Aizuri Murad

Rosuvastatin-induced pemphigoid.

Statins are widely prescribed medications and very well tolerated. Rosuvastatin is another member of this drug used to treat dyslipidaemia. It is a competitive inhibitor of the enzyme 3-hydroxy-3-methylglutaryl coenzyme A reductase. Immunobullous disease is usually idiopathic but can be drug-induced. Both idiopathic and iatrogenic forms share common clinical and immunohistological features. The authors report a case of pemphigoid induced by rosuvastatin, a commonly prescribed medication. To our knowledge, there is limited report on rosuvastatin associated with pemphigoid in the literature.

Extensive warfarin-induced skin necrosis successfully treated with negative pressure wound therapy.

A 55-year-old woman presented with an extensive warfarin-induced skin necrosis while an inpatient for treatment of a pulmonary embolism and thromboembolic stroke. She had a background of diabetes mellitus, hypertension and dyslipidaemia. Her warfarin was stopped and she was anticoagulated with low-molecular weight heparin. The wound was successfully treated with a combination of antibiotic, debridement and negative pressure wound therapy.

Granulomatous rosacea-like facial eruption in an elderly man: leukaemia cutis

A man in his 60s presented with a painful and non-pruritic facial eruption of 1-year duration, which was progressively worsening. He had neither ocular symptoms nor fever. He had been diagnosed with chronic lymphocytic leukaemia (CLL) 15 years prior and treated with an intravenous immunoglobulin, chlorambucil, fludarabine and cyclophosphamide combination, with rituximab on separate occasions, but had suboptimal response. His CLL had been gradually progressive in the later years. Examination of his face revealed erythaematous papules and plaques, most prominent on his nose and upper border of his eyebrows bilaterally (figure 1). There was background erythaema on his forehead and cheeks but there was no telangiectasia, and there were neither pustules nor comedones. His nose was not enlarged and the skin contour of the unaffected areas was within …

Rowell's syndrome induced by terbinafine.

Terbinafine, a systemic antifungal commonly prescribed for onychomycosis (fungal infection involving the nails) has been reported to cause various cutaneous adverse effects. We describe an overlap syndrome between cutaneous lupus and erythaema multiforme induced by this medication with a review of other reported cases.

Violaceous Perivulvar Nodular Eruption After Chemotherapy

A woman in her 60s developed fever, rigors, periorbital swelling, and a painful perivulvar eruption, 7 days after her first cycle of cytarabine and daunorubicin hydrochloride for newly diagnosed acute myeloid leukemia (AML). She had a history of type 2 diabetes mellitus, hypothyroidism, and hypercholesterolemia. Her regular medications included metformin, insulin, rosuvastatin calcium, levothyroxine sodium, and aspirin. Examination revealed edematous labia and multiple perivulvar tender nodules on violaceous and indurated plaques sparing the vaginal mucosa and inguinal creases (Figure, A). She also had bilateral injected conjunctivae with periorbital swelling. A punch biopsy of the perivulvar lesions was performed for histopathologic analysis (Figure, B and C) and tissue culture. A C

Purpura fulminans in a patient with mixed connective tissue disease.

A 43-year-old lady was admitted to the intensive care unit with sepsis. She had a history of mixed connective tissue disease, Raynauds syndrome and hypothyroidism. 2 days later, she developed a purpuric rash on her face and extremities with a livedoid background. Few days later, her distal fingers and toes became gangrenous which then had to be amputated. Laboratory investigations showed that she was coagulopathic and had multiple organ dysfunctions. Antiphospholipid antibodies were negative; however, protein C and antithrombin III levels were low. A skin biopsy showed fibrinoid necrosis in the vessel wall with microthrombi and red-cell extravasation. A diagnosis of purpura fulminans was made.

Updates in therapeutics for folliculitis decalvans: A systematic review with evidence-based analysis

REFERENCES 1. Chu SY, Chen YJ, Tseng WC, et al. Psychiatric comorbidities in patients with alopecia areata in Taiwan: a case-control study. Br J Dermatol. 2012;166:525-531. 2. Villasante Fricke AC, Miteva M. Epidemiology and burden of alopecia areata: a systematic review. Clin Cosmet Investig Dermatol. 2015;8:397-403. 3. Koo JY, Shellow WV, Hallman CP, Edwards JE. Alopecia areata and increased prevalence of psychiatric disorders. Int J Dermatol. 1994;33:849-850. 4. Sellami R, Masmoudi J, Ouali U, et al. The relationship between alopecia areata and alexithymia, anxiety and depression: a case-control study. Indian J Dermatol. 2014;59:421. 5. Ruiz-Doblado S, Carrizosa A, Garcia-Hernandez MJ. Alopecia areata: psychiatric comorbidity and adjustment to illness. Int J Dermatol. 2003;42:434-437.

Segmental pityriasis rosea within the area of BRAF-mutated metastatic melanoma

Editor A 50-year-old male presented with a 2 week history of an asymptomatic, segmental, eruption confined to his left axilla and left chest (Fig. 1a). He had a history of 1.3 mm Breslow thickness nodular melanoma excised from the left chest wall with axillary nodal metastases. This was treated with wide local excision and left axillary lymphadenectomy. 1 year later, he was commenced on vemurafenib for BRAF-mutated metastatic melanoma involving his left clavicle. He was systemically well. He was not on any new medications. His PET-CT scan did not show any disease progression. Examination revealed a localized papulosquamous eruption with fine peripheral collarette scale localized to his left axilla (Fig. 1b). Examination with Wood’s light was unremarkable. There was no lymphadenopathy or mucosal lesions. Serologies for syphilis, viral hepatitis, HIV and influenza were all negative. Skin scrapings were negative for fungal infection. Skin biopsy from his left axillary eruption showed hyperkeratosis, parakeratosis, epidermal spongiosis and moderate acanthosis. There was upper dermal perivascular chronic inflammatory cell infiltrate which included lymphocytes and plasma cells. Neutrophils were present within the parakeratotic scale crust and the superficial dermis (Fig. 2). PAS stain for fungi was negative. Clinical and histological findings were consistent with segmental pityriasis rosea (PR). PR is a benign, self-limiting eruption which normally affects young adults. It is most commonly associated with viral infections and rarely drug-induced. PR typically presents with a herald patch that precedes a more generalized papulosquamous eruption on the trunk which occurs 5–15 days later. PR variants include a non-papulosquamous morphology such as papular, vesicular, purpuric and targetoid lesions, presenting without a herald patch, scalp and facial involvement in children, involvement confined to the extremities and segmental eruptions have all been reported. In our case, the new onset of skin eruption was localized to an area of previous malignant melanoma recurrence. The localization of this eruption could represent a distinct atypical presentation of PR or possibly a modified presentation secondary to an immune dysregulation from lymphadenectomy or vemurafenib. Localized presentations of other inflammatory dermatoses can present in a segmental distribution. Ahmed et al. reported a localized PR involving the left breast in a 44-year-old female which was preceded by pharyngitis and initially thought to be shingles. In common acquired skin disorders with polygenic background such as psoriasis vulgaris, pustular psoriasis, atopic dermatitis, lichen planus, granuloma annulare and erythema multiforme, segmental presentation have been described to be more severe and potentially more difficult to treat compared to the non-segmental subtype. It has been proposed that it is likely due to a loss in the heterozygosity affecting one of the genes that predispose to the disorder. Our patient presented with a segmental eruption where the clinical morphology and histology were diagnostic of PR. PR normally resolves spontaneously between 6 and 12 weeks but could sometimes take as long as 6 months for compete clearance of the rash. Phototherapy with narrow band UVB could be used to treat patients with severe and persistent eruptions. Recurrence only occurs in about 2% of cases. In this case, the eruption gradually extended to involve his trunk a few weeks later and then subsided over 8 weeks with tapered topical bethemethasone valerate (0.025%) ointment. The authors wish to thank the following members: Dr. Singh J, Dr. Naseem S, Dr. Picardo S. (a) (b)

Cardiovascular Disease in Inflammatory Disorders - Psoriasis and Psoriatic Arthritis

Psoriasis, a papulosquamous skin disease, was originally thought to be a disorder primarily of epidermal keratinocytes, but is now recognised as one of the commonest immunemediated disorders. It is a chronic skin disorder that causes areas of thickened, inflamed, red skin, often covered with silvery scales. Worldwide psoriasis prevalence rates range from 0.6 percent to 4.8 percent. Children and adolescents can develop psoriasis, but it occurs primarily in adults. There seem to be two peaks in onset: one between ages 20 and 30 and another between 50 and 60. Women and men are equally affected. The immune system is involved and appears to be overactive in a way that causes inflammation. Specifically, there is excessive production of T-Helper 1 cytokines, particularly TNFα. These have many effects, including growth of extra blood vessels within the skin and increased turnover of the skin cells. Like most diseases, psoriasis is influenced by inherited characteristics. Up to 50% of people with psoriasis will know of another affected family member. Patients with a family history of psoriasis tend to develop psoriasis earlier in life than those without a family history.

Images in...: Spontaneous pneumomediastinum

A young, previously well primigravida presented a few hours after a short labour with sudden onset chest pain, shortness of breath and odynophagia. She had subcutaneous emphysema but did not have significant cardiorespiratory compromise. She was found to have a spontaneous pneumomediastinum, likely secondary to raised intrathoracic pressure during labour. Similar cases have been reported previously, however there are often risk factors associated such as pre-existing lung disease and illicit drug use for which this patient did not have a significant history. The patient made a speedy recovery without requiring invasive management, as is the case for most patients documented in the literature. Consideration should be given to subsequent labours for this patient to minimise excessive intrathoracic pressure, however recurrence is rarely documented. This case is useful for healthcare professionals in assessing patients with chest pain as a reminder that unusual presentations can be diagnosed through thorough history and examination.