B. Milpied

Twelve-Year Analysis of Severe Cases of Drug Reaction With Eosinophilia and Systemic Symptoms: A Cause of Unpredictable Multiorgan Failure

BACKGROUND Factors implicated in the severity of drug reaction with eosinophilia and systemic symptoms (DRESS) have not been identified. We retrospectively describe and analyze severe cases of DRESS defined by history of intensive care unit admission and death due to DRESS. OBSERVATIONS Of 15 patients retrospectively recruited in France, 14 were admitted to the intensive care unit and 3 died. The culprit drugs were already known to cause or trigger DRESS: allopurinol, minocycline hydrochloride, anticonvulsants, sulfonamides, and antibiotics. Visceral involvement with severe manifestations responsible for intensive care unit admission or death was variable and often multiple (pneumonitis, hepatitis, renal failure, encephalitis, hemophagocytosis, cardiac failure, and pancytopenia) and resulted in multiorgan failure in 11 patients. These severe complications sometimes developed late in DRESS. Human herpesvirus 6 infection was demonstrated in 6 of 7 patients. In addition, human herpesvirus 6 infection was demonstrated in involved viscera in 2 patients. CONCLUSIONS Severe DRESS is rare. Some specificities of visceral involvement were associated with allopurinol and minocycline. However, visceral involvement comprising multiorgan failure seemed to be unpredictable. Better knowledge of DRESS is necessary to propose specific and prompt treatment. Early demonstration of human herpesvirus 6 reactivation could be considered a prognostic factor for identifying patients at higher risk and, hence, needs to be evaluated.

A three-year-analysis of fixed drug eruptions in hospital settings in France

Fixed drug eruption (FDE) is one of the most typical cutaneous drug adverse reactions. This localized drug-induced reaction is characterized by its relapse at the same sites. Few large series of FDE are reported. The aim of this study was to retrospectively collect and analyse well informed cases observed in a hospital setting. This study involved 17 academic clinical centers. A French nation-wide retrospective multicentric study was carried out on a 3-year-period from 2005 to 2007 by collecting data in seventeen departments of dermatology in France. Diagnosis of FDE was based essentially on clinical findings, at times confirmed by pathological data and patch-testing. Records were reviewed for demographics, causative drugs, localization, severity, and patch-tests, when available. Fifty nine cases were analysed. Patients were 59-years-old on average, with a female predilection. The most common drug was paracetamol, followed by the non-steroidal anti inflammatory drugs. The time between drug intake and skin symptoms was, on average, two days. Beside these classical characteristics, some original findings were found including, a frequent non pigmentation course and a sex-dependent pattern of distribution. Women often had lesions on the hands and feet, and men on the genitalia. Given the fact that skin pigmentation is an inconstant feature of FDE, its French name (erythème pigmenté fixe) should be reconsidered. The sex-dependent distribution could help our understanding of the pathophysiology of fixed drug eruption.

Interest of High-Dose Pulse Corticosteroid Therapy Combined with Methotrexate for Severe Alopecia Areata: A Retrospective Case Series

Background: The combination of systemic pulse corticosteroids and methotrexate in the treatment of severe alopecia areata has never been reported. Objective: The objective of this work was to give arguments for the efficacy and safety of this combined treatment. Methods: This was a retrospective case series of patients treated with intravenous 500 mg methylprednisolone per day for 3 consecutive days monthly during 3 months plus methotrexate initiated at the end of the second pulse regimen. We reviewed all case notes of patients who received this regimen between January 1 2007 and December 1 2010. Results: Twenty patients were treated. Data on hair regrowth at month 12 were available for all patients; 14 patients were still receiving the treatment on December 1 2010, 2 patients were lost of follow-up, and 4 patients had stopped the treatment. Of the 14 patients who were still receiving the treatment regimen at month 18, 10 (10/20, 50%) had total hair regrowth and 4 (4/20, 20%) had incomplete but satisfactory hair regrowth. The treatment was well tolerated. Conclusion: The initial treatment by pulse intravenous corticosteroids may influence the overall response. This approach should be evaluated in a larger series of patients.

Long-term Use of Systemic Treatments for Moderate-to-Severe Atopic Dermatitis in Adults: A Monocentric Retrospective Study.

Data regarding systemic therapies in the management of atopic dermatitis are limited. The aim of this study was to provide evidence for the efficacy and tolerance of systemic immunosuppressive treatments for moderate-to-severe adult atopic dermatitis. A single-centre retrospective study was conducted. A total of 54 patients were prescribed systemic treatments between 2000 and 2014. Of these, 28 received methotrexate and 55.6% were considered as responders based on Physicians Global Assessment, 17 received azathioprine (37.5% responders), 43 received cyclosporin A (65.9% responders) and 7 received a combination therapy with methotrexate and azathioprine (57.1% responders). These treatments were well-tolerated overall and few adverse events required discontinuation of treatment. Combination therapy associating methotrexate and azathioprine appears to be a promising treatment for patients who fail to respond to conventional monotherapies.

Association of Immunologically Confirmed Delayed Drug Reaction and Human Herpesvirus 6 Viremia in a Pediatric Case of Drug-Induced Hypersensitivity Syndrome

child was seen for febrile lower back pain. An epiduritis was suspected on clinical signs, biology and spine MRI. No bacteria were isolated from blood culture and lumbar puncture. Antibiotics were initiated with cefotaxime and rifampicin for 2 weeks. Then the child received oral rifampin and trimethoprim/sulfamethoxazole. The child had never received these antibiotics before. Four weeks later, he presented a progressive generalized rash associated with hyperthermia and severe asthenia and was referred to our unit. Exanthematous eruption, diffuse edema ( fig. 1 ) and severe pruritus were observed on examination; in addition, polyadenitis and splenohepatomegaly were noted. The laboratory results revealed leukocytosis (WBC: 68,000/mm 3 , absolute eosinophil count: 1,800/mm 3 ) with mononucleosis, cholestasis and hepatic cytolysis (alkaline phosphatase: 623 IU/l, aspartate transaminase: 430 IU/l, alanine transaminase: 265 IU/l). Polymerase chain reaction for HHV-6 performed on day 3 after the onset of the rash was positive in blood (65,000 copies/ml). Cytomegalovirus and Epstein-Barr virus serologies were negative. The diagnosis of DIHS was made, and all drugs were discontinued. Corticosteroid therapy was started (prednisone 1 mg/kg/day) resulting in a rapid resolution of DIHS symptoms without epiduritis recurrence. Corticoids were stopped within 2 weeks without relapse. Two months later, drug patch tests were performed with the commercialized forms and with the purified active agent of all suspected antibiotics (drugs series, Chemotechnique , Sweden) in accordance with the guidelines for drug patch testing [1] . The patch tests were ap

The electronic cigarette: the new source of nickel contact allergy of the 21st century?

The electronic cigarette: the new source of nickel contact allergy of the 21st century? Claire Maridet1, Benoit Atge2, Jean-Michel Amici3, Alain Taïeb1 and Brigitte Milpied1 1Department of Dermatology, Hôpital Saint-André, CHU Bordeaux, 33075 Bordeaux, France, 2Department of Medicine and Occupational Diseases, Hôpital Pellegrin, CHU Bordeaux, 33076 Bordeaux, France, and 3Cabinet de Dermatologie Rive Droite, 33150 Bordeaux, France

Airborne allergic contact dermatitis caused by isothiazolinones in water-based paints: a retrospective study of 44 cases

Airborne allergic contact dermatitis caused by paints containing isothiazolinones has been recognized as a health hazard.

Treatment of Pre-ulcerative Necrobiosis Lipoidica with Infliximab

Necrobiosis lipoidica (NL) is a chronic idiopathic gra-nulomatous skin disease often occurring in the setting of diabetes mellitus. Clinically, the lesions present as painful yellow-brown inflammatory plaques with raised borders and atrophic centres. NL typically involves the anterior lower leg and has a tendency to progress to ulceration and scarring. Treatment is often challenging and, to date, no standardized therapy has been proposed. We report here the case of a patient who was seen at a pre-ulcerative stage of NL that had not responded to conventional therapies. CASe RePORT A 27-year-old white man consulted for a slightly eroded le-sion of the external side of his left ankle, which had gradually enlarged becoming very painful. The lesion had been present for more than 3 years. His medical history was otherwise unre-markable, except for a history of type 1 diabetes mellitus since childhood. examination revealed atrophic, yellow-brown to red, telangiectatic plaque, 6×9 cm in size (Fig. 1a). The patient reported that the lesion had a tendency to ulcerate following minimal trauma, which clearly affected his quality of life. Skin biopsy from the lesion was consistent with NL, showing necrobiotic collagen with sclerosis and palisaded granuloma in the dermis. The dermal interstitial infiltrate consisted of his-tiocytes, multinucleated giant cells, lymphocytes, and plasma cells. Treat ment with topical tacrolimus and intralesional tri-amcinolone acetonide (5 mg/l) was unsuccessful. Given the young age of the patient, and based on previous reports arguing for efficacy of biological agents in NL (1, 2), it was decided to start therapy with infliximab. Chest X-ray, tuberculin test, hepatitis B and C and HIV serologies were all negative. The patient was therefore started on intravenous infliximab therapy, 5 mg/kg, associated for the first infusion with 200 mg hydrocortisone. The patient received a total of four infusions (at weeks 0, 2, 6, and 12). At his first post-treatment visit (week 2), the lesion had become painless. Complete wound healing was achieved at week 6 of infliximab therapy, with fading of the erythematous component, flattening of the margin and an excellent cosmetic result (Fig. 1b). The treatment was well tolerated with no noted side-effects. At 9-month follow-up, no relapse had been noted. DISCUSSION NL is a rare chronic inflammatory granulomatous skin disease of unknown origin. It is reported to occur more frequently in women than men (3, 4). The disease is often associated with diabetes mellitus, although treat ment of a patients diabetes …

Pattern and Severity of Psoriasiform Eruptions in Patients with Inflammatory Bowel Diseases, Arthritis or Skin Inflammatory Disorders Treated with TNF-alpha Inhibitors

Psoriasiform eruptions are a classical adverse skin reaction of tumour necrosis factor (TNF)-α inhibitors. The aim of this study was to identify the association between the severity or pattern of psoriasiform reactions and the underlying disease. A retrospective study was conducted between January 2012 and May 2015. Adult patients who developed psoriasiform eruptions whilst being treated with TNFα inhibitors were included. For each patient, 3 independent blinded dermatologists graded twice the severity of the lesions according to 6 clinical psoriasiform eruption types. Inter- and intra-individual kappa tests were performed to evaluate the robustness of the scoring system. The association between severity score levels or the pattern of reactions and the underlying disease was assessed. The severity scoring system showed good inter- and intra-observer reproducibility. Women patients treated with TNFα inhibitors for inflammatory bowel diseases showed a higher risk of developing severe reactions with scalp and skin-fold involvement.

Exogenous Inflammatory Acne due to Combined Application of Cosmetic and Facial Rubbing

Background: Exogenous acne refers to acneiform lesions due to external factors such as cosmetic agents, exposure to various oils, skin rubbing or friction or chloracne, now better called metabolizing acquired dioxin-induced skin hamartoma (MADISH). Here we report a new form of severe inflammatory exogenous acne due to the association of two factors: facial friction with cosmetic agents. Observations: A 15-, 17- and 19-year-old female presented at the department with severe inflammatory acne. In all cases, the face had been strongly rubbed in a compulsory manner in the previous weeks with cosmetic agents. The disease has not responded to various conventional acne treatments and was well controlled by a combination of oral corticosteroids and low-dose isotretinoin. Conclusion: Because cosmetic face friction as a cosmetic care becomes more and more fashionable, dermatologists should be aware of this severe clinical condition, which can occur in patients without a personal history of acne.