Yun-Hwan Jang

Serial sections of atrophic acne scars help in the interpretation of microscopic findings and the selection of good therapeutic modalities

Background  Acne scar causes problems cosmetically and psychologically. Although microscopic examination of acne scars is a necessity for understanding and treatment of them, and it is not easy to find a paper reporting the microscopic characterization of acne scars.

Treatment of paediatric facial pyogenic granuloma with topical ingenol mebutate.

Pyogenic granuloma (PG), also known as lobular capillary haemangioma, is a relatively common benign vascular lesion of the skin and mucosa. Although spontaneous resolution may occur, treatment is often recommended to avoid ulceration and recurrent bleeding. In young children, local ablative therapies for PG include cryosurgery and laser treatment, but their use in dangerous or problematic lesions in areas such as the face may lead to cosmetic complications. Therefore, safe and effective options for treatment of facial PG in children are needed. A 4-year-old boy presented with a 3-month history of a solitary, vivid red, matchhead-sized, pedunculated papule on his left cheek, which was clinically diagnosed as PG. The patient was prescribed ingenol mebutate 0.015% cream, to be applied to the lesion once daily for 3 days. The patient returned to the clinic after 1 week with minor redness and irritation of the skin, but improvement of the lesion. The patient continued treatment once daily for another 3 days, with resolution of the lesion (Fig. 1). There were no signs of recurrence after 5 months of follow-up. Topical application of ingenol mebutate induces both chemoablative and immunostimulatory effects. A previous study also showed that the use of ingenol mebutate led to a reduction of vascularization in the lesion, as demonstrated by a decrease in median haemoglobin levels in treated areas. These immunomodulatory and antiangiogenetic properties of ingenol mebutate suggest that a therapeutic effect is likely in PG. The most consistently reported adverse effects of ingenol mebutate are erythema, flakiness, crusting, pruritus, and pain, with effects peaking between days 3 and 8 and mostly resolving by day 15. Severe skin reactions may include swelling, postulation, and ulceration. No persistent systemic absorption was reported during long-term followup. Our patient had minor redness and irritation at the site of application, which resolved spontaneously without any other treatment. Application of ingenol mebutate to children requires medical supervision or it can be done at home by the parents. Although the precise cost analysis of relevant comparators for PG treatment may be difficult due to differences between countries, topical ingenol mebutate is more expensive than topical timolol; however, relatively longterm treatment with a month of twice-daily use is required with timolol. Ingenol mebutate is also more expensive than cryotherapy and laser therapy; however, these treatments are associated with pain, scarring and local adverse effects, which can represent a challenge when dealing with paediatric patients. In conclusion, we report a patient with facial PG successfully treated with ingenol mebutate. Our case suggests that because of its short-term application, ingenol mebutate may be considered as a meaningful option for uncooperative paediatric patients who may be afraid of treatment, especially on facial and other exposed lesions causing unexpected cosmetic complications. Further studies are needed to clarify the underlying mechanism of action of ingenol mebutate, and to confirm its effectiveness in PG.

Epidermolytic Hyperkeratosis as an Incidental Finding in Drug‐Induced Acne

To the Editor: Epidermolytic hyperkeratosis (EH) is a pathological term applied to epidermal changes characterized by perinuclear clear spaces of various sizes primarily in the stratum granulosum and spinosum, a thickened granular zone with coarse keratohyalin-like granules, and an overlying compact hyperkeratosis (1). It is observed as an incidental finding in a variety of conditions. We recently observed EH as an incidental finding in corticosteroidor cyclosporin-induced acne. A 36-year-old man abruptly developed numerous acneiform eruptions with some hyperpigmentation on the face, which lasted about two weeks. Eight months prior to this, he was diagnosed as acute myelocytic leukemia, and it relapsed after complete remission with chemotherapy. Then conditioning chemotherapy with busulfan and cyclophosphamide, allogenic bone marrow transplantation, and administration of cyclosporin as the posttransplantation immunosuppressant were performed. Thereafter he developed erythematous confluent macules and papules over his entire body, which was diagnosed as acute graft-versushost disease, grade 3. During one week of high dose immuosuppressant including corticosteroid and cyclosporin, numerous acneiform eruptions appeared (Fig. 1). We took a skin biopsy under the impression of corticosteroid-induced acne or a peculiar feature of graft-versus-host disease. The biopsy specimen showed intradermal dilated follicles and typical epidermolytic hyperkeratosis in the epithelium of cystically dilated infundibulum in addition to overlying surface epidermis adjacent to cystic dilatation (Figs. 2, 3). There were several scattered dermal melanophages in the upper dermis and mild fibrosis of the dermis around cystic dilatation. The histologic features of EH are associated with various skin diseases such as bullous congenital ichthyosiform erythroThe Journal of Dermatology Vol. 32: 686–687, 2005

Urticarial dermatitis unresponsive to conventional treatment: a hidden sign of pancreatic cancer

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