Mycobacterium abscessus Hand‐and‐Foot Disease in Children: Rare or Emerging Disease?

Mycobacterium abscessus is emerging as an important cause of cutaneous infections in sporadic cases and outbreak settings. Although immunosuppressed or elderly patients are most commonly affected, in 2006 an outbreak of clinically distinct cutaneous lesions on the hands and feet caused by M. abscessus in a population of healthy children using a public swimming pool was reported. This article describes an outbreak of skin infection in a population of healthy Italian children attending the same school and using the same swimming pool. In January 2010 we identified three children with multiple, painful nodules on the palms and soles. M. abscessus was isolated from one child's lesions. A public health investigation was conducted and a team of dermatologists and public health officers visited all of the children; 514 children were screened and 29 cases were identified overall. All of the affected children had used the school's swimming pool. These children were treated with oral clarithromycin for 4 to 8 weeks. Because of the long period of time between the presentation and diagnosis of the first cases, the possibility that the number of cases may have been underestimated cannot be excluded. To our knowledge, this is the second largest reported cluster of M. abscessus skin infection suspected to be related to swimming pool exposure in a population of otherwise healthy children. It is unclear whether this disease is rare or should be considered as an emerging clinical entity.     

Pulmonary Mycobacterium abscessus infection-induced erythema induratum

Erythema induratum (EI) is clinically characterized by recurrent crops of tender nodules on the lower legs and lobular panniculitis with granulomatous inflammation and pathologically characterized by vasculitis and focal fat necrosis. Currently, many authors consider EI to be a multifactorial disorder with diverse causes, including Mycobacterium tuberculosis and hepatitis C infection. Here, we report a case of a 65-year-old female with a 1-year history of recurrent crops of tender nodules and plaques on her bilateral lower legs. In addition, she had suffered from a chronic cough with sputum for 1 year and had contact history with pulmonary nontuberculous mycobacterial infection from her husband. The histopathological findings of the skin biopsies were consistent with the diagnosis of EI. Chest computed tomography revealed multiple lymphadenopathy and two sets of sputum cultures showed M. abscessus. After 2 months of anti-nontuberculous mycobacterial therapy with ciprofloxacin, the skin lesions resolved completely and there was no recurrence within the following year.     

DERMATOLOGICAL MANIFESTATIONS IN HIV-INFECTED PATIENTS AT A TERTIARY CARE HOSPITAL IN A TRIBAL (BASTAR) REGION OF CHHATTISGARH, INDIA

Background:

Cutaneous disorders during HIV infection are numerous and skin is often the first and only organ affected during most of the course of HIV disease. Some Cutaneous disorders reflect the progression of HIV disease; though the relation is still controversial.

Aims:

The objective of this study, conducted at a tertiary care centre in Bastar, Jagdalpur, is to estimate the status of cutaneous manifestation in HIV-infected patients and its relationship with CD4 cell counts.

Methods:

We enrolled 137 HIV positive subjects. Demographic information such as age, gender, weight, height, socioeconomic status, and educational status were recorded. Laboratory parameter (CD4 counts) and treatment regimen were noted. Patients were examined for skin disorders by a dermatologist. Data were analyzed using chi-square test for categorical variables.

Results:

Majority of the patients were from rural area (65.69%) and belonged to a low socioeconomic and educational status. 30.65% of the patients were housewives, 23.35% drivers, and 16.78% labourers. Predominant mode of transmission was heterosexual contact (94.16%). Most common HIV-related dermatological manifestations were seborrheic dermatitis (74.16%), xerosis (52.5%), generalized skin hyperpigmentation 56 (46.67%), onychomycosis 53 (44.16%), pruritic papular eruption 27 (22.5%), oral candidiasis 21 (17.5%), photo dermatitis 21 (17.5%), and scabies 4 (3.33%). Significant correlation with low CD4+ cell counts was found for oral candidiasis (P < 0.0001) and Kaposi''s sarcoma (P = 0.03), while other disorders such as seborrheic dermatitis (P = 0.22), xerosis (P = 0.25), and onychomycosis (P = 0.08) were not statistically significant.

Conclusion:

This study showed high prevalence of dermatological manifestations in HIV-infected subjects, and they occur more frequently with progression of HIV and decline in immune functions. Therefore, early diagnosis and management of skin disorders can improve the quality of life of HIV-infected subjects.     

Mycobacterium abscessus infection following penetrations through wetsuits

Mycobacterium abscessus is a rapidly growing mycobacterium which is reportedly increasing in prevalence. Infection of the skin and soft tissue with M. abscessus is rare but typically associated with trauma. We present two cases of M. abscessus infection linked by penetration through wetsuits.     

Atypical Cutaneous Sporotrichosis in an Immunocompetent Adult: Response to Potassium Iodide

Cutaneous sporotrichosis, also known as “Rose Gardener''s disease,” caused by dimorphic fungus Sporothrix schenkii, is usually characterized by indolent nodular or nodulo-ulcerative lesions arranged in a linear pattern. We report bizarre nonlinear presentation of Sporotrichosis, in an immunocompetent adult occurring after a visit to Amazon rain forest, speculating infection with more virulent species of Sporothrix. The diagnosis was reached with the help of periodic acid-Schiff positive yeast cells and cigar shaped bodies seen in skin biopsy along with the therapeutic response to potassium iodide.     

METASTATIC CROHN'S DISEASE OF EXTERNAL GENITALIA

Metastatic Crohn''s disease is an uncommon extraintestinal manifestation of Crohn''s disease. Its hallmark features include the presence of cutaneous noncaseating granulomas that are noncontiguous with the gastrointestinal tract or fistula. We report a rare case of metastatic Crohn''s disease involving the external genitalia in a 14-year-old girl. Diagnosis was based on skin biopsy. Patient had complete recovery on treatment with oral and topical steroids along with azathioprine.     

A Case of Atrophoderma of Pasini and Pierini Associated with Borrelia burgdorferi Infection Successfully Treated with Oral Doxycycline

Atrophoderma of Pasini and Pierini is a form of dermal atrophy that manifests as either single or multiple, sharply demarcated, hyperpigmented, non-indurated patches. These patches are marked by a slight depression of the skin, with an abrupt edge (i.e., the "cliff-drop" borders), usually located on the backs of adolescents or young adults. The pathophysiology of the disease is unknown, but some authors have suggested a role of Borrelia burgdorferi infection. A 35-year-old woman visited our department because of asymptomatic, hypopigmented, depressed patches on her chest and back lasting for three months. Laboratory evaluations were normal, except for positive serum antibodies to Borrelia burgdorferi. Histologic examination revealed a significantly decreased thickness of the dermis. The patient underwent treatment with oral doxycycline 200 mg/day for six weeks, after which the depth of depression was improved. Herein, we report a case of atrophoderma of Pasini and Pierini, associated with Borrelia burgdorferi infection, successfully treated with oral doxycycline.     

RARE PRESENTATION OF KYRLE'S DISEASE IN SIBLINGS

Background:

Kyrle''s disease is a rare variant of primary perforating dermatosis. Its occurrence in a familial setting, especially in children, is extremely uncommon. Similar appearing skin lesions have been described in adults, secondary to metabolic disorders, infective agents as well as exposure to chemicals. We present a rare case of this genodermatosis in two siblings.

Materials and Methods:

Two siblings of a non-consanguineous marriage came with generalized discrete papular lesions with a central keratotic plug. All biochemical and serological investigations were within normal limits. Serial sections of the biopsy revealed typical epidermal invaginations filled with parakeratotic debris and perforation into the dermis with accompanying granulomatous reaction.

Results and Conclusions:

A careful history, detailed routine investigations and serial sections of the skin biopsy are required to demonstrate the typical morphology and stages of evolution of Kyrle''s disease. This helps to differentiate the rare primary Kyrle''s disease from other primary and secondary keratotic lesions. Due to the familial occurrence, screening of relatives of an index case is recommended.     

Prevalence of Metabolic Syndrome In South Indian Patients with Psoriasis Vulgaris and the Relation Between Disease Severity and Metabolic Syndrome: A Hospital-Based Case-Control Study

Background:

Psoriasis is a chronic inflammatory disease of the skin and joints with an increased cardiovascular risk. Previous studies have shown a higher prevalence of metabolic syndrome (MS) in psoriatic patients.

Objective:

To investigate the prevalence of MS in patients with psoriasis and healthy controls, and to determine the relation between disease severity and the presence of MS.

Materials and Methods:

We performed a hospital-based case-control study on 118 adult patients with psoriasis vulgaris and 120 controls matched for age, sex and body mass index. MS was diagnosed by the presence of three or more of the South Asian Modified National Cholesterol Education Program''s Adult Panel III criteria.

Results:

MS was significantly more common in psoriatic patients than in controls (44.1% vs. 30%, P value = 0.025). Psoriatic patients also had a higher prevalence of triglyceridemia (33.9% vs. 20.8%, P value = 0.011), abdominal obesity (34.7% vs. 32.5%, P value = 0.035) and elevated blood sugar. There was no difference in the high density lipoprotein (HDL) levels and presence of hypertension among patients with psoriasis and normal controls. There was no correlation between the severity and duration of psoriasis with MS.

Conclusion:

MS is frequent in patients with psoriasis. We have found no relationship between disease severity and presence of MS. Hence, we suggest that all patients must be evaluated for the MS, irrespective of the disease severity.     

Unusual Presentation of Subcutaneous Phaeohyphomycosis by Alternaria alternate

The Alternaria species are dematiaceous fungi. Human infection due to dematiaceous fungi is uncommon. Most reported cases of alternariosis have occurred in patients with immunodeficiency. The majority of cases were solid-organ transplantation recipients. Cutaneous alternariosis lesions are usually asymptomatic solitary nodules, plaques of ulcers or subcutaneous cysts. Here we report a case of a 77-year-old female who presented with hemorrhagic skin necrosis in right arm that had developed from hemorrhagic bullae. Her prior medical history included iatrogenic Cushing''s syndrome, hypertension, interstitial lung disease and congestive heart failure. Following administration of itraconazole, her lesions improved.     

Recurrent Scedosporium apiospermum mycetoma successfully treated by surgical excision and voriconazole

Scedosporium apiospermum is an emerging opportunistic fungus that can cause localized infection in healthy hosts or severe disseminated disease in immunocompromised hosts. Most cases are reported in Western Europe, Australia, and North America. We report a 52-year-old immunocompetent Taiwanese woman who presented with a 6-year history of recurrent asymptomatic papulonodular lesions on her right foot after minor trauma. Deep fungal infection caused by Scedosporium sp. was diagnosed after a skin biopsy with fungal culture of the skin specimen. She underwent two surgical excisions, each followed by a 4-month course of oral itraconazole and intralesional injections of amphotericin B as well, but similar lesions recurred at the same location 1 year later. She had another surgical excision and the pathological findings showed mycetoma. The fungus was identified as S. apiospermum by PCR assay of fungal culture specimen using the internal transcriber spacers (ITS1, similarity 99.4%; ITS2, similarity 100%) and the D1–D2 (similarity 99.0%) regions of the ribosomal operon. After 4 months of oral voriconazole (400 mg/day), no recurrence was noted in the subsequent 2 years.     

Prevalence of oral, skin, and oral and skin lesions of lichen planus in patients visiting a dental school in southern India

Background:

Lichen planus (LP) is a mucocutaneous disease that is relatively common among adult population. LP can present as skin and oral lesions. This study highlights the prevalence of oral, skin, and oral and skin lesions of LP.

Aims:

The aim of this study was to evaluate the prevalence of oral, skin, and oral and skin lesions of LP from a population of patients attending the Department of Oral Medicine and Radiodiagnosis, Pushpagiri College of Dental Sciences, Tiruvalla, Kerala, India.

Materials and Methods:

A cross-sectional study was designed to evaluate the prevalence of oral, skin, and oral and skin lesions of LP. This is a ongoing prospective study with results of 2 years being reported. LP was diagnosed on the basis of clinical presentation and histopathological analysis of mucosal and skin biopsy done for all patients suspected of having LP. Statistical analysis was carried out using SPSS (Statistical package for social sciences) software version 14. To test the statistical significance, chi-square test was used.

Results:

Out of 18,306 patients screened, 8,040 were males and 10,266 females. LP was seen in 118 cases (0.64%). Increased prevalence of LP was observed in middle age adults (40–60 years age group) with lowest age of 12 years and highest age of 65 years. No statistically significant differences were observed between the genders in skin LP group (P=0.12) and in oral and skin LP groups (P=0.06); however, a strong female predilection was seen in oral LP group (P=0.000036). The prevalence of cutaneous LP in oral LP patients was 0.06%.

Conclusion:

This study showed an increased prevalence of oral LP than skin LP, and oral and skin LP with a female predominance.     

Drugs and Wells' syndrome: a possible causal relationship?

In April 1997, a 28‐year‐old woman presented with a 3‐day history of multiple papules and vesicles on the fingers and wrist of her right hand. She reported that she had been taking nonsteroidal anti‐inflammatory drugs containing tenoxicam and diclofenac sodium, and had no history of an insect bite. The medical history also included pruritic erythema on her trunk 1 month before her initial visit, and oral tenoxicam and diclofenac sodium treatment for ankle arthralgia 2 days before the skin lesions appeared. At that time, her dermatologist had told her that the skin lesions might be due to an insect bite and were secondarily infected. She took amoxicillin for the lesions, and during the following days developed bullous lesions on her hands and feet. The patient was diagnosed with ‘‘drug reaction’' at another hospital based on a histopathologic examination of the affected skin. Treatment with topical corticosteroids and oral antihistamines was ineffective. Physical examination revealed a few crusted, erythematous, papular lesions on the dorsal aspects of the patient's feet, bullous lesions on her right wrist, and vesiculopapules on her fingers. She had no fever or other abnormal clinical findings. Laboratory studies showed a white blood cell count of 6000/mL with 16.5% eosinophils. A bacterial culture of the content of one of the bullous lesions was negative. The results of stool tests for parasites and ova were negative. Clinical and laboratory findings were in line with the diagnosis of drug reaction. The patient was advised not to take nonsteroidal anti‐inflammatory drugs. The skin lesions resolved rapidly on treatment with wet compresses of Burow's solution and oral prednisolone (40 mg/day). The dose of prednisolone was gradually reduced, and was discontinued after 3 weeks. The patient was readmitted in July 1997 for an indurated, erythematous plaque on her left foot, a lesion that resembled cellulitis. Her history at that time included the initiation of amoxicillin treatment for a gingival abscess 2 days before the skin lesion appeared. The lesion regressed after amoxicillin was discontinued and the patient received an intramuscular injection of triamcinolone acetonide. Several months later, in October 1997, she developed a similar cellulitis‐like lesion on her right ankle. This time there was no history of drug intake. We obtained a skin biopsy from the lesion, and histopathology revealed an intense eosinophilic infiltrate in the dermis and extending into the subcutaneous tissue. Flame figures were abundant ( Fig. 1 ). We also observed edema and erythrocyte extravasation in the dermis. Based on these features and her history, a diagnosis of Wells' syndrome was made. The skin lesion resolved spontaneously, and she has experienced no lesion recurrence since.

Figure 1 Open in figure viewer PowerPoint A characteristic ‘‘flame figure’' (hematoxylin and eosin stain; original magnification, × 230)     

The Efficacy of Topical 0.1% Adapalene Gel for Use in the Treatment of Childhood Acanthosis Nigricans: A Pilot Study

Background:

Vitiligo is one of the disorder that has social impact. Both skin and mucous membrane show depigmentation in vitiligo. Depigmentation in oral cavity can be more easily observed and the patient can be given awareness regarding the condition if they are unaware of vitiligo elsewhere in their body and can be guided for treatment.

Aim and objectives:

The aim of this study is to determine the frequency of occurrence of oral mucosal vitiligo in vitiligo patients and to determine the most commonly involved oral mucosal site.

Materials and methods:

The study sample included 100 vitiligo patients. The patients of all age groups and both genders were included. Vitiligo patients associated with systemic conditions such as thyroid disorders, juvenile diabetes mellitus, pernicious anemia, Addison''s disease were excluded in this study.

Results:

Out of 100 vitiligo patients 44 % male and 56% were female. The oral presentation of vitiligo in this study showed depigmentation of buccal mucosa in 5% of patients, labial mucosa in 5% of patients, palate in 8% of patients, gingiva in 2% of patients and alveolar mucosa 1%. Depigmentation of lip was seen in 42% of patients. Lip involvement refers to depigmentation of both the lips or either lip. Also vermilion border involvement was noted in majority of cases. In some cases, the depigmentation of lip extended to the facial skin also.

Conclusion:

In this study 55 patients out of 100 patients showed depigmentation in the oral cavity. Lip involvement was most common in this study showing about 42% of patients. Intraoral mucosal involvement was found in 21% of patients. Among intraoral mucosal site palate was common followed by buccal and labial mucosa, gingiva. Two patients had lip pigmentation as the only manifestation without any depigmentation in the skin.     

Determinants of quality of life in psoriasis patients: a cluster analysis of 50 patients

Background:

Although psoriasis generally does not affect survival, it certainly has a number of major negative effects on patients, demonstrable by a significant detriment to quality of life.

Aims:

We have done a study with the objective of assessing the clinical variables adversely affecting quality of life in patients diagnosed with psoriasis.

Materials and Methods:

This study is a cluster analysis of 50 consecutive consenting patients with psoriasis, of both sexes, aged over 18 years, attending the dermatology outpatient department of a tertiary care center. We measured the clinical severity using psoriasis area severity index and health-related quality of life using psoriasis disability index (PDI). Statistical analysis was performed using unpaired independent student''s t-test, analysis of variance (and Scheffe''s post hoc test as appropriate) and Pearson''s correlation coefficients.

Results:

There was a significant correlation between the physician-rated severity of psoriasis and the extent of impact of psoriasis on physical disability as measured by the PDI. We have identified that a younger age at onset of disease and self-reported stress exacerbators suffer greater disability in most aspects of quality of life.

Conclusions:

On the basis of this study, we would recommend that psoriasis patients especially with severe disease require a more holistic treatment approach that encompasses both medical and psychological measures.     

MOMETASONE-BASED TRIPLE COMBINATION THERAPY IN MELASMA: IS IT REALLY SAFE?

Background:

Kligman''s triple combination formula has been one of the most popular treatment options in melasma over the last three decades. The original Kligman''s formula has been modified in many ways over the years and the most recent modification that has been introduced is a triple combination of 2% hydroquinone, 0.025% tretinoin, and 1% mometasone. The use of this triple combination in patients with melasma has seen a sharp rise over the last few years and with this rampant use the side-effect profile of this triple combination has also come to the fore.

Aim

The aim of the present study was to assess the overall safety of the mometasone-based triple combination treatment in the management of melasma.

Materials and Methods:

This retrospective study was performed on 60 patients of melasma who had used a mometasone-based triple combination treatment for at least 3 weeks anytime in the previous 1 year. The patients were given a preformed questionnaire wherein they assessed the overall effect of the triple combination treatment on their melasma during its use as well as after its withdrawal. The patients were specifically asked about the status of their disease as well as the sun sensitivity of their skin before and after the use of triple combination treatment. In addition, the patients were assessed by a single trained dermatologist for the presence of any adverse effects arising out of the triple combination treatment in the form of telangiectasia, hypertrichosis, acne, skin atrophy, etc.

Results:

Majority of patients (51.7%) had used the combination treatment well beyond the recommended duration. About one-third (36.7%) of the patients rated their melasma as worse at the time of filling the questionnaire as compared with their disease before the use of triple combination treatment. On clinical examination, the evidence of steroid side effects was seen in 26 patients (43.3%). Steroid-induced telangiectasia was the commonest finding, seen in all of these 26 patients. Steroid-induced skin atrophy, hypertrichosis, and acneiform eruption were seen in 19, 17, and 11 patients, respectively.

Conclusions:

The propensity of a mometasone-based triple combination treatment to cause steroid adverse effects on the facial skin should always be borne in mind when the same is prescribed as a treatment option in melasma.     

The Relationship Between Alopecia Areata and Alexithymia,Anxiety and Depression: A Case-Control Study

Background:

Alopecia areata (AA) is a skin disease characterized by the sudden appearance of areas of hair loss on the scalp and other hair-bearing areas, but its aesthetic repercussions can lead to profound changes in patient''s psychological status and relationships.

Aim:

The goal was to investigate a possible relationship between AA and alexithymia as well as two other emotional dimensions, anxiety and depression.

Materials and Methods:

Fifty patients with AA seen in the Department of Dermatology of Hedi Chaker University Hospital, Sfax were included in this study. Anxiety and depression were evaluated by Hospital Anxiety and Depression scale questionnaire, alexithymia was assessed by Toronto Alexithymia scale 20, and severity of AA was measured by Severity of Alopecia Tool.

Results:

Patient''s mean age was 32.92 years. 52% of patients were females. Depression and anxiety were detected respectively in 38% and 62% of patients. There was statistically significant difference between patients and control group in terms of depression (P = 0.047) and anxiety (P = 0.005). Forty-two percent of patients scored positive for alexithymia. No significant difference was found between patient and control groups (P = 0.683) in terms of alexithymia. Anxiety was responsible for 14.7% of variation in alexithymia (P = 0.047).

Conclusions:

Our study shows a high prevalence of anxiety and depressive symptoms in AA patients. Dermatologists should be aware of the psychological impact of AA, especially as current treatments have limited effectiveness.     

DERMATOLOGY LIFE QUALITY INDEX SCORES IN VITILIGO: RELIABILITY AND VALIDITY OF THE TUNISIAN VERSION

Background:

Vitiligo is an important skin disease that can alter individual self-image and thus have major impact on the quality of life.

Aims:

The objective of this study was to translate and to test the reliability and validity of the 10-item Dermatology Life Quality Index (DLQI) questionnaire in Tunisian vitiliginous patients.

Methods:

Using a standard “forward-backward” translation procedure, the English language version of the questionnaire was translated into Persian (the Iranian official language) by two bilinguals. Seventy patients with vitiligo attending the Department of Dermatology, Regional Hospital, Medenine, Tunisia, were enrolled in this study. The reliability and internal consistency of the questionnaire were assessed by Cronbach''s α coefficient and Spearman''s correlation, respectively. Validity was performed using convergent validity.

Results:

In all, 70 people entered into the study. The mean age of respondents was 28.3 (SD=11.09) years. Scores on the DLQI ranged from 0 to 24 (mean ± SD, 7.05 ± 5.13). Reliability analysis showed satisfactory result (Cronbach''s α coefficient=0.77). There were no statistically significant differences between daily activity (DA) and personal relationship (PR) scale mean scores in generalized versus focal-segmental involvement in sufferers (P = 0.056, P = 0.053, respectively). There were also strong differences between the mean scores of the PR scale with the involvement of covered only and covered/uncovered areas (P = 0.016) that was statistically significant in the second group.

Conclusions:

The study findings showed that the Tunisian version of the DLQI questionnaire has a good structural characteristic and is a reliable and valid instrument that can be used for measuring the effects of vitiligo on quality of life.     

Wolf's isotopic response

The term “isotopic response” was coined by Wolf et al in 1995 to describe the occurrence of a new skin disorder at the site of another unrelated and already healed skin disease. When this term was found to be unsuitable for Medline searches because it generated hundreds of references that were linked with radioactive isotopes, it was changed to “Wolf's isotopic response” and eventually included as such in Stedman's Illustrated Dictionary of Dermatology Eponyms. Our search of the literature yielded 176 cases of Wolf's isotopic response. We describe this entity and present representative clinical examples. Some problems in the definition of Wolf's isotopic response are provided with special emphasis on its overlapping with the Koebner isomorphic response, a similar, but different, phenomenon. Also addressed are a number of issues associated with another term, “isotopic nonresponse,” which had been introduced in analogy to the “isomorphic nonresponse” for describing the absence of an eruption at the site of another unrelated and already healed skin disease, or the sparing of the sites of another unrelated and already healed skin disease. In the spirit of the present issue, this contribution discusses only the clinical morphology and not the etiology, pathomechanism, or molecular biology of Wolf's isotopic response.