J. Bazex

Treatment of mammary and extramammary Paget's skin disease with topical imiquimod

Background: Pagets disease is an uncommon epidermal cancer, affecting all skin regions wherever apocrine glands are present. It is divided into extramammary (EMPD) and mammary Pagets disease (MPD). It can be confined to the epithelium or may be associated with an underlying adenocarcinoma. The diagnosis is confirmed by skin biopsy and the treatment depends on characteristics of the underlying cancer. Surgery is the first‐line treatment. Imiquimod, a topical immunomodulator, approved its efficiency in several skin neoplasms and has been shown as a safe treatment for EMPD. However, it has never been reported for the treatment of MPD. Observations: We report on two cases of EMPD and MPD successfully treated with imiquimod 5% cream. Conclusion: This non‐surgical method may be considered as a primary treatment when Pagets disease is not associated with an underlying malignancy. The good prognosis with a long‐term survival, the anatomic localization and the poor general condition of elderly people may favor imiquimod as an alternative treatment. On the other hand, it will reduce the extent of excision when it anticipates surgery.

Prolonged Photosensitivity following Contact Photoallergy to Ketoprofen

We report the third case of prolonged photosensitivity secondary to contact photoallergy to topical ketoprofen, a 2-arylpropionic acid derivative. The patient suffered from persistent photosensitivity for more than 1 year after the withdrawal of ketoprofen with recurrent eruptions on sun-exposed skin areas. This photosensitivity was associated with a persistent decrease in polychromatic and UVA minimal erythemal doses. Photobiological testing revealed cross-reactivity with fenofibrate and benzophenones. Photoallergy to ketoprofen is due to the benzophenone structure or to the very similar thiophene phenylketone of tiaprofenic acid, but not to the arylpropionic function. Thus, fenofibrate, tiaprofenic acid and benzophenones should be avoided by patients with a positive history of photocontact dermatitis to ketoprofen.

Allergic and photoallergic contact dermatitis to Olaquindox in a pig breeder with prolonged photosensitivity.

To the editor, Olaquindox is an allergen and photoallergen specifically affecting pig breeders. Only a few cases of allergic and photoallergic contact dermatitis have been reported since 1985 (1–5). We report a new case which stresses the importance of Olaquindox as an allergen and photoallergen capable of inducing prolonged photosensitivity. A 53-year-old man presented in March 1999 with a photodistributed eczema on the face (sparing eyelids), neck and backs of the hands and fingers. He had been taking Rilmenidine (HyperiumA) and Diltiazem (MonotildiemA) for 4 years, Pravastatin (ElisorA) for 1 year withdrawn in March 1999. The patient was atopic. He had also worked as a pig breeder for 10 years and used azaperone (StresnilA), a sedative drug for pigs, oxytetracycline (DuphacyclineA) and Olaquindox, an antibiotic molecule which is added to the pigs food to avoid enteritis at the time of weaning. Olaquindox was included in a vitamin and mineral complex presented in powder form. The photobiological testing was performed with two sources of light: polychromatic irradiation (UVB, UVA, visible)

Palmoplantar pustulosis should not be considered as a variant of psoriasis

1 Lawrence SH, Salkin D, Schwartz JA, Fortner HC. Rupture of abdominal wall through striae distensae during cortisone therapy. JAMA 1953; 152: 1526–1527. 2 Stroud JD, Van Dersarl JV. Striae. Arch Dermatol 1971; 103: 103–104. 3 Bordier C, Flechet E, Thomine E, Lauret PH. Rupture de Vergetures au cours d’un Psoriasis Pustuleux traité par Étrétinate (Tigason). Ann Dermatol Venereol 1984; 111: 929–931. 4 Bowman PH, Hogan DJ. Ulcerated atrophic striae from Etretinate. Cutis 2000; 65: 327–328. 5 Shuster S. The cause of striae distensae. Acta Derm Venereol Suppl (Stockh) 1979; 59: 105–108. 6 Peterson JL, McMarlin SL, Read SI. Edematous striae distensae. Arch Dermatol 1984; 120: 1097–1098. 7 Lee JH, Lee EK, Kim CW, Kim TY. A case of edematous stiae distensae in lupus nephritis. J Dermatol 1999; 26: 122–124. 8 Ashcroft GS, Mills SJ, Lei K et al. Estrogen modulates cutaneous wound healing by downregulating macrophage migration inhibitory factor. J Clin Invest 2003; 111: 1309– 1318. 9 Gilliver SC, Ashworth JJ, Mills SJ, Ashcroft GS. Androgens modulate the inflammatory response during acute wound healing. J Cell Sci 2006; 119: 722–732. 10 Mills SJ, Ashworth JJ, Gillver SC, Hardmann MJ, Ashcroft GS. The sex steroid precursor DHEA accelerates cutaneous wound healing via estrogens receptors. J Invest Dermatol 2005; 125: 1053–1062.

Photodistribution of blue-gray hyperpigmentation after amiodarone treatment: molecular characterization of amiodarone in the skin.

BACKGROUND For decades, the photodistributed blue-gray skin hyperpigmentation observed after amiodarone therapy was presumably attributed to dermal lipofuscinosis. Using electron microscopy and high-performance liquid chromatography, we identified amiodarone deposits in the hyperpigmented skin sample from a patient treated with this antiarrhythmic agent. Our findings therefore indicate that the hypothesis relating the blue-gray hyperpigmentation to lipofuscin should be challenged. OBSERVATIONS A 64-year-old man, skin phototype III, presented with asymptomatic skin hyperpigmentation that had been slowly developing on sun-exposed areas since April 2004. He had been taking amiodarone for 4 years (cumulative dose, 277 g). Electron microscopy did not show lipofuscin pigments in his skin. Conversely, abundant electron-dense membrane-bound granule deposits were observed in most of the dermal cells (fibroblasts, macrophages, pericytes, Schwann cells, and endothelial cells), especially in photoexposed skin. High-performance liquid chromatography confirmed that the skin deposits were composed of amiodarone. These results demonstrate that amiodarone hyperpigmentation is related to drug deposition on photoexposed skin. CONCLUSION Amiodarone-related hyperpigmentation should be considered a skin storage disease that is secondary to drug deposition.

Contact urticaria from formaldehyde in a root‐canal dental paste

A 37-year-old woman presented, a few hours after a dental appointment, with itchy urticaria of the lower jaw that rapidly cleared with oral corticosteroids. Questioning her dentist revealed that he usually used Spad® rootcanal filling material for the treatment of infected teeth. Root-filling or pulp chamber filling is obtained in 1 session as follows: the canal is first irrigated with sodium hypochlorite, acidified with sulfuric acid, dried with hot air and then controlled by absorbing paper points. The paste is prepared by mixing a drop of 2 liquids: liquid L, containing glycerin and 28% formaldehyde, and liquid LD, containing hydrochloric acid, resorcinol and

Multiple perforating and non perforating pilomatricomas in a patient with Churg–Strauss syndrome and Rubinstein−Taybi syndrome

We report an unusual association of multiple perforating and non‐perforating pilomatricomas with Churg–Strauss syndrome, and a dysmorphic syndrome evocative of Rubinstein‐Taybi syndrome. These syndromes may be independent, but these rare diseases and genetic abnormalities may be linked together.

Pseudoxanthoma elasticum and nephrolithiasis

We report the case of a 42‐year‐old man with pseudoxanthoma elasticum (PXE) and recurrent bilateral nephrolithiasis. Diagnosis of PXE was made by yellow papules on the neck and ophthalmologic angioid streaks. This diagnosis was confirmed by a skin biopsy (Von Kossa stain) and by genotyping analysis of ABCC6 (homozygous mutation R1138Q). Nephrolithiasis was recurrent and biological investigations showed hypophosphoraemia, hyperphosphaturia, hypercalciuria, normocalcaemia, normal serum parathyroid hormone value, high 1,25‐dihydroxy vitamin D value and a renal calcium oxalate stone. ABCC6 encodes for MRP6, a multidrug resistant protein strongly expressed in the liver and kidney. The substrates of the MRP6 remain unknown. As PXE is characterized by calcification of elastic fibres and this patient presents important phosphocalcic anomalies, we discuss the possible implications of MRP6 in the phosphocalcic metabolism.

Treatment of Acquired Cutaneous Lymphangiectasis of the Thigh and Vulva with a Carbon Dioxide Laser

A 70-year-old woman presented su¡ering from lymphoedema of the left inferior limb, and skin lesions located on the vulva and the left thigh. She had been treated with surgery and radiotherapy for cervical squamous cell carcinoma 16 years previously. The lesions started 3 years after therapy and progressed slowly. For the last 4 years, the lesions had been complicated by oozing, lymphorrhoea and several erysipelas, which interfered with her social life. Clinical examination revealed prominent lymphoedema of the left thigh, left leg and vulva involving the major and minor labia. There were also multiple translucent thick-walled vesicles and prominent wart-like lesions in the a¡ected areas (F|g. 1). A skin biopsy demonstrated dilated lymph vessels lined by a single layer of endothelial cells in the upper dermis with epidermal acanthosis and hyperkeratosis. A diagnosis of acquired cutaneous lymphangectasis was made. No gynaecological disease was apparent and further investigations, including a CT scan of the abdomen and pelvis revealed no abnormalities. Laser therapy was performed with the carbon dioxide laser (Sharplan model) under local anaesthesia. The following irradiation parameters were used: hand-piece, skin distance 1 cm, spot size 2 mm, power 15 W, continuous exposure. The pathological tissue was vaporized to the middle dermis. A simple sterile dressing was applied postoperatively. Daily wound care consisted of chlorhexidine gluconate soaks, followed by application of a thin ¢lm of fucidic acid ointment. After a 4-week period with complete wound healing, all lesions were treated with the laser over 5 sessions. No infectious complications occurred during the 19-month follow-up. Recurrences of single pseudovesicles were re-treated with the carbon dioxide laser, using the same procedure as before. At the same time, manual lymphatic draining process associated with elastic contention was performed.

Evaluation of drug-induced photosensitivity by UVB photopatch testing

Case Report A 70-year-old white woman (phototype III), who had been treated for 15 years with AldactazineA (Altizide, spironolactone) because of arterial hypertension, was admitted in February 1998 with a photodistributed erythematous, papulosquamous eruption involving the face (eyelids, cheeks), lateral neck, dorsum of both hands and proximal phalanges. The accompanying symptoms were those of burning and itching. Although she reported protection of her eyes by regularly wearing sunglasses, the erythematous eruption occurred on both eyelids. On withdrawal of AldactazineA, lesions disappeared and she recovered within 4 weeks. Photobiological testing was performed with polychromatic irradiation (1.000 W Xenon light, Dermolum UM-WA, Muller, Moosinning, Germany) filtered with a Schott WG 305 filter, and a high-pressure metal halide UVA lamp (2.000 W, SunlabA). The UVB radiant energy was 3.0 mW/cm2 and that of UVA, 40 mW/cm2. Patch and photopatch tests were performed in triplicate with the French Society of Photodermatology standard series (1), AldactazineA 10% aq. and 10% pet. The patches were removed after 1 day (D). 1 set was irradiated with 5 J/cm2 of UVA and a 2nd set with a suberythemal UVB dose (0.75 UVB-MED). The 3rd, non-irradiated set served as the patch test control. Reading was made at D1 and D2 after irradiation.