Pyoderma gangrenosum: challenges and solutions.

Pyoderma gangrenosum (PG) is a rare disease, but commonly related to important morbidity. PG was first assumed to be infectious, but is now considered an inflammatory neutrophilic disease, often associated with autoimmunity, and with chronic inflammatory and neoplastic diseases. Currently, many aspects of the underlying pathophysiology are not well understood, and etiology still remains unknown. PG presents as painful, single or multiple lesions, with several clinical variants, in different locations, with a non specific histology, which makes the diagnosis challenging and often delayed. In the classic ulcerative variant, characterized by ulcers with inflammatory undermined borders, a broad differential diagnosis of malignancy, infection, and vasculitis needs to be considered, making PG a diagnosis of exclusion. Moreover, there are no definitively accepted diagnostic criteria. Treatment is also challenging since, due to its rarity, clinical trials are difficult to perform, and consequently, there is no "gold standard" therapy. Patients frequently require aggressive immunosuppression, often in multidrug regimens that are not standardized. We reviewed the clinical challenges of PG in order to find helpful clues to improve diagnostic accuracy and the treatment options, namely topical care, systemic drugs, and the new emerging therapies that may reduce morbidity.

Interstitial Granulomatous Dermatitis: A Clinicopathological Study.

INTRODUCTION: Interstitial granulomatous dermatitis (IGD) is an uncommon granulomatous dermatitis occurring in the setting of highly reactive immune states, with a polymorphic clinical presentation. Because there is overlap with other entities [namely palisading neutrophilic granulomatous dermatitis (PNGD)], controversy exists regarding its classification. OBJECTIVE: To understand if there are features allowing clear-cut distinction between IGD and PNGD. MATERIAL AND METHODS: Retrospective analysis of 10 cases previously diagnosed as IGD or PNGD, from 2000 to 2013, with review of the histopathologic findings and clinical correlation. RESULTS: Six females and 4 males presented mostly with erythematous papules/nodules (n = 7) but also with erythematous annular plaques (n = 3). In 2 patients, the lesions coexisted. They were mostly distributed symmetrically on the limbs. Associated disease was observed in 6 patients. Regarding histopathology, an inflammatory infiltrate occupying the superficial and mid dermis was present in 40% of cases, with an interstitial component in all biopsies and a palisaded arrangement in 60%. Neutrophils and mononuclear cells were present in all cases in varying proportions. Necrobiosis was found in 70%, and leukocytoclasia was observed in 80% of biopsies. CONCLUSIONS: Coexistence of the interstitial and palisaded inflammatory patterns occurred in 90% of cases, with no correlation between tissue neutrophilia and the predominant pattern of the infiltrate. There was also no clear-cut correlation between the infiltrate pattern and semiologic aspect of the lesions. Therefore, the features described in our study suggest that IGD and PNGD belong to the same clinicopathological spectrum.

Multinucleate cell angiohistiocytoma: a new case report with dermoscopy.

Multinucleate cell angiohistiocytoma (MCA) is a benign fibrohistiocytic and vascular proliferation usually located on the extremities. It may be underdiagnosed owing to lack of recognition by clinicians and pathologists. We report a 48-year-old man with asymptomatic grouped reddish papules on the dorsum of his right hand for 8 years. Histopathological and immunohistochemical examinations revealed features of MCA with a fibrohistiocytic cell infiltrate in the dermis and multinucleate cells in the stroma. Recently, the dermoscopy aspects of MCA have been described. We add another observation of this useful tool and correlate it with clinical evolution.

Tunnelized preauricular transposition flap for reconstruction of auricular defect.

BACKGROUND: Reconstruction of surgical defects of the auricular region is a complex challenge, especially when they are localized in the anterior surface, due to the convexities and concavities of this region. PATIENTS AND RESULTS: The authors present the case of an 89-year-old woman who underwent radical excision of basal cell carcinoma localized in the left scapha. The reconstruction of the resulting defect was performed using a preauricular transposition flap tunnelized through a cartilaginous fistula created at the crus helicis. The flap was deepithelialized at its base to allow the closure in a single step. The donor site was primarily closed. The procedure was performed under local anesthesia without complications and with acceptable aesthetic results. DISCUSSION: There are various surgical procedures described for the reconstruction of the anterior auricle, including local flaps, skin grafts and even healing by secondary intention. The authors consider the tunnelized preauricular transposition flap a good option especially when compared to interpolated flaps, since it allows a reconstruction in a single surgical step with decreased morbidity and favorable cosmetic results.

Conservative treatment of penile carcinoma - a retrospective study of 10 years.

Conservative treatment of penile squamous cell carcinoma has been advocated as a method of choice for tumours at early stages. Thirty patients with a mean age of 63.2 years were treated with CO2 laser ablation, radical local excision with preputial flap, direct closure or healing by secondary intention, circumcision alone or associated with CO2 laser and topical imiquimod. Sixteen patients had local recurrence. Partial penectomy was necessary in 3 patients. Conservative treatments of penile squamous cell carcinoma in early stages (≤ T1a) do not seem to compromise the survival rate, so it may be advisable for this subset of patients.

Conservative treatment of penile carcinoma - a retrospective study of 10 years / Tratamento conservador do carcinoma do penis - estudo retrospectivo de 10 anos

Conservative treatment of penile squamous cell carcinoma has been advocated as a method of choice for tumours at early stages. Thirty patients with a mean age of 63.2 years were treated with CO2 laser ablation, radical local excision with preputial flap, direct closure or healing by secondary intention, circumcision alone or associated with CO2 laser and topical imiquimod. Sixteen patients had local recurrence. Partial penectomy was necessary in 3 patients. Conservative treatments of penile squamous cell carcinoma in early stages (< T1a) do not seem to compromise the survival rate, so it may be advisable for this subset of patients.

O tratamento conservador do carcinoma espinocelular do pênis tem sido o método de escolha para tumores em estádios iniciais. Trinta doentes com idade média de 63,2 anos, foram tratados com: ablação com laser CO2, excisão radical seguida de retalho prepucial, encerramento direto ou cicatrização por segunda intenção, circuncisão isolada ou associada a laser CO2 e imiquimod. Dezasseis doentes apresentaram recidiva local. No seguimento, houve necessidade de penectomia parcial em 3 doentes. O tratamento conservador do carcinoma espinocelular do pênis em estádio < T1a não parece comprometer a taxa de sobrevida, pelo que pode ser recomendável neste subgrupo de doentes.

Pyoderma gangrenosum--a review of 24 cases observed over 10 years.

BACKGROUND AND OBJECTIVES: Pyoderma gangrenosum (PG) is a disorder, included in the spectrum of neutrophilic and auto-inflammatory dermatoses, whose clinical aspects and outcome we intend to characterize. MATERIALS AND METHODS: In a retrospective study based on files of patients diagnosed during a 10-year period (2000-2009), we evaluated demographic data, anatomic locations, number of lesions, clinical variants, associated diseases, treatment regimens, healing time, and recurrence. RESULTS: A total of 24 patients were included, 19 women and five men (F/M = 3.8/1), aged between 17 and 89 years (mean 58.3 ± 24.6 years) with a diagnosis of PG. Lesions, single in 15 patients (62.5%) and multiple in nine (37.5%), were localized in the lower limbs in 19 patients (79.2%), upper limbs (4), abdomen (4), face (2) and genital area (1). Clinical variants observed were ulcerative (17 patients), pustular (4), bullous (2) and superficial granulomatous (1). Associated systemic diseases were observed in 18 patients (75%), gastrointestinal in seven patients (29.2%), hematological in seven (25%), autoimmune inflammatory in three (12%), and solid tumors in two (8.3%). Systemic steroids were used in the treatment, either alone in 10 patients (41.7%) or combined with cyclosporine in eight (33.3%). Complete healing was achieved in 20 patients, on average five months after diagnosis, but lesions recurred one or more times in four patients (16.7%). CONCLUSIONS: As reported in the literature, PG is a rare disorder, more common in females, frequently associated with systemic disease, which compromises the prognosis.

Pityriasis lichenoides et varioliformis acuta: case report and review of the literature.

We report a case of a 63-year-old man hospitalized for a polymorphous generalized eruption consisting of maculopapules with peripheral scaling, vesicopustules, and ulceronecrotic and crusted lesions measuring 5-20 mm, localized on his trunk and extremities, particularly exuberant in the flexural area. Histopathology showed necrotic keratinocytes with exocytosis of red blood cells and lymphocytes and a dermal perivascular and periadnexal inflammatory infiltrate, composed of CD8+/CD4-/CD30- T cells, indicating the clinical diagnosis of pityriasis lichenoides et varioliformis acuta. He was treated with erythromycin and methylprednisolone reduced gradually over 5 months, with a slow but complete response; the patient was without lesions after 2 years of follow-up. The authors want to remind of this rare entity which may present difficulties in diagnosis and therapy.

Value of patch tests in clindamycin-related drug eruptions.

BACKGROUND: Patch tests help to confirm the aetiology of the cutaneous adverse drug reactions involving delayed hypersensitivity mechanisms, but the results vary with the pattern of skin reaction and the culprit drug. OBJECTIVES: To analyse the results of patch tests in patients with cutaneous adverse drug reactions imputable to clindamycin and assess their contribution to the diagnosis. PATIENTS AND METHODS: Between 2005 and 2009, we studied patients with delayed cutaneous adverse drug reactions following administration of clindamycin, usually associated with other drugs. After resolution of the cutaneous adverse drug reaction, patch tests were performed with a series of antibiotics, including pure clindamycin 10% in petrolatum. RESULTS: We studied 30 patients (23 females and 7 males) aged 33-86 years (mean 59.97 years) with generalized maculopapular exanthema where clindamycin was among the highly suspected drugs. Two patients had a previous positive involuntary rechallenge. Patch tests with clindamycin were positive in 9 of 30 patients (30%). More than 50 control patients patch tested with clindamycin were negative. DISCUSSION: We considered the positive patch tests results with clindamycin, in the 9 patients with maculopapular exantema, to be specific, versus the negative results observed in the control group. Although the sensitivity is low (30%), they confirmed the responsibility of this antibiotic in cutaneous adverse drug reactions in which, with only chronological criteria, it was not possible to conclude on the culprit drug.