Orthopedic and Cutaneous Reactions to Nickel after Total Hip Replacement.

Implant degradation products have shown signs of a cutaneous allergic response after implantation of a metal orthopedic replacement, loosening and failure of the joints as well as skin rashes, general fatigue, pain, and impaired wounds and bone healing. The prevalence of contact skin sensitivity in patients with a joint replacement device is higher than that in the general population. This delayed hypersensitivity to metallic orthopedic implants is more clearly defined and is a contributing factor to implant failure. Nickel was associated with hypersensitivity responses as the first cause in metallic orthopedic implants as early as 1966 by Foussereau and Laugieru and is a commonly used metal in alloys because it grants necessary strength and durability to the implant. Herein we report on delayed hypersensitivity to nickel sulfate in a patient with pain, fatigue, and contact allergic dermatitis in both inguinal regions, with instability of the left acetabular part and with five hip replacements from 1987 to 2013. The findings of this report support that primary sensitization to a metal due to an implant itself might develop. Proper investigation in patients with history or prior hypersensitivity reactions to metals and test evaluation before orthopedic device implantation is needed. before orthopedic device implantation is needed.

Drug-Induced Rosacea-like Dermatitis.

Rosacea is a common, chronic cutaneous disorder with a prevalence of 0.5-10%, predominantly affecting women. The disease presents with a heterogeneous clinical picture characterized by transient flushing, persistent facial redness, telangiectasias, and, in more severe clinical forms, the presence of inflammatory papules and pustules in the central third of the face. Although its pathophysiology is complex and still remains unknown, factors that exacerbate the disease are well defined. They include genetic predisposition as well as external factors such as exposure to UV light, high temperature, and diet. Besides these well-known factors, recent studies suggest that drugs and vitamins could also be possible factors inducing rosacea-like dermatitis or aggravating pre-existing rosacea. Although these are less common possible triggering factors, the aim of this article is to present the current knowledge on the association between use of certain drugs or vitamins and rosacea.

Erlotinib-induced Rosacea-like Dermatitis.

Skin and skin adnexa toxicities are the most common side effects associated with epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) and occur in most patients receiving this therapy. The majority of these cutaneous side effects are transient, reversible, and dose dependent. Although these symptoms are in general not severe, they significantly affect quality of life and can have a serious effect on treatment compliance as well as the treatment regimen. The most common early symptoms present as papulopustules on an erythematous base, usually localized in seborrheic areas. This clinical presentation is commonly described as "acneiform", although these adverse reactions have clinical presentations, such as rosacea-like and seborrheic-like dermatitis. In this context, we report a case of a 77-year-old man with a medical history of planocellular lung cancer with ipsilateral pulmonary metastasis and mediastinum infiltration who received erlotinib as a third-line therapy, presenting with centrofacial rosaceiform rash as a side effect associated with the use of EGFR-TKIs. The patient had a negative previous history of rosacea. Therefore, symptoms probably occurred as an adverse reaction due to the oncological therapy. Current terminology of early cutaneous adverse reactions caused by EGFR-TKIs refers to "acneiform" or "papulopustular" lesions, excluding less common side effects such as rosacea-like dermatitis so these symptoms might be overlooked and misdiagnosed. Thus, we would like to emphasize the importance of developing a more accurate classification of terms in order to provide early detection of all possible cutaneous side effects, including less common ones, providing specific and timely treatment, and allowing continuation of drug therapy.

Advanced Pyoderma Gangrenosum Previously Treated as Squamous Cell Carcinoma.

Pyoderma gangrenosum is a rare, neutrophilic ulcerative skin disease of unknown etiology often associated with an underlying systemic disease. We present a case of a pyoderma gangrenosum that was initially misdiagnosed and treated as squamous cell carcinoma in another hospital. Multiple surgical treatments triggered postoperative exacerbations and further rapid progression of the lesions. History of pathergy, clinical findings, and histopathological features examined at our Department indicated pyoderma gangrenosum. The diagnosis was confirmed by excluding other diseases that could cause similar-appearing cutaneous lesions. No associated underlying disease was determined. After the diagnosis was confirmed, corticosteroid therapy was initiated until complete remission of ulcerations.

Pyridoxine induced rosacea-like dermatitis.

Rosacea is a common chronic inflammatory cutaneous disease of unknown etiology, characterized by remissions and exacerbations, presenting with centrofacial erythema and telangiectasias. It affects mainly adults around the age of 30 years and classically predominates in females. The pathophysiology of rosacea has not yet been fully understood. Risk factors are positive family history, very light skin phototype, sun exposure and consumption of spicy food or alcohol. Recently, there has been some evidence that some drugs or vitamins could be potential factors that can aggravate rosacea or induce rosacea-like symptoms. In this context, we present a 53-year-old female developing rosacea-like dermatitis due to a fixed combination of isoniazid and pyridoxine, which she was receiving along with rifampicin for the treatment of pulmonary tuberculosis.

Dermoscopy and Early Melanoma.

The lack of effective therapies for patients with advanced melanoma establishes an early recognition as the aim of clinical and dermoscopic examination, which is the most important factor for improving patient survival and decreases the treatment and management costs. Melanoma in situ is the earliest stage of melanoma. The features of early melanomas, especially in those lesions smaller than 3mm, can be very subtle clinically, dermoscopically and pathohistologically, and it is often impossible to discriminate between a melanoma and nevus. Clinically, de novo melanomas are small brown to black macula with an irregular outline. In melanomas developing in a nevus, there is an asymmetry of the lesion with marked change in color and/or shape of the pre-existing nevus. Dermoscopically, early stages of melanoma show the same global features as thicker melanomas, but in a more subtle way. Asymmetry is the most important parameter; multiple colors are rare. Significant local melanoma-specific criteria, especially when present at the periphery, are irregular pigment network, irregular streaks, and irregular dots/globules, while blue-white structures are rarely found.

Significance of dermatoscopy in genital dermatoses.

Dermatoscopy as a non-invasive technique has become an integrative part in the evaluation of pigmented and non-pigmented skin lesions, particularly for the early detections of melanoma. Although dermatoscopy improves diagnosis of pigmented and nonpigmented lesions of the skin, it is unknown if dermatoscopy improves the diagnostic accuracy of pigmented mucosal lesions. The "entodermatoscopy" is used for the dermatoscopy of skin infections and infestations and revised as entomodermatoscopy, as it connects the research fields of dermatology and entomology, with its roots being found in these two words. In genital dermatology along with the clinical examination, dermatoscopy is also used for the diagnosis and treatment follow-up of pediculosis pubis, genital warts, molluscum contagiosum, and scabies.

Palisaded neutrophilic and granulomatous dermatitis in association with subcutaneous nodular and systemic sarcoidosis.

Palisaded neutrophilic granulomatous dermatitis (PNGD) is a rare entity that has been clearly defined neither clinically nor histopathologically. PNGD has been associated with some immune-mediated disorders such as rheumatoid arthritis, systemic lupus erythematosus, systemic vasculitis, Behçet's disease, as well as with lymphoproliferative conditions, bacterial endocarditis, sarcoidosis, and various drugs. We present a 44-year-old Caucasian woman with roundish erythematous-livid plaque and erythematous papules on the left calf that were present for three months. Histopathology of plaque lesion showed palisading neutrophilic and granulomatous dermatitis. Subsequently, she developed a firm and tender nodule on the right calf. Histopathology of the nodule showed typical naked sarcoid granulomas in the dermis and subcutis. Additionally, the patient developed non-tender subcutaneous nodules on the cheeks, submandibular region and left breast with normal overlying skin, which were histopathologically diagnosed as sarcoid granuloma. Red eyes and lower visual acuity on the right eye were diagnosed as anterior uveitis. Therefore, systemic sarcoidosis was established. This is a case of PNGD described in an adult patient with sarcoidosis with cutaneous, breast, eye and lung involvement established by clinical, radiographic, laboratory, and histopathologic criteria.

Risk factors for acute respiratory tract infections in children.

Acute respiratory tract infections (ARTI) are the most common cause of childhood morbidity and an important public health problem. The aim of this study was to identify the significant risk factors for ARTI in children. The study took place in Ivankovo which is a rural area of Eastern Slavonia and with small socio-economic differences. The study population were 159 children who were 3-5 years old at the time of the study, and who were registrated at doctor's office Ivankovo. The study was conducted retrospectively through a questionnaire from January 2008 to December 2008. The risk factors studied were the gender, breastfeeding history, any atopic manifestation in the form of atopic eczema, rhinoconjuctivitis and/or asthma, the size of the family, parents smoking habits and main form of childcare. The number of ARTI requiring the consultation of a doctor throughout 2007 were measured; and whether ARTI had been treated with antibiotic or there were recommendation for symptomatic treatment only. Results of this research show that the risk factor for consulting a doctor because ofARTI in children was passive exposure to cigarette-smoke. For receiving antibiotics because of ARTI in children, the risk factors were passive exposure to cigarette-smoke and atopic manifestation. By giving the available evidence, parents must be told that ceasing smoking offers a significant opportunity to reduce the risk of ARTI in their children.

Photodynamic therapy in dermatology: current treatments and implications.

This article provides an update on photodynamic therapy by discussing each of the essential components in sequence: mechanisms of action, common photosensitizers, typical light sources, and indications. In dermatology, photodynamic therapy (PDT) is mainly used in the treatment of superficial skin cancers: actinic keratoses, Bowen's disease and superficial basal cell carcinomas. However the range of indications has been expanding continuously. PDT is also used for the treatment of other oncological indications and non-malignant conditions such as acne vulgaris and photoaged skin. The 5-aminolevulinic acid (ALA) or its methyl ester (MAL) is applied topically as photosensitizer before activation with visible light. The advantages of topical PDT are: ability to treat multiple lesions simultaneously, low invasiveness, good tolerance and excellent cosmetic results.

Pyoderma chronica vegetans treated with mesh skin grafting.

Pyoderma chronica vegetans is a rare condition clinically characterized by large verrucous plaques with elevated borders and multiple pustules. Although the etiology is unknown, it is generally believed that vegetating reaction is due to an immune system dysfunction or immunosuppressive state. We report on a 72-year-old man with pyoderma chronica of the buttocks. The lesion on the left buttock worsened two years before with gradual onset of fistulas, scarring and verrucous plaques. Laboratory test revealed medium high erythrocyte sedimentation rate, anemia, shift to left in differential white blood cell count, and polyclonal hyperglobulinemia. Streptococcus species and Escherichia coli were detected in tissue samples. T-cell functional tests for mitogens were decreased. Flow cytometry analysis of phagocytic capability of monocytes and granulocytes by was normal. Inflammatory bowel diseases were excluded with clinical and radiological examination. Anti-HIV test was negative. Histology revealed hyperplasia and irregular acanthosis of the epidermis, sinus and abscess formation, fibrosis and diffuse infiltration of inflammatory cells such as plasma cells, lymphocytes, histiocytes, eosinophils and neutrophils. Surgery was chosen as a therapeutic option as conservative treatment proved ineffective. Therefore, complete excision of the lesion was performed and skin grafting was required to close the defect because of extensity of the lesions. The skin-graft donor site was normal skin. Good postoperative result was achieved, without recurrence of the pyodermatic process.

Dermoscopy and in vivo reflectance confocal microscopy of a congenital nevus of the nipple.

We report a 26-year-old male with a 4 mm diameter, asymmetric, irregularly pigmented and bordered, brown maculopapular lesion on the right nipple present since childhood with enlargement of the lesion within the last 3 months. Dermoscopy revealed a global globular pattern with the presence of focally light brown globules and irregular black globules in its centre. In vivo reflectance confocal microscopy (RCM) revealed dense junctional and dermal melanocytic nests of different sizes and shapes that appeared as sharply demarcated round to oval reflective structures; cellular outlines of single melanocytes were not always detected. In the centre of the lesion within the upper dermis, irregularly shaped, homogeneously reflecting structures were observed. As a clear differentiation between clusters of melanophages and melanocytic nests could not be made with certainty, an excisional biopsy was performed to establish the diagnosis of compound nevus with features of congenital nevus. Therefore, to prove that dermoscopic globules correlated with melanophages, the correlation between dermoscopic RCM and histopathology was necessary.

The role of CD4 and CD8 lymphocytes and macrophages in psoriasis vulgaris.

Current knowledge of the immunopathogenesis of psoriasis vulgaris is based on the crucial role of CD4 and CD8 lymphocytes. Also, the connection of activated lymphocytes with macrophages, especially dendritic cells and plasmacytoid dendritic cells, is considered to be significant. In the present study, the expression of CD4+ lymphocytes as well as CD8+ lymphocytes (P < 0.001) and macrophages (P < 0.001) was found to be significantly increased in lesional skin epidermis and dermis in psoriasis vulgaris patients as compared with healthy skin. These findings suggested a cascade or chain reaction with cells and cytokines playing an important role to be involved in the immunopathogenesis of psoriasis vulgaris.

Neurofibromatosis type 1 associated with dysplastic nevus syndrome.

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder that primarily affects the development and growth of neural cell tissues. It causes tumors to grow on nerves and produces other abnormalities such as skin changes and bone deformities. Dysplastic nevus syndrome (DNS) represents multiple atypical nevi associated with polygenetic inheritance pattern and may rarely occur together with NF-1. DNS type A is a marker of increased melanoma risk, while melanoma has been rarely reported in patients with NF-1. We describe a case of NF-1 type A with DNS presenting with multiple neural tumors, cafe-au-lait spots, hamartomas in globus pallidus and pigmented melanocytic iris hamartomas (Lisch nodules). The importance of close follow up of nevi in such patients with NF-1 and DNS for the development of melanoma as well as other NF-1 associated skin disorders and with multidisciplinary approach to other associated diseases is highlighted.

Halo phenomenon with regression of acquired melanocytic nevi: a case report.

We report a case of halo-phenomenon in excisional biopsy of junctional nevi in a 19-year-old girl. The diagnosis was established histopathologically because of the lack of clinical halo and unspecific dermoscopic features. Clinicopathologic difficulties in establishing the diagnosis of these pigmented lesions, etiopathogenesis and differential diagnosis of halo nevi are emphasized. Dermatologists should be familiar with the possible changes in benign melanocytic nevi, halo reactions and possible complete regression of melanocytic nevi. Diagnostic difficulties are seen in the ultimate phase of regression when melanocytes are diminished or destroyed with immune reaction.

Keratosis follicularis spinulosa decalvans associated with acne keloidalis nuchae and tufted hair folliculitis.

Keratosis follicularis spinulosa decalvans is a rare, X-linked disorder characterized by scarring alopecia of the scalp and eyebrows in the setting of widespread keratosis pilaris. Less frequent associations are ocular abnormalities and palmoplantar keratoderma. Acne keloidalis nuchae has previously been described in one patient with keratosis follicularis spinulosa decalvans. We report another case of keratosis follicularis spinulosa decalvans with acne keloidalis nuchae and tufted hair folliculitis, thus further establishing this association.

Treatment of vitiligo with narrow-band UVB and topical gel containing catalase and superoxide dismutase.

Narrow-band UVB has been reported to be efficacious in patients with vitiligo. The epidermis of patients with vitiligo showed reduction in the levels of catalase, in association with high levels of hydrogen peroxidase (H2O2) that is toxic for melanocytes. Based on these findings, we studied the efficacy and safety of a topical gel containing catalase and superoxide dismutase (Vitix) in combination with narrow-band UVB. The study included 22 patients of which 19 completed the 6-month study period. Patients applied the gel containing catalase and superoxide dismutase twice a day and received narrow-band UVB 3 times per week. Two different dermatologists evaluated the grade of repigmentation by photograph comparison. At the end of therapy, more than 50% of overall repigmentation was noticed in 11 of 19 (57.9%) patients. More than 75% repigmentation was recorded in three (15.79%), 26%-50% repigmentation in six (31.58%) patients and 1%-25% repigmentation in one (5.26%) patient, whereas one (5.26%) of 19 patients showed no repigmentation at all. The best response was achieved on the face and neck, with more than 50% repigmentation observed in 11 of 14 (78.6%) patients. Development of new lesions was not observed. Adverse events were mild and transient. The study showed that the combination therapy of narrow-band UVB and gel containing catalase and dismutase is a therapeutic option that could be considered in the management of vitiligo. Further evaluation of this combination in multicenter, double-blind, placebo-controlled studies should be undertaken.

Regressing seborrheic keratosis - clinically and dermoscopically mimicking a regressing melanoma.

The diagnosis of seborrheic keratosis is a clinical diagnosis. In a certain percentage of cases, differential diagnosis between seborrheic keratosis and malignant melanoma is difficult. We describe a case of regressing seborrheic keratosis simulating malignant melanoma. Clinical, dermoscopic and histopathologic examinations were performed for the occurrence of an asymmetric, irregularly demarcated, irregularly pigmented lesion measuring 1.3 x 1.5 cm on the right part of the abdomen in a 76-year-old male Caucasian. In order not to miss melanoma, the excision and histopathologic examination of the lesion with peppering is essential.