Dental infection simulating skin lesion

Orocutaneous fistulas or cutaneous sinus, a tract of dental origin, is an uncommon but welldocumented condition that usually requires emergency treatment. Such condition may be misdiagnosed by physicians and dentists and may sometimes be confused with bone and skin tumor, osteomyelitis, congenital fistula, salivary gland fistula, pyogenic granuloma, infected cyst, deep mycotic infection, and other pathologies. A case of facial sinus tract that was initially misdiagnosed by a physician as a nonodontogenic lesion is presented. Nonsurgical endodontic therapy was the treatment of choice for this case. Facial cutaneous sinus tracts must be considered of dental origin. Early diagnosis and prompt treatment minimize patient discomfort and esthetic problems, reducing the possibility of further complications such as sepsis and osteomyelitis.     

High‐concentration (20 μg g−1) tacalcitol ointment in the treatment of facial psoriasis: an 8‐week open‐label clinical trial

Background Facial psoriasis gives rise to considerable concern because of associated cosmetic problems and psychosocial distress. It requires a treatment approach other than topical corticosteroids, which bear a risk of cutaneous adverse reactions. Recently, topical tacalcitol has been shown to be effective in psoriasis. Objectives The aim of this open‐label single‐centre study is to investigate the efficacy and safety of high‐concentration (20 μg g^?1) tacalcitol ointment (Bonalfa‐high^®, Teijin Pharma, Tokyo, Japan) in patients with facial psoriasis and to evaluate clinical response according to the distribution of facial psoriatic lesions. Patients and methods Thirty‐seven patients were enrolled to this clinical trial. Tacalcitol 20 μg g^?1 ointment was applied once daily to psoriatic lesions of the face over an 8‐week period. Patients were also categorized into three subtypes according to facial lesion distribution. Efficacy was evaluated by the facial Psoriasis Area and Severity Index (facial PASI) and the Physician’s Global Assessment (PGA) score at weeks 2, 4 and 8. The Subjective Global Assessment (SGA) was also determined at the end of the study. Results Thirty‐three patients completed the clinical trial. Mean facial PASI of 33 patients at baseline was 9·58 and after 8 weeks of treatment the mean facial PASI decreased significantly to 3·88. By using PGA, patients showed the following responses to treatment: clearance (n = 1); excellent (6); good (16); fair (4); slight (5); no change (1). The response rate among the three facial psoriasis types showed no difference. Using the SGA, 27 (82%) of the patients presented excellent (15%) or good (67%) effect with tacalcitol 20 μg g^?1 ointment. No serious adverse reactions were observed. Conclusions This is the first clinical study reporting a relevant therapeutic effect and favourable safety profile of tacalcitol 20 μg g^?1 ointment in facial psoriasis. These results suggest that tacalcitol 20 μg g^?1 ointment can be used as the first‐line treatment in patients with facial psoriasis.     

Efficacy of sulfasalazine in the treatment of generalized lichen planus: randomized double‐blinded clinical trial on 52 patients

Background Oral sulfasalazine has been reported to be effective in patients with idiopathic cutaneous lichen planus (LP). Objectives Our purpose was to evaluate the efficacy of this drug in the treatment of generalized cutaneous lichen planus (GLP). In this study, we evaluated the effectiveness of the anti‐inflammatory drug sulfasalazine for the treatment of GLP. Methods A total of 52 patients with GLP presenting at the outpatient clinic were enrolled in this double‐blind, randomized, placebo‐controlled, prospective study. Of these patients, 44 completed the period of study. The patients were randomly divided into two groups. One group received placebo and the other was given sulfasalazine maximum 2.5 g/day. The patients were evaluated at the third and sixth weeks of treatment for improvement rate and occurrence of complications. Results After 6 weeks of treatment, the rate of cutaneous lesions improvement was 9.6% (two patients) in the placebo group and 82.6% (19 patients) in the sulfasalazine group. The improvement rate of pruritus was 14.3% in the placebo group and 91.3% in the sulfasalazine group. Side‐effects which were mild and tolerable were detected in 30.7% of patients, but three patients left the study because of side effects. Most of the reported side‐effects included gastrointestinal upset and headache. Conclusions Statistically, sulfasalazine was more effective than placebo in reducing cutaneous lesions and improving pruritus after 6 weeks of treatment. According to our study, sulfasalazine is a relatively safe and effective treatment option and may be an alternative therapy for the treatment of generalized lichen planus.     

Intralesional therapy of cutaneous leishmaniasis with sodium stibogluconate antimony

One hundred and thirty lesions of cutaneous leishmaniasis in 60 patients were treated with intralesional injections of Pentostam and 30 lesions were left untreated as controls. The injections were given at 8-day intervals and the patients followed-up for 42 days. One hundred and four lesions (80%) needed one injection only, 20 (15.4%) needed two and six (4.6%) needed three injections. One hundred and twenty three of the treated lesions (94.6%) showed a good clinical response with complete healing or marked improvement within the follow-up period. None of the control lesions showed marked improvement or complete healing. Scarring was minimal or absent following healing of treated lesions. The only side-effect was some localized pain following the injection. We recommend intralesional Pentostam as a safe and effective method of treating acute cutaneous leishmaniasis.     

Dermatologic toxicity from novel therapy using antimicrobial peptide LL‐37 in melanoma: A detailed examination of the clinicopathologic features

LL‐37 is a naturally occurring 37‐amino‐acid peptide that is part of the innate immune system in human skin. Preclinical studies have showed that intra‐tumoral injections of LL‐37 stimulate the innate immune system by activation of plasmacytoid dendritic cells, which mediate tumor destruction. LL‐37 intra‐tumoral injections have been utilized in a phase 1 clinical trial for melanoma patients with cutaneous metastases. We report dermatologic toxicity in a 63‐year‐old woman with stage IIIC melanoma of the right calf and inguinal lymph nodes. She was previously treated with nivolumab and combination chemotherapy (cisplatin, vinblastine and dacarbazine) and subsequently treated with LL‐37 injections upon progression of both prior regimens. She received a total of 8 weekly LL‐37 injections, with interval clinical shrinkage of injected lesions. However, approximately 45 days after initiation of this therapy, she presented with multiple verrucous papules and a vesiculo‐bullous lesion on the trunk and extremities. Clinically, most of these lesions were thought to be either squamous cell carcinoma or inflamed seborrheic keratosis. Histologically, 11 of the total 12 skin biopsies showed similar histopathologic features, with a prominent lichenoid inflammatory infiltrate admixed with eosinophils and an overlying atypical squamous epithelial proliferation with verrucous and keratoacanthoma‐like features and varying degrees of keratinocytic atypia. Interestingly, a majority of the lesions did not show spongiosis (11/12). All lesions resolved within 2 months of cessation of LL‐37 injection therapy. This case highlights adverse dermatological manifestations of LL‐37 therapy, similar to the consequences of other novel therapies.     

Subacute cutaneous lupus erythematosus leukoderma treated with melanocyte‐keratinocyte transplantation procedure

Depigmented lesions may occur as postinflammatory sequelae of subacute cutaneous lupus erythematosus (SCLE), leading to great psychosocial impact. A 53‐year‐old male patient presented with post‐SCLE depigmented facial lesions after five years of disease stability. We proposed surgical treatment with melanocyte‐keratinocyte transplantation procedure (MKTP), and after five months the patient achieved 90% repigmentation, without Koebner phenomenon (KP). In theory, KP is a possible complication of MKTP procedure since the preparation of the receptor area involves the use of dermabrasion. In an attempt to avoid it, we suggest to maintain the treatment of the underlying disease and wait for a minimum period of disease stability before the procedure.     

Sinus tracts to the chin and jaw of dental origin

This is a report of seven patients with cutaneous sinus tracts of dental origin who were seen in the past 10 years at the Mayo Clinic. Cutaneous sinus tracts of dental origin most commonly present on the chin or the mandibular region as nodulocystic lesions with suppuration. The lesion may be confused with pyogenic granuloma, foreign body reaction, deep fungal infection, squamous cell carcinoma, or osteomyelitis. However, if the lesion is suspected of being of dental origin, the diagnosis is easily confirmed by dental examination and dental roentgenograms of the involved area. Once the correct diagnosis has been made, treatment by appropriate endodontic therapy leads to prompt resolution of the sinus tract. This is an uncommon disease but one for which a high degree of alertness must be maintained when one sees a nodulocystic or ulcerative lesion of the face.     

Non‐cultured melanocyte‐keratinocyte transplantation for the treatment of vitiligo: a clinical trial in an Iranian population

Background Non‐cultured cellular grafting as a surgical procedure is indicated to treat stable vitiligo, refractory to medical treatment, and is gaining wider acceptance among dermatologists. Objective The aim of this study was to assess the efficacy of non‐cultured melanocyte‐keratinocyte transplantation (MKT) for the treatment of generalized vitiligo in Iranian patients. Methods In this clinical trial, a total of 14 vitiligo patches in eight patients were treated; eight patches with non‐cultured MKT and six patches dermabraded alone without application of keratinocyte‐melanocyte suspension. Repigmentation was compared at about 4 months post‐transplantation. Results Of the eight lesions treated with non‐cultured MKT, four lesions showed 96–100% repigmentation, one lesion 65–95% and three lesions 0–25%. Of the patients who showed excellent results, only one showed a post‐inflammatory hyperpigmentation in recipient and control areas. Of the six control lesions, five showed failed repigmentation and one showed post‐inflammatory hyperpigmentation. Conclusion Non‐cultured MKT is an effective method to treat stable vitiligo. Studies on larger series of vitiligo patients are required to confirm its efficacy.     

Long‐term efficacy of single‐dose radiofrequency‐induced heat therapy vs. intralesional antimonials for cutaneous leishmaniasis in India

Background Radiofrequency‐induced heat therapy (RFHT) has been found to be safe and effective against cutaneous leishmaniasis (CL) in the short term, but its long‐term efficacy is unclear. Objectives To compare the long‐term efficacy of RFHT vs. intralesional sodium stibogluconate (SSG) injections in the treatment of CL in India. Methods One hundred patients with a confirmed diagnosis of CL were randomly assigned in a 1 : 1 ratio to receive topical RFHT for 30–60 s or seven intralesional injections of SSG (50 mg cm^?2 of lesion). Improvement and recurrence were monitored every 15 days after the initiation of treatment for 4 months and then at 5, 6, 9, 12 and 18 months post‐treatment; the rates of complete cure were compared. Results Lesions were healed in 47 out of 50 patients (94%) in the RFHT group and in 46 out of 50 patients (92%) in the SSG group at week 12. Time to complete healing was comparable in the two groups. At 6 months post‐treatment, cure rates in the RFHT and SSG groups were 98% [95% confidence interval (CI) 94–100%] and 94% (95% CI 86–100%), respectively. Age, sex and lesion size or number had no effect on cure rates. No relapse of infection was recorded in cured patients in either group up to 12–18 months after initiation of treatment. Skin biopsies of cured lesions in eight out of eight (100%) patients from the RFHT group and three of three from the SSG group at 12 months showed minimal fibrosis and were negative for Leishmania tropica by polymerase chain reaction test. Conclusions A single application of RFHT is safe, cosmetically acceptable and effective in inducing a long‐term cure of CL.     

Use of injectable platelet‐rich fibrin in the treatment of plasma cell mucositis of the oral cavity refractory to corticosteroid therapy: A case report

Plasma cell mucositis (PCM) is a rare benign disease affecting adults characterized by an erythematous mucosa, an epithelial hyperplasia, and a dense submucosal infiltration of mainly mature plasma cells. PCM has been treated with topical, intralesional, and systemic corticosteroids, antibiotics, and topical cyclosporin with unreliable results and questionable benefits. Here, we present a case of PCM, refractory to previous treatments, treated with i‐PRF (injectable platelet‐rich fibrin) injections. The infiltrations were performed once a week for 2 months. There were no adverse reactions to the treatment. The pain gradually reduced until the score of zero at the fourth infiltration, and the patient remained free of pain during the whole study period. Clinically, we did not obtain a complete healing of the lesion, but a reduced perilesional inflammatory infiltrate was observed at a distance. Therefore, we can conclude that i‐PRF has been effective in the management of pain in PMC but does not result in complete healing of the disease.     

Cetuximab‐induced cutaneous toxicity

Background Epidermal growth factor receptor inhibitors are recently utilized by oncologists in advanced cases of certain malignancies. However, these agents are associated with numerous cutaneous adverse reactions. Objective To systematically review the cutaneous toxicity of cetuximab‐treated patients. Methods An analysis of a series of 24 patients (20 men and 4 women) treated with cetuximab (12 patients with head and neck cancer and 12 patients with colorectal cancer) was performed with respect to relevant clinical characteristics. Results A total of 22 patients (91.7%) developed pustular or maculopapular follicular eruption, often referred to as acneiform rash. One patient (4.2%) developed paronychia in the course of cetuximab therapy. All patients with head and neck cancer had a combination treatment with radiotherapy and experienced radiation dermatitis accompanied by skin xerosis. Anaphylactic reaction was observed in three patients (12.5%). Conclusions The most frequent cutaneous side effect reported in this series was acneiform eruption. The authors observed that all women with acneiform rash had only limited facial involvement, whereas all but one man experienced more widespread lesions of the face, the back and the chest. We found no association between the extent and severity of cutaneous eruptions (grade 1 vs. grade 2) and patients’ response to therapy.     

Epstein–Barr Virus‐Associated Hydroa Vacciniforme‐like Cutaneous Lymphoma in Seven Chinese Children

Abstract: Hydroa vacciniforme‐like cutaneous lymphoma is a rare type of Epstein–Barr virus‐associated lymphoma. We analyze clinicopathologic features of seven Chinese child patients with hydroa vacciniforme‐like cutaneous lymphoma and determine the pathogenic association of Epstein–Barr virus with this disorder. Clinical, histologic, and immunohistochemical features were reviewed. Skin lesions were subjected to Epstein–Barr virus‐encoded RNA detection by in situ hybridization. Serologic assay and quantitation of Epstein–Barr virus DNA were performed. All seven patients presented with facial vesicles, papulovesicles, and atrophic scarring. Histologically, skin specimens showed epidermal blister formation, and dense lymphoid infiltration throughout the dermis and subcutaneous tissue. The infiltrate was composed of both small and large irregular lymphocytic cells expressing CD45RO or CD56. Tumor cells positive for Epstein–Barr virus‐encoded RNA were detected in cutaneous infiltrates in all seven cases. Besides skin eruptions, all patients had systemic manifestations, such as intermittent fever, hepatosplenomegaly or lymph node enlargement. The amounts of Epstein–Barr virus DNA were increased in the peripheral blood in two detected cases, and antibody titers to Epstein–Barr virus revealed a chronic active Epstein–Barr virus infection in all cases. The diagnosis of hydroa vacciniforme‐like cutaneous lymphoma was made. Four of seven patients were treated with interferon α intramuscularly, and the skin eruptions improved. Hydroa vacciniforme‐like cutaneous lymphoma may present with severe facial edema, papulovesicular eruptions and permanent scars. The tumor cells often express natural killer‐ or T‐cell markers. The disease is often preceded by chronic active Epstein–Barr virus infection.     

Indolent course of cutaneous gamma‐delta T‐cell lymphoma

Cutaneous gamma‐delta T‐cell lymphoma (γδTCL) is a rare malignancy that typically displays an aggressive clinical course. We present an unusual case of a 57‐year‐old woman with a 3‐year history of lower extremity nodules. Histopathologic, immunophenotypic and molecular genetic studies revealed a clonal, predominantly pannicular gamma‐delta T‐cell infiltrate, leading to a diagnosis of cutaneous γδTCL. The clinical course was characterized by rapid improvement within months of starting systemic corticosteroids, with relapse in ulcerations but no new lesions more than 3 years after onset of disease. Our case and seven previously reported patients with indolent and relatively localized cutaneous γδTCL provide evidence that not all cases of this entity carry a poor prognosis. This indolent subset adds complexity to treatment of cutaneous γδTCL.     

Nasal‐type extranodal natural killer/T‐cell lymphoma presenting as a solitary non‐healing lower leg ulcer

Nasal‐type extranodal natural killer/T‐cell lymphoma (ENTCL) is an aggressive form of non‐Hodgkin's lymphoma with a poor prognosis. Primary cutaneous lesions of ENTCL usually present as nodules or infiltrative plaques. The presentation of ENTCL as a solitary ulcer, in the absence of other cutaneous lesions and systemic symptoms and signs, is extremely rare and may be easily misdiagnosed. In this report, we describe an unusual case of ENTCL with a diagnostically challenging clinical presentation as a solitary non‐healing leg ulcer in an elderly woman.     

Therapeutic removal of amyloid deposits in cutaneous amyloidosis by localised intra‐lesional injections of anti‐amyloid antibodies

Please cite this paper as: Therapeutic removal of amyloid deposits in cutaneous amyloidosis by localised intra‐lesional injections of anti‐amyloid antibodies. Experimental Dermatology 2010; 19 : 904–911. Abstract: In the skin, amyloidosis can be found with or without systemic disease. Primary cutaneous amyloidosis defines those amyloidoses restricted to the skin without involvement of other systems. Here, we used conformation‐specific antibodies to characterise both fibrillar and oligomeric amyloid aggregates in the skin from patients with cutaneous amyloidosis. Localised cutaneous amyloidosis with different morphology was reproduced in mice by intra‐dermal (i.d.) and subdermal administration of amyloid‐enhancing factor. Moreover, we demonstrated that conformational antibodies were effective in clearing amyloid deposits caused by localised intra‐lesional injections without the necessity of an immune response. Given the accessibility and amyloid localization in this disease, direct i.d. injections of conformational antibodies could be a convenient and direct method for treatment.     

Intense pulsed light in the treatment of non‐aesthetic facial and neck vascular lesions: report of 85 cases

Background Intense pulsed light (IPL) treatment is one of the most effective procedures for patients with non‐aesthetic vascular lesions in addition to signs of skin photoageing, and it has been reported as very successful in the treatment of telangiectasias, spider nevi, erythrosis, and above all, rosacea and poikiloderma. Its use is based on the principle of selective photothermolysis, which exploits the haemoglobin absorption peak among its range of wavelengths. Objective The aim of this study is to assess the efficacy and safety of intense pulsed light in treating non‐aesthetic vascular skin lesions, especially with regard to poikiloderma of Civatte and rosacea. Methods A total of eighty‐five patients, 64 women and 21 men, with 63 non‐aesthetic vascular lesions (28 Poikiloderma of Civatte and 35 rosacea), 22 pigmented lesions (UV‐related hyperpigmentation of solar lentigo‐type) and four precancerous lesions (actinic keratosis, AKs), were treated repeatedly with IPL for 2 years. The patients received a mean of five treatments (range 4–6) at 3‐weekly intervals. They were evaluated via clinical observations and professional photographs were taken before each treatment and after 2 weeks, 4 weeks, 3 months, 6 months and 12 months. The outcome of the IPL treatments was evaluated by four independent dermatologists, who were not informed about the study protocol, and who assessed the performance of IPL by dividing the results into four categories: no results, slight improvement, moderate improvement and marked improvement. Results All the patients showed improvements in their overall lesions: 72 lesions (80.9%) achieved a marked improvement, 14 lesions (15.7%) achieved a moderate improvement and three lesions (3.4%) achieved a slight improvement. The results of the 63 non‐aesthetic vascular lesions in Rosacea and Poikiloderma of Civatte were: 51 with a marked improvement, 10 with moderate improvement, whereas only two lesions achieved a slight improvement. The improvement of all four actinic keratoses was marked whereas the 22 pigmented lesions obtained a marked improvement in 17 cases, a moderate improvement in four cases and a slight improvement in one case. No undesirable effects were observed. Conclusions Our study confirms how by minimizing side‐effects, time and costs, IPL can be effective and safe for the treatment of non‐aesthetic facial and neck vascular lesions.     

Aromatase inhibitor‐induced skin adverse reactions: exemestane‐related cutaneous vasculitis

Background Three aromatase inhibitors, namely anastrozole, letrozole and exemestane, which reduce circulating oestrogen, are used to treat breast cancer patients; the therapeutic use of such aromatase inhibitors is quickly increasing. Objective We intended (i) to review aromatase inhibitor‐induced cutaneous adverse effects and (ii) to describe a recently observed case of cutaneous vasculitis triggered by exemestane. Patients/methods The so‐far reported literature cases of aromatase inhibitor‐induced cutaneous adverse effects were analysed retrospectively. Especially, the clinical case of exemestane‐induced cutaneous vasculitis herein reported is unique, because such an observation has not yet been published in the literature. Results Merely 12 cases of cutaneous adverse reactions induced by aromatase inhibitors, namely erythema nodosum (6), subacute cutaneous lupus erythematosus (1), cutaneous rashes (2), vasculitis (3, including the one described in this study), are reported in the literature. In fact, in the present case, cutaneous vasculitis was strictly related to exemestane. Conclusion As aromatase inhibitors (e.g. exemestane) are increasingly incorporated into the treatment strategy of breast cancer patients, it is important to recognize possible cutaneous adverse effects. Specifically, with regard to cutaneous vasculitis, some patients might progress to severe vasculitis manifestations if the offending drug (e.g. exemestane) is not quickly stopped.     

Objective and non‐invasive evaluation of photorejuvenation effect with intense pulsed light treatment in Asian skin

Background Intense pulsed light (IPL) has been widely used for photorejuvenation. Although previous literature has shown clinical effectiveness of IPL treatments on cutaneous photoaging, the associated changes in the biophysical properties of the skin following IPL treatments have not been fully elucidated. Objective The aim of this study was to evaluate changes in skin biophysical properties in patients with photoaging after IPL treatments, using non‐invasive, objective skin measuring devices. Patients and methods A total of 26 Korean women with facial dyschromias underwent three sessions of IPL treatment at 4‐week intervals. Outcome assessments included standardized photography, global evaluation by blinded investigators, patients’ self‐assessment and objective measurements of colour (Mexameter MX18, Chromatometer), elasticity (Cutometer), roughness (Visiometer), sebum (Sebumeter) and skin hydration (Corneometer). Results Intense pulsed light treatments produced a 15% decrease in the size of representative pigmented lesions (P < 0.05). Patients’ self‐assessment revealed that 84% and 58% of subjects considered their pigmented lesions and wrinkles were improved respectively. Objective colorimetric measurement demonstrated significant improvements following IPL treatments that were most remarkable after one session of IPL. Moreover, skin elasticity showed significant improvements at the end of the study. Skin wrinkles as measured using Visiometer showed a mild improvement without statistical significance. Sebum secretion and water content of skin remained unchanged. Conclusions Intense pulsed light provided significant improvement in the appearance of facial pigmented lesions in Korean patients. These effects appeared to be more remarkable in improving pigmentation, skin tone and elasticity.     

Congenital “self‐healing” Langerhans cell histiocytosis (Hashimoto‐Pritzker disease): A report of two cases with the same cutaneous manifestations but different clinical course

Congenital self‐healing Langerhans cell histiocytosis or Hashimoto‐Pritzker disease is a rare condition present at birth or in the neonatal period characterized by small reddish‐brown crusted papulonodular lesions. In most cases these lesions are not accompanied by systemic findings and tend to involute spontaneously within weeks or months, but in other cases there may be extracutaneous involvement and/or recurrence of the disease. This emphasizes that the clinical course is variable and a long‐term follow‐up is mandatory in order to reveal possible systemic involvement. We describe two cases of congenital self‐healing Langerhans cell histiocytosis with widespread and very similar cutaneous manifestations but different clinical course. The first patient had multisystemic disease (with lymph nodes, bones, liver and lungs affected) that required systemic therapy. The second patient had cutaneous and bony lesions that resolved spontaneously. We think that the adjective “self‐healing” is misleading and should be abandoned. We stress the importance of a complete systemic evaluation and the necessity of a long‐term follow‐up.