[Mucinous nevus]

Mucinous nevus is an exceptional entity and presents as flesh-colored to brownish papules or plaques, coalescing to form a pigmentary or verrucous lesion with either a blaschkoid, linear, grouped or zosteriform disposition. It usually appears at birth or during early childhood, but late onset has also been described. Mucinous nevus does not require additional work-up as no internal pathologies have been described. Abstention of any therapeutic intervention is usually preferred.

[Atopic dermatitis : the therapeutic revolution is underway]

The therapeutic prospects for patients with moderate to severe atopic dermatitis completely changed in 2017 with the arrival of the first targeted therapy, dupilumab. Achieving important clinical improvement scores are now possible with this monoclonal antibody directed against interleukins 4 and 13. Since that time, other agents such as tralokinumab arrived on the market, but also the small molecules called «JAK inhibitors» (upadacitinib, baricitinib, etc.). This article provides an inventory of the existing or imminent therapeutic options for atopic dermatitis.

[Köbner's phenomenon in dermatology]

Köbner's phenomenon and its related phenomena are dermatological curiosities that are still partially misunderstood. The Köbner phenomenon is by far the best known and the most studied. It is characterized as the appearance of an inflammatory or infectious dermatosis in an area of healthy skin after skin trauma. The dermatoses most frequently concerned are psoriasis, lichen planus and vitiligo. The inverse Köbner phenomenon and the Renbök phenomenon are two very similar phenomena. The first represents the disappearance of a skin lesion after skin trauma. The second is characterized by a skin trauma that is more specifically induced by another dermatosis. Finally, the Wolf's isotopic phenomenon corresponds to the appearance of a new dermatosis on an area of the skin that was previously the site of another healed dermatosis.

[Management of mycosis fungoide : focus on brentuximab vedotin]

Recently, brentuximab vedotin (BV) (Adcetris®) obtained the reimbursement in Belgium for the treatment of the primary cutaneous NKT-cell lymphomas mycosis fungoides (MF), large cell anaplastic lymphoma and lymphomatoid papulosis type A. BV is a monoclonal antibody directed against the CD30 expressed on tumoral T cells. The inhibition of this pathway releases the process of apoptosis leading to the cell death of the tumoral cells. BV is reimbursed after the use of another systemic treatment without success and if the number of CD30 positive atypical T-cells is larger than 10 %. BV is administered intravenously every 3 weeks with a dosing of 1,8 mg/kg with a maximum of 16 courses. The response rates exceed 75 %. In some instances, interesting treatment responses have been observed with BV in CD30 negative patients. The principal adverse effects are neutropenia and peripheral neuropathy. Two patients are presented with longstanding multi-resistant MF that were successfully treated with BV.

[Pediatric cutaneous mastocytosis]

Mastocytosis are orphan diseases characterized by the accumulation of mast cells in one or more organs. A distinction is made between systemic forms (10 %) and pure cutaneous forms (90 %), the latter being mainly pediatric and generally having a spontaneously favourable prognosis. In the absence of a systemic sign, the diagnostic criteria for cutaneous mastocytosis are Darier's sign, in principle, pathognomonic, as well as skin histology confirming mast cell infiltration. The treatment is essentially preventive (avoidance of factors triggering degranulation) and symptomatic (antihistamine agents).

[Actual treatments of psoriasis : from etanercept to anti-IL17 and anti-IL23 antagonists]

Psoriasis is a chronic inflammatory skin disease affecting around 2-3 % of the population. The disease spectrum evolves from to the knees and elbows limited disease to erythrodermic psoriasis. The impact on the quality of life, the pruritus, the pain from palmo-plantar disease, arthropathic psoriasis and the comorbidities are the major complaints of the patients. The treatment relies on topical treatments with dermocorticosteroids with or without vitamin D derivatives, UVA or UVB phototherapy, conventional treatments including methotrexate, ciclosporin and acitretin, and, since around 15 years, biological treatments. The biological treatments for moderate to severe psoriasis progressed in a spectacular way with an improvement of clinical results and an amelioration of the safety profile at every step. This article discusses these developments from the TNF? antagonists, including etanercept, adalimumab and infliximab to the newly arrivals, the anti-IL17 and anti-IL23 antagonists, the anti-PDE-4 antagonists and the JAK inhibitors.

[Locally advanced and metastatic cutaneous squamous cell carcinoma treated with cemiplimab]

The treatment of locally advanced or metastatic cutaneous squamous cell carcinoma (cSCC) essentially relies on surgery and eventually radiotherapy of the treated site and afferent lymph nodes. Unfortunately, some cases are no candidates for surgery or radiotherapy and a systemic treatment may be indicated. Chemotherapies are only partially efficacious and associated with potential toxicities. A recent study evaluating the efficacy and tolerance of cemiplimab, a PD1 antagonist for locally advanced and metastatic cSCC demonstrated an objective response rate of 49 % and 47 % for locally advanced and metastatic cSCC, while maintaining a response of at least 6 months of 63 % and 60 %, respectively. We present a clinical case of a patient with a locally advanced cSCC of the forehead with bone resorption and cervical lymphadenopathies. After failure of multiple surgical interventions and radiotherapies, he responded partially to cemiplimab immunotherapy with a good safety profile.

[Treatment of mucocutaneous toxicity of target therapy in oncology]

The spectrum of the mucocutaneous adverse effects of directed oncologic therapies, such as anti-EGFR, anti-VEGF, anti-TK and anti-BRAF, presents similarities but also differences compared to that of the classic chemotherapeutics. This article reviews the dermatological toxicities of the targeted therapies, with 11 clinical cases, including mucositis and oral toxicities, the acne-like eruptions, nail changes and complications, the «hand/foot» syndrome, radiosensitization, alopecias, xerosis and skin fissures. After a brief clinical case presentation and theoretical issues, the clinical management is discussed in detail.

[What's new in the treatment of suppurative hidradenitis in 2018 ?]

Hidradenitis suppurativa (HS), also known as Verneuil's disease and acne inversa, is a chronic inflammatory skin disease characterized by a dysfunction of the pilosebaceous structures resulting in occlusion and inflammation. The disease usually starts after puberty, on average between twenty and thirty years, with subcutaneous painful inflammatory nodules, abscess collections, fistulization and scars mainly in the axillary, inguinal, sub-mammary, perineal and perianal regions. It is a multifactorial disease with the most commonly cited risk factors or aggravating factors being smoking, obesity, and HS family history. The first line of treatment relies on antibiotics, including tetracyclins, clindamycin and rifampycin. In case of non-response, TNF? antagonists, more specifically adalimumab, may be considered.

[Rosacea]

Rosacea is a common centro-facial dermatosis with a high socio-esthetic impact. Different subtypes are distinguished, classified into grades according to their severity. This classification is essential for therapeutic management. In general, rosacea remains difficult to treat as its pathophysiology is still not entirely understood. Future research is needed for a better understanding of this disease and the development of targeted treatments.

[Cutaneous adverse effects of TNFalpha antagonists]

The TNFalpha antagonists, including adalimumab, etanercept and infliximab, represent a class of anti-inflammatory and immunosuppressive drugs. Although cutaneous adverse effects are uncommon, they are varied. There is no particular risk profile to develop cutaneous adverse effects. The principal acute side effects are injection site reactions and pruritus. The major long term cutaneous side effects are infectious and inflammatory conditions. Neoplastic skin diseases are exceptional. The association with other immunosuppressive agents can increase the risk of developing cutaneous adverse effects. Some adverse effects, such as lupus erythematosus, require immediate withdrawal of the biological treatment, while in other cases temporary withdrawal is sufficient. The majority of the other cutaneous adverse effects can be dealt without interrupting biologic treatment. Preclinical and clinical investigations revealed that the new biologics, aiming IL12/23, IL23 and IL17, present a similar profile of cutaneous adverse effects, although inflammatory skin reactions may be less often encountered compared to TNFalpha antagonists.

[Bilateral prophylactic mastectomy for women at very high risk for breast cancer: beyond the technique]

Bilateral prophylactic mastectomy is the most efficient risk management strategy for women at very high risk for breast cancer. Different methods can be used. The implementation of such a strategy must respond to the request of a well informed patient.

[Microsurgical breast reconstruction: for whom and how?]

Breast reconstruction is now an integral part of breast cancer treatment. There are several different procedures that make use of flaps or prostheses, or a combination of the two. Which of these procedures is indicated depends on the sequelae of the initial treatment and the patient's wishes and morphology. However, the constraints caused by the prosthetic material and the now regular use of microsurgical techniques have greatly favoured the purely autologous options. The different surgical techniques and their respective advantages and disadvantages will be described, before considering the timing of the various stages of the procedure. We will also give a summary of our experience with free flaps.

[When creams turn into a burden]

Topical treatment is the cornerstone of therapy for patients suffering from psoriasis. Its efficacy and safety have been demonstrated in a large number of publications. However, in daily life, the treatment outcome is often less satisfactory than the results published in the literature. This phenomenon is clearly linked to non-adherence. Indeed, patients with psoriasis frequently consider the topical therapies frequently as a heavy burden. The successful management of psoriasis with topical agents requires a perfect understanding between the patient and the practionner, which provides regular renewal of the patient's motivation.

[About the reticence to specific immunotherapy in alergic subjects]

The increasing number of allergic subjects and the alteration of their quality of life are major concerns of public health. Symptomatic treatments of allergic diseases are not always able to improve the patient's complaints. Allergic exploration aims to identify IgE-dependant mechanisms and subsequently to prove the responsibility of the detected allergen in the allergic disease. The efficacy of the specific immunotherapy (SIT) using allergens in either subcutaneous or sublingual forms has been proven in rhinitis, conjunctivitis, asthma and IgE-induced reactions to hymenoptera venom. The lack of training in allergology is an important reticence of general practitioners and specialists to prescribe SIT. Furthermore, the duration of the treatment and its important cost in Belgium (where, only venom SIT is reimbursed by the Social Security) interfere significantly with the compliance of the patients.

[Home plants and allergies]

Allergic manifestations due to outdoor plants are relatively well known, contrary to those related to home plants. This review presents the various allergens linked to home plants that may be responsible for several allergic manifestations affecting the skin, the lungs, the eyes, and the rhinopharynx. The ficus and its family members constitute the principal sources of the incriminated allergens.

[How I treat...varicosities by sclerotherapy]

Sclerotherapy is a technique for the treatment of varicosities, vascular ectasia, and sometimes, leg varicose veins. This method is aesthetic and in some cases therapeutics and uses sclerosing agents, electrocoagulation and exceptionally LASER. These relatively simple methods are safe and efficient if they are applied with a rigorous procedure by well trained physicians.

Contact and photocontact allergy to ketoprofen. The Belgian experience

Topical ketoprofen (KP) is widely used because of its anti-inflammatory effect. However, photocontact dermatitis is a side-effect. Between May 2001 and June 2002, the Belgian Contact & Environmental Dermatitis Group conducted a prospective, open patch and photopatch test study in 20 patients suspected of KP dermatitis. Severe skin symptoms requiring systemic corticotherapy occurred in 47%. 5 patients were hospitalized. 1 patient showed prolonged photosensitivity. All patients were tested with KP and the other constituents of KP gel. Attribution to KP was demonstrated in all cases. Patch and photopatch tests with KP 2% in petrolatum showed contact photoallergy in 17 patients, contact allergy in 1 patient and photoaggravated contact allergy in 2 patients. 5 patients also reacted to the fragrance components lavender (Lavandula augustifolia) oil and/or neroli (Citrus aurantium dulcis) oil 5% in alcohol. However, in 4 of these, irritant reactions to the ethanolic dilutions could not be ruled out. Additional tests with 3 non-steroidal anti-inflammatory drugs without benzophenone structure ibuprofen, naproxen and diclofenac identified only 1 contact allergic reaction to diclofenac. Cross-reactivity to the substituted benzophenones, oxybenzone and sulisobenzone occurred only to the first in less than 30% of the patients. A high frequency (69%) of contact allergy to fragrance mix was found. Dermatologists should be aware of the severity of photoallergic reactions to KP and the risk of cross-sensitization.

[Urticaria and systemic diseases]

Urticaria is a transient eruption of erythematous or oedematous swelling of the dermis and is usually associated with itching which clinically is very easy to diagnose. However, it causes several etiological, pathophysiological and therapeutic problems. We will develop the acute and chronic urticaria as well as their different associations with systemic diseases. Some current data concerning chronic idiopathic autoimmune urticaria is reviewed. The management and therapeutics will be discussed.

[Epidemiology, physiopathology and treatment of a frequent ailment: tinea pedis]

Tinea pedis is an infection of the stratum corneum caused by dermatophytes. Nowadays, fitness centers, saunas, subtropical swimming pools and sport-shoes are more and more fashionable and are certainly responsible for the increase of cases of tinea pedis as dermatophytes grow preferentially in warm and humid environments. The clinical aspect is affected by several factors such as the host reaction to the infection, the virulence of the infective strain, species, and some local and environmental factors. If a dermatophytosis is suspected, it is mandatory to validate the provisional diagnosis by demonstration of the fungus (by culture or/and microscopic examination) to avoid useless and expensive treatments. The new antifungal molecules are very effective, well tolerated and allow short course of therapy improving the compliance of the patient in clinical practice. Relapse of tinea pedis is very common but could be avoided by several simple preventive measures of hygiene.

Congenital psoriasis following the lines of Blaschko

Congenital psoriasis without an underlying nevus following the lines of Blaschko is described in a 6-year-old girl. In addition to this special type of psoriasis, she suffered from atopic dermatitis. The lesions were aggravated by sun exposure and phototherapy treatments, as well as by upper airways infections, without any clear explanation of these trigger factors. We propose to call this form of psoriasis congenital blaschkoid psoriasis.

Epithelioid cell histiocytoma: a report of two cases

Epithelioid cell histiocytoma is a rarely reported tumor derived from factor-XIIIa-positive dermal dendrocytes. Two additional cases are presented including their clinical, histologic and immunohistochemical features.