Geoff Strutton

Psoriasis induced by topical imiquimod

We report the provocation of localized psoriasis at the sites of application of topical imiquimod, possibly evolving into a generalized flare. A patient with pre‐existing psoriasis that had been stable for 14 years was treated with imiquimod 5% cream daily for 6 weeks to three superficial basal cell carcinomas. During treatment one of the lesions developed severe local skin reactions necessitating rest periods, and received only 18 applications in 6 weeks. The other two lesions were treated for all 42 days. Psoriasiform changes developed at all three application sites. Nine‐and‐a‐half weeks after completing treatment the patient developed disseminated small psoriatic lesions. Other recognized triggers of psoriasis were not identified. The psoriasis resolved slowly with conventional treatment.

Atypical fibroxanthoma with perineural or intraneural invasion: Report of two cases

Abstract:  We report two cases of atypical fibroxanthoma (AFX) that both had the previously unreported feature of neural invasion (one perineural and the other intraneural). AFXs recur in approximately 10% of cases but only rarely metastasize. Features associated with recurrence are inadequate excision and invasion into fat. Features associated with metastasis include recurrence, vascular invasion, deep tissue invasion, and tumor necrosis. Both of these tumors invaded deeply into subcutaneous fat and reached the deep fascia. Some authors would regard such cases as malignant fibrous histiocytoma (MFH) because of such deep extension; however, the concept of AFX as a superficial variant of MFH is outmoded – AFX is a distinct clinicopathologic entity with established clinical, histological, and immunohistochemical features.

Nuclear RelB+ cells are found in normal lymphoid organs and in peripheral tissue in the context of inflammation, but not under normal resting conditions.

Differentiated dendritic cells (DC) have been identified by the presence of nuclear RelB (nRelB) and HLA‐DR, and the absence of CD20 or high levels of CD68, in lymph nodes and active rheumatoid arthritis synovial tissue. The current studies aimed to identify conditions in which nRelB is expressed in human tissues, by single and double immunohistochemistry of formalin‐fixed peripheral and lymphoid tissue. Normal peripheral tissue did not contain nRelB+ cells. nRelB+ DC were located only in T‐ or B‐cell areas of lymphoid tissue associated with normal organs or peripheral tissues, including tonsil, colon, spleen and thymus, or in association with T cells in inflamed peripheral tissue. Inflamed sites included skin delayed‐type hypersensitivity reaction, and a wide range of tissues affected by autoimmune disease. Nuclear RelB+–HLA‐DR− follicular DC were located in B‐cell follicles in lymphoid organs and in lymphoid‐like follicles of some tissues affected by autoimmune disease. Lymphoid tissue T‐cell areas also contained nRelB−–HLA‐DR+ cells, some of which expressed CD123 and/or CD68. Nuclear RelB+ cells are found in normal lymphoid organs and in peripheral tissue in the context of inflammation, but not under normal resting conditions.

Cutaneous manifestations of cytomegalovirus disease in renal transplant recipients: a case series

Abstract: Cytomegalovirus (CMV) is an important and well‐described opportunistic virus in the immunocompromised host, with infection occurring mainly after the first month in the new renal transplant recipient. CMV can present as primary infection, reinfection, or reactivation of latent disease. It is capable of protean manifestations. Cutaneous manifestations are variable, rare, and diagnosis often delayed. We present 3 cases of cutaneous CMV disease in renal transplant recipients. Manifestations in our patients included ulceration of the tongue and perianal areas, facial petechiae, and nodular lesion involving the ear. This case series serves to highlight the importance of early skin biopsy in the diagnosis and management of cutaneous CMV disease.

An open-label, pilot study examining the efficacy of curettage followed by imiquimod 5% cream for the treatment of primary nodular basal cell carcinoma

The short‐term efficacy of imiquimod 5% cream for the treatment of primary superficial basal cell carcinoma has been established. This study investigated its efficacy following curettage (without electrodesiccation) for the treatment of primary nodular basal cell carcinoma on the trunk and limbs. Seventeen patients with a total of 34 lesions were enrolled. Curettage was used to de‐bulk the lesion and confirm suitable histology. Lesions displaying more aggressive subtypes (such as micronodular or morpheoic components) were excluded. Lesions were treated daily for 6 to 10 weeks with imiquimod 5% cream. Three months post treatment all lesions were excised, and 32 of 34 treated lesions (94%) were histologically clear of basal cell carcinoma. Fourteen of 17 patients rated the cosmetic outcome of treatment as excellent or good. Curettage followed by imiquimod 5% cream is effictive for the treatment of primary nodular basal cell carcinoma on the trunk and limbs, and most patients are pleased with the cosmetic outcome.

Use of biosynthetic dressings in paraneoplastic pemphigus

A 77‐year‐old woman with paraneoplastic pemphigus and non‐Hodgkins lymphoma was treated with supportive therapy and oral prednisone. Biobrane®, a biosynthetic dressing, was later applied to the extensive areas of erosion to assist in pain management and to provide a temporary barrier function. She reported an improvement in the pain associated with the areas of erosion. The use of biosynthetic dressings in blistering disorders has not been previously reported. Standard dressings such as silver sulfadiazine are messy and can cause discomfort with frequent changing. We feel that this is an area that warrants further evaluation as it may contribute to the overall treatment and comfort cares of these patients.

Generalized, Pruritic, Ulcerating Maculopapular Rash Necessitating Cessation of Sirolimus in a Liver Transplantation Patient

The use of sirolimus as an alternative to calcineurin antagonists has enabled the continuation of immunosuppression in patients with renal impairment with preservation of kidney function. Sirolimus is generally well tolerated, with the main causes of cessation of therapy related to its effect on blood lipid profile as well as leukopenia and thrombocytopenia. We report a case of a debilitating ulcerating maculopapular rash necessitating cessation of the drug in a liver transplantation patient. A 56‐year‐old Caucasian liver transplantation patient presented with a diffuse, debilitating rash attributed to sirolimus use. This ultimately necessitated cessation of the immunosuppressant with subsequent resolution of her symptoms. From a review of the current literature, this is a highly unusual adverse reaction to sirolimus. (Liver Transpl 2005;11:987–989.)

Comedonal Darier's Disease Diagnosed Incidentally In A Patient Undergoing A Routine Skin Examination for Sun Cancer

cases in the literature. Cutaneous manifestations are relatively uncommon, affecting 5% of cases in one series. The skin changes seen in leptospirosis are protean, including erythematous macules, papules, patches or plaques, which may be widespread. Thrombocytopaenia may occur, giving rise to petechial or purpuric lesions. Erythema nodosum is rarely reported in association with leptospirosis. During the summers of 1942–1944 there was an outbreak of leptospirosis in military camps at Fort Bragg in North Carolina. Troops infected with L. autumnalis presented with fever, erythema nodosum and splenomegaly. The infection was termed Fort Bragg fever or pretibial fever, reflecting the cutaneous involvement. Two additional cases of erythema nodosum associated with leptospirosis can be found in the literature (both reported in the 1970s). The first is a 12-year-old boy who presented with fever, meningism and erythema nodosum. Infection was confirmed with leptospira of the icterohaemorrhagiae serogroup. The second case was an 8-year-old girl admitted with fever and erythema nodosum secondary to L. canicola infection following a dog bite. Our case was secondary to L. hardjo, the most common form of bovine leptospirosis, consistent with the background of dairy farming. Erythema nodosum is described classically as a septal panniculitis, however, early changes may not be entirely limited to the septa. Perivascular changes (as in our case) include lymphocytic cuffing of venules and endothelial swelling. Reported atypical findings in erythema nodosum include neutrophilic infiltrates with suppuration, vasculitis and predominant lobular or mixed panniculitis (as in our case). In these cases a repeat biopsy later in the clinical course showed classical changes of erythema nodosum. Leptospirosis appears to be a forgotten and rare cause of erythema nodosum and this case highlights the need for considering a diagnostic work-up in patients presenting with erythema nodosum given an appropriate clinical setting, particularly in those with risk factors including occupational or recreational exposure. Harriet Cheng, Anthony Yung and Duncan Lamont Departments of Dermatology and Pathology, Waikato Hospital, Hamilton, New Zealand