Dermatology Online Journal

This document provides a summary of the Dutch S3-guidelines on the treatment of psoriasis. These guidelines were finalized in December 2011 and contain unique chapters on the treatment of psoriasis of the face and flexures, childhood psoriasis as well as the patient’s perspective on treatment. They also cover the topical treatment of psoriasis, photo(chemo)therapy, conventional systemic therapy and biological therapy.

Alopecia affects many individuals worldwide. Owing to the large role that hair loss plays in self-image and self-confidence, an increasing number of these men and women seek options for hair restoration.Major considerations and sources of hesitation for strip surgical restoration are the visible linear scar, prolonged downtime, and other expected side effects of invasive procedures. These problems can be circumvented by smaller harvest approaches. However, the traditional punch harvest, which produces no linear scar, does leave patients with an often-unsatisfactory “doll hair” appearance. Follicular Unit Extraction (FUE) is a minimally invasive surgical procedure that utilizes a punch device to harvest occipital follicular units that are later transplanted in areas of loss to restore hair growth. FUE captures the benefit of multiple available restoration techniques and avoids the disadvantages of traditional strip surgery. A number of variations on the procedure are currently in practice and many more exciting advances are underway.

Reticulohistiocytomas are benign dermal tumors that usually present as either solitary or multiple, cutaneous nodules.  Reticulohistiocytosis can present as solitary or generalized skin tumors or cutaneous lesions with systemic involvement and are potentially associated with internal malignancy.  A woman with a solitary red nodule on her knee is described in whom the clinical differential diagnosis included dermatofibroma and amelanotic malignant melanoma.  Hematoxylin and eosin staining and immunoperoxidase studies of the biopsy specimen established the diagnosis of adult-onset reticulohistiocytoma (solitary epithelioid histiocytoma).  Reticulohistiocytoma is characterized by mononuclear, and occasionally multinuclear, histiocytes with eosinophilic “glassy” cytoplasm.  The immunohistochemical profile of a  reticulohistiocytoma demonstrates consistent positive expression for CD68 (a marker that is expressed by histiocytes but can also show positive staining in melanomas and carcinomas), CD163 (a very specific marker for histiocytes), and vimentin.  Reticulohistiocytomas show variable positive expression for MITF (microphthalmia transcription factor) and S100 protein, both of which are more commonly used as markers for melanocytes.  Recurrence of a reticulohistiocytoma is rare, even for patients with an incompletely removed lesion.  However, our patient elected to have her residual tumor completely excised.

A pyogenic granuloma (PG) is a rapidly growing benign vascular tumor that can be found on the skin or subcutaneous tissue.  While some pyogenic granulomas may resolve spontaneously, most have a tendency to bleed easily and require treatment.  Current therapeutic modalities include topical imiquimod, cryotherapy, electrodessication, curettage, excision, laser therapy, sclerotherapy, and microembolization. We report a recalcitrant case of chronic pyogenic granuloma occurring on the scalp of a healthy young male which was unresponsive to conventional surgical and non-surgical modalities.  Ultimately, aggressive laser therapy, intralesional triamcinolone acetonide injections, and topical timolol application led to complete resolution and healing.

Adenoid cystic carcinoma is a rare neoplasm that originates from secretory glands, most commonly from the salivary glands. We present a 76 year-old white man with a history of adenoid cystic carcinoma from the base of the tongue diagnosed 15 years prior to the development of the metastatic lesion on his mid-posterior scalp. The present case represents the second reported instance of an extracutaneous adenoid cystic carcinoma metastasizing to the scalp. Differentiating between a primary cutaneous adenoid cystic carcinoma and an extracutaneous adenoid cystic carcinoma metastasizing to cutaneous structures is crucial in determining prognosis and management.

Solar urticaria is an uncommon condition characterized by erythema and whealing shortly after exposure to ultraviolet (UV) and/or visible light. We report a 25-year-old woman with an erythematous, edematous, pruritic reaction minutes after sun exposure while she was taking terbinafine for onychomycosis. Phototesting revealed a UVB-sensitive urticarial reaction, confirming the diagnosis of solar urticaria. This report describes the first patient with possible terbinafine-associated solar urticaria.

Angiolymphoid hyperplasia with eosinophilia is an uncommon, benign hyperproliferative disorder. Papules and nodules occur predominantly in the head and neck region. Involvement of other sites such as the trunk and mucosae has been rarely reported. We herein report a case of angiolymphoid hyperplasia with eosinophilia involving the right infra-axillary region.

Multinucleate cell angiohistiocytoma (MCA) is a benign fibrohistiocytic and vascular proliferation usually located on the extremities. It may be underdiagnosed owing to lack of recognition by clinicians and pathologists. We report a 48-year-old man with asymptomatic grouped reddish papules on the dorsum of his right hand for 8 years. Histopathological and immunohistochemical examinations revealed features of MCA with a fibrohistiocytic cell infiltrate in the dermis and multinucleate cells in the stroma. Recently, the dermoscopy aspects of MCA have been described. We add another observation of this useful tool and correlate it with clinical evolution.

Acral persistent papular mucinosis is a subtype of localized lichen myxedematosus. It presents as acrally located papules with a benign, but persistent course. It is a scarcely reported disease. We present a female with both the clinical and histopathological described criteria

An 11-month-old girl presented with an erythematous nodule on the chest, which had been growing for 8 months. The tumor was composed of uniform polygonal and spindle-shaped cells, forming nodules and fascicles. The diagnosis of neurothekeoma was based upon the histology and immunohistochemistry.

Plasma cell cheilitis is an extremely rare disease, characterized by erythematous-violaceous, ulcerated and asymptomatic plaques, which evolve slowly. The histological characteristics include dermal infiltrate composed of mature plasmocytes. We report a case of Plasma cell angular cheilitis in a 58-year-old male, localized in the lateral oral commissure.

Linear and whorled nevoid hypermelanosis (LWNH) is a rare sporadic disorder, characterized by hyperpigmented, reticulated, streaky, and whorled macules along Blaschko lines. Herein we report a 33-year-old male presenting with linear and whorled nevoid hypermelanosis.There was no family history. Dermatoscopy revealed a net like pattern. This case is been presented for its rarity and for its dermatoscopic pattern.

The use of systemic steroids for inflammatory diseases is a controversial issue—one that continuously invites disagreement throughout the healthcare community.  However, there is little, if any, mention of systemic steroid recommendations among widely used rheumatoid arthritis, psoriasis, and psoriatic arthritis guidelines. This relative dearth of information is contrasted by the pervasive systemic steroid use for decades both domestically and abroad [1,2]. The European League Against Rheumatism (EULAR) guidelines for rheumatoid arthritis discuss systemic steroid use, though relatively briefly [3]. The most recent American Academy of Dermatology (AAD) psoriasis and American College of Rheumatology (ACR) rheumatoid arthritis guidelines fail to make any recommendations regarding systemic steroid use [4,5]. Currently, there is a void in guidelines regarding when and how (if at all) to use systemic steroids in psoriasis and there are minimal recommendations regarding psoriatic and rheumatoid arthritis. Considering how often primary care physicians, dermatologists, and rheumatologists prescribe systemic steroids for rheumatic diseases and psoriasis, this void must be filled.

Background: Topical corticosteroids are the primary treatment for scalp psoriasis. Keratolytic agents are promoted as adjunctive treatments.  However, complex treatment regimens may result in poor adherence and outcomes.

Objective: To evaluate the evidence for the need for use of topical keratolytic agents as opposed to topical corticosteroid monotherapy in the treatment of scalp psoriasis.

Methods: A review of the literature was performed seeking clinical trials using topical keratolytics, topical corticosteroids or the combination for treatment of scalp psoriasis.

Results: Complete clearance of scalp psoriasis can be achieved in 10-78% of patients using topical corticosteroids alone, in 3% of patients using topical keratolytics alone, and in up to 84% using a combination of topical keratolytics and topical steroids. Clinical trials comparing the combination of keratolytics and topical corticosteroids versus topical corticosteroids alone found marginally more efficacy using combination regimens.

Limitations: We could not find any long term study evaluating the efficacy of combination therapy in scalp psoriasis and its effect on the patients’ adherence.

Conclusion: High potency topical corticosteroids are usually effective in treating scalp psoriasis in clinical trials.  Poor efficacy in clinical practice may be owing to poor adherence to the treatment regimen. Using a keratolytic agent in conjunction with a topical corticosteroid may provide marginal additional benefit in clinical trials, but that benefit is likely outweighed by the downside of complicating treatment and reducing adherence in the clinical setting, unless a single product containing both medications were used.

Acne vulgaris is a pervasive inflammatory disorder of the skin, with multiple etiologies and treatment options. Although first-line therapies exist, it is often the case that a patient will present with an underlying disorder that prohibits the use of most currently accepted treatment modalities. We present a patient with severe acne vulgaris and a history of retinitis pigmentosa who was treated with 595 nanometer pulsed dye laser therapy, in conjunction with therapeutic alternatives to first-line acne medications. Our patient exhibited a significant and sustained improvement with the combined use of 595 nanometer pulsed dye laser, Yaz (drospirenone-ethinyl estradiol), dapsone, topical metronidazole, sodium-sulfacetamide wash, and topical azelaic acid.  The positive results in this case, suggest that this combined treatment modality may serve as an example of a safe and effective treatment alternative in the management of acne vulgaris complicated by medical co-morbidities that contraindicate the use of most first-line treatment options.

Although rare, severe hidradenitis suppurativa (HS) of the anal, perianal, gluteal, thigh, and groin regions can evolve into squamous cell carcinoma (SCC). This usually does not occur until the HS has been present for more than 20 years. Malignant degeneration of HS in the axilla has not been reported. SCC has developed in dissecting cellulitis, acne conglobata, and pilonidal cysts (other members of the follicular tetrad). Whereas the male to female ratio of HS is 1:3, SCC in HS has a male to female ration of 5:1. The reasons behind malignant degeneration in HS are complex and might differ from the malignant degeneration causing Marjolin ulcers. It likely involves the presence of human papilloma virus (HPV) in affected areas (a rarity in the axilla), and impaired defensins, which combat HPV, in the skin of Hurley Stage III HS. In familial HS, the odds of developing SCC are likely greater because of independent loss-of-function mutations in the γ-secretase multiprotein complex, which regulates the Notch signaling pathway. Compromise of the Notch signaling pathway can undermine immune function and increase the risk of neoplastic development. Coincident SCC with use of tumor necrosis factor α blockers has been reported. I report a patient with long standing Hurley Stage III, familial HS, wwho developed metastatic SCC after 3 courses of infliximab and expired 11 months after the infliximab was started.A 47-year-old male presented with progressive HS since early adulthood. His stage III hidradenitis suppurativa (HS) involved his groin, legs buttocks, and perineal areas. Interestingly, his HS was familial; one daughter also suffered from HS. A pilonidal cyst had been excised in the past. He suffered from hypertension for which he took ramipril, 2.5 mg per day. He did not admit to smoking. He had undergone numerous surgeries and courses of clindamycin with rifampin and clindamycin with minocycline. He used pregablin among other stronger medications for pain control. He had also taken isotretinoin years before without substantial long-term benefit. The various treatments were palliative but the HS always returned. He expressed that the pain from his HS was not bearable. He decided in consultations with his doctors to try infliximab owing to the positive clinical data for its efficacy in HS. He took 3 courses of infliximab 500mg, each of which was followed by surgical debridement of the perineal and anal areas. At the 3rd surgical debridement his physician noted the presence of squamous cell carcinoma (SCC) on July 28, 2008. The infliximab was stopped. However, the patient developed the patient underwent scanning soon after that showed soon after that the SCC had metastasized. He expired in June of 2009.

Disseminated herpes zoster has been defined by some authors as a generalized eruption of more than 20 lesions beyond the primary or adjacent dermatomes, usually within a week of clinical manifestation of the primary lesion. In the case described by Takaoka et al. the two lesions presented simultaneously with no evidence of widespread eruption. Perhaps the term, disseminated should not have been employed in this situation.

Sarcoidosis is a systemic disease often with cutaneous manifestations. Scarring alopecia of the scalp is a rare form of cutaneous sarcoidosis. Herein, we describe a case of sarcoidosis of the scalp mimicking discoid lupus.