Validation of an Optical Pencil Method to Estimate the Affected Body Surface Area in Psoriasis

INTRODUCTION

Body surface area (BSA) affected by psoriasis is one of the most often used measures for assessing severity, but this method has shortcomings.

OBJECTIVE

To validate a new way to estimate BSA.

MATERIAL AND METHOD

Prospective, multicenter study in 56 patients with psoriasis. Each patient was evaluated by 2 dermatologists in 2 visits to the same hospital. Each dermatologist used 2 methods for estimating BSA: the traditional visual estimation in which the area of the palm equals 1% of the total body surface and an optical pencil (OP) method in which the affected area is drawn on a touch screen. Software in the application then calculates the BSA.

RESULTS

Overall concordance between the 2 methods was acceptable according to an intraclass correlation coefficient (ICC) of 0.87. However, the limits of agreement were unacceptably large and there was systematic bias: traditional estimates were consistently greater than OP calculations. Concordance between the methods was better (ICC>0.8) on the trunk and lower extremities. Intraobserver reliability was excellent with both methods (ICCs, 0.97 and 0.98 for the traditional and OP estimates, respectively). Interobserver reliability was also high (ICCs, 0.91 and 0.94 for the traditional and OP methods), although the mean BSA differed significantly between observers. The ICCs were much lower for BSA estimates on the head.

CONCLUSIONS

This study to validate the OP method for estimating the affected BSA in patients with psoriasis shows good agreement between the OP and traditional approaches. The OP calculations also showed less variance and better interobserver reliability.

Scleroderma-like syndrome due to hydroxyurea

Scleroderma-like cutaneous changes have been reported in association with several drugs, but not with hydroxyurea (HU), to our knowledge. We report the case of a 67-year-old man who was treated with HU (hydroxycarbamide) for 12 years for a myeloproliferative disorder, and presented a progressive pruritic woody induration, symmetrically affecting both legs. He also had Gottron-like papules on the back of the metacarpophalangeal joints, and a retroauricular undifferentiated squamous cell carcinoma. On histological examination of a skin biopsy taken from the leg, massive dermal fibrosis was seen, with thickening of collagen bundles throughout the entire dermis. Six months after HU withdrawal, the skin induration resolved without scarring. Scleroderma-like syndrome has not been previously considered one of the secondary effects of HU. The evolution of our patient's condition supports a causal relationship between the HU treatment and the sclerodermiform changes of the skin.

Clinical diagnosis of toenail onychomycosis is possible in some patients: cross-sectional diagnostic study and development of a diagnostic rule

BACKGROUND

Suspected toenail onychomycosis is a frequent problem. Clinical diagnosis has been considered inadequate.

OBJECTIVES

To assess the diagnostic accuracy of clinical findings for detecting fungi in toenails, and to develop and validate a clinical diagnostic rule aimed at improving dermatologists' diagnosis of onychomycosis.

METHODS

A cross-sectional diagnostic study was performed including a total of 277 patients seen by 12 dermatologists. The gold standard was the presence of dermatophytes on culture or a positive nail plate biopsy. For each sign we described prevalence, sensitivity, specificity, positive and negative predictive values, and likelihood ratios for positive and negative results. We developed a diagnostic clinical rule and validated it in a subsample.

RESULTS

Helpful findings to predict the presence of fungi are: previous diagnosis of fungal disease; abnormal plantar desquamation (affecting > 25% of the sole); onychomycosis considered the most probable diagnosis by a dermatologist; and presence of interdigital tinea. When dermatologists considered onychomycosis the most probable diagnosis and plantar desquamation was present (13% of patients), the positive predictive value for presence of fungi was 81%. When both signs were absent (34% of patients), the positive predictive value for absence of fungi was 71%. In other situations, clinical diagnosis might not give enough information to decide on therapy.

CONCLUSIONS

In 13% of the patients (a large number in absolute terms), when dermatologists consider onychomycosis the most probable diagnosis and plantar desquamation is present, therapy should be started without any further test, as clinical diagnosis is at least as accurate as laboratory tests. In other situations, an optimal management strategy should be defined.

Escrofulodermia con tuberculosis osteoarticular en el área sanitaria de Ferrol

INTRODUCTION

Scrofuloderma results from direct extension of an underlying tuberculous focus such as bone, joint or even the epididymis to the overlying skin, but is more frequent over a lymph node, mainly in the cervical region.

METHODS

We analysed all cases of scrofuloderma with a bone or joint focus evaluated in the sanitary area of Ferrol, with a current population of 220,000, during a 15-year period. We describe the clinical, histopathological, and microbiological data of patients.

RESULTS

We found 6 cases of scrofuloderma with osteoarticular tuberculosis. This series includes five men and one woman, aged 37 to 80. Visceral involvement was found in 3 patients (50 %).

CONCLUSION

Osteoarticular tuberculosis comprises 10 % of all extrapulmonary tuberculous infections. There is a high probability of visceral involvement in patients with scrofuloderma. Underlying bone involvement should be rule out in all patients with scrofuloderma, especially in those with incomplete response to medical treatment.

[Malignant syphilis in an HIV-infected patient]

Patients with HIV infection may develop common diseases with atypical clinical features. HIV infection may change the classic clinical course of syphilis and increase the incidence of a subtype of secondary syphilis named malignant syphilis. A homosexual patient with HIV infection consulted us about a one-month history of general malaise and widespread cutaneous ulcerative lesions, some with thick hemorrhagic crusts. Serology for syphilis was positive at high titers. Based on clinical, histological and serological findings, a diagnosis of malignant syphilis was made and the patient started treatment with penicillin G benzathine with progressive resolution of lesions. Malignant syphilis is a rare subtype of secondary syphilis that presents special clinical and histological features and has been associated with several processes characterized by variable degrees of immunosuppression. It is necessary to take into account this entity among the possible diagnoses in HIV-infected patients with cutaneous lesions.

[Porokeratosis in a patient with dermatomyositis]

There are several reports of porokeratosis in the context of immmunosuppressive diseases. These mainly include organ transplant, HIV infection, lymphomas and some inflammatory and autoimmune diseases commonly treated with immunosuppresive drugs or chemotherapy. Disseminated superficial actinic porokeratosis is the clinical variant of porokeratosis that most frequently develops in immunosuppressive states. We report a case of porokeratosis in a woman with dermatomyositis.

Confluent and reticulated papillomatosis (Gougerot-Carteaud) successfully treated with tacalcitol

Confluent and reticulated papillomatosis (CRP) is a rare dermatosis of unknown aetiology whose relationship to Malassezia furfur is still debated. Antifungal agents, antibiotics, retinoids, and, more recently, calcipotriol have been successfully used as treatment. The authors report on a 14-year-old female with confluent and reticulated papillomatosis in whom M. furfur was found. Anti-fungal therapy eliminated the fungus, but did not achieve the disappearance of the lesions. Further treatment with tacalcitol was successful, supporting the theory that CRP might be a disorder of keratinization. To the authors' knowledge, this is the first patient treated with tacalcitol for this entity.

Treatment of alpha1-antitrypsin-deficiency panniculitis with minocycline

A small proportion of patients with alpha1-antitrypsin (alpha1AT) deficiency experience recurrent ulcerating panniculitis. Studies suggest that alpha1AT-deficiency panniculitis reflects an uncontrolled inflammatory process because of the serum's incapacity to neutralize proteolytic enzymes released by leukocytes in the skin. Dapsone is considered the treatment of choice for this entity, but it is limited by its side effects, especially hematologic ones. Tetracyclines have anticollagenase and anti-inflammatory activity and have been used successfully to treat this type of panniculitis. We report the case of a 42-year-old woman with recurrent alpha1AT-deficiency panniculitis who did not tolerate the side effects of dapsone or systemic corticosteroid. Minocycline treatment led to disappearance of lesions, and long-term administration prevented recurrences without evident negative side effects. We consider minocycline a safe treatment that allows control of alpha1AT-deficiency panniculitis.

Sign of Leser-Trélat associated with adenocarcinoma of the rectum

The acute onset and/or rapid increase in size and number of multiple seborrheic keratoses associated with internal malignancy is called sign of Leser-Trélat. Although some authors reject its existence, there are more than 80 well-documented case reports in the literature. Here, we report a 75-year-old man who presented with abrupt appearance of multiple seborrheic keratoses without any suspicious symptom of cancer. The screening for malignant neoplasms let us detect a rectal adenocarcinoma that was in a curative stage. This case-report illustrates a true sign of Leser-Trélat, and proves that these patients must be appropriately investigated for underlying malignancy.

Blastoid NK cell leukemia/lymphoma with cutaneous involvement

Malignant neoplasms from natural killer (NK) cells are characterized by their positivity for CD56 and absence of monoclonal TCR gene rearrangement. Recently, they have been classified into four main types (nasal and nasal-type NK cell lymphoma, aggressive NK cell leukemia/lymphoma, and blastoid NK cell leukemia/lymphoma), based on clinical features, racial predisposition, presence of azurophilic granules, immunophenotype and association with Epstein-Barr virus (EBV) infection. A 72-year-old Caucasian man presented with a malignant neoplasm comprised of blastoid cells without azurophilic granules in the Giemsa stain, with positivity for CD2, CD4, HLA-DR, CD45 and CD56, and negativity for CD3 (surface and cytoplasmic) and CD5. In situ hybridization for EBV and PCR analysis of rearrangement of the T cell receptor gene were negative. Based on these results, a diagnosis of blastoid NK cell lymphoma was made. In this case the first clinical manifestations were the cutaneous lesions, and, although the disease was already advanced at the diagnosis, the patient responded completely to the treatment and remains asymptomatic 14 months after diagnosis.

Case Reports. Pityriasis amiantacea as manifestation of tinea capitis due to Microsporum canis

We report three patients, two infants and an adult, in whom their tinea capitis clinically appeared as pityriasis amiantacea. The mycological studies showed infection due to Microsporum canis in all cases. Correct diagnosis as well as adequate antimycotic chemotherapy of this atypical manifestation of tinea capitis remain a challenge to the clinician. Epidemiological aspects must be regarded also.

Expression of growth hormone receptor in benign and malignant cutaneous proliferative entities

The skin has the necessary elements to respond to growth hormone (GH) and suffers clinical changes in the pathological circumstances of excess and deficiency of GH. The GH has been involved in the development of different types of human neoplasms. Based on these data, we have studied the GH receptor (GHR) expression in acrochordons, seborrheic keratosis, melanocytic nevi, histiocytomas, squamous cell carcinomas, basal cell carcinomas, and malignant melanomas by means of the immunohistochemistry with the monoclonal antibody MAb 263. All the entities showed immunoreactivity for GHR. In the histiocytomas, the expression of GHR in the keratinocytes of the hyperplastic epidermis coating the lesion showed a strong nuclear pattern, but the non-hyperplastic epidermis of the edges of the histiocytomas expressed GHR with a cytoplasmic pattern. In the basal cell carcinoma and squamous cell carcinoma, the immunoreactivity was weaker than in normal skin. In the squamous cell carcinoma, the intensity of immunostaining correlated directly with the grade of cellular differentiation. In conclusion, the GH may be involved in the development of different kinds of cutaneous neoplasms, and the intracellular localization of GHR may imply a functional significance, at least in the histiocytomas.

Unilateral psoriasis: a case individualized by means of involucrin

Several authors have questioned the existence of unilateral (linear) psoriasis. These authors have suggested that the condition is actually an inflammatory linear verrucous epidermal nevus, or the result of an isomorphic effect on a pre-existing epidermal nevus. We report the case of a 25-year-old man, with no relevant personal or family history, who presented with a number of pruritic, punctiform erythematosquamous lesions that were linearly distributed over the left side of the body. Clinical examination and results of histopathologic and histochemical studies indicated unilateral psoriasis. Our findings confirm that involucrin immunohistochemistry can be a useful diagnostic tool in cases of this type. Treatment with keratolytics and topical calcipotriol led to a significant, but only temporary, improvement.

Cutaneous polyarteritis nodosa in a child

Cutaneous polyarteritis nodosa (CPAN) is a benign form of vasculitis of small and medium-size arteries with a recurrent but benign course without systemic involvement. This entity is very rare in children, with about 45 cases described in the literature we reviewed. Herein we report a 10-year-old girl with typical CPAN. Trigger factors such as streptococcal infection were not detected. Of four episodes over the last 2 years, only one required treatment with a moderate-sized oral dose of prednisone. In diagnosing CPAN, it is necessary to rule out systemic polyarteritis nodosa, which is also rare in children, as well as other panniculitides and vasculitides.