Management of a Trichophyton tonsurans outbreak in a day-care center.

Trichophyton tonsurans is the leading cause of tinea capitis in the United Kingdom (UK) as well as causing tinea corporis. This organism has been linked to several outbreaks in the UK and abroad, and such outbreaks may be prolonged since T. tonsurans can be difficult to control. There remains an incomplete consensus in the literature on the optimal management of such outbreaks of this infection. Following notification that a child with T. tonsurans was identified at a day-care center in the UK, initial investigations identified nine cases of fungal infection involving children and staff over the previous 7 months. We report on the management of an outbreak of T. tonsurans tinea capitis and tinea corporis among children and staff in a day-care center. An outbreak control team with representatives from dermatology, microbiology, day-care center management, and the Health Protection Agency initiated case ascertainment by scalp inspection and brushing of all children and staff at the nursery. Two complete rounds of screening were required before the outbreak was declared over. Infection control measures included antifungal shampoo use, exclusion of identified cases for a short period, removal of shared items from the center, and enhanced decontamination of fomites. The outbreak, which lasted longer than 12 months, involved 12 children and 7 staff members. Of these, 12 cases were confirmed by positive fungal culture. T. tonsurans is difficult to manage, especially in childcare settings, but case ascertainment, appropriate treatment with oral agents, and sustained infection control measures can be effective in controlling such outbreaks.

Eccrine nevus affecting the forearm of an 11-year-old girl successfully controlled with topical glycopyrrolate.

Eccrine nevi are rare lesions characterized by a sharply demarcated area of localized hyperhidrosis. We present an 11-year-old girl with an eccrine nevus on her right lower forearm. To the best of our knowledge, this is the first case successfully controlled with topical glycopyrrolate wipes.

Solar urticaria confined to areas of bruising.

Solar urticaria is a rare immunoglobulin E-mediated photodermatosis characterized by the development of a pathognomic wheal and flare within minutes of photoexposure. A 26-year-old man presented with a history of sun-induced urticaria only in areas of pre-existing bruising, which we were able to replicate with monochromator testing. We were also able to demonstrate, by autologous in vitro studies, that a serum factor was responsible.

Clinical and genetic heterogeneity of erythrokeratoderma variabilis.

The skin disease erythrokeratoderma variabilis (EKV) has been shown to be associated with mutations in GJB3 and GJB4 encoding connexin (Cx)31 and Cx30.3, respectively. Gap junctions composed of Cx proteins are intracellular channels providing a mechanism of synchronized cellular response facilitating metabolic and electronic functions of the cell. In the skin, Cx31 and Cx30.3 are expressed in the stratum granulosum of the epidermis with a suggested role in late keratinocyte differentiation. Molecular investigations of GJB3 and GJB4 were performed in five pedigrees and three sporadic cases of EKV. Mutational analyzes revealed disease-associated Cx31 or Cx30.3 mutations in only three probands of which two were novel mutations and one was a recurrent mutation. These genetic studies further demonstrate the heterogeneous nature of the erythrokeratodermas as not all individuals that were clinically diagnosed with EKV harbor Cx31 or Cx30.3 mutations.

Mucocutaneous leishmaniasis presenting as facial cellulitis.

We report a case of mucocutaneous leishmaniasis caused by Leishmania viannia braziliensis. Despite several courses of both oral and intravenous antibiotics no improvement was seen. This case highlights the importance of taking a thorough history, including details of recent travel, and considering rarer causes when no improvement with antibiotics is seen. Our patient was infected with a particularly virulent strain and destruction of the mucous membranes is not uncommon. Rapid diagnosis and treatment are therefore crucial.

Progressive multilayered banded skin in Winchester syndrome.

Winchester syndrome is a rare genetic disorder, one of the inherited osteolysis disorders which are a group of diseases characterized by destruction and resorption of affected bones with consequent skeletal deformities and functional impairment. The syndrome is characterized by dissolution of carpal and tarsal bones with generalized osteoporosis, progressive joint contractures, short stature, peripheral corneal opacities, and coarse facial features, though there is variability within the clinical features. Phenotypic heterogeneity of cutaneous features are also reported to date of diffusely thickened leathery skin, hypertrichosis, patches of hyperpigmented, hypertrichotic leathery skin in annular or linear distribution, widespread acne, subcutaneous nodules, and gingival hypertrophy. We describe widespread progressive multilayered symmetrical restrictive banding of the skin developing in a woman with Winchester syndrome during her mid-twenties.