An atypical form of pediatric pityriasis rosea of the diaper area: Pityriasis marginata et circinata of Vidal

Pityriasis rosea is a common, self-limited disease which in its typical form should not raise diagnostic doubts. Nevertheless, its atypical presentations can be a challenge for the clinician, and hence it is important to be aware of them. Recognition of these forms may enable a correct diagnosis to be made and avoid unnecessary procedures. We present two patients for whom we believe atypical PR was the most likely the diagnosis.

Effectiveness of Narrowband Ultraviolet Light in Chronic Kidney Disease-Associated Pruritus

INTRODUCTION

 Chronic kidney disease-associated pruritus (CKDaP) is a prevalent and challenging symptom in individuals suffering from advanced chronic kidney disease (CKD). Its underlying mechanism remains inadequately understood, leading to a limited array of unsatisfactory therapeutic interventions. Despite various attempts, identifying the most effective treatment remains inconclusive. Nevertheless, there is a growing interest in employing ultraviolet phototherapy, particularly for non-responsive patients, although its efficacy is not definitively established. To investigate the potential benefits of narrowband ultraviolet B (NB-UVB) phototherapy on individuals experiencing CKDaP, we report our experience with NB-UVB light in management of CKDaP in dialysis patients.

MATERIALS AND METHODS

The study group consisted of patients with end-stage chronic kidney disease who underwent hemodialysis. These patients received dermatological consultations and follow-ups for itching. They were all unresponsive to the conventional treatment (emollients and antihistamines). Screening laboratory examinations, including complete blood count, liver function test, thyroid function, electrolytes, and others, were also arranged to exclude systemic etiologies. The main potential pruritogens were dosed: calcium, phosphate, and parathyroid hormone. Itch intensity was evaluated with a numerical rating scale (0-10), based on the worst level of itching in the past two weeks. They had sessions of NB-UVB light (311 nm, TL01) twice per week. After UVB exposure, patients were advised to use topical emollients. A questionnaire was employed to document the extent, intensity, frequency, and sleep disruption experienced to evaluate the efficiency of the treatment, using a scale from 0 to 10.  Results: In a group of 38 patients, the average age of the patients was 56 years (16-80); 63.2% were female and 36.8% were male. Median duration of pruritus was 4.7 years, and that of dialysis was 8.4 years. Pruritus was intermittent and diffuse in most cases, localized to the arteriovenous fistula site in two cases, and exacerbated by heat in all cases. Itch intensity was evaluated with a numerical rating scale (0-10) based on the worst level of itching in the past two weeks and showed a moderate average score (5/10). Xerosis was found in 63%, and scratch lesions such as excoriation in 34%. NB-UVB phototherapy was used twice per week on nonconsecutive days, with protection of the genital area and also the eyes using UVB-blocking goggles. The initial dose was 0.4 J/cm2 and further doses were introduced according to the erythema response until a maximum of 2 J/cm2. No sunburn, hyperpigmentation, or blistering was noted. Emollients were maintained in patients with xerosis. Average number of sessions was 13 (6-24) and reduction of itch intensity was observed starting from the sixth session. Total improvement was obtained at the end of treatment duration except for three patients who required additional sessions. One patient had recurrence one year later.  Conclusion: In conclusion, phototherapy represents a significant advancement in the treatment options for CKD-associated pruritus. Its positive impact on reducing itching and improving the quality of life for many patients is undeniable. However, to fully unlock its potential, ongoing research is needed to optimize dosing, understand relapse mechanisms, and identify the patients who will benefit most from this therapy.

Vitamin B12 induced acneiform eruption

A 47-year-old, north african, male patient, has recently been diagnosed with pernicious anemia, treated with weekly intramuscular hydroxocobalamin. 6 weeks after its initiation, the patient presented a sudden, extensive and monomorphic eruption of inflammatory papulo-pustules and nodules, affecting the face, and the trunk. The eruption was pruritic, and comedones were also present, on the chest. The patient was diagnosed with vitamin B12-induced acneiform eruption. Levels of vitamin B12 were normalized. Hydroxocobalamin was therefore stopped and lymecycline was started, allowing a complete resolution of the lesions within 3 months. Drug intake, sudden and uncommon age of onset, pruritus, a monomorphic pattern and an involvement of extra-seborrheic areas are features that distinguish acneiform eruptions from acne vulgaris.

COVID-19 in Three Patients with Pemphigus

COVID-19 is an infectious disease caused by the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2). It has various clinical presentations, ranging from mild and moderate to severe manifestations. This infection has caused disruptions worldwide, particularly for healthcare professionals, regarding the prescribing of immunosuppressive drugs for chronic autoinflammatory and autoimmune pathologies, such as pemphigus. We report three pemphigus patients who being treated with immunosuppressive therapy developed the SARS-CoV-2 infection. (SKINmed. 2022;20:428-429).

Zona après l’administration du vaccin ChAdOx1 nCoV-19

Introduction

La nouvelle infection par le SRAS-CoV-2 a récemment été déclarée pandémie par l’Organisation mondiale de la santé (OMS). En réponse à la propagation mondiale du virus, de nombreux vaccins ont été développés, comme le vaccin ChAdOx1 nCoV-19. Bien que ce vaccin ait un bon profil de sécurité, ses effets secondaires ne sont pas encore complètement caractérisés. Nous décrivons onze cas de zona après vaccination.

Matériel et méthodes

De mars à mai 2021, onze cas de zona après vaccination ont été observés dans notre institution.

Résultats

Sur les onze patients atteints de zona, 6 étaient des hommes et 5 des femmes. L’âge moyen des patients était de 56,8 ans. À l’exception d’un patient qui avait des antécédents d’hypertension et d’un autre qui était diabétique, aucun n’avait d’antécédents médicaux. L’atteinte thoracique était la plus fréquente, suivie par l’atteinte du trijumeau. Neuf patients ont développé l’éruption après la première dose du vaccin et 2 patients après la deuxième dose. Tous les patients ont reçu du valaciclovir (3 g/jour) pendant dix jours avec un traitement symptomatique. Un seul patient a été hospitalisé et traité par ceftriaxone (2 g/jour) pendant 10 jours en association avec la gentamicine (160 mg/jour) pendant 3 jours. L’évolution était sans complication pour 10 patients, un patient a développé un syndrome régional complexe.

Discussion

Le zona est particulièrement fréquent au cours des hémopathies malignes, des cancers, des déficits immunitaires, notamment le VIH, et des traitements immunosuppresseurs, l’immunité à médiation cellulaire jouant un rôle important dans la défense antivirale. Des zonas ont également été observés dans plusieurs cas de COVID-19. Ceci pourrait être expliqué par la diminution du nombre absolu de lymphocytes, secondaire à l’infection. Dans la littérature, hormis la réactivation du zona après la vaccination contre la varicelle, il existe très peu de publications associant la vaccination et la survenue du zona. Jusqu’à présent, l’infection par le zona n’a pas été signalée comme étant un effet indésirable de vaccins contre la COVID-19. Il est possible que le zona observé chez nos patients ait été causé par l’immunomodulation induite par le vaccin, car le moment de l’infection a coïncidé avec l’administration du vaccin.

Conclusion

Notre étude suggère que l’immunomodulation secondaire à l’administration du vaccin contre la COVID-19 peut augmenter le risque de zona. Cependant, ces cas ne prouvent pas la causalité et des études approfondies sont nécessaires pour élucider le lien possible entre la vaccination contre la COVID-19 et la réactivation de l’infection VZV.

Multisystem Langerhans Cell Histiocytosis in Adults Revealed by Skin Lesions

A 37-year-old woman with no remarkable medical or family history presented with papules and vesicles on an erythematous background involving the neck, sacrum, and folds (postauricular, axillary, inguinal, and under the breasts) (Figure 1). During the previous year, she was treated with local and systemic antifungals without improvement. Her history included a secondary amenorrhea, polydipsia, and polyuria (6 L/d) that started 2 years prior. Physical examination revealed chronic bilateral purulent otorrhea with thick eardrums. Histologic examination of skin biopsy revealed a highly suggestive appearance of multisystem Langerhans cell histiocytosis (LCH) with immunohistochemistry (anti-PS100 and anti-CD1a), which were positive (Figure 2A and 2B). Pituitary magnetic resonance imaging showed a thickening of the pituitary stalk in relation to a location histiocytic (Figure 3). Bone gaps were objectified on two radiographic tibial diaphyseal. Results from computed tomography (CT) scan showed a magma coelio mesenteric, axillary, and inguinal lymph nodes.

[Necrotic leg ulcer revealing vasculitis induced by vitamin K antagonists]

Vitamin K antagonists are widely used in thromboembolic diseases. Hemorrhagic complications related to drug overdose represent their main side effect. We report a rare side effect, a severe and unexpected type of skin vasculitis - necrotic leg ulcer - induced by vitamin K antagonist.

CASE REPORT

A 63-year-old female with a history of diabetes developed hyperalgesic necrotic ulcerations on the lower limbs one month after starting an acenocoumarol-based treatment for ischemic heart disease. Histological examination revealed lymphocytic vasculitis with fibrinoid necrosis. Etiological explorations searching for vasculitis were negative. In the absence of a precise etiology, drug-induced ulcer was suspected. Low molecular weight heparin was prescribed to replace acenocoumarol. The lesions slowly resolved with topical treatment.

DISCUSSION

The chronological criteria and the negativity of etiological explorations allowed the diagnosis of vitamin K antagonist-induced necrotic skin ulcer. Clinicians should be aware of this rare complication induced by oral anticoagulants because of its practical therapeutic implications. This is the first case of necrotic leg ulcer induced by acenocoumarol corresponding histologically to necrotising lymphocytic vasculitis.

[Profuse sarcoidosis associated with multiple cutaneous squamous cell carcinomas]

BACKGROUND

The cutaneous signs of sarcoidosis are polymorphous and occasionally misleading. Herein, we report a rare case of profuse sarcoidosis involving various rare cutaneous signs specific to the disease associated with multiple cutaneous squamous cell carcinomas.

PATIENTS AND METHODS

A seventy-three-year-old man had been presenting dry ichthyosiform erythroderma for 2 years. The examination also revealed diffuse cutaneous atrophy with ulceration, superficial adenopathy and pseudotumoral hypodermic masses. Ophthalmological examination revealed conjunctival nodules. Biopsy samples for the various cutaneous lesions, salivary glands, conjunctival nodules, a hypodermic nodule and an adenopathy yielded similar images evocative of epithelioid granulomas and giant cells without caseous necrosis. Infectious causes were ruled out. Respiratory function tests showed a restrictive respiratory disorder. ACE levels were extremely high. Proteinuria was noted for 24-hour urine tests and renal punch biopsy showed an appearance of membrane-proliferative glomerulonephritis. Oral corticosteroids produced clinical and laboratory improvement. Furthermore, the patient was also presenting several invasive cutaneous squamous cell carcinomas in a setting of marked helioderma.

DISCUSSION

Erythrodermic, ichthyosiform, atrophied, ulcerated and pseudotumoral forms of cutaneous sarcoidosis are very uncommon and their simultaneous appearance in the same patient is extremely rare. Further, the existence of numerous cutaneous carcinomas in this patient raises the question of an association between sarcoidosis and cancer, with fortuitous association appearing unlikely.

[Cutaneous cryptococcosis mimicking basal cell carcinoma and revealing systemic involvement in acquired immunodeficiency]

BACKGROUND

Cryptococcosis is a rare and a serious opportunistic infection that occurs primarily on the field of immunodeficiency. We report a case of disseminated cryptococcosis in acquired immunodeficiency syndrome revealed by unusual skin lesions.

OBSERVATION

A 52-year-old patient consulted for two crusty ulcerative lesions situated on the left supraorbital and on the nasal tip that appeared 6 months ago. He also reported respiratory symptoms present since one year, with dry cough and dyspnea, chronic headache and vomiting with no alteration in visual acuity. The mycological study of the skin biopsy on both lesions isolated Cryptococcus neoformans as well as in the sputum and cerebrospinal fluid. Serology of human immunodeficiency virus infection was positive. Treatment with fluconazole, local care and antiretroviral triple therapy was implemented.

DISCUSSION

Skin lesions during cryptococcosis are rare and observed in 2-10% of cases. Cutaneous symptoms were the reason for consultation in our patient. This is a rare form of cutaneous cryptococcosis leading to the discovery of both pulmonary and central nervous system locations, and to diagnosis of HIV infection.

[An uncommon cause of delayed walking: idiopathic palmoplantar hidradenitis]

INTRODUCTION

Idiopathic palmoplantar hidradenitis is an uncommon neutrophilic dermatosis, occurring in children and young adults. Its pathogenesis is incompletely understood. It is characterized by spontaneous resolution, but it can relapse in 50% of cases. We describe a case of a child with atypical idiopathic hidradenitis remarkable for its impact on his motor development.

OBSERVATION

A 3-year-old boy was admitted to the pediatric unit for etiological assessment of delayed walking. Medullary MRI and TSH were normal. He was referred to a dermatologic consultation for recurrent and painful palmoplantar lesions, giving an equinus antalgic posture. Examination found erythematous tender plantar nodules. The palms were not affected. The exam was otherwise normal. Diagnosis of idiopathic plantar hidradenitis, pressure urticaria, and plantar erythema nodosum were discussed, leading to a skin biopsy. The histopathologic findings of nodular, neutrophilic infiltrates around the eccrine glands confirmed the diagnosis of idiopathic plantar hidradenitis. Anti-inflammatory treatment was given, followed by complete resolution of the lesions, but persistent equinus posture.

COMMENTS

Idiopathic palmoplantar hidradenitis is an uncommon neutrophilic dermatosis, distinct from neutrophilic eccrine hidradenitis. It corresponds to neutrophilic infiltrates of the eccrine sweat glands. It is more frequently reported in children and young adults with no medical history. Its pathogenesis is not completely explained. The lesions are usually painful, hindering walking for a few days or even delaying it, as for our patient. These lesions typically involute, but they may recur in more than half of the cases.

CONCLUSION

Through this observation, we highlight the atypical impact of idiopathic hidradenitis and the value of a dermatological examination in case of delayed walking.