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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 3, 2017

Review

An update in drug-induced subacute cutaneous lupus erythematosus

Background: It has been over three decades sincethe first report of drug-induced subacute cutaneouslupus erythematosus (DI-SCLE) was described. Withan increasing variety of implicated drugs and thepotential for publication bias, we must consider: 1) hasthere been a change in drugs most often reported inDI-SCLE over time, and, 2) if so, of which drugs shouldclinicians be most suspicious in the setting of possibleDI-SCLE?Objective: To determine which drug(s) present thehighest risk for inducing DI-SCLE.Methods: The PubMed database was queried forreports of DI-SCLE from August, 2009 until May,2016. Cases reported in the English language wereorganized by drug class and compared with theresults of our previous review.Results: From 55 selected publications, 95 qualifiedreports of DI-SCLE were identified. With theexception of a population-based study from Sweden,all other reports of DI-SCLE appeared as case reportsor small case series. Cases associated with protonpump inhibitors relative to all other medicationswere increased by 34.1%. Reports associated withantihypertensive and antifungal medicationsdecreased by 28.9% and 22.4%, respectively duringthis timeframe. The majority of new reports wereassociated with drugs not previously described.Greater than 70% of reports since August, 2009 werefrom European countries.Conclusions: The number of drugs associated withDI-SCLE is increasing. However, a form of publicationbias has likely contributed to this shift in reporting.There is a need for additional large, populationbasedstudies in this area.

Propranolol for infantile hemangiomas in developing countries

Background: Propranolol is the treatment of choicefor complicated infantile hemangiomas (IH). However,in some locations, propranolol has not yet becomestandard of care. To our knowledge, until 2014,propranolol had not been used in Afghanistan totreat IH. Objectives: To raise further awareness thatpropranolol is the treatment of choice for complicatedIH, suggest a propranolol induction, maintenance,and taper protocol, show an example of therapeuticsuccess in a resource-limited country, and discusspotential challenges. Methods: At an academicteaching hospital in Kabul, Afghanistan, we conducteda retrospective chart review of patients treated withpropranolol for IH from 2014-2015. Results: Seventeenpatients were treated using a modified protocol basedon consensus recommendations. Average age was 6.3months (range 2.5 to 18 months). Thirteen patientshad focal IH and four had large segmental facial IH.Three patients were lost to follow-up. The remaining14 had good response and very few complications,including one patient co-managed by utilizing storeand-forward teledermatology. Conclusions: Patientsin resource-limited countries can be managedsuccessfully using a modified version of a propranololinduction, maintenance, and taper protocol. Indeveloping countries where dermatologists arescarce, we suggest IH may be co-managed withprimary care physicians via teledermatology.

Commentary

Genital melanoma: are we adequately screening our patients?

Full-body skin exams (FBSE) play an integral role inearly detection and treatment of skin cancer. Promptdetection of melanoma is especially importantas survival outcomes decrease significantly withpresentation of advanced disease. Given thatmelanoma may grow in areas of skin with little to nosun exposure, genital melanomas are a recognizedentity in cutaneous oncology.

Case Report

Disseminated punctate keratoderma: a rare case report and review of the literature

We report a rare case of a 53-year-old womanpresenting with diffuse, late-onset disseminatedhyperkeratotic papules. Biopsy showed massivehyperkeratosis overlying a crateriform epidermaldepression and hypergranulosis with mild epidermalhyperplasia. There was no parakeratosis, cornoidlamella, or dyskeratosis. Based on the clinical findingsand histopathological features, a diagnosis ofdisseminated punctate keratoderma was made. Thisis a rare subtype of palmoplantar keratoderma, whichhas a putative increased risk of malignancy. This casereport emphasizes the importance of identifyingthe clinical and histological presentation of this rarecondition; referral of the patient for age-appropriatemalignancy screening is appropriate. We also presenta concise review of treatment options.

Cutaneous mucinosis in a patient taking ustekinumab for palmoplantar psoriasis

Discrete papular lichen myxedematosus (DPLM), asubset of localized lichen myxedematosus, is a rarecutaneous mucinosis of unknown etiology. We reporta case of a 57-year-old woman with palmoplantarpsoriasis who developed DPLM 8 weeks after addingustekinumab to a long-term course of methotrexate.The patient had previously failed 2 prior tumor necrosisfactor (TNF) inhibitors, adalimumab and etanercept.This case demonstrates an association between TNFinhibitor and ustekinumab use in a psoriasis patientand localized lichen myxedematosus for the secondtime in the literature. The presented case is of interestbecause of the rare diagnosis of DPLM, especially inassociation with the start of the anti-IL 12/23 agentustekinumab. The appearance of DPLM in this settingsuggests a possible etiology for the disease.

Precursor-B-cell-ALL leukemia cutis resembling lipomas: an atypical presentation of a rare entity and a review of the literature

Leukemia cutis (LC) is an extramedullary manifestationof leukemia owing to cutaneous infiltration ofneoplastic cells resulting in characteristic firm,erythematous nodules. Most cases of LC occur inpatients with acute myelogenous leukemia andchronic myelogenous leukemia. However in rarecases, LC has presented in patients with acutelymphoblastic leukemia (ALL). In these rare ALLassociatedcases, only 10 cases of precursor-B-ALL(pre-B-ALL) have been described in the literature.We report a case of a 22-year-old man with relapsingpre-B-ALL who presented with a 4-day history ofmultiple asymptomatic, soft, dome-shaped, lipomalikemounds on his scalp and chin, which exhibitedcutaneous involvement by leukemic cells. To date, thisis the first case of pre-B-ALL associated leukemia cutispresenting as soft, dome-shaped mounds resemblinglipomas.

Purple patches in an immunocompromised patient: a report of secondary disseminated cutaneous mucormycosis in a man with chronic lymphocytic leukemia

A 60-year-old man with chronic lymphocytic leukemiadeveloped a deeply violaceous annular patchwith a halo of erythema on the right thigh duringhospitalization for neutropenic fever. Associatedsymptoms included chronic cough and fatigue.Bilateral lung opacities with hilar lymphadenopathywere noted on chest computed tomographyscan. Punch biopsy and tissue culture confirmeda diagnosis of secondary disseminated cutaneousmucormycosis. Although rare, physicians shouldinclude mucormycosis in the differential diagnosisof purpuric patches in immunosuppressed patients.Prompt skin biopsy and tissue culture may optimizethe success of treatment.

Case Presentation

Anetoderma before development of antiphospholipid antibodies: delayed development and monitoring of antiphospholipid antibodies in an SLE patient presenting with anetoderma

Introduction: Anetoderma is an elastolytic skindisorder that has been associated with the presenceof antiphospholipid antibodies (aPL). Patients withantiphospholipid antibody-positive anetoderma havebeen reported to develop symptoms of Graves disease,antiphospholipid syndrome, and other autoimmuneconditions. The temporal relationship, however,between anetoderma onset and the emergence ofaPL remains unclear, a clarification of which may haveimplications for the screening and monitoring ofpatients with anetoderma. Case: Herein we report acase of a patient with systemic lupus erythematosuspresenting with anetoderma that preceded thedevelopment of aPL. The patient was found to havesubsequently developed IgM cardiolipin antibodiesat a serology follow-up approximately two years later.Conclusion and Relevance: This finding suggests thatanetoderma can precede aPL seroconversion andthat patients with anetoderma may require continuedserology monitoring. Such long-term monitoring willbe important for identifying laboratory indicationsthat may portend the development of furtherautoimmune symptoms associated with anetoderma.

TNF inhibitor induced alopecia: an unusual form of psoriasiform alopecia that breaks the Renbök mold

TNF-α-inhibitors are known to induce skin adverseeffects including psoriasis and alopecia areata. Here, wedescribe a unique pattern of hair loss that has psoriaticand alopecia areata-like features. Diagnosis requiresclinical-pathologic correlation and is supportedby increased catagen/telogen hairs, psoriasiformepidermal hyperplasia, perifollicular lymphocyticinfiltrate, and the presence of eosinophils and plasmacells. Although there are no treatment consensusguidelines, management options include stoppingtherapy, switching to a different TNF-α inhibitor orustekinumab (in severe cases), or continuing TNF-αinhibitor therapy with addition of topical, intralesional,or systemic immunosuppressants.

An elderly Filipino woman with follicular papules of the face and chest

An elderly woman developed pruritic follicularpapules over a period of 5 years. A biopsy revealedfocal intraepidermal eosinophilic pustules, leading tothe diagnosis of Ofuji disease or eosinophilic pustularfolliculitis. A discussion of this condition is presented.

A rare case of cutaneous acanthamoebiasis in a renal transplant patient

A 35-year-old woman receiving immunosuppressionfor renal transplantation presented with a onemonthhistory of tender skin nodules on herbilateral upper extremities. A skin biopsy revealedgranulomatous inflammation in the deep dermisand the subcutaneous fat with foci of necrosis.Within the foci of necrosis were large histiocytoidstructures with prominent nuclei. Periodic acid-Schiffstain revealed a round organism with a thick capsule,consistent with amoebal trophozoites. Testing withthe Center for Disease Control revealed the organismto be Acanthamoeba. Despite antimicrobial therapy,the patient continued to develop subcutaneousnodules that extended to the lower extremities andtrunk and ultimately extended to the bone, causingacanthamoebal osteomyelitis. Throughout thehospital course, the patient remained neurologicallyintact without evidence of central nervousinvolvement. A diagnosis of isolated disseminatedcutaneous acanthamoebiasis secondary to iatrogenicimmunosuppression was made. Historically, mostcases of granulomatous amoebic encephalitisand cutaneous acanthamoebiasis have occurredin patients with HIV/AIDS. However, with the useof newer and more effective immunosuppressiveregimens, both are occurring more frequently inthe setting of iatrogenic immunosuppression. Therare and isolated cutaneous nature of this patient’spresentation makes this case unique.

Multiple miliary osteoma cutis of the face associated with Albright hereditary osteodystrophy in the setting of acne vulgaris: a case report

Osteoma cutis is a condition characterized by theformation of bone within the skin. Such aberrantossification of the skin and subcutaneous tissue isconsidered primary when it arises in the absence ofunderlying tissue damage or a preceding cutaneouslesion. Conversely, secondary osteoma cutis occurswhen skin ossification is the result of a pre-existingskin lesion, trauma, or inflammatory process [1,2].Although rare, primary osteoma cutis has beenassociated with a number of different geneticdisorders. Albright hereditary osteodystrophy (AHO),a condition first described in 1942 by Fuller Albright,is an autosomal dominant metabolic disorder causedby a mutation in the GNAS1 gene [3]. This disease isassociated with a variety of phenotypic traits includingcutaneous ossification, short stature, brachydactyly,obesity, and mental retardation. It should be notedthat brachydactyly is the most specific feature of AHO[4]. However, owing to variable expressivity individualsmay present only with a subset of these symptoms [5,6]. The cutaneous ossification observed in patientswith AHO may be seen in infancy or early childhoodand is sometimes the earliest presenting symptom.Nonetheless, because clinical features of AHO canbe seen in the absence of metabolic derangements(i.e. normal serum calcium, phosphorus, and PTHlevels) an early diagnosis is often missed and delayedfor many years. Herein, we present a case of miliaryosteoma cutis of the face in a 68 year-old woman withphenotypic features of AHO and laboratory studiesconsistent with type 1a PHP.

Lichen planus secondary to rabies vaccination

Lichen planus (LP) is a papulosquamous disease withdistinctive clinical manifestations. The etiology of LPremains unknown. Recently, numerous cases of LPdeveloping after hepatitis B, influenza, and combinedDTaP-IPV-MMR vaccine have been described. In thisreport, we present the second case of LP after rabiesvaccination.

Photo Vignette

Anetodermic pilomatricoma: clinical, histopathologic, and sonographic findings

Pilomatricoma is a benign cutaneous tumor originatingfrom hair matrix cells. Anetodermic changes inthe skin overlying pilomatricomas are sometimesreported, although their precise mechanisms remainunknown. We present an unusual case of anetodermicpilomatricoma on the upper extremity of a 17-yearoldboy and report its clinical, histopathologic, andsonographic findings.

Oral inverted ductal papilloma: not related to HPV

Oral inverted ductal papilloma (OIDP) is a rare, nonrecurrent,benign lesion of salivary glands. The etiologyis still poorly understood; the correlation with humanpapilloma virus (HPV) is controversial. Herein wepresent a 74-year-old man with a tumor in lower lip.Incisional biopsy was performed and the histologicaldiagnosis was OIDP. Inno-LiPA assay, based onpolymerase chain reaction and in situ hybridizationwas used to assess for HPV with no detection of viralDNA. Surgical excision was performed without anyrecurrences after two years of follow-up.

Chronic granulomatous disease as a risk factor for cutaneous lupus in childhood

Chronic granulomatous disease (CGD) is a primaryimmunodeficiency disorder that affects the phagocyticcells of the innate immune system. It is characterizedby recurrent or persistent infections with granulomaformation. Lupus-like lesions have been reported incarriers of CGD and less frequently, in patients withCGD. Immunological study in these patients areusually negative. We describe the case of an 8-yearoldboy with CGD who developed chronic and acutecutaneous lupus erythematous with angular cheilitis,oral ulcers, Raynaud phenomenon, and positiveserologies for antinuclear, anticentromere, and anti-Saccharomyces cerevisiae antibodies.

Letter

Acitretin for the treatment of recalcitrant plantar warts

Plantar warts caused by human papilloma virus (HPV)may be challenging to treat when conventionalmodalities fail. We report a case of severely recalcitrantplantar warts, successfully treated with oral acitretinand topical 40% urea cream.

Unilateral striae distensae of the knee after a steroid injection for the treatment of Osgood-Schlatter disease

We report a 12-year-old girl with new diagnosisof right knee Osgood-Schlatter who developedhorizontal purple striae below the right tibial tubercletwo months after a right knee intra-articular steroidinjection. She is the second reported case of unilaterallocalized striae after an intra-articular steroid injectionand the first with triamcinalone as the corticosteroid.

Concurrent pyogenic granuloma and bullous impetigo of a pregnant woman’s finger

Background: Bullous impetigo is a superficial skininfection caused by Staphylococcus aureus (S.aureus). Pyogenic granuloma is a common benigntumor frequently associated with prior trauma.Bullous impetigo and pyogenic granuloma may occurin pregnant women.Purpose: The features of a pregnant womanwith pyogenic granuloma and bullous impetigoconcurrently present in a lesion on her finger aredescribed.Methods: PubMed was used to search the followingterms: bullous impetigo, pregnancy, and pyogenicgranuloma. All papers were reviewed; relevantarticles, along with their references, were evaluatedResults: A red ulcerated nodule with a collaretteof epithelium around the tumor and surroundingbullae appeared on the fifth digit of the left hand of a31-year-old woman who was at 36 weeks gestation. Abacterial culture grew methicillin sensitive S. aureus.An excisional biopsy was performed. Histologicfindings revealed not only a benign vascular tumorwith an infiltrate of mixed inflammatory cells, butalso an intraepidermal blister. She received oralantibiotics and there was complete resolution of thefinger lesion and infection with preservation of digitfunction.Conclusion: Albeit uncommon, pyogenic granulomaand bullous impetigo may concurrently occur in thesame lesion. Therapeutic intervention should focuson treating both the benign skin tumor and theinfection.

Recruitment Advertisement

Dermatologists & MOHS Surgeon

The University of California, Davis, School of Medicine, Department of Dermatology, is recruiting for four academic dermatologists in the Clinical X series or Health Sciences Clinical Professor (HSCP) series at the Assistant/Associate/Professor level based on experience and qualifications. Three of these positions are for general medical dermatologists, and one is for a fellowship-trained Mohs surgeon/procedural dermatologist.