Jonathan Chan

Nephrogenic systemic fibrosis associated with liver transplantation, renal failure and gadolinium

A 47‐year‐old man underwent liver transplantation for cirrhosis secondary to hepatitis C and alcoholism. This was complicated by primary donor liver dysfunction and acute renal failure requiring dialysis. Gadolinium magnetic resonance cholangiopancreatography was performed 2 weeks post transplant, and a second successful liver transplant was performed 1 week later. Shortly after this, the patient developed rapidly progressive erythematous plaques over his abdomen, lower and upper limbs. There was marked oedema and skin induration. Fibrosis severely limited his mobility, leaving him wheelchair‐bound. An abdominal plaque biopsy revealed increased dermal mucin and cellularity, with proliferation of spindled fibroblastic cells. Paraprotein was not detected in the serum. Facial sparing, the absence of serum paraprotein and the histopathological findings confirmed the diagnosis of nephrogenic systemic fibrosis. Immunohistochemical stains revealed CD34‐positive spindle‐shaped cells, and electron microscopy did not detect free gadolinium. Following improvement in renal function and various treatments, his plaques softened, fibrosis slowed and mobility partially improved. Gadolinium magnetic resonance cholangiopancreatography was performed following this improvement. Six weeks later, further progression of nephrogenic systemic fibrosis occurred despite normal renal function.

Treatment of severe recalcitrant plaque psoriasis with single-dose intravenous tumour necrosis factor-alpha antibody (infliximab)

Infliximab is a chimeric anti‐tumour necrosis factor‐α antibody that has been demonstrated to have marked efficacy in the treatment of psoriasis. Seven patients with chronic plaque psoriasis were treated with single‐dose intravenous infliximab (5 mg/kg), and the Psoriasis Area and Severity Index (PASI) and Dermatology Life Questionnaire Index (DLQI) were used as a measure of treatment efficacy. There was an average improvement in PASI scores of 69% at 2 weeks post infusion. There was an improvement in DLQI of 61%. Four of the seven patients were also seen at 10 weeks post infusion and the improvement in PASI and DLQI was sustained. All patients tolerated the initial infusion well without adverse events. The results indicate that single‐dose infliximab is an effective and efficacious therapy for recalcitrant psoriasis and has a prolonged therapeutic effect.

Bowel bypass syndrome/bowel-associated dermatosis arthritis syndrome post laparoscopic gastric bypass surgery.

Bowel bypass syndrome, also known as bowel‐associated dermatitis arthritis syndrome, has been described after a range of intestinal bypass procedures. With the increasing trend in laparoscopic gastric bypass surgery, we report an interesting case of bowel‐associated dermatitis arthritis syndrome that developed 12 months following this procedure. A 49‐year‐old woman presented with ulcerating lesions and pustules on the upper and lower limbs, polyarthralgia, fevers and joint effusions. Before the development of these symptoms she was well, with no significant past medical or family history. A skin biopsy taken from the left shin showed superficial to mid‐dermal neutrophilic dermatosis, consistent with bowel‐associated dermatitis arthritis syndrome. The patient received corticosteroids, antibiotics and colchicine treatment, with control of disease after continuing with colchicine. This case may illustrate another possible complication following bariatric surgery. The significant time period between the initial surgery and the development of bowel‐associated dermatitis arthritis syndrome may mean that more cases of this condition will continue to emerge.

Cutaneous sarcoidosis and infliximab: evidence for efficacy in refractory disease

Biological therapy with tumour necrosis factor alpha antibodies continues to offer a life‐changing option for a range of autoimmune and inflammatory skin conditions. We present three cases of sarcoidosis, with refractory cutaneous disease successfully treated with infliximab. A review of the literature shows increased numbers of cases of refractory cutaneous sarcoidosis successfully cleared with infliximab therapy.

Dermatology outpatient population profiling: Indigenous and non-indigenous dermatoepidemiology

Background:  Little is known about the population using Australian dermatology outpatient services, in particular, Indigenous patients. This information is important to direct the strategic planning of dermatology services.

Cyclophosphamide in dermatology.

Cyclophosphamide is a chemotherapeutic agent which was first discovered in experimental tumours in rats, and it has since been widely used to treat malignancies and severe manifestations of various auto‐immune diseases. High‐dose chemotherapy and continuous daily oral regimens are associated with significant toxicity profiles, but i.v. pulsed regimens have lowered the rates of adverse effects in rheumatological studies. Cyclophosphamide has been shown to be useful in the treatment of severe autoimmune conditions due to its powerful immunosuppressive ability; however, it remains a relatively underused modality in dermatology. This article reviews the current literature on cyclophosphamide and its clinical applications in dermatology.

Drug-induced dermatomyositis after zoledronic acid.

A 57‐year‐old woman with prior exposure to bisphosphonates developed myalgia, proximal muscle weakness and lichenoid rash over the upper extremities and face 3 days after infusion of zoledronic acid for the management of osteoporosis. The diagnosis of dermatomyositis was made on the basis of clinical, laboratory and histological findings. This is the first report of drug‐induced dermatomyositis secondary to zoledronic acid.

The Fixomull skin support method for wound closure in patients with fragile skin

We report the Fixomull (BSN Medical, Hamburg, Germany) skin support technique for wound closure, a novel method for closing elliptical incisions in patients with fragile skin. After the lesion of concern is excised, a strip of Fixomull is applied to the skin adjacent to the wound edge with an approximately 2 mm gap between the Fixomull and the incision edge. The wound is then closed with interrupted sutures through the Fixomull, with care to ensure wound edge eversion. Fixomull provides extra tensile strength. The sutures are removed at approximately 14 days, and the patient given a prophylactic course of oral antibiotics only if at high risk of infection. This is a simple, time efficient, inexpensive and effective measure to avoid skin grafts and reduce skin tears and trauma in patients with thin, fragile skin. In our practice there have been no significant skin infections using this technique.

Treatment of scalp dysesthesia utilising simple exercises and stretches: A pilot study

Scalp dysesthesia is characterised by abnormal cutaneous sensations such as burning, stinging or itching of the scalp in the absence of objective dermatological findings. We hypothesised that the unpleasant sensations are the result of a sensory neuropathy secondary to cervical spine dysfunction and chronic tension of the pericranial muscles. The aim of this pilot study was to evaluate the use of an exercise protocol consisting of cervical spine range of movement exercises, gentle mobilisation and muscle stretches over 4 weeks. The exercise protocol was designed to relieve cervical nerve compression through the restoration of cervical homeostasis.

Epidermotropic CD8 positive lymphoproliferative diseases: histological and immunophenotypic similarities but markedly differing clinical behaviour.

Sir, Primary diagnosis of cutaneous T-cell lymphomas is necessarily predicated upon correlation of clinical, routine microscopic, immunophenotypic and, in some cases, molecular study. However, there is probably no histopathological or immunophenotypic finding which is entirely specific for a particular disease entity in the absence of appropriate clinical circumstances. We present three cases of epidermotropic CD8 positive lymphoproliferative disorders with marked histological and immunophenotypic similarities, but very distinct clinical behaviour, covering a spectrum from indolent behaviour to rapid progression. Case 1 was a 38-year-old female with no relevant medical history who described a 5-year course of waxing and waning lesions occurring on the inner forearms bilaterally (Fig. 1A). The patient reported that episodes of eruption were heralded by a single night sweat and that the lesions typically resolved after exposure to sunlight. There were no other systemic symptoms. Examination revealed crusted papules symmetrically over the proximal inner forearms extending to the antecubital fossae. There was no lymphadenopathy or organomegaly. Full blood picture was normal. Biopsy of two forearm lesions showed mild spongiosis, acanthosis and parakeratosis (Fig. 1B). The epidermis contained an infiltrate of smallto medium-sized lymphocytes with convoluted nuclear membranes forming linear basal arrays and aggregates (Fig. 1B). There was a superficial perivascular infiltrate composed of smallto medium-sized lymphocytes. By immunohistochemistry the intraepithelial lymphocytes were positive for CD3; the majority were CD8þ (Fig. 2A), BF1þ and CD4e. There was strong CD30 staining of the mediumsized, convoluted cells (Fig. 2B). The superficial dermal lymphocytes showed mixed CD4 and CD8 positivity, with smaller numbers of CD30þ medium cells. A combined clinical and histological diagnosis of lymphomatoid papulosis (LyP) type D was made. Close follow-up without active management was initiated, and the patient reported continued occurrence of similar self-healing lesions. The patient remains otherwise well 22 months post-biopsy, with no signs of systemic involvement. Case 2 was a 57-year-old male who presented with rapidly progressing ulcerated plaques and tumours over the trunk, limbs and face (Fig. 1C). The lesions had been increasing in number and size for one year, having started with localised right abdominal plaques. At the initial presentation a skin biopsy had been reported at another institution to be consistent with mycosis fungoides, and staging PET scan and bone marrow biopsy had confirmed disease confined to the skin. On more detailed review there was no history of antecedent patches. Repeat biopsy of the abdominal lesions showed an