Neide Pereira

Pyoderma gangrenosum – a review of 24 cases observed over 10 years

Background and objectives  Pyoderma gangrenosum (PG) is a disorder, included in the spectrum of neutrophilic and auto‐inflammatory dermatoses, whose clinical aspects and outcome we intend to characterize.

Pyoderma gangrenosum: challenges and solutions

Pyoderma gangrenosum (PG) is a rare disease, but commonly related to important morbidity. PG was first assumed to be infectious, but is now considered an inflammatory neutrophilic disease, often associated with autoimmunity, and with chronic inflammatory and neoplastic diseases. Currently, many aspects of the underlying pathophysiology are not well understood, and etiology still remains unknown. PG presents as painful, single or multiple lesions, with several clinical variants, in different locations, with a non specific histology, which makes the diagnosis challenging and often delayed. In the classic ulcerative variant, characterized by ulcers with inflammatory undermined borders, a broad differential diagnosis of malignancy, infection, and vasculitis needs to be considered, making PG a diagnosis of exclusion. Moreover, there are no definitively accepted diagnostic criteria. Treatment is also challenging since, due to its rarity, clinical trials are difficult to perform, and consequently, there is no “gold standard” therapy. Patients frequently require aggressive immunosuppression, often in multidrug regimens that are not standardized. We reviewed the clinical challenges of PG in order to find helpful clues to improve diagnostic accuracy and the treatment options, namely topical care, systemic drugs, and the new emerging therapies that may reduce morbidity.

Value of patch tests in clindamycin-related drug eruptions

Background. Patch tests help to confirm the aetiology of the cutaneous adverse drug reactions involving delayed hypersensitivity mechanisms, but the results vary with the pattern of skin reaction and the culprit drug.

The UV filter tinosorb M, containing decyl glucoside, is a frequent cause of allergic contact dermatitis.

To the Editor: Tinosorb M (Chemotechnique Diagnostics, Vellinge, Sweden), an organic molecularly complex broad-spectrum UV filter composed of microparticles of methylene bis-benzotriazolyl tetramethylbutylphenol solubilized with decyl glucoside, propylene glycol, and xanthan gum, has rarely been described as a cause of allergic contact dermatitis (ACD). Because of its high efficacy and photostability, after 2000, it was introduced in the European and Australian markets but is still waiting approval by the Food and Drug Administration. The authors performed a retrospective study to evaluate the frequency of ACD from Tinosorb M, patients’ characteristics, and responsible allergens. In the Unit of Cutaneous Allergology of the Dermatology Department of the University Hospital of Coimbra, Tinosorb M at 10% Petrolatum (pet) was included in the photoallergens series in 2009, initially within the European Multicentre Photopatch test study, and since 2011, also in our cosmetic series for patch testing, patients with recurrent dermatitis localized mainly to the face. Between February 2009 and April 2012, among the 1033 patients studied at the department, 92 were photopatch tested using the irradiation dosis of 5 J/cm of UVA (Waldmann 7001 K), according to the guidelines published by the European Photopatch Test Task Force. An additional 87 patients were patch tested with the cosmetics series including the UV filters, namely Tinosorb M (10% pet) and bis-ethylhexyloxyphenol methoxyphenol triazine (bemotrizinol or Tinosorb S, 10% pet) and lauryl glucoside (3% pet) from Chemotechnique Diagnostics. Patch tests were applied on the upper back, for 48 hours, using Finn Chambers on Scanpor tape (Epitest Ltd, Tuusula, Finland) or, occasionally, I-Q ultra chambers (Chemotechnique Diagnostics, Vellinge, Sweden). Readings were performed at D2 and D3/D4, according to the International Contact Dermatitis Research Group recommendations (Lindberg), considering only 1+ or more intense reactions. Several personal products (facial cosmetics, sunscreens, and topical drugs) were patch tested, and rinse-off products (clearnsing agents and shampoos) were tested using the semiopen method, applying a drop of the product in a 2 2 cm area and covering it, after drying, with a semipermeable tape for 48 hours (Mefix, Molnlycke Health Care, Finland). During this period, positive patch tests to Tinosorb M were observed in 5 patients, 3 female and 2 male, between 39 and 66 years old. They had highly pruritic erythematous and scaly eczematous lesions with ill-defined borders, located mainly on the face and anterior neck (Fig. 1), with an evolution between 1 and 12 months, that recurred frequently despite topical corticosteroids (Table 1). Positive reactions (1+ or 2+) to Tinosorb M at 10% pet (Fig. 2) had an equal intensity after irradiation with 5 J/cm UVA in all patients. Patient 1, the object of a previous publication, was patch tested with purified decyl glucoside at 5% pet, kindly supplied by An Goossens (Leuven, Belgium). He had a 2+ reaction to decyl glucoside and reacted to several cosmetics containing alkyl glucoside, specially lauryl-, xylityl-, cetearyl-, myristyl-, coco-, and arachidyl glucosides, and to his own sunscreen and to several other sunscreens containing Tinosorb M (Fig. 3).

Interstitial Granulomatous Dermatitis: A Clinicopathological Study.

Introduction:Interstitial granulomatous dermatitis (IGD) is an uncommon granulomatous dermatitis occurring in the setting of highly reactive immune states, with a polymorphic clinical presentation. Because there is overlap with other entities [namely palisading neutrophilic granulomatous dermatitis (PNGD)], controversy exists regarding its classification. Objective:To understand if there are features allowing clear-cut distinction between IGD and PNGD. Material and Methods:Retrospective analysis of 10 cases previously diagnosed as IGD or PNGD, from 2000 to 2013, with review of the histopathologic findings and clinical correlation. Results:Six females and 4 males presented mostly with erythematous papules/nodules (n = 7) but also with erythematous annular plaques (n = 3). In 2 patients, the lesions coexisted. They were mostly distributed symmetrically on the limbs. Associated disease was observed in 6 patients. Regarding histopathology, an inflammatory infiltrate occupying the superficial and mid dermis was present in 40% of cases, with an interstitial component in all biopsies and a palisaded arrangement in 60%. Neutrophils and mononuclear cells were present in all cases in varying proportions. Necrobiosis was found in 70%, and leukocytoclasia was observed in 80% of biopsies. Conclusions:Coexistence of the interstitial and palisaded inflammatory patterns occurred in 90% of cases, with no correlation between tissue neutrophilia and the predominant pattern of the infiltrate. There was also no clear-cut correlation between the infiltrate pattern and semiologic aspect of the lesions. Therefore, the features described in our study suggest that IGD and PNGD belong to the same clinicopathological spectrum.

Overlap between maculopapular exanthema and drug reaction with eosinophilia and systemic symptoms among cutaneous adverse drug reactions in a dermatology ward.

Inpatients with cutaneous adverse drug reactions (CADR) with overlapping features between maculopapular exanthema (MPE) and drug reaction with eosinophilia and systemic symptoms (DRESS) were examined.

Tunnelized preauricular transposition flap for reconstruction of auricular defect

Background: Reconstruction of surgical defects of the auricular region is a complex challenge, especially when they are localized in the anterior surface, due to the convexities and concavities of this region. Patients and results: The authors present the case of an 89-year-old woman who underwent radical excision of basal cell carcinoma localized in the left scapha. The reconstruction of the resulting defect was performed using a preauricular transposition flap tunnelized through a cartilaginous fistula created at the crus helicis. The flap was deepithelialized at its base to allow the closure in a single step. The donor site was primarily closed. The procedure was performed under local anesthesia without complications and with acceptable aesthetic results. Discussion: There are various surgical procedures described for the reconstruction of the anterior auricle, including local flaps, skin grafts and even healing by secondary intention. The authors consider the tunnelized preauricular transposition flap a good option especially when compared to interpolated flaps, since it allows a reconstruction in a single surgical step with decreased morbidity and favorable cosmetic results.

A rarely diagnosed disorder of the gluteal cleft

A 37-year-old white man presented with a 10-year history of itching, keratotic skin lesions on his gluteal cleft. At the time of presentation, he was using topical corticosteroids for presumed psoriasis, but without benefit. There was no family history of similar lesions or of other skin disorder, including psoriasis. The patient was otherwise in good health, and had not been taking any systemic medication. On physical examination, well-demarcated, erythematous, verrucous papules and confluent plaques, measuring 10–30 mm in size, were seen on both sides of the inner gluteal cleft, sparing the anal margin. Some of the lesions had a raised hyperkeratotic border, whereas others were scaly and/or erosive (Fig. 1a,b). The rest of the physical examination was unremarkable.

Pityriasis Lichenoides et Varioliformis Acuta: Case Report and Review of the Literature

We report a case of a 63-year-old man hospitalized for a polymorphous generalized eruption consisting of maculopapules with peripheral scaling, vesicopustules, and ulceronecrotic and crusted lesions measuring 5–20 mm, localized on his trunk and extremities, particularly exuberant in the flexural area. Histopathology showed necrotic keratinocytes with exocytosis of red blood cells and lymphocytes and a dermal perivascular and periadnexal inflammatory infiltrate, composed of CD8+/CD4–/CD30– T cells, indicating the clinical diagnosis of pityriasis lichenoides et varioliformis acuta. He was treated with erythromycin and methylprednisolone reduced gradually over 5 months, with a slow but complete response; the patient was without lesions after 2 years of follow-up. The authors want to remind of this rare entity which may present difficulties in diagnosis and therapy.

Overlap between maculopapular exanthema and DRESS among cutaneous adverse drug reactions in a dermatology ward (2008-2012)

Background Immune-mediated cutaneous adverse drug reactions (CADR) present under different clinical patterns, some different from the main phenotypes of CADR. Our objective is to characterize manifestations and culprit drugs in CADR that required hospitalization, particularly exanthema associated with few systemic symptoms without fulfilling the European DRESS criteria (MP/DR).