Hong Liang Tey

A randomized double‐blind controlled trial to compare a triclosan‐containing emollient with vehicle for the treatment of atopic dermatitis

The use of topical antiseptics in the treatment of atopic dermatitis (AD) has previously been explored. However, no triclosan‐containing leave‐on emollient has been evaluated previously, to our knowledge. The aims of this study were to assess the safety and efficacy of an emollient containing triclosan compared with the emollient alone (vehicle) for the treatment of AD. Eligible patients with mild to moderate AD were randomized to receive either the study cream or vehicle. All patients also received a low‐potency corticosteroid cream to use during the treatment phase of the study if necessary. Patients were assessed for severity according to the SCORing Atopic Dermatitis (SCORAD) Index, amount of corticosteroid used, patient assessment of cream, and adverse events (AEs). In total, 60 patients received either the study cream or vehicle, and an intention‐to‐treat analysis was performed. At day 14, there was a significant decrease in SCORAD from baseline for the study cream compared with vehicle (P < 0.05). At day 27, although there was an improved mean reduction from baseline, this was no longer significant (P > 0.05). Only four patients had mild treatment‐related AEs. The mean total amount of topical steroid applied by the patients using the study was significantly lower than that used by controls (P = 0.40). Triclosan‐containing leave‐on emollient was safe and highly acceptable to patients. However, the overall benefit on day 27 was not significant. Nevertheless, the amount of topical steroid used by patients was significantly less with the study cream than with the vehicle, thus further studies are needed to confirm its steroid‐sparing effect.

Nasal-type extranodal natural killer/T-cell lymphoma presenting with extensive leg ulcers.

Primary cutaneous T‐cell lymphomas are rare and can be difficult to classify precisely. We present a case of extranodal natural killer (NK)/T‐cell lymphoma in a previously healthy, immunocompetent man who presented with extensive necrotic leg ulcers and disseminated skin nodules. Immunohistochemical studies revealed that the tumour cells were positive for CD3, CD30, granzyme B and T‐cell intracellular antigen‐1, and negative for CD5 and CD56, with positive staining for Epstein–Barr virus (EBV) RNA on in situ hybridization. A diagnosis of extranodal NK/T‐cell lymphoma was made, based on the presence of cytotoxic granules and positive EBV RNA staining. The patient was treated with a regimen of chemotherapy comprising corticosteroids, intravenous methotrexate, ifosphamide, L‐asparginase and etoposide with initial response.

Notalgia paresthetica: treatment with topical tacrolimus.

viously inflammatory processes in affected areas, internal malignancies and trauma, and medicine usage were not present. The histological examinations based on the punch biopsies taken from the lesions showed epidermal atrophy, vacuolar alteration of basal layer, and pigmentary incontinence in the upper dermis (Fig. 2a,b,c). The inflammatory infiltrates of lymphocytes in the upper dermis were moderate for two cases, whereas they were dense in the remaining three cases. Immunohistochemical examinations have revealed that the lymphocytic infiltrate is composed of CD8 (+) T cells (Fig. 2d). LPP is a relatively rare variant of lichen planus and characterized by the presence of the hyperpigmented, dark-brown macules in the sun exposed or flexural-fold areas of the body. Pock et al. reported seven cases with LPP-I as a variant of LPP arising in intertriginous areas. The differential diagnosis of LPP-I includes LPP and LP actinicus both affect the dark-skinned races of patients and are generally located in the sun-exposed areas. Other conditions include fixed drug eruption, acanthosis nigricans, and ashy dermatosis. Histopathological examination typically shows epidermal atrophy, vacuolar alteration of the basal layer, variable dense of lymphocyte infiltration, pigmentary incontinence and melanophages in the superficial dermis. In our cases we have found similar histopathological results, as well. It is thought that LPPI is the result of direct T-lymphocytemediated cytotoxic activity against basal keratinocytes, as in classic LP. In our three cases, we performed immunohistochemical staining and observed CD8 (+) T-cell infiltration as well as it has been observed in the literature. The treatment of LPP-I is unknown. In some cases reported in the literature, the lesions disappeared spontaneously within several months. Nevertheless, treatment with topical calcineurin inhibitors, medium or high potency corticosteroids are recommended to accelerate the healing process. We applied topical steroid (mometasone furoate) to our patients twice a day and monitored them for almost three months. The improvement was moderate in two cases and minimal in the rest. In conclusion, we have described a rare case of LPPI in Turkish patients with diagnosis based on intertriginous locations and histologic findings.

Approach to hypopigmentation disorders in adults.

Acquired hypopigmentation disorders in adults can be classified on the basis of lesion extent, and can generally be divided into disorders with localized, widespread or generalized lesions. Clinical findings, comprising the degree of pigment loss (hypopigmentation and depigmentation) and associated morphological findings (e.g. epidermal changes, infiltration and induration), are used to further distinguish the disorders. Diagnosing the disorders is important because the underlying causes may be treatable and some of the disorders are associated with malignancies. A systemic approach is useful for this clinical condition, as the causes are heterogeneous and investigations are usually nondiagnostic.

Adult Henoch-Schönlein purpura: Clinical and histopathological predictors of systemic disease and profound renal disease.

Background: A major challenge in the management of adult Henoch–Schönlein purpura is the difficulty in assessing the risk of systemic involvement. There is currently a paucity of data in this area. Aims: This study sought to determine specific clinical and histopathological features associated with systemic involvement in adult Henoch–Schönlein purpura. Methods: We reviewed the records of 99 adult Henoch–Schönlein purpura patients who presented at the National Skin Centre, Singapore, between January 2008 and May 2015. Results: Renal involvement was found in 56 (56.6%) patients, joint involvement in 21 (21.2%) and gastrointestinal involvement in 13 (13.1%). Age > 30 years was an independent predictor of renal involvement with an adjusted odds ratio of 2.97 (95% confidence interval, 1.08–8.16; P = 0.04). Risk factors for significant renal involvement necessitating nephrology referral were further evaluated: the odds were approximately 60% higher for every 10-year increase in age (95% confidence interval, 1.02–2.57; P = 0.04) and patients with cutaneous bullae and/or necrosis had an almost six times higher risk (95% confidence interval, 1.43–25.00; P = 0.01). Limitations: This study was limited by its retrospective design. We also lacked long-term data to examine how clinical and histopathological characteristics correlated with long-term disease outcomes. Conclusions: Adult Henoch–Schönlein purpura patients older than 30 years have a threefold increased risk of renal involvement. The risk of profound renal disease necessitating nephrology referral rose significantly with age and the presence of cutaneous bullae and/or necrosis.

Follicular spicules associated with Propionibacterium acnes with response to erythromycin

Dear Editor, Follicular spicules are an unusual clinical finding and have been reported as a clinical manifestation in trichodysplasia spinulosa associated with chronic immunosuppression, multiple myeloma and demodicosis. We present a patient with keratotic follicular spicules associated with Propionibacterium acnes, which has not been previously reported. A 22-year-old Chinese man presented with 6-year history of an asymptomatic rash over his neck. He was otherwise well with no systemic symptoms and there was no family history of a similar rash. On

Pegylated liposomal doxorubicin-induced miliaria crystallina and lichenoid follicular eruption

Sir, A 24‐year‐old woman was being treated for stage IV primary peritoneal carcinoma with pegylated liposomal doxorubicin at a dose of 40 mg/m2. Five days after the second dose, she developed a mildly pruritic eruption on the trunk, which became more extensive over the next 2 weeks [Figure 1a]. On inspection, her back, axillae and breasts were studded with tiny, closely spaced, clear vesicles with a silvery, shiny surface, measuring 1–3 mm in diameter [Figures 1b]. Dermoscopic examination revealed multiple translucent globules with a thin dark rim [Figure 2]. Concurrently, there was another morphologically different eruption consisting of extensive hyperpigmented follicular keratotic papules on the trunk, neck and thighs [Figure 1a and b]. The above lesions were further characterized using high‐definition optical coherence tomography imaging (Skintell®, Agfa HealthCare, Belgium) and the vesicles and hyperkeratotic papules were found to be intraepidermal in nature [Figure 3]. In addition to these lesions, the patient also developed palmar erythema and superficial erosions in the intertriginous areas [Figure 1a]. The patient’s body mass index was 30 kg/m2. A skin biopsy from a vesicle on the trunk [Figure 4a] revealed the location of vesicle to be within the stratum corneum, enclosed by a thin layer of keratin. The lesion was directly overlying an acrosyringium although the associated eccrine duct was unaffected. There was minimal spongiosis or inflammation within the surrounding dermis. A separate biopsy performed from a follicular papule [Figure 4b] showed a large keratin plug protruding outwards from the infundibulum. The follicular epithelium showed lichenoid changes comprising basal vacuolar alteration and scattered necrotic keratinocytes. A sparse, superficial perivascular lymphocytic infiltrate was also present.

Unilateral facial and upper truncal anhidrosis and absence of physiological flushing: A case of idiopathic harlequin syndrome

Sir, Unilateral absence of physiological facial heat‐induced flushing and sweating is a very rare and unique presentation. These features characterize the Harlequin syndrome,1 a rare autonomic disorder, which occasionally also involves the neck, upper thoracic region, and the arm.1 It results from sympathetic deficits localized to the anhidrotic side, but can involve the parasympathetic neurons in the posterior and ciliary ganglia.2

Palmoplantar hyperhidrosis: A paradoxical presentation of acquired idiopathic generalized hypohidrosis

Sir, The etiology of palmoplantar hyperhidrosis is primary in the vast majority of cases and the secondary causes, comprising drugs, neurological or endocrine disorders, are rare. Acquired idiopathic generalized anhidrosis is an uncommon disorder characterized by widespread anhidrosis in the absence of sweat gland pathology or neurologic symptoms.1‐4 Impaired ability to sweat can predispose the affected individuals to hyperthermia, heat stroke and even death. We report a patient with acquired idiopathic generalized anhidrosis who presented with palmoplantar hyperhidrosis.

Colonization and acquisition of Methicillin-resistant Staphylococcus aureus and secondary bacterial infections among dermatological in-patients

that are more sensitive to the biological effects of the drug than normal keratinocytes. The clinical and subclinical lesions in the cancerization field present outside the treated area could maintain a prolonged immunological reactions that can be the pathogenetical basis of EPDS in predisposed individuals. The differentiation of EPDS from an intense local inflammatory reaction is mainly based on the fact the EPDS lesions start a few weeks after completion of treatment and last for several months whereas common skin reactions to ingenol mebutate peak shortly and tend to resolve within 2 weeks. Moreover, the relapse that occurred in one patient after stopping topical steroids favour the diagnosis of EPDS. The most common therapy for EPDS is potent topical steroids that gave good results in our patients. In conclusion, topical ingenol mebutate should be added to the list of agents that may induce EPDS and dermatologists should be aware about this event to avoid misdiagnosis of EPDS as common local self-healing skin reaction due to topical ingenol mebutate.