The use of B vitamins for cutaneous ulcerations mimicking pyoderma gangrenosum in patients with MTHFR polymorphism.

BACKGROUND: Methylenetetrahydrofolate reductase (MTHFR) polymorphisms are associated with thrombophilia and vasculopathy that may result in cutaneous ulceration. Pyoderma gangrenosum (PG) is a clinical diagnosis that may be made following exclusion of alternate causes of ulceration, including vascular inflammatory or occlusive disease, infection, and malignant neoplasm. OBSERVATIONS: We describe 2 patients with MTHFR polymorphisms discovered during hypercoagulable evaluation for cutaneous ulcerations on the lower extremities. Both patients showed a rapid improvement following treatment with oral vitamin supplementation and local wound care. One patient developed several subsequent ulcers when he decided to discontinue his therapy, and following reinitiation of therapy, the new ulcerations healed. The treatment was tolerated well without any adverse effects. CONCLUSIONS: MTHFR polymorphisms should be part of a comprehensive laboratory evaluation during hypercoagulable workup. Vitamin supplementation with folic acid (B(9)), pyridoxine hydrochloride (B(6)), and cyanocobalamin (B(12)) may result in healing of cutaneous ulcerations in some patients with MTHFR mutations.

Common pediatric and adolescent skin conditions.

Skin lesions are encountered in all areas of medicine, and it is therefore important for physicians to understand the fundamentals of explaining and diagnosing common skin conditions. This article begins with a discussion of description and documentation of skin lesions based on color, size, morphology, and distribution. Pigmentation disorders such as vitiligo are depicted. Cutaneous growths that are found in the pediatric and adolescent population include acrochordons, dermatofibromas, keloids, milia, neurofibromas, and pyogenic granulomas. Treatment of these growths usually involves observation or curettage with electrodessication.Psoriasis, atopic dermatitis, poison ivy, and eczema are comprised of scaling patches and plaques; poison ivy and atopic dermatitis may also present with bullous and vesicular changes. Therapy typically consists of topical emollients and corticosteroids; phototherapy is reserved for refractory cases. Acne vulgaris is the most common skin disease of the pediatric and adolescent population. This condition can be psychologically debilitating and, therefore, proper treatment is of paramount importance. Therapeutic options include topical as well as oral antibiotics and retinoids. Extreme caution must be used when prescribing retinoids to post-pubescent females, as these agents are teratogenic. Vascular anomalies are most commonly exemplified as port wine stains and hemangiomas. Port wine stains may be treated with pulsed dye laser or may be observed if they are not of concern to the patient or physician. Hemangiomas typically spontaneously regress by age ten; however, there has been recent concern that certain cases may need to be treated. Dermal rashes may be localized or generalized. Treatment of generalized drug eruptions involves elimination of the inciting agent, topical antipruritics, and systemic corticosteroids for severe reactions. Infectious etiologic agents of skin disease include bacteria, fungi, and viruses. Many sexually transmitted diseases are bacterial or viral in origin and present as a rash or ulcer. Impetigo is a bacterial infection which may present as a bullous eruption or as an erosion with a honey colored crust. Other bacterial infections include erythema chronicum migrans, folliculitis, and cellulitis. Fungal infections include the various forms of tinea and are usually treated with topical antifungals; if the infection is located in a hair-bearing area, systemic antifungals are necessary. Viral infections include warts, varicella, molluscum contagiosum, and herpes. Treatment varies from observation or antivirals for varicella to cryosurgery and topical imiquimod for warts. Finally, scabies and lice are infectious agents that can be treated with permethrin and pyrethrin solutions.