Acquired perforating dermatosis: clinicopathological features in twenty-two cases

BACKGROUND: The term of acquired perforating dermatosis (APD) comprises the perforating dermatoses occurring in adult patients. Clinical and histological features of the disease are not uniform, and may resemble any of the four classic perforating disorders: elastosis perforans serpiginosa, reactive perforating collagenosis, perforating folliculitis or Kyrle's disease. Chronic renal failure and/or diabetes mellitus usually accompany this skin disease. OBJECTIVE: The aim of this study was to delineate the clinical and histopathological features of acquired perforating dermatosis and to investigate the potential relationship between this disease and associated conditions. METHODS: Twenty-two patients with acquired perforating dermatosis were enrolled in this study. Clinical findings of acquired perforating dermatosis and the spectrum of associated diseases were investigated. Haematoxylin and eosin sections were re-examined, and immunohistochemical stainings (elastic van Gieson and Masson trichrome stains) and periodic acid-Schiff stain were also used for histopathological evaluation. RESULTS: Different clinical types of lesions resembling reactive perforating collagenosis, perforating folliculitis or Kyrle's disease were observed. Histopathological features were consistent with any of the four types of perforating dermatoses. Most of the patients (86.4%) had at least one systemic disease. Chronic renal failure (72.7%) and diabetes mellitus (50%) were the most commonly associated conditions. Most of the patients with diabetes mellitus (90.9%) had chronic renal failure due to diabetic nephropathy. All of the patients with chronic renal failure were on dialysis treatment. The other associated conditions were hepatitis (27.3%), anti-HCV Ab-positivity (13.6%), hypothyroidism (9.1%) and tuberculosis lymphadenitis (4.5%). Of the 22 patients, 13.6% were otherwise healthy, and 9.1% were renal transplant recipients. CONCLUSION: Clinicopathological findings of our study indicate that the cases with APD represent the broad spectrum of perforating disorders rather than the variants of the same disease. Although APD is frequently associated with diabetes mellitus and chronic renal failure, this skin disorder may also develop in patients with other systemic disorders, and in those without any medical problems. This skin disease is probably linked to dialysis treatment in patients with chronic renal failure due to diabetes mellitus or other causes.     

Dermatosis perforante adquirida: presentación de 8 casos

Acquired perforating dermatosis (APD) is an uncommon disease characterized by lesions exhibiting transepidermal elimination of collagen or elastic fibers. APD affects adults and is associated with systemic diseases, mainly diabetes mellitus and renal failure.We present 8 cases of APD. Seven patients had concomitant diabetes mellitus with or without chronic renal failure, and 1 had alcoholic cirrhosis. In the patients with chronic renal failure, the onset of APD coincided with transient worsening of renal function. The mean increase in creatinine concentrations above baseline was 1.14 mg/dL. Acute deterioration of renal function may be involved in APD. Further studies are needed to investigate this association.     

Acquired reactive perforating collagenosis following diclofenac therapy in a patient with parapsoriasis

A case of acquired reactive perforating collagenosis in a 70-year old man with a long standing digitate parapsoriasis is reported. Multiple asymptomatic cutaneous hyperpigmented papules with a central adherent keratotic plug developed simultaneously with widespread purpuric eruption following a single i.m. diclofenac injection. Histologic examination of a keratotic lesion revealed an epidermal crater with centrally degenerated collagen and elastic fibre extrusion. This case is interesting for the lack of pruritus, the transepithelial elimination of both collagen and elastic fibres and the association with parapsoriasis. The etiologic role of diclofenac is discussed. The term acquired perforating dermatosis may be more suitable for this case.     

Pityrosporum folliculitis: renal transplantation case report

Pityrosporum folliculitis is caused by the fungus Pityrosporum ovale. It is characterized by the presence of pruriginous follicular papulae and papulae-pustules in face, upper part of the trunk, and upper limb root. It is more prevailing in places with hot and humid climates. Its incidence can be associated with either immunosuppressive or chemotherapy states secondary to pathologies. We report herewith a case of pityrosporum folliculitis in a patient who had previously underwent kidney transplantation and these result of the itraconazol therapeutics given.     

Acquired reactive perforating collagenosis associated with diabetes mellitus: eight cases that meet Faver's criteria

Reactive perforating collagenosis (RPC) is characterized by umbilicated papules with a central adherent keratotic plug. Histologically, this condition shows transepidermal elimination of altered dermal collagen bundles into a cup-shaped epidermal depression. The present paper describes eight patients with associated diabetes mellitus who meet the diagnostic criteria for the acquired form of RPC (ARPC). Although half of these patients underwent dialysis, the lesions did not tend to develop after dialysis. Pruritus and the Koebner phenomenon were common, and histologically a microvasculopathy was noted in the dermis of all patients. We speculate that this disease is triggered by a cutaneous response to superficial trauma. Furthermore, this response acts synergistically with vasculopathy in the dermis, primarily in the case of diabetes mellitus. A secondary sign of ARPC may be degenerated collagen fibres as a result of transepidermal elimination.     

The evolution of perforating folliculitis in patients with chronic renal failure

The evolution of perforating folliculitis in six patients with chronic renal failure was investigated with special attention to clinical and histopathologic changes in early, evolving, and mature lesions. Different and distinct histologic features at each stage were found. The earliest lesions, follicular pustules, evolved into perforating folliculitis that eventuated in prurigo nodularis. A combined treatment consisting of an anti-staphylococcal antibiotic by mouth, phototherapy, and application of a topical corticosteroid lotion proved helpful in controlling the generalized pruritus and the evolution of the lesions in these cases.     

慢性肾衰竭不同分期对性功能的影响

目的:探究慢性肾衰竭不同分期对性功能的影响。方法:选取我院于2008年12月至2010年10月收治的慢性肾衰竭患者82例,按照其病理分期进行分组探究,对激素水平、神经功能、并发症及心理状况进行对比,探讨慢性肾衰竭不同分期对性功能的影响。结果:代偿期患者促卵泡素、泌乳素及促黄体素均高于正常人群,且随着患者临床分期的加重,患者激素水平不断提高,女性提高程度较男性更为严重;代偿期患者出现3例(15.8%)神经障碍,失代偿期出现5例(21.7%),肾衰竭期出现8例(29.6%),尿毒症期出现11例(84.6%),随着患者临床分期的加重患者出现神经障碍比例不断提高;随着患者临床分期加重其并发症率不断上升,组间比较存在明显统计学差异;代偿期患者平均SCL-90得分为(157.6±51.2)分,失代偿期患者为(167.2±49.5)分,肾衰竭期为(185.0±58.7)分,尿毒症期为(193.6±59.1)分,均高于国内常模且随临床分期加重SCL-90得分显著上升,显示其心理状态不断下降。结论:随着慢性肾衰竭临床分期的加重,患者体内激素水平上升、并发症发生率不断提高,且神经系统障碍及心理障碍的程度不断加重,导致其性功能显著下降,因此,应在提供治疗的前提下加强心理治疗,帮助其恢复性功能。     

Acquired reactive perforating collagenosis: a clinicopathologic study of 15 cases from Saudi Arabia

Background Perforating dermatoses include a family of disease characterized by transepidermal elimination of collagen. Despite being described many years ago in association with systemic disease, it is still clinically misdiagnosed. Objective A retrospective clinical and pathologic review that will increase clinical and pathologic diagnostic awareness of this entity and explore associated systemic disease. Patients and methods In this report, we present from Saudi Arabia for the first time details of a series of patients seen at the King Abdulaziz Medical City, WR, Jeddah, Saudi Arabia, during the period 2002–2009. Results The study revealed 15 histologically confirmed cases of acquired reactive perforating collagenosis (ARPC). Patients were predominantly adult females with a mean age of 54 years. The lesions were pruritic, predominantly multiple, erythematous excoriated papules and umblicated nodules centrally crusted with an average duration of 6 months, involving the extremities with or without the trunk in 12 patients. Associated systemic disease included diabetes mellitus in 12 patients and chronic renal failure on dialysis in 8 patients. The provisional clinical differential diagnosis included perforating collagenosis in only eight patients. Conclusion ARPC is not uncommon in Saudi Arabia. The noduloulcerative lesions involve predominantly the extremities, and diabetes mellitus is the most common associate. It is hoped that this article will increase awareness for recognition of this entity to start appropriate therapy.     

A Clinicopathologic Study of Thirty Cases of Acquired Perforating Dermatosis in Korea

Background

Acquired perforating dermatosis (APD) is histopathologically characterized by transepidermal elimination of materials from the upper dermis. APD can be divided into four diseases: Kyrle''s disease, perforating folliculitis, elastosis perforans serpiginosa, and reactive perforating collagenosis. APD is usually associated with systemic diseases, especially diabetes mellitus or chronic renal failure. So far, there have only been a few Korean studies of APD, which have a limited number of patients.

Objective

The aim of this study is to evaluate the clinical and histopathologic characteristics of 30 cases of APD and to examine the association with systemic diseases.

Methods

We retrospectively reviewed the medical records and biopsy specimens of 30 patients who were diagnosed with APD.

Results

The mean age was 55.5 years, and the average duration of the lesion was 7.8 months. The lower extremities (73.3%) were the most frequently occurring sites of the lesion. Twenty-five patients (83.3%) had pruritus, and Koebner''s phenomenon was present in 11 patients. Patients of 63.3% had at least one systemic disease. Diabetes mellitus (n=17, 56.7%) and chronic renal failure (n=10, 33.3%) were the most commonly associated conditions. Most patients received topical steroids (93.3%) and antihistamines (80.0%). The most common histopathologic type was reactive perforating collagenosis (n=23, 73.3%).

Conclusion

In this study, most patients had a systemic association to the diseases. Therefore, we suggest that further evaluation is necessary for patients who present with APD. This includes reviewing patient''s comprehensive past medical history, clinical exam, and additional diagnostic testing to check for the possibility of associated systemic diseases.     

Eosinophilic pustular folliculitis: report of seven cases in Thailand

Seven cases of eosinophilic pustular folliculitis (EPF) were diagnosed at the Institute of Dermatology within the seven years from 1989-1996. There were 4 males and 3 females, age 24-44 years, with durations of the disease before diagnosis ranging from 3 months to 5 years. The face was the most commonly involved area. Lesions also occurred simultaneously on other sites including the chest, trunk, scalp, and palmoplantar areas. Diagnosis was made from clinical features, hematologic examinations, and histopathologic pictures. Topical piroxicam gel, 0.5%, and oral indomethacin gave good results; some lesions subsided within a few days, and the remissions lasted for four months to five years.     

Acquired perforating dermatosis: comparison of an acquired perforating dermatosis and perforation as an incidental histologic finding

A 66-year-old Japanese woman with a rare acquired perforating disorder, usually called adult-type reactive perforating collagenosis, is reported. The patient had poorly controlled diabetes mellitus with retinopathy under oral diabetic medication. She was found to have multiple papules and umbilicated nodules on the trunk and four extremities when she was admitted and examined for the origin of jaundice and severe pruritus of sudden onset. In the biopsy specimen, collagen fibers were observed to be eliminated from the dermis through epidermal tunnel-like perforations. No elastic fibers were eliminated, and serial sectioning of the specimen could not prove follicular perforation. Adenocarcinoma of the biliary duct was found to be the cause of the jaundice with pruritus. Although such cases are usually classified as acquired reactive perforating collagenosis of adult onset, proposed reclassification for acquired perforating disorders is discussed. Another case which also showed perforation and transepithelial elimination of both collagen and elastic fibers as an incidental histologic finding is described. Such elimination seems to be a not uncommon step in the formation of pruriginous eruptions. Therefore, these cases should be differentiated from acquired-type characteristic perforating disorders.     

慢性肾功能衰竭患者血清心肌肌钙蛋白Ⅰ的研究

目的观察慢性肾功能衰竭（CRF）血清心肌肌钙蛋白（cTnI）的异常变化及其与心血管疾病的相关性。方法131例慢性肾衰竭患者（56例有胸闷、心悸等症状,75例无症状）和70例正常人于空腹状态抽取外周静脉血,用双抗夹心酶联免疫吸附法检测cTnI,并检测血清肌酐、糖化血红蛋白,进行12导联心电图（EKG）、二维超声心动图（UCG）检查,同时记录血压、临床症状。结果慢性肾功能衰竭组的cTnI水平为（0．103±0．451）ng／ml,显著高于健康对照组[（0．016±0．062）ng／ml,P〈0．05]。慢性肾衰患有症状组的cTnI水平为（0．382±1．610）ng／ml,显著高于无症状组[（0．073±0．158）ng／ml,P〈0．05]。有症状组cTnI异常率分别为33．9％,显著高于无症状组（8．0％,P〈0．05）;有症状组、EKG、UCG异常率分别为87．5％和69．64,与无症状组相比均无显著性差异（76．0％和56．0％,均P〉0．05）。cTnI升高与肌酐水平、血压、血糖、透析方式均无相关性。结论CRF患者cTnI水平显著高于健康人群,心肌损伤发生率极高,cTnI可作为心肌损伤的更特异的预测指标并用以判断预后。     

Inflammatory status in chronic renal failure: The role of homocysteinemia and pro-inflammatory cytokines

AIM: To evaluate determinants of inflammatory markers in chronic renal failure patients according to the level of glomerular filtration rate.METHODS: One hundred fifty four patients (Age: 44 ± 06 years; male/female: 66/88) with chronic renal failure (CRF) were divided into 6 groups according to the National Kidney Foundation (NKF) classification. They included 28 primary stage renal failure patients (CRF 1), 28 moderate stage renal failure patients (CRF 2), 28 severe stage renal failure patients (CRF 3), 18 end-stage renal failure patients (CRF 4), 40 hemodialysis (HD) patients, and 12 peritoneal dialysis (PD) patients. Tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), interleukin-6 (IL-6) and C-reactive protein (CRP) were analyzed by immunosorbent assay kit (ELISA) (Cayman Chemical’s ACETM EIA kit). Immunoassay methods were used for total homocysteine (tHcy) (fluorescence polarization immunoanalysis HPLC, PerkinEmer 200 series), transferrin (MININEPHTM human transferin kit: ZK070.R), ferritin (ADVIA Centaur) and fibrinogen analysis (ACL 200). Differences between groups were performed using SPSS 20.0 and data are expressed as the mean ± SD.RESULTS: Results showed that in comparison with CRF 1 group and other groups, TNF-α and IL-6 levels were respectively more elevated in HD (16.38 ± 5.52 pg/mL vs 0.39 ± 0.03 pg/mL, 11.05 ± 3.59 pg/mL vs 8.20 ± 0.22 pg/mL, P < 0.001) and PD (14.04 ± 3.40 pg/mL vs 0.39 ± 0.03 pg/mL, 10.15 ± 1.66 pg/mL vs 8.20 ± 0.22 pg/mL, P < 0.001). IL-1β levels were increased in HD (9.63 ± 3.50 pg/mL vs 3.24 ± 0.10 pg/mL, P < 0.001) and CRF 4 (7.76 ± 0.66 pg/mL vs 3.24 ± 0.10 pg/mL, P < 0.001) patients than in CRF 1 and in the other groups. Plasma tHcy levels were higher in HD (32.27 ± 12.08 μmol/L) and PD (28.37 ± 4.98 μmol/L) patients compared to the other groups of CRF (P < 0.001). The serum CRP level was significantly increased in HD (18.17 ± 6.38 mg/L) and PD (17.97 ± 4.85 mg/L) patients compared to the other groups of CRF patients (P < 0.001). The plasma fibrinogen level was more elevated in HD (6.86 ± 1.06 g/L) and CRF 4 (6.05 ± 0.57 g/L) than in the other groups (P < 0.001). Furthermore; the ferritin level was higher in HD (169.90 ± 62.16 ng/mL) and PD (90.08 ± 22.09 ng/mL) patients compared to the other groups of CRF (P < 0.001). The serum transferrin value was significantly decreased especially in PD (1.78 ± 0.21 g/L) compared to the other groups (P < 0.001). We found a negative correlation between glomerular filtration rate (GFR), TNF-α levels (r = -0.75, P < 0.001), and tHcy levels (r = -0.68, P < 0.001). We observed a positive correlation between GFR and transferrin levels (r = 0.60, P < 0.001).CONCLUSION: CRF was associated with elevated inflammatory markers. The inflammation was observed at the severe stage of CRF and increases with progression of renal failure.     

Acquired perforating dermatosis in diabetes mellitus: An unusual case

A case of elastosis perforans serpiginosa in a patient who presented with insulin-dependent diabetes mellitus secondary to pancreatic insufficiency in a background of common variable immunodeficiency and endocrinopathy, as evidenced by pernicious anaemia and growth hormone deficiency, is described. In acquired perforating dermatosis occurring in patients with diabetes or renal failure, there is a spectrum of changes that may show an overlap of histological features of the four classic perforating diseases. The biopsy changes of the patient described in the present study most closely resembled those of elastosis perforans serpiginosa.     

Cutaneous larva migrans with folliculitis: report of seven cases and review of the literature

Seven patients (four men, three women, mean age 31 years), all returning from the tropics, presented with pruritic folliculitis and creeping eruption. The folliculitis consisted of 20-100 follicular papules and pustules confined to a particular area of the body, mainly the buttocks. The creeping eruption consisted of two to 10 serpiginous or linear burrows 1-5 cm long located either in the same area or in a different area from the folliculitis. Five patients were cured with one to three courses of ivermectin (one course in two cases, two courses in two cases and three courses in one case) and two patients were cured with a 3-day regimen of albendazole. Folliculitis should be added to the dermatological manifestations of cutaneous larva migrans. Treatment is more difficult than in classical forms of cutaneous larva migrans.     

Reactive Perforating Collagenosis and Acquired Perforating Dermatosis: Presentation of Two Cases

Two rare cases of patients suffering from diabetes mellitus and skin lesions with histological transepidermal elimination are presented. The clinical and histological findings confirmed the diagnoses of reactive perforating collagenosis and acquired perforating dermatosis. The relationship between the two entities and their pathogenesis are discussed.     

Eosinophilic pustular folliculitis associated with hematological disorders: A report of two cases and review of Japanese literature

Eosinophilic pustular folliculitis (EPF) occurs in patients with hematological disorders. However, clinical information about hematological disorder‐associated EPF is scarce. We report two cases of EPF associated with mantle cell lymphoma and reviewed the available published work on Japanese cases. We identified a total of 23 Japanese cases, including the two cases reported here, who had hematological disorder‐associated EPF. Fourteen cases were associated with treatment for hematological malignancies (transplantation‐related EPF) and nine cases were associated with hematological malignancies themselves (hematological malignancy‐related EPF). Although the skin eruption was clinically indistinguishable between the two subtypes, transplantation‐related EPF occurred on the face and trunk of young and middle‐aged men and women, whereas hematological malignancy‐related EPF occurred mostly on the face of older men. Peripheral blood eosinophilia was more frequently observed in transplantation‐related EPF. These observations suggest variations among patients with EPF associated with hematological disorders.     

Nail changes in chronic renal failure patients under haemodialysis

Background Chronic renal failure is known to cause various nail pathologies. They may be directly related to the renal condition itself or its complications or to the therapy. Objective To compare nail changes in end‐stage renal failure patients under haemodialysis with healthy persons and to study the potential relationship with various parameters in the patients. Patients and Methods The study comprised 100 patients with chronic renal failure under regular haemodialysis as well as 100 healthy control subjects of matched age and sex. Both groups were subjected to full history taking and thorough general and nail examination. Complete blood picture, liver and kidney function tests and fasting blood glucose level were investigated. Results Nail disorders were more prevalent in patients (76%) than in control group (30%). The half and half nail was the most common finding (20%) followed by – in descending manner – absent lunula, onycholysis, brittle nail, Beau's lines, clubbing, longitudinal ridging, onychomycosis, subungual hyperkeratosis, koilonychias, total leukonychia, splinter hemorrhage, pitting and pincer nail deformity. There was non‐significant correlation between nail changes and age of the patients or duration of haemodialysis. In addition, no evidence of significant relation was found between nail changes and both haemoglobin and albumin levels. Conclusion Frequent nail changes are observed on systematic nail examination of uraemic patients undergoing haemodialysis; however, the cause of them remains obscure and could not be traced to a particular abnormality in the renal condition, medication or the procedure itself and it needs further investigations.     

Vegetative pyoderma gangrenosum in chronic renal failure

We report the case of a 58-year-old woman with painful recurrent erythematous lesions on both legs of 6 months' duration. The patient had been treated with haemodialysis for chronic renal failure for the previous 10 years. Physical examination revealed pea-sized erythematous nodules with sinus formation and discharge of bloody pus, which yielded neither bacterial nor fungal cells in culture. These lesions healed leaving cribriform scars, after bed rest, topical disinfection and systemic and in some areas intralesional corticosteroids. Cases of pyoderma gangrenosum are usually classified as one of four clinical variants: ulcerative, pustular, bullous and vegetative. Our case might correspond to a vegetative form in view of the development of sinuses, neutrophilic abscesses and palisading granuloma, even though no ulceration was observed.