S2k guidelines on the management of paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome initiated by the European Academy of Dermatology and Venereology (EADV)

BACKGROUND

Paraneoplastic pemphigus (PNP), also called paraneoplastic autoimmune multiorgan syndrome (PAMS), is a rare autoimmune disease with mucocutaneous and multi-organ involvement. PNP/PAMS is typically associated with lymphoproliferative or haematological malignancies, and less frequently with solid malignancies. The mortality rate of PNP/PAMS is elevated owing to the increased risk of severe infections and disease-associated complications, such as bronchiolitis obliterans.

OBJECTIVES

These guidelines summarize evidence-based and expert-based recommendations (S2k level) for the clinical characterization, diagnosis and management of PNP/PAMS. They have been initiated by the Task Force Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology with the contribution of physicians from all relevant disciplines. The degree of consent among all task force members was included.

RESULTS

Chronic severe mucositis and polymorphic skin lesions are clue clinical characteristics of PNP/PAMS. A complete assessment of the patient with suspected PNP/PAMS, requiring histopathological study and immunopathological investigations, including direct and indirect immunofluorescence, ELISA and, where available, immunoblotting/immunoprecipitation, is recommended to achieve a diagnosis of PNP/PAMS. Detection of anti-envoplakin antibodies and/or circulating antibodies binding to the rat bladder epithelium at indirect immunofluorescence is the most specific tool for the diagnosis of PNP/PAMS in a patient with compatible clinical and anamnestic features. Treatment of PNP/PAMS is highly challenging. Systemic steroids up to 1.5 mg/kg/day are recommended as first-line option. Rituximab is also recommended in patients with PNP/PAMS secondary to lymphoproliferative conditions but might also be considered in cases of PNP/PAMS associated with solid tumours. A multidisciplinary approach involving pneumologists, ophthalmologists and onco-haematologists is recommended for optimal management of the patients.

CONCLUSIONS

These are the first European guidelines for the diagnosis and management of PNP/PAMS. Diagnostic criteria and therapeutic recommendations will require further validation by prospective studies.

Updated S2 K guidelines for the management of bullous pemphigoid initiated by the European Academy of Dermatology and Venereology (EADV)

BACKGROUND

Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease of the skin and mucous membranes. This disease typically affects the elderly and presents with itch and localized or, most frequently, generalized bullous lesions. A subset of patients only develops excoriations, prurigo-like lesions, and eczematous and/or urticarial erythematous lesions. The disease, which is significantly associated with neurological disorders, has high morbidity and severely impacts the quality of life.

OBJECTIVES AND METHODOLOGY

The Autoimmune blistering diseases Task Force of the European Academy of Dermatology and Venereology sought to update the guidelines for the management of BP based on new clinical information, and new evidence on diagnostic tools and interventions. The recommendations are either evidence-based or rely on expert opinion. The degree of consent among all task force members was included.

RESULTS

Treatment depends on the severity of BP and patients' comorbidities. High-potency topical corticosteroids are recommended as the mainstay of treatment whenever possible. Oral prednisone at a dose of 0.5 mg/kg/day is a recommended alternative. In case of contraindications or resistance to corticosteroids, immunosuppressive therapies, such as methotrexate, azathioprine, mycophenolate mofetil or mycophenolate acid, may be recommended. The use of doxycycline and dapsone is controversial. They may be recommended, in particular, in patients with contraindications to oral corticosteroids. B-cell-depleting therapy and intravenous immunoglobulins may be considered in treatment-resistant cases. Omalizumab and dupilumab have recently shown promising results. The final version of the guideline was consented to by several patient organizations.

CONCLUSIONS

The guidelines for the management of BP were updated. They summarize evidence- and expert-based recommendations useful in clinical practice.

AB0938 A new screening tool for Psoriatic Arthritis in Psoriasis Patients: TurPAS

Background

Psoriatic arthritis (PsA) is a heterogenous disease with different disease manifestations. Several tools have been developed for screening of PsA in patients with psoriasis with variable performances. An optimal screening tool for PsA is still an unmet need.

Objectives

We aimed to develop a new screening tool in Turkish which could detect different domains involved.

Methods

A core group was determined including 11 rheumatologists/10 dermatologist and a systematic literature review on PubMed until 15 August 2020 using the keyword ‘psoriatic arthritis` was performed. The review revealed tools named PEST, PASE, EARP, STRIPP, SIPAS, SIPAT, TOPAS-II, GEPARD, PASQ, CONTEST, A novel, short, and simple screening questionnaire. Each item of those tools were included in the Delphi set. After the 3 rounds of Delphi, a new set of screening questionss was developed.

Results

Overall 85 items were inquired, including questions on joint, dactylitis, enthesitis, back, skin-nail domains as well as morning stiffness, function, treatment and others for the first round of Delphi. Seventeen experts (9 dermatologists/ 8 rheumatologists from the core group) and fifteen patients (Female/Male= 9/6) answered the Delphi (mean (SD) age of 39.3 (10.9) participated to the first round. The involvemet types were peripheral (73.4%), axial (40%), entheseal (33.4) and dactylitis was present in 14% of the patients. As a result of this first evaluation, 44 out of 85 questions were selected and carried to second round The distribution of these questions was as follows; joint question n=13, skin and nail involvement n=6, dactylitis n=5, morning stiffness n=5, axial n=3, enthesitis n=2, general questions n=5. These questions were sent to the members through rheumatology and dermatology societies. In total, 85 rheumatology specialists and 48 dermatology specialists answered the questions in the second round. At the second tour, the number of questions was reduced from 44 to 22. The distribution of the questions was as follows; Skin and nail involvement n=5, dactylitis n=3, joint question n=2, axial involvement n=2, morning stiffness n=2, axial involvement and morning stiffness n=2, enthesitis n=1, general questions n=5. A consensus meeting was held to discuss 22 questions determined at the end of the second round within the initial core group. Each question was handled one by one, some of the questions were combined, if necessary, adapted to Turkish. The tool was given its final form. The final version of the questionnaire consists of 6 questions. (Table 1).

Table 1.

The new screening tool

DomainTurkish versionEnglish versionJointEl/ayak parmaklarinizda ya da herhangi bir ekleminizde hiç şişlik veya ağri oldu mu?Have you ever had swelling or pain in your fingers/toes or any of your joints?DactylitisResimde gösterildiği gibi el veya ayak parmağinizda sosis şeklinde şişlik oldu mu?Have you had a sausage-shaped swelling on your fingers or toes as shown in the picture?EnthesitisTopuk ağriniz olur mu?Do you have heel pain?Axial involvement and morning stiffnessBelinizde, sirtinizda veya boynunuzda istirahatle artan, özellikle sabaha karşi kötüleşen veya sabahlari hareketinizi kisitlayan ağriniz olur mu?Do you have pain in your lower back, back, or neck that increases with rest, worsens especially in the morning, or restricts your movement in the morning?Drug useEklem şikayetleriniz için zaman zaman ilaç kullanir misiniz?Do you take medication for your joint complaints from time to time?History of rheumatic diseaseSize daha önce iltihapli romatizma tanisi konuldu mu?Have you ever been diagnosed with a rheumatic disease before?

Conclusion

A new screening tool targeting different domains in Psoriatic disease was developed in Turkish. While cultural differences play an important role in screening, we believe that the first tool developed in Turkish will be helpful in clinical practice and research settings. Further assessments will be done to understand its validity and reliability within a large cohort of psoriatic patients.

Disclosure of Interests

None declared

Isotretinoin‐induced inflammatory back pain and sacroiliitis in patients with moderate to severe acne vulgaris

INTRODUCTION

Isotretinoin has been reported to induce inflammatory back pain (IBP) and sacroiliitis in the patients with acne vulgaris. The aim of this study is to investigate the incidence of IBP and sacroiliitis in patients receiving isotretinoin treatment compared with oral antibiotics for acne vulgaris.

MATERIALS AND METHODS

A total of 201 patients with moderate-to-severe acne vulgaris who received isotretinoin (n = 100) or oral antibiotics (n = 101) were included in the study. All patients were monthly questioned for IBP symptoms during their treatment. Patients described IBP were also evaluated for sacroiliitis by c-reactive protein, sedimentation rate, HLAB27, and sacroiliac magnetic resonance imaging (MRI). Isotretinoin was discontinued in all patients diagnosed as sacroiliitis, and these patients were reevaluated after 3 months.

RESULTS

IBP was observed in 21 (10.4%), and sacroiliitis was detected in 11 (11%) patients on isotretinoin treatment; in oral antibiotic group, we did not observe IBP or sacroiliitis. The incidence of IBP and sacroiliitis differed significantly between the isotretinoin and oral antibiotic groups (p < 0.0001, p = 0.02). Complete regression was observed in the great majority of patients following cessation of isotretinoin.

CONCLUSIONS

Our study is the largest prospective controlled study that investigated the incidence of sacroiliitis in patients receiving isotretinoin and compared with patients using oral antibiotics.

Prevalence and Dermoscopic Patterns of Acral Melanocytic Nevi in Turkey

Although nevi are frequently encountered in the acral region, very limited studies have reported their prevalence in specific populations. We aimed to determine the prevalence of acral nevi, their dermoscopic patterns, and evaluate patient awareness in a Turkish population. We prospectively examined 2644 patients admitted to the outpatient dermatology clinics between October 2016 and October 2017. The characteristics of the detected acral nevi and dermatoscopic images were recorded. A questionnaire of demographic characteristics was completed from all patients. Two hundred six of the 2644 patients had at least one acral nevus. Two hundred sixty nevi were examined. The general prevalence of acral nevi was 7.8%. Women were more likely to have acral nevi than men (8.7% vs. 6.3%; P=0.028). Moreover, darker-skinned patients were also had significantly more acral nevi (8.6% in skin type III-IV vs. 6.0% in skin type I-II; P<0.001). The prevalence of acral nevi was 9.4% before the age of 20, 9.5% in patients aged 20-40 years, and 4.6% after the age of 40. In addition, 51.5% of all nevi exhibited a parallel furrow, 13.5% were lattice-like, and 7.7% had a homogeneous pattern. The overall nevus awareness rate was 73.8% and was significantly higher in women at 78.3%. Our study is the first large-scale study of that showed the prevalence of acral nevi in Turkey. According to our study, the prevalence of acral nevi was higher in patients with female sex and darker skin type. We also found that the prevalence of acral nevi decreased over 40 years of age. The general awareness of nevi was higher in women.

AB0579 INSTRUMENTS FOR SCREENING PSORIATIC ARTHRITIS AMONG PATIENTS WITH PSORIASIS: A SYSTEMATIC LITERATURE REVIEW

Background:

Timely diagnosis is essential for the optimal management of psoriatic arthritis (PsA). Several instruments have been developed for screening PsA among patients with psoriasis. However, a delay in diagnosis is still frequently reported, possibly due to the lack of a wide use of these instruments.

Objectives:

We aimed to identify and compare the reported performance of these instruments with special emphasis on the PsA phenotypes.

Methods:

We conducted a systematic literature search on PubMed until 15 August 2020 using the keyword ‘psoriatic arthritis’. Two independent reviewers identified all studies published in English, that report on the validation, psychometric evaluation or use of an instrument for screening PsA. Any disagreements were resolved by the third investigator. Data on sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were extracted or calculated for each instrument. Additionally, instruments were assessed for their performance in patients with different disease phenotypes.

Results:

A total of 10754 references were screened, and 42 were identified that reported on 15 different screening instruments. Psoriatic Arthritis Screening and Evaluation (PASE), Psoriasis Epidemiology Screening Tool (PEST), Early Arthritis for Psoriatic Patients questionnaire (EARP) were the most commonly used instruments. There was important variability across studies regarding the sensitivity, specificity, PPV and NPV of these instruments based on the cut-offs for positivity, setting, patient population and disease phenotypes (Table 1). Specificity was higher when patients with a previous diagnosis of other rheumatic diseases were excluded. Lower sensitivity was reported among patients with shorter disease duration and when patients with a prior diagnosis of PsA were excluded from the study, whereas higher sensitivity was reported among patients with prior NSAID use. Screening tools showed differences in sensitivity in different domains (Figure 1).

Figure 1.

Performance Among Patients with Each Domain

Conclusion:

This systematic literature review revealed wide variability in the diagnostic estimates of currently available questionnaire-based screening instruments for identifying PsA among psoriasis patients, depending on study populations and disease phenotypes. There is an unmet need for a screening instrument with a better performance in all disease domains.

Table 1.

Diagnostic estimates of screening tools in different studies

InstrumentNumber of studiesSensitivity%Specificity%PPV%NPV%PASE1824-9138-9518-8813-96PEST1140 – 8537.2-98.623-9647.1-99.3EARP941-97.234-97.214-93.357.5-100TOPAS641-89.129.7-9025.7-91.868-81.6TOPAS-II444-95.880.5-9863.4-95.891-98PsA-Disk questionnaire187.246.458.678.5CONTEST270-76.556.5-9116-8968-95STRIPP191.593.379.697.5SiPAS179877390PASQ267-92.764-81.84383GEPARD277706680Swedish- Psoriasis Assessment Questionnaire163724585PAQ160622687.5SiPAT169699169A novel, short, and simple screening questionnaire186.971.35393.6

PASE: Psoriatic Arthritis Screening and Evaluation, PEST: Psoriasis Epidemiology Screening Tool, EARP: Early Arthritis for Psoriatic Patients questionnaire, TOPAS: Toronto Psoriatic Arthritis Screening Questionnaire, STRIPP: Screening Tool for Rheumatologic Investigation,

SIPAS: Simple Psoriatic Arthritis Screening questionnaire, PASQ: Psoriasis and Arthritis Screening Questionnaire, GEPARD: German Psoriatic Arthritis Diagnostic Questionnaire, PAQ: Psoriatic and Arthritic Questionnaire, SiPAT: Siriraj Psoriatic Arthritis Screening Tool

Disclosure of Interests:

None declared.

S2k guidelines (consensus statement) for diagnosis and therapy of dermatitis herpetiformis initiated by the European Academy of Dermatology and Venereology (EADV)

INTRODUCTION

Dermatitis herpetiformis (DH) is a chronic, pruritic, gluten-induced skin disorder characterized by subepidermal granular IgA deposition and a variable degree of enteropathy identical to that seen in coeliac disease. So far, there has been no European consensus about the management of DH.

METHODS

The guidelines were created by small subgroups of a guideline committee consisting of 26 specialists from various medical fields and one patients' representative. The members of the committee then discussed the guidelines and voted for the final version at two consensus meetings. The guidelines were developed under the support of the European Academy of Dermatology and Venereology (EADV) and in collaboration with the European Dermatology Forum (EDF).

RESULTS

The guidelines summarize evidence-based and expert-based recommendations (S2 level) for the management of DH (see Appendix).

CONCLUSION

These guidelines will improve the quality of management of DH and support dermatologists in their diagnostic and therapeutic decisions.

Diagnosis and management of pemphigus: Recommendations of an international panel of experts

BACKGROUND

Several European countries recently developed international diagnostic and management guidelines for pemphigus, which have been instrumental in the standardization of pemphigus management.

OBJECTIVE

We now present results from a subsequent Delphi consensus to broaden the generalizability of the recommendations.

METHODS

A preliminary survey, based on the European Dermatology Forum and the European Academy of Dermatology and Venereology guidelines, was sent to a panel of international experts to determine the level of consensus. The results were discussed at the International Bullous Diseases Consensus Group in March 2016 during the annual American Academy of Dermatology conference. Following the meeting, a second survey was sent to more experts to achieve greater international consensus.

RESULTS

The 39 experts participated in the first round of the Delphi survey, and 54 experts from 21 countries completed the second round. The number of statements in the survey was reduced from 175 topics in Delphi I to 24 topics in Delphi II on the basis of Delphi results and meeting discussion.

LIMITATIONS

Each recommendation represents the majority opinion and therefore may not reflect all possible treatment options available.

CONCLUSIONS

We present here the recommendations resulting from this Delphi process. This international consensus includes intravenous CD20 inhibitors as a first-line therapy option for moderate-to-severe pemphigus.

HLA-E*0101/0103X is Associated with Susceptibility to Pemphigus Vulgaris: A Case-control Study

Pemphigus vulgaris (PV) is a life-threatening, autoimmune blistering disease of the skin and mucous membranes. The relationship between PV and human leukocyte antigen (HLA) has been studied in several reports. Previous reports have demonstrated that HLA-E polymorphisms may have a role in the susceptibility to various autoimmune diseases. Our aim was to evaluate the role of HLA-E gene polymorphisms in the pathogenesis of PV in a Turkish population. A total of 49 patients with PV and 50 healthy subjects were enrolled into the study. We sequenced and analyzed the HLA-E gene from genomic DNA obtained from peripheral blood samples of the study groups. HLA-E haplotyping was performed by Sanger sequencing of PCR products of the HLA-E gene and HLA-E alleles determined by using SeqScape® software according to the World Health Organization (WHO) Nomenclature Committee for Factors of the HLA System. The frequency of the HLA-E*0101/*0103X genotype in male patients with PV was found to be significantly higher than in men in the control group (P=0.023). In addition, the frequency of the HLA-E*0103X/*0103X genotype was significantly lower in patients with PV than the control group (P=0.040). We also detected that the frequency of the HLA-E*0101/*0103X genotype in patients with mucocutaneous type PV and the frequency of the HLA-E*0101/*0101 genotype in patients with mucosal type PV was significantly higher than those in other types of PV (P=0.001 and P=0.006). The results of this study indicate that carrying the HLA-E*0101/0103X genotype may increase the risk of PV in male patients.

Epidemiology of Pemphigus in Turkey: One-year Prospective Study of 220 Cases

Pemphigus is a group of rare and life-threatening autoimmune blistering diseases of the skin and mucous membranes. Although they occur worldwide, their incidence shows wide geographical variation, and prospective data on the epidemiology of pemphigus are very limited. Objective of this work is to evaluate the incidence and epidemiological and clinical features of patients with pemphigus in Turkey. All patients newly diagnosed with pemphigus between June 2013 and June 2014 were prospectively enrolled in 33 dermatology departments in 20 different provinces from all seven regions of Turkey. Disease parameters including demography and clinical findings were recorded. A total of 220 patients were diagnosed with pemphigus during the 1-year period, with an annual incidence of 4.7 per million people in Turkey. Patients were predominantly women, with a male to female ratio of 1:1.41. The mean age at onset was 48.9 years. Pemphigus vulgaris (PV) was the commonest clinical subtype (n=192; 87.3%), followed by pemphigus foliaceus (n=21; 9.6%). The most common clinical subtype of PV was the mucocutaneous type (n=83; 43.2%). The mean Pemphigus Disease Area Index was 28.14±22.21 (mean ± Standard Deviation). The incidence rate of pemphigus in Turkey is similar to the countries of South-East Europe, higher than those reported for the Central and Northern European countries and lower than the countries around the Mediterranean Sea and Iran. Pemphigus is more frequent in middle-aged people and is more common in women. The most frequent subtype was PV, with a 9-fold higher incidence than pemphigus foliaceus.

Pemphigus. S2 Guideline for diagnosis and treatment--guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV)

BACKGROUND

Pemphigus encompasses a group of life-threatening autoimmune bullous diseases characterized by blisters and erosions of the mucous membranes and skin. Before the era of immunosuppressive treatment, the prognosis of pemphigus was almost fatal. Due to its rarity, only few prospective controlled therapeutic trials are available.

OBJECTIVES

For this reason, a group of European dermatologists with a long-standing interest and expertise in basic and clinical pemphigus research has sought to define diagnostic and therapeutic guidelines for the management of patients with pemphigus.

RESULTS

This group identified the statements of major agreement or disagreement regarding the diagnostic and therapeutic management of pemphigus. The revised final version of the pemphigus guideline was finally passed on to the European Dermatology Forum (EDF) for a final consensus with the European Academy of Dermatology and Venereology (EADV) and the European Union of Medical Specialists (UEMS).

Adalimumab in recalcitrant severe psoriasis associated with atopic dermatitis

Tumor necrosis factor-α inhibitors may induce various cutaneous side effects including eczematous-like lesions. The management of such side effects can be challenging. Herein, we report a case of a 55-year-old man who had a flare-up and subsequent improvement of atopic dermatitis during treatment of severe psoriasis with adalimumab.

Spitz nevus arising upon a congenital glomuvenous malformation

There are several reports of the collision of vascular and pigmentary anomalies (e.g., phakomatosis pigmentovascularis) and the association between congenital melanocytic nevi and infantile hemangiomas. We report a case of Spitz nevus arising in skin overlying a congenital plaque-like glomuvenous malformation (GVM). This is the first report of a Spitz nevus arising in direct contiguity to a GVM.

Lipoprotein-associated phospholipase A2 level in patients with Behçet's disease

BACKGROUND

Behçet's disease (BD) is a chronic multisystem inflammatory disorder characterized by vasculitis. Vasculitis is thought to underlie many of the clinical manifestations of Behçet's disease. Lipoprotein-associated phospholipase A2 (Lp-PLA2 ) is a highly specific biomarker for vascular inflammation, and has low biological variability. Those features make it more attractive than other inflammatory markers including C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), which may reflect systemic inflammation non-specifically.

OBJECTIVES

It was aimed to investigate circulating Lp-PLA2 levels and its relationship with CRP and ESR in patients with BD by considering disease activity.

METHODS

Study group included 72 patients with BD (34 men and 38 women with a mean age of 35.3 years) and 30 sex- and age-matched healthy subjects (15 men and 15 women with a mean age 32.6 years). Patients group included 40 patients with active and 32 patients with inactive BD.

RESULTS

Lp-PLA2 , CRP and ESR levels were found to be significantly higher in patient group than controls. In addition, those levels were also significantly higher in patients with active BD than in patients with inactive disease. Lp-PLA2 showed positive correlations with CRP and ESR (r = 0.63, P < 0.05 and r = 0.33, P < 0.05 respectively). Lp-PLA2 also showed significant important area under curve (AUC) value (0.779), besides CRP (0.941) and ESR (0.888). Optimum cut-off value was obtained as 218.5 ng/mL.

CONCLUSIONS

It was concluded that Lp-PLA2 may be a new useful biomarker to evaluate clinical or subclinical activity of the disease besides CRP and ESR.

Detection of linear IgE deposits in bullous pemphigoid and mucous membrane pemphigoid: a useful clue for diagnosis

BACKGROUND

Bullous pemphigoid (BP) is an autoimmune subepidermal blistering disease of the skin associated with IgG autoantibodies to BP180 and BP230, while mucous membrane pemphigoid (MMP) comprises a heterogeneous group of autoimmune blistering diseases characterized by a predominant mucous membrane involvement and scarring tendency associated with an autoantibody response to various autoantigens, including BP180. While the pathogenicity of IgG autoantibodies to BP180 has been demonstrated in BP, the role of IgE autoantibodies in mediating tissue damage in BP and MMP is unclear.

OBJECTIVES

To assess the presence of tissue-bound IgE in patients with BP and MMP, and their correlation with distinct clinical features.

METHODS

In this retrospective study, we assessed the presence of IgE deposits as detected by direct immunofluorescence microscopy of skin biopsy specimens obtained from 44 and 13 patients with a new diagnosis of BP and MMP, respectively. Distinct clinical features at time of diagnosis, such as itch, urticarial papules and plaques and eczematous lesions, were noted.

RESULTS

In 18 of 44 (41%) patients with BP linear deposits of IgE of variable intensity were detectable along the dermoepidermal junction. In 14 (32%) of the cases, IgE deposits were found concomitantly with IgG and C3. In two (5%) patients, diagnosis of BP was based on the isolated detection of IgE together with consistent clinicopathological features. Nine of 13 (69%) patients with MMP also exhibited linear IgE deposits, including one case with isolated linear IgE deposits. Patients with BP with tissue-bound IgE deposits had clinically significant urticarial papules and plaques when compared with patients with BP without IgE deposits.

CONCLUSIONS

Our findings indicate that demonstration of tissue-bound IgE deposits provides an additional useful criterion for diagnosis of BP and MMP in some patients. Prospective studies are needed to better correlate the presence of tissue-bound and circulating IgE autoantibodies and their specificity with distinct clinical features and course of BP and MMP.

Pontocerebellar hypoplasia associated with nevoid hyperpigmentation and dysmorphic findings: a new subtype?

Pontocerebellar hypoplasia consists of a rare heterogeneous group of congenital neurodevelopmental disorders characterized by hypoplasia and atrophy of the cerebellar cortex, dentate and pontine nuclei, and inferior olives. Lineer nevoid hyperpigmentation is a rare skin condition characterized by whorls and streaks of hyperpigmented macules in a reticulate pattern along Blaschko's lines. Herein we present a three year-old male patient with pontocerebellar hypoplasia associated with nevoid hyperpigmentation on the upper part of the body. Besides he has some dysmorphic features including microcephaly, triangular chin, long philtrum, long hand fingers, flexion contracture in all of the distal phalanges of both hands, and strabismus.

Erythema dyschromicum perstans: Response to dapsone therapy

Erythema dyschromicum perstans (EDP) is a rare disorder characterized by asymptomatic, slowly progressive, ash-gray macular pigmentation of the skin, which usually occurs from age 5 years through adult life. Most cases reported to date are of Latin American and Indian patients. Rare cases have been reported from Turkey. No treatment of choice is presently available. Various therapies have been tried, including sun protection, chemical peels, antibiotics, corticosteroids, vitamins, isoniazid, griseofulvin, and chloroquine, without any benefit. Some authors have suggested the therapeutic efficacy of clofazimine and dapsone on EDP. We report a case of EDP that responded remarkably well to treatment with dapsone.