Cyclosporin-induced periungual granulation tissue

Surgery for benign nail tumor

The vast majority of tumors in the nail apparatus have a different clinical presentation and course from their equivalents on the skin. Some, such as onychomatricoma and onychopapilloma, are unique to the nail and others, such as superficial acral fibromyxoma, have a tropism for the nail apparatus. As a rule, benign lesions respect the general architecture of the nail apparatus, whereas malignant tumors are destructive. Treatment is always surgical and good knowledge of the anatomy and the procedures is mandatory in order not to induce postoperative nail dystrophy.

Periungual and subungual pyogenic granuloma

BACKGROUND

Nail pyogenic granuloma (PG) is common, often seen as an urgent case, given the recent onset as a bleeding nodule. Nail PGs are due to different causes that act through different pathogenetic mechanisms and may be treated in several ways. Both causes and treatments of nail PG have never been classified.

OBJECTIVES

To classify nail PG according to the pathogenesis, describe the clinical and pathological features and provide guidelines for a correct diagnosis and treatment.

METHODS

A retrospective, observational study was performed reviewing epidemiological and clinical features of 58 cases of PG seen at our Departments in the last 5 years. A review of the literature was also carried out, using PubMed database and dermatological textbooks.

RESULTS

Nail PG is usually due to the following causes: drugs, local trauma and peripheral nerve injury. Histopathology shows similar features in every type of PG, irrespective of cause and location.

CONCLUSIONS

The localization of nail PG, the number of digits involved and clinical history help to identify the cause. When PG is single, especially if it involves the nail bed, histological examination is necessary to rule out malignant melanoma. Treatment must be chosen according to the underlying cause.

Hypertrophic pseudofolliculitis in white renal transplant recipients

Renal transplant recipients (RTRs) are susceptible to many cutaneous disorders, including drug-induced skin changes. Hypertrichosis, sebaceous hyperplasia and gingival hyperplasia are well-recognized effects of ciclosporin, one of the immunosuppressants commonly used in RTRs. Pseudofolliculitis barbae usually affects hair-bearing areas of skin in men with darkly pigmented skin who shave on a regular basis. We describe five cases of hyperplastic pseudofolliculitis occurring in white RTRs taking ciclosporin as part of their immunosuppressive regimen. All five had involvement of the chin, the classic site of pseudofolliculitis barbae, and two had additional psuedofolliculitis of the nose or occiput.

Common nail tumors

Nail abnormalities are varied and numerous. They include warts, keratoacanthomas, onychomatricomas, fibrokeratomas, osteochondromas, tumors (ie, glomus, giant cell, Koenen's, and others), and Bowen's disease. Although the gravity of these conditions may vary, prompt diagnosis and treatment is of the utmost importance. This article discusses the most common defects associated with the nail unit and its surrounding tissue, as well as the differential diagnosis and treatment of these conditions.

Cyclosporine-induced folliculodystrophy

We describe a 34-year-old kidney transplant patient who developed a distinct cutaneous side-effect to cyclosporine manifested as an infiltrated appearance to the skin with abundant flesh-colored, follicular papules predominantly affecting the ears, nose, and surrounding areas of the face, but also the trunk and extremities. The clinical and histologic findings in this case closely match those presented in 2 previous case reports, in which immunosuppressive doses of cyclosporine appeared to be causative. We present a detailed report of the clinical and histologic findings that are unique to these 3 cases and we introduce a theory, based on the recent in vitro studies involving cyclosporine, to help explain the pathogenic events induced by cyclosporine in these patients. We propose the term "cyclosporine induced folliculodystrophy" or CIF as an appropriate name for this distinct clinicohistopathologic entity. Finally, we set forth 3 clinical and 4 histopathologic criteria upon which the diagnosis of CIF can be made.

Hypertrophic scar formation following carbon dioxide laser ablation of plantar warts in cyclosporin-treated patients

We present four renal transplant patients who developed hypertrophic scars following carbon dioxide laser ablation of recalcitrant plantar warts. All of the patients were on long-term treatment with cyclosporin, which we believe to be responsible. We discuss several possible mechanisms by which cyclosporin may influence wound healing and scarring.

Skin diseases in children with organ transplants

BACKGROUND

Skin diseases are frequent in organ transplant recipients, but studies concerning children are sparse.

OBJECTIVE

We assessed skin diseases in children who had received organ transplants.

METHODS

A total of 145 children referred to our dermatologic consultation were studied.

RESULTS

Steroid-induced striae distensae and acne occurred only in adolescents; severe cyclosporine-related side effects were more frequent in younger children. The most common findings were warts (53.8%), tinea versicolor (14.5%), herpes simplex/zoster (9.6%), molluscum contagiosum (6.9%), and impetigo contagiosum and folliculitis (6.2%). Other notable disorders included a diffuse hyperpigmentation with a "dirty" appearance of the skin, pyogenic granulomas, melanocytic nevi proliferation, and skin tags. Two of 20 further adult patients who received transplants during childhood had squamous cell carcinomas.

CONCLUSION

Children who have received organ transplants frequently present side effects of immunosuppressive drugs and infectious diseases. Most disorders are related to the age of the patients rather than to the length of immunosuppression, whereas others are favored by the reinforcement of immunosuppression. Skin cancers were not encountered, but the risk of carcinomas in early adulthood should be considered.

Topical tacrolimus in the management of peristomal pyoderma gangrenosum

BACKGROUND

Peristomal pyoderma gangrenosum (PPG) is a potentially disabling disease in stoma patients. Topical tacrolimus has been shown to be effective in the management of pyoderma gangrenosum. Unfortunately, greasy topical treatments may be impractical for PPG because of impaired appliance adhesion.

OBJECTIVE

The purpose of this open study was to evaluate the therapeutic effectiveness of topical tacrolimus 0.3% formulated in carmellose sodium paste compared with topical corticosteroid preparations in the management of PPG.

RESULTS

A total of 11 patients with PPG received treatment with topical tacrolimus 0.3% in Orabase trade mark and 13 with topical clobetasol propionate 0.05% as monotherapy in each case. Seven of the tacrolimus-treated group healed completely (mean time to healing: 5.1 weeks) compared with five of the clobetasol propionate-treated group (mean time to healing: 6.5 weeks). Topical tacrolimus was significantly more effective than clobetasol propionate in managing larger PPG lesions (ulcer diameter > 2 cm). In six patients, who had failed to respond adequately to multiple systemic and topical treatments for PPG, the addition of topical tacrolimus was associated with healing of PPG within 6 weeks.

CONCLUSION

These results suggest that topical tacrolimus 0.3% in Orabase trade mark is a more effective and expeditious treatment than clobetasol propionate 0.05% for PPG. It is significantly more effective than clobetasol propionate 0.05% in managing lesions larger than 2 cm in diameter. Topical tacrolimus may be highly effective when other systemic or topical treatments have been unsuccessful.

Pilomatrix dysplasia in an immunosuppressed patient

Immunosuppressive drugs have been used for many years in the prevention of graft failure in transplant recipients. Although they improve morbidity and mortality after transplantation, these medications carry a significant risk of adverse mucocutaneous and systemic effects. We describe a patient receiving 4 immunosuppressive drugs who experienced persistent facial dysmorphism along with striking follicular disturbances. On histopathologic examination, the follicular structures were dilated and hyperplastic with a peculiar dysplasia of the pilar matrix. Based on a review of the clinical, microscopic, and investigational findings of the skin previously reported in association with her immunosuppressive drugs, we conclude that cyclosporine was the most likely causative agent. Moreover, hypertrichosis, dysmorphic facies, and tissue hyperplasia have all been observed in patients during cyclosporine administration.