Idiopathic CD4 T-Cell Lymphocytopenia: A Case Report of a Young Boy With Recalcitrant Warts.

IMPORTANCE: Idiopathic CD4 T-cell lymphocytopenia (ICL) is an immunodeficiency disorder that presents with a decrease in CD4(+) T cells without evidence of a human immunodeficiency virus infection. It is most commonly diagnosed after a patient presents with an opportunistic infection and can also be associated with malignancies and autoimmune diseases. This case presentation and literature review highlights the common skin findings in patients with ICL, mainly recalcitrant warts, and discusses the treatment options available. OBSERVATIONS: The patient described is the youngest reported with ICL presenting with isolated cutaneous findings of recalcitrant warts and psoriasis. Many treatment options were tried for the warts, with the most significant response to acitretin. CONCLUSIONS AND RELEVANCE: This case highlights the importance of considering underlying immunodeficiency in patients with recalcitrant warts as well as developing treatment plans. Such patients require close follow-up by both dermatology and immunology to monitor for the development of other diseases related to ICL.

Chronic Spontaneous Urticaria (CSU): Canadian Dermatologists' Perspective.

BACKGROUND: Chronic spontaneous urticaria (CSU) is a skin disorder that is said to be "frustrating" and "difficult to treat." It is characterized by recurrent hives for more than 6 weeks, and is further divided into spontaneous or inducible by physical stimuli.(1) To better understand dermatologists' perspective of this disorder, a survey was conducted with Canadian dermatologists. METHODS: A detailed online practice survey was sent to all currently practicing Canadian dermatologists. RESULTS: In all, 80 responses were received (response rate of 20%). Most respondents in Canada had treated patients with CSU (98.4%), with many of the patients having the disease last over 6 months (86.6%). A majority of the patients were female, with 84.1% of the respondents having over 50% of their patients as female. Most patients were over the age of 30 (74.2%). Of dermatologists, 85.7% felt that investigations were unhelpful in diagnosing CSU in a patient. Of respondents, 37.1% were not satisfied with current treatment methods of CSU, and 43.6% somewhat satisfied. Popular therapies included H1 and H2 antihistamines, oral corticosteroids, and montelukast. There were 16.1% of dermatologists who had over 50% of their patients refractory to treatment. CONCLUSIONS: There was a clear demographic preponderance for CSU patients with a majority as female over age 30. Investigations ordered for CSU patients do not seem to be helpful among dermatologists. Satisfaction with current therapies and investigations was quite low among Canadian dermatologists, suggesting new therapies are indicated.

Acitretin-induced hepatitis: when to monitor cholestatic enzymes.

IMPORTANCE: Acitretin is a systemic retinoid that is used in dermatology for a variety of conditions. A well-recognized potential adverse event from acitretin is elevated transaminases, indicating acute hepatocyte damage. Less well known is the possible cholestatic injury that can occur, signaled by elevated γ-glutamyltransferase (GGT) and alkaline phosphatase (ALP). OBSERVATIONS: Our patient presented with an acute acitretin-induced hepatitis with a mixed pattern of elevated transaminases as well as GGT and ALP. A literature review demonstrated that most cases of acitretin-induced hepatitis, outside clinical trials, describe patients with a similar mixed hepatitis pattern. CONCLUSIONS: This is the first literature review on acitretin-induced hepatitis. Although acitretin-induced hepatoxicity is rare, the seemingly unusual presentation of a mixed pattern of hepatocyte injury and cholestasis may be more common than previously thought. The findings should encourage clinicians not only to monitor transaminases but also to consider measuring cholestatic enzymes (ALP/GGT) in patients with transaminase abnormalities.