Gliptin-induced bullous pemphigoid.

OBJECTIVES: Bullous pemphigoid (BP) is a rare, autoimmune, blistering disease in elderly patients that can be triggered by external factors including drugs. Drug-induced bullous pemphigoid (DIBP) does not always follow a self-limiting course after the withdrawal of the offending drug. Dipeptidyl peptidase-4 (DPP-4) inhibitors or gliptins seem to be associated with a significant risk of inducing BP. CASE PRESENTATION: We report 2 cases of BP attributed to the DPP-4 inhibitor linagliptin. In both cases, the clinical manifestation was strongly suggestive of BP. The diagnosis was verified by histology and direct immunofluorescence (DIF). Linagliptin and all other possible drug triggers of BP were discontinued after consultation with an endocrinologist and a cardiologist. Systemic treatment of BP consisted of methylprednisolone and tetracycline. During the follow-up period, one of the patients suffered a fatal brain stroke while the other was managed with reduced doses of corticosteroids. CONCLUSION: The proper management of autoimmune bullous skin disorders in elderly patients includes a scrupulous assessment of plausible drug triggers. Systemic corticosteroids for treating severe cases of DIBP can worsen concomitant diseases which often necessitates multidisciplinary care.

Hidradenitis suppurativa from the typical patient to the new clinical phenotypes.

Hidradenitis suppurativa (HS) is a clinically heterogeneous disease with a broad spectrum of clinical features. Attempts to classify HS into distinct clinical phenotypes could lead to a better understanding of the condition and the development of individualized treatment protocols. We summarize some of the existing phenotype classifications and present our experience with 250 patients and their many clinical presentations. We have emphasized the pathophysiologic and clinical overlap between HS and pyoderma gangrenosum. The more severe presentations can include erosive and ulcerative lesions, sometimes associated with vegetative changes leading to diagnostic quandaries. We propose a new phenotype of pyoderma gangrenosum-like HS in which painful ulcerative or vegetative lesions appear in sites affected by HS, their activity coincides with the flareups of classic inflammatory manifestations of HS, and they heal with cribriform or atrophic scars.

Amelanotic subungual melanoma and chilblains.

A female patient in her 50s presented with blue discolouration of several toes and with single nail dystrophy affecting the little toenail. The nail changes were considered to be secondary to poor circulation and chilblains, which led to delay in the diagnosis of amelanotic subungual melanoma.

Direct patient-to-physician teledermatology: Not a flash in the pan(demic).

Dermatology is a clinical and visual discipline, which makes it the quintessential medical specialty for spot diagnosis and telemedicine. The COVID-19 pandemic has led to an unprecedented worldwide renaissance of teledermatology (TD). It has helped deliver high-quality medical care, while protecting the medical personnel and vulnerable patients from potential infection. Examining a patient from a distance through digital photography has many drawbacks, including lack of physical touch, difficulties in performing full body examinations, and several legal and ethical issues. We summarize have summarized the more common pitfalls and highlight the key aspects of direct patient-to-physician TD. Basic practical advice includes the use of TD for obtaining patient history, examining patient-captured photographs for inflammatory skin disease, and skin cancer screening.

Epidermolysis Bullosa Acquisita Mimicking Linear IgA Bullous Disease in a 5-year-old Child.

We present a case of a 5-year-old child with epidermolysis bullosa acquisita, clinically resembling linear IgA bullous disease. The case demonstrates that autoimmune bullous dermatoses in childhood may show a clinical overlap, which makes the diagnosis based on clinical features highly unreliable. Specific immunofluorescence and immunoserological tests are crucial for precise diagnosis - in our case circulating antibodies against collagen VII were detected using ELISA and indirect immunofluorescence on transfected cells. The disease was treated with systemic and topical steroids with excellent results.

The rash that presents as a vesiculobullous eruption.

Various infections and autoimmune and reactive skin conditions can present with blisters of varying sizes. Some of these disorders are seen in everyday practice, whereas others are rarely encountered. In many cases, the clinical picture is so typical that the diagnosis is easy and obvious; nevertheless, the significant clinical overlap between many of these diseases can cause frustration in both unexperienced and expert clinicians. We present the most typical clinical clues and offer simplified algorithms to the clinical diagnosis of skin conditions with vesicles and bullae. We focus on several aspects, when assessing a patient with blisters on the skin: age of onset, a history of comorbidities and medications intake, the general condition of the patient, and most importantly, the distribution, number, size, morphology, and evolution of the blisters, the characteristics of the peribullous skin, and the presence of mucosal involvement. Emphasis is put on differentiating between potentially life-threatening blistering eruptions and more benign self-limiting conditions. © 2020 Elsevier Inc. All rights reserved.

Skin signs of systemic infections and neoplastic diseases.

In recent years, emphasis on the physical examination has made way for a plethora of laboratory tests and sophisticated imaging diagnostic techniques. In addition, we are witnessing an underestimation of dermatology as a specialty around the world, which is accepted as an ambulatory specialty on the border of cosmetology and beautification. However, recognizing specific cutaneous clinical signs can facilitate timely diagnosis of various systemic infections and neoplastic diseases. Thus, a skilled dermatologist can play an essential role in the multidisciplinary team, involved in the care for systemically ill patients. In this article, we will focus on some life threatening systemic infections in which the skin changes can be a major clue for the diagnosis. Recent deadly epidemics will also be focused. Classic examples of paraneoplastic skin conditions will also be provided.

Autoimmune blistering dermatoses as systemic diseases.

Autoimmune blistering dermatoses are examples of skin-specific autoimmune disorders that can sometimes represent the cutaneous manifestation of a multiorgan disease due to potential common pathogenic mechanisms. As soon as a distinct autoimmune blistering dermatosis is diagnosed, it is imperative to consider its potential systemic involvement, as well as the autoimmune and inflammatory conditions that are frequently associated with it. In paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome, the internal organs (particularly the lungs) are affected by the autoimmune injury. Pemphigus erythematosus may manifest with overlapping serologic and immunohistologic features of lupus erythematosus. In patients with bullous pemphigoid, there is a greater prevalence of neurologic disease, possibly caused by cross-reactivity of the autoantibodies with isoforms of bullous pemphigoid antigens expressed in the skin and brain. Anti-laminin 332 pemphigoid shows an increased risk for adenocarcinomas. Patients with anti-p200 pemphigoid often suffer from psoriasis. A rare form of pemphigoid with antibodies against the α5 chain of type IV collagen is characterized by underlying nephropathia. Particularly interesting is the association of linear IgA disease or epidermolysis bullosa acquisita with inflammatory bowel disease. Dermatitis herpetiformis is currently regarded as the skin manifestation of gluten sensitivity. Bullous systemic lupus erythematosus is part of the clinical spectrum of systemic lupus erythematosus, a prototypic autoimmune disease with multisystem involvement.