Clindamycin-induced Maculopapular Exanthema with Preferential Involvement of Striae Distensae: A Koebner phenomenon?

Clindamycin is a lincomycin-derived antibiotic useful for the treatment of anaerobic and Gram-positive aerobic bacterial infections. Cutaneous adverse reactions are usually maculopapular exanthemas, although hypersensitivity syndrome, acute generalized exanthematous pustulosis, and Stevens-Johnson syndrome have also been reported (1). We report the case of a patient with a maculopapular rash triggered by clindamycin who developed cutaneous lesions on striae distensae (SD). A 47-year-old woman was referred to our clinic for pruritic cutaneous lesions which had started 6 days earlier. Her past clinical history included hypertension, hypothyroidism, hyperuricemia, cholecystectomy, caesarean section, and endometriosis-related abdominal surgery, and she was taking levothyroxine, allopurinol, imidapril, and omeprazole. The skin rash first developed on her neck and back on the 3rd day of clindamycin oral treatment (300 mg every 6 hours), which was prescribed as antibiotic prophylaxis for a tooth implant. General malaise (but not fever) was also reported. Physical examination revealed an erythematous maculopapular eruption symmetrically distributed on the neck, abdomen, and back (Figure 1, A), with isolated lesions involving the proximal upper and lower limbs (Figure 1, B). There was a striking vertical distribution of skin lesions along the SD on the lateral sides of the abdomen (Figure 1, C). No mucosal involvement was found, and laboratory studies showed no abnormalities. Clindamycin withdrawal was followed by prescription of a course of oral deflazacort, starting at 30 mg daily and tapering down during a 9-day period. On the 5th day of treatment, the rash had almost cleared with minimal desquamation (Figure 1, D). Eight weeks after clearance of the skin rash, informed consent was obtained in order to perform an allergological evaluation of clindamycin, including prick and intradermal (ID) tests on the forearm and patch tests on the upper back (2). For patch testing, powder of the commercial capsules (Dalacin®) was diluted in petrolatum (pet.) and water (aq.), resulting in a final 1% clindamycin dilution. Parenteral clindamycin preparations were used in therapeutic concentrations for prick tests (150 mg/mL) and dilutions in saline of 1/100 and 1/10 for the ID test. Other authors have reported that these concentrations do not seem to irritate the skin (3-6). Prick and ID tests were assessed after 20 min and 24 hours, respectively. Patch tests were removed after the 2nd day, and late reactions were evaluated on day 2 and day 4. Prick and ID test results after 20 min were negative. Late results of ID tests with clindamycin (1.5 and 15 mg/mL) were positive: erythematous infiltrated papules about 7×7 mm and 18×15 mm were observed at 24 hours and lasted until the 8th day. Patch tests with clindamycin 1% in pet. and 1% in aq. were also positive (+ on day 2 and day 4). Positive late skin tests suggested delayed-type non-IgE-mediated allergic clindamycin hypersensitivity. Oral challenge tests are considered to be the gold standard to establish or exclude drug hypersensitivity. Due to the positive result of late skin test to clindamycin, oral challenge was not performed in our patient (3,5). The Koebner isomorphic phenomenon has been described in cutaneous reactions induced by drugs, such as antibiotics and chemotherapy. Chronic pressure on the skin is probably involved in the onset of skin lesions in hand-foot eruptions induced by tyrosine kinase inhibitors (sorafenib and sutinib). Solar exposure and cutaneous trauma also seem to play a role in the location of papulopustular eruptions caused by endothelial growth factor receptor inhibitors (erlotinib) (7). More frequent involvement in traumatized skin and surgical scars has been reported in the context of linear IgA bullous dermatosis and leukocytoclastic vasculitis triggered by vancomycin and cefuroxime (8). SD are produced by non-penetrating physical trauma, similar to friction or pressure. Different dermatoses can develop along SD skin lesions (like plaque psoriasis, pustular psoriasis, lichen planus, vitiligo, discoid lupus erythematosus, lupus vasculitis, urticarial vasculitis, or chronic graft-versus-host disease) (9). Bevacizumab, etretinate, and corticosteroid-induced ulcers, hyperpigmentation caused by bleomycin, and urticariform lesions triggered by diclofenac are examples of different type of drug-induced abnormalities involving SD (10). In summary, we identified clindamycin as the cause of the cutaneous reactions that occurred in our patient on the basis of the results of the skin tests and clinical history. Our findings confirmed a delayed-type hypersensitivity reaction, possibly involving a T-cell-mediated immunologic mechanism. Intradermal and patch tests were found to be useful in order to confirm the diagnosis (4,5). We did not find reports in the literature of drug-induced cutaneous eruptions along the SD as a manifestation of a Koebner phenomenon. Clinical underreporting of this phenomenon could explain the scarce literature on this cutaneous adverse reaction.

[Superimposed lichen planus pigmentosus]. / Liquen plano pigmentoso sobreimpuesto.

Lichen planus pigmentosus is an uncommon variant of lichen planus that is characterized by the insidious onset of dark brown macules in sun-exposed areas and flexural folds. Superimposed linear lichen planus is an exceedingly rare disorder, but it has been found in both lichen planopilaris and lichen planus types. A 39-year-old woman is presented showing a segmental and linear lichen planus associated with non-segmental lesions meeting all criteria for the diagnosis of superimposed linear planus pigmentosus. The segmental lesions were always more pronounced.

El control de la vida personal, social y económica: desarrollo y estudio exploratorio de una escala de medida / The Control of Personal, Social and Economic Life: Development and Exploratory Study of a Scale of Measure

En este trabajo se presenta un estudio exploratorio sobre las características psicométricas de un instrumento sobre el control de de la vida personal, analizando su estructura factorial mediante un análisis exploratorio y confirmatorio de sus dimensiones. El tamaño del estudio final fue de 8.504 entrevistas y el criterio básico de estratificación fue el distrito municipal en 21 estratos. Los resultados encontrados señalan que los ítems en cada una de las dimensiones y sus pesos factoriales son aceptables y se relacionan con enunciados genéricos sobre la atribución de control. A su vez, los índices de bondad de ajuste encontrados de cada uno de los modelos propuestos, arrojan información interesante sobre las posibilidades que este cuestionario ofrece.

The purpose of this study was to examine the characteristics psychometrics of a scale on the control of the personal life, analyzing its factorial structure by means of an exploratory and confirmatory analysis of its dimensions. The size of the final study was 8.504 interviews and the basic criterion was of stratification was the municipal district in 21 strata. The results indicate that the items in each of the dimensions and his weight factorials are acceptable and are related to generic terms of reference on the attribution of control. Also, the opposing indexes of goodness of fit of each one of the proposed models, throw interesting information about the possibilities that this scale offers.

Prevalence of milia and palatal and gingival cysts in Spanish newborns.

We performed a descriptive survey of 1,000 consecutive newborns cared for in the first 3 days of life in the health area of Ferrol (in northwest Spain) to assess the prevalence and most-frequent locations of oral cysts and milia and to study the influence of different maternal and neonatal parameters in the development of these lesions. Prevalence of palatal, gingival, and cutaneous cysts was 53.7%, 13.4%, and 16.6%, respectively. Milia were predominantly located on the cheeks, chin, and forehead. We found a frequent association between palatal and gingival cysts but not between oral cysts and milia. Neonatal factors such as sex, weight at birth, and gestational age can significantly influence the development of palatal and gingival cysts.

Prospective study of erythema toxicum neonatorum: epidemiology and predisposing factors.

We performed a prospective study of 1,000 neonates investigated in the first 72 hours of life in the health area of Ferrol (northwest of Spain) to assess the prevalence of erythema toxicum neonatorum, the anatomical sites most frequently involved, the influence of different maternal and neonatal parameters, day of life of medical examination, and type of delivery (vaginal or Cesarean). Overall prevalence of erythema toxicum neonatorum was 16.7%. Lesions most frequently involved the trunk, buttocks, and proximal areas of limbs. A higher prevalence of this dermatosis was found in Caucasian newborns (p = 0.01) and those with higher birthweight (p < 0.05), greater gestational age (p < 0.05), vaginal delivery (p < 0.05), maternal age of <30 years (p = 0.28), and fewer than two previous pregnancies (p = 0.12).

A novel heterozygous point mutation in the p63 gene in a patient with ectodermal dysplasia associated with B-cell leukemia.

We report a 7-year-old boy with a past medical history of B-cell leukemia with dysmorphic features, including cleft palate, hypotrichosis with trichorrhexis nodosa, hypohidrosis, oligodontia, and ridging of nails. A heterozygous germline mutation, Ala111Thr, in the p63 gene was detected in the boy and in his mother, who had no clinical expression. This case emphasizes the spectrum of different phenotypical manifestations of mutations in the p63 gene and underlines the possible role of this gene as a tumor suppressor.

Ischemic onycholysis of the hands.

Onycholysis is the distal and/or lateral separation of the nail from the nail bed. Although it can be idiopathic, there are several factors associated with the development of this condition. Ischemia is recognized as one of the possible causes, but this relationship has been poorly described in the literature. We report a case of onycholysis with a striking clinical picture and discuss the role of ischemia in the development of the lesions.

Pachydermodactyly in a young girl: cutaneous manifestation of a psychiatric disorder?

; Pachydermodactyly is a benign process characterized by painless fusiform skin swellings affecting radial and ulnar aspects of the proximal interphalangeal joints of the fingers. We report a case of this condition in a young girl, suggesting a major role of psychiatric disorder in the development of cutaneous lesions.

Epidermal nevus syndrome associated with polyostotic fibrous dysplasia, CNS lipoma, and aplasia cutis.

Epidermal nevus syndrome is a rare congenital sporadic neurocutaneous disorder characterized by an epidermal nevus and various developmental abnormalities of the skin, eyes, nervous, cardiovascular and urogenital systems. We describe a patient with an extensive epidermal nevus associated with various organ abnormalities, particularly polyostotic fibrous dysplasia, central nervous system lipoma, and aplasia cutis. Our patient demonstrates the polymorphic spectrum of involvement in epidermal nevus syndrome.

[Down syndrome: another cause of immunosuppression associated with multiple eruptive dermatofibromas?]. / Síndrome de Down: ¿otra causa de inmunosupresión asociada con dermatofibromas eruptivos múltiples?

The term "multiple eruptive dermatofibromas" usually refers to a clinical situation characterized by the development of between five and eight dermatofibromas during a period of up to four months. It is usually linked to immunodeficiency associated conditions as autoimmune disorders, hematologic malignancies, HIV infection, and transplants. We report three patients with Down syndrome. One patient had psoriatic arthritis under treatment with methotrexate, one had Graves-Basedow disease, and one had hypercholesterolemia. All three patients developed multiple eruptive dermatofibromas. We suggest that the immunologic disturbances associated with Down syndrome, together with other underlying conditions present in these patients, could trigger the development of cutaneous lesions.

Role of positron emission tomography in the management of neurocutaneous melanocytosis.

Management of large congenital melanocytic nevi and neurocutaneous melanocytosis represents a difficult challenge for clinicians, due to the high risk of malignancy in both entities and the difficulty of an early diagnosis of this complication. We report a new case of neurocutaneous melanocytosis (NCM) in association with large congenital melanocytic nevi (LCMN) that illustrates a possible role of positron emission tomography in the work-up of these patients.