A. Zaouak

Bathing suit ichthyosis caused by a TGM1 mutation in a Tunisian child

Bathing suit ichthyosis (BSI) is an uncommon phenotype classified as a minor variant of autosomal recessive congenital ichthyosis (ARCI).

Frontotemporal hairline recession in a postmenopausal woman

A 69-year-old postmenopausal woman consulted for frontal hair loss for two years. She had started menopause at the age of 50 years old and had been taking bisphosphonates for her osteoporosis for two years. Her clinical history, including gynecological data, was otherwise negative. Anamnestic data ruled out the possibility of traction alopecia. Dermatological examination revealed a Fitzpatrick skin type III. She had a linear frontotemporal recession with perifollicular erythema, lonely hairs on the frontal region, and scarring alopecia ( Fig-ure 1). The patient had a total loss of eyebrows but she did not have body hair loss. There were no other skin or mucosal abnormalities. Thyroid hormone function was also normal. Dermoscopy with a non-contact polarizing FotoFinder der-matoscope x20 (FotoFinder Systems, Inc, Bad Birnbach, Germany) revealed perifollicular erythema and very mild perifollicular scaling in addition to hair shaft dystrophy and broken hair. Furthermore, dermoscopy noted the presence of white dots coexisting with irregular white and pink areas devoid of hair follicular openings ( Figure 2 ). No prior topical treatment was used before our consultation. A 4 mm scalp punch biopsy from the frontal hairline was performed. His-

A case of linear atrophoderma of Moulin successfully treated with methotrexate

Linear atrophoderma of Moulin is an acquired rare and self‐limited skin condition. It is characterized by atrophic bandlike skin lesions that often show hyperpigmentation and always follow the lines of Blaschko. Usually it begins in childhood or adolescence and there is no evidence of any long term progression. We describe a case of a 21‐year‐old woman with clinical and histological features of linear atrophoderma of Moulin. The patient was successfully treated with methotrexate 20 mg/week during 6 months with an improvement of skin pigmentation and atrophy. Approximately, 30 cases of linear atrophoderma of Moulin were described in the literature. There is not a proven effective treatment of this dermatosis. High dose penicillin, topical corticosteroids, heparin, and oral potassium aminobenzoate have been used but found to be uneffective. To our knowledge, this is the first case of extensive linear atrophoderma of Moulin treated with methotrexate.

My Daughter Has Thin and Short Hair

A 16-year-old female presented to our dermatology department for a history of congenital hypotrichosis. She was born from a consanguineous marriage. Her sister and brother also suffered from sparse and fragile hair. Dermatologic examination revealed diffuse hypotrichosis with sparse, short, and broken hair on her entire scalp (Fig. 1). Her hypotrichosis was more pronounced on her occipital scalp. She also had small keratotic papules on her occipital region. Her eyebrows and eyelashes were not affected. There were no tooth nor nail abnormalities. There was no evidence of mental retardation, epilepsy, or systemic diseases.

Unconventional use of fractional ablative CO2 laser in necrobiosis lipoidica

Dear Sir, Necrobiosis lipoidica is a rare noninfectious granulomatous disease classically associated with diabetes mellitus. It is characterized by collagen degeneration, granuloma formation, and endothelial swelling (1). It is a cosmetically displeasing condition affecting the patient’s quality of life. Usually necrobiosis lipoidica is treated with either topical or systemic therapies with an unsatisfactory response. The use of ablative fractional CO2 laser in the treatment of necrobiosis lipoidica has been rarely reported in the literature. Herein, we report a case of necrobiosis lipoidica successfully improved with ablative fractional CO2 laser. A female patient aged 32 years old with a past medical history of diabetes since 5 years was referred to our department for multiple cutaneous lesions located on her left foot and left leg since 3 years. Dermatological examination revealed multiple annular pigmented lesions with central atrophy in her left leg in addition to two annular erythematous plaques with whitish scales on the dorsum of her left foot (Figure 1(a, b)). According to her history and her clinical findings, necrobiosis lipoidica was suspected and a skin biopsy was performed on the affected skin. Histopathological examination revealed palisading granulomas surrounding large foci of necrobiosis involving the entire dermis and extending into the subcutaneous fat septa confirming the diagnosis of necrobiosis lipoidica. The patient was initially treated with topical corticosteroids for 2 months with no successful results. She was then scheduled to be treated with hydroxychloroquine. Ophthalmologic examination done before initiating hydroxychloroquine found retrobulbar optic neuritis contraindicating the use of this treatment. After giving written informative consent, the patient was treated with ablative fractional CO2 laser. This treatment alternative was proposed to the patient as an experimental approach. The patient was treated with ablative fractional CO2 laser (CO2 Limmer laser). Three sessions were performed with a 2-month interval. The session was performed under local anesthetic using 125 mm hand-piece, 10 mm spot, 25% density, and 10 Watts energy. At the end of the procedure, the wound was covered with topical fusidic acid ointment. The patient was seen 4 weeks after laser treatment. Neither scar nor pigmentary disorders nor skin ulceration were noted. After the third session, there was a significant improvement of the cutaneous lesions with a softening of the lesions, disappearance of scales, and improvement of the central atrophy of the lesions (Figure 2a, b). Necrobiosis lipoidica is characterized by yellow-brown atrophic telangiectasic plaques in the pretibial surface. The plaques are usually multiple and bilateral (2). Many treatment alternatives could be proposed to treat this skin condition such as phototherapy, photodynamic therapy, topical tacrolimus, topical corticosteroids and intralesional corticosteroids, hydroxychloroquine, infliximab, and etanercept with variable response (1). Improving glycemic control may contribute to necrobiosis lipoidica resolution, but this hypothesis is still controversial (3). Few cases of necrobiosis lipoidica were treated with laser therapy. The largest study is that of Buggiani et al. (4), which treated 11 patients affected with necrobiosis lipoidica with fractional CO2 laser with a significant improvement in 9 patients. Two other studies conducted by Moreno Arias et al. and Currie et al. (5,6) reported two cases of stable necrobiosis lipoidica treated with the pulsed dye laser with an improvement of their skin condition. Since fractional photothermolysis stimulates collagen formation and remodeling (7,8), its use in this skin condition where there is collagen degeneration could be very useful as seen in our case. Necrobiosis lipoidica could be very inesthetic with an impairment of the patient’s quality of life. This case illustrates that fractional resurfacing appears to be a new promising modality for an effective treatment of stable necrobiosis lipoidica with a safe and acceptable side effect profile. More studies are needed to confirm the immunomodulatory effect of fractional photothermolysis in the treatment of necrobiosis lipoidica.

A case of herpes simplex virus reactivation after fractional ablative carbon dioxide laser to treat a burn scar

ABSTRACT Fractional photothermolysis was initially introduced by Manstein in 2004 .Fractional CO2 laser technology introduced has allowed physicians to obtain good cosmetic results with a lower rate of complications than non-fractionated ablative laser treatment. However, adverse effects may still occur.Reported cases of HSV infection after fractional photothermolysis are rare. A 48-year-old woman with Fitzpatrick skin type III presented with a scar in her perioral area desiring esthetic improvement of her burn scar. She didn’t have a history of recurrent herpes simplex virus (HSV) infection periorally. A fractionated resurfacing laser Quadralase (Candela) was used to treat her perioral burn scar. Two sessions were performed with a month interval. Five days after the second session of laser therapy even after she took antiviral prophylaxis based on valacyclovir 500mg twice daily 24 hours before the laser session and 3 days after, she presented with a rash on the perioral area preceded by pain. Correlation of the history and the clinical presentation was consistent with HSV reactivation. Treatment was initiated with acyclovir 10mg/kg/8h administered intravenously for 10 days with a clearing of her vesicular eruption. Fractional CO2 laser is a very safe procedure when used with accepted parameters. Early recognition, close monitoring and careful wound care will prevent long term sequelae when complications occur.

Association of khellin and 308-nm excimer lamp in the treatment of severe alopecia areata in a child

ABSTRACT Alopecia areata (AA) is an autoimmune inflammatory disorder of hair, characterized by non-scarring hair loss. A 308-nm excimer lamp (EL) has been reported as one effective modality in the treatment of AA. Khellin is a furanochromone photosensitizer whose chemical structure is close to psoralens and has previously proven its efficacy in vitiligo in association with ultraviolet A. We evaluated the efficacy and safety of a combination of topical khellin and 308-nm EL in the treatment of a refractory ophiasic AA, of 1-year evolution, in a 5-year-old boy. Treatment consisted in topical application of khellin 45 mn before irradiation with EL (starting dose 50 mJ/cm2) twice a week for 3 months. The result was a complete regrowth of hair with no recurrence 1 year later. Further studies should be carried out to confirm this promising result and to propose khellin–excimer as a new alternative treatment for resistant cases of AA in children.

Acute generalized exanthematous pustulosis induced by terbinafine in a child confirmed by patch testing

Acute generalized exanthematous pustulosis induced by terbinafine in a child confirmed by patch testing Acute Generalized Exanthematous Pustulosis (AGEP) is a rare and severe skin condition typically caused by drugs. AGEP is more frequent in adults than in children. Herein, we report a case of AGEP in a child induced by terbinafine and confirmed by a positive patch test reaction. A 6-year-old boy without a past medical history of drug allergy or personal or family psoriasis was referred to our department following the sudden appearance of a generalized pustular eruption associated with fever (38.5 °C). Cutaneous examination revealed a generalized rash interspersed with millimeter-sized pustules located mainly on the trunk, axillary, and inguinal folds (Fig. 1a,b). There was no mucous membrane involvement. Systemic examination revealed small lymphadenopathies at cervical, auricular, and axillary regions. His mother reported that he had recently received oral terbinafine 250 mg per day for tinea capitis (Fig. 2) for 2 days. Then, the patient developed fever, and his doctor switched to amoxicillin and clavulanic acid to treat a suspected bacterial superinfection of his tinea capitis. The rash had appeared on the fifth day of treatment, at first located on the trunk then widespread to all his body. Laboratory tests showed an elevated white blood cell count with neutrophilia, an elevated erythrocyte sedimentation rate, and an elevated C-reactive protein level (83.88 mg/ml). Kidney and liver functions were normal. An infectious etiology was excluded by chest x-ray, cytobacteriological urinalysis, and swabs of pustules which were negative. A skin biopsy was performed, and histopathological findings revealed subcorneal pustules associated with neutrophilic spongiosis, few necrotic keratinocytes, and a papillary infiltrate including eosinophils (Fig. 3). Our patient was disgnosed to have AGEP according to the European Study of Severe Cutaneous Adverse Reactions (EuroSCAR) criteria. All the treatments taken by the child were discontinued. Symptomatic treatment was given with antipyretics, daily showers, dermocorticoids, and antihistaminic drugs. The pustular lesions disappeared within a week, followed by desquamation. Patch tests with terbinafine and amoxicillin-clavulanic acid (the commercialized form used by the patient diluted to 30% petrolatum) were performed 9 weeks later on the patient’s back, with exposure for 48 hours according to European Society of Contact Dermatitis guidelines. Patch test results showed a pustular skin reaction to terbinafine on the second day. No reaction to amoxicillin-clavulanic acid was observed. The responsibility of terbinafine was incriminated according to the French method of drug imputability of Begaud et al. 4 (with a score of I3). Hence, terbinafine was contraindicated in our patient. For his tinea capitis, the patient was treated with griseofulvin 500 mg per day for 6 weeks with a favorable outcome. This adverse drug reaction was more described in adults than in children. We report, to our knowledge, the second case of AGEP induced by terbinafine in a child where the diagnosis has been confirmed by a positive patch test reaction. In fact, only one case of AGEP induced by terbinafine in a child was

A pigmented nodule on the neck

A 58-year-old man was referred to our department for a slowly enlarging pigmented nodule on the neck since 2 years. The patient was otherwise in a good health and did not report any family history of skin cancers. Cutaneous examination revealed a pigmented nodule of 2 centimeters of diameter which was ulcerated in the center, located on the neck (Fig. 1). The rest of his dermatological examination was normal, and there were no regional

An acute acral papulovesicular eruption

A 58-year-old female patient was referred to our department for an acute acral vesiculobullous eruption present for 3 days. Her past medical history was unremarkable. The sudden onset of the painful vesiculobullous lesions (within 3 days) was extremely troublesome to the patient. Cutaneous examination revealed multiple erythematous and edematous round plaques with overlying ulcerated bullae and vesicular lesions on the forearms (Fig. 1a). Her oral mucosa was involved since she had superficial erosions on the lips with aphthous lesions (Fig. 1b). Concomitant with the cutaneous eruption, she also had a red painful right eye with no blurred vision. Ophthalmologic examination revealed two scleral nodules with surrounding episcleral injection located on the temporal and medial aspects of the right eye (Fig. 1c). The cornea was clear, and there was no anterior chamber activity consistent with the diagnosis of nodular scleritis. The patient also complained of fever and arthralgia of the knees and ankles. Laboratory investigation was notable with elevated leukocyte count with neutrophilia (neutrophils 87%). The erythrocyte sedimentation rate and C-reactive protein concentration were elevated at 80 mm and 54 mg/l, respectively. Renal and liver function were normal. HIV serology was also performed and was nonreactive.