Alfred Ammoury

Treatment of mammary and extramammary Paget's skin disease with topical imiquimod

Background: Pagets disease is an uncommon epidermal cancer, affecting all skin regions wherever apocrine glands are present. It is divided into extramammary (EMPD) and mammary Pagets disease (MPD). It can be confined to the epithelium or may be associated with an underlying adenocarcinoma. The diagnosis is confirmed by skin biopsy and the treatment depends on characteristics of the underlying cancer. Surgery is the first‐line treatment. Imiquimod, a topical immunomodulator, approved its efficiency in several skin neoplasms and has been shown as a safe treatment for EMPD. However, it has never been reported for the treatment of MPD. Observations: We report on two cases of EMPD and MPD successfully treated with imiquimod 5% cream. Conclusion: This non‐surgical method may be considered as a primary treatment when Pagets disease is not associated with an underlying malignancy. The good prognosis with a long‐term survival, the anatomic localization and the poor general condition of elderly people may favor imiquimod as an alternative treatment. On the other hand, it will reduce the extent of excision when it anticipates surgery.

Photodistribution of blue-gray hyperpigmentation after amiodarone treatment: molecular characterization of amiodarone in the skin.

BACKGROUND For decades, the photodistributed blue-gray skin hyperpigmentation observed after amiodarone therapy was presumably attributed to dermal lipofuscinosis. Using electron microscopy and high-performance liquid chromatography, we identified amiodarone deposits in the hyperpigmented skin sample from a patient treated with this antiarrhythmic agent. Our findings therefore indicate that the hypothesis relating the blue-gray hyperpigmentation to lipofuscin should be challenged. OBSERVATIONS A 64-year-old man, skin phototype III, presented with asymptomatic skin hyperpigmentation that had been slowly developing on sun-exposed areas since April 2004. He had been taking amiodarone for 4 years (cumulative dose, 277 g). Electron microscopy did not show lipofuscin pigments in his skin. Conversely, abundant electron-dense membrane-bound granule deposits were observed in most of the dermal cells (fibroblasts, macrophages, pericytes, Schwann cells, and endothelial cells), especially in photoexposed skin. High-performance liquid chromatography confirmed that the skin deposits were composed of amiodarone. These results demonstrate that amiodarone hyperpigmentation is related to drug deposition on photoexposed skin. CONCLUSION Amiodarone-related hyperpigmentation should be considered a skin storage disease that is secondary to drug deposition.

Moderate to severe psoriasis: from topical to biological treatment

Introduction  The simple use of topical corticosteroids in the treatment of severe psoriasis is often inefficient and harmful. The first line of treatment in these cases is based on systemic therapies such as methotrexate, cyclosporin and phototherapy. Later on, biological treatments can be used.

Point prevalence and risk factors for food allergy in a cohort of 386 children with atopic dermatitis attending a multidisciplinary dermatology/paediatric allergy clinic

There is considerable debate about the prevalence and relevance of food allergy (FA) in atopic dermatitis (AD). The aim of this study was to investigate the prevalence of and risk factors for FA in a cohort of children with AD attending a multidisciplinary paediatric allergy clinic.MethodsThe analysis was performed on 386 children (50.8% boys, median age 4 years) consecutively evaluated for AD. A diagnosis of FA was established on positive skin tests and/or a specific IgE value or a positive oral food challenge.ResultsPoint prevalence of FA was 17.8%. Egg, peanuts, milk, tree nut and mustard accounted for 93% of cases. 37.7% of children had ≥2 positive food reactions. Risk factors associated with FA were young age (OR = 7.9 when ≤2 years compared with ≥5 years), moderate to severe AD (OR = 7.8 for severe and 2.4 for moderate AD) and onset of AD before 3 months of age (OR = 5.7).ConclusionPoint prevalence of FA in children with AD is lower than initially reported in patients recruited in a paediatric allergology setting. Children ≤2 years of age with early-onset or severe AD are at higher risk of FA and may be candidates for FA evaluation.

Scleromyxoedema with associated peripheral neuropathy: successful treatment with thalidomide.

We report a patient with scleromyxoedema and peripheral neuropathy treated successfully with thalidomide. An objective evaluation was carried out using histopathology, cutaneous ultrasonography and magnetic resonance imaging (MRI). A 67‐year‐old woman presented with a leonine face, generalized thickened skin, an underlying peripheral neuropathy and a monoclonal gammopathy. She was treated with thalidomide 100 mg/day. After 20 months of therapy, there was a dramatic clinical improvement in the skin lesions, and the neuropathy also improved. Cutaneous ultrasonography showed a reduction in dermal thickness, whereas the results of the cutaneous MRI were inconclusive. Thalidomide appears to be effective in scleromyxoedema. Its specific effect on the underlying monoclonal gammopathy might have contributed to the improvement in the skin and neurological symptoms. In this case, assessment of cutaneous improvement with cutaneous ultrasonography was superior to that of cutaneous MRI. Thalidomide should be considered for the treatment of scleromyxoedema despite the presence of an underlying peripheral neuropathy.

Milia complicating bullous polymorphic light eruption

Polymorphic light eruption (PLE) is the most common photosensitivity disorder. Typically, PLE manifests in the spring or summer months as a recurrent pruritic papular and/or vesicular eruption occurring on photoexposed skin areas following sun exposure. The milia are caused by proliferative tendencies of the epithelium after injury. These may occur in areas of subepidermal bullous eruption. We report an original case of bullous PLE complicated by milia. Such association has not been reported previously.

Dermatite atopique de l’enfant : quand penser à l’allergie alimentaire ?

Resume Introduction. La prevalence et la pertinence du diagnostic d’allergie alimentaire (AA) au cours de la dermatite atopique (DA) est un sujet qui fait debat. L’objectif de cette etude etait de determiner la prevalence et les facteurs de risque associes a l’allergie alimentaire dans une cohorte d’enfants souffrant de dermatite atopique et consultant un service de dermatologie. Methodes. l’analyse a ete realisee a partir d’une cohorte de 400 enfants evalues consecutivement pour une DA dans le service de dermato-allergologie. Le diagnostic d’AA etait porte en s’aidant de prick tests positifs et/ou de valeurs seuils d’IgE specifiques, selon les aliments concernes ou bien du test de reintroduction orale. Des analyses univariees et par regression logistique ont ete realisees a partir des donnees obtenues lors des consultations pour determiner les facteurs de risque associes a l’AA. Resultats. la DA a pu etre confirmee chez 386 enfants, 195 (50,8 %) etaient des garcons. L’âge median etait de 4,0 ans (IIQ : 1,7-7,7). La prevalence de l’AA etait de 17,8 % ( n = 69 ; IC 95 % : 14,1-22,0). Les aliments les plus frequemment impliques etaient l’oeuf, l’arachide et le lait. Parmi les enfants presentant une AA, 26 (37,7 %) etaient concernes par deux aliments ou plus. Les facteurs de risque associes a l’AA etaient un âge inferieur a 2 ans (OR = 7,9 pour les enfants de moins de 2 ans compares a ceux de plus de 5 ans, IC 95 % : 3,3-19,0 ; p 10 -3 ), une DA moderee a severe evaluee sur la base du Scorad (OR = 7,8 pour une DA severe ; IC 95 % : 1,9-31,4 ; p 10 -3 et OR = 2,4 pour une DA moderee ; IC 95 % : 1,2-4,8 ; p 10 -3 ) et une DA precoce ayant debute avant l’âge de 3mois (OR = 5,7 ; IC 95 % : 1,8-18,3 ; p 10 -3 ). Conclusion. La prevalence de l’AA au cours de la DA de l’enfant, lorsque le diagnostic est base sur des criteres clinico-biologiques semble moins elevee que dans des etudes plus anciennes. Les facteurs de risque qui lui sont associes sont un enfant consultant tot, une DA moderee a severe et une DA precoce.

Purpuric lesions induced by UVA1 spectrum (340–400 nm) phototesting in an adult with persistent and severe hydroa vacciniforme

A 28‐year‐old man had presented a severe photosensitivity since his infancy. In March 2008, the clinical examination showed large crusts on the dorsum of his hands, on the edge of his ears with destruction of the underlying cartilage, and on his nose and cheeks. He also presented erythematosus fibrous scars on the temples. The diagnosis of hydroa vaccinforme was made. Phototesting including repeated UVA1 phototest was strongly positive with purpuric lesions from day 7 to day 10 and hypertrophic scars at day 67. A sequential histological study of the UVA1 triggered lesions was performed and showed bullous cleavage, dense inflammatory infiltrate in the whole dermis with numerous neutrophilic cells, nuclear dusts, superficial focal thrombosis of small blood vessels at day 10. We report an unusual case of hydroa vaccinforme with purpuric lesions leading to fibrous scars and with important infiltration of neutrophils in the dermis of the photoinduced lesions.