Case for diagnosis. A pruritic eruption of keratotic papules over the face and neck

Abstract Generalized eruptive keratoacanthoma of Grzybowski is a rare variant of multiple keratoacanthomas counting with about 40 cases reported. It is a chronic and progressive disease for which none of the described therapeutic options has been entirely satisfactory. We report a case of an 83-year-old female who presented with a 3-month history of extremely pruritic, multiple, skin-coloured to erythematous to brownish, millimetric papules, with a keratotic centre. Histological examination of an incisional biopsy was consistent with the diagnosis of keratoacanthoma. The patient started acitretin 25 milligrams daily with a complete resolution of pruritus and regression of numerous lesions.

Specific cutaneous infiltrates in patients with haematological neoplasms: a retrospective study with 49 patients.

BACKGROUND: Haematological neoplasms account for around 9% of all cancers, and they are recognised as an important cause of skin infiltration. However, studies analysing cutaneous metastasis of haematological neoplasms are scarce. We describe the clinical spectrum and outcomes of specific cutaneous manifestations of leukaemias, lymphomas, multiple myeloma (MM), and blastic plasmacytoid dendritic cell neoplasm (BPDN) and make a review of the literature. METHODS: Data from 49 patients diagnosed with secondary cutaneous infiltration of systemic haematological neoplasms over the last 10 years in a tertiary dermatology centre were retrospectively collected, and clinical-evolutive features were analysed. RESULTS: Most cases were lymphoma (44.9%, n = 22), followed by leukaemia cutis (38.8%, n = 19), secondary plasmacytoma (10.2%, n = 5) and BPDN (6.1%, n = 3). Nodules were the predominant type of lesion, and most patients presented with multiple (≥3) lesions. In 51% (n = 25) of cases, cutaneous infiltration was detected before the diagnosis of the underlying malignancy. The patients in diverse nosological groups did not differ in terms of survival (P = 0.052). CONCLUSIONS: We recognise the clinical heterogeneity of specific cutaneous infiltrates. The high proportion of cases in which skin involvement was key to the diagnosis of systemic malignancy emphasises the role of the dermatologist in recognising and correctly managing these patients.

[Cutaneous Manifestations Associated with COVID-19: A Narrative Review]. / Manifestações Cutâneas Associadas à COVID-19: Uma Revisão Narrativa.

INTRODUCTION: COVID-19 is an infectious disease caused by the new coronavirus, SARS-CoV-2, that has spread rapidly throughout the world. This has resulted in an urgent need to obtain information regarding its pathogenesis, diagnosis and clinical manifestations. More specifically, skin manifestations, seldom reported initially, have been increasingly described. MATERIAL AND METHODS: We performed a literature search in the PubMed database, regarding cutaneous manifestations associated with COVID-19. This article describes the clinical and histological findings of the main skin lesions observed in the context of SARS-CoV-2 infection. DISCUSSION: Cutaneous manifestations associated with COVID-19 have been described in multiple retrospective and prospective studies, case series and case reports. The reported incidence reached 20.4%. Although there was substantial heterogeneity in terms of clinical patterns, the main ones include: erythematous/maculopapular, urticarial, papulovesicular, and purpuric/petechial eruptions, chilblain-like lesions and livedoid/acro-ischemic lesions. In the vast majority, the underlying pathophysiologic mechanisms are not fully understood, although histopathological findings and biomolecular studies can add relevant data. CONCLUSION: The recognition of cutaneous manifestations associated with COVID-19 is of utmost importance. They may help establishing an early diagnosis, namely in oligosymptomatic patients or when confirmatory tests are impossible to perform. Moreover, chilblain-like lesions and acro-ischemia, also seem to play an important role in terms of prognosis.

Introdução: A COVID-19, doença infeciosa causada por um novo coronavírus, SARS-CoV-2, propagou-se rapidamente pelo mundo inteiro, resultando numa necessidade emergente de obtenção de conhecimentos alusivos à sua patogénese, diagnóstico e sintomatologia. Mais especificamente, um número cada vez maior de casos relativos a manifestações cutâneas, previamente desconhecidas, tem vindo a ser descrito.Material e Métodos: Foi realizada uma pesquisa de literatura, através da base de dados PubMed, referente às manifestações dermatológicas associadas à COVID-19. O presente artigo descreve os achados clínicos e histológicos das principais lesões cutâneas observadas em contexto da infeção por SARS-CoV-2.Discussão: Manifestações cutâneas associadas à COVID-19 foram descritas em múltiplos estudos retrospetivos e prospetivos, séries de casos e casos clínicos isolados. A incidência reportada atingiu os 20,4%, verificando-se uma heterogeneidade de padrões clínicos substancial. Destes destacam-se as erupções eritematosas/maculopapulares, urticariformes, papulovesiculares, purpúricas/petequiais, lesões tipo-perniose e lesões livedóides/acro-isquémicas. O conhecimento dos mecanismos fisiopatológicos subjacentes tem vindo a ser enriquecido com achados os histológicos e de biologia molecular.Conclusão: É essencial o reconhecimento das manifestações dermatológicas associadas à COVID-19, uma vez que podem permitir o diagnóstico precoce da infeção, nomeadamente em casos oligossintomáticos ou quando não é possível a realização de testes confirmatórios. Embora menos estabelecido, lesões tipo-perniose e acro-isquémicas, parecem ter também um papel importante a nível prognóstico.

Should Paraben Mix Be Removed from The European Baseline Series.

Dear Editor: The European Baseline Series (EBS) of contact allergens is used throughout Europe as a screening test to diagnose contact allergy as a proxy for allergy contact dermatitis and other hypersensitivity skin diseases (1). Parabens are alkyl esters of p-hydroxybenzoic acid with antimicrobial effects used as preservatives in cosmetics, foods, and drugs that have been included in the so called "baseline series" (2) for more than 40 years. Parabens, which are considered allergologically safe biocides and are classified as safe by the US Food and Drug Administration (FDA) and the Scientific Committee on Consumer Safety (SCCS) in Europe (2-4), are frequently present in cosmetics (5). Despite extensive and progressively expanding use worldwide, studies confirm that parabens are seldom responsible for allergic contact dermatitis to cosmetics, and the frequency of sensitivity to parabens has been low and stable for many decades (2). The frequency of positive reactions to paraben mix is less than 0.5% in most clinical series, although it seems that when it occurs it is often of high clinical relevance (6). Nevertheless, several authors have stated that these patients rarely or never have to avoid foods or cosmetics that contain parabens to control their dermatitis (2). Paraben allergy most frequently occurs in patients with long-lasting stasis dermatitis or disruption of skin integrity, with high use of topical drugs, and in those who do not get better under normal treatment and/or skin care (5). The EBS has been periodically adapted by the European Environmental and Contact Dermatitis Research Group (EECDRG) and the European Society of Contact Dermatitis (ESCD), according to frequency studies, but ensuring that tested haptens remain relevant (1). Bruze et al. recommend that haptens should be considered for inclusion in a baseline series when the contact allergy prevalence is 0.5-1.0% or above (7). So, why not exclude paraben mix from the EBS? We analysed all the EBS tests performed at our institution in the last 21 years (2000-2020) to evaluate the frequency of positive reactions to paraben mix 16% pet (Chemotechnique diagnostics, Vellinge Sweden). In total, 5885 patients were patch tested (MOAHLFA index - Table 1), of whom 29 (10 men and 19 women) patients presented with a positive reaction (1+ or more according to ESCD guidelines) to paraben mix (0.49%), with positivity rates varying between 1.79% and 0.0% and progressively falling for the past 20 years (Figure 1). Present or past clinical relevance was found in 19/29 (65.5%) patients (6 men and 13 women), and was related to the use of topical drugs in 16 patients (55.2%) and cosmetics in three patients (10.3%). Paraben reactions occurred mostly in patients with history of leg ulcer, leg dermatitis, and/or chronic venous insufficiency, which is in agreement with the overrepresentation of the group of patients with leg dermatitis compared with the whole population tested (Table 1). The proportion of patients with positive reactions to paraben mix was significantly higher in patients with leg dermatitis compared with patients without leg dermatitis (P<0.05), as well in patients aged >40 (P<0.05), in whom these leg comorbidities are more frequent. Additionally, the higher number of reactions frequently coincided with the highest number of patients with leg dermatitis patch tested in the same year (Figure 1). Cosmetics were considered the causative factor in only three patients, which explains the identical percentage of facial and atopic dermatitis in the paraben mix positive group and the total population tested. As expected, both hand and occupational dermatitis were underrepresented in the group of positive reactions to parabens. In 34.5% of the patients, positive tests were considered not relevant or of unknown relevance. Therefore, in total only 0.32% of all paraben mix reactions were clinically relevant. Patch test reactivity to paraben mix of 0.49% supports the ongoing discussion that parabens should not continue in the baseline series, a position that is further strengthened by the fact that only 0.32% represent relevant reactions (8). As the most relevant sensitizations are related to topical medications and, less frequently, from cosmetics, paraben mix should be part of the topical drugs and cosmetic series.

Case for diagnosis. A pruritic eruption of keratotic papules over the face and neck.

Generalized eruptive keratoacanthoma of Grzybowski is a rare variant of multiple keratoacanthomas counting with about 40 cases reported. It is a chronic and progressive disease for which none of the described therapeutic options has been entirely satisfactory. We report a case of an 83-year-old female who presented with a 3-month history of extremely pruritic, multiple, skin-coloured to erythematous to brownish, millimetric papules, with a keratotic centre. Histological examination of an incisional biopsy was consistent with the diagnosis of keratoacanthoma. The patient started acitretin 25 milligrams daily with a complete resolution of pruritus and regression of numerous lesions.

Tumoral melanosis after immunotherapy with pembrolizumab - a response sign mimicking melanoma.

Tumoral melanosis is a rare histopathological finding characterized by aggregates of melanophages, in the absence of melanocytes, usually observed in sites of regressed melanocytic lesions, including melanoma. A 72-year-old woman with a history of a completely excised melanoma on her right arm (T3bN0M0, Stage IIb) presented with clinically-evident regional lymph node metastasis. This was treated with right axillary lymphadenectomy. Subsequently, a 2-centimeter blue-colored patch over the excision scar was identified, along with a blue nodule within the posterior aspect of the same arm, consistent with in-transit metastases. Additional metastases on the right hilar region of the lungs were detected by PET/CT. Hence, the patient began immunotherapy with pembrolizumab. After three months, a second PET/CT revealed a complete response, but the patient maintained the blue-colored patch previously observed. Given the discrepancy between the clinical and metabolic response she underwent a skin biopsy; histological examination showed findings compatible with tumoral melanosis resulting from complete regression of a metastatic lesion. In cases of metastatic melanoma under immunotherapy with anti-PD1 agents, especially pembrolizumab, tumoral melanosis has been anecdotally associated with tumor regression and favorable treatment response. The patient has been maintained on pembrolizumab, accomplishing 15 cycles, and has had a complete response to date.

Pediatric Psoriasis.

Psoriasis is a chronic inflammatory systemic disease associated with an important physical and physiological burden. It primarily affects the skin, but it is associated with several serious medical co-morbidities. One third of total psoriatic cases have their onset during the pediatric age, although some of them may not be diagnosed until the patient reaches adulthood. Additionally, in the pediatric age, there is an association with several medical co-morbidities; thus, an early recognition of the disease and a subsequent appropriate approach may delay or even prevent considerable co-morbidities. Because children are not just 'small adults', specific guidelines for the diagnosis, management, and treatment of psoriasis are of extreme importance. However, these guidelines are still lacking in this age group. Most of the psoriasis treatments used in adults are not officially approved for the pediatric age and require off-label prescription. Moreover, efficacy and safety studies are lacking in this population, especially with long-term follow-up and outcomes. Many biologic agents have been recently approved for the treatment of psoriasis in children, while others are currently being studied. This bibliographic review aims to summarize the most relevant aspects, as well as updated information about the epidemiology, pathogenesis, clinical features, diagnosis, co-morbidities and treatment of pediatric psoriasis.