Cutaneous adverse effects associated with terbinafine therapy: 10 case reports and a review of the literature.

Terbinafine is an allylamine antifungal agent widely used to treat dermatophyte onychomycosis and dermatomycoses. We report 10 severe cutaneous adverse reactions associated with terbinafine therapy which required discontinuation of the antifungal agent: erythema multiforme (five patients), erythroderma (one), severe urticaria (one), pityriasis rosea (one) and worsening of pre-existing psoriasis (two patients). The spectrum of cutaneous adverse effects associated with terbinafine therapy is reviewed. Patients should be counselled about discontinuing terbinafine at the onset of a cutaneous eruption and about seeking medical advice about further management.

Clinical and immunologic studies in reticular erythematous mucinosis and Jessner's lymphocytic infiltrate of skin.

BACKGROUND: Little is understood about reticular erythematous mucinosis and Jessner's lymphocytic infiltrate of skin. OBJECTIVE: Our purpose was to define reticular erythematous mucinosis and Jessner's lymphocytic infiltrate of skin further with focus on immunologic studies. METHODS: In patients with reticular erythematous mucinosis and Jessner's lymphocytic infiltrate of skin, we measured circulating immune complexes before, during, and after therapy. We examined natural killer cells in a functional assay; we performed direct immunofluorescence and T- and B-cell marker studies in skin biopsy specimens. RESULTS: The infiltrate in reticular erythematous mucinosis is composed of helper T cells. Circulating immune complexes are increased in both reticular erythematous mucinosis and Jessner's lymphocytic infiltrate of skin and decrease with hydroxychloroquine therapy and clinical clearing. Natural killer cell function is decreased in reticular erythematous mucinosis and Jessner's lymphocytic infiltrate of skin. CONCLUSION: Changes in circulating immune complex titers accompanying therapy with hydroxychloroquine and clinical clearing, with recurrence of the condition and increase in circulating immune complexes on discontinuation of treatment, point to a possible relation between these events.

Generalized nodular cutaneous pseudolymphoma associated with phenytoin therapy. Use of T-cell receptor gene rearrangement in diagnosis and clinical review of cutaneous reactions to phenytoin.

The first reported case of phenytoin-induced generalized nodular cutaneous pseudolymphoma without symptoms of the phenytoin hypersensitivity syndrome is presented. Despite the malignant histologic appearance of the dermal infiltrate, T-cell receptor gene rearrangement studies did not demonstrate monoclonality. The cutaneous nodules resolved within 2 weeks after discontinuation of phenytoin therapy. The literature is reviewed with regard to the spectrum of cutaneous reactions to phenytoin and particularly with regard to the occurrence of lymphoma, pseudolymphoma, and phenytoin hypersensitivity syndrome. We suggest the use of T-cell receptor gene rearrangement studies in similar situations of phenytoin hypersensitivity syndrome and lymphadenopathy. A brief period of discontinuation of the drug will demonstrate the regression associated with benign lymphoproliferation and will forestall needless treatment.

Immunophenotypic and genotypic characterization of lymphomatoid papulosis.

BACKGROUND: Lymphomatoid papulosis (LyP) is a chronic dermatosis that histologically resembles malignant lymphoma. Thus far, only a few cases of LyP have been characterized in detail with regard to immunophenotype, genotype, and karyotype. OBJECTIVE: Our purpose was to study seven patients with LyP and compare the results to those reported in the literature. METHODS: Skin biopsy specimens were analyzed by frozen section immunohistochemical and molecular biologic techniques. Cytogenetic analysis was also performed in three cases. RESULTS: The atypical lymphoid cells consisted of activated helper T cells; four of the seven patients had lesions with a detectable clonal T-cell population. A peripheral T-cell lymphoma developed in one patient before the emergence of a genotypically different LyP T-cell clone. Cytogenetic studies were abnormal in one case of LyP and normal in another, whereas the karyotype of the lymphoma was abnormal. CONCLUSION: LyP is a preneoplastic proliferation of activated helper T cells, which is often clonal and may regress and expand with the development of new LyP clones or lymphoma.

Treatment of infantile cystic acne with oral isotretinoin: a case report.

Infantile cystic acne is rare, and its etiology is not clearly defined. Our patient had comedones at 2 months of age that were recalcitrant to multiple-antibiotic regimens. His condition worsened, and he was diagnosed with infantile cystic acne at 10 months of age and started on a trial of oral isotretinoin (Accutane). A five-month treatment period using doses ranging from 0.36 to 0.67 mg/kg was necessary to achieve adequate control. Oral isotretinoin may be safe and effective in cases of recalcitrant infantile acne, but we advocate close monitoring because of the well-known side effects of oral retinoids.

Congenital candidiasis limited to the nail plates.

Numerous case reports have been published of patients with cutaneous congenital candidiasis and neonatal candidiasis; however, this is the first reported case of congenital candidiasis confined to the nail plates. A subplacental candidal abscess, funisitis, and demonstration of hyphal invasion of fetal nail plates supported the diagnosis.

LN-3: a diagnostic adjunct in cutaneous graft-versus-host disease.

Expression of HLA Class II antigen on keratinocytes has been advocated as a diagnostic marker of acute graft-versus-host disease (GVHD). LN-3 is a murine monoclonal antibody marking an HLA Class II antigen that survives formalin fixation and paraffin embedding. We analyzed the LN-3 staining pattern on 56 skin biopsies from patients treated with bone marrow or peripheral stem cell transplantation, non-transplant patients receiving conventional chemotherapy and/or radiation therapy and controls. Keratinocyte staining, endothelial staining, and the number of epidermal and dermal Langerhans cells were evaluated and analyzed with respect to the histologic and clinical diagnosis in a blind and retrospective fashion. The most predictive parameter for GVHD was marking of endothelial cells by LN-3 which was present in 12 of 16 (75%) biopsies from patients with GVHD. Endothelial staining was found in a total of 19 biopsies of which 12 (63%) had GVHD. These data suggest that LN-3 immunohistochemistry may help identify cutaneous GVHD and discriminate it from conditions that are histologically similar.

Lymphomatoid papulosis and progression to T cell lymphoma: an immunophenotypic and genotypic analysis.

A 37-year-old white man had untreated lymphomatoid papulosis for 12 years before a submandibular T cell immunoblastic lymphoma developed. A genetic abnormality, composed of extra chromosomal material attached to the short arm of chromosome 9, was detected in the lymphoma tissue but not in the skin. The lymphomatoid papulosis skin lesions did not manifest clonal T cell receptor gene rearrangements, but the submandibular lymphoma tissue was clonal and of T cell lineage. The patient's lymphoma responded well to combination chemotherapy, but the lymphomatoid papulosis remains active.

Reticular erythematous mucinosis and thrombocytopenic purpura. Report of a case and review of the world literature, including plaquelike cutaneous mucinosis.

A case of reticular erythematous mucinosis associated with chronic idiopathic thrombocytopenic purpura and circulating immune complexes is described. We compare reticular erythematous mucinosis with the similar plaquelike cutaneous mucinosis. We discuss the apparent photosensitivity of reticular erythematous mucinosis and its possible relationship with altered states of immune function such as diabetes, thyroid disease, and neoplasia. The somewhat varied but characteristic histopathologic findings and staining are reviewed, including the characteristic perivascular and occasional perifollicular lymphocytic infiltrate and Alcian blue-positive dermal mucin. Treatment with antimalarial drugs still appears to be the most uniformly successful therapeutic approach to the management of this chronic dermatosis. Further research efforts should be directed at understanding its link with altered states of immune function.

Pyoderma gangrenosum or cutaneous lymphoma: a difficult clinical diagnosis.

Pyoderma gangrenosum is frequently associated with an underlying condition such as ulcerative colitis or a myeloproliferative syndrome. However, lymphoproliferative malignancies have only rarely been seen concurrently with pyoderma gangrenosum. We present the case of a patient with small lymphocytic lymphoma who noted a slowly enlarging skin ulcer that was clinically consistent with pyoderma gangrenosum. Examination of a biopsy specimen showed infiltration of the skin with lymphoma cells as well as deeper necrotic material and thrombosis of vessels that were infiltrated by lymphoma. This case illustrates the difficulty of differentiating pyoderma gangrenosum from cutaneous lymphoma clinically.

Excretion of varicella-herpes zoster virus in breast milk.

Two cases involving breast-feeding and varicella-herpes zoster virus infection are presented. The possibility of viral excretion in the breast milk and its effects on continued breast-feeding are discussed. In neither case was the virus isolated from the breast milk.