Successful treatment of PASH syndrome with infliximab, cyclosporine and dapsone

BACKGROUND

The group of autoinflammatory syndromes associated with Pyoderma gangrenosum, Acne, and Suppurative Hidradenitis are poorly defined and difficult to control with currently available treatment modalities.

OBJECTIVES

We describe a patient with PASH syndrome and report about the successful multimodal treatment with infliximab, cyclosporine, and dapsone.

METHODS

A review of the available literature to date about this group of autoinflammatory diseases was performed. We performed genetic analysis for PSTPIP1 mutations associated with PAPA syndrome.

RESULTS

A 22-year-old woman presented to our department with pyoderma gangrenosum, concomitant acne, and suppurative hidradenitis. She had previously been treated unsuccessfully with etanercept, adalimumab, fumaric acid and the IL-1 receptor antagonist (IL-1RA) anakinra without prolonged remission. Treatment with intravenous infliximab in combination with cyclosporine and dapsone lead to sudden and prolonged improvement of the clinical symptoms that we classified as PASH syndrome. We review the literature about this group of diseases and report the third case of PASH syndrome to date.

CONCLUSION

PASH syndrome and associated diseases should be considered whenever hidradenitis suppurativa is found in association with pyoderma gangrenosum. We provide a systematic overview about PASH syndrome and suggest a novel multimodal therapeutic regimen beyond isolated inhibition of TNF or IL-1.

Schnitzler's syndrome: diagnosis, treatment, and follow-up

Schnitzler's syndrome is characterized by recurrent urticarial rash and monoclonal gammopathy, associated with clinical and biological signs of inflammation and a long-term risk of AA amyloidosis and overt lymphoproliferation. An extensive literature review was performed, and the following questions were addressed during an expert meeting: In whom should Schnitzler's syndrome be suspected? How should the diagnosis of Schnitzler's syndrome be established? How should a patient with Schnitzler's syndrome be treated? How should a patient with Schnitzler's syndrome be followed up?. A diagnosis of Schnitzler's syndrome is considered definite in any patient with two obligate criteria: a recurrent urticarial rash and a monoclonal IgM gammopathy, and two of the following minor criteria: recurrent fever, objective signs of abnormal bone remodeling, elevated CRP level or leukocytosis, and a neutrophilic infiltrate on skin biopsy. It is considered probable, if only 1 minor criterion is present. In patients with monoclonal IgG gammopathies, diagnosis is definite if three minor criteria are present and possible if two are present. First-line treatment in patients with significant alteration of quality of life or persistent elevation of markers of inflammation should be anakinra. Follow-up should include clinical evaluation, CBC and CRP every 3 months and MGUS as usually recommended.

High-definition optical coherence tomography for the in vivo detection of demodex mites

BACKGROUND

Demodex mites are involved in different skin diseases and are commonly detected by skin scrape tests or superficial biopsies. A new high-definition optical coherence tomography (HD-OCT) with high lateral and axial resolution in a horizontal (en-face) and vertical (slice) imaging mode might offer the possibility of noninvasive and fast in vivo examination of demodex mites.

METHODS

Twenty patients with demodex-related skin diseases and 20 age- and gender-matched healthy controls were examined by HD-OCT. Mites per follicle and follicles per field of view were counted and compared to skin scrape tests.

RESULTS

HD-OCT images depicted mites in the en-face mode as bright round dots in groups of 3-5 mites per hair follicle. In the patients with demodex-related disease, a mean number of 3.4 mites per follicle were detected with a mean number of 2.9 infested follicles per area of view compared to a mean of 0.6 mites in 0.4 infested follicles in the controls. The skin scrape tests were negative in 21% of the patients.

CONCLUSION

The innovative HD-OCT enables fast and noninvasive in vivo recognition of demodex mites and might become a useful tool in the diagnosis and treatment monitoring of demodex-related skin diseases.

Morphology of basal cell carcinoma in high definition optical coherence tomography: en-face and slice imaging mode, and comparison with histology

BACKGROUND

Optical coherence tomography (OCT) allows real-time, in vivo examination of basal cell carcinoma (BCC). A new high definition OCT with high lateral and axial resolution in a horizontal (en-face) and vertical (slice) imaging mode offers additional information in the diagnosis of BCC and may potentially replace invasive diagnostic biopsies.

OBJECTIVES

To define the characteristic morphologic features of BCC by using high definition optical coherence tomography (HD-OCT) compared to conventional histology.

METHODS

A total of 22 BCCs were examined preoperatively by HD-OCT in the en-face and slice imaging mode and characteristic features were evaluated in comparison to the histopathological findings.

RESULTS

The following features were found in the en-face mode of HD-OCT: lobulated nodules (20/22), peripheral rimming (17/22), epidermal disarray (21/22), dilated vessels (11/22) and variably refractile stroma (19/22). In the slice imaging mode the following characteristics were found: grey/dark oval structures (18/22), peripheral rimming (13/22), destruction of layering (22/22), dilated vessels (7/22) and peritumoural bright stroma (11/22). In the en-face mode the lobulated structure of the BCC was more distinct than in the slice mode compared to histology.

CONCLUSION

HD-OCT with a horizontal and vertical imaging mode offers additional information in the diagnosis of BCC compared to conventional OCT imaging and enhances the feasibility of non-invasive diagnostics of BCC.

[Cheilitis granulomatosa as initial manifestation of Crohn's disease]

Cheilitis granulomatosa (CG) can be associated with many different disorders. A 37-year-old male patient presented with CG as an early manifestation of Crohn's disease. Patients suffering from CG need a thorough diagnostic work-up for associated or underlying diseases. Clinical follow-up examinations are necessary as CG can precede the causative diseases.

Serine protease inhibitor lymphoepithelial Kazal type-related inhibitor tends to be decreased in atopic dermatitis

BACKGROUND

A pathogenic role of serine protease inhibitor lymphoepithelial Kazal type-related inhibitor (LEKTI) in atopic dermatitis (AD) is currently in intense debate. Analyses of an association between genetic polymorphisms of SPINK5 and atopic diseases revealed contradictory results. Herein, we assessed the role of LEKTI in AD at an expressional and functional level.

METHODS

The expression of LEKTI and its inhibitory capacity was measured by real-time polymerase chain reaction and hydrolytic activity assay, respectively, in keratinocyte cell cultures of three AD patients in comparison to cultures of healthy individuals (5x) and Netherton (NS) patients (3x).

RESULTS

Expression of LEKTI was significantly decreased in AD vs. healthy volunteers. Due to reduced protease inhibition, trypsin-like hydrolytic activity in AD was slightly increased, although not significantly.

CONCLUSIONS

Even though the number of investigated subjects was small and hydrolytic activity was only slightly increased, the results denote that LEKTI might be diminished in AD. The study also disclosed the necessity of functional analyses in addition to genetic investigations to gain further and more detailed insights into the role of LEKTI in AD.

[Skin tumours of the facial area]

Almost the complete spectrum of skin tumours can occur within the facial area, ranging from benign tumours of infancy to typical malignancies of old age. This spectrum is quiet heterogeneous and comprises every cell type within the skin as a possible origin for tumour growth. Among these are cells derived from the epidermis; adnexal structures; connective, fatty, and vascular tissue; muscle; nerves; melanocytes; and skin-infiltrating inflammatory cells. Due to this diversity, a correct assessment of the clinical findings compared with a histopathologic appraisal in cases of uncertainty is mandatory in order to recommend appropriate therapy. The present overview aims to summarise the basics of the most frequent and most important skin tumours occurring on the face.

[Erythema annulare centrifugum Darier. Successful therapy with topical calcitriol and 311 nm-ultraviolet B narrow band phototherapy]

Erythema annulare centrifugum is an acute dermatosis of unclear etiology, which presents with annular erythematous lesions with marginal scale. Therapeutically, systemic and topical glucocorticosteroids are used primarily. We treated a patient with large lesions in the area of the thighs resistant to a therapy with topical glucocorticosteroids, with topical calcitriol in combination with 311 nm ultraviolet B narrow band phototherapy. After four weeks of treatment the skin lesions had cleared nearly completely without any side effects. The combination topical vitamin D3-analogue calcitriol and 311 nm ultraviolet B narrow band phototherapy was effective and can be regarded as a useful alternative to glucocorticosteroids for erythema annulare centrifugum.

Erythema multiforme due to contact with laurel oil

Erythema multiforme is a relatively common skin disorder. The best known cause is herpes simplex virus infection. We report the first case of erythema multiforme due to contact with laurel oil. The diagnosis was confirmed by the positive patch test to laurel oil, the histopathological studies of the lesions and the histopathological studies of the positive patch test to laurel oil.

Follikuläre Arzneimittelreaktion auf Cetuximab

Cetuximab belongs to a newly developed group of anti-cancer drugs, which have an inhibitory effect on the epidermal growth factor receptor (EGF-R). EGF-R plays a major role in the homeostasis of the epidermis and epidermal appendages. In addition, EGF-R is expressed on a variety of carcinomas of different origin and is thought to be partly associated with tumor progression. For this reason, inhibition of EGF-R seems a promising anti-cancer therapy, as shown in a few clinical trials. As a side effect of the therapy, a follicular rash often develops in the seborrheic areas; this cutaneous reaction is associated with longer survival. We present a typical case and discuss the important features of the follicular rash occurring after EGF-R inhibition.

Restoration of fatty aldehyde dehydrogenase deficiency in Sjögren-Larsson syndrome

Sjögren-Larsson syndrome (SLS) is an autosomal recessive neurocutaneous disorder caused by mutation in the ALDH3A2 gene that codes for human fatty aldehyde dehydrogenase (FALDH). Sjögren-Larsson syndrome patients lack FALDH, which catalyzes the oxidation of long-chain aliphatic aldehydes to fatty acids. The impaired FALDH activity leads to congenital ichthyosis, mental retardation and spasticity. The current lack of treatment is an impetus to develop gene therapy strategies by introducing functional FALDH into defective cells. We delivered human FALDH into keratinocytes of SLS patients using recombinant adeno-associated virus-2 vectors. Transduction of SLS keratinocytes resulted in an augmentation of FALDH activity comparable to phenotypically normal heterozygous carriers. Toxicity of long-chain aldehydes for FALDH-deficient cells decreased almost to the level of unaffected keratinocytes. Three-dimensional culture of corrected SLS keratinocytes revealed an ameliorated FALDH expression. These studies demonstrate the restoration of FALDH in human SLS cells supporting the concept of gene therapy as a potential future treatment option for SLS.

Histopathological characteristics of small diameter melanocytic naevi

BACKGROUND/AIMS

The clinical definition of an atypical naevus ("dysplastic naevus" or "naevus with architectural disorder and cytological atypia of melanocytes") stresses size larger than 5 mm in diameter as a major diagnostic criterion. Because malignant melanomas and their precursors may arise in smaller lesions, a histological study of melanocytic lesions smaller than 4 mm in diameter was conducted to evaluate their histological appearance.

METHODS

Two hundred and sixty one naevi smaller than 4 mm in diameter were collected and characterised by histological examination into benign naevi without architectural disorder and naevi with architectural disorder and mild, moderate, and severe atypical melanocytes according to criteria used on larger lesions.

RESULTS

Small melanocytic naevi covered the same complex histological spectrum from benign naevi to severely atypical naevi when compared with larger lesions. A high proportion of small naevi (72%) exhibited features diagnostic for naevi with architectural disorder and cytological atypia.

CONCLUSION

There is a discrepancy between histological and clinically defined atypical naevi. The same generally accepted criteria for the histological diagnosis of atypical naevi should be used for small melanocytic naevi in addition to large ones. Thus, small naevi exhibiting atypical features on histological examination should be categorised as atypical naevi, regardless of their small diameter.

Linear spiradenoma with focal malignant transformation

Malignant spiradenoma is an exceedingly rare adnexal tumour clinically characterized by rapid enlargement of a pre-existing, long-standing benign spiradenoma. Microscopic examination typically reveals a continuum between benign spiradenoma and areas of malignant transformation. Biological behaviour is unpredictable and it should be regarded as a potentially lethal neoplasm. Treatment recommendations require radical surgical excision. The reported case of a 23-year-old female illustrates the malignant transformation of a 1.5 cm nodule within a large linear spiradenoma almost covering the frontal aspect of the lower leg. In reviewing the literature, malignant transformation seems to occur slightly more often in multiple than in solitary spiradenomas. It is unclear whether excision restricted to the malignant area is an advisable treatment option in comparison to total excision of all spiradenoma nodules. In the presented case, the transformed area was excised. The patient is free of recurrence after 2 years.

[Palmoplantar vesicular lesions in childhood]

BACKGROUND AND OBJECTIVE

Palmoplantar vesicles in children have various underlying causes, requiring different therapies. We evaluated the most common underlying diseases and determined simple criteria for differentiation.

PATIENTS/METHODS

Within a two years period all children up to 14 years of age who presented with acral vesicles were included in this study.

RESULTS

The most common causes of acral vesicles in a group of 32 patients, were dyshidrotic eczema with (n=11) or without atopic diathesis (n=11) and scabies (n=7). Rarely, the cause of vesicular lesion was tinea (n=2) or infantile acropustulosis (n=1). While dyshidrotic eczema was a disease of late childhood, palmoplantar lesions caused by scabies developed in younger children up to the age of 4 years. Scabies in contrast to infantile acropustulosis tend to present with more generalized lesions, not being restricted to acral location. Dyshidrotic eczema revealed lesions bilaterally and in case of atopy, additional body areas were involved. Unilateral presentation was a clue for tinea.

CONCLUSIONS

Acral vesicles in childhood can be diagnostically discriminated by the age of the patient and the distribution of the lesions.

[Gene therapy concepts for promoting wound healing]

Growth factors are important players in orchestrating all stages of wound healing. They are mitogen, chemotactic, they regulate cell-cell interactions and influence synthesis and composition of extra-cellular matrix components. The use of growth factors to stimulate wound healing is a promising new therapeutic approach to repair chronic tissue defects. The delivery of genetic material offers an attractive treatment modality to produce an appropriate amount of growth factor proteins within the wound site. This review discusses several methods of growth factor gene transfer into wound tissue and presents recent experimental results of gene therapy approaches in stimulating wound repair.

[Scrotal leiomyoma]

Genital leiomyomas of the scrotal skin are extremely rare benign tumors, originating from the tunica dartos of the scrotum. We describe a 55-year-old caucasian male with a 3-year history of a slowly growing asymptomatic scrotal knot which was first clinically regarded as a cyst and finally diagnosed histopathologically as leiomyoma. This typical case demonstrates that leiomyomas should be considered in the differential diagnosis of scrotal tumors.

Galli-Galli disease: an unrecognized entity or an acantholytic variant of Dowling-Degos disease?

Galli-Galli disease is an inherited disease characterized by slowly progressive and disfiguring reticulate hyperpigmentation of the flexures, clinically and histopathologically diagnostic for Dowling-Degos disease, but also associated with suprabasal, nondyskeratotic acantholysis. A few patients exhibiting these features have been described, mainly in the non-English-language literature, which suggests that Galli-Galli disease is not an entity of its own, as originally thought, but is an acantholytic variant of Dowling-Degos disease. We report a typical case of Galli-Galli disease, which supports this concept.