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Open Access Publications from the University of California

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Dermatology Online Journal is an open-access, refereed publication intended to meet reference and education needs of the international dermatology community since 1995. Dermatology Online Journal is supported by the Department of Dermatology UC Davis, and by the Northern California Veterans Administration.

Volume 23, Issue 10, 2017

Review

Hormonal therapies for hidradenitis suppurativa: Review

Hidradenitis suppurativa is a recurrent inflammatory skin condition characterized by abscesses and boils, predominantly in the groin, armpit, and buttocks areas. HS is not a life-threatening condition, but severely impairs quality of life in those affected. Finding a successful treatment approach for HS has been challenging, in part because of the lack of a gold-standard treatment method, limited research-based information, and the nature of clinical variation in the disease. Treatment commonly consists of antibiotics, anti-inflammatory therapy, hormonal therapy, and more invasive clinical procedures. Treatment is chosen by the degree of severity by which the condition presents and is modified accordingly. This review describes the roles of hormones in the pathogenesis of hidradenitis suppurativa and describes the use of hormonal therapy such as, finasteride, dutasteride, spironolactone, and oral contraceptives. The outcomes of the use of these modalities in various clinical studies are summarized.

Commentary

Incorporating social media into dermatologic education

In the current digital age, medical education has slowly evolved from the largely lecture-based teaching style of the past to incorporate more interactive pedagogical techniques, including use of social media. Already used readily by millennial trainees and clinicians, social media can also be used in innovative ways to teach trainees and facilitate continuing education among practicing clinicians. In this commentary, we discuss many learning benefits of social media and review potential pitfalls of employing social media in both trainee and physician dermatological education.

Case Report

Cutaneous infection due to Mycobacterium immunogenum: an European case report and review of the literature

Abstract (no more than 200 words): In the last few years, the incidence of cutaneous infections caused by nontuberculous mycobacteria is increasing. Since Mycobacterium immunogenum was first described in 2001, few case reports have been described, all of them in the American continent. We report a case with cutaneous infection caused by this newly discovered NTB in Europe.

A 65-year-old woman presented with a 3-months history of pruritic lesions on abdomen. Examination revealed erythematous inflammatory papules, pustules, and crusts. Three weeks later, mycobacteria were cultured from the biopsy specimen. Mycobacterium immunogenum was identified based on susceptibility test results and polymerase chain reaction (PCR) restriction enzyme analysis. Treatment with clarithromycin was started. M. immunogenum is a nontuberculous mycobacterium that was first described by Wilson et al. in 2001 as a rapidly growing variety and new species in the Mycobacterium chelonae-Mycobacterium abscessus group. PCR-restriction analysis of a 439-bp segment of the hsp65 gene and/or sequencing the species-specific region of the 16S rDNA can confirm this new species. Since the description of M. immunogenum, 8 clinical case reports have been published, most involving cutaneous infections and all of them in the American continent. We present a case of cutaneous infection caused by M. immunogenum in a Spanish woman.

Non-dermatomal varicella-zoster skin infection: disseminated cutaneous herpes zoster without dermatome in an immunosuppressed woman

Disseminated herpes zoster is defined as the presence of more than 20 lesions outside the dermatome. This unusual presentation is more common in immunosuppressed patients. Complications such as hepatitis, encephalitis, and pneumonitis are more likely in individuals with disseminated varicella zoster virus infection.

A 63-year-old woman being treated for breast cancer developed multiple pustules and vesicles days after starting doxorubicin and cyclophosphamide chemotherapy. Ten individual lesions appeared on her chest, abdomen, back, and leg. Non-dermatomal disseminated herpes zoster was suspected. She was treated with oral antiviral therapy, as well as with oral and topical antibiotics. Varicella zoster virus infection was confirmed by direct fluorescent antibody staining. After one month, her skin lesions had resolved and she resumed chemotherapy.

In a setting of immunosuppression, the rare presentation of disseminated herpes zoster without dermatome should be considered. Appropriate antiviral therapy should be administered while waiting for confirmation of the diagnosis, so as to reduce the risk of visceral dissemination of the varicella zoster virus infection.

Case Presentation

Ponatinib-induced ichthyosiform drug eruption: insights into acquired ichthyosis

Cutaneous adverse events are commonly experienced with use of tyrosine kinase inhibitors in the treatment of leukemia and typically include nonspecific cutaneous eruptions and xerosis. We report the case of a man who experienced an ichthyosiform drug eruption while taking ponatinib, a third-generation tyrosine kinase inhibitor. Disruption of epidermal growth pathways through inhibition of various receptor tyrosine kinases by ponatinib may offer insights into the pathophysiologic mechanisms behind acquired ichthyosis.

Rapidly fatal metastatic cutaneous angiosarcoma initially mimicking a furuncle in a middle-aged male

Cutaneous angiosarcomas are rare but typically occur in three distinct clinical settings and are most commonly found on the scalp or face of elderly men. Positive prognostic factors include tumor size less than 5 cm, primary tumor location below the head, negative margins after excision, resectability, and younger age. Metastases drastically reduce survival and the most common metastatic site is lung. We present a 43-year-old man who had primary cutaneous angiosarcoma that initially mimicked a furuncle and eventuated in multiple metastases. The metastatic disease included brain involvement, which has rarely been reported, especially in a relatively young person without known predisposing conditions. This unique case also highlights the need for early diagnosis followed by advanced imaging, given the limitations of current therapies and high metastatic potential of angiosarcoma.

Delayed presentation of toxic epidermal necrolysis-like cutaneous acute graft-versus-host disease in the setting of recent immunosuppressant discontinuation.

Acute graft-versus-host disease (GvHD) is a process that classically has been defined as occurring less than 100 days after stem cell transplant. When Stage IV cutaneous acute GvHD occurs outside this window, it can be difficult to distinguish clinically from toxic epidermal necrolysis (TEN). A 50-year-old man with diffuse large B-cell lymphoma who had undergone an allogeneic stem cell transplant 20 months previously was admitted for neutropenic septic shock. He developed a slowly progressing macular/papular eruption with multiple tender bullae found to be consistent with TEN-like Stage IV cutaneous acute GvHD on biopsy. It was discovered that the patient’s maintenance immunosuppression had been completely discontinued one month prior to admission in preparation for clinical trial enrollment, causing a late presentation of cutaneous acute GvHD. This case provides particular insight into the diagnosis and management of late-presenting acute GvHD given that it is the first reported case of Stage IV cutaneous acute GvHD more than 12 months after stem cell transplant. In the setting of decreased immunosuppression in a patient with a history of a stem cell transplant, acute graft-versus-host disease must be considered regardless of the time that has elapsed since transplant.

A case of erythema multiforme major following administration of ciprofloxacin ophthalmic drops

A 49-year old woman was hospitalized for generalized rash and pruritus following the administration of ophthalmic drops containing ciprofloxacin to treat conjunctivitis. Physical examination demonstrated diffuse erythematous papules and plaques with a targetoid appearance, injected sclera, and multiple erosions in the oropharynx. Skin biopsy confirmed a diagnosis of erythema multiforme major. The eye drops were discontinued and supportive treatment was initiated; the patient recovered in four weeks and was discharged from the hospital. Although cases such as this are rare, it is important that physicians take a thorough medication history from all patients with suspected erythema multiforme, including topical and ophthalmic medications. Prompt discontinuation of the offending agent can hasten patient recovery and optimize outcomes.

Pénfigo foliáceo agravado por fármacos en un paciente con psoriasis, con buena respuesta a adalimumab

El pénfigo foliáceo es una enfermedad autoinmune ampollosa debida a la producción de autoanticuerpos frente a la desmogleína 1. Presentamos el caso de un paciente con psoriasis y pénfigo foliáceo agravado por enalapril y amlodipino, con buena respuesta de ambas patologías a la terapia con adalimumab.

Pemphigus foliaceus is a blistering autoimmune disease related to the production of autoantibodies against desmoglein 1. We present a patient with psoriasis and pemphigus foliaceus aggravated by enalapril and amlodipine intake, with successful response of both conditions to adalimumab therapy.

Primary vulvar Paget disease – the importance of clinical suspicion

Extramammary Paget disease of the vulva is a rare condition that accounts for only 1-2% of vulvar malignancies and represents a frequent cause of misdiagnosis. It is most commonly seen in postmenopausal women. Clinically it is similar to Paget disease of the breast, appearing as red, well-demarcated eczematoid lesions, with slightly raised edges. A high degree of clinical suspicion is very important when evaluating these lesions in order to avoid misdiagnosis and delay of effective treatment. We present a case of vulvar Paget disease treated with vulvectomy.

Telangiectasia macularis eruptiva perstans associated with a sicca complex

We present the case of woman in her 50s who developed numerous red-brown telangiectatic macules on her trunk and extremities, as well as persistent dry eyes and dry mouth. Skin biopsy was consistent with telangiectasia macularis eruptiva perstans (TMEP). Serum tryptase was elevated suggesting systemic involvement. Anti-Ro and La were negative. ANA was positive. Salivary gland biopsy revealed a focus score of 3 and immunostains revealed infiltrates of aberrant CD117 positive mast cells. This case suggests a mechanistic role of mastocytosis in salivary compromise.

Erythematous asymptomatic nodule on the sole

A 75-year-old man presented to the dermatology clinic with an asymptomatic lesion on his right plantar surface. The lesion had progressively grown for two months. Physical examination revealed an erythematous and slightly scaly nodule measuring 10x10 mm. Dermoscopy examination showed central diffuse erythema with small red globules. A punch-biopsy revealed a proliferation of irregularly branched small vessels with collapsed lumen, extending in an infiltrative pattern in the superficial and deep dermis. Although this is a rare location, a diagnosis of microvenular hemangioma was made.

Paquidermodactilia, engrosamiento digital proximal. Pachydermodactyly, digital proximal thickening

We report a case of pachydermodactyly (PDD). PDD is a benign, asymptomatic soft tissue swelling affecting the skin of the lateral aspects of the proximal interphalangeal joints of the fingers, mostly in young adolescent males. It has often been interpreted as a consequence of tic-like behavior as part of an obsessive-compulsive disorder. Although the diagnosis is essentially clinical, skin biopsy shows compact orthokeratotic hyperkeratosis, increased numbers of collagen fibers and fibroblasts, and no inflammatory changes. A rapid clinical recognition of PDD should avoid many unproductive and expensive diagnostic tests.

Jessner lymphocytic infiltration – rare in childhood

We present a 13-year-old girl with Jessner lymphocytic infiltrate of the skin, who has suffered from the disease since the age of 9 years. It is a rare disease in childhood, and we highlight the clinical features and therapeutic response of tacrolimus.

Hyperkeratotic and hypertrophic lichen nitidus

Lichen nitidus typically presents as shiny pin-head sized papules on the trunk and extremities, often affecting children and young adults. In this prototypical form, it rarely presents a diagnostic challenge being characterized by distinctive clinical and histopathologic findings. We describe a rare variant of lichen nitidus, which we term “hyperkeratotic and hypertrophic lichen nitidus."

Photo Vignette

Kimura disease

Kimura disease is a rare, benign, chronic, immune-mediated inflammatory disorder. We report a 46-year-old man who presented with a cutaneous nodule behind his left ear. Surgical removal of the growth confirmed the histological diagnosis of KD. There was no recurrence found after 3 years follow-up.

Letter

Lesiones subcutáneas dolorosas en paciente con melanoma metastásico: un caso de paniculitis linfocítica asociado a vemurafenib

Vemurafenib ha probado ser una herramienta útil en el tratamiento de melanoma metastásico con mutación BRAF-V600E. Los efectos adversos incluyen artralgias, fatiga y toxicidad cutánea, siendo infrecuente la paniculitis. Presentamos el caso de una paciente de 43 años con melanoma metastásico que desarrolla lesiones subcutáneas dolorosas en miembros inferiores y superiores, asociadas a clínica sistémica después de 2 semanas de inicio de tratamiento con Vemurafenib + Cobimetinib. La histología demostró paniculitis linfocitaria septal y lobulillar. La paciente tuvo mala tolerancia al tratamiento anti diana a dosis plenas, requiriendo su ajuste, generando una corticodependencia para controlar sintomatología, y que finalmente obligó a la descontinuación de la terapia dirigida contra melanoma.  A la fecha, se han descrito 29 casos en la literatura de paniculitis asociada a vemurafenib, siendo la mayoría paniculitis neutrofílicas con adecuado control de sintomatología asociando antiinflamatorios no esteroidales y/o corticoides orales sin requerir en su mayoría modificación de la terapia contra melanoma; sin embargo hay que tener presente que pueden haber casos con mala evolución que obligan a la reducción de dosis de vemurafenib y descontinuar el tratamiento, como ha ocurrido en nuestro reporte.

Vemurafenib has proven to be a useful tool in the treatment of metastatic melanoma with BRAF-V600E mutation. Adverse effects include arthralgia, fatigue, and skin toxicity; panniculitis is a rare complication. We present the case of a 43-year-old patient with metastatic melanoma who developed painful subcutaneous nodules of the lower and upper limbs and associated systemic clinical symptoms after 2 weeks of treatment with vemurafenib plus cobimetinib. Histology showed a septal and lobular lymphocytic panniculitis.

The patient had poor tolerance of the full-dose treatment, requiring its adjustment. Systemic corticosteroids were required to control symptomatology, which finally forced the discontinuation of the medication.

To date, 29 cases have been described in the literature of panniculitis associated with vemurafenib. Most of these have been neutrophilic panniculitis, but adequate control of symptoms is usually achieved with nonsteroidal anti-inflammatory drugs and/or oral corticosteroids without requiring modification of melanoma therapy. However, it must be borne in mind that there may be cases that force the reduction and discontinuation of

vemurafenib treatment. We believe that this histological variant of lymphocytic panniculitis and its poor response to decrease in vemurafenib makes this case unusual and instructive.

Inflamed actinic keratoses associated with pemetrexed and carboplatin therapy

Eruptive actinic keratosis (AK) consequent to systemic chemotherapy can be confused with drug allergies. We present the first case of inflamed AKs in one patient after receiving combination therapy with pemetrexed and carboplatin.

A 68-year-old woman with non-small cell lung adenocarcinoma (NSCLC) presented with numerous pruritic ill-defined, gritty, erythematous papules consistent with AKs on her upper chest, upper back, and arms two weeks after completing the first cycle of combination therapy with carboplatin and pemetrexed. The care team managed her with topical steroids and the lesions resolved within one month. The patient resumed the second cycle of chemotherapy and reported the occurrence of a similar but milder eruption.

This case illustrates that eruptive AKs should be considered in the differential diagnosis of drug-related rashes, especially if the physical exam is suggestive. The mainstay of treatment should be directed at symptomatic improvement, and chemotherapy may be continued.

Eritema anular eosinofílico en un adulto Eosinophilic anular erythema in an adult

Eosinophilic annular erythema (EAE) is an uncommon eosinophilic dermatosis. Clinically it is characterized by recurrent episodes of annular or figurative plaques. The histopathological study shows a perivascular inflammatory infiltrate in the superficial and deep dermis, composed of lymphocytes and eosinophils. It was originally described in children. We report an adult woman who presented with recurrent erythematous annular plaques on the trunk and extremities. A biopsy showed a mainly perivascular lymphocytic infiltrate with numerous eosinophils in the dermis. Laboratory examinations revealed subclinical hypothyroidism. The lesions resolved with topical corticosteroid spontaneously after 3 months.

El eritema anular eosinofílico (EAE) es una dermatosis eosinofílica poco frecuente. Clínicamente se caracteriza por episodios recurrentes de placas anulares o figuradas.

El estudio histopatológico muestra un infiltrado inflamatorio en dermis superficial y profunda, de localización perivascular y compuesto por linfocitos y eosinófilos. Se describió originariamente en niños. Presentamos una mujer adulta con episodios recurrentes de placas anulares o figuradas en el tronco y extremidades. La biopsia mostró un infiltrado linfocítico perivascular con numerosos eosinófilos en la dermis. La analítica reveló la presencia de hipotiroidismo subclínico. Las lesiones se resolvieron después de tres meses de tratamiento con una crema de corticoesteriodes.

Trends in unsolicited dermatologic opinions: a national survey

In dermatology, a particularly common ethical dilemma can arise when the skin lesions of bystanders are inadvertently viewed in public settings. Dermatology is a unique field, where a person’s organ of interest is readily visible to others. When lesions are suspicious for skin disease, unsolicited medical opinions may or may not be given depending on several factors. This study examined the actions and attitudes of dermatologists with different levels of experience through the use of case scenarios with various settings and skin lesions.

A gastronomic delight?

Flagellate dermatitis (FD) exhibits a striking clinical appearance similar to whiplash marks. General dermatologists are likely to encounter this clinical appearance as a more localized presentation of phytophotodermatosis. Jellyfish stings may also cause localized linear or FD. Chemotherapeutic agents such as bleomycin, doxorubicin, docetaxel, and trastuzumab are well-recognized causes of a widespread FD and it may more rarely be seen in connective tissue disease such as dermatomyositis or Still disease. In our case, this was a presentation of shiitake mushroom dermatitis.

Complete resolution of erythema elevatum diutinum using oral sulfasalazine

Erythema elevatum diutinum (EED) is a rare, chronic small-vessel vasculitis that presents as firm, red, violaceous, or brown papules and nodules on the extensor surfaces of the limbs. Oral dapsone is considered first-line therapy for EED; in the current case report, a patient presenting with EED began dapsone treatment and symptoms subsided within two weeks. Seven months later, the patient became pregnant and stopped dapsone owing to her concerns with dapsone use during pregnancy, resulting in recurrence of EED symptoms. We present a novel treatment approach with oral sulfasalazine, which was given to the patient in lieu of dapsone and resulted in complete resolution of EED symptoms.

Complete response of secukinumab in palmoplantar psoriasis

Palmoplantar psoriasis is plaque psoriasis involving the palms and soles. Palmoplantar psoriasis is a treatment challenge for dermatologists and it is difficult to treat with topical and systemic therapies. Owing to its location and manifestations, palmoplantar psoriasis is associated with greater pain, functional limitations, and significant impairment of health-related quality of life. Recently a new biologic agent, secukinumab, has been approved for treatment of moderate to severe plaque psoriasis. GESTURE trial is a study of the secukinumab clinical development that evaluates efficacy and safety in this subpopulation of patients. We present a patient with palmar psoriasis refractory to systemic treatments who showed a gradual and complete response to secukinumab sustained at week 30 and without adverse events. Our patient had a significant improvement in his quality of life and work activity.

Analysis of population inquiry on practices for ultraviolet radiation protection

UV radiation exposure is one of the key modifiable risk factors for skin cancer. Hence, patient education regarding skin protection and sunscreen use is of tremendous importance to public health. To better understand patient practices regarding skin protection in a population level, we looked into the Internet search behavior of the US-based population. We investigated patient inquires on the United States Food and Drug Administration (FDA) announcements regarding sunscreen use by quantifying search terms such as “broad spectrum sunscreen”, “sunscreen” and “sunblock” with Google Trends, a novel methodology for understanding internet search practices. Our findings show that “broad spectrum sunscreen” searches were significantly increased post 2011 FDA announcements, which suggest increased public awareness regarding the importance of broad spectrum protection. It is encouraging these preliminary results indicate that skin protection practices are being increasingly investigated by the general public and may serve as a novel approach for identifying areas of improvement regarding patient education on the reduction of the risk for skin cancer.

Undisturbed characteristic herpes simplex virus 2 outbreak

Herpes simplex virus 2 (HSV-2) is a common sexually transmitted disease that typically presents with focal erosions or small vesicles on an erythematous base.Herein, a case is described in which a 42-year old man experienced a genital HSV-2 outbreak after sustaining a spinal cord injury. No typical prodromal symptomswere experienced; therefore the vesicular lesions remained completely intact, granting an unusual opportunity to visualize herpetic infection in its most classic morphology.