Antihypertensives in dermatology Part II - Cutaneous adverse reactions to antihypertensives

Antihypertensive drugs are prescribed frequently and can cause cutaneous adverse reactions. The exact incidence and frequency of these reactions are unknown. Multiple antihypertensive drug consumption has contributed to a substantial increase in the number of cutaneous adverse reactions to them. Thus, there is a need for dermatologists and physicians to be aware of the wide range of available antihypertensives and the type of reactions that can be expected. This review article focuses on the various clinical presentations that have been implicated or associated with them. The diagnosis and management have been discussed in brief.

Chronic Graft-Versus-Host Disease Mimicking Psoriasis in a Patient with Hemophagocytic Lymphohistiocytosis

Graft-versus-host disease (GVHD) is a common complication of bone marrow transplantation (BMT) that can be classified as acute or chronic. Chronic GVHD, which usually occurs more than 3 months after BMT, includes typical lichenoid or sclerodermatous lesions. Psoriasiform eruption is a rare clinical manifestation of chronic GVHD, and there have been no reports of psoriasiform chronic GVHD associated with hemophagocytic lymphohistiocytosis. A 33-year-old woman who was diagnosed with hemophagocytic lymphohistiocytosis 10 years ago visited our outpatient clinic with psoriasiform eruption over her entire body. She underwent allogeneic BMT 7 months previously from her sibling. Skin biopsy was performed on the lesion, and the histological features suggested GVHD. The psoriasiform lesions improved with narrow-band ultraviolet B phototherapy, with secondary vitiligo remaining on the corresponding locations.

Degos’ Like Nonclear Cell Acanthoma: Could this be a New Entity.

Degos’ acanthoma is a tumor that is clinically and histologically distinct. Typically, the lesions are solitary, sharply delineated red nodules or plaques 1-2 cm in diameter, usually covered by a thin wafer like crust. On microscopy, the striking presence of pale and slightly enlarged epidermal cells is essential to clinch the diagnosis. Here we present a case where the clinical picture was that of Degos’ acanthoma with the absence of glycogen rich clear cells on histology.

A Case of Psoriasiform Dermatitis Followed by Tumor Necrosis Factor Inhibitor Treated with Phototherapy

Although tumor necrosis factor (TNF)-alpha antagonist is a successful treatment modality for various autoimmune diseases, including rheumatoid arthritis (RA), ankylosing spondylitis and psoriatic arthritis, many adverse effects have been reported. Cutaneous adverse reactions of TNF-alpha antagonist include skin rash, urticaria, lupus like rash, seborrheic dermatitis and different kinds of psoriasiform dermatitis. We report a case of psoriasiform dermatitis during TNF-alpha antagonist treatment in a 50-year-old woman with RA. The patient has been treated with adalimumab. After 2 months, she developed pruritic erythematous eruption and desquamative lesions on the head and limbs, which were defined as psoriasiform change by a skin biopsy. These skin lesions are successfully treated with combination therapy, including cessation of adalimumab, corticosteroid and phototherapy.

A Case of Psoriasiform Dermatitis Following Adalimumab Injection for Treatment of Ankylosing Spondylitis / 대한피부과학회지

Adalimumab (Humira(TM)) is the first fully humanized monoclonal TNF-alpha antibody that antagonizes the effects of TNF-alpha. Its use has been found in the treatment of various rheumatologic disorders, namely rheumatoid arthritis, Crohn's disease, and ankylosing spondylitis, as well as for various skin conditions such as psoriasis. As the use of this particular biologic agent is becoming more widespread, cutaneous adverse effects of the drug is now being reported at a steady rate. The authors herein report a case of 32 year-old female who presented with multiple psoriasiform eruptions on her trunk, back and lower extremities. She had a four-year history of ankylosing spondylitis, for which she was started on subcutaneous adalimumab injection monthly, three and a half years prior to her initial visit.

The clinical and histopathological co-relation of psoriasiform dermatoses.

Background: Psoriasiform dermatoses is a common presentation of a wide spectrum of underlying diseases from a relatively harmless disease like chronic dermatitis to a detrimental disease like mycosis fungoides. Psoriasiform reaction pattern is a commonly encountered denominator in a wide variety of unrelated disorders. They include several unrelated disorders of the integument, which either in the beginning or in the course of progression/resolution, exhibit lesions resembling psoriasis. Aims: This study was designed and conducted to enlist clinical parameters, histopathology and clinicohistopathological co-relation of psoriasiform disorders. Methodology: 100 cases of psoriasiform dermatoses over a period of two years were studied. Their history, age, sex as well as morphology, distribution and histopathology of skin lesions were analysed. Results: Psoriasis is the commonest of all psoriasiform dermatoses (31%) followed by lichen planus (23%),lichen nitidus(9%), pitryasis rosea (7%) , seborrheic dermatitis (6%). The remaining dermatoses like lichenoid drug eruptions ,parapsoriasis , Reiter’s disease , mycosis fungoides , pitryriasis rubra pilaris and lichen striatus, lichen simplex chronic etc were uncommon. There was a slight male preponderance. (M: F: 1.3:1). Lesions were more common in limbs. There was a wide age variation for example lichen striatus was seen in 5 year male and mycosis fungoides in a 69 year old male. A good clinicopathological co-relation filled up the lacunae of both, the clinical approach as well as that of histopathology and helped in pinpointing the diagnosis (62 cases). In 10 cases, there was no co-relation between clinical and histopathological diagnosis. Conclusion: As the morbidity of these disorders ranges from a trifling affliction to a life threat, thorough clinico-pathological co-relation and prompt institution of specific treatment results in a better prognosis.

A Case of Psoriasiform Tinea Corporis Caused by Microsporum canis / 대한의진균학회지

Tinea corporis is dermatophytosis of trunk and extremities except terminal hair present region. We report a case of psoriasiform tinea corporis in a 11-year-old girl. The lesions were showed multiple, pruritic, thick scaly erythematous macules and patches on the left forearm and trunk. She had been treated with topical and oral corticosteroid for 5 months. Direct microscopic examination and fungal culture were positive for hyphae and colonies of Microsporum canis. Histopathologic examination of the skin lesion revealed parakeratosis, psoriasiform epidermal hyperplasia and perivascular inflammatory infiltration in upper dermis with presence of fungal hyphae in stratum corneum. She was treated with 250mg of terbinafine daily and topical lanoconazole for 1 month. Skin lesions cured without recurrence.

Nevo epidérmico inflamatorio lineal (NEVIL): Presentación en la edad adulta / Inflammatory linear verrucous epidermal nevus (ILVEN): Late onset disease

El NEVIL es la variedad inflamatoria del nevo epidérmico; es un tumor benigno hamartomatoso, que se distribuye siguiendo las líneas de Blaschko. Estas líneas representarían mosaicismos cutáneos del desarrollo embriológico. El NEVIL suele aparecer en la infancia. Son generalmente unilaterales y en ocasiones muy pruriginosos. El diagnóstico diferencial es frecuentemente dificultoso. Presentamos una paciente en la cual la manifestación de esta patología se produce en forma tardía, siendo esto poco frecuente. El tratamiento es un desafío, se han probado múltiples modalidades terapéuticas, con resultados en ocasiones desalentadores. La cirugía, puede utilizarse en lesiones de pequeño tamaño. Los tratamientos con luz láser podrían ser de utilidad.

The ILVEN is the inflammatory variety of epidermal nevi, benign hamartomatous tumor that distributed following Blaschko lines. These lines represent cutaneous mosaicism in embryologic development. The ILVEN usually appear in the infancy. Generally unilateral and occasionally is very pruriginous. The differential diagnosis is often difficult. We present a patient in which the manifestation of her disease is produced in late onset, being this infrequent. Management is a challenge, multiple therapeutic modalities have been tested, with discouraging results. Surgery can be utilized in small size lesions. Laser therapy could be of utility.

A Case of Psoriasiform Eruption Triggered by Tumor Necrosis Factor-alpha Antagonist Therapy / 대한피부과학회지

Tumor necrosis factor-alpha antagonists include monoclonal antibodies, infliximab, adalimumab, etanercept and golimumab. Clinical trials of these agents have shown that they are remarkably effective for psoriasis, but cutaneous adverse reactions of these agents including paradoxical aggravation of psoriasiform eruption have been also reported. We present a case of psoriasiform eruption triggered by golimumab therapy in a patient with rheumatoid arthritis. A 53-year-old woman presented with a skin lesion on the sole. She had been treated by golimumab every 4 weeks for rheumatoid arthritis from September 2006. 16 weeks after the treatment, she developed a erythematous and scaly patch on the sole. She had a history of palmoplantar pustulosis, but the skin lesions had not appeared for a long time, recurring when she started golimumab treatment. The skin lesion improved with topical steroid treatment, but as golimumab was re-administrated, the skin lesion exacerbated.

Two Cases of Psoriasiform Syphilid / 대한피부과학회지

The clinical feature of secondary syphilis is of `the great imitator'. The rarity of clinical syphilis today has led to an erosion of clinical skills to determine this condition. It is important for physicians to keep in mind that any atypical skin lesions may be syphilid. We report two cases of psoriasiform syphilid in a 64-year-old man and a 45-year-old woman. They presented with multiple, erythematous to brown colored scaly papules and plaques on the abdomen, back and chest. The differential diagnosis included papulosquamous diseases, especially psoriasis. Histopathologic findings were not consistent with that of psoriasis, but consisted rather with that of interface dermatitis. Serum VDRLs were strongly positive (1: 256 and 1: 64, respectively), and TPHAs were positive, too. After intramuscular treatment with 2.4 million units of benzathine penicillin G, the skin lesions cleared within 1 month.

A Case of Psoriasiform Sarcoidosis as Early Manifestation of Systemic Sarcoidosis / 대한피부과학회지

Sarcoidosis is a granulomatous disease with undetermined etiology, and shows variable skin manifestations. Although there have been numerous reports on cutaneous sarcoidosis, the early manifestations of systemic sarcoidosis are not clearly defined. Occurrence of both psoriasiform lesions and subcutaneous nodules in the same patient is rarely seen. A 39-year-old woman had psoriasiform lesions on her extremities for 1 year, and was treated with a topical steroid and calcipotriol ointment. One and half years after the initial skin lesions, pulmonary lesions were developed and treated with anti-tuberculosis medication for three months without any improvement. Since then, subcutaneous nodules on the upper extremities subsequently developed. Histopathological examination revealed non-caseous epithelioid granulomas in subcutaneous tissue and psoriasiform lesions. Furthermore, routine laboratory tests revealed anemia, leukopenia, hypercalcemia and elevated serum level of angiotensin converting enzyme (ACE), and chest X-ray revealed disseminated air space nodules on both lungs with non-segmental distribution. Considering initial poor response to anti-tuberculosis medication and subsequent good response to systemic steroid treatment, this condition was diagnosed as systemic sarcoidosis. Since we considered psoriasiform sarcoidosis as the early cutaneous manifestation of systemic sarcoidosis, we herein reported the case.

A Case of Psoriasiform Syphilid / 대한피부과학회지

Psoriasiform lesion is rare in secondary syphilis. We report a case of psoriasiform syphilid in a 36-year-old man, who showed condyloma lata on the perianal area and multiple erythematous scaly plaques on the face, glans penis, scrotum, and both palms and soles. He had sexual contact with prostitute about 3 months ago. The differential diagnosis included papulosquamous diseases, especially psoriasis but a psoriasiform syphilid was confirmed through skin biopsies and serologic tests. The patient was treated with benzathine penicillin G 2.4 million units intramuscularly weekly for 3 weeks. After the treatment with benzathine penicillin G, the skin lesions disappeared completely.

Psoriasiform Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of undetermined etiology and pathogenesis that involves the skin and many of the internal organs. It involves any organ of the body; how-ever, the most common sites are the lung, lymph node, skin, and eye. Psoriasiform eruption is a rare morphologic manifestation of sarcoidosis. We report herein a case of 36-year-old man with psoriasiform papules on the elbows, forearms and knees of 5-year duration. Histopathologic examination revealed sarcoid granuloma throughout the dermis. This is the second case of psoriasiform sarcoidosis in Korea.

A Case of Psoriasiform Syphilid / 대한피부과학회지

Psoriasiform lesion is a rare manifestation in secondary syphilis. A 34-year-old woman patient presented with a month history of condylomata lata on the perineum and erythematous scaling psoriasiform plaque on the back. The preliminary differential diagnosis included psoriasis and lichen simplex chronicus but a psoriasiform syphilid was confirmed through skin biopsies and serologic tests. We report a case of psoriasiform syphilid.

A Case of Multiple Bowen's Disease with Atypical Psoriasiform Large Plaque Associated with Internal Malignancies / 대한피부과학회지

We report a case of multiple Bowen's disease of probable arsenic origin associated with internal malignancies. A 63-year-old man who had a history of arsenicals injections showed pruritic erythematous 11 8 cm sized psoriasiform plaque on the right flank and multiple keratotic plaques on the trunk and both extremities. He had operation on his bladder due to transitional cell carcinoma. He was found to have a bronchogenic carcinoma by chest X-ray and CT scan. We report this as an interesting case of atypical multiple Bowen's disease manifestating a psoriasiform large plaque associated with internal malignancies of lung and bladder.

A Case of Lymphocutaneous Sporotrichosis with Unusual Clinical Features / 대한피부과학회지

We report a case of lymphocutaneous sporotrichosis with unusual clinical features in a 62-year-old male patient, who presented with a painless, well-defined psoriasiform plaque and central ulceration on the dorsam of the right hand which progressively spread into the lymphatics draining area. The fully matared lesions produced a chain of firm. mild prickling subcutaneous nodules on both upper extremities probably due to autoinoculation. The biopsy specimen of the lesion showed hyperkeratosis with chronic granulomatous inflammation and PAS-positive fungal spores in the dermis. Sporothrix schenckii was identified using a fungal culture of tissue specimen. The lesions improved with treatment of a topical antifungal agent and KI solution at the dose of 2 g/day for 1 month, but returned to initial cutaneous manifestation due to the patient failing to the treatment.

A Case of Reiter' s syndrome / 대한피부과학회지

Reiters syndrome is classically described as the triad of urethritis, coijuctivitis, and arthritis along with the skin manifestation. of keratodermia blenorrhagica, circinate b lanitis and oral ulcetation. Since arthritis is now recognized as the only consistent component, iricr nplete forms consisting of characteristic arthritis associeited with one or more of these features and of dysentery are common, We reported a 48-year-old male who presented with a 3 years histor of significant arthralgia and psoriasiforrn skin involvemeni. He had neither an episode of dysentery not, history of sexual exposure before the onset of symptomes. Showed a correlation with the HLAB 7 tialotype. C-reactive protein levels were significantly elevated. He was treared with corticosteroid, pcycline, methotrexate and indomethacin for about 3 months resulting favorable improvement.