A dermatologic emergency; Sweet's syndrome

BackgroundSweet's syndrome (SS), also known as acute febrile neutrophilic dermatosis, is a rare condition characterized by recurrent erythematous skin lesions. Skin lesions appear as papules, nodules and plaques located on the upper extremity, trunk, neck and face.Case reportA 72-year-old male patient presented to the emergency department with a 10-day history of generalized rash, generalized muscle and joint pain and high fever. He had a history of upper respiratory tract infection. He presented with painful erythematous plaques on both lower and upper extremities and the trunk as well as serohemorrhagic bullous lesions on the feet. The laboratory results revealed WBC count of 20.6 × 10³/mm³ (76.9% neutrophils), CRP (c-reactive protein) of 33 mg/L and erythrocyte sedimentation of 110/h. The patient was referred to a dermatologist with prediagnosis of SS due to the presence of typical painful skin lesions, high fever and neutrophilic leukocytosis. A systemic corticosteroid therapy was initiated. The diagnosis for SS was confirmed after the skin biopsy revealed the presence of dense dermal infiltrate of neutrophils and leukocytoclasis in the upper dermis. The patient responded rapidly to corticosteroids and the skin lesions improved.ConclusionWe reported this case as it was a rare life-threatening dermatosis diagnosed in the emergency department, which is generally difficult to diagnose therein, and the skin lesions appeared on the lower extremities.     

Case study on drug-related adverse effects of hepatitis C therapy

The case of a 46-year-old woman with chronic hepatitis C who was prescribed subcutaneous pegylated interferon once a week and oral ribavirin once a day is presented. Within 24 h after the first injection to her left arm, the patient developed pruritus and erythematous papules at the injection site and painful papules on her hands. After immediate administration of antihistamines, the pruritus and papules remitted. One wk later, after injection in the right arm, skin lesions and pruritus were seen. After the third injection to the abdomen, the patient developed a rash, and after the fourth and fifth injections to other areas of the abdomen, injection-site papules were seen. The patient had no skin reactions for the next 12 mo, with the exception of injection-site papules. Hepatitis C virus RNA was negative after 12 mo of treatment. Clearly, patience is important during hepatitis C therapy in order to avoid unnecessary examinations and to promote successful outcomes.     

Generalized pruritus without primary lesions. Differential diagnosis and approach to treatment

A 65-year-old man presented with recurrent generalized pruritus and excoriations of many years' duration. He had been treated with antihistamines, topical corticosteroids, and antibiotics for secondary wound infections, but improvement was only temporary. He had also been hospitalized for leg ulcers complicated by cellulitis. Examination revealed multiple oval and linear red papules and nodules measuring 0.5 to 2 cm in diameter. Some of the lesions were eroded and had a central crater and yellowish crust. The patient also had hypopigmented linear scars localized to the posterior scalp, neck, upper back, chest, abdomen, arms, and legs with sparing of the middle and lower back (figures 1 and 2). An ulcer measuring 1.5 x 2 cm that was surrounded by indurated skin was present on the medial aspect of his right ankle. The ulcer was partially covered by yellow exudate. There was no evidence of cellulitis. Liver enzyme, serum creatinine, and thyrotropin levels, as well as a chest roentgenogram, were normal. Wound cultures for bacteria and fungi were nonsignificant. A punch biopsy from a representative lesion showed an abrupt epidermal defect with sparse superficial lymphocytic infiltrate in the dermis. The patient was admitted to the hospital to isolate him from his home environment. He received a 10-day course of systemic cephalexin, topical clobetasol propionate ointment for the affected skin areas, and oral hydroxyzine for pruritus. Ultraviolet light therapy was instituted once daily and was to continue for 2 months. His lesions had improved moderately by the time he was discharged from the hospital. On follow-up 2 weeks later, his lesions were flat and had resulted in hypopigmented scars. Three months later, however, he had persistent, intense pruritus, and new excoriations had developed on his forearms and back. He improved after receiving treatment with oral doxepin hydrochloride.     

Pruritus in pregnancy: Treatment of dermatoses unique to pregnancy

Question

Some of my pregnant patients complain about pruritus. Are there conditions in pregnancy that present with pruritus that might put the mother or fetus at risk?

Answer

Although most cases of pruritus can be attributed to itchy dry skin, there are conditions unique to pregnancy that involve pruritus as a leading symptom. These include pemphigoid gestationis, pruritic urticarial papules and plaques of pregnancy, intrahepatic cholestasis of pregnancy, and atopic eruption of pregnancy. These conditions are associated with severe pruritus and some might be associated with adverse fetal outcomes. Clinical history and physical examination are the most important diagnostic clues when evaluating pruritus in pregnancy.     

Clinical outcomes and 5-year follow-up results of keratosis pilaris treated by a high concentration of glycolic acid

BACKGROUNDKeratosis pilaris is a hereditary abnormal keratosis of the hair follicle orifice. Gray-brown keratotic plugs in the pores and dark red keratotic papules at the openings of hair follicles can be seen, which contain coiled hair and are often accompanied by perifollicular erythema and pigmentation. Glycolic acid can correct the abnormalities of hair follicular duct keratosis and eliminate excessive accumulation of keratinocytes. It also promotes skin metabolism and accelerates the melanin metabolism. The therapeutic effect is related to the glycolic acid concentration.AIMTo evaluate the efficacy and safety of a high concentration of glycolic acid in the treatment of keratosis pilaris, and to observe the outcomes at 5-year of follow-up.METHODSTwenty-five participants were recruited and areas with typical keratosis pilaris were selected as testing sites. High concentrations of glycolic acid (50% or 70%) were applied to a circular area (d = 8 cm, S = 50 cm²) and repeated four times, on days 0, 20, 40 and 60. Before each treatment and 20 d after the last treatment, on days 0, 20, 40, 60, and 80 and at a 5-year follow-up, The number of follicular keratotic papules were counted and the extent of perifollicular erythema and pigmentation was determined. At the same time, the participants provided subjective evaluations of treatment efficacy and safety.RESULTSTreatment effectiveness was indicated by the percentage of keratotic papules in the test site, on days 20, 40, 60 and 80, which were 8%, 12%, 36%, and 60%, respectively. Compared with day 0, each difference was significant (P < 0.05). Compared with day 0, differences in melanin content (M) in the skin and skin lightness (L) on days 40, 60 and 80, the were statistically significant (P < 0.05); skin hemoglobin content (E) on days 60 and 80 was statistically different as compared with before treatment (P < 0.05). There were no significant differences in the number of keratotic papules, M, L, and E in 9 participants at the 5-year follow-up compared with before treatment (P > 0.05%).CONCLUSIONA high concentration of glycolic acid significantly improved skin roughness as well as follicular hyperpigmentation of patients with keratosis pilaris. The treatment was relatively safe, but there was no significant difference at the 5-year follow-up compared to before treatment.     

皮肤护理对增强组合型人工肾治疗尿毒症患者皮肤瘙痒疗效的作用

目的探讨皮肤护理对组合型人工肾治疗尿毒症皮肤瘙痒疗效的作用，减轻瘙痒症状。方法将40例尿毒症皮肤瘙痒接受组合型人工肾治疗的患者随机分为实验组和对照组各20例。对照组接受常规护理，实验组在此基础上给予皮肤护理。采用可视模拟评分法（VAS）观察1周护理结果。结果治疗第7天，对照组16例患者评分≥6分，需要接受组合型人工肾治疗，实验组只有1例；治疗第1，3天，2组得分的差异无统计学意义，而第5，7天2组得分的差异有统计学意义。结论皮肤护理可增强组合型人工肾治疗尿毒症皮肤瘙痒疗效的作用，减轻瘙痒症状。     

Grover's disease: successful treatment with acitretin and calcipotriol

A 74-year-old man presented with a five-month history of highly pruritic keratotic papules on the trunk and extremities. Laboratory data revealed mild eosinophilia, elevated IgE (483KE/I) and no other signs of atopy. Tests to exclude parasitic infestation were negative. Two biopsies showed non-specific changes. The third biopsy revealed small acantholytic clefts in the upper part of the epidermis and confirmed the diagnosis of Grover's disease. Topical treatment with calcipotriol ointment and systemic treatment with acitretin in low doses successfully reduced the pruritus within one week, and brought about a complete remission within three weeks without any recurrence.     

血液透析联合血液灌流治疗尿毒症皮肤瘙痒患者的临床护理观察

目的探讨血液透析联合血液灌流尿毒症皮肤瘙痒的临床护理。方法将本院进行血液透析联合血液灌流治疗的75例尿毒症皮肤瘙痒患者,按入院先后分为常规护理组和综合护理组,分别给予其常规护理和综合性护理干预。对比护理干预实施前后2组患者的皮肤瘙痒程度评分、瘙痒发作时间及HAMA、HAMD评分,并对比护理干预后2组患者的皮肤瘙痒缓解程度。结果护理干预前,2组患者的皮肤瘙痒程度评分、瘙痒发作时间、HAMA、HAMD评分均无显著差异(P0.05);护理干预后,2组患者的上述各项评分及瘙痒发作时间均有所改善,但综合护理组患者的改善幅度明显大于常规护理组,组间比较差异有统计学意义(P0.05)。综合护理组患者的皮肤瘙痒缓解率为86.84%,明显高于常规护理组(75.68%),差异有统计学意义(P0.05)。结论血液透析联合血液灌流配合综合性护理干预能够有效缓解尿毒症患者的皮肤瘙痒症状,延长瘙痒发作时间,改善心理状态。     

Malignant acanthosis nigricans with Leser–Trélat sign and tripe palms: A case report

BACKGROUNDAcanthosis nigricans (AN), Leser–Trélat sign, and tripe palm are all skin diseases. To date, reports of these appearing as a paraneoplastic syndrome in a gastric cancer patient are quite rare.CASE SUMMARYWe report the case of a 61-year-old man with darkened skin color in the face and torso with no obvious inducement after 1 year of treatment for Riehl’s melanosis. He had 40 brown maculopapular eruptions on his face and the top of his head with obvious itching. Papillary wart-like hyperkeratosis with dark brown pigmentation was also observed on both sides of the areola. He had papilloma-like lesions on the face, around the orbit, and on the neck. His bilateral palms had small, smooth, papillary projections with millet-like appearance. Histopathological examination of the skin showed that the patient was suffering from AN, tripe palms, and Leser–Trélat sign. Gastroscopy showed the patient’s cardia was affected, and pathological biopsy revealed that he had moderate-to-poorly differentiated adenocarcinoma. Computed tomography test results showed that his cardia wall had thickened. Based on these histological and skin characteristics, the patient was diagnosed with gastric cancer with AN, tripe palms, and Leser–Trélat sign.CONCLUSIONResearchers should follow up on patients with malignant AN, Leser–Trélat sign, and tripe palms.     

Pulmonary Langerhans cell histiocytosis and multiple system involvement: A case report

BACKGROUNDPulmonary Langerhans cell histiocytosis (PLCH) is a relatively rare type of lung disease, common in middle-aged smoking men. It is characterized by proliferation and infiltration of Langerhans cells, and the formation of multiple parabronchial mesenchymal nodules in lung tissue, and may lead to organ dysfunction. There are no typical symptoms and signs, and it is easily misdiagnosed or missed, and therefore deserves clinical attention and further discussion.CASE SUMMARYWe describe the case of a nonsmoking 46-year-old man with PLCH diagnosed based on clinical manifestations of fever and dry cough, with a history of hypothyroidism and diabetes insipidus for 9 years. Computed tomography (CT)- and CT-guided puncture examinations revealed no abnormalities, and he ultimately underwent thoracoscopic biopsy to confirm the diagnosis. The pathological diagnosis was PLCH. Thyroid function was maintained by medication. Pituitary magnetic resonance imaging showed that the pituitary stalk had become thinner.CONCLUSIONLCH often involves multiple systems. Moreover, the pathogenesis is not clear, clinical manifestations lack specificity, and diagnosis requires special attention. Diagnosis of PLCH can significantly benefit from comprehensive multidisciplinary analysis.     

Thiazide Diuretics Induce Cutaneous Lupus-Like Adverse Reaction

Abstract

One of the side effects reported in patients taking thiazide diuretics is photosensitivity. We report two patients who developed lupus-like skin lesions while taking thiazide diuretics. One patient developed erythematous scaling papules, patches and plaques on the upper extremities and trunk resembling subacute cutaneous lupus erythematosus. Histopathology of a skin biopsy from the trunk showed basal cell layer liquefaction and lichenoid interface changes suggestive of lupus erythematosus. The skin lesions resolved completely within two months of discontinuing thiazide therapy. The second patient developed multiple flesh colored urticarial plaques on the trunk one year after beginning thiazide therapy. Slight lichenoid interface changes were noted on a skin biopsy, along with dense mucin deposition in the papillary and deep dermis, suggestive of tumid lupus erythematosus. The skin lesions persisted despite discontinuing thiazide therapy, necessitating systemic corticosteroid treatment. Both patients had circulating anti-SSA/Ro autoantibodies and antinuclear antibodies. These two patients illustrate that thiazide diuretics may induce a cutaneous lupus erythematos us-like adverse reaction and production of anti-SSA/Ro autoantibodies as demonstrated by immunodiffusion, immunoblot and immunoprecipitation testing.     

THE EFFECT OF THE X-RAY ON THE NODULES OF VERRUGA PERUANA

The supposition that X-ray would affect the developing and the developed verruga nodules experimentally induced in the monkey, has proved correct. The experiments show that the early verruga nodules when exposed to a single, properly graduated dose of X-ray producing merely erythema of the skin, are inhibited in their evolution. Moreover, the skin of Macacus rhesus monkeys is modified by a single erythema dose of X-ray in such a way that infection of it with Bartonella bacilliformis is rendered more difficult. These results are sufficiently striking to warrant the trial of X-ray in suitably guarded doses in the treatment of verruga nodules in man. Should the employment of convalescent serum influence the course of Carrion''s disease favorably and the use of X-ray bring about a more certain and rapid devolution of verruga nodules in man, two practically applicable therapeutic measures will have been provided for the treatment of the two forms of the human disease.     

Phase III Study of Silver Leaf Nylon Dressing vs Standard Care for Reduction of Inframammary Moist Desquamation in Patients Undergoing Adjuvant Whole Breast Radiation Therapy

AimsThe primary objective of this study was to assess silver leaf nylon dressings as a prophylactic measure in reducing inframammary fold radiation induced dermatitis in women receiving adjuvant whole breast radiotherapy compared with standard skin care. A secondary objective was to assess if the dressing influenced breast skin–related pain, itching and burning resulting from whole breast radiotherapy.Material and methodsA prospective randomized trial compared silver leaf nylon dressing worn continuously from the sixth fraction of whole breast radiotherapy until 14 days after therapy completion to standard skin care in patients deemed to be at risk of inframammary radiation induced dermatitis by virtue of a large breast volume or a significant inframammary skin fold in the treatment position. Stratification before randomization was for anthracycline chemotherapy and fractionation scheme. Digital photos of the inframammary region were taken at one week before, the last day of whole breast radiotherapy, and one week after treatment completion. Three observers blinded to treatment arm assessed the images for the presence of moist desquamation and the Radiation Therapy Oncology Group (RTOG) skin toxicity score. Patients completed questionnaires comprising visual analogue scales for pain, itching and burning sensation, and questions regarding which topical skin cream was being used, at the before-mentioned times as well as at baseline and two weeks after completing whole breast radiotherapy.ResultsA total of 196 patients completed the study. Moist desquamation occurred in 38% of patients. No difference in incidence or maximum size of moist desquamation or RTOG skin toxicity scores was seen between the treatment arms. However, on the last day of radiation treatment and one week after completion of treatment, patient reports of itching decreased in the experimental arm. At one week before whole breast radiotherapy completion, patients using Glaxal Base cream reported worse burning, those using aloe vera reported worse pain and burning, whereas patients who had not used a moisturizing cream reported less pain.ConclusionSilver leaf nylon dressing use did not demonstrate a decrease in the incidence of inframammary moist desquamation, but did decrease itching in the last week of radiation and one week after treatment completion.     

Efficacy of a topical formulation of henna (Lawsonia inermis L.) in contact dermatitis in patients using prosthesis: A double-blind randomized placebo-controlled clinical trial

BackgroundContact dermatitis is a common complication in prosthetic limb users. There are no effective, available and cheap treatments for skin problems of these patients. In traditional Iranian medicine, henna (Lawsonia inermis L.) is a plant that has anti-inflammatory, antimicrobial and skin-enhancing properties, all of which are beneficial for people with artificial limbs. The aim of this study was to assess the efficacy of a topical henna preparation in management of contact dermatitis in patients using lower limb prosthetics.MethodsThe current randomized, double-blind, placebo-controlled clinical trial was conducted on ninety-five participants with lower extremity amputation using limb prosthetics, aged 12–70 years who complained of contact dermatitis. They were randomly assigned to receive either two weeks of topical henna preparation every night as the intervention group, or topical placebo as the control group. Participants were instructed to spread henna preparation on the surfaces of the amputated limb that were in contact with the prosthesis. Severity of contact dermatitis symptoms was set as the primary outcome measure. Edema, papules and erythema were evaluated by a physician using standard color atlas. Secondary outcomes included symptoms such as burning, itching, pain, thickness and skin sweating evaluated by a self-administered questionnaire.ResultsA significant improvement was observed in the symptoms of contact dermatitis including skin edema, itching, sweating, skin thinning and pain (p-value<0.05) in the henna group compared to the placebo group. Skin burning decreased more in the henna group compared to the placebo group, but this was not statistically significant (p-value = 0.052). Moreover, skin redness significantly increased in the henna group (p-value = 0.001).ConclusionTopical formulation of henna might be a complementary choice for improving contact dermatitis in patients using lower limb prosthetics.     

Treatment of prurigo nodularis with pregabalin

What is known and objective:  Prurigo nodularis (PN) is a chronic skin condition that is difficult to treat. Pregabalin is one of the possible treatments for PN but its safety and efficacy are not well defined. We aimed to assess the efficacy of pregabalin in patients with PN. Methods:  Thirty patients (10 men, 20 women; mean age 51.6 ± 9.39 years) were treated with pregabalin (75 mg/day) for 3 months. Efficacy was classified as (i) successful (disappearance of the pruritus and reduction of nodules); (ii) slight improvement/reduction of the nodules, that is, number and/or flattening, no disappearance of itching; or (iii) unsuccessful. Results:  Twenty‐three patients (76%) responded successfully after 3 months of treatment. There was a statistically significant difference between visual analogue scale scores before and after 1 month treatment period (8·15 ± 2·04 and 1·5 ± 1·12, respectively; P < 0·0001). Pregabalin was generally well tolerated with only six (20%) patients reporting side effects. No patient showed any renal insufficiency. What is new and conclusion:  In our study, pregabalin was effective for the treatment of PN. However, given the open and non‐controlled study design used, a properly powered randomized controlled validation study is called for.     

Is sinusoidal obstructive syndrome a recurrent disease after liver transplantation? A case report

BACKGROUNDSinusoidal obstructive syndrome (SOS) is a disease that damages hepatic sinusoidal endothelial cells, resulting in progressive occlusion and fibrosis of the lobular central vein and the occurrence of intrahepatic sinusoidal portal hypertension. However, SOS after liver transplantation (LT) is uncommon and potentially fatal. Here, we report a rare case of second-time recurrence of SOS after liver retransplantation (rLT).CASE SUMMARYA 22-year-old woman received a living donor LT due to SOS. Four years later, she developed abdominal distention and ascites with no apparent cause. She was diagnosed with recurrence of SOS and underwent rLT. But 2 mo post rLT, the patient suffered from aggravated jaundice and ascites again. She was diagnosed with second-time recurrence of SOS post-rLT according to computed tomography and liver pathology. After treatment with warfarin anticoagulation and immunosuppressant conversion, she gradually recovered with improvement of liver function and liver pathology. During the 17-mo follow-up period, she was in good condition with normal liver function and no ascites.CONCLUSIONSOS can be a recurrent disease after LT, and autoimmune antibody and genetic sequencing should be screened before LT. For susceptible patients, anticoagulant drugs should be used for an extended period, and tacrolimus or other pathogenic agents should be avoided. Early diagnosis and treatment can improve the prognosis of patients and avoid graft failure or death.     

Brachioradial Pruritus: Approach to the Patient With Enigmatic Forearm Pruritus

This article offers a brief case study and overview of treatment options for patients diagnosed with brachioradial pruritus (BRP). BRP is characterized by localized itching on the dorsolateral aspect of the forearm or upper arm. Patients with BRP often report seasonal itching in late summer and into fall. Although the symptoms of BRP may be subjectively severe, the physical exam is often benign. The pruritus associated with BRP is often intense and frequently compromises the patient's quality of life. Treatment options vary and include both topical and oral medications.     

Treatment of leiomyomatosis peritonealis disseminata with goserelin acetate: A case report and review of the literature

BACKGROUNDLeiomyomatosis peritonealis disseminata (LPD) is a rare condition characterized by multiple pelvic and abdominal nodules, which are composed of smooth-muscle cells. To date, no more than 200 cases have been reported. The diagnosis of LPD is difficult and there are no guidelines on the treatment of LPD. Currently, surgical excision is the mainstay. However, hormone blockade therapy can be an alternative choice.CASE SUMMARYA 33-year-old female patient with abdominal discomfort and palpable abdominal masses was admitted to our hospital. She had undergone four surgeries related to uterine leiomyoma in the past 8 years. Computed tomography revealed multiple nodules scattered within the abdominal wall and peritoneal cavity. Her symptoms and the result of the core-needle biopsy were consistent with LPD. The patient refused surgery and was then treated with tamoxifen, ulipristal acetate (a selective progesterone receptor modulator), and goserelin acetate (a gonadotropin-releasing hormone agonist). Both tamoxifen and ulipristal acetate were not effective in controlling the disease progression. However, the patient achieved an excellent response when goserelin acetate was attempted with relieved syndromes and obvious shrinkage of nodules. The largest nodule showed a 25% decrease in the sum of the longest diameters from pretreatment to posttreatment. Up to now, 2 years have elapsed and the patient remains asymptomatic and there is no development of further nodules.CONCLUSIONGoserelin acetate is effective for the management of LPD. The long-term use of goserelin acetate is thought to be safe and effective. Hormone blockade therapy can replace repeated surgical excision in recurrent patients.     

Chest pain in a heart transplant recipient: A case report

BACKGROUNDHeart transplantation is recommended for the treatment of patients with refractory heart failure. Chest pain after heart transplantation is usually considered noncardiac owing to the denervated heart. However, data from case reports on tacrolimus-induced achalasia after heart transplantation are limited. We aimed to present a case of tacrolimus-induced achalasia that developed after heart transplantation, which was successfully relieved by laparoscopic Heller myotomy.CASE SUMMARYA 67-year-old man with a history of Type 2 diabetes mellitus, hyperlipidemia, and dilated cardiomyopathy had congestive heart failure following orthotopic heart transplantation with tacrolimus treatment 12 years ago. At the 10-year follow-up after the heart transplantation, the patient presented with persistent cough, dysphagia, heartburn, and retrosternal chest pain lasting for 2 wk. Upper endoscopy revealed no specific findings. Two years later, the patient experienced the same symptoms, including chest pain lasting for 4 wk. Esophagogram and manometry confirmed the presence of achalasia. Previous reports showed that discontinuing calcineurin inhibitor (CNI) treatment and endoscopic botulinum toxin injection could treat CNI-induced achalasia. Owing to the risk of rejection of the transplanted heart and considering the temporary benefits of botulinum toxin injection in achalasia, the patient underwent laparoscopic Heller myotomy. Dysphagia was relieved without complications. Eight months later, he had no signs of recurrence of the achalasia.CONCLUSIONIn transplant patients with chest pain and gastrointestinal symptoms, CNI-induced achalasia may be one of the differential diagnoses. Esophagogram/manometry is useful for diagnosis.     

Gastric mixed adenoma-neuroendocrine tumor: A case report

BACKGROUNDGastric mixed adenoma-neuroendocrine tumors (NETs) are quite rare. In the 2019 world health organization classification of tumors of the digestive system, these were designated as a combination of grade 1 or grade 2 NETs and adenomas or tubular adenomas. There are no treatment guidelines for these tumors, and pathological and clinical studies are ongoing. Herein, we review previous case reports and present a case of gastric mixed adenoma-NET.CASE SUMMARYA 66-year-old man underwent gastrointestinal endoscopy for the evaluation of upper abdominal pain. Histopathological examination of the biopsy specimen indicated the possibility of gastric cancer. A histopathological examination by endoscopic submucosal dissection showed a mixed adenoma-NET that was completely excised by endoscopic submucosal dissection. No recurrence was observed on gastrointestinal endoscopy at the 6-mo follow-up.CONCLUSIONClinicians'' awareness of this rare tumor is important for its timely diagnosis and treatment.