Journal of Cutaneous Medicine and Surgery

Psoriasis is a chronic, immune-mediated inflammatory skin disorder of unknown etiology. Interleukin (IL)-17a, a key product of the recently identified Th17 cell subset, has been found to play a critical role in the immunopathogenesis of psoriasis. IL-17 antagonists are a new class of biological agent currently in development for psoriasis that selectively inhibit IL-17a activity.

This review aims to summarize the current efficacy data from phase II randomized controlled trials of the IL-17 antagonists brodalumab, ixekizumab, and secukinumab for the treatment of moderate to severe psoriasis.

Patients treated with IL-17 antagonists achieved marked reduction in psoriasis disease severity as demonstrated by the Psoriasis Area and Severity Index (PASI) 75 response rates. A sizable proportion of patients treated with brodalumab and ixekizumab achieved unprecedented clinical clearance of their psoriasis (PASI > 90). These encouraging results demonstrate the efficacy of these agents and validate the proinflammatory role of IL-17 in the pathophysiology of psoriasis.

Acitretin is a systemic retinoid that is used in dermatology for a variety of conditions. A well-recognized potential adverse event from acitretin is elevated transaminases, indicating acute hepatocyte damage. Less well known is the possible cholestatic injury that can occur, signaled by elevated γ-glutamyltransferase (GGT) and alkaline phosphatase (ALP).

Our patient presented with an acute acitretin-induced hepatitis with a mixed pattern of elevated transaminases as well as GGT and ALP. A literature review demonstrated that most cases of acitretin-induced hepatitis, outside clinical trials, describe patients with a similar mixed hepatitis pattern.

This is the first literature review on acitretin-induced hepatitis. Although acitretin-induced hepatoxicity is rare, the seemingly unusual presentation of a mixed pattern of hepatocyte injury and cholestasis may be more common than previously thought. The findings should encourage clinicians not only to monitor transaminases but also to consider measuring cholestatic enzymes (ALP/GGT) in patients with transaminase abnormalities.

Oral psychostimulant (PS) drugs, the pharmacologic treatment of choice for attention-deficit/hyperactivity disorder (ADHD), have been associated with diseases of abnormal sensitivity to cold (DASC) such as Raynaud phenomenon and acrocyanosis.

In a cohort of pediatric patients with DASC, we sought to identify prevalence and clinical features of patients on PS drugs.

A 6-year retrospective chart review (2005-2011) of Ste-Justine University Hospital Center DASC patients with and without exposure to PS drugs was performed. Clinical data were analyzed with descriptive statistical methods.

Of 43 patients with DASC, 11 (25%) were exposed to PS drugs. In this group males were overrepresented, there was no evidence of collagen vascular diseases, serologic findings were not significant and the mean duration of PS intake was of 2.5 years. DASC age of onset was similar in both exposed and nonexposed patients. The incidence of more than one DASC type was greater in teenager patients with a positive family history of autoimmune and/or collagen vascular diseases.

This study is limited by its small population size, short follow-up period and its retrospective nature.

Physicians should be aware of PS drugs as possible triggers for DASC.

Pyoderma gangrenosum (PG) is a severe extraintestinal manifestation of inflammatory bowel disease (IBD).

To better characterize PG features and management among an IBD cohort.

Subjects with PG were identified using a large database at a tertiary center. Patient demographics and clinical characteristics were summarized using descriptive statistics.

Eighty patients with an episode(s) of PG were identified, yielding an overall prevalence of 1.9%. Overall, 93% of patients with PG had some degree of colonic inflammation. Thirty-one (39%) patients required hospitalization for PG. Underlying bowel disease was active at the time of PG episode(s) in 52 (65%) patients. The PG location was variable, with the lower extremity being the most common. Most patients (71.3%) required multiple therapies to achieve PG healing.

We describe one of the largest case series of PG among patients with IBD. The variety of treatment strategies used highlights the lack of clear guidelines in managing this complex group of patients.

There is currently a lack of evidence-based therapies that are safe and effective for plaque-type morphea. We aimed to evaluate the therapeutic potential and safety profile of imiquimod 5% cream in plaque-type morphea.

We enrolled 25 adult patients from two Canadian centers with histologically confirmed plaque-type morphea. Imiquimod 5% was applied to a representative plaque, and vehicle was applied to a control plaque for 9 months. Treatment efficacy was assessed with the Dyspigmentation, Induration, Erythema, and Telangiectasias (DIET) score, histology, and ultrasound evaluation.

Twenty-two patients completed the entire length of the study. Imiquimod 5% was superior to vehicle in reducing DIET scores at 3, 6, 9, and 12 months (p < .05). Induration demonstrated the greatest response. Histologic evaluation showed significant improvement or resolution of disease. However, no ultrasonographic differences were found in dermal and hypodermal thicknesses between the treatment and vehicle groups (p > .05). Adverse effects were minimal and well tolerated.

Although the occurrence of psoriasis and vitiligo is reported in a few studies, no proper relationship has been found between these two diseases.

The aim of this study was to identify the frequency of the coincidence of these two diseases.

A descriptive and cross-sectional study was conducted on 6,200 patients referred to dermatology clinics from September 2004 to June 2005.

Among these patients, 219 and 154 patients suffered from psoriasis (3.53%) and vitiligo (2.48%), respectively, and 12 patients (0.19%) had psoriasis and vitiligo simultaneously. The coincidence in the psoriasis group was 5.48% and in the vitiligo group was 7.79%, so the coincidence of both diseases was greater than the incidence of each alone. This association was significant (p = .004).

Coincidence of these two diseases was seen, but more studies should be done to find common genetic and immunologic factors.

Vitiligo is an idiopathic skin disease characterized by white areas on the skin due to loss of the functional melanocytes, with possible involvement of oxidative stress. Glutathione peroxidase (GPx) is an antioxidant enzyme that protects cells against oxidative damage.

To examine serum GPx levels in patients with vitiligo and to relate the findings to the clinical features.

The study group included 60 patients with vitiligo and 30 matching healthy controls. GPx activity was evaluated using enzyme-linked immunosorbent assay.

We found a significant decrease in serum GPx activity level in the patients with vitiligo compared to the healthy controls (0.29 ± 0.14 versus 0.47 ± 0.13, p < .001). The levels were significantly low in skin phenotypes III and IV (p < .001). Higher levels were also observed with increasing age (≥ 14 years), prolonged disease duration (≥ 3 years), and generalized and extensive vitiligo (<50%). However, these variations were statistically insignificant.

Low levels of serum GPx activity, indicative of a disturbed oxidant-antioxidant system, may contribute to the development of vitiligo.

The prevalence of rosacea is poorly characterized. Because selection bias may affect prevalence estimates, there is a need to characterize the prevalence of rosacea outside the clinic setting.

To assess the prevalence of rosacea in community settings.

A clinical research fellow and a medical student stood in public places (a mall, the Department of Motor Vehicles, a grocery store) and examined consecutive individuals who passed by ≤ 2 yards away. They tallied demographic and descriptive data on the subject and included the subject in one of three categories: clearly rosacea, possible rosacea, and definitely no rosacea. Subanalyses by perceived gender, age, race, and rosacea subtype were also performed. Comparisons between groups were made using the Fisher exact test.

Considering the prevalence of rosacea among all observed individuals in the community setting, 5.4% (95% CI 3.6-7.8) of individuals had “possible” rosacea and 6% (95% CI 4.1-8.5) of individuals had “definite” rosacea. Older, white individuals with fairer skin types (Fitzpatrick skin types I, II, and III) were more likely to have rosacea. There was no gender predisposition.

Distance from subjects made it difficult to assess patients with mild rosacea or a few telangiectasias, as well as ocular rosacea. The study could not assess those individuals who were too embarrassed by their rosacea to be in the public settings observed. Additionally, some subjects may have applied significant makeup in an effort to conceal their rosacea, making assessment difficult.

Based on direct observation of individuals in community settings, rosacea is more common than previously reported in the United States.

Pemphigoid nodularis is a rare clinical variant of bullous pemphigoid characterized by overlapping clinical features of both prurigo nodularis lesions and bullous pemphigoid blisters. The condition appears to be more common in females and is often resistant to treatment.

To raise awareness of this rare variant of bullous pemphigoid.

Case report.

Scleroderma encompasses a spectrum of disorders characterized by thickening of the skin and subcutaneous tissue with increased collagen deposition. Linear scleroderma is subdivided into progressive hemifacial atrophy and en coup de sabre subtype.

We report a case of congenital linear scleroderma identified in an adult, misdiagnosed since birth as birth trauma.

We completed a review of the literature for similar cases using PubMed and Medline.

This is the first report of congenital linear scleroderma en coup de sabre diagnosed in an adult following an initial misdiagnosis of birth trauma. The sequelae of linear scleroderma can be significant as it can result in growth retardation, muscle atrophy, contractures, limb length discrepancy, and disfigurement.

This report emphasizes the importance of educating practitioners about linear scleroderma. Early recognition is key as a delay in diagnosis can result in potentially preventable, irreversible growth defects and disfigurements.

The clinical and histopathologic findings of a rare simultaneous occurrence of papulonecrotic tuberculid and nodular tuberclid in a patient with active but asymptomatic pulmonary tuberculosis are presented. Papulonecrotic tuberculid was observed at a very early stage, presenting as molluscum-like lesions. This has been described once in the literature. This was observed in conjunction with lesions compatible with the rare clinicopathologic variant of nodular tuberculid. Critical to the diagnosis of active pulmonary tuberculosis was the use of induced sputum testing, which confirmed the diagnosis despite the lack of a cough and a chest x-ray negative for active tuberculosis.

A 40-year-old male presented with a 2-week history of fever and a skin eruption consisting of molluscum-like papules on the ears, arms, and abdomen and nodules on his legs. Biopsies from both lesions were consistent with papulonecrotic and nodular tuberculid, respectively. Despite the lack of any respiratory symptoms, induced sputum grew Mycobacterium tuberculosis, and the lesions resolved on antituberculous therapy.

Tuberculids are rare in Western countries but must be considered in the differential diagnosis of eruptions in patients from endemic countries. An active tuberculous focus must be sought out.

Benign chronic familial pemphigus (BFCP) is an autosomal dominant dermatosis characterized by flares of painful and often debilitating blistering lesions in high friction areas of the body such as the groin, axillae, lateral neck, and intergluteal cleft. Limited knowledge of its pathophysiology has made treatment of BFCP a considerable challenge and efficacy with current first line therapies, topical corticosteroids and antibiotics, is variable.

We present a case of this disease in a 52 year old woman that has responded dramatically to the addition of oral cyclosporine to her existing regimen of oral acitretin, with significant improvement of skin lesions, mobility, and quality of life. Cyclosporine's mechanism of action in BFCP is poorly understood, although it possibly acts through inhibition of proinflammatory cytokines in keratinocytes or modulation of intracellular calcium. BFCP, the use of cyclosporine for its treatment, and possible mechanisms of action of cyclosporine are reviewed.

In-transit metastases are dermal and subcutanous metastatic foci located between the tumor and the closest regional lymph node. Although in-transit metastasis has been commonly described for malignant melanoma, there have been some reports of in-transit metastases arising from primary cutaneous malignancies. The risk of development of in-transit metastases is higher in patients with high-risk squamous cell carcinoma.

We present a case of in-transit metastasis in a nonimmunosuppressed patient with a primary cutaneous squamous cell carcinoma.

Tinea indecisiva is characterized by concentric scaly rings simulating tinea imbricata but caused by dermatophytes other than Trichophyton concentricum.

Tinea indecisiva has been rarely reported. We report a unique case and review of the previously reported cases, pathogenesis, and management.

An adult Indian man developed extensive tinea cruris and tinea corporis with concentric rings of scaly lesions over the groin, buttocks, and thighs following the use of oral corticosteroids and antifungal-steroid cream for 3 months. Mycologic and immunologic studies were performed for diagnosis.

Diagnosis of tinea indecisiva was confirmed on the appearance of “ring-within-a-ring”; lesions clinically and isolation of Trichophyton mentagrophytes var. interdigitale as the etiologic agent on mycologic testing. Intradermal testing with Trichophyton extract showed fluctuating hypersensitivity responses. Four-week treatment with daily oral terbinafine resulted in complete resolution.

Tinea indecisiva should be considered in a patient with tinea imbricata-like lesions with local immunosuppression caused by a non-concentricum dermatophyte.

Patients with segmental vitiligo (SV), unlike those with nonsegmental vitiligo (NSV), have a more predictable course and are more responsive to surgery.

To report 10 patients with SV treated with the melanocyte-keratinocyte transplantation procedure (MKTP), who responded with unusual responses not previously reported in the literature.

This is a retrospective, observational study that reports 10 patients with SV who underwent the MKTP between May 2003 and May 2012.

Two patients had successful repigmentation after split-thickness skin grafting after failure of the MKTP. Two patients developed a hypopigmented ring at a margin of the MKTP-treated area. One patient had complete repigmentation after a second MKTP. Two patients developed koebnerization of the recipient site. Three patients developed new vitiligo patches in previously unaffected areas after the MKTP.

Uncommon and even suboptimal responses can occur following the MKTP in SV patients. There is a need for studies to provide better understanding and outcomes for SV patients undergoing the MKTP.

Tissue necrosis is a rare yet potentially serious complication of intra-articular (IA) hyaluronic acid (HA) injections for treatment of knee osteoarthritis.

To report a case of a patient with cutaneous necrosis after IA HA injection for treatment of knee osteoarthritis, presenting as a livedoid violaceous patch on the right knee.

We report a case of cutaneous necrosis as a rare complication of IA HA injection for treatment of knee osteoarthritis. A literature review was undertaken of similar cases.

Use of HA IA injections in the treatment of osteoarthritis can result in similar skin necrosis at uncommon anatomic locations corresponding to the site of HA injection.

Although tissue necrosis is a rare complication, physicians need to be aware of this possibility as a complication of HA IA injections in the treatment of osteoarthritis and should be mindful of potential treatment options to manage this adverse event.