Sofia Georgala

Increased density of Demodex folliculorum and evidence of delayed hypersensitivity reaction in subjects with papulopustular rosacea

Rosacea is a common chronic dermatosis that evolves in stages. The mite Demodex folliculorum has been implicated in its obscure aetiopathogenesis.

A randomized trial of amorolfine 5% solution nail lacquer in association with itraconazole pulse therapy compared with itraconazole alone in the treatment of Candida fingernail onychomycosis

Summary Background Treatment failures and relapses are not uncommon in onychomycosis. Therefore, it is worthwhile to consider the combination of systemic and topical antifungals to improve the cure rates further and to reduce the duration of systemic treatment.

Persistent pigmented purpuric eruption associated with mycosis fungoides: a case report and review of the literature

A purpuric eruption may be an unusual early manifestation of mycosis fungoides (MF). On the other hand, persistent pigmented purpuric dermatoses (PPPD) may, occasionally, evolve to cutaneous T‐cell lymphoma. Coexistence of these two conditions has been reported, but it is extremely rare. We present the case of an elderly woman with a long‐standing pruritic, pigmented purpuric eruption. On 1‐year follow‐up, histological features suggesting early MF were observed and molecular analysis of the rearrangement of T‐cell receptor genes revealed clonality. Our patient may represent a case of PPPD evolving to MF, a case of MF clinically featuring PPPD, or an intermediate condition in a nosological continuity extending from PPPD to MF. A persistent pigmented purpuric eruption may rarely be a harbinger of cutaneous T‐cell lymphoma. Therefore, vigilant long‐term follow‐up of PPPD is highly recommended.

Contact reactions to fragrances

BACKGROUND The most common reaction to fragrances is contact dermatitis, a delayed hypersensitivity reaction; however, other reactions include immediate contact reactions (contact urticaria) and photo-allergic reactions. Fragrance mix (FM) and balsam of Peru (BP) are used to screen for fragrance allergy. OBJECTIVE To study the different types of allergic skin reactions to fragrance compounds. METHODS Delayed hypersensitivity reactions to FM and BP were studied in 4,975 patients with suspected contact dermatitis by routine patch testing interpreted at 48 and 96 hours. In 664 of the patients, patch tests were read at 30 minutes to evaluate for immediate (wheal-and-flare) contact reactions and again at 48 and 96 hours. Photopatch tests to FM were performed in 111 patients with suspected photo-allergic dermatitis. RESULTS Delayed contact reactions to FM occurred in 6.6% of females and 5.4% of males and to BP in 3.9% of females and 4.1% of males. Analysis of data over time (12 study years) showed an increased trend for reactions to fragrances, particularly in males. Sensitivity to other contact allergens (polysensitivity) was found in 62% of patients and polysensitivity presented more often with generalized contact dermatitis. The most sensitizing components of the fragrance mix that were tested in 38 patients were cinnamic alcohol, oak moss, and cinnamic aldehyde. There were 112 immediate patch test reactions to FM and 113 to BP in 664 patients. Immediate contact reactions were followed by delayed contact reactions in 13.4% of patients for FM and 8.8% for BP, representing a significant increase in the frequency of delayed contact reactions. Patients with immediate contact reactions to fragrances did not have a higher incidence of atopy (25.9%). No cases of positive photopatch test reactions to FM were seen. CONCLUSION Fragrances commonly cause both delayed and immediate patch test reactions and patients with immediate contact reactions have an increase in delayed contact reactions to the same allergen.

Evaluation of the role of contact sensitization and photosensitivity in the pathogenesis of poikiloderma of Civatte

Background Poikiloderma of the face and neck (Civatte) is a rather common, indolent, chronic dermatosis, most often affecting menopausal females. Cumulative excessive sun exposure, a phototoxic or a photoallergic reaction, hormonal changes of menopause and genetic factors have all been incriminated in its obscure aetiopathogenesis.

Tacrolimus ointment 0.1% in pityriasis alba: an open-label, randomized, placebo-controlled study.

Background  Pityriasis alba (PA) is a frequent reason for dermatological consultation because of its chronic course, tendency to relapse and aesthetic impact.

GENERALIZED PUSTULAR PSORIASIS PRECIPITATED BY TOPICAL CALCIPOTRIOL CREAM

International Journal of Dermatology 2005, 44 , 791–792 791 Generalized pustular psoriasis precipitated by topical calcipotriol ointment Dear Sir, A 55-year-old Japanese man presented with a 20-year history of generalized pustular psoriasis (GPP) controlled by oral etretinoid (0–30 mg/day), oral cyclosporine (0–5 mg/kg/ day), and topical application of a mild steroid (0.025% beclometasone dipropionate). On June 19, 2001 he started treatment with topical calcipotriol ointment (50 μ g /g) (Dovonex®) instead of the topical mild steroid, and continued the 30 mg/ day of oral etretinoid and 1.6 mg/kg/day of oral cyclosporine. Two weeks later, after applying a total of 100 g of the ointment to his trunk and extremities, he became feverish and numerous pustules appeared on most of his body and his laboratory data revealed an increased white blood cell count of 10 800/ mm 3 and a CRP level of 26.3 mg/dl. These findings indicated an exacerbation of the GPP (Fig. 1). The GPP was successfully controlled within 2 weeks by replacing the topical calcipotriol ointment with topical 0.025% beclometasone dipropionate ointment and increasing the dose of oral cyclosporine to 5 mg/kg/day. Two months later, during remission, when he resumed treatment by applying a total of 100 g of calcipotriol ointment on his trunk and extremities in the same manner, the GPP was again exacerbated. Thus, we considered that calcipotriol ointment triggered the GPP. Therefore, while in remission on 30 mg/day of oral etretinoid and topical 0.025% beclometasone dipropionate ointment, we admitted the patient for challenge tests of calcipotriol ointment applications. On the first day, 5 g of calcipotriol ointment was applied to his right leg, and on the second day 10 g was applied to both legs. On the third day, the patient’s skin, not only on the legs but also on the trunk where the ointment had not been applied, was fiery red and tender, and he had a 38 ° C fever. A 48-h closed patch test of calcipotriol ointment with Finn Chambers and Scamper tape was carried out once the GPP subsided. The calcipotriol ointment gave a positive irritant reaction (Fig. 2). Generalized pustular psoriasis, first described by von Zumbusch in 1910, is an uncommon and rather serious variant of psoriasis. 1 Various treatments such as topical steroids, oral retinoid, methotrexate, cyclosporine, and PUVA have been used for this intractable disease. In 1992, the efficacy of topical calcipotriol, a synthetic vitamin D 3 analog, was first reported in three patients with GPP. 2 Since then topical

Pemphigus vegetans confined to the scalp

Pemphigus vegetans confined to the scalp Pemphigus vegetans is a rare variety of pemphigus vulgaris, appearing with two clinical subtypes: Neumann and Hallopeau. The most commonly involved sites of the characteristic vegetating plaques are the intertriginous areas. In 60–80% of all cases, there is also an involvement of the oral mucosa. We report here a case of pemphigus vegetans confined exclusively to the scalp. A 54-year-old woman presented with two extensive, roundshaped, verrucous, vegetating plaques on the scalp, which had appeared 4 months previously (Fig. 1). The larger lesion, located on the crown of the head, had a diameter of 4.3 cm, protruding about 1.5 cm, and making the patient feel uncomfortable. There were no other lesions on the skin and/or mucous membranes and no history of other skin or systemic diseases. The patient had been treated with several antimicrobials without any benefit and the lesions were growing rapidly. Cultures for bacteria revealed Staphylococcus epidermidis. Direct microscopy and culture for mycology were negative. Full blood count, erythrocyte sedimentation rate (ESR), Creactive protein (CRP), blood sugar, liver and renal function tests were normal. Human immunodeficiency virus (HIV) serology was negative. Biopsy showed papillomatous, proliferating, acantholytic lesions in the epidermis and eosinophilic infiltrate in the dermis (Fig. 2). Direct immunofluorescence demonstrated intercellular immunoglobulin G (IgG) and C3 deposits mainly in the lower part of the epidermis. Antibodies to desmoglein 1 and 3 were analyzed using specific enzymelinked immunosorbent assay (ELISA). Index values to desmoglein 3 were 158 (normal, < 10), whereas those to desmoglein 1 were negative. The patient was treated with oral prednisolone (initial dose, 60 mg daily) and local application of clobetasol propionate twice daily. The lesions started to diminish rapidly within the first week and disappeared after 5 weeks, but relapsed 20 days after discontinuation of treatment. The same treatment was repeated and the lesions disappeared again, but relapsed when the dose of prednisolone was tapered below 15 mg. Therefore, during the last 4 months, we have combined an alternate-day dose of prednisolone (10 mg/15 mg) with mycophenolate mofetil (CellCept) (2 g/ 24h), and the patient has been free of recurrent disease. Our patient’s rather extensive lesions were confined exclusively to the scalp; therefore the diagnosis of pemphigus vegetans was not considered at the beginning. In the few cases of patients with scalp involvement mentioned in the literature, typical lesions have also existed in intertriginous areas and/or the oral mucosa. To our knowledge, single lesions of pemphigus vegetans confined exclusively to the scalp have not been described previously. There is, however, a report of a single lesion on the foot. According to the above, the diagnosis of pemphigus vegetans should be considered even in single lesions located in nontypical sites. Bearing in mind that this disease is a variety of pemphigus vulgaris, it should be treated with sufficiently high doses of corticosteroids and/or other immunosuppressive agents, even if it is limited to a single area.

Inosiplex for Treatment of Alopecia Areata: a Randomized Placebo-controlled Study

Treatment of alopecia areata remains unsatisfactory. We decided to test if systemic therapy with inosiplex (Isoprinosine(R)), an immunomodulator could influence the disease. Thirty-two subjects with recalcitrant alopecia areata, aged 16-48 years (mean 30.3+/-5.1 years), were randomized into two treatment groups of 16 subjects each. They were assigned to receive either oral inosiplex (group 1), or placebo (group 2) on a double-blind basis. Inosiplex dosage was 50 mg/kg/day in five divided doses for 12 weeks. Of the 15 evaluable patients in group 1, 5 (33.3%) had full remission, 8 (53.3%) responded partially and 2 (13.3%) did not respond. Of the 14 evaluable patients in the placebo group, none had full remission, 4 (28.5%) responded partially and 10 (71.4%) did not respond. The therapeutic difference between patients receiving active and placebo therapy was statistically significant (?2=7.82, p<0.01). Compared with placebo, oral inosiplex showed considerable efficacy in alopecia areata with insignificant side-effects. Larger studies are required, however, before inosiplex may be recommended as an efficacious and safe alternative systemic form of therapy for recalcitrant alopecia areata.

Polymorphic eruption of pregnancy

Polymorphic eruption of pregnancy (PEP) is a benign, self‐limiting, pruritic disorder of pregnancy, which usually affects the primigravida during the last trimester or immediately postpartum. Its pathogenesis is unclear and its clinical manifestations are variable, leading frequently to an incorrect diagnosis. In cases of PEP the histological findings are nonspecific and the laboratory results, including direct immunofluorescence (DIF) and indirect immunofluorescence (IIF), are negative. Polymorphic eruption of pregnancy is not associated with any fetal risk and symptomatic treatment is all that is usually required.