Aplasia cutis congenita and other anomalies associated with methimazole exposure during pregnancy

A Case Series of Aplasia Cutis Congenita and Its Management

INTRODUCTION

 Aplasia cutis congenita is a rare condition characterized by a localized or widespread, complete or partial absence of skin at birth. In accordance with the pattern, location, underlying causes, and anomalies, Frieden divided aplasia cutis congenita into nine types. Approximately 80% of all lesions are found on the scalp. The purpose of this study is to describe uncommon instances of aplasia cutis congenita and how they are treated.

MATERIALS AND METHODS

Our study comprises six patients with aplasia cutis congenita belonging to either sex who attended to our dermatology outpatient department at Great Eastern Medical School and Hospital, Srikakulam during the 12-month study period from December 2023 to December 2024. This study was started after obtaining institutional ethical clearance. Patients with traumatic injuries were excluded from the study. All patients with congenital aplasia cutis were included in this study. All patients were treated with recombinant human platelet derived growth factor gel and hydrocolloid dressings for two weeks and a response was elicited.

RESULTS

We have encountered six newborns with aplasia cutis congenita in our study, out of which four (80%) were having aplasia cutis congenita of scalp (Group I) with no other congenital anomalies, fifth case (10%) was aplasia cutis congenita with epidermolysis bullosa and dystrophic nails (Group VI - Bart syndrome) and the sixth one (10%) had aplasia cutis congenita on lower extremities without epidermolysis bullosa (Group VII). One of the newborns was born to the mother who was taking methimazole in the first six weeks of gestation. Out of six, five babies had no consanguineous background, while one was born to parents with second-degree consanguinity. Most common site involved was the parietal region of the scalp (80%). The smallest lesion measured 0.5x0.5 cm, while the largest was 5x3x1 cm. All the lesions showed noticeable improvement after treatment with recombinant human platelet derived growth factor 0.01% gel twice daily along with hydrocolloid dressings for two weeks.

CONCLUSION

Aplasia cutis congenita, being a rare disorder with less incidence is clinically diagnosed and needs to be carefully evaluated for underlying etiologies alongside other congenital anomalies co-existing with it for better management. To conclude with, our study throws a light on conservative management of aplasia cutis congenita which gave promising results minimizing complications of surgical management.

Treatment of Graves' hyperthyroidism with thionamides: a position paper on indications and safety in pregnancy

CONTEXT

Graves' disease affects 3% of women and 0.5% of men in the general population. The first line treatment of Graves' hyperthyroidism is based on the administration of antithyroid drugs (ATD), propylthiouracil (PTU), methimazole (MMI) and carbimazole. A recent warning from the Italian Drug Agency (Agenzia Italiana del Farmaco AIFA) reported the risk of MMI-induced acute pancreatitis. In addition, AIFA highlighted the possible association of MMI treatment during the first trimester of pregnancy with congenital malformations, thus recommending the use of effective contraceptive methods in women of childbearing age treated with MMI.

METHODS AND RESULTS

Revision of literature reported less than ten cases of the alleged MMI pancreatitis, allowing the inclusion of MMI in class III drug regarding the relative risk for drug-induced pancreatitis. Data available on the effect of hyperthyroidism per se on the risk of fetal malformations, although scanty, are sufficient to recommend treatment with ATD of the hyperthyroid pregnant woman. Case reports and population studies either suggesting or not suggesting MMI-induced fetal malformations do not allow unquestionable conclusions on this matter.

CONCLUSIONS

This consensus by experts from Italian Endocrine and Gynecologic Scientific Societies has edited recommendations derived form the available data and published guidelines of International Scientific Societies.

Aplasia cutis congenita: Two case reports and discussion of the literature

Background:

Aplasia cutis congenita (ACC) is a part of a heterogeneous group of conditions characterized by the congenital absence of epidermis, dermis, and in some cases, subcutaneous tissues or bone usually involving the scalp vertex. There is an estimated incidence of 3 in 10,000 births resulting in a total number of 500 reported cases to date. The lesions may occur on every body surface although localized scalp lesions form the most frequent pattern (70%). Complete aplasia involving bone defects occurs in approximately 20% of cases. ACC can occur as an isolated defect or can be associated with a number of other congenital anomalies such as limb anomalies or embryologic malformations. In patients with large scalp and skull defects, there is increased risk of infection and bleeding along with increased mortality and therefore prompt and effective management is advised.

Case Description:

We describe two cases of ACC, involving a 4 × 3 cm defect managed conservatively and a larger 10 × 5 cm defect managed surgically with the use of a temporo-occipital scalp flap. Both cases had an excellent outcome.

Conclusions:

Multiple treatment regimens exist for ACC, but there is no consensus on treatment strategies. Conservative treatment has been described and advocated, but many authors have emphasized the disadvantages of this treatment modality. Decision between conservative and surgical management must be individualized according to lesion size and location.

[Aplasia cutis congenita and antithyroid drugs during pregnancy: Case series and literature review]

BACKGROUND

Aplasia cutis congenita (ACC) following in utero exposure to antithyroid drugs such as methimazole/carbimazole (MTZ/CMZ) has been reported since 1972. Though currently included in MTZ/CMZ embryopathy, it remains poorly characterized and is little discussed. Having seen two cases within a short period of time, we carried out a literature review and searched the French pharmacovigilance database for notification of cases.

PATIENTS AND METHODS

We performed a search of the literature in the Medline database using the following keywords: "aplasia cutis congenita", "birth skin defects", "pregnancy" and "drug". All articles reporting cases of ACC following in utero exposure to antithyroid drugs were included. All cases of ACC under antithyroid drugs reported to French pharmacovigilance centres were analysed.

RESULTS

Three hundred and sixty-eight articles were retrieved and 31 were analysed, including a further 4, mentioned in selected articles, giving 59 cases of ACC under MTZ/CMZ reported in the literature and having an intrinsic accountability score of plausible or dubious. ACC was typically isolated, single, small in size, and localised on the median scalp area. Exposure occurred in the first weeks of gestation. There were 6 familial cases involving siblings. Ten ACC and MTZ/CMZ cases were reported to pharmacovigilance centres in France.

DISCUSSION

Practitioners should be aware of ACC following MTZ/CMZ exposure in utero, whether it occurs in isolation or not. It is likely a teratogenic effect of MTZ/CMZ enhanced by a genetic predisposition.

Pregnancy outcome in women treated with methimazole or propylthiouracil during pregnancy

PURPOSE

Control of thyroid function in hyperthyroid women during pregnancy is based on antithyroid drugs (ATD) [propylthiouracil (PTU) and methimazole (MMI)]. While a teratogenic effect has been suggested for MMI and, more recently, for PTU, a clear demonstration is still lacking. Aim of this study was to assess the safety of ATD during pregnancy.

METHODS

A total of 379 pregnancies were retrospectively recruited in eight Italian Departments of Endocrinology and divided in five groups: (1) MMI-treated and euthyroid throughout pregnancy (n = 89); (2) MMI-treated and hyperthyroid on at least two occasions (n = 35); (3) PTU-treated women and euthyroid throughout pregnancy (n = 32); (4) PTU-treated women and hyperthyroid on at least two occasions (n = 20); and (5) non-ATD-treated (n = 203). Data on maternal thyroid function, miscarriages, type of delivery, neonatal weight, length and TSH, perinatal complications and congenital malformation were analyzed.

RESULTS

The gestational age at delivery, the rate of vaginal delivery, neonatal weight, length and neonatal TSH did not significantly differ among groups. In all groups, the rates of spontaneous miscarriage and of major congenital malformations were not higher than in the general population. No newborns were born with a phenotype similar to those described in the "MMI embryopathy".

CONCLUSIONS

While a clear demonstration of a teratogenic effect of MMI is currently lacking, it seems reasonable to follow the current guidelines and advice for PTU treatment in hyperthyroid women during the first trimester of pregnancy. Further, large and prospective worldwide studies will be needed to fully clarify the issue of ATD safety during pregnancy.

Congenital anomalies in children exposed to antithyroid drugs in-utero: a meta-analysis of cohort studies

Background

Hyperthyroidism affects about 0.2%-2.7% of all pregnancies, and is commonly managed with antithyroid drugs (ATDs). However, previous studies about the effects of ATDs on congenital anomalies are controversial. Therefore, the present meta-analysis was performed to explore the risk of congenital anomalies in children exposed to ATDs in-utero.

Methods

Embase, Pubmed, Web of Knowledge, and BIOSIS Citation Index were searched to find out studies about congenital anomalies in children exposed to ATDs in-utero reported up to May 2014. The references cited by the retrieved articles were also searched. The relative risks (RRs) and confidence intervals (CIs) for the individual studies were pooled by fixed effects models, and heterogeneity was analyzed by chi-square and I² tests.

Results

Eight studies met the inclusion criteria. Exposure to propylthiouracil (PTU), methimazole/carbimazole (MMI/CMZ), and PTU & MMI/CMZ was investigated in 7, 7 and 2 studies, respectively. The pooled RR was 1.20 (95%CI: 1.02-1.42), 1.64 (95%CI: 1.39-1.92), and 1.83 (95%CI: 1.30-2.56) for congenital anomalies after exposure to PTU, MMI/CMZ, and PTU & MMI/CMZ, respectively.

Conclusions

The meta-analysis suggests that exposure to ATDs in-utero increases the risk of congenital anomalies. The use of ATDs in pregnancy should be limited when possible. Further research is needed to delineate the exact teratogenic risk for particular congenital anomaly.

Conservative Healing of an 11 × 9-cm Aplasia Cutis Congenita of the Scalp with Bone Defect

Objectives Aplasia cutis congenita is a rare congenital condition, and it is difficult to find scientific support for optimal treatment strategies. In addition, these may vary due to defect size, tissue layers involved, contemporary malformations, and the physiologic status of the affected child.

Clinical Presentation This case report describes complete skin coverage in 20 weeks and uneventful healing of a large 11 × 9-cm defect of the vertex, involving both skin and skull bone, using conservative treatment. To prevent infection and promote healing, the defect was kept moist and covered at all times, and it was treated with surgical debridement when necessary. For infection control, ionized silver-coated dressings were used in addition to prophylactic antibiotics over the first 3.5 weeks. Follow-up was 2 years.

Conclusion Surgical treatment is usually preferred for larger aplasia cutis congenita defects, but it is accompanied with potential risks and will exacerbate secondary reconstruction of alopecia or skull bone defects. This case shows that even very complex defects may be treated conservatively.

Coexistence of aplasia cutis congenita, faun tail nevus and fetus papyraceus

BACKGROUND

Aplasia cutis congenita is a disorder of the skin embryonic development characterized by a defect of localized or widespread areas of skin at birth. The lesions are mostly oval, 1-3 cm in diameter, with localization on the parietal part of scalp (60%) and rarely on the face and extremities.

MAIN OBSERVATIONS

Herein, we reported a case of aplasia cutis congenita termly born at 39 weeks of gestation to a 30-year-old mother with bronchial asthma attacks. She was referred for 3 punched-out punctate depressed defective lesions in 0.4 cm's diameter on the vertex covered with necrotic and hemorrhagic crusts. There was a hypertrichotic area consisting of tufts of terminal hair on the lumbosacral area over a sinus tract. Maternal perinatal drugs included aerosol salbutamol sulfate, ipratropium bromide and oral montelukast sodium for bronchial asthma. The pregnancy was firstly started as a di-chorionic, di-amniotic twin gestation, but deteriorated after the fetal resorption of the co-twin in the 20th gestational week resulting in fetus papyraceus.

CONCLUSION

In multi-gestational pregnancies, the presence of the fetus papyraceus or the death of the co-twins should make the neonatologists and dermatologists be aware of the possible cutaneous defects like aplasia cutis congenita. We emphasize that the possibility of this rare entity should be kept in mind in the presence of fetus papyraceus, perinatal drug use, maternal cigarette smoke, or maternal diseases like bronchial asthma in multiple gestations.

Maternal transfer of methimazole and effects on thyroid hormone availability in embryonic tissues

Methimazole (MMI) is an anti-thyroid drug used in the treatment of chronic hyperthyroidism. There is, however, some debate about its use during pregnancy as MMI is known to cross the mammalian placenta and reach the developing foetus. A similar problem occurs in birds, where MMI is deposited in the egg and taken up by the developing embryo. To investigate whether maternally derived MMI can have detrimental effects on embryonic development, we treated laying hens with MMI (0.03% in drinking water) and measured total and reduced MMI contents in the tissues of hens and embryos at different stages of development. In hens, MMI was selectively increased in the thyroid gland, while its levels in the liver and especially brain remained relatively low. Long-term MMI treatment induced a pronounced goitre with a decrease in thyroxine (T₄) content but an increase in thyroidal 3,5,3'-triiodothyronine (T₃) content. This resulted in normal T₃ levels in tissues except in the brain. In chicken embryos, MMI levels were similar in the liver and brain. They gradually decreased during development but always remained above those in the corresponding maternal tissues. Contrary to the situation in hens, T₄ availability was only moderately affected in embryos. Peripheral T₃ levels were reduced in 14-day-old embryos but normal in 18-day-old embryos, while brain T₃ content was decreased at all embryonic stages tested. We conclude that all embryonic tissues are exposed to relatively high doses of MMI and its oxidised metabolites. The effect of maternal MMI treatment on embryonic thyroid hormone availability is most pronounced for brain T₃ content, which is reduced throughout the embryonic development period.

Scientific Opinion on the public health hazards to be covered by inspection of meat from sheep and goats

A risk ranking process identified Toxoplasma gondii and pathogenic verocytotoxin-producing Escherichia coli (VTEC) as the most relevant biological hazards for meat inspection of sheep and goats. As these are not detected by traditional meat inspection, a meat safety assurance system using risk-based interventions was proposed. Further studies are required on T. gondii and pathogenic VTEC. If new information confirms these hazards as a high risk to public health from meat from sheep or goats, setting targets at carcass level should be considered. Other elements of the system are risk-categorisation of flocks/herds based on improved Food Chain Information (FCI), classification of abattoirs according to their capability to reduce faecal contamination, and use of improved process hygiene criteria. It is proposed to omit palpation and incision from post-mortem inspection in animals subjected to routine slaughter. For chemical hazards, dioxins and dioxin-like polychlorinated biphenyls were ranked as being of high potential concern. Monitoring programmes for chemical hazards should be more flexible and based on the risk of occurrence, taking into account FCI, which should be expanded to reflect the extensive production systems used, and the ranking of chemical substances, which should be regularly updated and include new hazards. Control programmes across the food chain, national residue control plans, feed control and monitoring of environmental contaminants should be better integrated. Meat inspection is a valuable tool for surveillance and monitoring of animal health and welfare conditions. Omission of palpation and incision would reduce detection effectiveness for tuberculosis and fasciolosis at animal level. Surveillance of tuberculosis at the slaughterhouse in small ruminants should be improved and encouraged, as this is in practice the only surveillance system available. Extended use of FCI could compensate for some, but not all, the information on animal health and welfare lost if only visual post-mortem inspection is applied.

A 6-week-old girl with a scalp lesion

CME EDUCATIONAL OBJECTIVES: 1.Identify the clinical features of aplasia cutis congenita (ACC).2.Understand the differential diagnosis of ACC.3.Recognize features of concern for underlying associations of ACC. A 6-week-old girl presented to the dermatology clinic for evaluation of a scalp lesion. She was born full-term by vaginal delivery to a 27-year-old healthy mother with normal prenatal labs. The delivery was complicated by prolonged rupture of membranes and a scalp electrode was placed at hour 20 of labor. Forceps or other instrumentation were not used during delivery. In the general care nursery, the infant was noted to have a scalp lesion. No bleeding or drainage was ever noted from the area. The lesion remained unchanged since birth with no intermittent enlargement noted. Review of systems was unremarkable. Family history was noncontributory.