A. Almila Tuncel

Rapid improvement of human orf (ecthyma contagiosum) with topical imiquimod cream: report of four complicated cases

Orf is a zoonosis caused by an epitheliotropic DNA parapox virus. Human orf is a generally benign, self‐limiting condition that usually regresses in 6–8 weeks without specific treatment. However, it may be accompanied by local symptoms including pain, pruritus, lymphangitis and axillary adenitis, or less frequently by systemic symptoms such as fever or malaise. Furthermore, it may be complicated by erythema multiforme, Stevens‐Johnson syndrome, erysipelas, generalized mucocutaneous eruption, toxic erythema, eyelid oedema and giant, persistent or recurrent lesions in immunocompromised patients. Imiquimod, a potent topical immune response modifier, enhances both the innate and acquired immunity by stimulation of immune system cells resulting in local antiviral, antitumour and immunoregulatory activity. We present, for the first time, four complicated cases of orf successfully treated by topical imiquimod resulting in rapid regression of both orf and associated lesions. Two of the cases were complicated with erythema multiforme, one with recurrent eyelid oedema, and another had giant orf associated with axillary lymphadenitis. We suggest that topical imiquimod may be an effective and safe therapy for complicated orf cases.

A prospective epidemiologic survey on the prevalence of onychomycosis and dermatophytosis in male boarding school residents.

Dermatophyte infections and onychomycosis are not usually serious in term of mortality; however, they may have significant clinical consequences such as secondary bacterial infections, chronicity, therapeutic difficulties and esthetic disfigurement in addition to serving as a reservoir of infection. Our aim was to determine the prevalence of onychomycosis and dermatophytosis in a selected high risk group, consisting of male boarding school residents. A total of 410 males inhabiting two houses were evaluated by two dermatologists. In cases of clinical suspicion, appropriate samples were taken for direct microscopy and culture. The results showed that the prevalences of tinea pedis (athlete’s foot) and pure pedal onychomycosis were 51.5% (n:211) and 4.4% (n:18), respectively. Thirty cases of those with tinea pedis were complicated by toenail onychomycosis. Tinea cruris was present only in five cases with tinea pedis. Interestingly 71.1% of those with tinea pedis and 45.8% of those with onychomycosis, associated with or without tinea pedis were unaware of their diseases. The most common fungal isolate was Trichophyton rubrum (76.6%) followed by Epidermophyton floccosum (11.6%), T. interdigitale (10.55%). Approximately one third of the cultures from nail specimens yielded pure growths of nondermatophyte moulds or Candida albicans. In conclusion, we found unexpectedly high prevalences of occult athlete’s foot and toenail onychomycosis among the male residents of student houses. Our results indicate that health-care workers of such common boarding-houses should be more aware of clinical and subclinical dermatophyte infections and onychomycosis, and have more active approaches to educational measures and management strategies to prevent further infections. To our knowledge, this is the first epidemiologic study on the prevalences of dermatophytosis and onychomycosis in boarding-houses from Turkey.

Association of insertion/deletion polymorphism of the angiotensin‐converting enzyme gene with psoriasis

Background  Genetic factors are likely to be of fundamental importance in the pathogenesis of psoriasis. There are reports concerning the induction or/and exacerbation of psoriasis by angiotensin‐converting enzyme (ACE) inhibitors, which have been attributed to the ACE inhibitor‐induced augmentation of kinin levels in skin. However, to the best of our knowledge there has been no molecular genetic study investigating whether ACE insertion/deletion (I/D) polymorphism may contribute to the genetic background in psoriasis.

Successful treatment of antifungal- and cryotherapy-resistant subcutaneous hyalohyphomycosis in an immunocompetent case with topical 5% imiquimod cream.

Hyalohyphomycosis is an unusual opportunistic mycotic infection where the tissue morphology of the causative organism is mycelial. Etiological agents, which are not responsible for the otherwise-named infections like aspergillosis, are the species of non-dematiaceous hyaline hyphomycetes including Penicillium, Paecilomyces, Acremonium (formerly known Cephalosporium), Beauveria, Fusarium, and Scopulariopsis. Several cases of Acremonium infection have been described in immunocompromised patients; however it can cause invasive disease in an immunocompetent person very rarely. Optimum therapy of Acremonium infection is unclear because of the limited number of reported cases and conflicting results of therapies. Imiquimod, an imidazoquinoline with potent antiviral, antitumor and immunoregulatory properties, is currently approved for the topical treatment of external anogenital warts and actinic keratosis. Imiquimod has also been found to be effective for other virus-associated dermatologic lesions, including common and flat warts, molluscum contagiosum, and herpes simplex virus type-2 as well as for some cases of cutaneous leishmaniasis. We report herein, for the first time, a case of unusually recalcitrant hyalohyphomycosis of the face due to Acremonium strictum successfully treated with topical 5% imiquimod in an immunocompetent patient, who had failed to respond to various antifungals, including itraconazole, and cryotherapy.

Prevalence of skin diseases among male adolescent and post-adolescent boarding school students in Turkey.

Skin disease is a common problem in boarding schools and may account for significant morbidity. To document the prevalence and patterns of skin diseases among male adolescent and post‐adolescent boarding school residents, a cross‐sectional epidemiologic survey was performed. A total of 682 students were examined for evidence of any skin disease, and subjects with skin disease(s) were also asked to fill in a questionnaire. Of the study population, 378 (55.42%) had at least one skin disease. The most prevalent diseases were tinea pedis (32.5%), acne vulgaris (28.6%), onychomycosis (8.06%), androgenetic alopecia (5.6%), common warts (5.3%), unguium incarnatus (4.1%), irritant hand dermatitis (3.6%), foot callosities (3.6%), and pitted keratolysis (2.6%). Of those with skin problem(s), 245 (65%) were not aware of their disease(s) and 45% of the remaining 133 subjects who were aware of their disease(s) had not sought medical help. We concluded that skin diseases, especially foot problems, are very common among male boarding school students. In additional to monitoring the epidemiology of skin diseases, intermittent medical education programs for both health‐care workers and residents living in these communities would be useful for enhancing knowledge of available and effective treatments and implementing appropriate preventive measures.

Tuberculosis verrucosa cutis in a patient with long-standing generalized lichen planus: improvement of lichen after antitubercular polychemotherapy.

Tuberculosis verrucosa cutis (TBVC) is a rare form of skin tuberculosis in Western communities, and is generally seen in certain risk groups. A 52‐year‐old housewife with recalcitrant generalized cutaneous and mucosal lichen planus (LP) of more than a 20‐year duration presented with an erythematous‐edematous plaque with a warty surface containing deep hemorrhagic fissures and numerous orifices draining purulent material on the back of her left hand. On the basis of clinical, histological and bacteriological findings, TBVC was diagnosed. The patient was successfully treated with isoniazid, rifampicin, ethambutol and pyrazinamide. Interestingly, all lichen lesions improved completely with this therapy. To the best of our knowledge, this is the first documented case of TBVC associated with LP, which was cured by antitubercular polychemotherapy. The case is presented because it reflects a possible reciprocal causal relationship between two cutaneous conditions of different natures.

Diffuse biphasic cutaneous amyloidosis in an HCV‐seropositive patient: another extrahepatic manifestation of HCV infection?

The amyloidoses are a large group of protein-misfolding diseases in which a fibrillar protein amyloid is deposited in extracellular tissues and organs. Primary cutaneous amyloidosis (PCA) is classified as macular, papular (lichenoid) and nodular amyloidosis. Coexistence of macular and lichenoid lesions is termed as biphasic amyloidosis (BA). Diffuse BA is very rare and mostly reported from Southeast Asia (1). HCV infection is associated with various extrahepatic manifestations including autoimmune thyroiditis, lymphocytic sialadenitis, membranoproliferative glomerulonephritis, mixed cryoglobulinemia, leukocytoclastic vasculitis, lichen planus and porphyria cutanea tarda (2). No case of HCV in association with PCA has been reported up to date. We present a Caucasian case of widespread BA in association with chronic inactive hepatitis C who responded well to IFN-a. A 75-year-old man presented with a 10-year history of progressive hyperpigmentation, followed by itching and gradual development of numerous firm papules. Examination revealed extensive grey-brown hyperpigmentation sparing oral mucosa, palms and soles and numerous hyperkeratotic papules located mainly on the extensor aspects of extremities, back, abdomen, lumbosacral regions and glutea. The lower extremities were most severely involved by two types of lesions, but the knees were spared. There were depigmented atrophic areas among the lichenoid papules on the anterior aspects of the shins (Figure 1). Remaining findings were normal except congenital kyphoscoliosis. Histological examinations of macular and papular lesions revealed hyperkeratosis, hypergranulosis, irregular acanthosis, pigment incontinence, superficial perivascular lymphocytic infiltrate and globular homogeneous eosinophilic deposits stained with crystal violet and Congo red in the expanded dermal papillae. Changes were more pronounced in the specimen belonging to a papule. Immunohistochemistry revealed that amyloid deposits reacted with monoclonal antikeratin antibodies like AE1 recognising low molecular keratin peptides K10, 14, 15, 16 and 19. Analyses including biochemical profile, ESR, urine analysis, coagulation tests, serum PTH, T3, T4, TSH, complement and immunoglobulin levels showed normal results. No monoclonal spike was demonstrated by serum protein electrophoresis. Serological investigations revealed that anti-HCV and HCV-RNA were positive, whereas HBsAg, anti-HBs, anti-HBc IgM, HIV-1, HIV-2 antibodies, rheumatoid factor, cryoglobulins, and antinuclear, antismooth muscle, antithyroid, anti-liver, anti-kidney and anti-DNA antibodies were negative. Further interview revealed a history of blood transfusion because of a traffic accident 12 years ago. HCV replication could not be detected in lesional skin sections by in situ hybridisation technique. Considering the age of the patient, no specific therapy for inactive HCV infection was planned. The patient was initially treated with oral antihistamines, topical corticosteroids with occlusive covering on the shins without beneficial effects. Systemic UVB therapy thrice weekly for 3 months also yielded no improvement. The patient was then temporarily lost to follow-up. We later saw him again and learned that he had received 3 million units of IFN-a thrice weekly for 6 months in a private clinic. Interestingly, this therapy yielded a significant regression in hyperpigmented macules and his pruritus along with seroconversion of HCV while papular lesions generally persisted. A control biopsy from the back skin showed no amyloid deposits. The pathogenesis of PCA is not well understood. Chronic cutaneous irritation, causing excessive degenerate keratin production with subsequent conversion into amyloid deposits, has been proposed to be an aetiologic factor (3). Amyloid deposits in these types of amyloidosis are thought to be derived from degenerate keratins of apoptotic basal keratinocytes, as they contain sulfhydryl groups and bind to keratin antibodies. Recent immunohistochemical studies showed keratin epitopes with a positive staining of amyloid deposits with antibodies to keratin (4). Various factors may be responsible for keratinocyte degeneration leading to amyloid formation later, including repeated localised mechanical traumas Correspondence to: Dr Zülal Erbagci, Gazimuhtarpasa Bulvari. Gecit 1. No: 1/5, 27090 Gaziantep, Turkey Fax: þ 90 342 3601617 Email: zerbagci@yahoo.com

Erythrokeratodermia variabilis with adult onset: Report of a sporadic case unresponsive to systemic retinoids

Erythrokeratodermia variabilis is a rare autosomal‐dominant genodermatosis characterized by migratory and erythematous patches changing over the course of hours to days, and fixed keratotic plaques. The disease begins mostly at birth or within the first year of life; it very rarely starts after childhood. We present herein a sporadic case with adult onset that was unusually resistant to both isotretinoin and acitretin.