Isotretinoin: is there any arrhythmic effect?

BACKGROUND: Oral isotretinoin is currently the most effective therapy for acne, but is associated with numerous adverse effects. To investigate the cardiac effects of isotretinoin, acne patients receiving isotretinoin for 6 months were studied. Methods Twenty-six patients with acne vulgaris were enrolled in the study. The patients were treated with a dose of 0.8 mg/kg/day of isotretinoin (Roaccutane, Hoffman-La Roche, Basle, Switzerland) for 6 months. All participants were assessed pretreatment and at the third month of therapy with 24-h Holter monitoring of electrocardiography. Results Twenty-two patients completed the study (19 females and three males). Initial 24-h Holter monitoring showed normal sinus rhythm in all patients, with a mean heart rate of 79 beats/min (lowest, 63 beats/min; highest, 97 beats/min). At the third month of therapy, 24-h Holter monitoring showed normal sinus rhythm in all patients, with a mean heart rate of 81 beats/min (lowest, 67 beats/min; highest, 91 beats/min). All patients were in sinus rhythm throughout the recording period. None of the patients had supraventricular tachycardia or atrial arrhythmia. Conclusion In this study, 6 months of isotretinoin therapy significantly improved acne and did not cause any cardiac adverse effects at a dose of 0.8 mg/kg/day.     

Epidermolysis bullosa acquisita associated with relapsing polychondritis: an association with eosinophilia?

Epidermolysis bullosa acquisita is a blistering disorder that has been associated with other autoimmune diseases. It has not previously been associated with relapsing polychondritis (RPC). RPC is an autoimmune disorder that frequently displays peripheral eosinophilia. The eosinophil has been implicated in mediation of tissue damage and bullae formation. RPC should be added to the list of diseases seen in association with EBA.     

Pemphigus vulgaris and herpesviruses: is there any relationship?

Background Pemphigus is an autoimmune disorder, which results from interaction of exogenous and endogenous factors. One of these environmental factors is viral infections particularly, herpesviruses. We aimed to detect the presence of HSV 1 and 2 (herpes simplex virus) and HHV8 (human herpesvirus 8) in our patients who were suffering from pemphigus vulgaris. Methods In this cross‐sectional study, 38 patients (19 male and 19 female patients) with pemphigus vulgaris were entered, 32 skins and six peripheral blood cells samples were obtained from the study population. Thereafter, the presence of HHV8 and HSV DNA were evaluated by using polymerase chain reaction (PCR). Results The mean age of patients was 45.05 ± 17.24 years (range: 16–81 years). Twelve patients mentioned history of herpes labial in the past (31.57%). Results of PCR test for detection of HSV and HHV8 DNA in all 32 skin samples and five peripheral blood samples and one case with skin and blood samples were reported negative. Conclusion Inability to detect HHV8 and HSV DNA in this study suggests that herpesviruses may be only occasional factors for development or exacerbation of pemphigus vulgaris.     

Marginal acrokeratoderma and psoriasis: is there an association?

Case 1 A 70‐year‐old housewife presented to us with multiple, asymptomatic, depressed, crateriform plaque lesions over the radial margin of the index finger and thumb and thenar and hypothenar eminences of both hands of 25 years' duration ( Fig. 1 ). There was no history of prolonged sun exposure or repeated trauma to the hands and there were no such lesions on the soles. None of her other family members were affected. We made a provisional diagnosis of keratoelastoidosis marginalis. Skin biopsy revealed an unremarkable epidermis, with minimal lymphocytic infiltration in the upper dermis and hyalinization in the reticular dermis, extending to the deeper dermis. Two years later she returned with well‐defined, erythematous, scaly, mildly itchy plaque lesions over the instep of both feet and the center of both palms. A clinical diagnosis of palmoplantar psoriasis was made.

Figure 1 Open in figure viewer PowerPoint Case 1. Crateriform plaque lesions on the hands. Note the palmoplantar psoriasis     

Is morphoea caused by Borrelia burgdorferi? A review

The aetiology of morphoea and lichen sclerosus et atrophicus is still unknown. Since the detection of Borrelia burgdorferi (B. burgdorferi) as the causative agent of Lyme disease, there has been debate about a possible association between B. burgdorferi and morphoea. Initial serological and cultural studies showed controversial results. The introduction of polymerase chain reaction (PCR) initially suggested an association between B. burgdorferi and morphoea. We reviewed the literature on B. burgdorferi (specific serology, immunohistology, culture, lymphocyte stimulation and DNA detection by PCR) since 1983, using Medline and Current Contents. Histological and immunohistological detection of B. burgdorferi was reported in 0-40% (20 of 82) of the cases with morphoea and in 46-50% (17 of 36) of the cases with lichen sclerosus et atrophicus. Cultivation of spirochetes from lesional skin succeeded in five patients (five of 68) with morphoea, but failed in patients with lichen sclerosus et atrophicus. In Europe and Asia, serological detection of antibodies against B. burgdorferi was described in 0-60% (138 of 609) of patients with morphoea and in 19% (six of 32) in the U.S.A. For lichen sclerosus et atrophicus 0-25% of the published cases (three of 23) in Europe and Asia were seropositive. DNA from B. burgdorferi was detected by PCR in 0-100% (17 of 82) of the tissues of patients with morphoea in Europe and Asia, but not a single case among 98 patients was reported to be positive from the U. S.A. In Europe and Asia, borrelial DNA was detected in 0-100% (nine of 28) of the cases with lichen sclerosus et atrophicus, whereas in the U.S.A. none of 48 patients was positive. There are two possible explanations for these contradictory findings: the most likely is that B. burgdorferi is not a causative agent for morphoea. Another possible explanation could be that a subset of morphoea is caused by a special subspecies of B. burgdorferi that is present in Europe and Asia but does not occur in the U.S.A.     

Dermopathy and retinopathy in diabetes: is there an association?

BACKGROUND/AIMS: Diabetic dermopathy is the most common cutaneous marker of diabetes mellitus presenting as single or multiple well-demarcated brown atrophic macules, predominantly on the shins. Although diabetic dermopathy and diabetic retinopathy are both considered by some authors as manifestations of diabetic microangiopathy, only a few studies are published about their possible association. Our purpose was to investigate the association of diabetic dermopathy and diabetic retinopathy. METHODS: We conducted a cross-sectional study in an outpatient diabetes clinic during a 6-month period. One-hundred and eighty-one consecutive patients (8 cases of insulin-dependent diabetes mellitus and 173 cases of non-insulin-dependent diabetes mellitus) were examined for the presence of diabetic dermopathy and diabetic retinopathy. RESULTS: Forty-seven (26%) showed diabetic dermopathy and 68 patients (37.6%) suffered from diabetic retinopathy. The frequency of retinopathy in patients with diabetic dermopathy (44%; 30 cases) was significantly greater than in patients without dermopathy (15%; 17 cases; p < 0.0001). Retinopathy showed a statistically significant association with dermopathy [odds ratio (OR): 3.60; 95% confidence interval (CI): 1.53-8.44; p = 0.003] and diabetes duration (OR: 3.36; 95% CI: 1.67-6.77; p = 0.001). CONCLUSION: Our study further supports that diabetic dermopathy might be used as a telltale sign of diabetic retinopathy, necessitating more intensive ophthalmologic care, especially in long-lasting diabetes.     

Melanocytic naevi and basal cell carcinoma: is there an association?

Background Melanoma and basal cell carcinoma (BCC) affect similar body sites and share a complex relationship with sun exposure. Objective To establish the existence and magnitude of association between melanocytic naevi, the strongest predictors of melanoma, and BCC to give possible insights into shared pathways of solar ultraviolet tumourigenesis. Methods In a community‐based longitudinal Australian study, detailed information was collected about sun sensitivity, and dermatologists assessed skin colour and counted naevi on the forearms (1986) and back (1992). The BCC frequency and sites were prospectively monitored until 2007. Multivariate logistic regression was used to assess the association of naevi on the forearms or on the back with the development of BCC, adjusting for other risk factors. Results Of 1621 study participants in 1992, 1339 (average age 49) had complete follow‐up and 401 (30%) of these had 1202 histologically confirmed BCCs until 2007. After adjustment for age, gender, skin colour, naevi on the back and sun exposure, overall BCC risk increased significantly in those with forearm naevi (odds ratio: 1.5; 95% confidence intervals: 1.1–1.9). Risk of BCC specifically on the back was doubled in those with many (11 or more) forearm naevi compared with no forearm naevi (odds ratio: 2.4; 95% confidence interval: 1.1–4.8). Naevi on the back were not associated with subsequent basal cell carcinoma. Conclusions High naevus prevalence on the arms is associated with future BCC development.     

Oral lichen planus and hepatitis C virus: is there real association?

Lichen planus is an inflammatory, mucocutaneous disease that in addition to the skin involves oral mucosa in about 60-70 % of cases. In recent years, several reports have supposed a relationship between oral lichen planus (OLP) and chronic liver disease, especially hepatitis C (HCV). Here we present an extensive review of the literature in English that examines the association between HCV and OLP.     

Partial regression of primary cutaneous melanoma: is there an association with sub-clinical sentinel lymph node metastasis?

Whether partial regression of a primary melanoma has an adverse impact on prognosis is controversial. As an indirect mechanism of addressing this question we drew a correlation between the histopathological characteristics of 107 cutaneous melanomas and the presence of sub-clinical metastasis in corresponding sentinel lymph nodes. Partial regression of the primary tumor, defined as focal replacement of the lesion by a scar, unrelated to a previous biopsy, was observed in 20 (19%) cases in the group as a whole. Excluding cases in which an accurate Breslow thickness of the primary melanoma could not be established and/or the presence of a capsular nevus was detected in the sentinel node, a total of 97 remained. Seventeen cases (Breslow thickness 0.63-9.7; mean 2.4 mm) showed partial regression and 80 (Breslow thickness 0.25-7.00; mean 1.8 mm) were devoid of regression. Of the 17 cases with regression 5 (29%) had nodal metastasis (by histopathology and/or molecular analysis) and of the 80 cases without regression 23 (29%) had nodal metastasis (by one or both evaluations). Our data reveals no association between partial regression of the primary melanoma and sentinel node involvement by the disease. The Breslow thickness proved to be the only significant independent variable related to nodal metastasis. Of interest, ulceration of the primary lesion was significantly associated with nodal disease on univariate, but not on multivariate, analysis. While acknowledging that the cohort size may lack the statistical power to demonstrate subtle associations, our data supports the known relevance of tumor thickness and ulceration to regional lymph node metastasis and thereby, to outcome of melanoma in its early stages, but fails to support a similar role for partial regression.     

Management of haemorrhagic bullous lesions in Henoch-Schonlein purpura: is there any consensus?

Henoch-Schonlein purpura (HSP) is the most common form of vasculitis affecting children. The cutaneous manifestations classically present as urticarial wheals, erythematous maculopapules, petechiae, purpura or oedema, which characteristically involve the lower extremities and buttocks. Haemorrhagic bullous lesions are a recognized but rare occurrence with HSP in children. We report a 6-year-old boy with HSP who developed extensive haemorrhagic bullae requiring dermatological referral and treatment. Scrutiny of our management and available literature reveals a lack of consensus in the management of extensive cutaneous involvement in HSP.     

Cutaneous T‐cell lymphoma and atopy: is there an association?

BACKGROUND: Case reports have suggested a relationship between atopic diatheses and Sézary syndrome, pre-Sézary syndrome or mycosis fungoides. However, Sézary and pre-Sézary syndromes are rare entities, and this association has never been analysed in greater detail for specific subtypes of cutaneous T-cell lymphoma (CTCL). OBJECTIVES: To evaluate the prevalence of atopy in subjects with Sézary syndrome, pre-Sézary syndrome or mycosis fungoides, and to compare the rates with the reported prevalence of atopy in the general population. METHODS: We retrospectively reviewed the records of 157 patients with the diagnosis of Sézary or pre-Sézary syndrome seen between 1965 and 2000, and 102 patients with the diagnosis of mycosis fungoides evaluated from 1994 to 2000 at Mayo Clinic. RESULTS: Of 157 subjects with Sézary or pre-Sézary syndrome and 102 subjects with mycosis fungoides, 18 and 12, respectively, were identified as having a history of atopic dermatitis, asthma or allergic rhinitis. The prevalence rates of atopy in Sézary or pre-Sézary syndrome and mycosis fungoides were 11.5% (95% confidence interval 6.9-17.5%) and 11.8% (6.2-19.7%), respectively. CONCLUSIONS: No significant difference exists in the prevalence of atopy in Sézary or pre-Sézary syndrome compared with that in mycosis fungoides (chi2-test, P = 1.00). Furthermore, the rates of atopy in Sézary or pre-Sézary syndrome and mycosis fungoides are not significantly different from the prevalence of atopy in the general population (17-40%). On the basis of these observations, no evidence currently implicates a causal association of CTCL with atopy.     

Morphoea: a manifestation of infection with Borrelia species?

BACKGROUND: Morphoea or localized scleroderma is a cutaneous inflammatory disease with still unknown aetiology. Borrelia burgdorferi as causative agent has been discussed controversially. OBJECTIVES: To assess the evidence for infection with B. burgdorferi in patients with morphoea by focus-floating microscopy (FFM). METHODS: Using standard histological equipment, tissue sections stained with a polyclonal B. burgdorferi antibody were simultaneously scanned through in two planes: horizontally as in routine cytology, and vertically by focusing through the thickness of the section, i.e. FFM. Part of the material was also investigated with a Borrelia-specific polymerase chain reaction (PCR). RESULTS: One hundred and twenty-two cases of morphoea and 68 controls (58 negative and 10 positive by PCR) were investigated for the presence of Borrelia within tissue specimens. Using FFM Borrelia was detected in 84 cases (68.9%) of morphoea and in all positive controls, but was absent in all negative controls. Borrelia was significantly more frequent in early inflammatory-rich (75%) than late inflammatory-poor (53%) cases (P = 0.018). What seemed to be vital microorganisms were mostly found close to the active border, while degenerated forms were more common in fibrosclerotic parts. The presence of B lymphocytes determined by CD20 staining proved to be a good positive predictor of the microorganism (correlation 0.85, P < 0.001). Borrelia-specific DNA was detected in only one of 30 cases of morphoea analysed by PCR. CONCLUSIONS: FFM is a reliable and highly sensitive method to detect Borrelia in tissue sections. The frequent detection of this microorganism in morphoea points to a specific involvement of B. burgdorferi or other similar strains in the development of or as a trigger of this disease.     

Paraneoplastic pemphigus: an association with fludarabine?

Paraneoplastic pemphigus is a relatively recently described immunobullous disease with characteristic features. We report three cases of paraneoplastic pemphigus in adult men with chronic lymphocytic leukaemia arising within a week of completion of treatment with fludarabine. In all cases, withdrawal of fludarabine and treatment of the blistering was associated with marked cutaneous improvement. Fludarabine, a synthetic nucleoside analogue, which has only been available in Britain since 1994, is known to be associated with autoimmune phenomena and may have been involved in the development of paraneoplastic pemphigus in these cases.