HIDRADENITIS SUPPURATIVA IN POSTMENOPAUSE

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, debilitating disease with a profound impact on the quality of life of patients.

OBJECTIVES

To describe a rare case of HS with postmenopausal onset, to review the literature data regarding late onset HS and to discuss the current knowledge on the role of endocrine abnormalities in the development of HS.

CASE REPORT

We report the case of a 68-year-old patient in whom HS occurred 10 years after menopause. She was referred to our clinic for the presence of an open fistula on the left groin, fibrotic scars and visible alteration of the vulvar anatomy due to numerous surgical interventions. The patient shared features of the metabolic syndrome (obesity, arterial hypertension, dyslipidemia, aortic atherosclerosis), but showed no signs of virilism and no hormonal abnormality. HS was controlled using antiseptics, topical retinoids and antibiotics.

CONCLUSIONS

This case is of particular interest given the late onset of HS, long time after menopause. The development of HS requires a complex interaction between genetic predisposing factors, endocrine dysregulation, metabolic alterations, bacterial overgrowth and an aberrant inflammatory response. Evidence points to an important role of sex-hormones in the emergence and progression of the disease, but the underlying mechanisms are still unclear. A better understanding of HS pathogenesis is needed to elucidate the precise way in which endocrine factors influence the disease onset and course. This would guide the way to novel therapies and a better control of this challenging disease.

POLYGLANDULAR AUTOIMMUNE SYNDROME ASSOCIATED WITH MULTIPLE AUTOIMMUNE CONDITIONS AND ATOPIC DERMATITIS - AN UNUSUAL MANIFESTATION OF A POLYAUTOIMMUNITY PHENOTYPE

Introduction

The polyglandular autoimmune syndrome (PAS) type III is a rare condition defined as the coexistence of autoimmune thyroid disorder with other endocrine autoimmune diseases, including type 1 diabetes, without adrenal dysfunction. PAS may associate with other non-endocrine autoimmune diseases, overlapping with the multiple autoimmune syndromes (MAS). We present a case of PAS III/ MAS type 3, including autoimmune thyroiditis, autoimmune diabetes, vitiligo, lupus erythematosus, associated with adult-onset atopic dermatitis, a combination not reported previously.

Case report

A 40 years old woman, registered as nurse working in dialysis unit, previously diagnosed with vitiligo, euthyroid autoimmune thyroiditis and disseminated granuloma annulare, with personal and familial history of atopic disorders, presented in our clinic for disseminated eczematous and lichenoid cutaneous rashes. She was tested positive for antinuclear, anti-double stranded DNA and anti-histone antibodies, with inflammatory syndrome and marginal lymphopenia and she was diagnosed with systemic lupus erythematosus (SLE). Subsequently, moderate hyperglycemia, positive anti-glutamic acid decarboxylase antibodies and low C-peptide level prompted the diagnosis of autoimmune diabetes. Recurrent flexural eczematous rashes, with negative epicutaneous tests but positive specific IgE tests for common allergens fulfilled the clinical criteria for the diagnosis of atopic dermatitis. The clinical, immunological and glycemic status were controlled with low doses of oral prednisone (<0.5 mg/kg), methotrexate (10mg/week), antimalarials, metformin, emollients and photoprotection. After changing her workplace, the immunosuppressive treatment could be discontinued, and the patient maintained normal immunological and biochemical profile at 6 months follow-up.This case brings a unique perspective on the evolution, associations spectrum and the management challenges of endocrine polyautoimmunity associated with atopic diathesis.

Oxidative stress in androgenetic alopecia

Rationale:Androgenetic alopecia is not considered a life threatening disease but can have serious impacts on the patient's psychosocial life. Genetic, hormonal, and environmental factors are considered responsible for the presence of androgenetic alopecia. Recent literature reports have proved the presence of inflammation and also of oxidative stress at the level of dermal papilla cells of patients with androgenetic alopecia Objective:We have considered of interest to measure the oxidative stress parameters in the blood of patients with androgenetic alopecia Methods and results:27 patients with androgenetic alopecia and 25 age-matched controls were enrolled in the study. Trolox Equivalent Antioxidant Capacity (TEAC), malondialdehyde (MDA) and total thiols levels were measured on plasma samples. Superoxide dismutase (SOD), glutathione peroxidase (GPx), catalase (CAT) activities, and also non protein thiols levels together with TEAC activity were determined on erythrocytes samples No statistically significant changes were observed for TEAC erythrocytes, non-protein thiols, GPx and CAT activities. Significantly decreased (p<0.01) SOD activity was found in patients with androgenetic alopecia. For plasma samples decreased TEAC activity (p<0.001), increased MDA levels (p<0.001) and no change in total thiols concentration were found in patients when compared with the controls. Discussions:Decreased total antioxidant activity and increased MDA levels found in plasma samples of patients with androgenetic alopecia are indicators of oxidative stress presence in these patients. Significantly decreased SOD activity but no change in catalase, glutathione peroxidase, non protein thiols level and total antioxidant activity in erythrocytes are elements which suggest the presence of a compensatory mechanism for SOD dysfunction in red blood cells of patients with androgenetic alopecia.

ABBREVIATIONS

AAG = androgenetic alopecia, MDA = malondialdehyde, SOD = superoxide dismutase, CAT = catalase, GPx = glutathione peroxidase, GSH = glutathione, GST = glutathione transferase, SH = thiols, TEAC = trolox equivalent antioxidant capacity, ABTS = 2,2'-azino-bis (3-ethylbenzothiazoline-6-sulfonic acid), CDNB = 1-chloro-2,4-dinitrobenzene.

Cutaneous complications of molecular targeted therapy used in oncology

The new molecular targeted therapy has been developed over the past decades by using the molecular targeted molecular changes discovered in specific types of cancer. Unfortunately, most of these agents (epidermal growth factor receptors, multi-targeted small molecule tyrosine kinase inhibitors, monoclonal antibodies) have severe cutaneous adverse reactions, that not only interfere with the patient's quality of life, but also are dose-limiting and may require treatment interruptions. These cutaneous complications and their management must be very well known by any oncologist and dermatologist who treat oncologic patients.

ABBREVIATIONS

EGFR = epidermal growth factor receptors, EGFRI = epidermal growth factor receptors inhibitors.

Cutaneous adverse reactions specific to epidermal growth factor receptor inhibitors

Classical antineoplastic therapy is encumbered by extensively studied adverse reactions, most often of systemic nature. The emergence of new generations of anticancer treatments, including epidermal growth factor receptor inhibitors, besides improving the response to treatment and the survival rate, is accompanied by the occurrence of new specific side effects, incompletely studied. These side effects are most often cutaneous (hand foot syndrome, acneiform reactions), and in some cases are extremely severe, requiring dose reduction or drug discontinuation. The prevention of the cutaneous adverse effects and their treatment require a close collaboration between the oncologist and the dermatologist. The occurrence of some of these skin adverse effects may be a favorable prognostic factor for the response to the cancer treatment and the overall survival.

Oxidative stress and alopecia areata

Alopecia areata (AA) is an inflammatory and autoimmune disease presenting with non-scarring hair loss. The aethiopathogenesis of alopecia areata is unclear and many factors including autoimmunity, genetic predisposition, emotional and environmental stress are thought to play important roles in its development. Antioxidant/ oxidant balance perturbation is a common feature in autoimmune, emotional and environmental stress. Therefore, our paper discusses the implications of oxidative stress in alopecia areata.

Pyoderma gangrenosum, rare parietal complication after colorectal surgery

Pyoderma gangrenosum (PG) is a rare chronic destructive inflammatory skin disease characterized by the presence of nodules and pustules with progressively enlarging ulcers and orcutaneous necrosis. In most cases PG is idiopathic, but sometimes it is associated with conditions that often have vasculitis, such as gammapathies, inflammatory bowel diseases or chronic arthritis. PG is neither infectious nor gangrenous,but some authors advanced the theory that an infectious etiology (streptococci and staphylococci) could be incriminated.Recently, there are reports in the literature stating that PG is a condition that can occur after local trauma, especially surgery.We report the case of a 73 year old man who presented himself to the Surgery Department with rectal adenocarcinoma and postoperatively developed well-demarcated, vegetative plaques,ranging from 2 to 5 cm in diameter, with central ulceration associated with necrosis and a purulent secretion, delimitated by raised, dusky erythematous borders. These lesions were located on the abdomen and it is important to mention that the injuries occurred at the site of surgical stitches used during the rectum amputation surgery, with no other anatomical locations,pruritus or pain associated. We performed two different histopathological examinations for this patient, regarding the rectal specimens and the cutaneous specimen. The first examinations revealed rectal adenocarcinoma and nonspecific colitis. The second examination was concluded with the diagnosis of pyoderma gangrenosum, the ulcerative stage. The patient had a very good clinical response to systemic steroid therapy.

Psoriasis and Metabolic Syndrome--scientific evidence and therapeutic implications

Psoriasis is a chronic inflammatory disease, predominantly affecting the skin, being included in the group of Immune Mediated Inflammatory Diseases. Growing evidence from the last 10 years suggests that several systemic conditions like metabolic syndrome, cardiovascular disease, diabetes, psychological disorders or inflammatory bowel disease are prevalent in psoriasis patients. The linker might be the chronic secretion of pro-inflammatory cytokines. In this current review, the scientific evidence that explains the relationship between psoriasis and the metabolic syndrome in particular will be addressed, as the metabolic syndrome comprises a group of risk factors for cardiovascular disease, thus offering an overall picture of the systemic involvement in psoriasis. An integrated approach, with an early detection and treatment of the components of the metabolic syndrome, are important steps in psoriasis management. Attention should be paid on influence of psoriasis treatment upon comorbidities and vice-versa.

Photodynamic therapy in the treatment of basal cell carcinoma

Photodynamic therapy (PDT) is a medical procedure based on the activation of the molecules of various exogenous or endogenous chemical substances called photosensitizers by a light source emitting radiation of an adequate wavelength, usually situated in the visible spectrum; photosensitizers are chemical compounds bearing the capacity to selectively concentrate in the neoplastic cells. The energy captured by the molecules of these substances pervaded in the tumor cells is subsequently discharged in the surrounding tissue, triggering certain photodynamic reactions that result in the destruction of the tumor. The procedure is applicable in numerous medical fields. Skin basal cell carcinoma (BCC), the most frequent type of cancer of the human species, is a cutaneous tumor that responds very well to this innovative treatment method. By reviewing numerous recent studies in the field, this article aims to present the role and the indications of photodynamic therapy in the management of basal cell carcinoma, as well as the most important results achieved so far by this therapy in the field of dermato-oncology.

Clinical application of optical coherence tomography for the imaging of non-melanocytic cutaneous tumors: a pilot multi-modal study

CONTEXT

Optical coherence tomography (OCT) is an emergent imaging technique, based on the interference of infrared radiation and living tissues, that allows the in vivo visualization of the skin structures, at high resolution and up to 1.6 mm depth. As such, there is mounting evidence that OCT may be an interesting technique for the diagnosis of skin diseases, including the noninvasive early detection of cutaneous tumors.

OBJECTIVE

We aimed to investigate the utility of OCT for the diagnosis of non-melanocytic, non-pigmented cutaneous tumors.

METHODS

Preliminary results are presented from an initiated study. Fifteen consecutive patients with clinical suspicion of epithelial cancers and precancers registered over one week in a university dermatologic department were included. As control were selected 7 patients with inflammatory skin diseases (psoriasis, lichen planus, cutaneous lupus erythematosus). In all study and control patients, the lesions and samples of normal, perilesional skin were documented by clinical digital photography, contact dermoscopy with digital image capture and OCT with central wavelength of 930 nm. Final diagnosis was certified by histopathological analysis.

RESULTS

We could identify morphological features in OCT examination that distinguished between normal and lesional skin, and between neoplastic vs. inflammatory lesions. In the same time, combining OCT and dermatoscopical evaluation of a lesion improved the performance of diagnosis when compared to clinical diagnosis alone and with either OCT or dermoscopy imaging used alone.

CONCLUSIONS

OCT appears as a promising method of in vivo diagnosis of early neoplastic cutaneous lesions with equivocal clinical and/or dermoscopic aspect. Continuation of our study as well as other larger investigation will be able to contribute with new insights in the role of OCT in the non-invasive diagnosis of skin disease.

Erythrodermic atopic dermatitis with late onset--case presentation

Atopic dermatitis is a chronic inflammatory disease, usually associated with a personal or family history of atopic diseases such as AD, allergic rhinitis or asthma that most commonly arise in childhood and present with elevated IgE serum in up to 85% of patients. The severity of AD is based on the extent of affected areas, itch intensity and appearance of skin lesions. Here, we present the case of a 21-year-old female patient with generalized erythematous eczematous skin lesions, flexural lichenifications accompanied by intense pruritus, painful fissures and erosions resulting from scratching. She also presented erythematous plaques with thin scales on the scalp. The patient had no personal or familial history of AD, allergic rhinitis or asthma and the onset of cutaneous symptoms presented severe exacerbation in the last 2 months of the last 3 years. The main laboratory findings were- high serum eosinofilia (2400/microL) and very high total IgE serum (11449 UI/L). The flare remission was induced with systemic treatment (corticotherapy, oral H1 antihistamines, and antibiotherapy) and topical therapy (UVB 311 nm, topical glucocorticoids and hydration). It is very important to recognize AD as a cause of erythroderma, especially in a patient with a late onset of the disease, in order to treat it promptly and to prevent ulterior recurrences, by educating the patient to have an adequate life style and to treat the recurrences at the very first symptoms.