Capillary malformation-arteriovenous malformation syndrome: a multicentre study

BACKGROUND

Capillary malformation-arteriovenous malformation (CM-AVM) syndrome is a rare syndrome with characteristic skin lesions that are associated with fast-flow vascular malformations (FFVMs) in one-third of patients. Few case series have been described, and none in Spain.

AIM

To identify the prevalence of dermatological parameters, FFVMs and associated features in a large series of patients with CM-AVM.

METHODS

We conducted an observational study of patients with CM-AVM syndrome diagnosed in 15 Spanish hospitals over 3 years. The main clinical, radiological, genetic findings and associated diseases were analysed.

RESULTS

In total, 64 patients were assessed. In 26.5% of cases, the diagnosis was incidental. In 75% of patients, there was one significantly larger macule, which we termed the 'herald patch'. FFVMs were detected in 34% of the patients, with 30% located on the skin, 7.8% in the brain and in 1.5% in the spine. There was a positive family history in 65% of the 64 patients. Genetic analysis was performed for RASA1 mutations in 57 patients, of whom 42 (73%) had a positive result. All 4 patients tested for EPHB4 mutations had a positive result. No tumour lesions were detected in the series, except for five infantile haemangiomas.

CONCLUSIONS

Our data on clinical lesions, associated FFVM, family history and genetics are similar to those previously published in the literature. An extensive data analysis failed to demonstrate any statistically significant association between the presence of an FFVM and any clinical, familial or genetic parameter that could predict its onset, although a link between the presence of a herald patch on the midline face and the presence of a brain FFVM was observed. We did not detect any genotype-phenotype correlation.

Comparison of PCR-based methods for the diagnosis of cutaneous leishmaniasis in two different epidemiological scenarios: Spain and Morocco

BACKGROUND

Cutaneous leishmaniasis (CL) is a disfiguring and stigmatising disease occurring in more than 70 countries across the world including Spain and Morocco. The use of sensitive tests that can differentiate Leishmania species is advised.

OBJECTIVE

To evaluate the influence of the epidemiological scenario on the reliability of the PCR techniques and contribute to the selection of the most efficient one for CL diagnosis.

METHODS

The sensitivities of parasitological methods and four PCRs were compared in cutaneous samples from 77 patients from Spanish (PSH) and Moroccan hospitals (PMH). Exudates and fresh or paraffin-embedded tissue biopsies were used.

RESULTS

None of the PCRs used in this study allowed the diagnosis of all CL cases, showing also some drawbacks. Lmj4/Uni21-PCR displayed the best sensitivity with PMH, but it did not provide positive results in PSH with CL confirmed by other PCRs. Conversely, JW13/JW14-PCR and L. infantum-PCR-ELISA displayed good sensitivities with PSH that were not achieved with PMH. Nested-ITS-1-PCR did not show enough sensitivity with paraffin-embedded tissue biopsies. False-negative results were obtained in 19% of PSH due to unspecific hybridizations of ITS-1 primers with human chromosome1.

CONCLUSIONS

PCR should be routinely used in patients with cutaneous lesions compatible with CL and furthermore, the combination of two PCR techniques is advisable. The selection of these PCRs will be influenced by the epidemiological scenario: In areas where L. infantum is endemic, the use of the PCR-ELISA joint with JW13/JW14-PCR seems an appropriate choice, whereas in areas such as Morocco, Lmj4/Uni21 and ITS-1 provide satisfactory results.

Reconstruction Techniques of Choice for the Facial Cosmetic Units

BACKGROUND AND OBJECTIVES

A broad range of skin flaps can be used to repair facial surgical defects after the excision of a tumor. The aim of our study was to develop a practical guideline covering the most useful skin grafts for each of the distinct facial cosmetic units.

MATERIAL AND METHODS

This was a multicenter study in which 10 dermatologists with extensive experience in reconstructive surgery chose their preferred technique for each cosmetic unit. The choice of flaps was based on personal experience, taking into account factors such as suitability of the reconstruction technique for the specific defect, the final cosmetic result, surgical difficulty, and risk of complications. Each dermatologist proposed 2 flaps in order of preference for each cosmetic subunit. A score of 10 was given to the first flap and a score of 5 to the second.

RESULTS

The total score obtained for each of the options proposed by the participating dermatologists was used to draw up a list of the 3 best grafts for each site. There was notable unanimity of criteria among most of the dermatologists for reconstructive techniques such as the glabellar flap for defects of the medial canthus of the eye, the bilateral advancement flag flap or H flap for the forehead, the rotary door flap for the auricle of the ear, the Mustarde flap for the infraorbital cheek, the O-Z rotation flap for the scalp, the Tenzel flap for the lower eyelid, and the island flap for the upper lip.

CONCLUSIONS

The results of this study will be useful as a practical guide to choosing the best reconstruction technique for each of the facial cosmetic units.

Erythema nodosum as azathioprine hypersensitivity reaction in a patient with bullous pemphigoid

A 65-year-old woman with bullous pemphigoid presented with fever and several red-purple nodular subcutaneous lesions on both lower legs 1 week after starting treatment with azathioprine (AZA). Biopsy of a skin nodule was compatible with erythema nodosum (EN) and hypersensitivity reaction to AZA was suspected. AZA was subsequently discontinued, observing complete remission of fever and EN within 2 weeks. This case highlights the importance of recognizing EN as a possible manifestation of hypersensitivity reaction to AZA.

Successful treatment of congenital erythropoietic porphyria using matched unrelated hematopoietic stem cell transplantation

Congenital erythropoietic porphyria (CEP), or Günther's disease, is an inborn error of metabolism produced by a deficiency of uroporphyrinogen III synthase (UROS), the fourth enzyme of the heme biosynthesis pathway. This enzymatic defect induces the accumulation of isomer I porphyrins in erythrocytes, skin, and tissues, producing various clinical manifestations. Severe cases are characterized by extreme photosensitivity, causing scarring and mutilations, and by hemolytic anemia, reducing life expectancy. CEP is caused by mutations in the UROS gene, and one of the most severe forms of the disease is associated with a cysteine to arginine substitution at residue 73 of the protein (C73R). CEP has been successfully treated only by the transplantation of hematopoietic precursors. We report the case of a male infant with severe postdelivery symptoms diagnosed with CEP and found to be homozygous for the C73R mutation. He underwent successful allogeneic bone marrow transplantation from a matched unrelated donor at 7 months of age. The hemolytic anemia was corrected and the porphyrin overproduction was significantly reduced. The patient remained asymptomatic after 1 year. This new case confirms that patients with severe CEP can benefit from early postnatal hematopoietic stem cell transplantation.

[Allergic contact dermatitis to temporary henna tattoos]

INTRODUCTION

In the last years there have been increasing reports of adverse cutaneous reactions to temporary black henna tattoos. Black henna does not exist naturally, it is obtained from original henna after the addition of other compounds, among them paraphenylenediamine (PPD), that darken it and facilitate the process of tattoing. Paraphenylenediamine is an aromatic compound that presents cross reactions with other components that have a benzene ring in their molecular structure. Many of these products may be present in the daily life of any person.

MATERIAL AND METHODS

We reviewed patients that have shown erythema, inflammation and/or vesiculation in a previously tattooed area. The patients have undergone a temporary tattoo in street stalls during the summer period (2004-2005). A total of five patients were included, there were four men and one woman with a mean age of 13 years (3-34) and a mean latency period of 9.4 days (5-14). Black ink and plastic stencils were used to perform the tattoo. None of the patients has had previous contact with hair dyes or tattoos and none of them referred a personal history of atopic dermatitis. Patch testing was carried out using the standard set of the Spanish Group for Research in Contact Dermatitis [GEIDC] (TRUE TEST, Pharmacia. Hillerod. Denmark), with readings at 48 and 96 hours.

RESULTS

Sensitization to PPD is confirmed in three patients, one of them was also sensitized to formaldehyde. Hypopigmented scars persist in three patients.

CONCLUSIONS

Black henna pseudotattoos are a source of sensitization to PPD with potential severe consequences in a medium to long term. Currently there is no specific legislation with respect to the practice of this type of tattoos in our country.

Autoimmune progesterone dermatitis: treatment with oophorectomy

Autoimmune progesterone dermatitis is a rare manifestation of hypersensitivity to endogenous hormones with polymorphic clinical manifestations. We report a 28-year-old woman with a 5-year history of mucocutaneous erythema multiforme occurring cyclically in the premenstrual period. Progesterone sensitivity was demonstrated by challenge test with medroxyprogesterone acetate. Treatments with oestrogens, tamoxifen and triptorelin had to be withdrawn because of intolerable adverse effects. Oophorectomy finally cured the disease.

[Keratotic neurocutaneous syndromes]

OBJECTIVE

To review current knowledge of etiologic, clinic, diagnostic and therapeutic aspects of ichthyotic diseases with neurologic manifestations.

DEVELOPMENT

Classic keratotic neurocutaneous syndromes including Sjögren-Larsson syndrome, trichotyodystrophy, KID (keratitis, ichthyosis and deafness) syndrome and Rud syndrome, are reviewed. Furthermore, we pay attention to syndromes whose description and study are of current importance: cardiofaciocutaneous syndrome, neutral lipids storage disease with ichthyosis, multiple sulphatase deficiency disease and peroxisomal disorders.

CONCLUSIONS

Keratotic neurocutaneous syndromes knowledge will help to improve its diagnosis and therapeutic approach.

Linear IgA disease in a patient with bladder carcinoma

We report a patient with a transitional bladder carcinoma who developed a widespread blistering eruption. The lesions showed immunopathological findings characteristic of linear IgA disease with a good response to sulphapyridine. The relationship between linear IgA disease and neoplasia has been the subject of several reports suggesting that this association is not due to chance.

Sun exposure, pigmentary traits, and risk of cutaneous malignant melanoma: a case-control study in a Mediterranean population

The main objective of this study was to assess the influence of sun exposure and pigmentary traits on the risk of cutaneous malignant melanoma (CMM) in a Mediterranean population (Andalusia, southern Spain). Cases and controls were selected from 1988 to 1993. The study population included 105 incident cases with non-familial CMM (ICD-9 code 172) and 138 controls aged 20 to 79 years. Data were collected by personal interview, and melanocytic nevi were counted over the entire body surface. Crude, and multiple-risk factor adjusted, odds ratios (OR) and their 95 percent confidence intervals (CI) were computed. After adjustment, the major constitutional risk factor was skin type I-II (OR = 29.8, CI = 8.9-100) compared with skin type V. Statistically significant and positive trends were observed between the risk of CMM and occupational sun exposure of the skin (P = 0.003), recreational exposure (P < 0.001), and cumulative lifetime sun exposure (P < 0.001). Several characteristics related to sun exposure during summer increased the CMM risk, e.g., episodes of blistering sunburns and the number of sunbaths in childhood. Use of sunscreens and spending summer holidays in places other than beach were associated with a lower risk of CMM. Regarding pigmentary traits, CMM significantly occurred with more frequency in individuals with a high degree of freckling and quoted numbers of melanocytic nevi. In conclusion, the results support sun exposure and pigmentary traits (skin type, melanocytic nevi, and freckles) as main risk factors for CMM in this population.

Multivariate analysis of cutaneous markers of aging in chronic hemodialyzed patients

BACKGROUND

Although hemodialysis has been associated with lesions of cutaneous aging, no controlled studies have been done in patients with chronic renal failure under periodic hemodialysis. Our purpose was to determine the prevalence of several clinical parameters of cutaneous aging and their relationship with hemodialysis.

METHODS

One hundred fourteen patients on chronic hemodialysis were investigated for the presence of several cutaneous aging markers in a cross-sectional study, using multivariate analysis to minimize the confounding effect of age.

RESULTS

Skin cancer was diagnosed in 3 patients (2.6%), actinic keratoses in 12 (10.5%), senile lentigo in 22 (20%), senile purpura in 15 (13%), and Favre-Racouchot disease in 6 (5%). There was no association with skin types or facial wrinkles with any other of the skin-aging features studied. Multivariate analysis, controlling for age as a confounding variable, indicated that the degree of facial wrinkles and the decrease in stratum corneum hydration (capacitance) correlated significantly with the length of time on hemodialysis (P = 0.012 and P = 0.012, respectively). Favre-Racouchot disease (Odds Ratio [OR] = 1.23, P = 0.055, 95% confidence interval [CI] 0.99-1.52) and actinic keratoses (OR = 1.15, P = 0.076, CI 0.98-1.34) became increasingly frequent with the duration of chronic hemodialysis.

CONCLUSIONS

These data show a high prevalence of cutaneous aging lesions in patients on chronic hemodialysis. Acceleration of cutaneous aging is associated with time on hemodialysis.

[Skin aging and smoking]

Facial wrinkling is a marker of skin ageing. The association between smoking and facial wrinkling has been previously studied. Nevertheless, there are no reports assessing the role of sun exposure and smoking in an area with a great proportion of sunny days. Smoking habits were investigated in 282 healthy individuals. Facial wrinkles were measured according to the Daniell scale at the external canthus. A logistic regression model was developed controlling for age, sex, sun exposure, smoking habit and searching for the interaction between sun exposure and smoking. A statistically significant risk was found for smoking habit (OR = 3.1; 95% CL 1.28-7.76; p = 0.008), sun exposure (OR = 1.50; 95% Cl 1.25-1.80; p = 0.05), and age (OR = 1.18; 95% Cl 1.13-1.23; p = 0.024) for facial wrinkling. These results show the evidence of an accelerated skin ageing in smokers. A clear explanation given to smokers could be a useful strategy to persuade them to leave smoking.

Purely cutaneous Rosai-Dorfman disease

Sinus histiocytosis with massive lymphadenopathy is an entity that exceptionally appears as a purely cutaneous disease. We described 2 cases of this form with spontaneous involution. Histology showed a polymorphic infiltrate in the dermis and hypodermis composed of large histiocytes with lymphophagocytosis, neutrophils and plasma cells. Immunohistochemical stains demonstrated the positivity of histiocytes for protein S-100 and MAC 387.

Muir-Torre syndrome associated with a family history of hyperlipidemia

The Muir-Torre syndrome is a rare disorder characterized by sebaceous neoplasms of the skin and multiple visceral malignancies. The syndrome appears to be a familial, autosomal dominant condition. We diagnosed this syndrome in a previously unreported patient and found a personal and family history of malignancies and hyperlipidemia. The association of Muir-Torre syndrome with a family history of hyperlipidemia, another autosomal dominant condition, has not been previously reported. The possible genetic relationship between the two disorders is discussed.

Cyclic neutropenia: a cause of recurrent aphthous stomatitis not to be missed

Cyclic neutropenia is a rare hematological disorder consisting of recurrent episodes of aphthous stomatitis and skin infections caused by a periodic decrease in blood neutrophil counts. We present the case of such a patient successfully treated with steroids. Recurrent aphthous stomatitis with a periodicity of around 3 weeks should alert the dermatologist to the possibility of cyclic neutropenia.