Ricardo Suárez-Fernández

Generalised pustular psoriasis and neutrophilic cholangitis: An infrequently reported association with excellent response to tumour necrosis factor inhibitors

the cutaneous eruption within 10 days. The lymphadenopathy showed improvement within 5 days. Thereafter, he was transitioned to a weaning dose of oral dexamethasone. Vismodegib, approved for locally advanced and metastatic BCC, frequently produces side-effects such as muscle cramps, alopecia, dysgeusia and weight loss. However, other cutaneous reactions are uncommon. DRESS is a heterogeneous group characterised by a widespread cutaneous eruption together with eosinophilia and multi-visceral involvement. The liver is the most commonly involved organ, with hepatocellular necrosis being the most frequent pattern of injury and a cholestatic picture seen less often. Pulmonary involvement is less common, but the constellation of symptoms seen in our patient has been described in DRESS. The great variability in presentation contributes to diagnostic difficulty. Patients are frequently treated for suspected infectious or lymphoproliferative aetiologies prior to a definitive diagnosis. The characteristic delay between treatment initiation and symptom onset further adds to diagnostic complexity. The typical latency period is 2– 6 weeks, but longer periods have been observed. There is little evidence for the optimal management strategy for DRESS due to its infrequent presentation and the consequent lack of clinical trials, but pulsed i.v. methylprednisolone has been advocated. This is the second known case of DRESS resulting from vismodegib treatment worldwide and appears to be an emerging side-effect. DRESS is a life-threatening condition and as such, its probable association with vismodegib treatment is important to consider. After diagnosis, the withdrawal of non-essential medications and the institution of corticosteroid therapy should not be delayed.

Antibodies to the amino-terminal domain of desmoglein 1 are retained during transition from pemphigus vulgaris to pemphigus foliaceus

BackgroundPemphigus vulgaris (PV) and pemphigus foliaceus (PF) are two blistering skin diseases mediated by antibodies to desmoglein 3 (Dsg3) and/or Dsg1. Phenotypic transition from PV to PF is rarely reported.ObjectivesTo determine the immune response to extracellular (EC) domains of Dsgs during this transition.Materials and MethodsWe report two PV patients who subsequently developed a PF phenotype. To map the conformational epitopes in these cases, we examined the reactivity of the sera of two patients by immunoprecipitation-immunoblotting analysis, using five Dsg1/Dsg3 domain-swapped molecules on a backbone of Dsg2.ResultsReactivity exclusively with the EC1 domain of Dsg1 was maintained in both PV and PF stages. No reactivity to Dsg3 in the PF stage was found in patient 1. Various changes in immunoreactivity to Dsg3 were found and the EC1 and EC2 domains of Dsg3 reacted weakly to serum taken at remission and PF stages in patient 2.ConclusionsOur findings suggest that amino-terminal pathogenic antibodies to the EC domain of Dsg1 were retained, while considerable epitope changes occurred in response to Dsg3 during the shift from PV to PF, with an absolute or significant decrease in pathogenic antibodies to the EC1 domain of Dsg3.

Cutaneous implantation of papillary thyroid carcinoma secondary to percutaneous ethanol injection into nodal metastasis

Papillary thyroid carcinoma is the most common malignant neoplasm of the thyroid gland, accounting for 50-89% of the cases. It usually presents as a well-differentiated, slow-growing, malignant disease with common spread to locoregional lymph nodes and high recurrence rates. In patients with limited cervical lymph node metastases who are not candidates for surgery or radioiodine therapy, percutaneous ethanol injection (PEI) guided by ultrasonography has proven to be a valuable treatment alternative. This article is protected by copyright. All rights reserved.

Hypopigmented patches on the buttocks of a 7‐year‐old boy

A 7-year-old Hispanic boy presented with a 2-year history of asymptomatic hypopigmented patches on his legs (Fig. 1). He was otherwise healthy. Physical examination revealed slightly scaly, ill-demarcated and asymptomatic lesions on the patient’s legs. The patient’s family reported that the lesions showed a cyclical summer improvement and winter relapse. There were no other relevant findings during the physical examination, and the patient reported that he had no other symptoms. There was no personal or family history of atopic dermatitis or other eczematous dermatoses. Hepatosplenomegaly and lymphadenopathy were absent, and laboratory tests, including full and differential blood counts, blood smear, blood immunophenotyping, and liver and kidney function tests, were all within normal limits. A 4 mm punch/ biopsy was taken for histology.

Neoadjuvant intralesional methotrexate in squamous cell carcinoma of the lip

tested to propolis 10% petrolatum and to his own honey. Patch tests were applied to the back using Finn Chambers (SmartPractice Dermatology|Allergy, Phoenix, Arizona), and were read at 48 and 96 h, showing positive reactions to propolis (+++), honey (++) and Balsam of Peru (++). Due to its anti-inflammatory, antiseptic, antibacterial and antioxidant properties, propolis is widely used in many over-the-counter cosmetic and hygiene products. Propolis is a frequent contact allergen with very few cases reported in the literature of allergic contact dermatitis caused by propolis-enriched honey. The incidence of contact allergy to propolis is steadily increasing with the more frequent use of propolis in biocosmetics and in biopharmaceuticals. A review by de Groot and colleagues reviewed 22 studies and found that prevalence of positive patch tests to propolis ranged from 0.5% to 15%. Propolis shares allergens with Balsam of Peru, colophony and fragrance mix I, thus cross-reactions to these allergens frequently occur. Despite that, propolis is not included in the standard baseline tests in the European Union or the United States. Most recently, it has been proposed that propolis should be added to the European baseline series. Dermatologists should be on the lookout for potential contact dermatitis of the genital area and query on the use of any natural remedies. Furthermore, we propose the routine testing of propolis in the baseline patch tests, given the high prevalence of contact allergy to propolis.

Dermoscopic Features of Circumscribed Palmar Hypokeratosis

Report of Cases | Case 1. A healthy woman in her 40s presented with a 10-year history of an asymptomatic, erythematous, and scaly plaque on the palmar aspect of the fifth finger on the right hand. Physical examination revealed a 7 × 3-mm atrophic and eroded plaque (Figure 1A, top). Polarized light dermoscopic examination showed a rounded pink lesion with a rim of peripheral stairlike desquamation. In the center of the lesion, a dotted pattern composed of white dots with regular distribution over a light pink background was observed (Figure 1A, bottom). On histopathological analysis, the periphery of the lesion showed an abrupt stairlike thinning of the horny layer forming an area of hypokeratosis in the center. Dilated congestive capillaries and a mild chronic inflammatory infiltrate were present in the papillary dermis (Figure 2).

Disseminated Erythematous Crusted and Pustular Plaques on the Trunk

A healthy woman in her 60s presented with multiple erythematous crusted plaques on her trunk that had appeared 4 weeks previously, sparing her limbs and facial region (Figure, A). She had a long-standing history of several outbreaks of skin lesions limited to both axillae and groin. Previous episodes had been successfully treated with various topical drugs that were administered by her primary care physician. No family history of similar lesions was recorded. Physical examination revealed multiple annular erythematous plaques surrounded by a peripheral crusted and pustular collarette on her trunk (Figure, B). No active lesions were present in her axillae, inframammary folds, or groin. After obtaining informed consent, 2 biopsy specimens were taken from the periphery of the lesion for hematoxylineosin stain and direct immunofluorescence (Figure, C and D). A skin swab specimen from a pustular lesion was taken for microbiological culture. Clinical presentation A

Coma blisters with deep soft tissue involvement after drug overdose

Coma blisters or coma bullae (CB) are bullous lesions that have been associated with a variety of neurological diseases, especially with drug and nondrug-induced coma. They are usually related to drug overdose in patients with previous history of suicide attempt (barbiturate, antipsychotics, antidepressants, or opiate overdose) or in the setting of metabolic imbalance (diabetic ketoacidosis, chronic renal failure). The exact pathogenesis remains unclear. CB represent a self-limited disease; however, some patients may develop deep skin and soft tissue involvement presenting as pain, edema, and functional impairment. Herein, we describe the case of a patient with CB and muscle necrosis, erroneously diagnosed as bacterial cellulitis. A 49-year-old man was admitted to the emergency department with progressive loss of consciousness after an attempted suicide with tricyclic antidepressant, opiates, and benzodiazepine overdose. Laboratory tests revealed positive urine toxic levels, leukocytosis (14,300/l), and renal dysfunction with rhabdomyolysis (creatinine 1.44 mg/ml, estimated glomerular filtration rate of 52 ml/min, serum creatinine phosphokinase 3757) with elevation of acute phase reactants (reactive C protein 24.3). Chest x-ray showed posterior right lung infiltrate compatible with the diagnosis of aspiration pneumonia. Within 48 hours, he presented a sudden and rapid onset of hemorrhagic and serous blisters symmetrically distributed over the legs, heels, dorsum of toes, and back of the hands (Fig. 1a–c). Punch biopsy was taken from a pretibial lesion. Histological findings included necrosis of sweat glands and sweat duct keratinocytes, as well as a focal eosinophilic thickening of the basement membrane (Fig. 2d). When the patient was conscious again (approximately 96 hours after admission), he also complained of pain in the lateral side of his right leg. On examination, the leg was edematous and slightly erythematous, which was interpreted as bacterial cellulitis (Fig. 1d). Clindamycin and levofloxacin were added to the treatment. However, no response was seen with antibiotics. Soft tissue ultrasound imaging showed a hypoechoic signal distally in the leg suggestive of muscle edema (Fig. 2a). Magnetic resonance showed edema of the subcutaneous fat with increased volume along the distal part of the long peroneal muscle and with signs of muscle necrosis (Fig. 2b,c). Pressures within the compartment were normal. At discharge, the leg was still edematous and mildly painful. Posterior clinical and radiological follow-up was carried out, with slow improvement. The first description of CB dates back to early XIX century, when Larrey (Napoleon’s surgeon) noticed blisters in soldiers who had been comatose from carbon monoxide intoxication. Since then, there is a wide list of drugs and clinical settings that can potentially cause this entity. They consist of tense and flaccid blisters more frequently located distally in the limbs. Typically, adjacent skin is spared. CB are thought to be caused partly by pressure and ischemia in patients with impaired mental

Cutaneous drug Reactions: Chemotherapy-induced hyperpigmentation

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Dermoscopic features in three cases of rounded and velvety epidermal naevus

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