The course and prognosis of pemphigus in 47 Tunisian patients.

BACKGROUND: Pemphigus is a severe and life-threatening autoimmune bullous dermatosis. OBJECTIVE: We have analysed parameters that may influence prognosis of pemphigus (P). METHODS: It was a retrospective study (2002-2010), with pemphigus considered as severe if body surface involvement ≥ 30%. Disease control and relapse-free survival (Kaplan-Meier) were analysed and compared according to several parameters (P < 0.05). RESULTS: 47 cases of pemphigus were collected, mean age 51 years ± 16.8 (F/H = 3.27). There were 30 pemphigus profundus and 17 superficial pemphigus. The median remission period was of 9 months (1.2 months-5 years). The mean healing time was of 40 days (6 days-4 months), which did not depend on type of P, its severity or infectious complications, whereas it was shorter in aged patient (≥ 65 years) compared to non aged ones (P = 0.018). 36.2% of patients had relapsed. Relapses were significantly more frequently observed only in the presence of mucosal involvement at presentation (P = 0.015). The median overall 1st relapse-free survival was of 2.33 years. Only mucosal involvement at presentation was associated with a shorter median 1st relapse-free survival time (1.28 years vs. 3 years) (P = 0.0017). Mortality rate was of 10.6% (n = 5); in four patients the death was directly related to pemphigus and occurred rapidly after the onset of lesions. CONCLUSION: Our study illustrates the poor prognosis of pemphigus by a long duration to disease control, a high initial dose of oral steroid, a high rate of relapse and a short remission period. Only mucosal involvement at presentation was identified as a poor prognostic factor.

[Pyoderma gangrenosum: 6 cases]. / Le pyoderma gangrenosum: à propos de 6 observations.

Pyoderma gangrenosum (PG) is an uncommon extensive cutaneous ulceration belonging to the neutrophilic disease spectrum. It is associated to a systemic disease in almost 50% of cases. The diagnosis primarily relies on clinico-pathological features and the treatment is empirical. We report a retrospective series of 6 observations of PG (4 women and 2 men, median age = 43 years) enrolled over 15 years. The diagnosis was established based on the presence of 2 major criteria and 2 minor criteria of the disease. In 3 patients, PG was associated to an already known ulcerative colitis. The treatment consisted in general corticotherapy.

Acquired erythroderma in adults: a clinical and prognostic study.

BACKGROUND: Erythroderma is a severe syndrome and prognostic studies are rare in the literature. OBJECTIVES: Through a retrospective study of erythroderma in adults, we have analysed epidemiological and clinical data and precised the relevant aetiologies and survival in our patients. METHODS: This study was performed at the Department of Dermatology of Charles Nicolle Hospital of Tunis (1995-2007) including 82 cases of acquired erythroderma (>16 years). We have recorded epidemio-clinical, biological and histological data, treatment and outcome. Clinical-histological correlation was analysed [kappa coefficient (kappa)]. Follow-up time and disease-free survival time were calculated as were Kaplan-Meier estimates of overall survival and relapse-free survival for some aetiologies. RESULTS: Erythroderma represented 0.44 per thousand of all dermatoses with an age of 55.13 +/- 18.16 and no sex predilection. Psoriasis was the predominant aetiology (32.9%) with a median duration of 6.75 years and previous one or more episodes of erythroderma. Psoriasis was significantly associated with pruritus (P = 0.0001), pachyonychia (P = 0.00001), palmoplantar keratoderma (P = 0.0001) and hypereosinophilia (P = 0.008). The latter is then not specific for drug induced erythroderma (P = 0.004). Carbamazepine (27.8%) and penicillin (22.2%) were the most implicated drugs. Positive Clinical-histological correlation was found in 77% of cases (kappa = 0.753). Relapse was seen in all aetiologies, but drug reactions and had occurred in the first 3 years in 90% of them. Mortality rate was 11.3 per 1000 patients-years. CONCLUSIONS: Our study illustrates the severity of erythroderma. It alters heavily the quality of life of patients which is initially altered by the pre-existent dermatosis. It may be life threatening as mortality rate is high.

[Tuberculous lupus]. / Le lupus tuberculeux.

UNLABELLED: Cutaneous tuberculosis accounts for 2% of all extrapulmonary tuberculosis and is one of the multiple clinical presentations of extrapulmonary tuberculosis. We report a case of cutaneous tuberculosis with unusual clinical and histological presentations. CASE REPORT: We report the case of a 29-year-old woman with plurifocal tuberculous lupus. Histological examination of cutaneous lesions revealed the presence of a granuloma with caseum necrosis. Chest X-ray showed a severe pulmonary tuberculosis lesion. The Mantoux test performed by intradermal injection was positive. Skin lesion PCR and sputum culture were negative. Both skin and pulmonary lesions responded to antituberculous treatment. COMMENTARY: Lupus vulgaris is commonly presents on the head and neck. The diagnosis may be difficult when lupus vulgaris occurs at unexpected sites or in unusual clinical presentations. Caseum necrosis observed in our patient was unusual.

Cutaneous sarcoidosis in Tunisia.

AIM: Sarcoidosis is a multisystem disease of unknown etiology characterized by granulomatous infiltration. As clinical features vary among patients from different ethnic groups and geographic areas, local reports are of great interest. The aim of this study was to make an inventory of the clinical presentation of cutaneous sarcoidosis in Tunisia. METHODS: The study was conducted in an academic teaching hospital, inpatient and outpatient department. The authors retrospectively reviewed the medical records of all patients diagnosed with sarcoidosis at the Dermatological Departement of Charles Nicolle teaching Hospital, Tunis, within a 32-year period. RESULTS: One hundred and eighteen patients were diagnosed to have sarcoidosis, corresponding to 25 males and 93 females. Mean age at presentation was 39.5 years. Childhood sarcoidosis represented 14.4% of cases. Cutaneous involvement was dominated by micronodular lesions. Chest X-rays abnormalities were present in 28 patient/93 (30.1%). Most of them were at stage 1 or 2. Peripheral lymph node enlargement was reported in 15 patients (12.7%). Other internal organ involvements corresponded to: eyes (15 cases); bones (12 cases), joints (5 cases), gasto-intestinal tract (5 cases), upper airways (5 cases), liver (4 cases), kidney ( 1 case) and muscles (1 case). Systemic involvement was noticed in 88% patients with lupus pernio. Treatment modalities included topical and oral corticosteroids, hydroxychloroquine, allopurinol and surgical excision with variables outcomes. CONCLUSION: The data of this study suggest that sarcoidosis manifests with a wide range of cutaneous lesions in Tunisian patients and that extracutaneous involvement is not rare. Remarkable clinico-epidemiological characteristics are the clear predominance in women, the high frequency of childhood cases and the predominance of micronodular skin lesions.

A study of skin diseases in Tunis. An analysis of 28,244 dermatological outpatient cases.

BACKGROUND: Epidemiological studies of skin diseases are rather rare. Most of them are based on hospital attendance. The aim of this study was to determine the spectrum of skin diseases in the Tunis region. METHODS: This prospective study encompasses consecutive patients attending a number of public or private dermatological outpatient clinics in Tunis from June 1999 to July 2000. Diagnosis was mainly based on clinical findings, but supplemented by further investigations when needed. RESULTS: The total number of patients was 28,244, with 28,515 pathological conditions reported. The mean age was 31.6 years with a M/F sex ratio of 0.82:1. Infections constituted the major group of disorders (38.6%), followed by hair follicle and sebaceous gland diseases (14.3%), allergic skin diseases (13.6%), and tumors (7.8%). Infectious diseases included fungal (16.38), viral (9.9%), and bacterial (9.24%) conditions. Dermatitis accounted for 9.9% of cases and acne for 6.9%. Tumors were mainly benign (7%) and very rarely malignant (0.5%). CONCLUSIONS: The survey revealed that more than 50% of the diseases were of infectious origin, followed by hair follicle and sebaceous gland disorders. Socioeconomic status and environmental factors may be responsible for this.

Low-dose X-ray depilatory treatment induces trichoblastic tumors of the scalp.

BACKGROUND: Depilatory radiotherapy for ringworm was largely used before antifungals were available. Patients who underwent this treatment are at high risk of developing scalp tumors or other cancers. The aim of this study was to characterize scalp tumors occurring after X-ray therapy for ringworm. METHODS: We included cases of postradiotherapy scalp tumors recorded at the Dermatology Department of the Charles Nicolle Hospital, Tunis between 1988 and 2001. We recorded clinical descriptions and all cases were resubmitted to microscopic analysis. RESULTS: Sixty-one tumors occurred in 33 men and 12 women with a mean age of 49.8 years. Radiodermatitis was present in 21% of patients. Tumors were basal cell carcinomas in 47 cases, trichoblastomas in 10 cases and trichoblastic carcinomas in 4 cases. Twelve patients had 2-5 tumors, with combinations of tumor types in 3 of them. Mean delay of onset of tumors after radiotherapy was 39.4 years in basal cell carcinoma cases, 38.3 years in trichoblastoma cases and 35.6 years in trichoblastic carcinoma cases. CONCLUSIONS: This series shows that although basal cell carcinoma is the most frequent tumor in this situation, trichoblastomas are common. We describe, for the first time, radio-induced trichoblastic carcinomas. Trichoblastic tumors have not yet been described in this context because this concept is relatively recent.

Tinea faciei: a report on four cases.

Four cases of tinea faciei that were observed at the Department of Dermatology of Charles Nicolle Hospital in Tunis are reported. All patients were females, ages 54 (patient 1), 38 (patient 2), 30 (patient 3), and 50 (patient 4). The lesions lasted 1 year, 2 months, 4 months, and 1 month, respectively. Tinea faciei was initially suspected in three patients, whereas for the second patient eczema was initially suspected. She was first treated topically with corticosteroids leading to exacerbation. Through mycological examination, Trichophyton rubrum was isolated in three patients, but was negative in patient 2. Three patients recovered completely after one month of griseofulvin associated with topical terbinafine. Patient 3 was topically treated because she was pregnant. Erythematous lesions of the face must be checked for fungi.

[Skin diseases in the elderly: a multicentre Tunisian study]. / Pathologie cutanée chez le sujet âgé Etude multicentrique tunisienne.

INTRODUCTION: With progressive aging of populations, geriatric health care has become a major international issue for health authorities. However, little data is available about geriatric skin diseases. The aim of this study is to determine the pattern of skin disorders among elderly patients seen in private and public skin outpatient clinics in Tunis. PATIENTS AND METHODS: We performed a prospective, multicentre and descriptive study of all new skin diseases diagnosed in dermatological outpatients aged over 65 years. This study lasted one year (June 1999 to July 2000) and evaluated the activity of eleven Tunisian dermatologists in private or public practice, who collated all cases of skin diseases diagnosed in their practices. RESULTS: A total of 1518 patients with 1550 new diagnoses were examined. Mean age was 72.6 years with a sex M/F -ratio of 1.41. Fungal infections were the most common conditions (16.9%), followed by tumors 12.8% (benign 63.3%), eczema (11.9%), keratinization anomalies (8.7%), bacterial infections (8.7%), viral infections (6.8%) and pruritus (6.4%). Fungal infections were mainly represented by toe-web intertrigo and onychomycosis. Basal cell carcinoma and epidermoid cysts were the most common malignant and benign tumors respectively. DISCUSSION: This study reflects the frequency of mycoses, benign tumors and eczema in elderly patients. This is consistent with the results of other studies of the literature showing eczema as the predominant skin disease. The high prevalence of mycosis in our study may be explained by climatic conditions (heat, moisture). Pruritus seems to be frequent in geriatric patients. Skin disorders are an important source of morbidity in elderly patients.