Daniel Morgado-Carrasco

Clinical and photobiological response in eight patients with solar urticaria under treatment with omalizumab, and review of the literature

Solar urticaria (SU) is a rare photodermatosis. Treatment is challenging, and outcomes are often disappointing. Omalizumab is an anti‐IgE, currently approved for treatment of chronic spontaneous urticaria. We sought to evaluate therapy with omalizumab in refractory SU and describe predictive factors for response.

Resolution of aquagenic pruritus with intermittent UVA/NBUVB combined therapy

To the Editor, Aquagenic pruritus (AP) is a rare skin disease of unknown etiology characterized by the abrupt onset of pruritus without visible cutaneous lesions after contact with water or humidity. AP can have a severe impact on the patient’s quality of life. Although AP is mostly idiopathic, it can be associated with polycythemia vera, other hematologic disorders and medications.1 Treatment is challenging and often disappointing, and may consist in topical agents such as capsaicin 0.025%1.0%, alkaline baths and glycerol trinitrate 2%. Systemic therapy includes antihistamines, propanolol, selective serotonin reuptake inhibitors, opioid receptor antagonists, anticonvulsants, and phototherapy— perhaps the most effective treatment1—including psoralene+UVA (PUVA), narrow band UVB (NBUVB), broad band UVB (BBUVB), and UVA/NBUVB combined therapy (UVA/NBUVB).2 Here, we describe a patient with AP who presented complete resolution of the symptomatology with a UVA/NBUVB therapy cycle (17 to 26 sessions) once a year.

Delayed Allergic Reactions to Jellyfish Stings: Usefulness of Ultrasonographic Evaluation: Ultrasonographic Features of Delayed Allergic Reactions After Jellyfish Stings

Jellyfish stings often cause immediate local skin reactions, and, less frequently, the affected individuals may develop delayed allergic reactions days or months after the sting. Here, we present 4 such cases. In all cases, color Doppler ultrasonography was performed at the time of diagnosis, and in 3 of the cases, clinical follow‐ups with ultrasonographic evaluations were performed. Ultrasonography initially showed dermal thickening with decreased echogenicity that progressively normalized during follow‐up. Ultrasonography was useful in quantifying inflammation by measuring the thickness of the dermis and was more precise than standard clinical follow‐up of cutaneous lesions in these cases.

When passion hurts: adverse cutaneous reaction to tattoo in a FC Barcelona soccer fan (‘Culé Dermatitis’)

Tattooing is an ancestral practice made for diverse reasons. In clinical practice it is frequent to see tattoos eliciting feelings of love and passion. Unfortunately, adverse reactions from tattooing are common, and cutaneous reactions to red pigment have been widely reported.1 Herein we describe a passionate soccer fan that developed a granulomatous reaction to red pigment. This article is protected by copyright. All rights reserved.

Assessment of Treatment of Refractory Granuloma Faciale With Intralesional Rituximab

Importance Granuloma faciale (GF) is a rare, benign inflammatory dermatosis of unknown cause. Some reports have suggested that it could be part of the spectrum of IgG4-related sclerosing diseases. Granuloma faciale is characterized by single or multiple red-brown nodules, most frequently occurring on the face, and it can produce severe disfigurement. Treatment is difficult, and poor outcomes are often seen. Rituximab is a monoclonal antibody against CD-20 approved by the US Food and Drug Administration for treatment of some autoimmune and tumoral diseases. Objective To evaluate the treatment of refractory GF with intralesional rituximab. Design, Setting, and Participants In this case series, 3 patients with biopsy-proved refractory GF who underwent treatment at a dermatology outpatient clinic of a tertiary referral hospital were evaluated. The study was conducted from August 2015 to December 2017. Interventions Doses of 0.5 to 1 mL/cm2 of intralesional rituximab, 10 mg/mL, were administered monthly for 6 months and thereafter depending on clinical response. In 2 patients, peripheral blood B-cell counts were monitored before and during treatment, and in 1 patient, only during treatment. Main Outcomes and Measures Reduction in size of the lesions, ultrasonography evaluation, subjective improvement, and adverse events were monitored throughout the course of therapy. Results All 3 of the patients were men (ages from 30s to 60s). They showed a significant reduction in the size and thickness of GF both clinically and on ultrasonography evaluation. Two patients had a complete response and the third, a partial response. A reduction in peripheral blood B-cell count was observed in the 3 patients, suggesting that the action of rituximab could be systemic. No severe adverse reactions were reported. Conclusions and Relevance Intralesional rituximab may represent a novel and well-tolerated therapy for refractory GF.

Rituximab for the treatment of autoimmune subepidermal blistering diseases

Dear Editor, Conventional therapy for autoimmune subepidermal blistering diseases (ASBD) includes topical or systemic corticosteroids (SC) and adjuvants such as immunosuppressive agents (ISA), dapsone, plasma exchange, or tetracyclines. Experience regarding rituximab (RTX) in blistering diseases mainly comes from pemphigus, where it is highly effective. RTX is usually reserved to treat ASBD refractory to conventional therapy. Evidence about its efficacy in ASBD is mainly documented in case series and case reports (Cho, Chu, & Wang, 2015, Maley et al., 2016). The aim of this manuscript was to evaluate RTX therapy in refractory ASBD. Retrospective cohort of 10 patients treated with RTX for ASBD at a single tertiary referral center between March 2007 and April 2017. Clinical outcomes were defined following the international consensus criteria (Murrell et al., 2012, 2015) NC16-BP180 levels and CD20+ B-cells were measured in all patients before RTX administration. Two patients with bullous pemphigoid (BP), 1 chronic pemphigoid gestationis (CPG), 5 mucous membrane pemphigoid (MMP), and 2 epidermolysis bullosa acquisita (EBA) were included. Median age was 60.5 (interquartile range [IQR], 50–71) years. Clinical manifestations, previous and concomitant treatments, RTX dosages, follow-up, and outcomes are detailed in Table 1. All patients were unresponsive to SC and to at least one systemic adjuvant agent before introducing RTX. After a median follow up of 20.5 (IQR 9–48) months, the 2 patients with BP were in complete remission off treatment (CR-off ), and the patient with CPG did not respond. After treatment, BP180 antibodies were undetectable in patients with both BP and CPG. Of the 5 patients with MMP, 4 had favorable outcomes: 2 patients were in CR, 1 of them on treatment (CR-on), and 2 patients presented partial remission on treatment (PR-on). One patient did not respond. Both patients with EBA remained with a PR-on. Scarring, blindness or severe strictures were not observed after RTX treatment. No patient within the cohort achieved CR-off after a single RTX cycle. The 2 patients with sustained CR-off, presented disease flare-ups at 6 months (patient 4, MMP) and 12 months (patient 1, BP) after the first cycle. They received additional doses of RTX, requiring no further treatment. No adverse reactions or deaths were observed. Our findings, consistent with those reported in the literature, show an overall improvement in most patients with ASBD treated with RTX, and a better response to this agent in BP than in MMP or EBA. Although RTX did not lead to long-term remission in all patients with MMP or EBA, it appears to be beneficial in stabilizing and preventing progression and therefore, secondary scarring associated with these diseases as previously reported (Shetty & Ahmed, 2013). Once inflammation is under control after receiving RTX, patients could continue with conventional therapy or RTX as a maintenance regimen (Heelan, Walsh, & Shear, 2013). While our patient diagnosed with CPG did not respond, there have been cases of successful treatment of persistent CPG with RTX (Cianchini et al., 2007). Recently, successful preventive treatment with RTX of CPG in a pregnant woman has been published (Tourte, Brunet-Possenti, Mignot, & Gavard, 2016). Promising results with RTX associated with monthly regimens of immunoglobulins, have been reported in case series. (Ahmed, Shetty, Kaveri, & Spigelman, 2016; Foster, Chang, & Ahmed, 2010). Further studies are needed to explore the cost-effectiveness of administering RTX as first-line therapy in high-risk patients with MMP and EBA. This could halt the inflammatory response and thus avoid scarring and complications associated with conventional treatment. It is yet to be defined, which is the optimal adjuvant and/or the convenience of a maintenance regimen with RTX.

Systemic allergic dermatitis caused by disulfiram (Antabuse) in a patient previously sensitized to rubber accelerators

Disulfiram (tetraethylthiuram disulfide; Antabuse) is an aldehyde dehydrogenase inhibitor widely used for the treatment of alcoholism. Chemically, it is a thiuram, and it is also used as rubber accelerator. Thiuram mix is composed of 4 thiurams, including disulfiram, all of which are used in rubber manufacturing and are included in most patch test baseline series. Thiurams can be found in industrial and domestic rubber products, and are common causes of allergic contact dermatitis (ACD). Concomitant sensitization between thiurams is frequent.

Sífilis maligna, una presentación de sífilis a tener en cuenta

Malignant syphilis is an uncommon form of secondary syphilis associated with HIV infection. Clinically, it is characterized by necrotic nodules and generalized ulcerated lesions. We present 4 cases of malignant syphilis diagnosed after evaluating syphilis cases diagnosed at our hospital between 2012 and 2016. We describe the epidemiologic, clinical, histiopathologic, and serologic characteristics of malignant syphilis and explore its response to treatment and association with HIV infection. Although malignant syphilis is uncommon, there has been an increase in the number of cases published in recent years, particularly in young HIV-positive patients. Malignant syphilis must be contemplated in the differential diagnosis of HIV patients with ulcerated, necrotic lesions.

Porokeratosis ptychotropica responding to photodynamic therapy: An alternative treatment for a refractory disease

Porokeratosis ptychotropica (PP) is a rare variant of porokeratosis with a special predisposition to affect body folds, particularly the intergluteal cleft. This disease is resistant to most topical and systemic treatments, as shown in the review of the literature we provide here. Itching and discomfort are often a difficult problem to solve.

Alopecic and aseptic nodule of the scalp in a girl

Alopecic and aseptic nodule of the scalp is a rare entity characterized by the presence of nodules or cysts with sterile punctured material and negative cultures accompanied by nonscarring alopecia in the scalp of young men. We describe a case in which an 11‐year‐old girl presented with a nodular, fluctuant, round lesion on the vertex with localized alopecia. High‐resolution ultrasound showed a hypoechoic lesion with increased flow on Doppler imaging and culture of the citrine‐yellowish material obtained by puncture was negative. The patient showed complete clinical response to treatment with topical indomethacin.