Enrique Gutiérrez-González

Elastolytic Actinic Giant Cell Granuloma

Actinic granuloma and annular elastolytic giant cell granuloma are different terms used to define skin lesions characterized by elastolysis, elastophagocytosis, and multinucleated giant cell infiltrate. The clinical appearance varies from papules to annular plaques. Although elastolytic actinic giant cell granuloma shares some clinical features with granuloma annulare, they can be differentiated by histopathologic findings. The disease is initiated by an immune response triggered by different factors that alter the elastic tissue. The course tends to be chronic, with variable response to treatments, although spontaneous remission may occur. Diabetes mellitus is the systemic disease most frequently associated with this condition.

Photosensitivity induced by naproxen

We present two cases of systemic photosensitivity due to naproxen that presented as photodistributed erythema multiforme (EM) and lichenoid photodermatitis (LP). Although naproxen is a commonly used nonsteroidal antinflammatory drug and has the capacity of causing systemic photosensitivity, there are very few reports about it in the literature. The diagnosis was suspected by the recent ingestion of the drug and the photodistribution of the lesions. A positive photopatch test in the first patient and the normalization of the MED‐UVB after discontinuing naproxen in the second patient supported the diagnosis.

Allergic contact dermatitis caused by tetracaine contained in otic drops.

Hypersensitivity reactions to local anaesthethics account for less than 1% of side effects caused by these compounds (1). They may be caused by an immediatetype immune reaction, or most often by a delayed-type one, presenting clinically as eczematous lesions after skin contact with the drug (2). Patch testing is essential not only to confirm the diagnosis but also to identify local anaesthetics that the patient can rely on in future medical procedures or treatments (1).

Annular Elastolytic Giant Cell Granuloma Associated to Late-Onset X-Linked Dominant Protoporphyria

X-linked dominant protoporphyria (XLDPP) is a genetic disorder that affects the synthesis of the heme group due to an increase in delta-aminolaevulinate synthase 2 (ALAS2) enzyme activity. Moreover, annular elastolytic giant-cell granuloma (AEGCG) is a rare reactive granulomatous dermatosis, usually associated with actinic damage. An 86-year-old man presented with edematous-erythematous lesions in photoexposed areas of the face and on the dorsum of both hands. Protoporphyrin levels in serum and feces were significantly elevated and a heterozygous frameshift mutation in the exon 11 of the ALAS2 gene: c.1706-1709del (p.Glu569GlyfsX24) was identified. Concomitantly, we observed an annular plaque with raised borders on the back of his right hand, clinically and histologically compatible with a diagnosis of AEGCG. Skin lesions disappeared only upon use of a physical sunscreen. We report two rare photodermatoses in an elderly patient and discuss the significance of dermal elastic fiber damage induced by the XLDPP as a main triggering factor of AEGCG.

Cefuroxime-induced cutaneous pustular leukocytoclastic vasculitis with Koebner phenomenon on the donor area of a skin graft

of a skin graft Editor, Cutaneous leukocytoclastic vasculitis (CLV) describes a skin reaction process, the pathogenesis of which refers to the development of circulating immune complexes and their deposition, predominantly on the capillaries and post-capillary venules of the superficial plexus, thereby causing inflammation and necrosis. Drugs, infections, autoimmune diseases, and malignancy are causes of CLV. Of these, drugs are the most common offending agents. A 66-year-old White woman presented with a 6-day history of tender, purpuric papules and pustules on the legs (Fig. 1). The lesions had appeared two days after the subject had taken cefuroxime prescribed for a recurrent urinary tract infection. The patient’s medical history included arterial hypertension, venous insufficiency, and a skin graft for a venous leg ulcer. She had been treated with atorvastatin, olmesartan, and pantoprazole for five years. Dermatologic examination revealed purpuric papules and pustules distributed over both limbs. The area more affected by these lesions was that of the donor skin graft, where some of the lesions had coalesced to form pustular lakes. Blood tests showed the following results: hematocrit 36%; hemoglobin 11.6 g/dl; platelet count 412,000 · 10/ll; and leukocytes 13,550 · 10/ll (neutrophils, 79%; lymphocytes, 5.7%; monocytes, 1.7%; eosinophils, 0.8%). Hepatitis B and C virus, human immunodeficiency virus (HIV), and syphilis serologic tests were negative. Rheumatoid factor, antinuclear antibody (ANA), and antineutrophil cytoplasmic antibody (ANCA) tests were also negative. Serum levels of complement and immunoglobulins were within normal limits. Cryoglobulins were not detected. Chest x-ray and urinalysis were normal. Skin biopsy of a lesion was performed. Histologic examination revealed an intraepidermal pustule constituted by neutrophils, which also appeared in the dermis, developing perivascular infiltrates and penetrating the vascular walls. Leukocytoclasia and erythrocyte extravasation were also evident (Fig. 2). Pustular CLV was diagnosed. Because no other cause could be identified, the vascular damage was attributed to cefuroxime. Cefuroxime was stopped after the admission of the patient as a result of this clinical suspicion of a cutaneous

Sweet’s syndrome and acute parvovirus B19 infection

the disease is not controlled with monotherapy. Both treatments seem to target the hyperproliferative and immune aspects of psoriasis, although the mechanism of action of acitretin is not fully understood. Two retrospective reviews of patients treated with acitretin and biologic agents for refractory psoriasis have been reported in the literature. Conley et al. presented a series of eight patients with severe psoriasis who were treated with a combination of acitretin and biologic agents (adalimumab, etanercept, and alefacept) to show successful outcomes. Smith et al. 9 reported 15 patients with psoriasis in whom treatment with concomitant acitretin (10–50 mg/d) and biologics achieved complete clearance in 29% of patients, a 90% improvement in 43%, a 75% improvement in 14% of patients, and a 50% improvement in 7% of patients; the remaining 7% of patients showed no change in psoriasis. Gisondi et al. undertook a trial evaluating the combination of etanercept with acitretin, the results of which suggested that etanercept could be administered at a lower dose with this combination. We reviewed the literature but were unable to find any patient with pustular psoriasis treated with a combination of acitretin and adalimumab. In our case, this combination enabled us to safely control the patient’s severe, highly therapy-resistant pustular psoriasis. Although further studies are needed to evaluate the efficacy and safety of this combination, it may represent an alternative strategy for the treatment of some patients with recalcitrant pustular psoriasis.

Granuloma annulare photoinduced by paroxetine

Granuloma annulare (GA) is a benign granulomatous skin disease with several clinical manifestations and characteristic histological findings. GA located in photoexposed areas is a rare finding and its association to a drug‐induced systemic photosensitivity is even less common. To the best of our knowledge, only one case of systemic drug photosensitivity manifesting as a GA has been reported. We describe a patient with systemic photosensitivity to paroxetine with clinical and histological manifestations of GA, which was confirmed by the photobiological study. The phototest revealed a reduction of the minimal erythematous dose for UVB while taking the paroxetine and its normalization after its withdrawal, which was accompanied by the clinical resolution of the skin eruption. The manifestation of systemic drug photosensitivity as a GA like in our case is exceptional.

Adult-onset verrucous nevus lipomatosus cutaneous superficialis.

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Photoletter to the editor: Basal cell carcinoma on the vermilion lip.

The vermilion and vermilion border are rare locations for basal cell carcinoma. We report a case of a 72-year-old woman, who presented with an asymptomatic erosive lesion on the vermilion area of the upper lip. Histopathology examination was consistent with basal cell carcinoma. We suggest that basal cell carcinoma should be included in the differential diagnosis of erosive/ulcerative lesions arising on the vermilion area of the lip.

Skin granulomatous infection caused by Serratia liquefaciens in an immunocompetent patient.

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