Hyperkeratotic flexural erythema responding to amoxicillin-clavulanic acid therapy: Report of four cases.

Hyperkeratotic eruptions in the flexures, especially in the inguinal region, often pose a diagnostic and therapeutic dilemma. Inguinal keratotic eruptions may be caused by various infections, inflammatory dermatoses, vesico-bullous dermatoses, nutrient deficiencies, medication allergies and other miscellaneous causes such as granular parakeratosis. We hereby report four patients who presented with idiopathic hyperkeratotic erythematous eruptions with a migratory nature involving the inguinal region and occasionally showing the histopathologic features of granular parakeratosis. All four patients showed a dramatic therapeutic response to amoxicillin-clavulanic acid combination. We suggest that 'granular parakeratosis' should be considered as a histopathologic feature rather than the diagnosis. We would prefer to label our cases as 'Hyperkeratotic Flexural Erythema'. We recommend that detailed study of skin microbiome may help identify a possible alteration in skin microbiome contributing to the pathogenesis. We briefly review strategies on characterising the skin microbiome and the latest knowledge surrounding how alterations to the skin microbial populations can contribute to some diseases.

Macular pigmentation of uncertain aetiology revisited: two case reports and a proposed algorithm for clinical classification.

Ashy dermatosis, erythema dyschromicum perstans, lichen planus pigmentosus and idiopathic eruptive macular pigmentation are various types of acquired macular hyperpigmentation disorders of the skin described in literature. However, a global consensus on the definitions of these entities is lacking. We report two cases of acquired macular (hyper)pigmentation of uncertain aetiology diagnosed as ashy dermatosis and attempt to clarify the various confusing nosologies based on existing literature. We infer that acquired small and large macular pigmentation of uncertain aetiology should be considered separate from that associated with lichen planus. We also propose a diagnostic algorithm for patients with acquired macular hyperpigmentation.

Tea tree oil gel for mild to moderate acne; a 12 week uncontrolled, open-label phase II pilot study.

BACKGROUND: The efficacy, tolerability and acceptability of a tea tree oil gel (200 mg/g) and face wash (7 mg/g) were evaluated for the treatment of mild to moderate facial acne. METHODS: In this open-label, uncontrolled phase II pilot study, participants applied tea tree oil products to the face twice daily for 12 weeks and were assessed after 4, 8 and 12 weeks. Efficacy was determined from total numbers of facial acne lesions and the investigator global assessment (IGA) score. Tolerability was evaluated by the frequency of adverse events and the mean tolerability score determined at each visit. Product acceptability was assessed via a questionnaire at the end of the study period. RESULTS: Altogether 18 participants were enrolled, of whom 14 completed the study. Mean total lesion counts were 23.7 at baseline, 17.2 at 4, 15.1 at 8 and 10.7 at 12 weeks. Total lesion counts differed significantly over time by repeated measures anova (P < 0.0001). The mean IGA score was 2.4 at baseline, 2.2 at 4, 2.0 at 8 and 1.9 at 12 weeks, which also differed significantly over time (P = 0.0094). No serious adverse events occurred and minor local tolerability events were limited to peeling, dryness and scaling, all of which resolved without intervention. CONCLUSION: This study shows that the use of the tea tree oil products significantly improved mild to moderate acne and that the products were well tolerated.

Cutaneous drug toxicity from 2,4-dinitrophenol (DNP): Case report and histological description.

The use of 2,4-dinitrophenol (DNP) has regained popularity as a weight loss aid in the last two decades due to increased marketing to bodybuilders and the increasing availability of this banned substance via the Internet. 2,4-DNP is a drug of narrow therapeutic index and toxicity results in hyperthermia, diaphoresis, tachycardia, tachypnoea and possible cardiac arrest and death. Skin toxicity from 2,4-DNP has not been reported since the 1930s. We report a case of a 21-year-old bodybuilding enthusiast who presented with a toxic exanthem after taking 2,4-DNP, and describe the first skin biopsy findings in a case of 2,4-DNP toxicity.

Mycosis fungoides: an important differential diagnosis for acquired palmoplantar keratoderma.

Mycosis fungoides is the most common subtype of primary cutaneous lymphoma and has several clinical variants. We report a 74-year-old man presenting with an acquired palmoplantar keratoderma initially diagnosed and treated as psoriasis with suboptimal improvement. Several months later the patient developed patches and plaques that were histologically consistent with mycosis fungoides. These lesions were ameliorated with the treatment of the underlying mycosis fungoides and the palmoplantar keratoderma resolved promptly with radiotherapy. This case highlights the importance of considering mycosis fungoides as an infrequent but serious cause of acquired palmoplantar keratoderma.

Dermatological problems of asylum seekers arriving on boats: a case report from Australia and a brief review.

Assessing the skin of asylum seekers, immigrants, migrant workers, tourists or even locals who return from abroad, can be a confronting task due to the possibility of such people having non-autochthonous diseases. Primary-care physicians and dermatologists need to have a systematic approach in the assessment of such dermatoses. This article describes an interesting case of possible kerosene-induced and diesel-induced skin injury in an asylum seeker arriving on a boat. Dermatological conditions in asylum seekers and a suggested template for skin assessment are discussed.

Multiple minute digitate hyperkeratosis: a proposed algorithm for the digitate keratoses.

BACKGROUND: Multiple minute digitate hyperkeratosis (MMDH) is a rare disorder of keratinization with many different names. OBJECTIVE: We present a case of MMDH and review the literature. We propose and discuss the classification the digitate keratoses, which include MMDH, lichen spinulosus, phrynoderma, spiny keratoderma, arsenical keratosis, multiple filiform verrucae, postirradiation digitate keratosis, trichodysplasia spinulosa, and hyperkeratotic spicules. We present a table of suggested and synonymous terms and propose a diagnostic algorithm for these digitate keratoses. METHODS: A literature search using PubMed and MEDLINE was performed. This included the search terms "MMDH," "familial disseminated filiform hyperkeratosis," "punctate porokeratotic keratoderma," "disseminated spiked keratosis," "minute aggregate keratosis," "digitate keratosis," "conical keratosis," "hyperkeratotic spicules," and "music box spine dermatosis." A case of MMDH in an 89-year-old woman is described. RESULTS: The digitate keratoses are presented alongside their synonymous terms and are divided into those that are generalized or localized using an algorithm. LIMITATIONS: Separate disease entities are likely to arise within the digitate keratoses with increased reporting of immunohistochemical keratin analysis and molecular genetic studies. CONCLUSION: We report a new case of MMDH and provide a clinical approach to diagnosis of the digitate keratoses.

The burden of bacterial skin infection, scabies and atopic dermatitis among urban-living Indigenous children in high-income countries: a protocol for a systematic review.

BACKGROUND: Bacterial skin infections and scabies disproportionately affect children in resource-poor countries as well as underprivileged children in high-income countries. Atopic dermatitis is a common childhood dermatosis that predisposes to bacterial skin infection. In Australia, at any one time, almost half of all Aboriginal and Torres Strait Islander children living remotely will have impetigo, and up to one-third will also have scabies. Yet, there is a gap in knowledge of the skin infection burden for urban-living Australian Aboriginal and Torres Strait Islander children, as well as atopic dermatitis which may be a contributing factor. The objective of this study is to provide a global background on the burden of these disorders in Indigenous urban-living children in high-income countries. These countries share a similar history of colonisation, dispossession and subsequent ongoing negative impacts on Indigenous people. METHODS: This protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols statement. Observational studies reporting incidence and/or prevalence data on bacterial skin infection, scabies and/or atopic dermatitis in urban-living Indigenous children in high-income countries will be included. Literature searches will be conducted in several international electronic databases (from 1990 onwards), including MEDLINE, Embase, EmCare, Web of Science and PubMed. Reference lists and citation records of all included articles will be scanned for additional relevant manuscripts. Two investigators will independently perform eligibility assessment of titles, abstract and full-text manuscripts, following which both investigators will independently extract data. Where there is disagreement, the senior author will determine eligibility. The methodological quality of selected studies will be appraised using an appropriate tool. Data will be tabulated and narratively synthesised. We expect there will be insufficient data to perform meta-analysis. DISCUSSION: This study will identify and evaluate epidemiological data on bacterial skin infection, scabies and atopic dermatitis in urban-living Indigenous children in high-income countries. Where available, the clinical features, risk factors, comorbidities and complications of these common childhood skin disorders will be described. The evidence will highlight the burden of disease in this population, to contribute to global burden of disease estimates and identify gaps in the current literature to provide direction for future research. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021277288.

'Orf on the ear', in a patient with Guillain-Barré Syndrome.

We report a case of orf on an ear in a patient admitted to hospital following the onset of Guillain-Barré syndrome. While the underlying causes of Guillain-Barré syndrome are not completely understood, immune stimulation appears to play a key role in pathogenesis. Any association between orf infection and Guillain-Barré syndrome has not been documented. A 22-year-old male sheep farmer, who was previously fit and well, presented to his local hospital with a 2-day history of distal upper and lower limb paraesthesia and weakness. He was transferred to a tertiary hospital where the diagnosis of Guillain-Barré syndrome was confirmed. History revealed that he had experienced a mild respiratory illness 3 weeks prior to presentation and an inflamed nodular lesion over his left ear, which had appeared 2 weeks prior to admission. Differential diagnoses of orf, atypical mycobacterial infection, subcutaneous mycosis and a squamous cell carcinoma were considered. Histopathology from a biopsy of the lesion was consistent with orf, which was confirmed by polymerase chain reaction testing. This case is of interest for two reasons: orf has not been described in association with Guillain-Barré syndrome, and orf on the ear is uncommon.

Cutaneous Signs in Dermatological Diseases; An Overview.

Cutaneous signs in dermatology are pathognomonic or diagnostic for certain conditions. A knowledge of these signs is a useful skill, which must not be forgotten in the recent trend towards relying on molecular biology and other investigative tools including histological findings to make a diagnosis. The aim of this review is to summarize all cutaneous signs in dermatology in a systematic way that would benefit dermatologists, trainee or experienced, in identifying diseases and sharpening their clinical skills. A keyword search for the terms "cutaneous signs," "sign" AND "dermatology" was conducted through PUBMED, Google, and the major textbooks in dermatology (i.e., Rooks Textbook of Dermatology; Fitzpatrick's Dermatology in General Medicine and Dermatology). References were searched thoroughly for all cutaneous signs described. One hundred and nineteen signs were noted and summarized under the following categories: autoimmune, infective, inflammatory, neoplastic, genetic, trauma/miscellaneous. This review would serve as a good reference for those wanting to improve their clinical acumen in diagnosing dermatological disease.

A global consensus statement on ashy dermatosis, erythema dyschromicum perstans, lichen planus pigmentosus, idiopathic eruptive macular pigmentation, and Riehl's melanosis.

Ashy dermatosis (AD), lichen planus pigmentosus (LPP), erythema dyschromicum perstans (EDP), and idiopathic eruptive macular pigmentation are several acquired macular hyperpigmentation disorders of uncertain etiology described in literature. Most of the published studies on these disorders are not exactly comparable, as there are no clear definitions and different regions in the world describe similar conditions under different names. A consensus on the terminology of various morphologies of acquired macular pigmentation of uncertain etiology was a long-felt need. Several meetings of pigmentary disorders experts were held to address this problem. A consensus was reached after several meetings and collation of e-mailed questionnaire responses and e-mail communications among the authors of publications on the above conditions. This was achieved by a global consensus forum on AD, LPP, and EDP, established after the 22nd International Pigment Cell Conference held in Singapore in 2014. Thirty-nine experts representing 18 countries participated in the deliberations. The main focus of the deliberations was terminology of the conditions; as such, we present here the consensus statement of the forum and briefly review the available literature on the subject. We have not attempted to discuss treatment modalities in detail.

Painful Leg Ulceration in a Poorly Controlled Hypertensive Patient: A Case Report of Martorell Ulcer.

Martorell ulcer is a form of lower limb ulceration, preceded by a small area of excruciating pain. It often appears as a solitary lesion on the outer aspect of the lower limb, and is primarily associated with poorly controlled hypertension and diabetes. Treatment of the ulcer involves awareness and early correct diagnosis, adequate control of blood pressure, management of infection, and wound care. We describe a 77-year-old diabetic and hypertensive woman presenting with excruciating pain in her right lower lateral leg leading to a necrotic ulcer. Serial photographs of the evolution of the lesion and eventual healing of the ulcer are presented.