Arianna Fay Agnoletti

Remitting seronegative symmetrical synovitis with pitting edema associated with parvovirus B19 infection: two new cases and review of the comorbidities.

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is a rare syndrome consisting of acute symmetrical tenosynovitis of the hands and wrists associated with pain and marked pitting edema of the dorsum of the hands or the feet. Persistent rheumatoid factor seronegativity and elevated acute phase reactants are the rule, while radiographic findings are characterized by the absence of bony erosions. The syndrome has occasionally been associated with a wide range of diseases including solid and hematological malignancies, polymyalgia rheumatica, and other inflammatory rheumatic diseases.

Fissured tongue responding to biologics during the treatment of psoriasis: the importance of detecting oral involvement of psoriasis

Recent studies have provided more evidence that psoriasis can give mucosal lesions, especially oral. Nonspecific lesions such as fissured tongue and geographic tongue are relatively frequent in patients suffering from psoriasis. We report a case of a patient presenting an important improvement of his fissured tongue paralleling the improvement of the cutaneous lesions after a 5‐month systemic therapy with infliximab. The authors think it would be important to consider possible oral lesions in patients suffering from psoriasis in normal practice and to evaluate them introducing specific clinical scales.

Madurella mycetomatis mycetoma treated successfully with oral posaconazole.

A 31-year-old male, born in senegal and living in italy for 10 years, presented to our outpatient unit with an 8-year history of nodular swelling and discharging sinuses on the dorsum of the right foot. The previous diagnoses, at other health-care facilities, were recurring bacterial abscesses. The patient underwent three surgical cleansings and repeated cycles of antibiotic treatment with no improvement. The patient reported suffering trauma to his right foot when he was 18 years old, while working with an axe in senegal. Physical examination revealed swelling on the dorsum of the right foot at the i metatarsal, with several fistulas either draining a serosanguineous discharge or covered with crusts (Figure 1). General examination revealed no significant findings. Routine blood chemistry, including liver function tests, and renal function, were normal. The blood test for human immunodeficiency virus (HiV) was negative. no bone lesions were seen on the x-ray of the foot. Echographic examination of the soft tissues revealed the presence of small areas with nonhomogeneous structure at the i, iV and V metatarsal bones. A biopsy of the i metatarsus revealed several hard, black, lobed granules of 0.6-0.7 mm in size. The histopathological findings showed a granulomatous infiltrate containing brown granules. The grains were surrounded by a narrow zone of polymorphs and further surrounded by a mixed inflammatory infiltrate consisting of mononuclear cells, histiocytes, and a few foreign body giant cells (Figure 2). The granules consisted of large vesicular hyphae (Figure 3). The examination of granules in KOH 20% mounts showed brown, septate hyphae, with large swollen cells at the periphery, conglobated in a matrix. several granules were cultured on sabouraud glucose agar containing chloramphenicol and gentamicin and incubated at 37°C. After 3 weeks, folded-whitish colonies had developed, which became blackish in color with brown diffusible pigment around the medium after another 2 weeks. Microscopic examination of the colonies showed moniliform hyphae and enlarged chlamydospore-like cells. On the basis of the macroscopic and microscopic features of the granules, the isolate was identified as Madurella mycetomatis. The treatment with 200 mg capsules of itraconazole daily for 10 months (during the main meal and with no coadministration of antacids or other medicines) was unsuccessful. We decided, therefore, to start a therapy with posaconazole (400 mg capsules twice a day) and after 15 months the lesions had cleared completely with minimal scarring. After 12 months of follow-up, no lesions reappeared. Eumycetoma is a chronic suppurative and/or granulomatous subcutaneous fungal infection characterized by indolent, deforming, swollen lesions and sinuses involving cutaneous and subcutaneous tissues, fasciae and bones, usually occurring on a foot or hand. The draining sinuses discharge numerous small particles or grains whose colors vary according to the etiologic agent.

Efficacy of treatment with oral alitretinoin in patient suffering from lichen simplex chronicus and severe atopic dermatitis of hands

Lichen simplex chronicus (LSC) is a skin disorder characterized by chronic itching and scratching, which can lead to thick, leathery, brownish skin, sometimes with papules and can be associated with atopic eczema. We report the case of a 52‐year‐old man with a 45‐year atopic condition and presenting LSC in his dorsum. After a 3‐month treatment with alitretinoin at the daily dosage of 30 mg, we have observed a moderate improvement of the hand eczema together with a substantial clinical improvement of LSC and an almost complete resolution of pruritus. We want to report this peculiar case to suggest the use of oral alitretinoin for LSC.

Skin ulcer as a presenting manifestation of pulmonary Mycobacterium avium infection.

Conflicts of interest: None. Funding sources: This article was supported by research funds of Chonbuk National University in 2012. References 1 Agero ALC, Dusza SW, Benvenuto-Andrade C, et al. Dermatologic side effects associated with the epidermal growth factor receptor inhibitors. J Am Acad Dermatol 2006; 55: 657–670. 2 Benomar S, Boutayeb S, Afifi Y, et al. Hand-foot syndrome and seborrheic dermatitis-like eruption induced by erlotinib. Dermatol Online J 2009; 15: 2. 3 Segaert S, Van Cutsem E. Clinical signs, pathophysiology and management of skin toxicity during therapy with epidermal growth factor receptor inhibitors. Ann Oncol 2005; 16: 1425–1433. 4 Rouxel AM, Roguedas AM, Descourt R, et al. Hand-foot syndrome: a new side effect of erlotinib. Ann Dermatol Venereol 2008; 135: 762–764. 5 Razis E, Karina M, Karanastassi S, et al. Three case reports of hand-foot syndrome with gefitinib. Cancer Invest 2006; 24: 514–516. 6 Trarbach T, Reinacher-Schick A, Hegewisch-Becker S, et al. Gefitinib in combination with capecitabine as second-line therapy in patients with advanced colorectal cancer (aCRC): a phase I/II study of the arbeitsgemeinschaft internistische onkologie (AIO).Onkologie 2010; 33: 89–93. 7 Baack BR, Burgdorf WH. Chemotherapy-induced acral erythema. J Am Acad Dermatol 1991; 24: 457–461. 8 Susser WS, Whitaker-Worth DL, Grant-Kels JM. Mucocutaneous reactions to chemotherapy. J Am Acad Dermatol 1999; 40: 367–398. 9 Tsai KY, Yang CH, Kuo TT, et al. Hand-foot syndrome and seborrheic dermatitis-like rash induced by sunitinib in a patient with advanced renal cell carcinoma. J Clin Oncol 2006; 24: 5786–5788. 10 Hiatt KM, Horn TD. Cutaneous toxicities of drugs. In: David E, Rosalie E, Bernett LJJ, George FM, Xiaowei X, eds. Lever’s Histopathology of the Skin, 10th edn. Philadelphia: Lippincott, 2009: 315.

Eyelid contact dermatitis caused by unusual allergens in hair dye: the importance of testing with additional series.

hair dye: the importance of testing with additional series Editor, Hairdressing chemicals may be associated with allergic contact dermatitis. Usually, the first step to diagnosing a possible allergic contact dermatitis involves patch testing the patient with a standard series of haptens. This provokes positive reactions in 40–65% of cases. We report a 33-year-old woman who presented with eyelid dermatitis. The patient manifested edema associated with pruritus and burning on both upper and lower eyelids. All the periorbital tissue showed slight desquamation (Fig. 1). The patient also demonstrated pruritus on the scalp, face, and neck. The symptoms had appeared three days after the subject had applied a hair dye at her own home. Her history revealed two episodes of eczematous rash on the trunk which had occurred four to five days after using the same hair dye the previous year. An allergological investigation conducted at the time using a standard SIDAPA (Società Italiana di Dermatologia Allergologica, Professionale e Ambientale Italian Society of Allergological, Occupational and Environmental Dermatology) series showed positive results only for nickel sulfate. A brief cycle of topical and systemic corticosteroids was administered to resolve the symptoms and the patient was tested again with a standard series. Additional patch testing with our specific hairdressing series showed a positive reaction to hexyl cinnamal (2% in pet.) and phenoxyethanol (1% in pet.), a preservative for personal care products that is a component of Euxyl K400 (Schülke & Mayr Italia S.r.l., Milano). Lastly, a patch test using the patient’s hair coloring (50% in pet.) was performed, revealing a positive reaction. The condition did not recur after the patient stopped using this particular hair dye. We report this unusual case because neither the allergens nor the localization of the dermatitis (eyelids) are common in dermatitis related to hairdressing chemicals. We also wish to emphasize the importance of testing with specific additional series when the patient’s history leads to a reasonable diagnostic hypothesis, and when testing the products used by the patient is possible. Francalanci et al. demonstrated the importance of using additional series in a study in which a small group (8.2%) of patients undergoing patch testing were negative to a standard series but positive to additional series. In addition, Wang et al. showed that 6.4% of allergies to hairdressing products were not detectable using the standard allergen series alone. Although the prevalence of contact allergy to Euxyl K400 is increasing, the Italian standard series does not include the substance in this form, but as methyldibromoglutaronitrile, which is considered a major sensitizer. Phenoxyethanol is included only in the additional series. In other countries, hexyl cinnamal is included in standard series, such as in Germany since 2005 and in the UK since 2007. Hexyl cinnamal (which is included in fragrance mix II) is not included in the SIDAPA standard series used at the time of this investigation. It is very important that a detailed patient history is obtained and a specific allergological investigation conducted in order to ascertain the most likely suspect allergen and, thereby, establish the cause of a diagnosis of eyelid contact dermatitis. Figure 1 Erythematous and edematous lesions on both eyelids