residents’corner april 2014. squiz your knowledge!: multiple nodular lesions on the leg
TRANSCRIPT
EJD, vol. 24, n◦ 2, March-April 2014 281
topical treatments for actinic keratosis have been investi-gated and the need for efficient field-directed treatmentshas been recognised, in order to prevent progression tosquamous cell carcinoma and local recurrence in high-riskpatients.Candidate field-directed treatments require a mechanism ofaction which has an effect on field cancerisation; immediateand long-term efficacy against visible lesions and sub-clinical actinic keratoses. Compared with other possibletreatments (namely: ingenol mebutate, 5-FU, imiquimod,photodynamic therapy and chemical peels), the authors con-clude that the efficacy and tolerability profile of topicaldiclofenac 3% in 2.5% hyaluronic acid gel make it anappropriate candidate for consideration as a field-directedtreatment for actinic keratoses.
References
1. Bircher A, Scherer Hofmeier K. Tolerance induction in hypersensi-tivity reactions from drugs: a brief overview. Eur J Dermatol 2014; thisissue.2. Barbaud A, Goncalo M, Bruynzeel D, Bircher A. Guidelines for per-forming skin tests with drugs in the investigation of cutaneous adversedrug reactions. Contact Dermatitis 2001; 45: 321-8.3. Kim B, Choi JK, Jung HJ et al. Effects of topical application of arecombinant staphylococcal enterotoxin A on DNCB and dust miteextract-induced atopic dermatitis-like lesions in a murine model. EurJ Dermatol 2014; this issue.4. Kamada N, Seo SU, Chen GY, Núnez G. Role of the gut micro-biota in immunity and inflammatory disease. Nature Rev Immunol2013; 13: 321-35.5. Urrez, R, Pelegay, J. Impact of obesity on the effectiveness of adal-imumab for the Treatment of psoriasis: a retrospective study of 30patients in daily practice. Eur J Dermatol 2014; this issue.6. Puig L. Obesity and psoriasis: body weight and body mass indexinfluence the response to biological treatment. J Eur Acad DermatolVenereol 2011; 25: 1007-11.
Figure 1. Non-pitting edema of the right leg covered bymultiple, firm, exophytic, tense, coalescing, cobblestone-likeerythematous-to-hyperpigmented papules and nodules on theright popliteal cavity.
7. Reich K. The concept of psoriasis as a systemic inflammation:implications for disease management. J Eur Acad Dermatol Venereol2012; 26(Suppl 2): 3-11.8. Ulrich M, Pellacani G, Ferrandiz C, Lea J. Evidence for field can-cerisation treatment of actinic keratoses with topical diclofenac inhyaluronic acid. Eur J Dermatol 2014; this issue.
doi:10.1684/ejd.2014.2358
Residents’corner April 2014.sQUIZ your knowledge!: Multiple nodularlesions on the leg
Massimiliano GALEONE, Andrea BASSI
Department of Surgery and Translational Medicine, Division ofDermatology, University of Florence, Florence, Italye-mail: [email protected]
A 71-year-old man was referred to our clinic with a 4-yearhistory of progressive lymphedema and multiple nodularlesions of the right leg (figure 1). His medical history wassignificant for essential hypertension and recurrent genitalherpes. The patient reported no history of trauma, surgeryor radiation and no travel outside of Italy. Histological examrevealed hyperkeratosis, parakeratosis and acanthosis ofthe epidermis, loss of dermal papillae, fibrosis of the der-mis and subcutaneous tissues and dilated lymphatic vessels(figure 2). Special stains for mycobacteria and fungi werenegative.
What is your diagnosis (figures 1-2)? Theanswer is on the next page.
Figure 2. Histological features of a nodular lesion.
282 EJD, vol. 24, n◦ 2, March-April 2014
The answer to sQuiz: Elephantiasisnostras verrucosa
On this basis, a diagnosis of elephantiasis nostras verrucosa(ENV) was made. The patient refused any surgical inter-vention and he was treated with oral etretinate and topicalemollients without noticeable improvement.ENV is an uncommon and singular array of dermatologicmanifestations that can complicate chronic lymphedema.ENV can be diagnosed clinically with history and physi-cal examination alone. Skin biopsy and imaging techniquescan rule out other causes of secondary lymphedema,such as obstructive malignancy. Differential diagnosesinclude chromoblastomycosis, filariasis, lipodermatoscle-rosis, venous stasis dermatitis, verrucous carcinoma,papular mucinosis and pretibial myxedema [1, 2]. �
References
1. Dean SM, Zirwas MJ, Horst AV. Elephantiasis nostras verru-cosa: an institutional analysis of 21 cases. J Am Acad Dermatol2011; 64: 1104-10.2. Baird D, Bode D, Akers T, Deyoung Z. Elephantiasis Nostras Ver-rucosa (ENV): a complication of congestive heart failure and obesity.J Am Board Fam Med 2010; 23: 413-7.
doi:10.1684/ejd.2014.2359
Residents’corner April 2014.DeRmpath & Clinic: Differential diagnosisof two psoriasiform dermatoses
Ana Rita TRAVASSOS1, Luís SOARES-DE-ALMEIDA1,2
1 Dermatology Department, Hospital de Santa Maria, Centro HospitalarLisboa Norte, Lisboa, Portugal2 Faculty of Medicine, University of Lisboa, Lisboa, Portugale-mail: [email protected]
Case 1: A 43-year-old healthy male with a recurrent chronicdermatosis, characterized by thick plaques covered with asilvery white scale, localized on the extensor surfaces of theknees, elbows, trunk and scalp.
Case 2: A 46-year-old male with no relevant pastmedical history. A five-month history of a diffuse, ery-thematous, scaly, cutaneous eruption, with craniocaudalprogression, characterized by reddish-orange colored scal-ing plaques with well defined borders, covering almostthe entire body, sparing some areas on the trunk andlimbs.Certain histopathologic features are common to bothentities, such as parakeratosis, elongated rete ridges,increased number of mitotic figures in the epidermal ker-atinocytes and the presence of lymphocytes in a sparseinfiltrate of inflammatory cells. However, there are somespecific features, which help to distinguish the twodiseases.In the first case (figures 1A and 2A), the following findingsare observed:
– Parakeratosis, mostly confluent;– Presence of neutrophils in the cornified layer (Munro’smicroabscesses) and in the epidermis (subcorneal spongi-form pustules of Kogoj);– Long rete ridges, of approximately equal length, with aclub-like appearance of the fusion tips;– Thinning of suprapapillary plates;– Absent/thin granular cell layer;– Dilated, tortuous capillaries in dermal papillae;– Lymphocytic superficial dermal infiltrate.
In the second case (figures 1B and 2B) we observe:
– Psoriasiform hyperplasia;– Hyperkeratosis with parakeratosis alternating withorthokeratosis in both vertical and horizontal directions(chessboard pattern);– No neutrophils in the cornified layer;– Preservation of the granular zone across the entire frontof a section;– Rete ridges longer than normal, but not thin and not ofeven length;– Thick suprapapillary plates:– Spar se lymphocytic superficial perivascular dermal infil-trate.
Diagnosis: Case 1: Psoriasis Case 2: Pityriasis rubrapilaris (PRP)The differential diagnosis of these two entities is still a con-troversial issue and, in fact, some authors still believe thatthe two diseases are indistinguishable from one another byconventional microscopy.