Erythema elevatum diutinum--evidence for disease-dependent leucocyte alterations and response to dapsone

Transient Erythema Elevatum Diutinum Associated With HIV Viremia

Erythema elevatum diutinum (EED) is a rare cutaneous small vessel vasculitis of unknown etiology. It is thought to be due to immune complex deposition in small vessels, resulting in complement fixation and subsequent inflammation. EED classically presents with asymptomatic, symmetric, red-brown to purple papules, plaques, and nodules overlying extensor surfaces with a lapsing-remitting course that typically resolves within five to 10 years. We discuss the case of a 47-year-old male with HIV and a new history of EED presenting after several days of missed antiretroviral medications and resolved with improved compliance with antiretroviral medications. A 47-year-old male presented with a four-week history of mildly tender violaceous plaques and nodules on the dorsal feet and posterior heels bilaterally. Medical history was significant for HIV that was well-controlled on antiretrovirals although the patient had missed two days of therapy. A punch biopsy of the lesion demonstrated leukocytoclastic vasculitis with dense dermal mixed infiltrate consisting of histiocytes, neutrophils, and eosinophils. Laboratory findings revealed the presence of HIV RNA. Prior to the initiation of Dapsone therapy, the patient's eruption cleared entirely within a month solely by restarting his antiretroviral therapy, for which he continues to remain disease-free. EED is a rare, chronic leukocytoclastic vasculitis with a poorly understood etiology. Treatment is typically aimed at treating underlying systemic disease, however, treatment of EED with Dapsone is typically first-line.

A comprehensive insight into the anti-inflammatory properties of dapsone

The 4,4'-diaminodiphenyl sulfone (DDS), also known as dapsone, is traditionally used as a potent anti-bacterial agent in clinical management of leprosy. For decades, dapsone has been among the first-line medications used in multidrug treatment of leprosy recommended by the World Health Organization (WHO). Shortly after dapsone's discovery as an antibiotic in 1937, the dual function of dapsone (anti-microbial and anti-inflammatory) was elucidated. Dapsone exerts its anti-bacterial effects by inhibiting dihydrofolic acid synthesis, leading to inhibition of bacterial growth, while its anti-inflammatory properties are triggered by inhibiting reactive oxygen species (ROS) production, reducing the effect of eosinophil peroxidase on mast cells and downregulating neutrophil-mediated inflammatory responses. Among the leading mechanisms associated with its anti-microbial/anti-protozoal effects, dapsone clearly has multiple antioxidant, anti-inflammatory, and anti-apoptotic functions. In this regard, it has been described in treating a wide variety of inflammatory and infectious skin conditions. Previous reports have explored different molecular targets for dapsone and provided insight into the anti-inflammatory mechanism of dapsone. This article reviews several basic, experimental, and clinical approaches on anti-inflammatory effect of dapsone.

Erythema elevatum diutinum: a case report and review of literature

Erythema elevatum diutinum (EED) is a rare cutaneous leukocytoclastic vasculitis thought to be related to increased levels of circulating antibodies. It has been shown to be associated with HIV infection, tuberculosis, as well as various autoimmune diseases. A retrospective review of all cases of EED indexed in PubMed between 1990 and 2014 was performed. Inclusion criteria for articles was availability of full text in English and a biopsy-confirmed diagnosis of EED. All other articles were excluded. Cases were stratified by age and anatomic location of the lesions. Treatment response was coded as "complete," "partial," and "none." A total of 133 cases of EED with 381 lesions detailed in case reports and case series were included. Twenty-one cases were associated with HIV. Of 47 patients with reported paraproteinemias, IgA paraproteinemia was found in 57.45%, IgG paraproteinemia in 29.8%, IgM paraproteinemia in 10.6%, and IgD paraproteinemia in 2.1% of cases. Of 40 (30.1%) patients with reported comorbid autoimmune disease, rheumatoid arthritis was associated with 10 cases. Cancer was found to be associated with 9.77% of cases. Seventy-five patients were treated with dapsone, with 36 (48%) achieving complete treatment response, 24 (32%) achieving partial response, and seven (9.3%) achieving no response. Keeping the clinical associations of EED in mind, especially malignancy, is critical in management of the disease. More structured studies need to take place in order to fully define the mechanisms and strength of these associations.

Dapsone in dermatology and beyond

Dapsone (4,4′-diaminodiphenylsulfone) is an aniline derivative belonging to the group of synthetic sulfones. In 1937 against the background of sulfonamide era the microbial activity of dapsone has been discovered. Shortly thereafter, the use of dapsone to treat non-pathogen-caused diseases revealed alternate antiinflammatory mechanisms that initially were elucidated by inflammatory animal models. Thus, dapsone clearly has dual functions of both: antimicrobial/antiprotozoal effects and anti-inflammatory features similarly to non-steroidal anti-inflammatory drugs. The latter capabilities primarily were used in treating chronic inflammatory disorders. Dapsone has been investigated predominantly by in vitro methods aiming to get more insights into the effect of dapsone to inflammatory effector cells, cytokines, and/or mediators, such as cellular toxic oxygen metabolism, myoloperoxidase-/halogenid system, adhesion molecules, chemotaxis, membrane-associated phospholipids, prostaglandins, leukotrienes, interleukin-8, tumor necrosis factor α, lymphocyte functions, and tumor growth. Moreover, attention has been paid to mechanisms by which dapsone mediates effects in more complex settings like impact of lifespan, stroke, glioblastoma, or as anticonvulsive agent. Additionally, there are some dermatological investigations in human being using dapsone and its metabolites (e.g., leukotriene B₄-induced chemotaxis, ultraviolet-induced erythema). It could be established that dapsone metabolites by their own have anti-inflammatory properties. Pharmacology and mechanisms of action are determining factors for clinical use of dapsone chiefly in neutrophilic and/or eosinophilic dermatoses and in chronic disorders outside the field of dermatology. The steroid-sparing effect of dapsone is useful for numerous clinical entities. Future avenues of investigations will provide more information on this fascinating and essential agent.

Why dapsone stops seizures and may stop neutrophils' delivery of VEGF to glioblastoma

Lopez-Gomez et al. recently published remarkable but mechanistically unexplained empirical evidence that the old antibiotic dapsone has antiepileptic activity. We addressed the question "Why should a sulfone antibiotic reduce seizures?". We report here our conclusions based on data from past studies that seizures are associated with elevated interleukin-8 (IL-8) and that dapsone inhibits IL-8 release and function in several different clinical and experimental contexts. Diverse CNS insults cause an increase in CNS IL-8. Thus, the pro-inflammatory environment generated by increase IL-8 leads to a lower seizure threshold. Together this evidence indicates dapsone exerts anti-seizure activity by diminishing IL-8 signalling. Since IL-8 is clearly upregulated in glioblastoma and contributes to the florid angiogenesis of that disease, and since interference with IL-8 function has been shown to inhibit glioblastoma invasion and growth in several experimental models, and dapsone has been repeatedly been shown to clinically inhibit IL-8 function when used to treat human neutrophilic dermatoses, we believe that dapsone thereby reduces seizures by countering IL-8 function and may similarly retard glioblastoma growth by such anti-IL-8 function.

[Erythema elevatum diutinum associated with pyoderma gangrenosum in an HIV-positive patient]

BACKGROUND

Erythema elevatum diutinum (EED) is a very rare form of chronic dermatosis clinically characterised by reddish-violet papular nodules extending to the surfaces of the limbs and extremities. Histologically, there are classically two phases of progression initially involving associated neutrophilic dermatosis and leucocytoclastic vasculitis, which is later followed by fibrosis of characteristic appearance. We report the association of EED and pyoderma gangrenosum in a patient infected with HIV.

PATIENTS AND METHODS

A 53-year-old male seen since 1989 for HIV infection had been presenting firm bilateral and symmetrical nodules on the feet for 6 months. Histological analysis of one of these nodules resulted in diagnosis of chronic erythema elevatum diutinum and treatment with dapsone was initiated. Three months later, despite regression of the EED lesions under dapsone, two large pustules appeared on the outer aspect of the right leg; they were confluent and progressed towards a superficial ulcer with rounded edges with a clinical appearance evocative of pyoderma gangrenosum (PG). Histopathological analysis demonstrated a massive dermal infiltrate beneath the ulcer comprising neutrophils with evidence of leucocytoclasia, all of which militated in favour of the diagnosis of pyoderma gangrenosum.

DISCUSSION

We report for the first time the association of two forms of neutrophilic dermatosis, EED and PG, in an HIV-positive patient. This case report and certain data in the literature suggest that the various forms of neutrophilic dermatosis tend to result in a range of lesions rather than in clearly distinct entities.

Erythema elevatum diutinum in systemic lupus erythematosus

Erythema elevatum diutinum (EED) is a rare chronic form of leukocytoclastic vasculitis with unknown etiology. EED has been described in association with hematological malignancies, infections and a number of rheumatological diseases. We report a patient with systemic lupus erythematosus (SLE) who presented with intermittent attacks of tender nodules and plaques on the shins and ankles for 6 months. Skin biopsy confirmed the diagnosis of EED. Treatment with dapsone resulted in complete resolution of the skin lesions. EED is rarely reported in SLE, and its presentation and treatment is reviewed.

[Case for diagnosis. Erythema elevatum diutinum]

Erythema elevatum diutinum is a rare presentation of cutaneous vasculitis. Typical lesions are papules, plaques, and nodules that may coalesce and later turn to yellow-brown color. The extensor surface of the extremities is the most involved area and older lesions may present xanthomatous appearance. Light microscopy of acute lesions shows neutrophilic, perivascular infiltrate with dermal fibrin deposits, endothelial expansion, and leukocytoclasis. We present a case of erythema elevatum diutinum without associated disease.

Management of leukocytoclastic vasculitis

Leukocytoclastic vasculitis (LcV) is the most common form of vasculitis of the skin and usually results from deposition of immune complexes at the vessel wall. It presents in different forms and in association with different diseases. When IgA is the dominant immunoglobulin in immune complexes, systemic involvement is likely in both children and adults (Henoch-Schönlein purpura--HSP). LcV due to IgG- or IgM-containing immune complexes has less systemic involvement and a better prognosis than HSP. Other forms of LcV include cryoglobulinaemic, urticarial and ANCA-associated LcV as well as LcV associated with vasculopathy and coagulopathy in SCLE/SLE or in bacteraemia/sepsis. The aim of diagnostic guidelines is to determine the specific type and systemic involvement of LcV and to identify an underlying cause. Basic work-up should encompass history of drug intake and of preceding infections, biopsy with immunofluorescence, differential blood count, urine analysis and throat swabs. Therapy of immune complex LcV often does not require aggressive therapy due to a usually favourable course. It includes avoidance or treatment of eliciting agents and use of compression stockings to reduce purpura. There are no large prospective randomized controlled studies. Corticosteroids are indicated when there are signs of incipient skin necrosis. In chronic or relapsing LcV we suggest colchicine as a first-line and dapsone as a second-line therapy. Corticosteroids may reduce the incidence of severe renal insufficiency in children according to some studies, but there is no study showing such an effect in adults. Severe systemic vasculitis requires immunosuppressive strategies.

Aseptic abscesses: a study of 30 patients with or without inflammatory bowel disease and review of the literature

Aseptic abscesses (AA) are characterized by deep, sterile, round lesions consisting of neutrophil that do not respond to antibiotics but improve dramatically with corticosteroids. We report the clinical, laboratory, and radiologic characteristics and the associated conditions of 29 patients from the French Register on AA plus 1 patient from the Netherlands.The mean age of patients at AA diagnosis was 29 years (SD = 14). The main clinical manifestations of AA were fever (90%), abdominal pain (67%), and weight loss (50%). Duration of symptoms was 4.7 months on average until abscesses were discovered. The abscesses involved the spleen in 27/29 patients (93%; the thirtieth patient had a personal history of splenectomy after a trauma). In 7 they were unifocal and in the others they were multifocal, involving in addition the abdominal lymph nodes in 14 (48%), liver in 12 (40%), lung in 5 (17%), pancreas in 2 (7%), and brain in 2 (7%). They were not splenic in 3, including 2 with abdominal lymph nodes and 1 with superficial lymph nodes and testicle and lung involvement. Twenty-two patients (70%) had elevated white blood cell and neutrophil count; antineutrophil cytoplasmic autoantibodies with a perinuclear, cytoplasmic or atypical pattern (negative for antiproteinase 3 and negative for antimyeloperoxidase except for 1) were positive in 21% of the 24 patients tested. Twenty-one patients had inflammatory bowel disease (IBD), which preceded the occurrence of abscesses in 7, was concomitant in 7, and appeared secondarily in 7. Six patients had neutrophilic dermatosis (20%), 3 had relapsing polychondritis as an associated condition, and 3 others had monoclonal gammopathy of undetermined significance. Three patients had no associated condition. Splenectomy was performed in 15 (52%) patients. All patients received steroid therapy. Thirteen (43%) were given additional immunosuppressive therapy, 1 immediately and the others after a relapse, of whom 3 were also treated by anti-tumor necrosis factor-alpha agents. Mean follow-up was 7 years. Eighteen (60%) patients experienced 1 or several relapses, but there was no death related to AA. Relapses occurred on immunosuppressive therapy in 2 patients and off immunosuppressive therapy in the others while corticosteroids were being tapered. We surveyed the literature and analyzed 19 additional cases. AA is an emergent and probably underrecognized entity. It represents an apparently noninfectious inflammatory disorder involving neutrophils that responds to corticosteroid therapy. AA mainly affects patients with IBD but also affects those with other conditions, or with no other apparent disease.

Therapierefraktäre kutane nekrotisierende Vaskulitis

The clinical picture in vasculitis varies from few self-limiting symptoms to life-threatening illnesses affecting multiple organs. We describe the course of a woman patient who had had a severe cutaneous necrotizing vasculitis for more than 10 years. Various immunsuppressants, including cyclophosphamide, had failed to improve the clinical course, although adequate doses were given for a sufficient period. Treatment with DADPS (diaminodiphenylsulfone, dapsone), however, finally led to complete remission of the severe and chronic vasculitic ulcerations. Indications for DADPS treatment of inflammatory cutaneous diseases are discussed, and an overview of cutaneous vasculitis is provided.

Erythema Elevatum Diutinum in the Setting of Connective Tissue Disease and Chronic Bacterial Infection

Erythema elevatum diutinum (EED) is a rare and chronic cutaneous leukocytoclastic vasculitis. It is predominantly seen on the extensor surfaces of the extremities. Although a specific cause is largely unknown, EED has been noted to occur in association with a wide variety of diseases. A 28-year-old man with systemic lupus erythematosus (SLE) and a 53-year-old woman with an overlap syndrome of rheumatoid arthritis and polymyositis are presented. Both patients developed EED in the setting of chronic recurrent bacterial infections. Patients with a connective tissue disease are at increased risk for such infections secondary to immunosuppression, either from the disease itself or secondary to immunosuppressive therapy. EED has been independently reported to occur in the setting of connective tissue disease as well as in the setting of chronic infection. Our patients had both of these underlying conditions, which are known to predispose patients to immune complex-mediated vasculitides, in this case EED. One patient's EED responded to treatment of the SLE and the other improved, as has been previously reported with dapsone.

Disulone

For 60 years, dapsone has been used as a both antibacterial and anti-inflammatory agent. Dapsone (4,4'-diaminodiphenylsulfone, DDS) continues to be used successfully to treat a wide range of dermatologic disorders, notably those characterized by abnormal neutrophil and eosinophil polynuclear accumulation. A considerable number of other inflammatory as well as bullous dermatoses, of which dermatitis herpetiformis is the best known, have been shown to respond in varying degrees to dapsone, although the indication for the molecule has not been demonstrated in of them all. This article reviews current knowledge on the pharmacokinetics, mechanism of action and side effects of dapsone in dermatology. Despite the lack of controlled studies, the aim of this study is to specify and classify the pathological states in which disulone could be indicated.

Primary cutaneous small vessel vasculitis

Disorders associated with cutaneous vasculitis include numerous well-described etiologies. Primary cutaneous vasculitis limits discussion to primary leukocytoclastic vasculitis, essential mixed cryoglobulinemia, urticarial vasculitis, Henoch-Schönlein purpura, and erythema elevatum diutinum. Although the therapeutics for these disorders are based on limited data, we attempt to construct a consensus opinion on the management of primary cutaneous vasculitis. Therapy of primary cutaneous vasculitis is indicated for symptomatic or systemic involvement, because cutaneous small vessel vasculitis is frequently a self-limited, single episodic disease. Conservative, symptomatic treatment includes leg elevation, warming, antihistamines, and nonsteroidal anti-inflammatory drugs. For mild recurrent disease, colchicine, dapsone, and prednisone are first-choice agents. Systemic or severe cutaneous disease requires more potent immunosuppression (eg, prednisone, azathioprine, or mycophenolate mofetil). Plasmapheresis/plasma exchange and intravenous immunoglobulin are viable considerations for refractory disease, but are cumbersome and expensive modalities. There is insufficient evidence to advocate the use of new biological or monoclonal antibody therapies in primary cutaneous vasculitis.

Studies on the toxicity and efficacy of some ester analogues of dapsone in vitro using rat and human tissues

The toxicity and efficacy of a series of 13 anti-tubercular sulphone esters has been evaluated using human and rat tissues. The toxicity studies involved comparison of the esters' ability to generate rat microsomally mediated NADPH-dependent methaemoglobin with that of dapsone. All the compounds formed significantly less methaemoglobin in the 1 compartment studies compared with dapsone itself. The ethyl, propyl, 3-methyl-butyl cyclopentyl esters and the carboxy parent derivative all yielded less than 5% of the methaemoglobin generated by dapsone. The 3-nitro benzoic acid ethyl and propyl esters generated 30 and 25% of dapsone's methaemoglobin formation. A similar effect was seen in the 2 compartment system, except for the butyl ester, which yielded similar haemoglobin oxidation to dapsone. The low toxicity ethyl and propyl esters, were also low in toxicity using human liver microsomes, producing less than 30% of the dapsone mediated methaemoglobin. All the compounds except the benzoic acid parent were superior to dapsone in terms of suppression of human neutrophil respiratory burst using a lucigenin-based chemiluminescence assay. The most potent derivatives were the phenyl, propyl and 3-nitro benzoic acid ethyl esters, which were between two- and threefold more potent compared with dapsone in arresting the respiratory burst. Overall, the ethyl ester showed the best combination of low toxicity in the rat and human microsomal systems and its IC(50) was approximately 40% lower than that of dapsone in neutrophil respiratory burst inhibition. These compounds indicate some promise for future development in their superior anti-inflammatory capability and lower toxicity compared with the parent sulphone, dapsone.

Dapsone and sulfones in dermatology: overview and update

In their 60-year history, dapsone and the sulfones have been used as both antibacterial and anti-inflammatory agents. Dapsone has been used successfully to treat a range of dermatologic disorders, most successfully those characterized by abnormal neutrophil and eosinophil accumulation. This article reviews and updates the chemistry, pharmacokinetics, clinical application, mechanism of action, adverse effects, and drug interactions of dapsone and the sulfones in dermatology.

Novel therapies in vasculitis

The vasculitides comprise various clinical and pathological entities which pose a therapeutic challenge in terms of disease control versus drug toxicity. Glucocorticoids are important in most regimens; duration of exposure and dosages can be minimised by the use of cytotoxic drugs and transplant immunosuppressives such as cyclosporin, tacrolimus and mycophenolate mofetil. Among alkylating agents, cyclophosphamide has proven to be highly effective; switching to less toxic antimetabolites, typically methotrexate, for maintenance after achieving disease control is an effective strategy. Plasmapheresis may be considered when pharmacological options are maximised. IVIG infusions are of proven benefit in Kawasaki disease and possible benefit in other vasculitides. Targeting infective aetiologies is the basis of therapies such as lamivudine and vidarabine for hepatitis B associated polyarteritis nodosa as well as ribavarin and IFN-alpha for hepatitis C associated cryoglobinaemic vasculitis. IFN-alpha also has immunomodulatory effect even in non-hepatitis C-associated vasculitis. Trimethoprim-sulphamethoxazole has been used in limited Wegener's granulomatosis. Thalidomide, colchicine and dapsone are miscellaneous agents that have been used in Behcet's disease and cutaneous vasculitis. Anti-lymphocytic monoclonal antibodies have been employed for induction therapy in Wegener's granulomatosis. The tumour necrosis factor inhibitor etanercept is just being explored as a therapeutic agent. Bone marrow and stem cell transplantation may find a role in refractory disease.

"Essential" cutaneous vasculitis: what every rheumatologist should know about vasculitis of the skin

Although the classification of small-and medium-vessel vasculitides involving the skin remains complex and imperfect, a substantial body of knowledge related to cutaneous vasculitis exists. Some components of this knowledge, though beyond the usual purview of rheumatologists, are essential to understanding the vasculitides. The correct interpretation of cutaneous findings combined with a properly performed skin biopsy yields important insights not only into underlying diagnoses, but also into the pathophysiological mechanisms of individual cases. In this review, we discuss a classification scheme for the cutaneous vasculitides, outline the work-up for evaluating patients with these disorders, and describe the essential features of the major categories of skin vasculitis.