Figurate annulare erythemas

T. Colcott Fox (1849-1916) first introduced in 1889 the term "figurate erythemas." According to the clinical pattern, figurate erythemas are annular, circinate, concentric, polycyclic, or arciform. The most important figurate annulare erythemas are erythema annulare centrifugum, erythema marginatum, erythema gyratum repens, erythema migrans, erythema chronicum migrans, and the pediatric annular erythemas. Erythema annulare centrifugum might be due to fungal, bacterial, or viral infections or drugs. It tends to spread centrifugally while developing central clearing. The most common locations are the trunk and the proximal extremities. Individual lesions last from several days to weeks and may resolve spontaneously. Erythema marginatum is one of the criteria for the diagnosis of acute rheumatic fever, but it also might be seen as a symptom of other diseases such as hereditary angioedema with C1-inhibitor deficiency and psittacosis. The typical clinical picture is presented by serpiginous erythematous macules and plaques with central clearing and accentuated borders. Erythema gyratum repens is a figurate erythema associated with internal malignancy. It has been linked especially to lung, esophageal, and breast cancers. Erythema gyratum repens is characterized by multiple erythematous, rounded macules or papules, rapidly progressing and forming concentric bands with an unique wood-grained appearance with desquamation on the edges of the erythema. Erythema chronicum migrans is the most common sign of infection with Borrelia burgdorferi and other Borrelia species. It is characterized by a round or oval erythematous or livid macule with a central depressed or raised area on the spot of a previous tick bite. Erythema migrans grows centrifugally and slowly in a matter of days or weeks. Central clearing is observed in 60% of patients, thus forming a targetoid appearance of the lesion. Many other figurate erythemas can be observed in infancy (pediatric annular erythemas). To this group belong neonatal lupus, erythema gyratum atrophicans transiens neonatale, annular centrifugal erythema, familial annular erythema, annular erythema of infancy, eosinophilic annular erythema, and figurate neutrophilic erythema of infancy. The treatment of the various types of figurate erythemas should be etiologic, and when the underlying condition is addressed, the therapy usually is successful.

Cutaneous adverse effects of the available COVID-19 vaccines

Vaccination has played a crucial role in the improvement of global health. Some of the world's deadliest diseases, like smallpox and rinderpest, have been eradicated with the help of vaccines, and many others have been restrained. The appearance of the strain of coronavirus disease 2019 (COVID-19) severe acute respiratory syndrome coronavirus 2 and its impact on global health have made the development of effective and safe vaccines crucial for this new lethal disease. So far, there are three main types of COVID-19 vaccines in use around the world: messenger RNA-based vaccines, adenoviral vector vaccines, and inactivated whole-virus vaccines. Some of them have passed through phase 3 of safety and efficacy trials and are widely used for prophylaxis of COVID-19 infection. A plethora of cutaneous adverse events have been reported, most of them mild or moderate injection-site reactions. Some rare delayed inflammatory reactions such as "COVID arm" have also been reported, posing questions on their pathophysiology and clinical importance. Some rare serious adverse events, such as vaccine-induced prothrombotic immune thrombocytopenia and anaphylaxis, have been described raising great concerns on the safety of some widely spread vaccines. More data need to be collected with further and more detailed analysis. The overall risk of such severe adverse reactions remains extremely low, and the benefits of the existing vaccines in combating the widespread threat of COVID-19 continue to outweigh the risk of their side effects.

Prevention and occupational hazards for the skin during COVID-19 pandemic

The life of medical specialists worldwide has dramatically changed due to the spread of the coronavirus disease 2019 (COVID-19) pandemic. Health care professionals (HCPs) have personally faced the outbreak by being on the first line of the battlefield with the disease and, as such, compose a significant number of people who have contracted COVID-19. We propose a classification and discuss the pathophysiology, clinical findings, and treatments and prevention of the occupational skin hazards COVID-19 poses to HCPs. The multivariate pattern of occupational skin diseases during the COVID-19 pandemic can be classified into four subgroups: mechanical skin injury, moisture-associated skin damage, contact reactions, and exacerbation of preexisting dermatoses. The clinical pattern is versatile, and the most affected skin sites were the ones in contact with the protective equipment. Dermatologists should recognize the plethora of HCPs’ occupational skin reactions that are occurring during the COVID-19 pandemic and implement treatment and preventive strategies.

WITHDRAWN: Reply to: Introducing special cutaneous “sign” tribute to healthcare workers managing new coronavirus disease (Covid -19)

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.clindermatol.2020.04.012. The duplicate article has therefore been withdrawn.

The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

COVID-19 pandemic and the skin: what should dermatologists know?

The world has changed dramatically since the COVID-19 pandemic began. In addition to our social, occupational, and personal lives, the new coronavirus also poses novel challenges for all physicians, including dermatologists. Several skin conditions have emerged, mainly as a result of prolonged contact with personal protective equipment and excessive personal hygiene. Pressure injury, contact dermatitis, itch, pressure urticaria, and exacerbation of preexisting skin diseases, including seborrheic dermatitis and acne, have been described. We have focused on the dermatologic aspects of the COVID-19 infection so that dermatologists are aware of the skin complications and preventive measures can be taken in the COVID-19 pandemic.

Ocular changes in patients with psoriasis

Eye involvement in psoriasis is little known to many dermatologists, although psoriasis has been acknowledged as a systemic disease for decades. The ophthalmic complications of psoriasis are numerous and can affect almost any part of the eye. The most common ocular changes in patients with psoriasis, including blepharitis, conjunctivitis, keratitis, iridocyclitis, UV-induced cataracts, uveitis, and birdshot chorioretinitis, have been described in the literature. Recognition of the ocular complications of psoriasis is of significant clinical importance, because various pathogenic mechanisms may contribute to the development of ocular manifestations, including direct eye involvement with psoriatic plaques, psoriasis-related immune-mediated inflammatory processes, and complications of psoriasis treatments.

Skin hydration, microrelief and greasiness of normal skin in Antarctica

BACKGROUND

The skin is the primary defence of the human body against external factors from physical, chemical, mechanical and biologic origin. Climatic factors together with low temperature and sun radiation affect the skin. The effect of climatic conditions in Antarctica on healthy skin has not been previously addressed.

OBJECTIVES

The aim of this study was to evaluate the changes in the skin hydration, greasiness and microrelief due to the extreme climatic environmental factors during the stay of the members of the Bulgarian Antarctic expedition.

MATERIAL AND METHODS

Fifty-nine Caucasian healthy subjects, 42 men and 17 women with mean age 50.9 years (27-68), were enrolled. The study was performed in five consecutive years from 2011 to 2016 at the Bulgarian Antarctic base camp at Livingston Island. The study protocol consisted of two parts: study A: duration of 15 days with measurement of skin physiology parameters on a daily basis, and study B: five measurements at baseline and at days 14, 30, 45 and 50 upon arrival in Antarctica. We measured three biophysical parameters related to skin physiology at cheek skin by an impedance measuring device.

RESULTS

No statistically significant difference between parameters at the different measurement points. There is a variation in skin hydration reaching its lower point at day 11 and then returning to values similar to baseline. Initially, an increase in skin greasiness was witnessed with a sharp depression at day 11 and final values at day 15 resembling the ones at baseline. An increase, although not statistically significant, in skin roughness was observed in the first 15 days of the study. Study B showed no statistically significant variances between values of the three parameters.

CONCLUSION

Our studies show the pioneer results of the effect of Antarctic climate on human skin physiology.

Acrally distributed dermatoses: Vascular dermatoses (purpura and vasculitis)

Purpuric lesions appear in acral distribution in a variety of conditions and often provide clues to the clinical diagnosis. Purpuric means "hemorrhagic"-that is, the lesions do not blanch from pressure. This review focuses on dermatoses that produce hemorrhagic lesions in acral distribution from the large groups of the vasculitic diseases and their mimics. Cutaneous small vessel vasculitis is confined to the skin, involves mainly postcapillary venules, and has the hallmark manifestation of palpable purpura. Henoch-Schönlein purpura is an immune complex-mediated systemic vasculitis of the small vessels with manifestations from the skin, joints, kidneys, and gastrointestinal system. Only cases where the immune complexes contain immunoglobulin A type are classified as Henoch-Schönlein purpura. Cryoglobulinemic vasculitis is induced by the deposition of cold-precipitated immune complexes in the small vessels. Urticarial vasculitis comprises a spectrum of conditions with the characteristic course of chronic urticaria, with wheals that persist longer than 24 hours, leave hyperpigmentation, and have leukocytoclastic vasculitis on histologic examination. Polyarteritis nodosa is a rare multisystem, segmental necrotizing vasculitis of mainly the medium-sized vessels. Pigmented purpuric dermatoses are chronic benign dermatoses characterized by petechiae, purpura, and increased skin pigmentation. The hallmark of pigmented purpuric dermatoses is their orange-brown, speckled, cayenne pepper-like discoloration.

The skin as a target organ in multisystemic diseases II

Progress in medical science has given a new reading to the claim that the skin could be a mirror of the pathological changes found in the internal organs. The concept that we previously promoted is furthered in this issue; namely that the greatest part of skin diseases are systemic ones. In this issue we focus on another group of diseases with systemic involvement and skin manifestations. We review such inflammatory conditions as lichen planus, autoinflammatory syndromes, and pyoderma gangrenosum focusing on their systemic involvement. We have not missed such classic examples of systemic involvement as scleroderma. In this issue we have included two infectious diseases with multi-organ involvement: Lyme disease and Herpes simplex. In contrast to our previous work, we have also addressed neoplastic diseases - namely mycosis fungoides.

Complications of injected vitamin E as a filler for lip augmentation: case series and therapeutic approach

The strive for proficient cosmetic facial appearance is growing in the past decades. Fillers for tissue augmentation are gaining wide popularity. Uncertified products based on oleic solutions are applied by untrained staff, thus growing the risk for certain complications such as infections, allergic and irritant contact dermatitis, and lipogranuloma formation. We present a series of three cases lipogranuloma after liquid vitamin E injection for lip augmentation. In all cases, painful edema at the injected area followed the procedure. The patients were presented with erythema, firm indurations of the lips and the perioral skin, and tenderness. Histological examination of skin biopsies showed round-ovoid cavities of varying sizes, resulting in a Swiss cheese-like appearance, consistent with a lipogranuloma. In this paper, we propose a protocol for treatment of this specific complication with systemic corticosteroids and a broad spectrum antibiotics.

Phytodermatitis to Euphorbia trigona

A 56-year-old Caucasian woman presented with acute onset of dermatitis on her face accompanied by intense itching. The patient reported that the condition began after cleaning a decorative plant, Euphorbia trigona, and contact with some drops of the plant's latex sap released upon cutting its leaves. The clinical examination revealed erythema and edema of the infraorbital and perioral regions (Figure 1). The patient was in otherwise good general health, had no personal or family history of systemic or skin disease, and was not receiving any concomitant medications. Therapy with topical methylprednisolone aceponate 0.1% cream once daily was initiated and systemic desloratadine 5 mg tablets once daily was administered for the intense itch. Seven days after the introduction of the treatment a significant improvement was noticed (Figure 2). Patch testing with the leaves of the plant as well as with the latex sap was undertaken in order to prove the causative role (Figures 3 and 4). Strongly positive reactions with bulla formation were observed on day 2 and 3, most likely suggesting acute irritation instead of true delayed hypersensitivity.

Psoriasis as a systemic disease

Psoriasis is an inflammatory immune-mediated disease that affects the skin and has pathogenic effects with systemic impact. The relationship between psoriasis and comorbidities remains controversial. The hypothesis of a causative role of psoriasis in its cardiovascular and metabolic comorbidities is based on pathophysiologic concepts establishing a link between chronic inflammation in psoriasis, endothelial dysfunction, formation of atherosclerotic plaques, and the different compounds of metabolic syndrome. Psoriasis management has to be multidisciplinary. It implicates identification and treatment of psychological disorders, addictions, and associated cardiovascular and metabolic diseases, together with improvement of quality of life of patients.

The novel protease inhibitor SRD441 ointment is not effective in the treatment of adult subjects with atopic dermatitis: results of a randomized, vehicle-controlled study

BACKGROUND

There is evidence that excessive protease activity in the skin is an important factor in the development of atopic dermatitis. SRD44 is a topically formulated novel protease inhibitor that selectively inhibits Staphylococcal-derived aureolysin and matrix metalloproteinases (MMPs).

METHODS

This was a double-blind, vehicle-controlled randomized trial conducted in thirteen hospital dermatology outpatient clinics in Germany (9), Bulgaria (3) and Finland (1). Ninety-three out of 103 screened adult subjects with confirmed atopic dermatitis affecting ≤ 20% of body surface area, with an IGA score of 2 or 3 at randomization were randomized following a washout period to either SRD441 ointment or matching vehicle twice daily for 28 days. The primary efficacy endpoint was the clearance of Atopic dermatitis (AD score of 0 or 1 IGA) at Day 21. Secondary endpoints included measures of SCORing Atopic Dermatitis, pruritus self-assessment, rescue medication use and occurrence of new exacerbations. A range of safety and tolerance endpoints were included.

RESULTS

There were no significant treatment differences in IGA success rates at Day 21 (SRD441 ointment, 11.1%; vehicle ointment, 12.5%; P = 1.000). Evaluation of secondary efficacy variables revealed no clinical or important statistical differences between treatment groups. Eighteen subjects (19.4%) discontinued the study drug because of an AE (seven subjects [15.6%] in the SRD441 group and 11 subjects [22.9%] in the vehicle group). Twenty-seven subjects (60.0%) in the SRD441 group and 34 subjects (70.8%) in the vehicle group reported an adverse event (AE).

CONCLUSIONS

SRD441 ointment did not demonstrate efficacy in the treatment of atopic dermatitis raising questions on the effectiveness of MMPs as a target for the treatment of atopic dermatitis. NCT00882245.

Rifampicin--a mild immunosuppressive agent for psoriasis

The immunosuppressive properties of rifampicin have been discussed in the literature for more than 30 years. It is hypothesized that rifampicin acts as a mild immunosuppressive agent in psoriasis rather than an antibacterial one. We report our studies on the therapeutic efficacy of rifampicin in guttate psoriasis. We try to give light on the mechanism of action of rifampicin in psoriasis. Our therapeutic results together with data from the literature revealed rifampicin to be a mild immunosuppressive agent. Its best effectiveness is in the guttate type of the disease.

Old drug – new indication. Rifampicin in psoriasis

BACKGROUND

The efficacy of traditional systemic therapies for psoriasis is limited by various side effects, toxicity, drug-drug interactions, and the need for frequent laboratory monitoring. In animal models, rifampicin causes immunosuppression and in conventional doses it suppresses the T-cell function.

OBJECTIVE

To show that rifampicin has a therapeutic effect in eruptive psoriasis and to try to explain its mode of action.

MATERIALS AND METHODS

A total of 76 patients (34 men and 42 women, aged between 12 and 68 years) with eruptive psoriasis were enrolled in the study. They were divided into two groups according to the evidence of a concomitant streptococcal infection. Rifampicin was administered orally in a 600 mg daily dosage for at least 60 days. Only emollients were given for topical therapy.

RESULTS

A statistical (chi-squared test) analysis was done and it could be concluded that improvement in the two groups was statistically indistinguishable (p = 0.892), while comparison with the control group showed a significant difference (p = 0.00082).

CONCLUSION

The results express that there is no statistically significant difference between the treating groups and the effect of rifampicin could not be related only to its antimicrobial properties. Its therapeutic effect most probably is due to its immunosuppressive properties.

Climatotherapy of psoriasis

In the era when biological treatments for psoriasis are gaining more and more popularity, climatotherapy represents a safe and efficient alternative to the conventional therapeutic modalities. Climatotherapy comprises alternative treatment methods, which are based on the healing capacities of natural resources. This paper provides the reader with relevant information on the different climatotherapeutic methods, the intimate mechanisms of their action, and the cumulated clinical experience in the treatment of psoriasis. The positive effect of thalassotherapy for psoriasis has been known since ancient times. However, in the past decades a number of controlled studies revealed the efficacy of thalassotherpay in the treatment of psoriasis. Herein, it is exemplified on the experience in the centers at the Dead Sea and the Black Sea coast. Originating from Europe, balneo- and spa therapy are becoming popular alternatives for psoriasis treatment worldwide. A short review on the centers profiled for psoriasis therapy is provided. The unique sites of Blue Lagoon in Iceland and Kangal in Turkey are selected in this paper. Additionally, alternative nature-based treatments for psoriasis such as high mountain climatotherapy and naphtalotherapy are discussed.

Non-invasive in vivo methods for investigation of the skin barrier physical properties

Skin as an organ of protection covers the body and accomplishes multiple defensive functions. The intact skin represents a barrier to the uncontrolled loss of water, proteins, and plasma components from the organism. Due to its complex structure, the epidermal barrier with its major component, stratum corneum, is the rate-limiting unit for the penetration of exogenous substances through the skin. The epidermal barrier is not a static structure. The permeability barrier status can be modified by different external and internal factors such as climate, physical stressors, and a number of skin and systemic diseases. Today, different non-invasive approaches are used to monitor the skin barrier physical properties in vivo. The quantification of parameters such as transepidermal water loss, stratum corneum hydration, and skin surface acidity is essential for the integral evaluation of the epidermal barrier status. Novel methods such as in vivo confocal Raman microspectroscopy offer the possibility for precise and detailed characterization of the skin barrier. This paper will allow the readership to get acquainted with the non-invasive, in vivo methods for the investigation of the skin barrier.

Skin irritation and sensitization: mechanisms and new approaches for risk assessment. 1. Skin irritation

Cutaneous irritation presents a major health problem with serious social and occupational impact. The interaction between an irritant and the human skin depends on multiple factors: the intrinsic properties and the nature of the irritant itself, and specific individual- and environment-related variables. The main pathological mechanisms of irritancy include skin barrier disruption, induction of a cytokine cascade and involvement of the oxidative stress network; all of them resulting in a visible or subclinical inflammatory reaction. In vivo, different non-invasive parameters for the evaluation of skin irritation and irritant potential of compounds and their specific formulations have been introduced, such as epidermal barrier function, skin hydration, surface pH, lipid composition, skin colour and skin blood flow. The diverse physiological changes caused by irritating agents require implementation of a multiparametric approach in the evaluation of cutaneous irritancy.

Foreign-body granuloma of the penis in sexually active individuals (penile paraffinoma)

BACKGROUND

The practice of insertion of foreign bodies in the penis is well documented, but the clinical characteristics of penile foreign-body granuloma (FBG) and social motivation of the patients has not been studied in large groups.

OBJECTIVE

The aim of this study was to evaluate the clinical and epidemiological profile of patients with penile insertion of foreign bodies and assess the significance of social motivation.

METHODS

Twenty-five heterosexual male patients, who visited our clinic from 1990 to 2005, were retrospectively studied. All of them had implanted two different types of foreign bodies in their penis and had tattoos in the same area. Twenty-five male patients with genital tattoos served as clinical controls.

RESULTS

The age of peak incidence of patients with penile FBG was 28 years. The youngest patient was 19 years. Twenty-three (23 of 25, 92%) of the patients were from gipsy origin, and two men were of Bulgarian origin. All the patients had risky social behaviour (prisoners and beggars). The motivation of 20 (20 of 25, 80%) of the patients was to enlarge the penile size. Fifteen (15 of 25, 60%) wanted to increase the feelings of the sexual partners. The majority of the patients (23 of 25, 92%) had injection of fatty substances, and 2 (2 of 25, 8%) had undergone implantation of a plastic pellet. In 14 cases (14 of 25, 56%), the insertion of mineral oil was complicated by formation of fistulas and wide ulcers with histological features of FBG.

CONCLUSION

The reported cases represent an example of the detrimental effects of the insertion of foreign bodies in the penis. Immediate measurements should be performed to prevent severe outcomes.

Temporary henna tattoos

Today, temporary henna tattoos drawn on the skin are very fashionable and have become more and more popular. At the same time, allergic reactions following these tattoos has increased worldwide. Actually, henna has a very low allergic potential. In most cases, allergic reactions are caused by the mixtures used by the so-called "artists" which contain not only natural henna but also many chemical coloring agents such as diaminotoluenes and diaminobenzenes. The long duration of skin contact, the high concentrations of sensitizing materials, and the lack of a neutralizing agent dramatically increases the risk of skin sensitization. We summarized 31 of our own cases with allergic contact dermatitis due to temporary henna tattoos and outlined the main characteristics for this peculiar contact dermatitis.

Toxic epidermal necrolysis as a dermatological manifestation of drug hypersensitivity syndrome

Drug hypersensitivity syndrome (DHS) is believed to be an adverse idiosyncratic drug reaction associated mainly with administration of aromatic antiepileptic drugs, such as phenytoin, carbamazepine, phenobarbital, lamotrigine. The syndrome is defined by the clinical triad of fever, skin rash and internal organ involvement and can be life-threatening condition. We describe three patients treated in our institution. The first was a 32-year-old man who developed toxic epidermal necrolysis (TEN) with pulmonary and liver involvement after initiation of lamotrigine therapy for concomitant epilepsy. The second 32-year-old man was treated with salazopyrine and omeprazole in order to relief the symptoms of inflammatory bowel disease, but as a result developed toxic epidermal necrolysis with elevated liver enzymes. The third patient was a 28-year-old man with long history of alcohol abuse who began treatment with carbamazepine and a few days later he was admitted to the clinic with symptoms of severe disseminated skin rash. The patients had peripheral eosinophilia. All the patients needed urgent life-saving therapy, intensive care and nursing. The culprit drug was discontinued and prompt systemic therapy with corticosteroids at an initial dose of 2 mg/kg/d and with broad spectrum antibiotics was started. Topical therapy included spraying Avène thermal water and local antiseptics. Resolution and epithelization of skin erosions were observed in about 4 weeks after the initiation of the therapy. Medications can give rise to certain adverse reactions including serious cutaneous and systemic involvement. TEN is a rare complication of DHS. Patients who develop DHS need optimal and adequate treatment. The concomitant use of corticosteroids and broad spectrum systemic antibiotics is essential. The local therapy plays an important part in relieving symptoms and should consist of mild preparations with minimally sensitizing potential.

Tattoos: dermatological complications

From the Eskimo in Greenland to the tribes in Polynesia-the whole world knows the art of tattoo. Despite their wide popularity the relation between the skin diseases and the tattooed pictures aren't studied in depth. With the appearance of professional tattoo studios, the risk of infectious complications was reduced. Simultaneously, on a global scale there has been an increase in pseudolymphoma and allergic reactions caused by the introduction of an exogenous pigment into the dermis. The results of our clinical and therapeutic research and review of literature on the subject outline the major problems related to tattoos, i.e. clinical complications. The summarized data showed infectious diseases transmitted through the process of tattooing and many allergic reactions, granulomas and tumors as complications of a tattoo.