clinical assessment and the patient’s individual requirements how long after starting treatment is it reasonable to wait for a response? 11. the onset of clinical response varies among patients. if response is still unsatisfactory after 3 months of treatment, a change of therapy is recommended the dosage of dmf is flexible and can be individualized according to the patient’s clinical response and tolerability. a slow and individualized titration schedule is essential for optimal patient management since it helps prevent the occurrence of side effects, which are often experienced during treatment initiation, or minimize their intensity. dmf is available as 30 mg and 120 mg gastro-resistant tablets. the recommended starting dosage is 30 mg/day, with subsequent gradual increases over the following 9 weeks up to a maximum of 720 mg/day. if treatment success is achieved before reaching the maximum allowed dosage, no further uptitration is necessary. if during the titration period a particular dose increase is not tolerated (or abnormalities in laboratory parameters are observed), the dosage of dmf should be temporarily reduced to the last tolerated dosage.5 the recommended up-titration schedule of dmf can be adjusted, especially during the first three weeks, in order to personalize the treatment according to patient need and physician’s opinion.17 after clinically relevant improvement has been obtained (usually measured by a pasi score <3), a gradual dosage reduction to each patient’s maintenance effective dose should be considered.5 once the individual maintenance dose has been achieved, dmf offers the advantage of a long-term therapy characterized by sustained efficacy, an acceptable safety profile and excellent drug survival.13-15,20 based on clinical experience and the results of observational studies, most patients require daily maintenance doses of dmf in the range of 240–480 mg.11,12 in the prospective interim analysis of the skill study, the dmf maintenance dose at week 52 was in the range of 120–480 mg in 75% of the study population and <120 mg in 10%.12 dmf is a slow-acting drug that may require several weeks before a meaningful clinical effect is experienced, and side effects are common during the first period of drug exposure. these facts need to be clearly communicated to the patient before treatment initiation. onset of response after starting dmf or faes varies among patients, while full effectiveness of therapy is usually reached after 24 weeks of therapy.20 in the bridge trial (where assessments were scheduled at 3, 8, and 16 weeks after treatment initiation), a decrease in bsa involvement was first observed after 3 weeks of dmf therapy and became significantly different from placebo after 8 weeks.2 in the retrospective future study, 30.8% of patients were classified as ‘markedly improved’ or ‘clear’ after 3 months of fae therapy, increasing to 67% after 6 months and 76% after 1 year.13 based on clinical experience, if a patient fails to show a meaningful improvement after 3 months of treatment, dmf should be discontinued and replaced with another therapy. dmf can be associated with other treatments for psoriasis, such as topical therapies or phototherapy, at various stages during the treatment course, according to the physician’s opinion. combined use of faes and phototherapy during the induction phase is a common practice, as it may induce a faster therapeutic response compared with dmf monotherapy.14,28,29 data are limited on dmf safety and efficacy when used concomitantly with other immunosuppressive or immunomodulating therapies, conventional or biologic.5,20 dmf should be used cautiously with other systemic anti-psoriatic treatments. in particular, concurrent use with nephrotoxic drugs (e.g. methotrexate or ciclosporin) may increase the risk of renal adverse reactions.5 however, off-label concomitant use of faes and methotrexate, though not recommended, is quite common in clinical practice. in a single-center, retrospective study, co-treatment with methotrexate was associated with a favorable safety profile and satisfactory efficacy, as demonstrated by analysis of the digital records of 110 patients with psoriasis treated with faes plus methotrexate for a mean duration of 2.2 years.14 once the maintenance dosage has been established, patients should continue taking dmf without interruptions (as long as efficacy and tolerability are maintained). however, dmf therapy is it possible to use dmf in association with other treatments? 12. dmf can be associated with other treatments (e.g. phototherapy or local therapies) at various stages of treatment, based on clinical opinion is it possible to discontinue dmf treatment? 13. dmf treatment can be discontinued, for whatever reasons, and rebound effects are not observed 14. dmf treatment can be resumed after a withdrawal period, at a dosage that depends on the cause of discontinuation: if due to the patient’s requirements, treatment can be resumed at the same dosage used before discontinuation; if due to side effects, it is recommended to restart treatment at the last tolerated dosage, followed by gradual uptitration side effects management what is the side effect profile of dmf? do side effects jeopardize efficacy? 15. dmf side effects (mainly flushing and gi disorders) are often mild, usually occur at the beginning of treatment and during the titration phase and tend to improve or resolve during the course of treatment. side effects do not jeopardize the efficacy of dmf, but may require dosage adjustments or treatment discontinuation if clinically important or not tolerated by the patient how should dose-dependent side effects be managed? 16. with dose-dependent side effects, the recommended option is to go back to the maximum tolerated dose. subsequent dosage adjustments may be considered after clinical reassessment of the patient how should leukopenia/lymphopenia be managed? 17. leukopenia and lymphopenia may occur in the course of treatment. these white blood cell abnormalities are usually mild and transient. hematologic screening is recommended pretreatment (therapy should not be initiated with leukocyte counts <3.0×109/l or lymphocyte counts <1.0×109/l) and during treatment at 3-month intervals 18. if leukocyte counts fall to <3.0×109/l, or lymphocyte counts fall to <1.0×109/l but remain ≥0.7×109/l during treatment, monthly hematologic monitoring is suggested until lymphocyte levels return to normal (≥1.0×109/l) for two consecutive tests, at which point routine monitoring at 3-month intervals can be resumed. with leukocyte counts <3.0×109/l or lymphocyte counts <0.7×109/l, testing should be repeated after 1 month and treatment promptly discontinued if there is no improvement. hematologic monitoring should be continued after stopping dmf until lymphocyte counts return to the normal range. extreme caution is advised about considering the option of resuming dmf treatment once lymphocyte levels are back to normal follow-up how frequently should follow-up visits be planned and how long should dmf therapy last? 19. follow-up visits can be planned at 3-month intervals, at the same time as the hematology tests 20. once the clinical response has been reached and the minimum maintenance dosage identified, therapy with dmf can continue indefinitely based on the maintenance of clinical response discussion 1. patient selection statement based on 1. dmf is one of the first-choice treatments to be considered in adult patients with mild-to-moderate plaque psoriasis for whom local therapy is ineffective or not applicable literature data 2. dmf is not indicated in patients with non-stable or rapidly progressing disease, or those with psoriatic arthritis literature data 3. dmf can be used in patients with comorbidities, elderly patients, and those with mild-to-moderate renal or hepatic impairment (provided renal/hepatic function is monitored) literature data 4. dmf is a valid systemic option in young patients who refuse immunosuppressant therapies and/or in patients who prefer an oral treatment to an injectable one expert opinion 5. dmf is a valid treatment option in patients with psoriasis involving areas that are difficult to treat with topical therapy (i.e. scalp, genitals, and palmoplantar areas) literature data 6. dmf is not contraindicated in: • patients with metabolic syndrome • patients with a cancer history • patients with latent tuberculosis • women of childbearing potential, provided they are using adequate contraception literature data 7. dmf is a slow-acting drug that requires time to induce a clinical response. it is therefore not a first-line option in patients with expectations of an immediate response expert opinion dmf is one of the first-line options available for systemic treatment of mild-to-moderate plaque psoriasis. the european approval of dmf for this indication (in 2017) was based on the results of the phase 3 bridge trial, as well as supportive evidence on the long-term efficacy and tolerability of fae preparations containing dmf and other salts.5 in the bridge trial, 671 patients with moderate-to-severe chronic plaque psoriasis (defined as a pasi score >10, body surface area (bsa) involvement >10%, and a pga score ≥3 on a 6-point scale) were randomized 2:2:1 to receive dmf, a combination of dmf and monomethyl fumarate, or placebo for 16 weeks.2 dmf was proven to be superior to placebo and noninferior to the fae preparation in reducing the severity and extent of the disease. at the end of the study, 37.5% of dmf-treated patients achieved a pasi 75 response compared with 15.3% of placebo recipients (p<0.001), and 33% vs 13.0% (p<0.001), respectively, had a pga score of 0 (clear) or 1 (almost clear), co-primary endpoints of the study. dmf was also found to be superior to placebo on most secondary endpoints (including improvement in bsa score and pasi 90 response at week 16) and on dermatology life quality index-related outcomes, as documented in a post-hoc analysis).10 the efficacy and safety of dmf have also been investigated in real-world settings. in a prospective, single-blind study from the netherlands, a cohort of 176 patients with moderate-to-severe psoriasis who were treated with high-dose dmf for a median duration of 28 months demonstrated a decrease from baseline in mean pga scores by 1.7 points (as assessed blindly from digital photographs of the lesions), and 34% of patients had a score of ‘clear’ or ‘minimal’ when reaching the maintenance phase.11 a recently published interim analysis of the prospective, real-world skilarence in long-term treatment (skill) study, examining data from 257 patients after 52 weeks of dmf treatment, shows a mean reduction in pasi scores of 79.5% in the observed-cases (oc) population and 65.7% in the last-observation-carried-forward (locf) population, while pasi 75 response rates were 63.3% (95% confidence interval [ci] 56.9– 69.3) and 51.0% (95% ci 46.3–55.6) in the oc and locf populations, respectively.12 the treatment was well tolerated, with no unexpected safety concerns. regarding treatment satisfaction, dmf treatment was rated as ‘good’ or ‘very good’ by 94.6% of patients and 95.5% of physicians for effectiveness, and by 87.7% and 92.6%, respectively, for tolerability. although information from large clinical studies with dmf is still scarce, many data have been collected over time from studies of fae preparations, supporting the evidence for the long-term efficacy of dmf.5 as reviewed by blair,7 the efficacy and tolerability of faes have been investigated in randomized, placeboor active-controlled trials as well as observational studies. the retrospective future study from germany included data from 984 patients who had been treated with faes for a mean duration of 44 months, and the percentage of patients classified as ‘clear’ or ‘markedly improved’ according to pga score was 67% after 6 months of therapy, 78% after 24 months and 82% after 36 months.13 in the retrospective study by dickel et al,14 which included records from 859 patients treated with faes as monotherapy (n=626) or with concomitant therapies (n=233) for a mean duration of 3.6 years, 50% of patients experienced considerable improvement (≥2-point reduction from baseline in pga score) after 1 year of treatment. notably, in this study all patients were included in the data analysis, irrespective of treatment discontinuation. the efficacy of dmf or faes has also been documented in patients with psoriasis involving body areas that are difficult to treat with topical therapy, such as the scalp, nails, genitals, palms, or soles.12,13,17,19 in the interim analysis of the skill study, improvements from baseline in nail-pga and palmoplantar-pga were observed in 70.2% and 57.3% of patients, respectively, after 52 weeks of dmf therapy.12 when difficult-totreat areas are involved, patients with mild-to-moderate psoriasis should also be considered candidates for dmf therapy. nearly all clinical studies of dmf or faes include patients with moderate-to-severe psoriasis, generally defined as a pasi score ≥10 (despite faes having been originally approved for severe disease only), which is reflected in the approved indications for dmf use in europe and in the s3-guidelines recommendations regarding fae treatment.5,16 overall, information is limited in the literature about clinical response to dmf (or faes) according to disease severity at baseline. in the future study, where efficacy data were stratified into three groups according to pga-rated severity at baseline (‘severe and very severe,’ ‘moderate-to-severe,’ and ‘moderate’), the improvement of skin signs and symptoms over time was found to be independent of disease severity before initiation of fae treatment.13 as for disease dynamics and characteristics, there is general agreement in the literature that dmf should not be used in patients with non-stable or rapidly progressing disease, or those with psoriatic arthritis.20 unlike other systemic treatments for psoriasis, dmf can be used in a broad population of patients, including those who are elderly or have comorbidities, and those with mild-to-moderate renal or hepatic impairment (all conditions where the safety of anti-psoriatic treatment needs to be evaluated carefully). management of elderly patients can be challenging due to various factors, including functional impairment of vital organs, comorbidities, and consequently polypharmacy.21 because of its favorable pharmacokinetics, dmf has advantages over other systemic treatments. since faes are not metabolized by common pathways such as the cytochrome p450 system, the potential for drug–drug interactions is low, making dmf a safe option in patients with comedication.18,22,23 in the future study, the efficacy of faes was similar in patients with or without comorbidities.13 as documented in a retrospective study that analyzed data from 81 elderly psoriatic patients treated with dmf for up to 24 weeks, dmf seems to be effective and well tolerated irrespective of age.24 since the primary route of excretion of fae metabolites is via exhalation of carbon dioxide (with only small amounts being excreted in the urine or feces), dmf can be used safely in patients with mild-to-moderate hepatic or renal impairment (provided hepatic or renal function is monitored throughout the treatment course) and no dose adjustment is needed.5,6 dmf is not contraindicated in patients with metabolic syndrome or a history of cancer, although efficacy and safety data in these patient groups are scarce. the prevalence of metabolic syndrome in patients with psoriasis is estimated to be in the range of 20–50% and there is increasing evidence that psoriasis and metabolic syndrome share multiple metabolic risk factors, as well as genetic background and pathogenic pathways.25 preliminary investigations suggest that the antiinflammatory activity of dmf and its effects on reduction of oxidative stress through regulation of glutathione-s transferase may also have a role in ameliorating metabolic disturbances.9 in a small prospective, randomized study which evaluated the effects of 6 months’ treatment with faes vs adalimumab on cardiovascular disease parameters in patients with moderate-to-severe psoriasis, fae treatment was associated with a significant reduction of total cholesterol, low-density lipoprotein cholesterol, and apolipoprotein b levels, whereas adalimumab did not affect lipid markers but significantly improved flow-mediated dilation.26 although there are no specific clinical studies of faes in patients with a history of malignancies, small numbers of such patients were included in real-world observational studies. a retrospective study in a population with a high prevalence of comorbidities (103 patients) found no evidence of recurrence of malignancy during dmf treatment in the group with a cancer history (18% of the total population).23 overall, dmf treatment was found to be effective in this study, with almost 80% of the patients who were still on treatment achieving a pasi 75 response at 26 weeks. however, discontinuation rates due to side effects were high (51%). given the scarcity of anti-psoriatic treatments that can be used in patients with malignancies, dmf should definitely be considered an option for oncology patients in hospital settings. treatment with faes is not associated with an increased risk of infection (except for a few isolated cases of opportunistic infections reported in patients with prolonged and severe lymphopenia), and screening for latent tuberculosis is not needed when starting dmf treatment.5,20 in patients with pre-existing clinically relevant infections, the physician should decide whether to initiate dmf therapy once the infection has resolved.5 in patients who develop an infection during dmf treatment, suspension of treatment should be considered and the risk–benefit ratio should be reassessed before re-initiation of therapy.5 dmf is not contraindicated in women of childbearing potential who are using adequate contraception. although data on the outcome of pregnancies of women exposed to dmf are limited, no increased risk of fetal abnormalities or adverse pregnancy outcomes has been reported in post-marketing studies for women with multiple sclerosis treated with dmf.27 individual patient preferences and expectations are important factors in selecting a long-term therapy for psoriasis. dmf offers the advantage of being an oral treatment, thus offering a valid systemic option for patients who prefer to avoid an injectable therapy. similarly, dmf is suitable for young patients wanting to avoid immunosuppressant therapies. since dmf is a slow-acting drug, it should not be offered as a first-line option in patients with expectations of an immediate clinical response. 2. dosage and titration statement based on 8. dmf treatment allows for dosage flexibility and dosage individualization based on patient characteristics and clinical response literature data 9. to improve tolerability, a slow titration of dmf is recommended. dmf is usually started at 30 mg/day, with gradual increases up to a maximum dose of 720 mg/day literature data 10. when the optimal therapeutic dose has been reached for each patient (clinical response → pasi <3), a gradual reduction of the daily dose should be considered until a maintenance dose is identified, which should be personalized based on clinical assessment and the patient’s individual requirements literature data/ expert opinion 11. the onset of clinical response varies among patients. if response is still unsatisfactory after 3 months of treatment, a change of therapy is recommended expert opinion 12. dmf can be associated with other treatments (e.g. phototherapy or local therapies) at various stages of treatment, based on clinical opinion literature data/ expert opinion 13. dmf treatment can be discontinued, for whatever reasons, and rebound effects are not observed literature data 14. dmf treatment can be resumed after a withdrawal period, at a dosage that depends on the cause of discontinuation: if due to the patient’s requirements, treatment can be resumed at the same dosage used before discontinuation; if due to side effects, it is recommended to restart treatment at the last tolerated dosage, followed by gradual uptitration literature data/ expert opinion can be temporarily discontinued, according to the patient’s needs. no rebound effects are expected on treatment discontinuation.2 after a period of withdrawal, dmf therapy can be resumed at a dosage that depends on the reason for treatment discontinuation. if treatment was discontinued for patient requirements not related to tolerability issues, it can be restarted at the same dosage administered before discontinuation, whereas a lower dose (followed by uptitration) should be considered if the patient stopped dmf because of side effects. discontinuing dmf therapy is not needed in patients undergoing minor surgical procedures (e.g. dental procedures or ophthalmic surgery in outpatient settings). 3. side effects management statement based on 15. dmf side effects (mainly flushing and gi disorders) are often mild, usually occur at the beginning of treatment and during the titration phase and tend to improve or resolve during the course of treatment. side effects do not jeopardize the efficacy of dmf, but may require dosage adjustments, or treatment discontinuation if clinically important or not tolerated by the patient literature data 16. with dose-dependent side effects, the recommended option is to go back to the maximum tolerated dose. subsequent dosage adjustments may be considered after clinical reassessment of the patient literature data/ expert opinion 17. leukopenia and lymphopenia may occur in the course of treatment. these white blood cell abnormalities are usually mild and transient. hematologic screening is recommended pre-treatment (therapy should not be initiated with leukocyte counts <3.0×109/l or lymphocyte counts <1.0×109/l) and during treatment at 3-month intervals literature data 18. if leukocyte counts fall to <3.0×109/l, or lymphocyte counts fall to <1.0×109/l but remain ≥0.7×109/l during treatment, monthly hematologic monitoring is suggested until lymphocyte levels return to normal (≥1.0×109/l) for two consecutive tests, at which point routine monitoring at 3-month intervals can be resumed. with leukocyte counts <3.0×109/l or lymphocyte counts <0.7×109/l, testing should be repeated after 1 month and treatment promptly discontinued if there is no improvement. hematologic monitoring should be continued after stopping dmf until lymphocyte counts return to the normal range. extreme caution is advised about considering the option of resuming dmf treatment once lymphocyte levels are back to normal literature data faes have a well-characterized side effect profile, with gi disorders, flushing, and white blood cell count abnormalities being the most frequently reported adverse events in studies of dmf or faes.5,30,31 although side effects are experienced by up to 86% of treated patients, they are generally mild, tend to occur at the onset of therapy, and often resolve or become more tolerable once the patient is established on treatment.11,20,30,31 side effects do not have an impact on dmf efficacy, but often require dosage adjustments. treatment discontinuation should only be considered if side effects are clinically important (e.g. severe lymphopenia) or not tolerated by patients even after lowering dmf dosage. literature data indicate that side effects are often the cause of treatment discontinuation, especially during the first weeks of therapy. in the bridge trial, adverse events leading to treatment discontinuation (mostly gi disorders) were reported in 23% of dmf-treated patients and 25% of those receiving faes (vs 4% in placebo recipients).2 long-term observational studies of dmf or faes report discontinuation rates due to side effects ranging from 13% to 25%.11,14,15 with dose-dependent adverse events, dosage adjustments are often sufficient to improve tolerability. the recommended practice is to go back to the last tolerated dose and reassess the patient’s clinical condition before restarting uptitration. in general, a slow uptitration schedule, especially in the first weeks of treatment, is the best way to minimize the burden of side effects. a good doctor–patient communication is also critical in ensuring treatment adherence during the initial phases of dmf therapy.20 gi disorders (most commonly diarrhea, abdominal pain, abdominal distension, and nausea) are reported in approximately 30–63% of patients treated with dmf or faes.2,11,14 they are most likely to occur during the first 2–3 months of therapy.5 some authors suggest that the intensity of gi disorders peaks at 3–6 weeks after starting treatment and tends to stabilize by weeks 8–9.20 it is recommended that dmf be taken with food to improve gi tolerability.5 the use of specific drugs to ameliorate gi symptoms is not recommended, although mebeverine may be helpful because of its antispasmodic properties.20 another commonly reported adverse event is flushing, experienced by approximately 14–65% of patients on dmf or fae treatment.2,11,14,30 episodes of flushing usually start shortly after drug intake and resolve within a few hours. similarly to gi disorders, flushing is most likely to occur during the first weeks of treatment and tends to decrease in intensity over time.5 in patients experiencing severe episodes, pre-treatment with aspirin may decrease the incidence and intensity of flushing, although continuous use of aspirin is not recommended.20 white blood cell count abnormalities, particularly lymphopenia, may occur during treatment with dmf or faes. lymphopenia is most likely to be observed during the first 3 months of treatment, is generally mild, and in most cases can be managed with dose adjustments. however, treatment discontinuation is required if dose adjustments fail to restore normal lymphocyte levels.5,20 in the randomized bridge trial, 10% of dmf-treated patients experienced lymphopenia, which was considered severe (<0.5×109/l lymphocytes) in 1.1%. hematologic monitoring throughout the study showed that the decrease in lymphocyte levels reached a maximum at 12 weeks after initiation of treatment, when approximately one-third of the patient population had lymphocyte counts <1.0×109/l.2,5 in the observational future study on long-term treatment with faes, leukopenia and lymphopenia were reported after 24 months of therapy in up to 12% and 41% of patients, respectively.13 in a retrospective, long-term study that analyzed data from 859 patients treated with faes (as monotherapy or associated with other treatments), 4.3% of patients experienced leukopenia and 16.3% severe lymphopenia (<0.5×109/l lymphocytes) at some point during treatment.14 dickel et al.32 also evaluated the effects of long-term fae treatment on specific lymphocyte subpopulations in a large subcohort (n=371) of the population of their study, and found that faes significantly reduced the number of cd4+ and cd8+ t cells, as well as cd19+ b and cd56+ natural killer cells, compared with baseline. the mean percentage reduction was highest for cd8+ t cells after 2 years of therapy. the risk of t-cell lymphopenia was found to be significantly increased with older age of patients at initiation of treatment and significantly decreased with methotrexate co-treatment and folic acid supplementation. a tendency towards faster improvement in symptom severity in patients with decreased cd4+ and cd8+ t-cell counts was also observed, supporting evidence for a link between fae efficacy and lymphopenia. since persistent moderate or severe lymphopenia is considered a risk factor for opportunistic infections, such as progressive multifocal leukoencephalopathy, the ema has issued recommendations for pre-treatment hematologic screening and regular hematologic monitoring (a complete blood count including differential) at 3-month intervals, in patients undergoing dmf treatment.5 treatment should not be initiated if leukocyte counts are <3.0×109/l or lymphocyte counts are <1.0×109/l. cut-off values for drug discontinuation during dmf treatment are a leukocyte count <3.0×109/l or a lymphocyte count <0.7×109/l on two consecutive tests 1 month apart. with lymphocyte counts <1.0×109/l but ≥0.7×109/l, monitoring should be performed monthly until levels return to ≥1.0×109/l for two consecutive tests, at which point monitoring every 3 months can be resumed. patients in whom treatment was discontinued because of lymphopenia should be monitored until their lymphocyte count has returned to normal. extreme caution is advised about the option of restarting dmf treatment in these patients once hematologic parameters are back to normal. regarding lymphocyte monitoring, we would like to clarify that only absolute lymphocyte counts are included in the ema recommendations. some authors suggest that periodic monitoring of cd4+ and cd8+ counts may be warranted, especially in older patients.32 however, more information is required before lymphocyte subpopulation monitoring can be recommended. transient increases of eosinophil counts may also be observed in some patients at the start of fae treatment. however, eosinophilia is usually self-limiting without dose adjustments and rarely leads to treatment discontinuation.20,30 increases in liver enzymes and serum creatinine levels in up to 40% and 19% of patients, respectively, have been reported in long-term studies of faes, but were usually mild and very rarely necessitated treatment discontinuation.13,14 4. follow-up statement based on 19. follow-up visits can be planned at 3-month intervals, at the same time as the hematology tests expert opinion 20. once the clinical response has been reached and the minimum maintenance dosage identified, therapy with dmf can continue indefinitely based on the maintenance of clinical response literature data once the desired clinical effect has been achieved and the maintenance dosage identified, dmf treatment should be continued indefinitely, as long as efficacy and tolerability are maintained. since hematologic parameters need to be monitored every 3 months, follow-up visits for clinical assessment can be scheduled at the same time. although data on long-term treatment with dmf are limited, the sustained efficacy and longterm safety of faes in real-world settings are well documented. in the future study, which collected data from 984 patients with psoriasis who had been treated with faes for ≥2 years, clinical efficacy actually improved over the course of treatment, with 83.6% of patients classified as ‘markedly improved’ or ‘clear’ (according to pga) after >36 months of therapy compared with 67% after 6 months. in addition, >80% of patients were still being treated with faes at the time of documentation.13 cumulative improvements over time in pga and pasi responses were also observed in the retrospective study by dickel et al,14 which included 859 patients who had been continuously treated with faes for a mean of 3.6 years. considerations about safety with long-term therapy also support protracted use of faes. data from the german psoriasis registry psobest regarding 2444 patients treated with conventional or biologic systemic drugs (including 981 patients treated with faes for a total exposure time of 807.8 years) show that faes did not increase the risk of infections, major adverse cardiac events or other severe cardiovascular events, or malignancies compared with other systemic treatments for psoriasis.33 in particular, fae treatment was associated with the lowest risk for non-severe infections and non-melanoma skin cancer among all anti-psoriatic agents. drug survival analyses are another important source of information documenting the long-term therapeutic benefits of dmf or faes. drug survival is an indicator of therapeutic success, reflecting a combination of efficacy, safety, and treatment satisfaction. in a retrospective analysis of 373 patients who had been treated for psoriasis in a university hospital in the period 2003–2014, cumulative 1-year survival rates for faes (46%) were higher than those observed for the other systemic non-biologic anti-psoriatic agents (43% for methotrexate, 37% for acitretin, and 16% for ciclosporin); 3-year survival rates were 35% for faes, 20% for methotrexate, and 23% for acitretin.34 in another retrospective study, the 4-year survival rate of faes was 60%.15 conclusions despite the introduction of newer highly efficacious biologic agents, we think that dmf still plays an important role as a first-line treatment option for moderate-to-severe psoriasis, since it offers some advantages over other treatments and displays pharmacokinetic characteristics that may be highly appreciated in selected patient populations. in particular cases, dmf may indeed be the only option (or one of very few options) available for systemic therapy. several clinically meaningful factors characterize treatment with dmf: (1) dosage flexibility allows for personalized dosing tailored to the patient’s clinical response and individual requirements (2) dmf is not metabolized by common pathways such as the cytochrome p450 system, and consequently the drug–drug interaction potential is very low. therefore, dmf can be used in patients with comorbidities receiving co-medication (unlike other systemic anti-psoriatic agents, which have known interactions with commonly used drugs) (3) the metabolic pathway and route of elimination of dmf (mainly via exhalation of carbon dioxide) enable safe use in patients with mild or moderate hepatic or renal impairment (such as many elderly patients) without dose adjustments (4) dmf has an excellent long-term safety profile in terms of risks of infection, cardiovascular events, or malignancies, which has been established over a long history of experience with fae-based products (5) once the maintenance dose has been reached, dmf demonstrates sustained clinical efficacy, with drug survival rates that compare favorably with those of other systemic treatments (6) dmf has proven efficacy also in the treatment of impactful areas, such as the scalp, nails, genitals, palms, and soles dmf is a slow-acting drug, often requiring months or even years before reaching maximum effectiveness. side effects (especially gi disorders and flushing) are common when starting therapy and may be burdensome, but are generally mild and transient and can often be managed successfully with a careful titration schedule based on gradual dosage increases, particularly during the first few weeks. lymphopenia (another frequently reported side effect of dmf) can also be corrected with dose adjustments in most cases, and regular hematologic monitoring should be performed throughout the treatment course. when properly managed, dmf treatment can provide meaningful clinical benefits to many patients with moderate-to-severe psoriasis, especially those with treatment needs that, for various reasons (e.g. age, comorbidities, polypharmacy), are still unmet. references 1. korman nj. management of psoriasis as a systemic disease: what is the evidence? br j dermatol. 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2015;29(12):2277–2294. 17. malara g, fabbrocini g, trifirò c, et al. dimethyl fumarate titration for the systemic treatment of moderate-to-severe plaque psoriasis. drugs context. 2021;10:2020-12-4. 18. mcmillan ss, king m, tully mp. how to use the nominal group and delphi techniques. int j clin pharm. 2016;38(3):655–662. 19. mazzilli s, cosio t, botti e, et al. dimethylfumarate efficacy and safety in palmoplantar psoriasis patient affected by hepatitis b and depression: a case report. dermatol ther. 2020;33(4):e13659. 20. mrowietz u, barker j, boehncke wh, et al. clinical use of dimethyl fumarate in moderate-to-severe plaque-type psoriasis: a european expert consensus. j eur acad dermatol venereol. 2018;32(suppl 3):3–14. 21. balato n, patruno c, napolitano m, et al. managing moderate-to-severe psoriasis in the elderly. drugs aging. 2014;31(4):233–238. 22. thaçi d, weisenseel p, philipp s, et al. efficacy and safety of fumaric acid esters in patients with psoriasis on medication for comorbid conditions a retrospective evaluation (facts). j dtsch dermatol ges. 2013;11(5):429–435. 23. corazza m, odorici g, conti a, et al. dimethyl fumarate treatment for psoriasis in a real-life setting: a multicentric retrospective study. dermatol ther. 2021;34(5):e15066. 24. ricceri f, bardazzi f, buggiani g, et al. efficacy and safety of dimethylfumarate in elderly psoriasis patients: a multicentric italian study. j dermatolog treat. [published online 2021 aug 11];1–4. doi:10.1080/09546634.2021.1962000. 25. gisondi p, fostini ac, fossà i, et al. psoriasis and the metabolic syndrome. clin dermatol. 2018;36(1):21–28. 26. holzer g, hoke m, sabeti-sandor s, et al. disparate effects of adalimumab and fumaric acid esters on cardiovascular risk factors in psoriasis patients: results from a prospective, randomized, observerblinded head-to-head trial. j eur acad dermatol venereol. 2021;35(2):441–449. 27. gold r, phillips jt, havrdova e, et al. delayed-release dimethyl fumarate and pregnancy: preclinical studies and pregnancy outcomes from clinical trials and postmarketing experience. neurol ther. 2015;4(2):93–104. 28. weisenseel p, reich k, griemberg w, et al. efficacy and safety of fumaric acid esters in combination with phototherapy in patients with moderate-to-severe plaque psoriasis (fast). j dtsch dermatol ges. 2017;15(2):180–186. 29. tzaneva s, geroldinger a, trattner h, et al. fumaric acid esters in combination with a 6-week course of narrowband ultraviolet b provides an accelerated response compared with fumaric acid esters monotherapy in patients with moderate-to-severe plaque psoriasis: a randomized prospective clinical study. br j dermatol. 2018;178(3):682–688. 30. balak dmw, gerdes s, parodi a, et al. long-term safety of oral systemic therapies for psoriasis: a comprehensive review of the literature. dermatol ther (heidelb). 2020;10(4):589–613. 31. reszke r, szepietowski jc. a safety evaluation of dimethyl fumarate in moderate-to-severe psoriasis. expert opin drug saf. 2020;19(4):373–380. 32. dickel h, bruckner t, höxtermann s, et al. fumaric acid ester-induced t-cell lymphopenia in the real-life treatment of psoriasis. j eur acad dermatol venereol. 2019;33(5):893–905. 33. reich k, mrowietz u, radtke ma, et al. drug safety of systemic treatments for psoriasis: results from the german psoriasis registry psobest. arch dermatol res. 2015;307(10):875–883. 34. arnold t, schaarschmidt ml, herr r, et al. drug survival rates and reasons for drug discontinuation in psoriasis. j dtsch dermatol ges. 2016;14(11):1089–1099. microsoft word dr 9625.docx eissn 2036-7406 publisher's disclaimer. e-publishing ahead of print is increasingly important for the rapid dissemination of science. dermatology reports is, therefore, e-publishing pdf files of an early version of manuscripts that undergone a regular peer review and have been accepted for publication, but have not been through the copyediting, typesetting, pagination and proofreading processes, which may lead to differences between this version and the final one. the final version of the manuscript will then appear on a regular issue of the journal. e-publishing of this pdf file has been approved by the authors. please cite this article as [epub ahead of print] with its assigned doi: 10.4081/dr.2023.9625 note: the publisher is not responsible for the content or functionality of any supporting information supplied by the authors. any queries should be directed to the corresponding author for the article. all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. dermatology reports https://www.pagepress.org/journals/index.php/dr/index autoinflammatory diseases: what’s behind them and what’s new. a review michele maalouly m.d.1, serena saade m.d.2, mazen kurban m.d.2,3,4 1department of internal medicine, american university of beirut, beirut, lebanon; 2department of dermatology, american university of beirut, beirut, lebanon; 3department of biochemistry and molecular genetics, american university of beirut, beirut, lebanon; 4division of genomics and translational biomedicine, american university of beirut, beirut, lebanon. corresponding author: michele maalouly m.d. e-mail address: mm347@aub.edu.lb phone number: 009613003431 fax number: 009611745320 key words: autoinflammatory diseases, molecular dysregulation, signalosomes. funding: this article has no funding source conflict of interest: the authors have no conflict of interest to declare ethical approval: none required abstract autoinflammatory diseases are characterized by bouts of systemic or localized inflammation in the absence of an infection. while some autoinflammatory diseases are caused by a single gene mutation, others have been shown to be multifactorial, involving a large array of genes coupled with environmental factors. previous studies briefly elucidated the molecular mechanisms behind the many autoinflammatory diseases, focusing on the dysregulation of il-1β or il-18, nf-κb activation, and ifn secretion. in this review, we precisely highlight the autoinflammatory disease-specific signalosomes, and we aim to provide a scaffold of the link between the various affected pathways. introduction both autoinflammatory and autoimmune diseases can cause repeated attacks of self-lead inflammatory immunological reactions independent of any external triggers. notably, autoinflammatory diseases are due to hyperactivation of the innate immune system, while autoimmune diseases result from abnormalities of the adaptive immune system.1 inflammation is a physiological adaptive response to infection and tissue injury. many other conditions can lead to inflammation, triggering the recruitment of leukocytes and plasma proteins to the affected tissue site. abnormal activation of the immune system targeting selfantigens is thought to be the main culprit of autoinflammatory diseases. in recent years, considerable progress has been made in the understanding of cellular and molecular events behind the acute inflammatory response, tissue injury and signalosome dysregulations.2 historical origin familial mediterranean fever was the first autoinflammatory disease to be characterized at the molecular level. in the late nineties, the second periodic fever disease emerged when the molecular basis of familial hibernian fever fhf was elucidated with the identification of the tnfrsf1a gene mutations. this disease was renamed tumor necrosis factor receptor-1 associated periodic syndrome (traps). since then, the term autoinflammation was coined to describe new diseases involving the innate immune system. these include but are not limited to: cleavage-resistant ripk1-induced autoinflammatory syndrome (cria) cryopyrin-associated periodic syndromes (caps) deficiency of adenosine deaminase 2 (dada2) familial cold autoinflammatory syndromes (fcas) haploinsufficiency of a20 (ha20) hyper igd syndrome (hids) mucklewells syndrome (mws) neonatal onset multisystem inflammatory diseases (nomid) otilupenia periodic fever, aphtous stomatitis, pharyngitis and cervical adenitis (pfapa) pyogenic arthritis, pyoderma gangrenosum and acne (papa) retinal dystrophy, optic nerve edema, splenomegaly, anhidrosis and migraine headache (rosah) vexas (vacuoles, e1 ligase, x-linked autoinflammatory syndrome) the main culprit behind autoinflammatory diseases is a dysregulation of the pattern recognition receptors (prr)-containing interactomes. dysfunction of each specific interactome results in a particular disease as follows: inflammasomes cause inflammasomopathies, nuclear factor (nf)-κb-activating signalosomes cause relopathies, type i interferon-inducing signalosomes cause interferonopathies, and finally immuno-proteasomes cause proteasome-associated autoinflammatory syndromes (praas) in this review, we will explore four categories of autoinflammatory diseases: the inflammasomopathies, nf-kb activation (relopathies), interferonopathies, and il-1 receptorrelated autoinflammatory diseases (table 1). 1) inflammasomopathies inflammasomes are a group of multiprotein signaling cascades that are known to control the inflammatory response and coordinate antimicrobial host defense mechanisms. the inflammasome is comprised of a sensor, an adaptor, and an effector all working together to establish an immune response. inflammasome complexes are named after their sensor.3 they are recruited by prrs following the detection of pathogenic microorganisms and danger signals in the cytosol of host cells. this consequently leads to the activation of inflammatory caspases to produce cytokines and induce pyroptotic cell death. the clinical importance of inflammasomes reaches beyond the infectious level, as dysregulated inflammasomes are very much associated with inflammatory disorders.4 one of the key innate immune pathways relies on the inflammasome complexes, which consist of an array of ligand-sensing nucleotide-binding domain, leucine-rich repeat containing (nlr) proteins, the adaptor protein asc, and caspase-1. nlr proteins patrol the content of the cytosol, when prompted by a ligand, they initiate the inflammasome cascade, pyroptotic cell death, and pro-inflammatory cytokine release.5 since single-nucleotide polymorphisms (snps) were discovered in inflammasome genes, they were gradually being linked to common auto-inflammatory diseases. examples of such associations include periodic fever syndromes. inflammasome signaling has been further dissected at the molecular level throughout the years.6 several autoinflammatory disorders such as cryopyrin-associated periodic syndromes and familial mediterranean fever among others have been associated with mutations of genes encoding inflammasome components.7 from a dermatological standpoint, it has been shown that ultraviolet (uv) irradiation injures the epidermis, resulting in sunburn and triggering local inflammation. uv-irradiated keratinocytes secrete interleukin-1b through a caspase-1-dependent mechanism. in search for a link between uv-irradiation and caspase-1 activation, a prominent role for the nod-like receptor (nlr) family of innate immunity proteins was recently discovered. nlrs activate caspases through the assembly of macromolecular complexes also known as the inflammasomes. although the mechanism by which uv-irradiation activates inflammasomes remains obscure, these recent findings shed light on the role of nlrs as intermediates between cell injury and inflammation. 8 1.1) nlrp1-associated autoinflammation with arthritis and dyskeratosis the nlrp1 “inflammasome” was the first to be identified, it was distinguished from other inflammasome sensors by having an aminoterminal pyd as well as a carboxyterminal card. it has been established that the pyd does not act as an effector domain but is rather required for self-inhibition of nlrp1.9 host defenses inside a cell are triggered by a signaling cascade that starts with caspase-1 and ultimately results in cytokine maturation and cell death. asc is an adaptor protein that connects the sensor proteins with the caspase-1 to form a ternary inflammasome complex. this is achieved through pyrin-domain (pyd) interactions between sensors and asc, leading to caspase activation and recruitment domain (card) interactions between asc and caspase1.10 nlrp1 interacts with asc through its pyd domain. asc subsequently bind to pro-caspase-1 via its card domain, which promotes il-1β secretion. nlrp1 also interacts with caspase-1 directly through its card domain to activate il-1β secretion. several mutations in the gene coding for nlrp1 were discovered and clinically correlated (a54t, a59p, a66v, m77t, r726w, t755n, f787, r843del, and p1214r). patients harboring these mutations exhibit diffuse skin dyskeratosis, autoinflammation, autoimmunity, oligo/polyarthritis, recurrent fever, along with immunological dysfunction such as high translational b cell level in addition to some instances of vitamin a deficiency.11 the mutations may trigger proteasomedependent functional degradation of nlrp1, degraded card-fiind-containing-nlrp1 fragments act as a scaffold similar to asc for inflammasome activation.12 1.2) familial mediterranean fever the causative gene of familial mediterranean fever (fmf), mefv, encodes pyrin (also named marenostrin), it has an autosomal recessive inheritance. mutations in pyrin are thought to result in the loss of its ability to inhibit inflammasomes which translates clinically into the phenotype of fmf. mutations appear to result in decreased phosphorylation of pyrin and gain of function, resulting in increased activation of the pyrin inflammasome and release of il-1β. the latest data shows that pyrin assembles with asc and pro-caspase-1 to form the pyrin inflammasome, as well as the nlrp3 inflammasome. usually, pyrin is phosphorylated by serine/threonine-protein kinases pkn1 and pkn2, and inhibited by 14-3-3 proteins. when virulence factors are expressed or secreted by bacteria and/or viruses, they inhibit rhoa gtpase, which induces activation of the pyrin inflammasome and secretion il-1β. on the other hand, bacteria that resemble yersinia pestis developed adaptive mechanisms to avoid and dampen the inflammatory response. they have a yopm protein which interacts with pyrin to inhibit inflammation and thus shield the pathogen from anti-bacterial response. in patients with fmf, binding to asc is disrupted by the mutant b30.2 protein domains of pyrin, causing a continuous inflammasome activation and unregulated il-1β secretion. familial mediterranean fever is by far the most common inherited autoinflammatory disease. it occurs worldwide but is most frequent in eastern mediterranean populations. typical onset is early in life, with 50% having their first attack prior to 10 years of age, and 90% prior to 20 years. symptoms include recurring bouts of fever and extremely painful serositis lasting 12 to 72 h. peritonitic abdominal pains occur in 80% of attacks (40% of patients undergo exploratory laparoscopy prior to diagnosis), and other common symptoms include pleuritic chest pain and nonerosive arthritis. the skin manifestation is an erysipelas-like erythema, usually between the knee and the dorsum of the foot, which is more common in children and associated with the commonest and most severe mutation, m694v. 1.3) mevalonate kinase deficiency/hyper-igd syndrome mevalonate kinase deficiency (mkd), also called hyper-igd syndrome, is a very rare autosomal recessive entity caused by a hypomorphic mutation in the mevalonate kinase gene (mvk) gene. the mvk protein contributes to the biosynthetic pathway that produces cholesterol and nonsterol isoprenoids. thus, mvk deficiency leads to a reduced synthesis of isoprenoids, which in turn reduces prenylation of roretgtpases, and disrupts their role in cytoskeletal regulation and vesicular trafficking. this leads to overactivation of the pyrin inflammasome and translates into an increased production of il-1β. geranylgeranyl pyrophosphate is a key mediator produced by the mevalonate pathway; it serves as a substrate for geranylgeranylation. deficiency of mvk leads to depletion of geranylgeranyl pyrophosphate, resulting in the inactivation of rhoa. consequently, mkd leads to an inflammasomopathy via the unrestricted activation of the pyrin inflammasome. mkd has two clinical phenotypes. total enzyme deficiency results in the metabolic disorder mevalonic aciduria, which is lethal unless treated with early bone marrow transplantation. currently there are around 300 reported patients with the milder periodic fever syndrome variant, mostly from northwestern europe, although the disease occurs worldwide. onset of mkd characteristically occurs in the first 6 months of life with recurrent episodes of fever lasting 3 to 7 days. typical symptoms are gastrointestinal upset and lymphadenopathy in the vast majority of patients. other symptoms may include arthralgia, oral aphthae, maculopapular rash, headache as well as eye inflammation. long-term complications include aa amyloidosis, severe or recurrent infections, abdominal adhesions and joint contractures. treatment is difficult, but il-1 blockade appears to be promising. in fact, it has been shown that canakinumab, an anti-il-1β monoclonal antibody, is an effective treatment for mkd, suggesting that il-1β is a common mediator of these diseases. patients who are resistant to this treatment may sometimes respond to il-6 blockade. 1.4) interleukin-1β-mediated autoinflammatory diseases il-1β is a known potent proinflammatory cytokine that has the ability to kick start an inflammatory cascade by recruiting immune cells and inducing il-6 production. as such, uncontrolled il-1β activity underlies the pathology of common inflammatory diseases.13 pyroptotic cell death occurs caspase-1 is activated by an adaptor protein. the latter interacts with nod-like receptors harboring a pyrin domain (pyd) such as nlrp1, 2, 3, 6, 9,12 and other pyrin domain-containing prrs such as pyrin, aim2 and ifi-16. this interaction is triggered by the recognition of damps, pamps and other intracellular microenvironmental changes. the adaptor that mediates this interaction is the apoptosis-associated speck-like protein containing a caspase-recruitment domain (asc) that binds via pyd, and a pro-caspase1 that binds via a card domain. nlrp3 is a prototype for a family of proteins, known as the nlr family that is intimately involved with the innate immune system. originally called cryopyrin, nlrp3 is a component of the inflammasome, a macromolecular complex that senses various microbial products and intracellular “danger signals” (damage-associated molecular patterns, damps) and activates caspase-1. activated casp1 triggers downstream inflammatory responses by cleaving inflammatory cytokines il-1β and il-18 to their active form, a key step in the innate immune response.14 it also plays a role in the inflammatory pathway leading to cell death, also referred to as pyroptosis.15 nlrp3 inflammasome is genetically associated with some autoimmune diseases such as psoriasis. patients with psoriasis exhibited higher plasma levels of inflammasome-generated il-1β and il-18 without any correlation to skin lesion severity. increased constitutive expression of the inflammasome sensors nlrp3, nlrp1, and aim2 was found in peripheral blood cells of patients with psoriasis, along with some increased caspase-1 reactivity in the myeloid blood subsets.16 the inflammasome activation in times of stress such as infection is not always negative and should be looked at as a protective mechanism. however, the uncontrolled nlrp3 activation as a response to non-infectious or non-threatening stimuli may cause unwanted reactions and diseases, of which the auto-inflammatory entities.17 though a number of inflammasomes have been described, the nlrp3 inflammasome is the most extensively studied, but also the most elusive. it is distinguished by the fact that it responds to numerous physically and chemically diverse stimuli.18 the nlrp3 inflammasome may directly or indirectly interact with proteins mutated in other autoinflammatory diseases, including pyrin (in fmf) and pstpip1 (in papa syndrome). from a mechanistic perspective, the cyclic gmp-amp (cgamp) synthase (cgas) is a cytosolic dna sensor that mainly acts by activating the innate immune response. its action is mainly mediated by the production of a second messenger cgamp which in its turn activates the adaptor sting.19 cgas is an intracellular enzyme that binds double-stranded dna (dsdna) and activates a subsequent signaling cascade that includes the sting adaptor leading to the production of inflammatory responses.20 mitochondrial dna (mtdna) escaping the stressed mitochondria can mediate inflammation via the cgas-sting pathway activation, and once oxidized (ox-mtdna), it binds cytosolic nlrp3 and triggers inflammasome activation.21 however, the exact mechanism by which the oxidized mitochondrial dna exits the stressed mitochondria in non-apoptotic macrophages is still unknown. nlrp3 inflammasome activators partly work on uniporter-mediated calcium uptake to open mitochondrial permeability transition pores also called mptp and subsequently trigger vdac oligomerization without generating reactive oxygen species. the mptp is an inducible channel that regulates solute exchange between the mitochondrial matrix content, and the surrounding cytoplasm, which acutely leads to loss of mitochondrial inner membrane potential, and eventually organelle swelling and rupture. mitochondrial rupture due to prolonged mptp engagement, which is often the result of ischemic cellular injury due to elevated intracellular ca2+ levels and reactive oxygen species, leads to regulated necrotic cell death.22 inhibition of vdac oligomerization has been shown to decrease mtdna release, ifn signaling, neutrophil extracellular traps, and worsen clinical disease severity in a wide range of autoinflammatory and autoimmune diseases such as systemic lupus erythematosus (figure 1).23 pharmacological inhibition of nlrp3 activation results in adequate therapeutic effects in a wide variety of rodent models of inflammatory diseases, these effects were also replicated in models with genetic ablation of nlrp3. although these findings highlight the potential of nlrp3 as a drug target, there isn’t a clear and complete understanding of nlrp3 structure and activation mechanisms up until today, which has slowed the discovery and development of novel therapeutic agents against this molecule.24 figure 1: nlrp3 inflammasome activators partly work on uniporter-mediated calcium uptake to open mitochondrial permeability transition pores also called mptp and subsequently trigger vdac oligomerization without generating reactive oxygen species. ischemic cellular injury due to elevated intracellular ca2+ levels and reactive oxygen species underlies regulated necrotic cell death in interleukin-1β-mediated autoinflammatory diseases. cgas: cyclic gmp–amp synthase mptp: mitochondrial permeability transition pore nlrp3: nlr pyrin domain 3 psting: stimulator of interferon genes vdac: voltage-dependent anion selective channel 1.5) cryopyrin-associated periodic syndrome (caps) the cryopyrin-associated periodic syndrome (caps) mainly arises following a gain-offunction mutation in the nlrp3.25 the caps consists of a range of diseases that include familial cold autoinflammatory syndrome (fcas, formerly termed familial cold urticaria (fcu)), muckle–wells syndrome (mws), and neonatal-onset multisystem inflammatory disease (nomid; also called chronic infantile neurologic cutaneous and articular syndrome (cinca). the observed pathogenesis in this spectrum of disorders is mainly a gain of function mutation in a key component of the interleukin (il)-1 inflammasome.26 dysregulated production of il-1 leads to the development of fever along with myalgia, chills and night sweats, as well as severe fatigue, headache, ocular inflammation (resulting in red eyes) and a characteristic urticarial rash. 27 the described rash is distributed equally over arms, trunk and legs. the lesions present as erythematous macules or slightly raised papules/plaques. they are neither edematous nor annular in nature, although they may have a peripheral halo of vasoconstriction. the lesions in question resolve within 24 hours. if caps remain untreated, irreversible damage may occur, which can include sensorineural hearing loss, vision loss, skeletal deformities, cognitive disability and systemic aa amyloidosis. 1.6) tnf receptor-associated periodic fever syndrome (traps) the causative gene product of tnf receptor-associated periodic fever syndrome (traps) is the tnf receptor superfamily member 1a (tnfrsf1a). so far, 180 variations of the tnfrsf1a gene have been reported. disease pathogenesis is greatly mediated by the cysteine-to-cysteine disulfide bonds in the extracellular domain of tnfrsf1a. in traps, misfolding of mutated tnfrsf1a leads to accumulation of the protein in the endoplasmic reticulum (er), which causes er stress and increased generation of mitochondrial reactive oxygen species; this in turn activates inflammasomes. traps are a group of autoinflammatory diseases resulting from the biologic consequences of protein misfolding in the cells of the innate immune system.28 this process is mainly mediated by a missense substitution in the p55 tnf receptor causing the protein misfolding. this substitution subsequently leads to ligand-independent kinase activation and unregulated cytokine productions. traps have an estimated prevalence of 1 per million in the uk. median age at presentation is 7 years, with initially episodic attacks. these attacks can be discrete or become nearcontinuous, and are often prolonged, lasting several weeks. they are accompanied by fever, abdominal pain, rash, eye manifestations, pleuritic pain, headache and lymphadenopathy. the disease-associated rashes can be nonspecific and pleomorphic. the most commonly described skin manifestations are a swollen periorbital rash, migratory erythematous plaques overlying areas of muscle pain. less commonly, serpiginous and urticarial rashes can also occur. traps are associated with an acute phase response characterized by very elevated inflammatory markers as well as leukocytosis. 1.7) pyogenic arthritis, pyoderma gangrenosum, and acne syndrome (papa) the causative gene product of pyogenic arthritis, pyoderma gangrenosum, and acne (papa) syndrome is proline-serine-threonine phosphatase-interacting protein 1 (pstpip1) (also called cd2-binding protein 1 (cd2bp1)). in patients with papa syndrome, mutations in pstpip1 result in hyperphosphorylation of pstpip1, which strengthens its interaction with pyrin via the b-box domain to activate the pyrin inflammasome. this leads to increased secretion of il-1β.29 2) nfkb activation syndromes (relopathies) dysregulations of nf-κb signaling are closely linked to the ubiquitination system. in addition to constitutive activation of nf-κb, loss-of-function mutations in the ubiquitinmediated nf-κb regulatory system causes autoinflammatory diseases.30 2.1) blau syndrome/early-onset sarcoidosis the gene responsible for blau syndrome (bs)/early-onset sarcoidosis (eos) is ibd1, and its causative gene product is nod2. usually, nod2 recognizes muramyl dipeptide (mdp), leading to activation of nf-κb. activating mutations lead to increased production of nod2 resulting in more active signaling via the nod2-ripk2-associated activation of nf-κb. from a clinical standpoint, blau syndrome is characterized by a triad of granulomatous uveitis, arthritis, and skin rash along with camptodactyly, a flexion contracture of the fingers.31 3) interferonopathies the innate immune receptors (e.g., cgas, mda5, and rig-i) are responsible for the first-line defense against intracellular pathogens such as viral, bacterial, or own nucleic acid. this is achieved by a signaling cascade leading up to type i interferon signaling. interferonopathies are associated with dysfunction of these innate immune receptors, subsequent type i interferon signaling, and immunoproteasome dysfunction.32 3.1) proteasome-associated autoinflammatory syndromes (praas) nakajo–nishimura syndrome (nns) and chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature syndrome (candle) were the first praas to be described.33 loss-of-function mutation in immunoproteasome components such as proteasome subunit b type (psmb)8, psmb4, psma3, psmb9, or proteasome maturation protein (pomp) leads to increased secretion of type i ifn by immune cells.34 3.2) candle syndrome (chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature) candle syndrome occurs due to an abnormal functioning of the multicatalytic system proteasome–immunoproteasome. the final result is a sustained production of type 1 interferons (ifns) that can be very much increased by minor triggers such as cold, stress, or viral infections. in candle syndrome the proteasome system dysfunction leads to an inability of the cell to get rid of its waste proteins. this situation may lead to a weak or moderate state of pro-inflammation in the absence of triggers, but under situations of stress, higher requirements of removing waste proteins cannot be met. the first gene mutations detected in patients with candle syndrome were located in the gene psmb8 (proteasome subunit, b-type, 8) in chromosome 6p21.32, encoding the β5i (i = inducible) subunit of the immunoproteasome. additionally, mutations in psmb8 were responsible for the development of nakajo-nishimura syndrome.35 the candle genotype kept expanding with the discovery of new mutations in genes encoding other proteasome–immunoproteasome subunits, or the regulatory protein pomp. candle syndrome is a disease of proteasome–immunoproteasome dysfunction, it can be inherited in a recessive homozygous, compound heterozygous or digenic trait, and less commonly in a dominant fashion. clinically, patients typically start manifesting signs in early infancy. they suffer from recurrent or daily fevers, characteristic skin lesions, wasting, and fat loss. the dermatologic manifestations include but are not limited to: acral, perniotic lesions. these usually appear in newborns and infants and are not regularly seen in childhood or later on. they consist of intense, red or purplish, edematous plaques mostly located on the nose, ears, fingers, or toes. cold may be a trigger for these lesions, but there is usually no history of cold exposure in such presentations. annular plaques can also be seen: these lesions usually start in infancy or childhood and consist of erythematous or purpuric edematous lesions, often with an annular shape and raised borders associated with a flat, purpuric center. they may appear in crops or individually and tend to fade within days or weeks, leaving a purpuric macule behind. new, active lesions coexist with residual, purpuric macules, which gives a very typical appearance to the patients. these lesions are very conspicuous during childhood, but in adult life they may be less visible and may be absent in long-standing disease. perioral and periocular edema has also been observed in these patients. they usually develop a persistent erythematous to violaceous edema during infancy and childhood that mainly involves the periorbital and perioral areas. these may also be visible after puberty and in longstanding disease.36 4) il-1 receptor-related autoinflammatory diseases mutations in the il-1rn (interleukin-1 receptor antagonist) gene lead to an autosomal recessive autoinflammatory disease. it manifests phenotypically as a deficiency of interleukin1 receptor antagonist (dira).37 4.1) deficiency of the interleukin-1 and interleukin-36 receptor antagonists a mutated il1rn gene is the main culprit in the development of dira. this disease is a rare autosomal recessive entity mainly caused by the absence or the dysfunction of the il1-receptor antagonist, leading to unregulated il1 receptors activity. patients with dira present with a neonatal-onset pustular rash, multifocal osteitis and periarticular soft tissue swelling. it can be treated successfully with anakinra, which mitigates the effects of this genetic deficiency. on the other hand, ditra is an autosomal recessive disease that is mainly caused by il-36 receptor antagonist deficiency. onset of ditra spans typically from childhood to the sixth decade of life, and may be precipitated by stress, pregnancy or drugs. it is characterized by a recurrent generalized sterile pustular rash accompanied by neutrophilia and fever. several case reports have demonstrated a favorable and beneficial role for anakinra in patients suffering from ditra. 38 figure 2: pathophysiology and molecular signaling mediating autoinflammatory diseases. candle: chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature syndrome caps: cryopyrin-associated periodic syndrome copa: coatomer protein alpha dira: deficiency of il1 receptor antagonist er: endoplasmic reticulum fmf: familial mediterranean fever mkd: mevalonate kinase deficiency ros: reactive oxygen species tnfr: tumor necrosis factor receptor traps: tnf receptor-associated periodic fever syndromes what’s new? cria syndrome cleavage-resistant ripk1-induced autoinflammatory (cria) syndrome, is a recently discovered entity caused by mutations within the receptor-interacting serine/threonine-protein kinase 1 (ripk1) gene. symptoms of cria syndrome include: episodic unexplained fevers lasting 3 to 5 days and recuring every 2 to 4 weeks, tender lymphadenopathy, headache, mouth ulcers, tonsillitis, severe gastrointestinal symptoms such as pain and diarrhea, and hepatosplenomegaly in a smaller percentage of patients.39 in cria syndrome, mutation of ripk1 allows the cell to bypass normal cellular checkpoints, resulting in uncontrolled cell death and inflammation. due to its potent influence on cell death, ripk1 activity is highly regulated in human cells. when ripk1 is divided in half, it is ‘disarmed’ and thus loses its ability to induce inflammation. in cria, genetic mutations hinder the cleavage of the molecule in two pieces, resulting in an autoinflammatory process.40 vexas syndrome the first description of vexas syndrome was in october 2020, exclusively described in males, with most cases diagnosed in mid to late adult life. vexas syndrome is caused by an acquired somatic mutation, either be mosaic postzygotic in nature, involving the methionine41 codon in uba1. this gene encodes the major e1 enzyme involved in the activation of ubiquitin, a small regulatory protein which attaches to substrates destined for degradation (ubiquitylation). the p.met 41 mutation results in decreased ubiquitylation, particularly in hematopoietic stem cells, leading to undue activation of the innate immune system. despite being clinically heterogenous, vexas syndrome is characterized by treatmentresistant autoinflammatory manifestations, most commonly involving the skin and bone marrow. hematologic features in vexas syndrome include macrocytic anemia, thrombocytopenia as well as myelodysplastic syndromes.41 cutaneous manifestations include polychondritis involving the nose and ear, vasculitis resembling polyarteritis nodosa, and neutrophilic dermatoses resembling acute febrile neutrophilic dermatosis with tender, red-violaceous, firm, and pigmented papules nodules and plaques.42 conclusions in this review, we highlighted the pathophysiology and molecular signals mediating various autoinflammatory diseases including inflammasomopathies, nf-kb activation (relopathies), interferonopathies, and il-1 receptor-related autoinflammatory diseases. we also presented more recent entities mediated by ripk1 mutation and ubiquitin activation (figure 2). in conclusion, dysregulation of the disease-specific signalosome pathways greatly contributes to the pathogenesis and development of most autoinflammatory diseases. further exploration of the molecular dysregulations behind each of these autoinflammatory diseases will facilitate the development of disease-targeting drugs. subsequent studies should focus pathophysiology and molecular mechanisms of signalosomes which may uncover potential candidates for targeted therapy and future drug development. inflammasomopathy relopathy interferonopathy il1 receptorrelated fmf blau syndrome candle syndrome dira mevalonate kinase deficiency a20 protein haploinsufficiency nakajonishimura syndrome (nns) ditra caps aicardi-goutieres traps coatomer protein alpha (copa) il1 b singleton merten syndrome (sms) nlrp1 pyogenic arthritis, pyoderma gangrenosum, acne syndrome table 1: autoinflammatory disorders can be divided into four categories: inflammasomopathies, relopathies, interferonopathies and il 1 receptor-related conditions. abbreviations bs: blau syndome candle: chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature syndrome caps: cryopyrin-associated periodic syndrome card: caspase-recruitment domain cd2bp1: cd2-binding protein 1 cgamp: cyclic gmp-amp cgas: cyclic gmp–amp synthase cinca: cutaneous and articular syndrome copa: coatomer protein alpha cria: cleavage-resistant ripk1-induced autoinflammatory (cria) il-1: interleukin 1 dada2: deficiency of adenosine deaminase 2 damps: damage-associated molecular patterns dira: deficiency of il1 receptor antagonist ditra: deficiency of the il-36 receptor antagonist er: endoplasmic reticulum fcas: familial cold autoinflammatory syndrome fcu: familial cold urticaria fmf: familial mediterranean fever ha20: haploinsufficiency of a20 hids: hyper igd syndrome ifn: interferon il1rn: interleukin-1 receptor antagonist il-18: interleukin 18 il-1β: interleukin 1 beta mkd: mevalonate kinase deficiency mptp: mitochondrial permeability transition pore mws: muckle–wells syndrome nf-κb: nuclear factor kappa b nlr: nucleotide-binding domain, leucine-rich repeat nlrp3: nlr pyrin domain 3 nomid: neonatal onset multisystem inflammatory diseases nns: nakajo–nishimura syndrome papa: pyogenic arthritis, pyoderma gangrenosum, and acne pfapa: periodic fever, aphtous stomatitis, pharyngitis and cervical adenitis pomp: proteasome maturation protein praas: proteasome-associated autoinflammatory syndromes psmb: proteasome subunit b type psting: stimulator of interferon genes pstpip1: proline-serine-threonine phosphatase-interacting protein 1 pyd: pyrin domain ripk1: receptor-interacting serine/threonine-protein kinase 1 ros: reactive oxygen species rosah: retinal dystrophy, optic nerve edema, splenomegaly, anhidrosis and migraine headache sms: singleton merten syndrome tnfr: tumor necrosis factor receptor tnfrsf1a: tnf receptor superfamily member 1a traps: tnf receptor-associated periodic fever syndrome vdac: voltage-dependent anion selective channel vexas: vacuoles, e1 ligase, x-linked autoinflammatory syndrome references 1. arakelyan a, nersisyan l, poghosyan d, et al. 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(in eng). doi: 10.1186/s12969-019-0338-1. 39. shabir o. what is cria syndrome? . 2020 (https://www.newsmedical.net/health/what-is-cria-syndrome.aspx). 40. kastner dd, lalaoui, d. n., boyden, d. s., & silke, p. j. . the genetic mutation behind a new autoinflammatory disease. pursuit by the university of melbourne 2019. 41. syuenng wh. vexas syndrome. 2021 (https://dermnetnz.org/topics/vexassyndrome). 42. bg06: vexas syndrome: a case series. british journal of dermatology 2022;187(s1):91-91. doi: https://doi.org/10.1111/bjd.21322. dr [page 12] [dermatology reports 2019; 11:7675] clinical picture, diagnosis and treatment of rosacea, complicated by demodex mites alexey kubanov, yuliya gallyamova, anzhela kravchenko russian medical academy of continuous professional education, ministry of healthcare of the russian federation, moscow, russia abstract the article analyzes the clinical picture and course of rosacea in patients with demodex mites. it presents the advantages of using the method of confocal laser scanning microscopy over the method of light microscopy of facial skin scrapes. the aimes were to study the influence of demodex mites on the clinical picture and course of rosacea; to compare laboratory and instrumental diagnostic methods for detecting demodex mites; to evaluate the effectiveness of external therapy aimed at eliminating demodex mites. 212 people were examined. the study included healthy patients, patients with a diagnosis of rosacea with the presence and absence of demodex. the presence of demodex mites was confirmed by two methods of study (light microscopy of skin scrapes and confocal laser scanning in vivo microscopy). demodex mites promote the development of acute-inflammatory morphological elements, increase the duration of the condition (more than 5 years, p<0.01) and the probability of recurrence (from 1 to 3 relapses in 39.5% of patients, p<0.05), resulting in a decrease in the quality of life of patients (dermatology life quality index is 12.5±4.5, p<0.05). antiparasitic drug ivermectin, in the form of an external form, at a concentration of 1% has a high therapeutic efficacy (in 93.3% of cases). demodex folliculorum shows signs of parasitism, while demodex folliculorum brevis is a saprophyte. the severity of the condition does not depend on the quantitative load of the mites in the scrape. as an antiparasitic drug, it is recommended to use 1% ivertmectin. introduction in connection with the growth of cultural level of the society as a whole and the increase in individual exactingness to one’s own appearance, both among men and women, face dermatosis remain one of the pressing problems. despite the large number of scientific works devoted to the pathogenesis of rosacea, the question of demodex mites’ role in the development of the clinical picture of the condition remains open in the contemporary literature. according to some authors, demodex mites are representatives of the conditionally pathogenic microflora of facial skin along with propionibacterium acnes, staphylococcus epidermidis and malassezia fungi.1,2 this opinion is supported by the fact that in 55-100% of cases, mites are detected, both in patients with face dermatosis and with patients having no clinical signs of dermatological illnesses.3-5 however, there are scientific papers proving that demodex mites are capable of pathogenic parasitization and are the most frequently detected microbial agents in rosacea.4 at the same time, attention is drawn to the lack of demodicosis diagnosis in the international classification of illnesses of x revision, which points to the fact that demodex mites species act rather as an agent complicating the course of rosacea. currently, two species of demodex mites parasitize on human skin: demodex folliculorum and demodex brevis.6 the modern literature has no substantiated scientific studies indicating the role of the species belonging of the causative agent in the formation of the clinical picture of rosacea. existing assumptions are not fully proven. the available data on the parasitization of demodex mites in patients with rosacea are inconsistent and, in many cases, are mutually exclusive. the available diagnostic methods for detecting demodex mites do not meet the requirements of modern medicine, do not guarantee the absolute reliability of the test results, and are often traumatic. one modern diagnostic technique in dermatology is 25 lasers scanning in vivo microscopy.7 this is an innovative method, the advantages of which are non-invasiveness and high information content, however, to date, in the russian federation this method has not been used to detect demodex mites. thus, in order to improve the quality of diagnosis and therapy, it becomes necessary to conduct a scientific study with an analysis of the clinical picture, comparing the methods of diagnosis and treatment of patients with rosacea associated with demodex mites. the purpose of the study is to evaluate laboratory and instrumental diagnostics and therapy of patients with rosacea complicated by demodex mites. objectives of the study i) to study the influence of demodex mites on the clinical picture and course of rosacea; ii) to study the features of the clinical picture of rosacea associated with demodex mites, depending on the species belonging to demodex mites; iii) evaluate the effectiveness of laboratory and instrumental diagnostic methods for detecting demodex mites; iv) to evaluate the effectiveness of external therapy aimed at eliminating demodex mites in patients with rosacea. materials and methods the work was performed at the databases of the department of dermato venereology and cosmetology of the federal state-funded educational institution continuing professional education “russian medical academy of postgraduate education” of the ministry of health of the russian federation and the federal government budgetary institution “government research centre of dermatovenereology and cosmetology” of the ministry of health of the russian federation from 2013 to 2016 years. the dermatology reports 2019; volume 11:7675 correspondence: yuliya gallyamova, russian medical academy of continuous professional education, ministry of healthcare of the russian federation, 123995, 2/1 barrikadnaya street, moscow, russia. e-mail: yulya.gallyamova.69@mail.ru key words: dermatology life quality index; demodex mites; demodex folliculorum; demodex folliculorum brevis. contributions: aku and yg conceived the present idea, planned the experiments and supervised the findings of this work. akr performed the computations and verified the analytical methods. all authors together investigated all aspects of the influence of demodex mites on rosacea patients, discussed the results and contributed to the final manuscript. conflict of interest: the authors declare no potential conflict of interest. funding: none. received for publication: 11 march 2018. revision received: 19 june 2018. accepted for publication: 25 july 2018. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright a. kubanov et al., 2019 licensee pagepress, italy dermatology reports 2019; 11:7675 doi:10.4081/dr.2019.7675 no nco mm er cia l u se on ly study protocol was approved of the ethical committee of the russian medical academy of continuous professional education. each participant was familiarized and signed the informed consent of the participant in biomedical research. during the study, a total of 212 people (men and women) were examined. the study included healthy patients, patients with a diagnosis of rosacea with the presence and absence of demodex mites on the facial skin. during the study, three groups of patients and healthy people over the age of 18 were formed. i group patients with a diagnosis of rosacea with the presence of demodex mites. patients were included in group i, in which the presence of demodex mites was confirmed by two methods of study (light microscopy of skin scrapes and confocal laser scanning in vivo microscopy in an amount of more than 5 individuals per 1 cm2). ii group is a comparison group, which was composed of patients with a diagnosis of rosacea with no demodex mites. in group ii patients, two methods of study of demodex mites were not found. iii group comprises a comparison group, which included healthy people. due to the fact that in 20 patients with rosacea, demodex mites were detected by only one research method, they were did not include to the study, but the data of this group were used for statistical processing when comparing the effectiveness of diagnostic methods for the presence of demodex mites. methods of the study anamnesis was collected and questionnaire survey according to the questionnaire of the dermatology life quality index, which included 10 items was filled by every participant. clinical: inspection and establishment of a preliminary diagnosis. the diagnosis of rosacea was established based on the clinical picture of the condition. to determine the severity of rosacea guided classification of the national rosacea society.8 all patients diagnosed with rosacea were counted morphological elements on the entire surface of the facial skin. laboratory: i) determination of the presence and species affiliation of demodex mites with the help of light microscopy of skin scrapes, the contents of the sebaceous glands, hair follicles of the eyelashes and/or eyebrows, counting of the detected individuals, larvae, eggs per unit area (1 cm2); ii) determination of the ph level of the facial skin is made as follows. instrumental: i) photographing patients before and after treatment; ii) study of the facial skin with the help of confocal laser scanning in vivo microscopy to determine the presence of demodex mites. statistical: statistical processing of data was carried out by the packages of microsoft excel 2013 and spss 21. the interconnection of categorical indicators was established by fisher’s exact method. fisher’s exact test is a statistical significance test used in the analysis of categorical data when sample sizes are small. to assess the significance of the differences in the follicles, single-factor analysis of variance was used with paired comparisons. to assess the significance of the differences in the absence of a normal distribution, the mann-whitney test, the kruskal-wallis multiple comparison test, were used. differences were considered significant at p<0.05. results clinical characteristics of patients included in the study a total of 192 respondents aged 18 to 79 (mean age 30.0±11.9) were under supervision. there were 82 male participants and 110 female participants. the diagnosis of rosacea was exposed to 120 patients. according to the method of the study, the patients were divided into two groups. group i included patients with rosacea (60 people) who had a demodex mite detected by two methods of study: laboratory – light microscopy of scrapes and instrumental – confocal laser scanning in vivo microscopy in an amount of more than 5 individuals per 1 cm2, the second group included rosacea patients (60 people) who had a negative analysis for the presence of demodex mites (table 1). when comparing the data of the anamnesis of groups i and ii, the factors statistically significantly more frequent in patients with rosacea associated with demodex mites were found. statistical processing of data revealed that the frequency of detection of demodex mites significantly differs depending on the factor triggering the development of the condition (p=0.001). all cases of mites’ detection were recorded with the following predisposing factors: emotional stress (n=60; 100%), inadequate nutrition (n=24; 40%), exacerbation of concomitant diseases (n=2; 3.3%). there were no statistical differences in the exacerbations of diseases, depending on the season. in the comparison of the duration of the rosacea in patients of groups i and ii significant difference was found (p<0.01). the presence of demodex mites in rosacea promotes a longer course of the condition of i group patients (1-5 years duration of rosacea was observed in 10 patients (16.7%); 44 patients (73.3%) had a more than 5 years duration of rosacea). at the same time, in the ii group 24 patients (40%) had a less than one year duration of rosacea, the same number of patients had 1-5 years (24; 40%) and only 12 patients had more than 5 years of rosacea duration (20%). comparing the frequency of rosacea recurrence between patients of groups i and ii, a statistically significant difference was revealed (p<0.05). in patients with absence of demodex mites, in most cases the condition recurred only once (20; 33.3%), whereas in group i the highest number of patients had 1-3 recurrence a year (30; 50%). thus, demodex mites complicate the clinical picture of the condition and contribute to a more frequent recurrence of the process. evaluation of the dermatology quality of life index when comparing the average indices of the dermatology life quality index, a statistically significant difference was revealed. in group i patients, the mean value of the index was 12.5±4.5 (min=5.0, max=19.0). in group ii patients, the mean value of the dermatology life quality index was 8.0±3.4 (min=2.0; max=19.0), (p<0.05). the average value of the dermatology life quality index in the presence of demodex brevis is 10.5. in the presence of demodex folliculo article table 1. the distribution of patients by sex, age, diagnosis and the presence of demodex mites. group i (with the presence of demodex mites) total (n; %) sex male female n=28; 46.7% n=32; 53.3% 60 (100%) age 47±10.4 51±17.6 group ii (with no demodex mites) sex male female n=24; 40.0% n=36; 60.0% 60 (100%) age 41±6.3 33±2.9 group iii (healthy people) sex male female n=30; 41.7% n=42; 58.3% 72 (100%) age 26±1.4 31±3.1 [dermatology reports 2019; 11:7675] [page 13] no nco mm er cia l u se on ly rum and the combined cases of simultaneous detection of two mites species 15.5 and 13.5, respectively. clinical picture of patients with rosacea the distribution of patients by severity of rosacea is presented in table 2. determination of species affiliation of demodex mites the greatest number of rosacea cases in group i patients was associated with parasitizing demodex folliculorum (n=40; 66.7%), demodex brevis was found in 14 patients (23.3%); both mites were found in 6 patients (in 10.0% of cases). when examining 72 healthy people by light microscopy of scrapes, demodex mites were detected in six cases (n=6; 2.8%), in the remaining 66 cases (97.2%), mites failed to identify. in determining the species of demodex mites in healthy people, the parasitism of demodex brevis was revealed in all 6 cases. demodex folliculorum (n=40; 66.7%) is statistically significant in the structure of species affiliation in patients with rosacea. the number of detection cases of this species of mite prevails over the frequency of detection of demodex brevis and associated parasitism by two species of mite. a further study showed that demodex folliculorum accompanies heavier forms of the condition (pustulous and infiltrativeproductive forms of rosacea) (n=16; 26.7% and n=22; 36.7%, respectively). combined cases of simultaneous detection of two species of mites (demodex folliculorum and demodex brevis) on the scrapes of facial skin by light microscopy also correlated with severe forms of rosacea (n=4; 6.7% and n=2; 3.3%, respectively). comparative analysis of diagnostic methods for detecting demodex mites in this step we compared all patients with rosacea included those, in which cases demodex mites were revealed by only one method. to assess the validity of the confocal laser scanning in vivo microscopy method, the survey was conducted in all three groups of subjects. a comparative study was performed on the effectiveness of confocal laser scanning in vivo microscopy and scrape methods followed by microscopic study. the data obtained are presented in table 3. positive results for the detection of demodex mites by the method of light microscopy scrapes were 60 patients with rosacea (28.3%), confocal laser scanning in vivo microscopy 80 patients (37.7%). using confocal laser scanning in vivo microscopy, it was also possible to identify demodex mites in healthy people (n=12; 5.7%), and in the light microscopy of scrapes of demodex mites in the number of 5 individuals per 1 cm2, only 6 healthy persons (n=6; 2.8%); in the remaining 66 healthy people (31.2%), the light microscopy of the scrapes was negative. quantification of demodex mites as a result of the study, we found that it is difficult to detect the mite by light microscopy of scrape per 1 cm2 of skin (table 4). article table 2. distribution of patients with rosacea i and ii groups according to the severity of the condition. form of the condition group i (n; %) group ii (n; %) total (n) erythematous-telangiectatic 6; 10 28; 46.7* 34 papular 8; 13.3 22; 36.7 30 pustulous 22; 36.7* 10; 16.6 32 infiltrative-productive 24; 40* 0 24 total 60; 100 60; 100 120 *p≤0.05. table 3. comparative analysis of study methods for the presence of demodex mites in diagnostically significant amounts. method identification of patients diagnosed healthy people total demodex mites with rosacea (n=72; 34%) (n=212; 100%) (>5 individuals per 1 cm2) (n=140; 66%) scrape with subsequent + 60; 28.3% 6; 2.8% 66; 31.1% light microscopy 80; 37.7% 66; 31.2% 146; 68.9% method identification of patients diagnosed healthy people people demodex mites with rosacea (n=72; 34%) (n=212; 100%) (>5 individuals per 1 cm2) (n=140; 66%) confocal laser scanning + 80; 37.7% 12; 5.7% 92; 43.4% in vivo microscopy 60; 28.3% 60; 28.3% 88;56.6% table 4. detection of demodex mites by the method of light microscopy of scrapes. patients with patients with rosacea healthy total rosacea with with no demodex mites people (n; %) (n; %) the presence (n; %) of demodex mites (n; %) presence of presence of absence of presence of presence of absence of demodex mites demodex mites demodex mites demodex mites demodex mites demodex mites >5/cm2 <5/cm2 >5/cm2 >5/cm2 60; 28.3 22; 10.4 58; 27.4 2; 0.9 4; 1.9 66; 31.1 212; 100 60; 28.3 80; 37.8 72; 33.9 [page 14] [dermatology reports 2019; 11:7675] no nco mm er cia l u se on ly [dermatology reports 2019; 11:7675] [page 15] demodex mites in a diagnostically significant amount (>5 individuals per 1 cm2) were revealed in 60 patients with rosacea (28.3%), included in group i. in 80 patients with rosacea (37.8%) with demodex mites were detected in an amount of less than 5 individuals per 1 cm2 or were absent altogether with a developed clinical picture of the condition. in the examination of healthy people, 66 people (31.1%) had a negative analysis for the presence of demodex mites, while demodex mites were found in a diagnostic amount (more than 5 individuals per cm2) in two subjects (0.9%), in four respondents, the mites were found in an amount of less than 5 individuals per cm2 (1.9%). demodex mites in an amount of <5 individuals per 1 cm2 were detected much more often (n=80; 37.8%, respectively). while study the same respondents using confocal laser scanning in vivo microscopy, the following data were obtained (table 5). when analyzing the data in table 6 attention is drawn to the fact that there were no <5 mites per cm2 in any case by using confocal laser scanning in vivo microscopy, demodex mites were found in patients with rosacea (n=80, 37.8%) and in healthy people in a larger number of cases (n=12; 5.7%). using a confocal laser scanning in vivo microscope allowed determining the average size of demodex mites. when determining the size of mites from 100 to 200 μm, it was believed that in this case demodex brevis was observed, while the average length of the mite was 125 μm; from 200 to 400 μm – demodex folliculorum with an average length of 293 μm. the average size of the width of demodex mites was 24 μm. when measuring the size of the follicular aperture and estimating their number per unit area, for which a randomly chosen site of 25 mm2 was taken, statistically significant differences between the three groups were revealed (p<0.01). it was established that the size of the follicular aperture and their number per unit area in all three groups differ significantly. it was found that the largest size of the mouths of the hair follicles and the excretory ducts of the sebaceous glands were patients of group i with demodex mites (0.125±25 μm), whereas in group ii the size of the hair follicles and sebaceous glands was 0.89±32 μm, in group iii 0.072±29 μm. patients of group i had the highest number of follicles and excretory ducts of sebaceous glands in study groups per 25 mm2 (324±11), in group ii 114±6 and in group iii 28±7. antiparasitic therapy in patients with rosacea after obtaining a positive result of the study for the presence of demodex mites, the patients were randomized according to treatment regimens into two equal subgroups (a and b, respectively) for 30 people each. patients enrolled in subgroup a received only external therapy with a drug containing 1% ivermectin in the form of a cream 1 time per day for 30 days. patients enrolled in subgroup b received a drug containing 250 mg of metronidazole systemically 2 times a day, externally 1% metronidazole in the form of a gel 1 time per day for 30 days. a repeat visit of the patients took place after 30 days of continuous therapy. subjectively, treatment regimens of patients were well tolerated, no side effects were noted, no patient was excluded from the study. when comparing the efficacy of the therapy, it was found that statistically significantly more demodex mites were found after treatment with confocal laser scanning in vivo microscopy (p≤0.05) (table 7). for a comparative evaluation of the effectiveness of treatment methods in subgroups a and b, the clinical picture was compared in the next stage in patients with rosacea associated with demodex mites before and after treatment. complaints of patients before and after the treatment are given in table 8. as can be seen from table 8, after treatment statistically reliably decreased complaints of patients on rashes, burning sensation, pain, pruritus, and rubeosis. moreover, in patients with subgroup a, complaints of greasy lusters of skin gloss decreased, which is an additional advantage of topical therapy. an objective analysis of the clinical picture of patients with rosacea associated with demodex mites after the therapy showed that the following morphological elements in subgroups a and b significantly regressed: papules, pustules, excoriation (p≤0.05) compared with the original data. analysis of the clinical picture showed a positive dynamics of therapy, which manifested itself in a significant decrease in the number of morphological elements characterizing the severity of inflammation (p≤0.05). the effectiveness of the therapy was confirmed by a reduction in subjective complaints of patients after the treatment, and patients who received only external therapy had no complaints of a feeling of lusters of skin and the appearance of greasy lusters, which is an additional advantage. thus, clinical observations demonstrated a lack of superiority in combined antiparasitic therapy using a systemic drug compared to external therapy using a preparation containing 1% ivertmectin as a cream, as confirmed by statistical analysis. discussion association of demodex mites identification with predisposing factors such as emotional stress, inadequate nutrition, exacerbation of concomitant diseases are correlated with the data of already available studies, in which the role of trigger factors in the development of demodecosis is discussed.912 in addition, the effect of heat, cold, spicy food on the development of rosacea wasdetailed in a study by aubdool.13 our findings confirm the hypothesis of turgut erdemir et al., that the demodex mites affect the severity of the disease and contribute to the progression of the pathological process. in addition, the authors article table 5. detection of demodex mites by confocal laser scanning in vivo microscopy. patients with patients with rosacea healthy total rosacea with with no demodex mites people (n; %) (n; %) the presence (n; %) of demodex mites (n; %) presence of absence of presence of absence of demodex mites >5/cm2 demodex mites demodex mites >5/cm2 demodex mites 80; 37.8 60; 28.3 12; 5.7 60; 28.3 212; 100 80; 37.8 60; 28.3 72; 34 no nco mm er cia l u se on ly [page 16] [dermatology reports 2019; 11:7675] have proved that the density of mites increases depending on the severity of the disease.14 the effect of rosacea on the life and social activity of patients is still debated.15 in a meta-analysis of bewley et al., which included 1,624 patients diagnosed with rosacea, 26.4% complained of anxiety and depression, and 43% had a quality of life violation. 62% of respondents indicated that rosacea affected their work and social life, and 26.1% began to avoid social contacts because of the disease.16 when comparing the average indicators of the dermatology quality of life index, it was revealed that in patients of group i the condition has a very strong effect on the life of the patient, in patients in group ii; rosacea had a moderate effect on the life of patients. rosacea, complicated by the presence of demodex brevis, has a moderate effect on life of patients. in the presence of demodex folliculorum and combined cases of simultaneous detection of two species of mites, the condition greatly affects the life of patients. in patients with the presence of demodex folliculorum, the dermatology life quality index is statistically significantly different from the index of patients with demodex brevis (p<0.05), which is logically logical, since we established that demodex folliculorum is found in patients with heavier forms of diseases. the detection of demodex mites is not only statistically more significant in patients with rosacea than in the rest of the population,17 but also as can be seen from the table 2, demodex mites were more often found in patients with more severe clinical forms of rosacea (pustulous, infiltrative-productive forms). such pathological formations as deep papulopustulous elements and nodes, facial skin erythema, greasy lustre are more pronounced in patients of group i, which again confirms that the presence of demodex mites predisposes to the emergence of acute inflammatory morphological elements, contributing to the development of more severe clinical forms of diseases. our results coincide with the results of a study by moravvej et al., where it was proved that mites play a role in the development of rosacea, stimulate the formation of an inflammatory process, which subsequently leads to tissue damage and the formation of telangiectasias.18 the data obtained in determining the species belonging to demodex mites show that demodex folliculorum is more often detected in the analyses than demodex brevis and demodex brevis is detected more often than the combined cases are recorded. demodex folliculorum is statistically significantly more common in patients than simultaneous parasitization of two species of mites (p<0.01). this suggests that in the absence of a clinical picture of rosacea, it is significantly more significant that demodex mites` species will not be found in scrape (p<0.01). in studies by erbağci et al. (1998), divani et al. (2009) and gonzalezhinojosa et al. (2018) demonstrated that statistically significantly more people in the clinical manifestations of rosacea will be found to have demodex mite than in healthy volunteers.19-21 comparing the results obtained by light microscopy and confocal laser scanning in vivo microscopy in patients with rosacea and healthy people, in more cases demodex mites are detected by confocal laser scanning in vivo microscopy, whereas scrape in these patients were negative. the obtained data demonstrate not only high information content of the confocal laser scanning in vivo microscopy method, but also its superiority over microscopic diagnostics. this was also demonstrated in studies by gonzalez et al. and rajadhyaksha et al.22,23 in the examination of healthy people by light microscopy, demodex mites were detected in 6 cases (2.8%). given the ability of the mites to move over the surface of the skin at a speed of 8-16 mm/h,9,10 as well as random selection of the study site, this fact does not prove the absence of mites. given the species belonging to demodex mites in healthy people (all had demodex brevis); the absence of a clinical picture of the condition confirms that this species belongs to saprophyte of facial skin. by using confocal laser scanning in vivo microscopy, demodex mites were defined as rounded or long conical formations in the mouths of the hair and sebaceous glands with the presence of peripheral contouring in the number from one to 25 individuals (an average of 3.37). sattler et al. showed the possibility of using confocal laser scanning in vivo microscopy to determine demodex mites and described article table 7. comparative detection table of demodex mites after the therapy in subgroups a and b. scrape of the skin, squeezing the contents confocal laser scanning of the sebaceous glands followed in vivo microscopy by microscopy presence of absence of presence of absence of demodex mites demodex mites demodex mites demodex mites (n; %) (n; %) (n; %) (n; %) sub-group a 2; 3.3 28; 46.7 4; 6.7* 26; 43.3 sub-group b 4; 6.7 26; 43.3 10; 16.7* 20; 33.3 *p≤0.05. table 6. analysis of the clinical picture of patients with rosacea associated with demodex mites, before and after the therapy. elements sub-group a sub-group b before after before after treatment treatment treatment treatment papules 100* 43 74* 48 pustules 82* 30 63 42 open comedons 87* 42 87* 47 milium 60* 23 41* 14 teleangiectasias 41* 14 56* 12 perifocal erythema 56* 20 75* 36 excoriations 45* 11 68* 21 pigmentation 74 53 90* 63 greasy lusters of skin 65* 25 72 56 *p≤0.05. no nco mm er cia l u se on ly them as rounded and long conical structures.7 a comparison of the effectiveness of the performed therapy once again demonstrates the superiority of confocal laser scanning in vivo microscopy over the subsequent light microscopy (table 7). when analyzing the data obtained in table 7, it can be stated that both methods of treatment had high antiparasitic efficacy. considering the fact that there was no statistically significant difference in negative analyzes for the presence of demodex mites in both laboratory and instrumental diagnostics, we can speak of a high antiparasitic efficacy of a topical medicine containing 1% ivertmectin in comparison with combined treatment with the systemic drug metronidazole and a topical agent containing 1% metronidazole. the relevance of ivermectin for the treatment of rosacea has been shown in a study by cardwell et al.24 when comparing 1% ivermectin and 0,75% metronidazole, ivermectin showed greater efficacy. this was expressed in the quality of life of patients, reducing the number of inflammatory elements and the absence of side effects.24 analysis of the clinical picture showed a positive dynamic of therapy, which manifested itself in a significant decrease in the number of morphological elements characterizing the severity of inflammation (p<0.05). the effectiveness of the therapy was confirmed by a reduction in subjective complaints of patients after the treatment, and patients who received only external therapy had no complaints of a feeling of lustre of skin and the appearance of a greasy lustre, which is an additional advantage. thus, clinical observations demonstrated a lack of superiority in combined antiparasitic therapy using a systemic drug compared to external therapy using a preparation containing 1% ivertmectin as a cream, as confirmed by statistical analysis. stein et al. showed that after 12 weeks of ivermectin treatment, the skin of patients was defined as clean or almost clean. there was a significant reduction in the percentage of inflammatory lesions in the ivermectin treatment group. the results of the study showed that 1% ivermectin is an effective and safe treatment for inflammatory lesions in patients with rosacea.25 conclusions as a conclusion, the following is stated: i) demodex mites complicate the clinical picture and the course of rosacea. when analyzing the clinical picture and the course of the condition in patients with rosacea associated with demodex mites, it is established that demodex mites, promote the development of acute-inflammatory morphological elements (deep papular, pustulous elements, nodes, perifocal erythema), increase the duration of the condition (more than 5 years, p<0.01) and the probability of recurrence (from 1 to 3 relapses in 39.5% of patients, p<0.05), resulting in a decrease in the quality of life of patients (dermatology life quality index 12.5±4.5, p<0.05). the severity of the clinical manifestations of rosacea does not depend on the number of individuals detected by the method of light microscopy of scrapes of facial skin. the most significant factors predisposing to the development of complications are: morphofunctional characteristics of the skin (high greasiness, reduced moisture, alkaline ph shift, and larger pore size), emotional impact, including stress, inadequate nutrition and exacerbation of concomitant diseases. ii) in patients with severe manifestations of the condition (pustulous and infiltrative-productive forms of rosacea), the species of the mites demodex folliculorum (p<0.01) is more often detected. demodex brevis is found in mild forms of the condition and in healthy people, without showing signs of parasitism (p<0.01). iii) confocal laser scanning in vivo microscopy is an effective diagnostic method to detect demodex mites that does not require preliminary preparation for analysis and allows detecting demodex mites at the level of the spiky epidermis layer, which is not accessible for scarification, to identify the species belonging to the size of demodex mites (from 100 up to 200 μm demodex brevis, 200 to 400 μm – demodex folliculorum). iv) antiparasitic drug ivermectin, in the form of an external form (cream), at a concentration of 1% (1 time per day, the general course of 30 days) has a high therapeutic efficacy in patients with associated with demodex mites (in 93.3% of cases). the effectiveness of external therapy with a drug containing 1% ivermectin (course of 30 days) is comparable to the combined treatment with the systemic drug metronidazole 250 mg per os 2 times a day and the external application of 1% metronidazole (gel) 1 time per day for 30 days. v) all patients diagnosed with rosacea pustulous and infiltrative-productive form are examined for the presence of demodex mites with the definition of their species. vi) when demodex folliculorum is detected, regardless of its quantitative load, treatment with antiparasitic drugs is indicated. vii) when demodex brevis is found, given its weak possibility of parasitism, treatment with antiparasitic drugs is not indicated. as an antiparasitic drug in the treatment of rosacea associated with demodex mites, it is recommended to use 1% ivermectin in the form of a cream for 30 days externally. the drug should be applied a thin layer on the previously cleaned facial skin at night. the subsequent treatment should be carried out in accordance with the main diagnosis. references 1. lazaridou e, giannopoulou c, fotiadou c, et al. the potential role of microorganisms in the development of rosacea. j dtsch dermatol ges 2011;9:21-5. 2. schommer nn, gallo rl. structure and function of the human skin microbiome. trends microbiol 2013;21:660-8. 3. norn ms. demodex folliculorum. incidence, regional distribution, patho article table 8. comparison of subjective complaints of patients with rosacea associated with demodex mites before and after treatment. complaints sub-group a sub-group b before after before after treatment treatment treatment treatment rashes 100% 70%* 100% 65%* pain 68% 34%* 75% 30%* burning sensation 59% 40% 64% 30%* rubeosis 69% 40%* 70% 40%* pruritus 70% 20%* 54% 10%* chromatosis 42% 25% 36% 17% presence of crusts/excoriations 45% 30% 39% 20% starburst veins 60% 40% 58% 40% greasy lusters of skin 70% 40%* 65% 40% *p≤0.05. [dermatology reports 2019; 11:7675] [page 17] no nco mm er cia l u se on ly [page 18] [dermatology reports 2019; 11:7675] genicity. dan med bull 1971;18:14-7. 4. rufli t, mumcuoglu y. the hair follicle with demodex folliculorum and demodex brevis mites: biology and medical importance. dermatologica 1981;162:1-11. 5. fujiwara, s, okubo y, irisawa r, tsuboi r. rosaceiform dermatitis associated with topical tacrolimus treatment. j am acad dermatol 2010;62: 1050-2. 6. akbulatova lk. the pathogenic role of demodex mites and the clinical form of demodicosis in human being. vestn dermatol venerol 1963;40:57-61. 7. sattler ec, maier t, hoffmann vs, et al. noninvasive in vivo detection and quantification of demodex mites by confocal laser scanning microscopy. br j dermatol 2012;167:1042-7. 8. wilkin j, dahl m, detmar m, et al. standard classification of rosacea: report of the national rosacea society expert committee on the classification and staging of rosacea. j am acad dermatol 2002;4:584-7. 9. hoekzema r, hulsebosch hj, bos jd. demodecosis or rosacea: what did we treat? br j dermatol 1995;133:294-9. 10. demmler m, de kaspar hm, mohring c, klauss v. blepharitis. demodex folliculorum, associated pathogen spectrum and specific therapy. ophthalmologe 1997;94:191-6. 11. wilkin jk. oral thermal-induced flushing in erythematotelangiectatic rosacea. j invest dermatol 1981;76:15-8. 12. bernstein je. rosacea flushing. int j dermatol 1982;21:24. 13. aubdool aa, brain sd. neurovascular aspects of skin neurogenic inflammation. j investig dermatol symp proc 2011;15:33-9. 14. turgut erdemir a, gurel ms, koku aksu ae, et al. demodex mites in acne rosacea: reflectance confocal microscopic study. australas j dermatol 2017;58:e26-30. 15. gallo rl, granstein rd, kang s, et al. rosacea comorbidities and future research: the 2017 update by the national rosacea society expert committee. j am acad dermatol 2018;78:167:70. 16. bewley a, fowler j, schöfer h, et al. erythema of rosacea impairs health– related quality of life: results of a meta–analysis. dermatol ther 2016;6:237-47. 17. roihu t, kariniemi al. demodex mites in acne rosacea. j cutan pathol 1998;25:550-2. 18. moravvej h, dehghan-mangabadi m, abbasian m-r, meshkat-razavi g. association of rosacea with demodicosis. arch iranian med 2007;10:199-203. 19. erbağci z, ozgöztaşi o. the significance of demodex folliculorum density in rosacea. int j dermatol 1998;37:4215. 20. divani s, barpakis k, kapsalas d. chronic blepharitis caused by demodex folliculorum mites. cytopathology 2009;20:343-4. 21. gonzalez-hinojosa d, jaime-villalonga a, aguilar-montes g, lammogliaordiales l. demodex and rosacea: is there a relationship? indian j ophtalmol 2018;66:36-8. 22. gonzalez s, rajadhyaksha m, anderson rr. non-invasive (real-time) imaging of histologic margins of a proliferative skin lesion. in vivo. j invest dermatol 1998;111:538-9. 23. rajadhyaksha m, grossman m, esterowitz d, et al. in vivo confocal scanning laser microscopy of human skin: melanin provides strong contrast. j invest dermatol 1995;104:946-52. 24. cardwell la, alinia h, tuchayi sm, feldman sr. new developments in the treatment of rosacea – role of oncedaily ivermectin cream. clin cosmet investig dermatol 2016;9:71-7. 25. stein l, kircik l, fowler j, et al. efficacy and safety of ivermectin 1% cream in treatment of papulopustular rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies. j drugs dermatol 2014;13:31623. article no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. dr [dermatology reports 2019; 11:7916] [page 1] dermoscopy is a new diagnostic tool in diagnosis of common hypopigmented macular disease: a descriptive study khitam al-refu faculty of medicine, mutah university, jordan abstract one of the most frequent complaints in dermatology clinics is the eruption of hypopigmented patchy skin lesions. the aim of the study was to investigate the utility of dermoscopy in common hypopigmented macular diseases. patients with the followings diseases were examined by dermoscopy: vitiligo, pityriasis alba, nevus depigmentosus, achromic pityriasis versicolor, idiopathic guttate hypomelanosis, and extragenital guttate lichen sclerosus. this study showed that these hypopigmented macular diseases might display specific dermoscopic features. in vitiligo, the mean dermoscopic features were the presence of a diffuse white glow with perifollicular pigment, perilesional hyperpigmentation, leukotrichia and the pigmentary network. in idiopathic guttate hypomelanosis, the characteristic features were the presence of multiple, shiny, scaly macules with welland ill-defined edges borders that coalesced into polycyclic macules. for nevus depigmentosus, the mean features were hypopigmented patches with irregular border with a faint reticular network. for pityriasis alba, the fairly ill-demarcated hypopigmented macules with fine scales were the mean feature. in lichen sclerosus, there were white structureless areas, perilesional erythematous halo, follicular plugging and white chrysalis like structures. dermoscopy of achromic pityriasis versicolor showed a fairly demarcated white area with fine scales localized in the skin creases. introduction over the last few years, dermoscopy has been shown to be a helpful tool in the diagnosis of many general dermatological disorders.1-7 in addition to its well-documented value in the diagnosis of skin tumors and pigmentary melanocytic lesions, dermoscopy is very helpful in assisting the diagnosis of various general dermatological disorders, including scalp/hair diseases,8 nail/ nail-fold abnormalities,9 and inflammatory dermatoses.1 one of the commonest complaints in dermatology clinics is the eruption of macular or patchy hypopigmented skin lesions. this complaint may be very disturbing to the patient, especially for those with dark skin. some of important hypopigmented macular diseases1 are vitiligo, pityriasis alba, extragenital lichen sclerosus, achromic pityriasis versicolor, idiopathic guttate hypomelanosis and nevus depigmentosus. generally, these disorders share the same patient’s complaint which is characterized by the presence of hypo or depigmented patches or macules. in this study, the aim was to provide an overview on the use of dermoscopy in dermatology by analyzing the dermoscopic features of some of important hypopigmented macular diseases. new studies have documented dermoscopic features in vitiligo.10-19 very few reports documented these changes in idiopathic guttate hypomelanosis20,21 nevus depigmentosus,22-24 achromic pityriasis versicolor25 and extragenital lichen sclerosus.26-28 this study investigated 108 patients presented at dermatology clinics during the last three years complaining of hypopigmented and depigmented cutaneous lesions. this current study contained a larger number of cases, aiming to describe the common and uncommon dermoscopic features for the hypopigmented macular disease; comparing the findings with the previous reports and documenting the frequency of them. materials and methods a total of 108 patients were seen at the dermatology clinics (mutah university medical center) during january 2015 to october 2017 complaining of patchy or macular hypopigmented lesions. detailed and informed consent was taken from the patients. the sample collection was not consecutive, as the intention was to investigate the patients who were diagnosed with specific hypopigmented skin diseases. the following skin diseases were included in the research: vitiligo, pityriasis alba, nevus depigmentosus, achromic pityriasis versicolor, idiopathic guttate hypomelanosis, and extragenital guttate lichen sclerosus. all of the cases which were on treatment were excluded from the study. this was of particular concern for the cases of vitiligo; the patients were on no treatment for three months prior investigations. a detailed history was taken, and dermatological examination was done. a histopathological examination was done for all cases of idiopathic guttate hypomelanosis and lichen sclerosus et atrophicus to confirm the diagnosis of the disease. the histology was not performed for other hypopigmented skin diseases as the diagnosis was based on clinical background combined with wood’s light examination and potassium hydroxide (koh) scrapping. all of the cases were underwent wood’s light examination. this was a very crucial method to confirm the diagnosis of some cases such as vitiligo and pityriasis versicolor. all of the scaly macules and patches were examined with potassium hydroxide scrapping. this is a very important test to confirm the diagnosis of all suspected cases of pityriasis versicolor. the gently scrapped skin scales were placed directly onto a microscope slide and are covered with 10% potassium hydroxide, and were left to stand until clear and gently heated to speed up the action of koh. a dermoscopic examination of all cases was performed using a hand-held dermoscope (dermlite dl3, gen, usa) application (10× magnification) with both polarized and non-polarized lights. iphone camera was attached to capture images. the dates and times of capturing photos were automatically stored. the dermoscopic examination was done for all cases looking for specific diagnostic finding for each case. the dermoscopic examination was done blindly without referring to the clinical or histological information. the following parameters were taken into consideration when applying dermoscopy in these diseases: i) presence of altered pigmentation within the patch or macule; ii) the edge of the macules or patch; whether it is fairly demarcated or ill-defined; iii) presence of dermatology reports 2019; volume 11:7916 correspondence: khitam al-refu, faculty of medicine, mutah university, jordan. tel.: 00962797401149. e-mail: alrefukhi@yahoo.com alrefukhi@mutah.edu.jo key words: dermoscopy; diagnosis; hypopigmented macules; vitiligo. conflict of interest: the author declares no potential conflict of interest. funding: none. received for publication: 26 october 2018. revision received: 28 november 2018. accepted for publication: 29 november 2018. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright k. al-refu, 2018 licensee pagepress, italy dermatology reports 2019; 11:7916 doi:10.4081/dr.2018.7916 no n c om me rci al us e o nly the scales within the lesion or surrounding skin; iv) presence of perifollicular pigmentation; v) presence of perilesional reticulated hyperpigmentation or telangiectasia; vi) the color of the hair within the hypopigmented lesions; vii) the morphology/ arrangement of vascular structures. regarding the pattern or the shape of macules in dermoscopy, there were different patterns described included:10 trichrome pattern, nebulous pattern, polka dot pattern (several depigmented macules), comet tailing of the lesion, amoeboid pattern, and petaloid pattern. results in this study, 108 patients with the followings diseases were enrolled in the study: vitiligo (48 cases), pityriasis alba (16 cases), nevus depigmentosus (8 cases), achromic pityriasis versicolor (16 cases), idiopathic guttate hypomelanosis (11 cases), and extragenital guttate lichen sclerosus (9 cases). out of 48 patients with vitiligo included in the study, 25 were females, and 23 were males. the duration of the disease ranged from 8 months to 2 years; with an average duration of 4 months. the mean age of onset was 24 years. among the patterns of vitiligo, 23 patients had vitiligo vulgaris, acral distribution in 11 cases, a focal variant in 10 cases and 4 had segmental distribution. the most common site was extremities followed by trunk and face. all cases demonstrated bright white (depigmented) areas with wood’s light illumination with bright bluewhite fluorescence. the dermoscopic analysis was done for established, progressive, or regimenting vitiligo. all of the cases showed different activity of the disease even within the same patient. regarding the pattern of pigmentation dermoscopy, a diffuse white glow was seen in 78% of cases, perilesional hyperpigmentation was present in 30% of cases, perifollicular hyperpigmentation was present in 75% of cases, interfollicular pigmentation was seen in 40% of cases, white villus and terminal hair in 70% of cases, the pigmentary network within the lesions in 23% of cases, lesional and perilesional telangiectasia were present in 8% of cases. all of the lesions were not scaly in this study. regarding the pattern in dermoscopy, there were different patterns seen in this study in order of frequency as follows: nebulous pattern (72% of lesions), amoeboid pattern (63% of lesions), trichrome pattern (58% of lesions), petaloid pattern (51% of lesions), polka dot pattern (46% of lesions) and comet tailing of the lesion (28% of lesions). figure 1 demonstrates some of these dermoscopic features in vitiligo patients. patients with idiopathic guttate hypomelanosis were 11 cases (7 males, four females). the average age of the patients was 55.3 years with a range of 35 years to 80 years. on physical examination, there were multiple circular hypopigmented macules of various sizes ranging from 1 to 3 mm in diameter. the skin was scaly and showed some features of sun-damage. average disease duration was 6 years. the histopathological findings for skin biopsies from these lesions demonstrated basketwave hyperkeratosis, epidermal atrophy, and flattened rete ridges, and reduction of melanin pigment and numbers of melanocytes. dermoscopic features (figure 2a) for these cases were nearly similar in all cases and was characterized by the presence of multiple, shiny, porcelain-white macules with welland ill-defined edges borders. these macules may coalesce into polycyclic macules. hyperpigmented networks may be seen within the lesions or surrounding skin giving the appearance of the cloudy-sky pattern. the surrounding skin was scaly. the hair was pigmented with no peri-follicular hyperpigmentation. in addition, as has been described in vitiligo, it was common to see the petaloid, amoeboid, and nebuloid and polka dot appearance in some cases (even in the same patient and in the same dermoscopic view) as has been described in figure 2a. nevus depigmentosus was one of the common differential diagnosis of vitiligo. all of the presented cases in this research were children. eight cases presented with an asymptomatic light patches that had been first noted in the neonatal period. the patches had been stable in shape, texture, but increasing in size with age. the mean age of presentation was 3 years with a range (1.5-12 years). physical examination for each patient revealed a single, well-defined, hypopigmented patch, with a serrated border. the surrounding skin was normal. wood’s light examination of the patch showed an off-white accentuation without fluorescence. on dermoscopy (figure 2b), the hypopigmented patch with an irregular and serrated boarder was the prominent feature. some of patches showed faint reticular network within them. the borders also showed pseudopods pattern protruding into the normal skin. hairs within the patches was of normal colors, and there was no peripheral hyperpigmentation. sixteen patients with pityriasis alba were examined with dermoscopy. the mean age of presentation was 8.2 years. the mean duration of the patches was 12 weeks, and no treatment was prescribed. koh scraping was negative for all cases and similarly was the wood’s light examination. on dermoscopic examination (figure 3a), the hypopigmented macules were fairly illdemarcated white area with fine scales that are commonly distributed within and outside the macules. the hair inside the patch article figure 1. (a) dermoscopic view for vitiligo show depigmented patch, perilesional hyperpigmentation (blue arrows) and depigmented hair (leukotrichia) (red arrow). it is prominent in the same view that the lower margin of the depigmented patch with ill-defined margins that merge indistinctly into the surrounding (nebulous pattern) (blue stars). (b) dermoscopic view for vitiligo show polka dot appearance with several depigmented macules within a hyperpigmented background. few macules show perifollicular repigmentation and leukotrichia as well. a b [page 2] [dermatology reports 2019; 11:7916] no n c om me rci al us e o nly es was of normal color. there is no sharp margin to differentiate the hypopigmented patch from the surrounding skin. these features were seen in all cases of pityriasis alba. in addition, 30 % of cases demonstrated erythematous changes within and surrounding the macules and patches. all of 16 patients with pityriasis versicolor were 12 males and four females. mean age was 23 years. they did not have treatment prior to presentation. the mean duration of disease was 9 weeks. all cases had the lesions on their necks and upper trunk. the patients were asymptomatic. the diagnosis was confirmed based on clinical assessment, koh scrapping, and wood’s light illumination. the characteristic dermoscopic feature (figure 3b) in 85% of cases was diffuse hypopigmented blotches (fairly defined) with fine scales that were commonly localized in the skin furrows. in addition, some of the cases (65%) demonstrate satellite lesions (nearby small round white globules). in 22% of cases, the hypopigmented blotches were ill-defined, but with prominent white, scaly globules. none of the cases demonstrated perilesional hyperpigmentation or perifollicular hyperpigmentation. the hair inside these macules was of normal color but covered by scales in some cases. in this study, 9 cases with extragenital lichen sclerosus were examined with dermoscopy. seven females with mean age 11 years, with a range 7-18 years. two cases are males, of age 28 and 34 years. the mean duration of the disease 1, 8 years (with a range from 1,2 to 2,3 years). the presentation of these cases was white macules over the trunk and extremities. it started as erythema, expanding gradually, and finally turned out to be a white patch. examination revealed a well-demarcated, mild atrophic porcelain-white macules. the diagnosis for this cases was confirmed by histopathology (figure 4) which showed hyperkeratosis, epidermal atrophy, squamatization of the basal cell layer and homogenization and hyalinosis of the upper dermis. the predominant dermoscopic feature of lichen sclerosus (figure 5) was whiteyellowish structureless areas and white chrysalis like structures. this whitish color is glowing white and surrounded by an erythematous halo (as delicate linear branching vessels with different lengths and calibers) especially in active lesions. fine whitish scales were prominent. follicular plugging was seen in new lesions of lichen sclerosus et atrophicus and was not started on treatment yet. table 1 summarized all the previous dermoscopic features in all examined hypopigmented macular diseases. discussion hypomelanosis of the skin encompasses a wide spectrum of congenital and acquired alterations in melanin pigmentation. they pose a diagnostic challenge for the clinician; many of these hypopigmented skin lesions appear similar. vitiligo is one of the most common forms of acquired hypomelanosis of the skin which can be treated in a guideline-oriented manner. but it carries tremendous social implications as social stigma, especially in arab countries and one of these jordan (this research has been done). the eruption of hypopigmented skin lesions is of particular concern especially in darker skin patients. the common skin type in arab countries is the type iii and iv fitzpatrick skin types. therefore, article a b figure 3. (a) dermoscopic feature for a child with pityriasis alba. the hypopigmented macules were fairly ill-demarcated white area with fine scales that are commonly distributed within and outside the macules. the hair inside the patches was of normal color. there is no sharp margin to differentiate the hypopigmented patch from the surrounding skin. (b) dermoscopic view for achromic pityriasis versicolor showed a fairly demarcated white area with fine scales that are commonly localized in the skin creases. figure 4. histopathology of a lesion of extragenital lichen sclerosus showed hyperkeratosis, epidermal atrophy, squamatization of the basal cell layer and homogenization and hyalinization of the upper dermis. figure 2. (a) dermoscopy of a lesion of idiopathic guttate hypomelanosis shows multiple, roundish, homogenous, white-porcelain macules, and two were well defined (amoeboid pattern) (red arrows) and with irregular cloudy whitish pattern (nebuloid) (blue arrow). several white shades present within the field represents the scales. in addition, these whitish areas were surrounded by a patchy hyperpigmented network (cloudysky pattern) (blue stars). (b) the hypopigmented patches of nevus depigmentosus with irregular border (serrated) and with a faint reticular network within the patch. a b [dermatology reports 2019; 11:7916] [page 3] no n c om me rci al us e o nly there is a need for standardized criteria to differentiate this disease from other hypopigmented macular diseases. the dermoscopy may be a helpful as a non-invasive tool in assisting the differential diagnosis of several hypopigmented macular lesions and has the potential to improve the diagnostic accuracy. vitiligo is an acquired, autoimmune disorder characterized by well-demarcated depigmented macules and patches with or without leukotrichia. evolving new lesions of vitiligo are difficult to be distinguished clinically from other causes of hypopigmentation and depigmentation. the dermoscopic examination can detect subtle changes which may be useful in the early diagnosis of vitiligo from other differential diagnoses of vitiligo. some workers have studied the utility of dermoscopy in the diagnosis of vitiligo. a pattern of depigmentation with residual reservoirs of perifollicular pigment have been noted, and this was signifying focally active or regimenting vitiligo.15 this residual perifollicular pigmentation had been observed in (91.9%) of patients with progressing vitiligo and (62.9%) of those with stable vitiligo,16 and this can be considered as characteristic for vitiligo lesions as it was absent in the nonvitiligo depigmented skin.16 in this study, 48 cases of vitiligo had been examined by dermoscopy. a diffuse white glow was seen in 78% of cases, perilesional hyperpigmentation was present in 30% of cases, and perifollicular hyperpigmentation was present in 75% of cases. in this study, the dermoscopic analysis was done for established, progressive, or regimenting vitiligo, and this may explain the difference in frequency from the previous study. in addition, interfollicular pigmentation was seen in 40% of cases, white villus and terminal hair in 70% of cases, the pigmentary network within the lesions in 23% of cases and lesional and perilesional telangiectasia were present in 8% of cases. the presence of telangiectasia may be related to the history of treatment of patients by topical steroids. this marginal and perifollicular marginal and perifollicular hyperpigmentation, reticular pigmentation and marginal reticular pigmentation may be associated with stability and repigmentation of vitiligo.17 since the progressive lesions of vitiligo display perifollicular pigmentation and stable/remitting lesions display perifollicular depigmentation.18 regarding the pattern, there were different patterns seen in order of frequency as follows: nebulous pattern (72% of lesions), amoeboid pattern (63% of lesions), trichrome pattern (58% of lesions), petalloid pattern (51% of lesions), polka dot pattern (46% of lesions) and comet tailing of the lesion (28% of lesions). a similar pattern has been reported before.10 conclusions in conclusion, this study confirmed the findings in previous studies; the glowing white color was characteristic for vitiligo. in addition, this perifollicular pigmentation was seen in all stable and progressive cases of vitiligo. there was a different pattern for the depigmented patch of vitiligo, and this may reflect the activity and the progression of the disease. idiopathic guttate hypomelanosis is another disease characteristically presented with such depigmented macules. it is commonly seen in elderly patients and characterized by hypopigmented macules. the diagnosis of idiopathic guttate hypomelanosis is usually simple and can be assessed clinically, but sometimes, especially in atypical sites, the distinction from other macular hypopigmented dermatoses19 especially vitiligo may be challenging. this study reported the dermoscopic features of 11 cases with idiopathic guttate hypomelanosis. these cases were complaining of the presence of multiple tiny white spots on shins and forearms resembling teardrops. there are two reports prior to this study demonstrating dermoscopic features in this disease.20,21 the first one showed four patterns (amoeboid, feathery, petaloid and nebuloid patterns). the other study showed the typical features as cloudy sky-like pattern (multiple small areas coalescing into polycyclic macules, with several white shades and both welland ill-defined edges, surrounded by a patchy hyperpigmented network) and the cloudy pattern (well or illdefined roundish homogeneous whitish areas surrounded by a patchy hyperpigmented network. this study which was done in 11 cases, were nearly similar to the findings of the second study. dermoscopic features for these cases were nearly similar in all cases which characterized by the presence of multiple, shiny, white macules with welland ill-defined edges borders. these macules coalesce into polycyclic macules. the surrounding skin was scaly. the hair was pigmented as the surrounding skin with no follicular hyperpigmentation. in addition, it was common to see the petaloid, amoeboid, and nebuloid in all cases. these dermoscopic features were observed in this study may be useful to support the clinical diagnosis of idiopathic guttate hypomelanosis, distinguishing it from other hypopigmented macular lesions. for nevus depigmentosus, 8 cases presented with an asymptomatic light patch that had been first noted in the neonatal period. generally, the diagnosis of these cases was clinical. the commonly used clinical criteria proposed by coupe22 for nevus depigmentosus are as follows: leukoderma present at birth or of an early onset; no alteration in the distribution of leukoderma throughout life; no alteration in texture or change of sensation; and absence of a hyperpigmented border. nevus depigmentosus should be differentiated from vitiligo, as both showed off-white accentuation. in dermoscopy, depigmented patches appeared with irregular and serrated border. there was a faint reticular network within the hypopigmented patch. the borders also showed pseudopods pattern protruding into article a b figure 5. the dermoscopic features of new lichen sclerosus et atrophicus (a) and an old lse lesions (b). dermoscopy showing white structureless areas (blue stars) and comedolike openings (yellow arrows) with telangiectasia of different lengths and calibers (red arrows). [page 4] [dermatology reports 2019; 11:7916] no n c om me rci al us e o nly [dermatology reports 2019; 11:7916] [page 5] article t ab ll e 1 . d er m o sc o p ic f ea tu re s o f h yp o p ig m en te d m ac u la r d is ea se . t he d is ea se t he n at ur e of t he e dg e t he p re se nc e t he p re se nc e of t he p re se nc e of t he c ol or o f ha ir p ig m en ta ti on of l es io ns of s ca le s p er if ol li cu la r t el an gi ec ta si a an d ar ra ng em en t p ig m en ta ti on o f va sc ul ar s tr uc tu re vi til ig o (4 8 ca se s) a d iff us e w hi te g lo w t he e dg e w as w el l a ll of th e le si on s a p er ifo lli cu la r le si on al a nd p er ile si on al w hi te v ill us a nd w as s ee n in 7 8% o f c as es . d em ar ca te d in a ll le si on s w er e no nsc al y. h yp er pi gm en ta tio n te la ng ie ct as ia te rm in al h ai r in 7 0% i nt er fo lli cu la r pi gm en ta tio n w ith p er ile si on al w as p re se nt in 7 5% o f c as es . w er e pr es en t i n 8% o f c as es . w as s ee n in 4 0% o f c as es . h yp er pi gm en ta tio n in t he p ig m en ta ry n et w or k 3 0% o f c as es . w ith in th e le si on s in 2 3% o f c as es . id io pa th ic g ut ta te p re se nc e of m ul tip le , s hi ny , t he e dg es o f t he se m ac ul es th e su rr ou nd in g sk in th er e w as n o pe ri fo lli cu la r n o sp ec ifi c ch an ge s. t he h ai r w as h yp om el an os is p or ce la in -w hi te m ac ul es . w er e ei th er w el l-d ef in ed w as s ca ly. h yp er pi gm en ta tio n. p ig m en te d. (1 1 ca se s) h yp er pi gm en te d ne tw or ks o r ill -d efi ne d ev en w ith in w ith in th e le si on s or th e sa m e le si on . s ur ro un di ng ( cl ou dy -s ky p at te rn ). n ev us so m e of th e pa tc he s sh ow ed se rr at ed b or de r of th e a ll of th e le si on s t he re w as n o pe ri ph er al n o sp ec ifi c ch an ge s. h ai rs w ith in th e d ep ig m en to su s f ai nt r et ic ul ar n et w or k p at ch es w as th e pr om in en t w er e no nsc al y. hy pe rp ig m en ta tio n. p at ch es w as o f n or m al (8 c as es ) w ith in th em . fe at ur e. co lo rs . t he b or de rs a ls o sh ow ed p se ud op od s pa tt er n p ro tr ud in g in to th e no rm al s ki n. pi ty ri as is a lb a th e hy po pi gm en te d m ac ul es th er e is n o sh ar p m ar gi n f in e sc al es th at a re th er e w as n o pe ri ph er al 3 0% o f c as es d em on st ra te d t he h ai r in si de th e (1 6 ca se s) w er e fa ir ly il l-d em ar ca te d to d iff er en tia te th e c om m on ly hy pe rp ig m en ta tio n. e ry th em at ou s ch an ge s w ith in p at ch es w as o f n or m al c ol or . w hi te a re a. hy po pi gm en te d pa tc h fr om di st ri bu te d w ith in a nd s ur ro un di ng th e t he s ur ro un di ng s ki n. a nd o ut si de th e m ac ul es . m ac ul es a nd p at ch es . ac hr om ic d iff us e hy po pi gm en te d in 2 2% o f c as es th e p re se nc e of fi ne s ca le s t he re w as n o pe ri ph er al n o sp ec ifi c ch an ge s. t he h ai r in si de th es e pi ty ri as is bl ot ch es ( fa ir ly d ef in ed ) h yp op ig m en te d bl ot ch es th at w er e co m m on ly h yp er pi gm en ta tio n. m ac ul es w as o f n or m al ve rs ic ol or i n 85 % o f c as es . w er e ill -d ef in ed , b ut w ith l oc al iz ed in th e c ol or , b ut c ov er ed (1 6 ca se s) sa te lli te le si on s (n ea rb y pr om in en t w hi te , sk in fu rr ow s. by s ca le s s m al l r ou nd w hi te g lo bu le s) s ca ly g lo bu le s. in s om e ca se s. i n (6 5% ). ex tr ag en ita l l ic he n w hi te -y el lo w is h th er e is n o sh ar p f in e w hi tis h sc al es t he re w as n o pe ri ph er al p re se nc e of te la ng ie ct as ia t he h ai r in si de th e pa tc he s sc le ro su s (9 c as es ) st ru ct ur el es s ar ea s. m ar gi n to d iff er en tia te w er e pr om in en t. h yp er pi gm en ta tio n. w ith d iff er en t l en gt hs w as o f n or m al c ol or . w hi te c hr ys al is li ke th e hy po pi gm en te d pa tc h a nd c al ib er s. p re se nc e of a n s tr uc tu re s. fr om th e su rr ou nd in g sk in . er yt he m at ou s ha lo ( as d el ic at e lin ea r br an ch in g v es se ls w ith d iff er en t l en gt hs a nd c al ib er s) e sp ec ia lly in a ct iv e le si on s. no n c om me rci al us e o nly [page 6] [dermatology reports 2019; 11:7916] the normal skin. hair within the patches was of normal colors, and there was no peripheral hyperpigmentation. in addition, there was a normal colored peri-lesional skin. this feature was described before.23,24 pityriasis alba is a common benign skin condition causing hypopigmented facial patches in children. parents and patients are often concerned about the cosmetic appearance and the similarity to the lesions of vitiligo (from the community view). but here, the patches tend to be ill-defined. in addition, wood’s light has little effect on the hypopigmentation of pityriasis alba. sixteen cases with pityriasis alba were examined with dermoscopy. one previous report investigated this disease by dermoscopy.25 on dermoscopic examination, the hypopigmented macules were fairly illdemarcated white area with fine scales that are commonly distributed within and outside the macules. the hair inside the patches was of normal color. there is no sharp margin to differentiate the hypopigmented patch from the surrounded skin. these features were seen in all cases of pityriasis alba. in addition, 30% of cases demonstrated erythematous changes within and surrounding the macules and patches. in this study, all of 16 patients with pityriasis versicolor were examined by dermoscopy. the characteristic dermoscopic feature in 78% of cases was diffuse hypopigmented blotches (fairly defined) with fine scales that were commonly localized in the skin furrows. in addition, most of the cases (85%) demonstrate satellite lesions (nearby small round white globules). in 22% of cases, the hypopigmented blotches were ill-defined, but with prominent white, scaly globules. actually, this dermoscopic feature of presence of scales that were localized in the skin furrows was characteristic to pityriasis versicolor and was not seen in other diseases that have been studied here. extra-genital lichen sclerosus et-atrophicus is a chronic inflammatory dermatosis of unknown etiology. the presentation of these cases was with white macules over the trunk and extremities. it started as erythema, expanding gradually, and finally turned out to be a white patch. examination revealed a well-demarcated, mild atrophic porcelain-white macules. these cases were examined with dermoscopy, the predominant dermoscopic feature of lichen sclerosus is white-yellowish structureless areas, this whitish color is glowing white, and surrounded by an erythematous halo especially in active lesions. in addition, these active lesions showed follicular plugging which was absent from old lesions, and this was in correlation with a previous studies.26,27 fine whitish scales were prominent. in addition to the presence of shiny, fibrotic, white beams radiating from the center of the lesions toward the periphery, they are described as white chrysalis like structures in previous reports.26,27 they are parallel or orthogonal or disordered linear streaks and usually seen in dermatofibroma, basal cell carcinoma, spitz nevus and melanoma.28 although the diagnosis of lichen sclerosus is mainly clinically and by histopathology, in early stages of the disease, both are uncharacteristic.29,30 it has been reported that histopathological changes were nonspecific in one-third of men with characteristic clinical signs of lichen sclerosus. this disease is a scarring disease, and prompt diagnosis is mandatory. these dermoscopic features were highly characteristic and not demonstrated in other hypopigmented macular lesions. this study showed that these hypopigmented macular diseases might display specific and characteristic dermoscopic features. as described in this research, some of the dermoscopic findings in these hypopigmented macular diseases were non-specific. so, these dermoscopic findings should always be interpreted within the overall clinical context of the patient history, integrated with information from the history and the macroscopic examination.2,3 dermoscopy may scores over routine histopathology in the diagnosis of some skin disease in which skin biopsy may be traumatic as in case of nevus depigmentosus and pityriasis alba. it’s an additive test to confirm the diagnosis of pityriasis versicolor, lichen sclerosus et atrophicus and idiopathic guttate hypomelanosis. references 1. errichetti e, stinco g. the practical usefulness of dermoscopy in general dermatology. j ital dermatol venereol 2015;150:533-46. 2. lallas a, giacomel j, argenziano g, et al. dermoscopy in general dermatology: practical tips for the clinician. br j dermatol 2014;170:514-26. 3. lallas a, zalaudek i, argenziano g, et al. dermoscopy in general dermatology. dermatol clin 2013;31:679-94. 4. errichetti e, stinco g. dermoscopy in general dermatology: a practical overview. dermatol ther (heidelb) 2016;6:471-507. 5. zalaudek i, argenziano g, di stefani a, ferrara g, et al. dermoscopy in general dermatology. dermatology 2006;212:718. 6. micali g, lacarrubba f, massimino d, schwartz ra. dermatoscopy: alternative uses in daily clinical practice. j am acad dermatol 2011;64:1135-46. 7. zalaudek i, lallas a, moscarella e, et al. the dermatologist’s stethoscope-traditional and new applications of dermoscopy. dermatol pract concept 2013;3:67-71. 8. miteva m, tosti a. hair and scalp dermatoscopy. j am acad dermatol 2012;67:1040-8. 9. lencastre a, lamas a, sa d, tosti a. onychoscopy. clin dermatol 2013;31: 587-93. 10. gandhi s, shamanur m, shashikiran ar, et al. study of clinico-epidemiological and dermoscopic patterns of vitiligo in pediatric age group. ind j paediatr dermatol 2017;18:292-8. 11. alghamdi km, kumar a, taïeb a, ezzedine k. assessment methods for the evaluation of vitiligo. j eur acad dermatol venereol 2012;26:1463-71. 12. sosa jj, currimbhoy sd, ukoha u, et al. confetti-like depigmentation: a potential sign of rapidly progressing vitiligo. j am acad dermatol 2015;73:272-5. 13. benzekri l, gauthier y. clinical markers of vitiligo activity. j am acad dermatol 2017;76:856-62. 14. thatte ss, khopkar us. the utility of dermoscopy in the diagnosis of evolving lesions of vitiligo. ind j der vl 2014;80:505-8. 15. chuh aa, zawar v. demonstration of residual perifollicular pigmentation in localized vitiligo-a reverse and novel application of digital epiluminescence dermoscopy. comput med imaging graph 2004;28:213-7. 16. meng r, zhao g, cai rk, et al. application of polarized light dermoscopy in the early diagnosis of vitiligo and its differential diagnosis from other depigmented diseases. chin j dermatol 2009;42:810-3. 17. chandrashekhar l. dermoscopy: a tool to assess stability in vitiligo. in: khopkar u, ed. dermoscopy and trichoscopy in diseases of the brown skin: atlas and short text. new delhi, india: jaypee brothers medical publishers; 2012. pp 112-113. 18. kumar jha a, sonthalia s, lallas a, chaudhary rkp. dermoscopy in vitiligo: diagnosis and beyond. int j dermatol 2017;26. 19. jackson sm, nesbitt lt. the diagnosis. in: jackson sm, nesbitt lt, eds. differential diagnosis for the dermatologist, 2nd ed. new york, ny: springer; 2012. pp 767-768. 20. ankad bs, beergouder sl. article no n c om me rci al us e o nly [dermatology reports 2019; 11:7916] [page 7] dermoscopic evaluation of idiopathic guttate hypomelanosis: a preliminary observation. indian dermatol online j 2015;6:164-7. 21. errichetti e, stinco g. dermoscopy of idiopathic guttate hypomelanosis. j dermatol 2015;42:1118-9. 22. coupe rl. unilateral systematized achromic naevus. dermatologica 1967;134:19-35. 23. ankad bs, shah s. dermoscopy of nevus depigmentosus. pigment int 2017;4:121-3. 24. sarma n, akkad bs. dermoscopy in nevoid disorders: dermoscopy in darker skins. new delhi, india: japee brothers; 2017. pp 127-128. 25. nayak ss, mehta hh, gajjar pc, nimbark vn. dermoscopy of general dermatological conditions in indian population: a descriptive study. clin derm rev 2017;1:41-51. 26. ankad bs, beergouder bl. dermoscopic patterns in lichen sclerosus: a report of three cases. ind d j 2015;6:237-40. 27. errichetti e, lallas a, apalla z, et al. dermoscopy of morphea and cutaneous lichen sclerosus: clinicopathological correlation study and comparative analysis. dermatology 2017;233:46270. 28. marghoob aa, cowell l, kopf aw, scope a. observation of chrysalis structures with polarized dermoscopy. arch dermatol 2009;145:618. 29. carlson ja, lamb p, malfetano j, et al. clinicopathologic comparison of vulvar and extragenital lichen sclerosus: histologic variants, evolving lesions, and etiology of 141 cases. mod pathol 1998;11:844-54. 30. edmonds ev, oyama n, chan i, et al. extracellular matrix protein 1 autoantibodies in male genital lichen sclerosus. br j dermatol 2011;165:218-9. article no n c om me rci al us e o nly 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. dr [dermatology reports 2019; 11:8006] [page 27] skin tissue expression and serum level of thymic stromal lymphopoietin in patients with psoriasis vulgaris oki suwarsa, hartati purbo dharmadji, endang sutedja, lengga herlina, putri reno sori, reti hindritiani, reiva farah dwiyana, hendra gunawan department of dermatology and venereology, faculty of medicine, universitas padjadjaran; hasan sadikin general hospital, bandung, west java, indonesia abstract thymic stromal lymphopoietin (tslp) is known to be associated with allergic diseases. it is also suggested that tslp has a role in autoimmune diseases such as psoriasis; however, the associated pathways remain unknown. there is currently little information on tslp in psoriasis vulgaris. we investigated tslp expressions on lesional and non-lesional skin of psoriasis vulgaris patients using reverse transcription-polymerase chain reaction. tslp level was also investigated in serum from psoriasis vulgaris patients compared to healthy control using enzyme-linked immunosorbent assay. tslp expression was higher in lesional skin (1.90) compared to non-lesional skin (1.76); however, the difference was not statistically significant (p>0.05). tslp serum levels were significantly higher in psoriasis patients (287.40 pg/dl) as compared to controls (114.70 pg/dl) (p<0.05). this study concluded that tslp levels in the serum of psoriasis vulgaris patients are higher than controls. tslp was also found in keratinocyte of psoriasis patients, the expression was higher in the lesional compared to non-lesional skin; however, this difference is statistically insignificant. these findings suggest that tslp may play a role in the pathogenesis of psoriasis vulgaris, but its exact role remains unclear. introduction psoriasis is a chronic inflammatory skin disease, with a strong genetic basis, characterized by complex alterations in epidermal growth and differentiation, as well as multiple biochemical, immunologic, and vascular abnormalities.1 the pathogenesis of this disease is linked to many interactive responses among infiltrating white blood cells, dendritic cells, proinflammatory cytokines, chemokines, and chemical mediators produced in the skin.2 nowadays, it is believed that psoriasis is most likely a t helper-1 (th1)/ th17 induced inflammatory disease.3 thymic stromal lymphopoietin (tslp) or interleukin (il)-7-like cytokine has already been associated with atopic dermatitis for its role in inducing a proallergic th2 response.4 the associated pathways of tslp in psoriasis remains unknown. there is currently little information on tslp in psoriasis vulgaris patients.5 in this study, we report the skin tissue expressions on lesional and non-lesional skin and serum level of tslp of psoriasis vulgaris patients. materials and methods patients the study was performed in accordance with the ethical guidelines in the declaration of helsinki and was approved by the health research ethics committee of hasan sadikin general hospital, bandung, west java, indonesia. oral explanation was given about the study and written informed consent was subsequently obtained from each participant. seventeen subjects for psoriasis vulgaris group and 17 subjects for control group were recruited from the dermatology clinic at hasan sadikin general hospital using a consecutive sampling technique. exclusion criteria include patients who had systemic and/or topical corticosteroids, antibiotics, and other immunosuppressive agents, such as cyclosporine, methotrexate, azathioprine within the last two weeks prior to the start of the study, as well as history of atopic manifestations, infections, and malignancies. reverse transcription-polymerase chain reaction for thymic stromal lymphopoietin expression in skin after obtaining informed consent from patients, 2.5-mm punch skin biopsy specimens were taken from lesional and nonlesional skin in psoriasis vulgaris patients. skin samples were collected in eppendrof tube and immediately stored at -2°c temperatures. tslp transcript expression was analyzed on ribonucleic acid (rna) extracted from homogenized skin and reverse transcribed using standard protocols. deoxyribonucleic acid (dna) was analyzed for the expression of human glyceraldehyde-3-phosphate dehydrogenase (gapdh; forward, atcagcaatgcctcctgcac; reverse, tggcatgga ctgtggtcatg) and tslp (forward, caccgtctct tgtagcaatcg; reverse, tagcct gggcaccagatagc) using rotor-gen-q. enzyme-linked immunosorbent assay for thymic stromal lymphopoietin level in serum approximately 5 ml of blood were collected in a tube without heparin from patients and participants in the control group. healthy ageand sex-matched control subjects were also included in the study. tslp were measured using enzyme-linked immunosorbent assay (elisa) kit, according to the manufacturer’s instructions (cloud-clone corp, houston, usa). tslp level (pg/ml) were used for data analysis. statistical analysis this study was an observational study, using a cross-sectional method to determine tslp levels in the serum of psoriasis vulgaris patient and healthy control, as well as tslp expression in lesions and non-lesions dermatology reports 2019; volume 11:8006 correspondence: oki suwarsa, department of dermatology and venereology, faculty of medicine, universitas padjadjaran; hasan sadikin general hospital, jl. pasteur no. 38, bandung, west java, 40161, indonesia. tel.: +62.22.2032426 (ext. 3449) – fax: +62.22.2032426. e-mail: oki.suwarsa@unpad.ac.id key words: psoriasis vulgaris; serum; skin; thymic stromal lymphopoietin. acknowledgments: the authors would like to thank the contribution of health research unit, universitas padjadjaran, bandung, west java, indonesia, for technical assistance. contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. funding: the work was support by an internal grant of universitas padjadjaran, bandung, west java, indonesia (grant no. 2476/un6c/lt/2018). received for publication: 1 february 2019. revision received: 10 may 2019. accepted for publication: 13 may 2019. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (cc by-nc 4.0). ©copyright o. suwarsa et al., 2019 licensee pagepress, italy dermatology reports 2019; 11:8006 doi:10.4081/dr.2019.8006 no nco mm er cia l u se on ly [page 28] [dermatology reports 2019; 11:8006] skin of psoriasis vulgaris patients. statistical significance was retained for pvalues of less than 0.05. results demographic details seventeen subjects from each group were reviewed and analyzed descriptively. patients with psoriasis vulgaris included 13 males and 4 females, with age ranges between 10 and 68 years old (table 1). the healthy control group with no complaint of any dermatological disorder comprised of 13 males and 4 females, their age ranges between 12 and 67 years old. psoriasis area severity index psoriasis area severity index was used to assess the degree of severity of disease in this study. in general, 58.8% of participants in this study had a mild form of the disease. thymic stromal lymphopoietin expression in psoriasis skin we analyzed the expression of tslp in lesional and non-lesional psoriasis skin. samples from 17 patients were assessed and were all positive for tslp (table 1). as shown in table 2, the lesional skin (median=1.90; range=1.51-2.21) showed elevation of tslp expression compared to nonlesional skin (median=1.76; range=1.662.17). statistical analysis showed that the difference between tslp expression in lesional and non-lesional skin of psoriasis patients was statistically insignificant (p>0.05). thymic stromal lymphopoietin serum level to determine whether tslp could be involved in pathogenesis psoriasis vulgaris, we analyzed the serum level of tslp in psoriasis vulgaris patients and normal controls. sample from 17 patients and 17 controls were assessed (table 1). tslp serum levels in subjects with psoriasis vulgaris patients (median=286.30 pg/ml; range=71.90-695.1 pg/ml) were significantly higher than normal controls (median=114.70 pg/ml; range=50.0-206.1 pg/ml) (p<0.05) (table 3). discussion tslp is a cytokine expressed mainly in the epithelial cells of the lungs, gastrointestinal tract, thymus, tonsils, and epidermal keratinocytes.6 tslp will bind to the a-chain il-7 receptors (il-7ra) and tslp receptor (tslpr),6,7 which are expressed in various hematopoietic cells, such as in dendritic cells, t cells, b cells, mast cells, and macrophages.6 tslp has been associated with atopic dermatitis,8 asthma,9,10 and allergic rhinitis8 for its role in inducing a proallergic th2 response.8 here we report that tslp is also produced in patients with psoriasis vulgaris, a th1-related autoimmune disease. our findings add to the existing complexity of the cytokine and inflammatory networks in patients with psoriasis and suggest that tslp might have different immunomodulatory roles, depending on the type of inflammatory environment. in addition, it can also explain that one cytokine may have different functions. in the pathogenesis of psoriasis, when precipitating factors from the environment were exposed to a person with genetic predisposition, this will cause keratinocytes to release il-1 and tnf-α cytokines which will induce dendritic cells in the skin as antigen presenting cell. it is also known that keratinocytes in psoriasis patients express tslp that bind to tslpr and il-7rα receptors in dendritic cells.5 maturation of dendritic cells will produce cytokines such as il-12 and il-23 which will induce differentiation of naive t cells into th1/th17 cells. th1/th17 cell differentiation will result in the secretion of cytokines that contribute to keratinocyte proliferation and inflammatory responses.4 in our study, tslp was observed in serum and skin of psoriasis patients, indicating that their production and function are linked to the pathogenesis of the disease. the current study shows that tslp is produced by keratinocytes in patients with psoriasis and that tslp, in this context, primes for il-23 production by dendritic cells.5 article table 1. thymic stromal lymphopoietin expression in serum and skin biopsy specimens from patients with psoriasis. no. sex age (y) pasi score tslp in serum tslp in serum tslp in tslp in psoriasis (pg/ml) control (pg/ml) lesional non-lesional a f 31 10.2 359.1 204.3 2.05 1.71 b m 48 8.4 223.6 149.9 1.90 1.92 c m 28 18.7 215.9 58.1 1.95 1.76 d m 45 2.7 286.3 153.4 2.03 1.80 e m 56 2.6 288.5 74.7 2.06 1.73 f f 51 2 338.3 144.7 1.90 1.67 g m 42 2.7 279.1 79.3 1.57 1.72 h m 24 3 209.6 122.4 1.86 1.72 i m 62 15.7 260.1 69.9 1.70 1.70 j f 64 4.3 149.2 68.8 1.89 1.66 k m 37 6.2 505.8 204.8 2.21 1.87 l m 49 9.9 438.0 206.1 1.67 1.83 m m 43 13.9 695.1 50.0 1.83 1.75 n f 20 2.1 643.7 155.4 1.51 2.17 o m 10 3.3 292.2 90.0 1.78 2.15 p m 68 10.6 544.0 160.2 1.95 2.01 q m 52 3.0 179.0 149.9 2.05 1.83 pasi, psoriasis area severity index; tslp, thymic stromal lymphopoietin; f, female; m, male. no nco mm er cia l u se on ly from a pathological perspective, it will be important to establish the links between tslp and other cytokines involved in pathogenic inflammatory networks in patients with diverse autoimmune diseases. in patients with psoriasis, tslp could serve as a therapeutic target to reduce dendritic cell activation and production of pathogenic il23.4 this study also found that the difference in tslp expression in lesional and non-lesional skin was insignificant. several factors that can affect the result in various studies on cytokine levels include different standardization, reagent sensitivity, examination material, sample handling, and various biological factors such as age, race, and genetic polymorphism.11 in 2010, tindall et al.12 found genetic polymorphisms in the il-23a gene in south african populations and european populations. in this study, 33 different dna variations were identified, and the suspected functional variation of il-23a will have a significant impact on the patient’s immune response. to date, there is no data available that explains the existence of tslp polymorphisms in psoriasis vulgaris. however, several researches have been conducted on graves’ disease. in 2012, tsai et al.13 from taiwan found tslp polymorphisms in graves’ disease which can be used to estimate the prognosis and target therapy. the results yielded in this study were different from that of previous research conducted by volpe et al. in 2014 in paris.5 that study, tslp were assessed with reverse transcription-polymerase chain reaction (rt-pcr), found that tslp expression was higher in lesional than in non-lesional skin of psoriasis vulgaris patients and normal individuals.5 genetic and environmental factors are thought to play a significant role in the pathogenesis of psoriasis vulgaris, due to the fact that these conditions often affect the results of psoriasis research, and yielded varying results in each country. the limitation of this study was we could not investigate tslp expression in normal skin control and the correlation between serum and skin tslp directly. there was no report about serum tslp level in previous studies. as tslp is a circulating mediator, we assumed that there might be indirect correlation between serum and skin tslp and further studies are required to obtain further knowledge on this correlation. conclusions this study found that tslp level in the serum of psoriasis vulgaris patients are higher than controls, while tslp expression was higher in the lesional skin compared to the non-lesional skin of psoriasis vulgaris patients; however, this difference is statistically insignificant. these findings suggest that tslp may play a role in the pathogenesis of psoriasis, but its exact role remains unknown. references 1. gudjonsson je, elder jt. psoriasis. in: wolff k, goldsmith la, katz si, et al., eds. fitzpatrick’s dermatology in general medicine. 8th ed. new york: mcgraw-hill; 2012. pp 197-231. 2. lowes ma, bowcock am, krueger jg. pathogenesis and therapy of psoriasis. nature 2007;445:866-73. 3. coimbra s, figueiredo a, castro e, et al. the roles of cells and cytokines in the pathogenesis of psoriasis. int j dermatol 2012;51:389-98. 4. blauvelt a. new concept in the pathogenesis and treatment of psoriasis: key roles for il-23, il-17a and tgf-β. expert rev dermatol 2007;2:69-75. 5. volpe e, pattarini l, martinezcingolani c, et al. thymic stromal lymphopoietin links keratinocytes and dendritic cell-derived il-23 in 209 patients with psoriasis. j allergy clin immunol 2014;134:373-81. 6. he r, geha rs. thymic stromal lymphopoietin. ann acad sci 2010;1183: 13-24. 7. ziegler sf, roan f, bell bd, et al. the biology of thymic stromal lymphopoietin (tslp). adv pharmacol 2013;66:129-55. 8. soumelis v, reche p, kanzler h, et al. human epithelial cells trigger dendritic cell mediated allergic inflammation by producing tslp. nat immunol 2002;3:673-80. 9. zhou b, comeau mr, de smedt t, et al. thymic stromal lymphopoietin as a key initiator of allergic airway inflammation in mice. nat immunol 2005;6:1047-53. 10. al-shami a, spolski r, kelly j, et al. a role for tslp in the development of inflammation in an asthma model. j exp med 2005;202:829-39. 11. banks re. measurements of cytokine in clinical samples using immunoassay: problem and pitfalls. j rev clin lab sci 2000;37:131-82. 12. tindall ea, hayes vm. comprehensive sequence analysis of the human il23a gene defines new variation content and high rate of evolutionary concervation. dna res 2010;17:117-22. 13. tsai kh, tsai fj, lin hj, et al. thymic stromal lymphopoietin gene promoter polymorphisms and expression levels in graves disease and graves ophtalmopathy. bmc med gen 2012;13:1-7. article table 2. thymic stromal lymphopoietin expression on lesional and non-lesional skin of psoriasis vulgaris patients. variable group p-value* lesional skin n=17 non-lesional skin n=17 tslp 0.234 mean ± std 1.87±0.186 1.82±0.156 median 1.90 1.76 range (min-max) 1.51-2.21 1.66-2.17 tslp, thymic stromal lymphopoietin. *p-value by wilcoxon test analysis. statistical significant was accepted at p<0.05. table 3. comparison of thymic stromal lymphopoietin serum level in psoriasis patients and control group. variable group p-value** psoriasis n=17 control n=17 tslp 0.000 mean ± std 332.18±170.531 121.11±53.501 median 286.30 114.70 range (min-max) 71.90-695.10 50.00-206.10 tslp, thymic stromal lymphopoietin. **p-value by t test analysis. statistical significant was accepted at p<0.05. [dermatology reports 2019; 11:8006] [page 29] no nco mm er cia l u se on ly 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have 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