Acquired reactive perforating collagenosis: A case report and review of the literature.

INTRODUCTION: Acquired reactive perforating collagenosis (ARPC) is a rare skin disorder, which is associated with various internal diseases and even malignant neoplasms. A comprehensive knowledge of the concomitant diseases in ARPC patients is helpful to decrease the misdiagnosis. Although the treatment of ARPC is challenging, systemic assessment of existing regimens is not available. PATIENT CONCERNS: A 50-year-old woman was admitted to the hospital due to cutaneous pruritus and papules all over the body. DIAGNOSIS: Physical examination showed various sized papules on the lower limbs, buttocks, back, chest, and upper arms with keratotic plugs in the center. Histopathology showed typical collagenous fiber perforation. The diagnosis of ARPC was made according to histopathology, onset age and typical skin lesions. Type 2 diabetes mellitus (T2DM), chronic renal failure (CRF), and hypothyroidism simultaneously presented in this patient. INTERVENTIONS: This patient was initially treated with topical corticosteroids and oral antihistamines for the skin lesion and pruritus. Medications for glucose control and recovery of renal and thyroid functions were also applied. On the second admission, the combined therapy of topical retinoic acid, Chinese medicinal herb-Qingpeng ointment, and Zinc oxide ointment was added. OUTCOMES: Papules and pruritus were improved significantly after the second hospitalization. CONCLUSION: We present a case of ARPC associated with T2DM, CRF, and hypothyroidism, which has rarely been described. There is no standardized treatment for ARPC. Co-administration of two or more agents for dermatologic interventions and treatment for associated diseases may help to improve skin symptoms.

Calcinosis Cutis and Calciphylaxis.

Calcinosis cutis (CC) is defined as the deposition of calcium salts in the skin. The condition is divided into 5 types: calciphylaxis and dystrophic, metastatic, idiopathic, and iatrogenic CC. Dystrophic CC is the most common form and usually occurs in association with autoimmune diseases. CC can be treated surgically or with the use of drugs such as diltiazem, bisphosphonates, warfarin, ceftriaxone, probenecid, minocycline, or aluminum hydroxide. Calciphylaxis is defined as calcification of the media of small- and medium-sized blood vessels in the dermis and subcutaneous tissue. Clinically, calciphylaxis causes livedo racemosa, which progresses to retiform purpura and skin necrosis. First-line treatment is with sodium thiosulfate. We present a review of the calcifying disorders of the skin, focusing on their diagnosis and treatment.

Acquired reactive perforating dermatosis.

Acquired reactive perforating dermatosis is characterized by umbilicated erythematous papules and plaques with firmly adherent crusts. Histopathological examination shows a typical cup-shaped ulceration in the epidermis containing cellular debris and collagen. There is transepidermal elimination of degenerated material with basophilic collagen bundles. The etiology and pathogenesis of acquired reactive perforating dermatosis are unclear. Metabolic disorders and malignancies are associated with this dermatosis. Associated pruritus is regarded as a key pathogenic factor. Constant scratching may cause a repetitive trauma to the skin. This pathogenesis may involve a genetic predisposition. The trauma may lead to degeneration of the collagen bundles. Treatment of acquired reactive perforating dermatosis follows a multimodal approach. Apart from the treating any underlying disease, treatment of pruritus is a major goal. Systemic steroids and retinoids, as well as UVB phototherapy are well-established treatment options. Some patients may also benefit from oral allopurinol.

[Acquired reactive perforating collagenosis following herpes zoster as isotopic response?]. / Erworbene reaktive perforierende Kollagenose nach Herpes zoster als isotopische Antwort?

Reactive perforating collagenosis is a disease whose pathogenesis is still not fully understood. Histological findings are degenerated collagen bundles which are arranged in vertical direction penetrating the epidermis into a dome-shaped crater. Usually diabetes mellitus and renal failure can be found among patients with reactive perforating collagenosis. To date, there have been five cases described where the eruption of reactive perforating collagenosis followed herpes zoster infection. This could be a form of Wolf's isotopic response, a term that is used for dermatoses which arise after the healing of a preexisting dermatosis. We report the sixth case of a herpes zoster-associated reactive perforating collagenosis and discuss the current literature.

Acquired reactive perforating collagenosis: current status.

Acquired reactive perforating collagenosis is a unique perforating dermatosis, characterized clinically by umbilicated hyperkeratotic papules or nodules and histologically by a focal hyperkeratosis in direct contact with transepidermal perforating dermal collagen. Several inflammatory or malignant systemic diseases may coexist with acquired reactive perforating collagenosis. The possible biochemical or immunological mechanisms of the systemic diseases, potentially responsible for the development and appearance of acquired reactive perforating collagenosis, are still under investigation. Several topical treatments, ultraviolet B phototherapy and allopurinol p.o. administration may be effective.

[Acquired reactive perforating collagenosis associated with diabetes mellitus and renal insufficiency requiring dialysis]. / Erworbene reaktiv perforierende Kollagenose bei Diabetes mellitus und dialysepflichtiger Niereninsuffizienz.

HISTORY: A 60-year-old man with diabetes mellitus and chronic renal insufficiency needing hemodialysis was admitted with a 3 months history of multiple hyperkeratotic papules on the trunk and extremities partly ulcerated with a keratotic central plug. INVESTIGATIONS: Laboratory tests revealed elevated levels of blood urea nitrogen, creatinine, and HbA (1c). Histopathology showed vertical strands of collagen perforating from the ulcerated lesions. COURSE, DIAGNOSIS AND TREATMENT: The biopsy specimen was consistent with acquired reactive perforating collagenosis. The progression was stopped and secondary wound healing was initiated after two weeks of therapy with allopurinol and PUVA. CONCLUSION: Acquired reactive perforating collagenosis should be considered when ulcera with oystershell-like keratotic plugs are found especially in patients with predisposing diseases like diabetes and renal insufficiency. A good interdisciplinary cooperation between internist and dermatologist is crucial for the early recognition by histopathology and the immediate treatment.

Alterações estruturais do colágeno da placa de crescimento irradiado por laser de baixa intensidade: uma investigação por microscopia de força atômica / Structural changes of collagen in the irradiated growth plate by low intensity laser: an investigation through microscopy of atomic force

O presente estudo investigou através da microscopia de força atômica o efeito sistêmico e local da radiação laser sobre a placa de crescimento ósseo. Foram utilizados ratos Wistar, com 30 dias de idade, divididos aleatoriamente: Grupo GC (n = 5), não irradiados pelo laser; Grupo G5J (n = 10), irradiado por um laser (fluência = 5 J/cm2) e finalmente, o grupo G60J (n = 10) também irradiados por um laser de baixa intensidade (60 J/cm2). Dos grupos tratados, foi avaliado o efeito sistêmico na placa contralateral, sendo denominados como G5JS (n = 10) a avaliação da placa de crescimento contralateral à irradiada do grupo G5J e o grupo G60JS (n = 10) a avaliação da placa de crescimento contralateral à irradiada do grupo G60J. O tratamento consistiu de 06 aplicações de laser pela técnica pontual na pata traseira direita sobre a região ântero-medial da placa de crescimento proximal da tíbia, com intervalo de 48 horas entre as irradiações. Observamos aumento na espessura dos feixes de colágeno, alteração do sentido de orientação e organização destes feixes, principalmente através de seu efeito local. O laser pode provocar alterações estruturais nos feixes de colágeno, porém os nossos resultados não são suficientes para afirmar que o crescimento ósseo possa ser afetado.

This study investigated through the microscopy of the atomic force the systemic and local effect of the laser radiation on the bone growth plate. 30-day-old Wistar rats, randomly divided, were used in this experiment: Group GC (n = 5), not irradiated by laser; Group G5J (n = 10), irradiated by laser, (ë = 780 nm, mean output power = 20 mW, fluency rate = 5 J/cm2, time = 10 seconds) and finally, the Group G60J (n = 10) also irradiated by low intensity laser (ë=780 nm, mean output power = 20 mW, fluency rate = 60 J/cm2, Time = 120 seconds). From these groups, we evaluated the systemic effect on the contra lateral plate and we named them as G5JS (n = 10) – the evaluation of the contra lateral growth plate to the irradiated one of the Group G5J and the Group G60JS (n = 10) – the evaluation of the contra lateral growth plate to the irradiated one of the Group G60J. The treatment consisted of six laser applications through the punctual technique on the back right paw over the antero-medium region of the growth plate near the tibia, with a 48-hour interval between the irradiations. We observed an increase on the thickness of the collagen sheaves, changing of orientation sense and organization of these sheaves, mainly through the local effect. Laser can cause structural changes on the collagen sheaves, but our results are not enough to claim that the bone increase can be affected.

Koebnerization of reactive perforating collagenosis induced by laser hair removal.

Laser hair removal, due to demonstrated efficacy and safety, has become a commonly performed office procedure. We report an unusual occurrence after laser hair removal with the 800 nm diode laser that previously has never been described. After laser hair removal treatment to the ventral surface of the ears, a patient developed lesions of previously diagnosed reactive perforating collagenosis. Interestingly, the lesions appeared on the dorsal surface of the ears. Perhaps the koebner phenomenon was invoked as the laser energy penetrated to the untreated dorsal surface, which was not protected by epidermal contact cooling.

[Evolution and treatment response in microscopic colitis]. / Curso evolutivo y respuesta al tratamiento de las colitis microscópicas.

AIM: To study the clinical characteristics, treatment response and evolution in patients with microscopic colitis. MATERIAL AND METHODS: We performed a retrospective analysis of 24 patients (15 with collagenous colitis and 9 with lymphocytic colitis). Clinical and diagnostic features, treatment response and evolution according to the presence of maintenance therapy were evaluated. RESULTS: The mean age of the patients was 59.7 years and most were male. Nine patients took non-steroidal anti-inflammatory drugs (NSAID). No significant association was found with other drugs. Four patients presented associated rheumatological disease. Most patients presented insidious-onset diarrhea without pathological products, which was frequently associated with other symptoms (abdominal pain, bloating, weight loss, asthenia, tenesmus, and incontinence). Seven patients showed a slight increase in globular sedimentation rate. Fat in stools and radiological investigations (transit and opaque enema) were normal in patients who underwent these tests. Endoscopy revealed non-specific alterations in 42% of the patients while results were normal in the remaining patients. One patient showed clinical improvement on withdrawal of NSAIDs and 4 patients improved spontaneously. Clinical response was achieved in 7 of 13 patients treated with antimotility drugs, in 8 of 9 patients treated with salicylates, in 3 treated with oral corticoids, in 1 treated with cholestyramine and in 1 treated with topical budesonide. Nineteen patients required no maintenance therapy, 4 were administered salicylates and 1 was administered cholestyramine. After a mean follow-up of 42 months, evolution was chronic and intermittent in 14 patients and chronic and continuous in 1; 9 patients presented a single episode. No significant differences were found between patients administered maintenance therapy and those who were not or between collagenous colitis and lymphocytic colitis in the parameters analyzed. CONCLUSIONS: Microscopic colitis constitutes a group of diseases characterized by chronic diarrhea, few systemic effects and minimal radiological and/or endoscopic alterations. Evolution is characterized by recurrent episodes, with good response to treatment with cholestyramine, salicylates or corticoids when required.

Colitis colágena: una entidad con diversas opciones terapéuticas / Collagenous colitis: an entity with different therapeutic options

La colitis colágena es una enfermedad cuya frecuencia ha aumentado progresivamente en los últimos años debido fundamentalmente a la toma rutinaria de biopsias en el estudio de pacientes con diarrea crónica. Se han comunicado buenas respuestas con numerosos tratamientos, aunque hay pocos ensayos clínicos realizados por el escaso número de pacientes con esta patología. Presentamos dos casos de colitis colágena cuyo interés reside en su manejo terapéutico, revisando las distintas alternativas existentes en el tratamiento de esta entidad de creciente importancia en la práctica clínica diaria (AU)

Treatment of pruritus of reactive perforating collagenosis using transcutaneous electrical nerve stimulation.

Reactive perforating collagenosis is a form of perforating dermatosis due to transepithelial elimination of collagen and characterized by itchy papulonodular eruptions frequently seen in patients with diabetes mellitus and end stage renal failure. Pruritus is often severe and treatment is difficult. Two adult Chinese diabetic patients with acquired reactive perforating collagenosis unresponsive to topical therapies and oral antihistamines, were treated with transcutaneous electrical nerve stimulation. There was a significant reduction of itch followed by gradual resolution of the skin lesions.

[Collagenous colitis: an entity with diverse therapeutic options]. / Colitis colágena: una entidad con diversas opciones terapéuticas.

Collagenous colitis is a disorder which has been diagnosed with increasing frequency in the last few years, probably due to the routine obtention of colon biopsy specimens in the study of patients with chronic diarrhoea. Good responses have been reported with a number of therapies, although only a scarce number of clinical trials have been performed, partly because of the small number of patients studied. Two cases of collagenous colitis with different therapeutic approaches are here reported. All medical therapy options for this interesting disorder are reviewed.

Qu'est-ce que la rhumatologie? / What is rheumatology?

Par definition: de rheumatisme (1549) puis rhumatisme (1673), emprunte par l'intermediaire du latin rheumatismus, au grec rheumatismos, elle designe un ecoulement d'humeur, en particulier un catarrhe... (AU)

Silicon tissue assay: a measurement of capsular levels from chemotherapeutic port-a-catheter devices.

A plethora of data has been used to condemn and defend the role of silicone and its association with "adjuvant disease." In the ongoing attempt to enhance our knowledge, we have chosen to identify tissue silicon levels (n = 15) in capsules that form around chemotherapeutic port-a-catheter devices, which consist of a metal dome encapsuled by silicone. We have compared these levels with previously established silicon levels in augmented breast capsules, distant tissue sites in these same augmented women, and nonaugmented cadaveric tissues from various geographic locations in the United States. All specimens were harvested by a "no touch" technique, not formalin fixed, frozen, and shipped to an independent toxicology laboratory for analysis. Inductively coupled plasma atomic emission spectroscopy was employed to obtain the tissue silicon measurements. Results demonstrated silicon values ranging from nondetectable in 9 patients to as high as 41 micrograms/gm. These values fell in between our cadaveric (0.5 to 6.8 micrograms/gm) and augmented tissue silicon levels (18 to 8700 micrograms/gm). Although the sample size is small and the power of statistical analysis is low, there was no correlation between the patient's silicon level and age, type of cancer, type of chemotherapeutic agent, radiation therapy, or length of time the port-a-catheters were in place. Although detectable levels of silicon identified around port-a-catheter devices were higher than expected, it is impossible to make any conclusions about these levels and the role of a potential collagen-vascular disease. What we have shown, however, is that silicone breast implants may not be the only medical device that can elevate tissue silicon levels. Our data seem to suggest that there may be a progression of measurable tissue silicon levels based on the amount of environmental or device-related silicon exposure a person has had at a particular time in his or her life. It is our belief that as we identify these tissue silicon levels, they will serve as a baseline and reference for further scientific studies.

10 years experience in performing Shouldice operation.

206 male patients were operated for primary direct and indirect inguinal hernia, or both, by Shouldice technique at general surgical departments of Madadeni Hospital, Newcastle, South Africa, Pásztó Hospital and Szolnok MAV Hospital, Hungary between 1986 and 1996. Mean age was 51 yrs +/- 15 yrs (17-91 yrs). The operations were performed by the original way of Shouldice described that type of hernia repair in 1945. 175 patients had spinal and 31 patients had local anesthesia with intravenous fluid and sedation respectively. Studies indicate that collagen metabolic dysfunction plays a major rule in the etiology of groin hernia. Until this is more clearly defined, surgeons will continue to repair groin hernias constitute 15% of operations in general surgery. In approach to groin hernia, the best view for examination of the inguinal region can be obtained by Shouldice technique to decide the proper surgical intervention to repair groin hernia. With low recurrence rate and rapid rehabilitation, author reports 2% of recurrence rate, the Shouldice operation highly recommended.