Cutaneous Complications of BCG Vaccination in Infants with Immune Disorders: Two Cases and a Review of the Literature

Two infants, one with a T-cell-signaling defect resulting in a primary immunodeficiency syndrome and the other with severe combined immunodeficiency (SCID), are described. Both infants developed cutaneous infections secondary to their bacillus Calmette-Guérin (BCG) vaccinations. Both patients were from countries where BCG is routinely administered in infancy. The infant with the T-cell-signaling defect developed a disseminated infection involving the skin, while the infant with SCID developed a localized cutaneous infection at the site of his BCG immunization. These two cases resemble other reported cases of cutaneous BCG infection following routine vaccination in immunocompromised patients. Mycobacterium bovis infection should be considered in patients with cutaneous eruptions who have received BCG vaccination, especially those who are immunocompromised.     

Melanoma and squamous cell carcinoma on different nails of the same hand

Nail dyschromia, including melanonychia and erythronychia, encompasses a wide range of possible diagnoses. While the majority of these lesions are benign, malignancies of the nail unit represent a sinister, and potentially life-threatening, cause of nail dyschromia. Unfamiliarity with tumors of the nail apparatus can lead to a delay in diagnosis. A case is presented of a patient with two separate and concurrent malignant neoplasms of the nail unit, on different nails on the same hand, each featuring an unusual clinical presentation: amelanotic melanoma presenting as longitudinal erythronychia and squamous cell carcinoma in situ presenting as longitudinal melanonychia. This presentation underscores the need for a low threshold for biopsy in the presence of nail dyschromia of uncertain etiology.     

'Dyschromia in confetti' as a side effect of topical immunotherapy with diphenylcyclopropenone.

"Dyschromia in confetti" is a pigmentary disturbance that so far has not been reported to have occurred during topical immunotherapy. In a group of 243 patients treated with diphenylcyclopropenone for alopecia areata, four patients showed a similar pattern of hyperpigmentation and hypopigmentation. In one patient the pigmentary disturbance was confined to the site of diphenylcyclopropenone application on the scalp. Besides dyschromic skin changes on her scalp, one patient had development of a hyperpigmentation on her forearms. In the remaining two patients, dyschromia in confetti became manifest exclusively in areas other than the scalp. This type of pigmentary disturbance appeared 4 to 14 months after the start of treatment, and it has remained unchanged in three patients during a follow-up period of 3 to 10 months. In one patient, the pigmentary changes disappeared when therapy was discontinued but recurred, albeit to a lesser extent, after treatment had been resumed. We conclude that dyschromia in confetti should be regarded as a possible, but probably rare, side effect of topical immunotherapy with diphenylcyclopropenone, especially in individuals with a rather dark complexion.     

Extensive Tinea in a Patient With Severe Combined Immunodeficiency

Abstract:   Severe combined immunodeficiency (SCID) is a heterogeneous group of disorders characterized by a defect of T and B cell immunity with a genetic origin in most cases. Although the X-linked recessive form is most common (60–70%), there are autosomal recessive forms (20%) and spontaneous mutations. While SCID may present with many nosocomial infections, dermatophyte infections are not common. We reported a case of SCID which was associated with a widespread skin infection with Trichophyton mentagrophytes .     

Onychoscopy

Dermatoscopy can be used to evaluate the nail apparatus (ie, onychoscopy), and it is helpful for the diagnosis of numerous nail diseases and tumors. This article reviews the information that can be obtained in cases of nail dyschromia and especially in cases of melanonychia, in which the distinction between benign melanocytic activation or proliferation and malignancy is crucial. Dermatoscopic changes that accompany specific nail diseases are also reviewed, such as those observed with subungual hemorrhage, bacterial and fungal nail infections, psoriasis of the nail, lichen planus of the nail, and vascular abnormalities of the nail fold.     

Nail disorders from epothilone

We present the cases of two patients diagnosed with non-microcytic lung carcinoma who were treated with epothilone, a new chemotherapeutic agent which disrupts microtubule dynamics. The first one developed nail symptoms consisting of painful nails with a hemorrhagic appearance, which developed into significant structural disorders and onycholysis of all of the fingernails. The patient required antibiotic treatment for the associated paronychia and surgical removal of some of the nails. In the second case, asymptomatic dyschromia of the toenails appeared, with no inflammatory component. These findings show the similarity of the adverse effects of epothilone with those of the taxanes.     

Subungual blue nevus with combined phenotypic features

Blue nail dyschromia may represent melanocytic, vascular, or other etiologies. A case of a subungual blue nodule is presented, with a pseudo-clubbed nail. On histopathologic examination, there was a combined subungual blue nevus, with features of a common blue nevus and a pigmented epithelioid melanocytoma. This unusual presentation is reviewed, with a discussion of blue nail dyschromia and subungual blue nevi.     

Topical Cidofovir for Recalcitrant Verrucae in Individuals with Severe Combined Immunodeficiency After Hematopoietic Stem Cell Transplantation

Verrucae vulgaris in patients with severe combined immunodeficiency (SCID) after hematopoietic stem cell transplantation (HCST) can be challenging to manage. We describe two brothers with X‐linked SCID who had severe, persistent verrucae that did not respond to traditional topical therapies, including liquid nitrogen, imiquimod, salicylic acid, sinecatechins, 40% urea, and 5‐fluorourcil. Both brothers had full response to topical 3% cidofovir, which should be considered in recalcitrant warts in individuals with SCID after HSCT.     

Parry‐Romberg syndrome treatment with fat transfer and a new bleaching formula

Parry‐Romberg syndrome is a hemifacial atrophy which can be complicated by melasma. We present two cases of Parry‐Romberg syndrome, treated by fat transfer and bleaching of the skin using a modified “Kligman's formula.” The atrophy, as well as the skin dyschromia, improved, and the results were stable.     

Cutaneous Lesions in Severe Combined Immunodeficiency: Two Case Reports and a Review of the Literature

Two patients with severe combined immunodeficiency (SCID) in whom cutaneous lesions were the first clinical feature were studied. Neither the morphology nor the histology of the lesions was uniform, although we have noted some common findings that can, in subsequent cases, lead us to suspect SCID. The immunologic defects were not uniform, representing the two poles of the spectrum of SCID. We believe that early recognition of the skin lesions is very important, since the patient's life expectancy can be increased by a bone marrow transplantation (1).     

Presenting skin disorders in black Afro-Caribbean patients: a multicentre study conducted in the Paris region

BACKGROUND: There have been few studies in France concerning the specific features of dermatological practice regarding dark skin (Fitzpatrick's phototype V and VI) or the special requirements of black African and Afro-Caribbean patients. AIM: To determine the principal reasons for dermatological consultation among black patients of African or Afro-Caribbean descent in the Paris region. METHODS: This was a prospective clinical study conducted between 15 February and 15 May 2004. The diagnoses of cutaneous conditions leading to dermatological consultation for all black patients of phototype V to VI were recorded by 10 dermatologists practicing in 14 centres within the Paris region. LIMITS: The method used did not allow any conclusions to be drawn regarding the incidence of the presenting conditions among the global population nor did it allow comparison between populations of different phototypes. The absence of any preset list of diagnoses or of precise inclusion criteria regarding evaluation of skin colour left individual investigators with a broad margin of interpretation. RESULTS: In 836 adults and 228 children (half of whom were from Africa and half from the West Indies), diagnoses were as follows: acne in 29.2% of adults and 13.2% in children, and eczema in 6.8% of adults and 27.2% of children. Among dermatoses more specific to black subjects, scalp conditions were frequently seen in both adults (alopecia 7% of diagnoses) and children (tinea capitis 9.6% and alopecia 3.6% of diagnoses). In at least 25% of cases, consultation was associated with dyschromia. Clinical signs suggesting the use of skin lightening products were seen in 95 patients. CONCLUSION: In France, as in other industrialized countries, black patients consult dermatologists essentially for common benign dermatoses also seen amongst white people. Nevertheless, it is important to emphasise the presence of skin problems specific to black patients such as dyschromia and pigmentary disorders, hair and scalp dermatoses, and side effects associated with the use of skin lightening products.     

The Russell-Silver syndrome: a case report and brief review of the literature

The Russell-Silver syndrome's phenotypic features consist of musculoskeletal abnormalities, genitourinary malformations, craniofacial dysmorphy and cutaneous dyschromia, which is usually reported as café au lait spots. We present the first instances of a large, unilateral, achromic patch as an additional cutaneous manifestation of the Russell-Silver syndrome.     

Common dermatologic disorders in skin of color: a comparative practice survey

There is a paucity of data on the epidemiology of dermatologic disease in populations with skin of color. Our objective was to compare the most common diagnoses for which patients of various racial and ethnic groups were treated at a hospital-based dermatology faculty practice. We reviewed the diagnosis codes of 1412 patient visits from August 2004 through July 2005 at the Skin of Color Center at St. Luke's-Roosevelt Hospital Center, in New York. New York, in whom race and ethnicity were recorded. The most common diagnoses observed during dermatologic visits by black and white patients were compared. The leading diagnoses observed during the study period differed between black and white patients. During visits by black patients, the 5 most common diagnoses observed at our center were acne (ICD-9 [International Classification of Diseases, Ninth Revision] 706.1); dyschromia (ICD-9 709.09); contact dermatitis and other eczema, unspecified cause (ICD-9 692.9); alopecia (ICD-9 704.0); and seborrheic dermatitis (ICD-9 690.1). During visits by white patients, the 5 most common diagnoses recorded were acne (ICD-9 706.1); lesion of unspecified behavior (ICD-9 238.2); benign neoplasm of skin of trunk (ICD-9 216.5); contact dermatitis and other eczema, unspecified cause (ICD-9 692.9); and psoriasis (ICD-9 696. 1). Although similarities were seen in the frequency of acne and eczema, conditions such as dyschromia and alopecia were commonly seen during black patient visits but were not among the leading 10 diagnoses made during white patient visits.     

局灶性光热作用技术治疗光老化研究进展

光老化主要表现为皮肤皱纹增加、角质增厚、微循环变化以及色素异常改变.局灶性光热作用技术是激光治疗光老化的新技术.该技术主要有非气化型局灶性光热作用技术和气化型局灶性光热作用技术,其中气化型光热作用技术主要有点阵CO_2技术和点阵铒激光技术.从治疗的组织学改变、临床应用评价和不良反应三方面概述非气化型局灶性光热作用技术、点阵CO_2激光技术和点阵铒激光技术治疗皮肤光老化的研究进展.     

A case of eruptive lichen spinulosus after toxic epidermal necrolysis

We report a case of a 13-year-old boy who presented with eruptive monomorphic white papules on the trunk and arms involving regions previously affected by toxic epidermal necrolysis (TEN). Biopsy revealed compact keratin involving the hair follicle and sparse mixed perivascular infiltrate, findings consistent with lichen spinulosus. Improvement was noted after treatment with ammonium lactate 12% lotion. While cutaneous dyschromia and xerosis are common after TEN, lichen spinulosus has not yet been described in the literature. It is important for providers to be aware of any potential cutaneous sequelae of TEN that can affect quality of life in order to best counsel their patients.     

Disseminated Bacille Calmette‐Guérin infection in a patient with severe combined immunodeficiency caused by JAK3 gene mutation

Bacille Calmette‐Guérin (BCG), a live attenuated vaccine prepared using Mycobacterium bovis, can prevent tuberculosis in children and is routinely administered to infants in China and many other countries. A serious complication following vaccination is disseminated BCG infection. The risk is greatly increased in patients with severe combined immunodeficiency disease (SCID), a syndrome characterized by deficiency of both humoral and cellular immunity. We report a case of disseminated BCG infection in an infant with SCID caused by two novel janus kinase 3 (JAK3) gene mutations.     

Tazarotene cream for postinflammatory hyperpigmentation and acne vulgaris in darker skin: a double-blind, randomized, vehicle-controlled study

Previous investigations have reported the efficacy of tazarotene 0.1% cream for the treatment of dyschromia associated with photoaging and for acne vulgaris. The present investigation assessed tazarotene 0.1% cream for the treatment of postinflammatory hyperpigmentation (PIH) in a double-blind, randomized, vehicle-controlled study of 74 patients from darker racial ethnic groups who had acne. Once-daily application of tazarotene cream was shown to be effective against PIH, achieving significantly greater reductions compared with vehicle in overall disease severity and in the intensity and area of hyperpigmentation within 18 weeks (P< or =.05). Mean levels of erythema, burning, and peeling were no more than trace in both groups throughout the study, and mean levels of dryness were no more than mild in both groups. In our study, tazarotene cream was effective and well tolerated in the treatment of PIH in patients with darker skin.     

Paederus dermatitis in Sierra Leone

Paederus dermatitis, a type of irritant contact dermatitis attributed to a Staphylinid beetle, is prevalent in most parts of the world. We studied 50 cases of Paederus dermatitis at the United Nations Hospital at Koidu Sierra Leone (West Africa), over a period of 6 months from Oct 2003 to Mar 2004. The objectives of the study were to determine clinical patterns of dermatitis and its response to topical steroids, with and without antibiotics. Patients with a definite history of contact with the insect were included in the study. Amongst these, 14 of the more severe cases were treated with oral prednisolone or intralesional triamcinolone acetonide. The remainder of the 36 patients were divided in two equal groups A and B. Patients in Group A were treated with topical diflucortolone valerate 0.001 percent and oral cetirizine hydrochloride; patients in group B were given oral ciprofloxacin in addition. In 50 patients studied, 43 (86%) were males and 7 (14%) were females. The neck was the most common site involved followed by face. Healing time ranged from 14 to 28 days and lesions in all the patients healed with residual dyschromia. Healing time was shorter in Group B patients in comparison with those in Group A. Paederus dermatitis in Sierra Leone is a relatively severe form of this dermatitis. The better response to a combination of topical steroids and oral antibiotics may indicate concurrent bacterial infection.     

Longitudinal Erythronychia

Longitudinal erythronychia is a linear red band on the nail plate that originates at the proximal nail fold, traverses the lunula, and extends to the free edge of the nail plate. Longitudinal erythronychia is classified based upon the number of nails affected and the number of red streaks present on each nail as follows: type Ia (monodactylous - single band), type Ib (monodactylous - bifid bands), type IIa (polydactylous - single band), and type IIb (polydactylous - multiple bands). Associated morphologic findings that can be present at the distal tip of the nail with longitudinal erythronychia include fragility, onycholysis, splinter hemorrhage, splitting, subungual keratosis, thinning, and V-shaped nick. Some patients with longitudinal erythronychia seek medical evaluation because of pain in the associated distal digit; however, the linear red nail plate dyschromia is often asymptomatic and the individual is concerned about the cosmetic appearance or distal nail fragility. Longitudinal erythronychia can be a clinical manifestation of an underlying local or systemic condition. Benign tumors (glomus tumor, onychopapilloma, and warty dyskeratoma), malignant neoplasms (malignant melanoma and squamous cell carcinoma), and other conditions (hemiplegia and postsurgical scar) can be associated with monodactylous longitudinal erythronychia or it may be idiopathic or the initial stage of polydactylous longitudinal erythronychia-associated systemic conditions. Polydactylous longitudinal erythronychia is most commonly reported in patients with Darier disease (keratosis follicularis); other associated conditions include acantholytic dyskeratotic epidermal nevus, acantholytic epidermolysis bullosa, acrokeratosis verruciformis of Hopf, amyloidosis, graft-versus-host disease, lichen planus, and pseudobulbar syndrome. Polydactylous longitudinal erythronychia has also been observed as an idiopathic finding. Biopsy of the nail matrix and nail bed may be necessary to establish the diagnosis of a longitudinal erythronychia-associated condition. Indeed, a biopsy should be seriously considered in patients aged more than 50 years who present with a monodactylous longitudinal red band to exclude squamous cell carcinoma. Treatment of longitudinal erythronychia depends on the etiology. For patients with longitudinal erythronychia-associated discomfort or severe nail splitting, a surgical excision may provide not only the underlying diagnosis of the nail dyschromia, but also relief of related symptoms.