[Usefulness of bilateral sympathectomy using video-assisted thorascopic surgery in the treatment of essential hyperhidrosis]

Essential, idiopathic, or primary hyperhidrosis is defined as excessive sweating in certain areas of the body due to factors unrelated to other disease. Clinical presentation can be categorized as palmar, plantar, axillary, or craniofacial. Medical treatment (aluminium salts, iontophoresis, anticholinergic drugs, and alpha2-agonists) is of questionable effectiveness. Intradermal injections of botulinum toxin are very effective for the treatment of axillary hyperhidrosis. Surgical treatment involves resection (sympathectomy) or electrocautery (sympathicolysis) of the thoracic sympathetic chain, or compression of the sympathetic chain with clips, in all cases via video-assisted thorascopic surgery. One or more ganglia between T2 and T5 are usually resected depending on the area affected by hyperhidrosis: T2 for craniofacial hyperhidrosis, T3 and T4 for palmar hyperhidrosis, and T3 to T5 for combined palmar and axillary hyperhidrosis. The technique is very useful and is effective in those patients with primary hyperhidrosis who have not responded to conservative treatment.

[Waldenström macroglobulinemia associated with cutaneous lesions and type I cryoglobulinemia]

Waldenström macroglobulinemia is a blood dyscrasia characterized by monoclonal proliferation of B cells in the bone marrow, lymph nodes, and spleen. Patients with this disease show elevated serum levels and tissue deposition of monoclonal immunoglobulin (Ig) M produced by these aberrant cells. We present the case of a patient with Waldenström macroglobulinemia who suffered cutaneous lesions resulting from deposition of k light chains of IgM and clinical manifestations secondary to associated type I cryoglobulinemia. We discuss the different pathological cutaneous processes caused by IgM in Waldenström macroglobulinemia.

Ear, nose and throat manifestations in pemphigus vulgaris

BACKGROUND

Pemphigus vulgaris (PV) is an autoimmune disease characterized by mucocutaneous intraepithelial blisters and pathogenic autoantibodies against desmoglein 3. There are two clinical forms: mucosal (MPV) and mucocutaneous (MCPV). The frequency of ear, nose and throat (ENT) involvement in PV is not clearly defined. Only a few isolated individual cases have been reported.

OBJECTIVES

The objective of our study was to determine the incidence of ENT involvement in patients with PV.

PATIENTS

We studied prospectively all 16 patients diagnosed with PV and treated in the Department of Dermatology of the University Clinic of Navarra between 2001 and 2005. They were 10 cases of MPV and six cases of MCPV. All patients were evaluated for ENT manifestations by endoscopic examination.

RESULTS

Of the 16 patients, 13 presented with throat symptoms (81%), 12 pharyngeal (75%) and seven laryngeal symptoms (44%). Fourteen patients (88%) had active PV lesions on endoscopic evaluation (eight patients had active lesions on both pharyngeal and laryngeal mucosa, four had PV lesions only on laryngeal mucosa and two had PV lesions on pharyngeal mucosa). Laryngeal lesions were most commonly present in MPV patients. The frequency of nasal symptoms (38%) was lower than active PV lesions (62%) found on ENT examination. Oral symptoms and oral active PV lesions were the most frequent findings (94%). Only three patients with MCPV showed erosions on the external auditory canal.

CONCLUSIONS

As ENT endoscopy allows more extensive areas of mucosa to be examined than simple visual inspection, we recommend that it be included in the examination of all patients with PV. By obtaining more complete information concerning the extent of the disease, a more accurate diagnosis can be made, better choice of drug and dose may be decided and, ultimately, response to treatment may be improved.

[Surgical treatment of penile lymphedema associated with hidradenitis suppurativa]

Penoscrotal lymphedema is a rare disease in the developed countries, although it is relatively frequent in tropical countries. The most common cause is filariasis, although in our practice usually is associate to neoplasic and inflammatory processes, surgery, radiotherapy, hidroelectrolitic disbalances and idiopathic. We present a 22 years old patient with penoscrotal lymphedema due to hidradenitis suppurativa. After unsuccessful medical treatment, was performed a total excision of the penile skin and subcutaneous tissue to Buck's fascia. Split thickness skin grafts were used to cover the defect. Even medical management of penoscrotal lymphedema is not effective for most patients, surgery is a safe and effective procedure that gives excellent functional and cosmetic results.

Successful treatment of lichen planus with sulfasalazine in 20 patients

BACKGROUND

Lichen planus (LP) is a disturbing pruritic cutaneous disease that may have an spontaneous resolution or exhibit a more chronic course during some weeks or months.

OBJECTIVE

Our objective was to demonstrate that sulfasalazine is effective in the treatment of LP.

METHODS

Twenty patients were diagnosed in our department with LP of the skin and/or mucosa between 1985 and 2001 on the basis of clinical and histologic findings.

RESULTS

All patients were treated with sulfasalzine at initial doses of 1.5 g/day, increasing by 0.5 g/week to 3 g/day for 4-16 weeks. Some patients also received descendent doses for 2-12 months. Complete responses were observed in 13 patients and partial responses in seven patients. All patients reported an early resolution of the pruritus. No changes were detected in mucosal LP. Most of the patients tolerated the treatment well and only eight patients presented some minor side-effects.

CONCLUSION

Sulfasalazine is a successful therapeutic option for cutaneous LP, constituting an alternative to corticosteroids and retinoids.

In vivo blockade of pemphigus vulgaris acantholysis by inhibition of intracellular signal transduction cascades

BACKGROUND

Pemphigus vulgaris (PV) is an autoimmune disease characterized by mucocutaneous intraepithelial blisters and pathogenic autoantibodies against desmoglein 3. The mechanism of blister formation in pemphigus has not been defined; however, in vitro data suggest a role for activation of intracellular signalling cascades.

OBJECTIVES

To investigate the contribution of these signalling pathways to the mechanism of PV IgG-induced acantholysis in vivo.

METHODS

We used the passive transfer mouse model. Mice were injected with IgG fractions of sera from a patient with PV, with or without pretreatment with inhibitors of proteins that mediate intracellular signalling cascades.

RESULTS

Inhibitors of tyrosine kinases, phospholipase C, calmodulin and the serine/threonine kinase protein kinase C prevented PV IgG-induced acantholysis in vivo.

CONCLUSIONS

These observations strongly support the role of intracellular signalling cascades in the molecular mechanism of PV IgG-induced acantholysis.

Pemphigus vulgaris autoantibodies induce apoptosis in HaCaT keratinocytes

Pemphigus vulgaris (PV) is an autoimmune disease characterized by binding of IgG autoantibodies to epidermal keratinocyte desmosomes. IgG autoantibodies obtained from a patient with mucocutaneous PV reacted with plakoglobin (Plkg) in addition to desmoglein-3 (Dsg3) and Dsg1. Immunofluorescence analysis confirmed that IgG autoantibodies, unlike antibodies from a healthy volunteer, caused disruption of cell-cell contacts in HaCaT keratinocytes. Moreover, apoptosis was enhanced in cells treated with autoantibodies compared to those treated with normal antibodies. The apoptotic process induced by IgG autoantibodies was characterized by caspase-3 activation, Bcl-2 depletion and Bax expression. The present report demonstrates that PV IgG autoantibodies promote apoptosis in HaCaT keratinocytes.

Acneiform lesions secondary to ZD1839, an inhibitor of the epidermal growth factor receptor

Drugs that inhibit the epidermal growth factor receptor, such as ZD1839 or C225, are being used increasingly in the treatment of solid tumours. This has led to the appearance of new secondary effects. We describe the case of a patient who presented with an acneiform eruption secondary to the administration of ZD1839. These lesions healed in a few days after stopping the drug.

Porphyria cutanea tarda, dermatomyositis and non-Hodgkin lymphoma in virus C infection

Virus C infection has been associated with a broad spectrum of extrahepatic diseases such as essential mixed cryoglobulinemia, membranous glomerulonephritis, vasculitis, rheumatoid arthritis and lupus erythematosus. The etiologic role of virus C has also been observed in some neoplasms such as non-Hodgkin's lymphoma and the monoclonal gammapathies. Many studies also support the link between this virus and porphyria cutanea tarda (PCT). Isolated cases suggest a relationship with dermatomyositis. Herein, we report the coexistence of PCT, non-Hodgkin's lymphoma and dermatomyositis in the same patient affected with virus C infection which has never previously been described.

Systemic lupus erythematosus-associated anetoderma and anti-phospholipid antibodies

Anetoderma is characterized by a loss of normal elastic tissue that presents clinically as localized areas of wrinkled or flaccid skin. We describe the case of a 30-year-old woman with systemic lupus erythematosus-associated anetoderma and positive anti-phospholipid antibodies. We discuss the possible role of these antibodies in the pathogenesis of anetoderma, and, when detected, the need to check for an associated anti-phospholipid syndrome in such patients.

Bleomycin in the treatment of keloids and hypertrophic scars by multiple needle punctures

BACKGROUND

The treatment of keloids and hypertrophic scars has been difficult and a recent French study showed that bleomycin has been useful in the treatment of these lesions.

OBJECTIVE

To determine the effectiveness and safety of bleomycin in the treatment of hypertrophic scars and keloids when this drug is administered through multiple superficial punctures.

METHODS

We applied bleomycin to keloids and hypertrophic scars in 13 patients using a multiple-puncture method on the surface of the skin. All patients were given bleomycin at a concentration of 1.5 IU/ml. Clinical response after treatment was classified according to the following scale: complete flattening (100%), highly significant flattening (>90%), or significant flattening (75-90%).

RESULTS

The clinical response was very positive in all cases: complete flattening in six cases, highly significant flattening in six cases, and significant flattening in one case. Two patients presented a recurrence as a small nodule 10 and 12 months after the last infiltration.

CONCLUSIONS

These clinical findings show that administration of bleomycin in keloids and hypertrophic scars shows promise and needs further investigation.

Correlation between profile of circulating mononuclear cells and clinical manifestations in patients with pemphigus vulgaris

Phenotypes of 38 samples of mononuclear (PBMC) cells from 11 different patients with pemphigus vulgaris (PV) at different stages of the disease were explored looking for a possible relationship between cell immunity, mucocutaneous or mucosal lesion intensity and capacity of serum autoantibodies to elicit the disease in mice. PBMC from 5 patients with mucocutaneous lesions and sera with IgG capable of inducing the disease in neonatal mice had a high proportion of mature monocytes with CD14low DRhigh, and co-expressing CD16 and CD11b. In addition, a high proportion of CD19+CD5+ activated B cells and a very low proportion of naive CD4+CD45RA+ and CD8+CD11b+ T lymphocytes was observed. Monocytes from these patients expressed inducible nitric oxide synthase (iNOS). In contrast, PBMC from 6 patients, with lesions restricted to mucosal membranes and IgG lacking the capacity to induce the disease in mice, contained a high proportion of CD14high DRlow co-expressing CD16 circulating macrophages, CD8+CD11b+ T cells, and a low proportion of activated B lymphocytes. The results suggest a possible association between proportion of different antigen presenting cells (monocytes with high HLA-DR and low CD14 expression and activated B lymphocytes, or differentiated monocytes/macrophages), type of PV and capacity of serum autoantibodies to elicit the disease in mice.

Langerhans' cell histiocytosis on the vulva

BACKGROUND

Langerhans' cell histiocytosis (LCH) affecting the vulva alone is rare. At present, there are 51 published cases of LCH affecting the genital area. Of these, only 7 had LCH located in the genital area alone; in these cases, there was no subsequent systemic spread of the disease. A report of the 8th such case is presented with a review of the previous 7 cases.

CASE

A 40-year-old white woman presented with a several-month history of pruritic and ulcerous lesions on the vagina which had then spread to the vulva. No tiredness, general malaise, or associated temperature was observed. Physical examination disclosed an erythematous plaque on the labia minora, which was bilateral and slightly infiltrated. The rest of the physical examination brought no other disorders of interest to light. Histological findings were characteristic of LCH. Four cycles of iv vincristine (2 mg/m cycle) 15 days apart did not obtain objective or symptomatic improvement in the vulvar lesions. Therefore, a local and partial extirpation of both labia minora was performed. Eighteen months after surgery, the patient has no symptoms or signs of local recurrence or systemic spread.

CONCLUSIONS

Although the occurrence of LCH on the vulva is very unusual, we must bear this possibility in mind when a woman presents atypical chronic lesions on the genital mucosa. In such cases, it is necessary to perform a biopsy on the mucosa, rule out the possibility of systemic disease, and review the patient periodically in order to forestall a possible spread of the disease at any time.

Congenital infiltrating lipoma of the upper limb in a patient with von Willebrand disease

Infiltrating lipoma is a rare variety of lipoma, characterized by an infiltration of the adipose tissue of the muscles. Infiltrating lipomas are usually classified in two groups: intermuscular infiltrating lipoma and intramuscular infiltrating lipoma. Most are acquired, and they usually appear in middle-aged individuals. Exceptionally, they are congenital. In such cases they are not related to other diseases. We report an 8-year-old boy with a congenital infiltrating lipoma of the upper limb and von Willebrand disease. Both diseases are linked to an alteration in chromosome 12, but this clinical association seems to be random rather than causal.

Disseminated epidermolytic acanthoma probably related to trauma

Epidermolytic acanthoma is a rare benign tumour, which may occur in both isolated and disseminated forms. Only seven cases of disseminated epidermolytic acanthoma (DEA) have been described. This entity should be distinguished from other hereditary or acquired conditions which involve epidermolytic hyperkeratosis and other benign acanthomas. On the basis of the clinical history and the histological findings, we diagnosed a case of DEA which was probably secondary to repeated trauma.