Symmetrical acral keratoderma revisited: proposal for a new term, 'pigmented carpotarsal hyperkeratosis'.

First reported from Taiwan mistakenly as acral acanthosis nigricans in 1991, pigmented carpotarsal hyperkeratosis or hyperkeratosis nigricans carpi et tarsi displays a peculiar distribution of velvety brown-grey hyperpigmented plaques symmetrically on the flexural side of the wrists and ankles and on the dorsal sides of the hands and feet. A marked epidermal hyperkeratosis with typically mild acanthosis and papillomatosis is observed in histology. Whitish maceration upon perspiration or water exposure, with exacerbation in summer but remission in winter, is common. The association with obesity, endocrine disorders, atopic dermatitis, ichthyosis or malignancy is unknown. Familial occurrence and hereditary patterns are ill-defined. There is preliminary evidence indicating a pathogenic role of missense mutation in the transcription factor 4 gene. Treatment is empirical, with good outcome with topical retinoids and keratolytic agents. Recurrence is common, and long-term prognosis is unclear. To be distinguished are acral acanthosis nigricans, palmoplantar keratoderma of the Nagashima type, palmoplantar keratoderma of the Bothnian type and aquagenic palmoplantar keratoderma. Most reported cases are from Southern China and are predominantly observed in men between the ages of 20 and 40 years. The currently used term 'symmetrical acral keratoderma' is non-specific and misleading and may lead to global unawareness, underreporting or misdiagnosis of this phenomenon. Further genetic and molecular studies are required to clarify its pathogenesis and relation to palmoplantar keratoderma.

"Pseudo-Circumscribed Palmar or Plantar Hypokeratosis (Pseudo-CPH)": a Histologic Pattern Secondary to Trauma; Further Characterization of a Known Entity.

Circumscribed palmar or plantar hypokeratosis (CPH) is defined clinically as well-circumscribed areas of erythematous eroded skin mostly over thenar or hypothenar eminences of the palms and less commonly soles. Histologically, lesions demonstrate a characteristic abrupt drop-off in the cornified layer leading to broad areas of hypokeratosis. In the original description in 2002, Perez et al favored these lesions to be a distinctive epidermal malformation. Since then, some reports implicate trauma; however, the exact etiology remains uncertain. The authors present 11 cases in which the histologic changes of CPH are present as an incidental finding that they favor to represent a reaction pattern to trauma. The changes of CPH overly traumatized neoplasms [ie, a poroma, squamous cell carcinoma (2), dermatofibroma], verruca vulgaris (3), inflammatory processes (lichen amyloid and granulomatous inflammation secondary to a ruptured infundibular cyst), and scar and fibrosing granulation tissue from previous procedures. Classic clinical findings of CPH are not present. The changes most commonly but not exclusively occur on acral skin (8/11), both volar (4) and dorsal skin (4). Six patients are female and 5 are male. Ages range from 21 to 87 years (median 64 years). The authors propose that, in some instances, the histologic changes of CPH are present as a secondary phenomenon and represent a reaction pattern to trauma. They name this finding of secondary histologic change of CPH as "pseudo-CPH" to distinguish it from primary lesions of CPH ("primary CPH") with classic clinical and histologic features.

[New clinical classification for onychomycoses]. / Nouvelle classification clinique des onychomycoses.

We have updated our clinical classification on onychomycosis (2011) to render it of more practical value for the clinician. It should provide a better understanding of onychomycosis and facilitate an improved approach to treatment, taking into account, for example, the link between the proximal subungual variety and some superficial forms emerging from beneath the cuticle.

[Controversies over heel pressure ulcers]. / Controversias sobre las úlceras por presión en talones.

Article whose content was exposed in the workshops of the GNEAUPP Congress, held in Seville in November2012, and which refers to ulcers by pressure on the heels as a location exposed to the analysis. A pressure ulcer is a lesion located in skin I underlying tissue usually over a bone prominence, as a result of the pressure, or pressure in combination with the shears. A number of contributing factors or confounding factors are also associated with ulcers by pressure; the importance of these factors still not been elucidated. The heels are next to the sacred area, parts of the body that most frequently presents ulcers by pressure, The importance of the predisposing factors for ulcers in the sacral area as humidity has been studied in recent years, but in heels, remains one of the most important locations in the extremities, which entails adverse outcomes such as amputation in persons with comorbid diseases like Diabetes Mellitus (DM). The incidence of ulcers on heels in patients with DM and without it, is approximately 19-32%. Everything and be a problem associated with elderly people and chronic pathologies, in acute patients are a problem that this underrated, but not devoid of controversy. In hospitals of treble in 2006, the NPUAP encrypted the incidence of UPPin heels in a 43%; in one systematic review conducted by Reddy et al. (2006) puts revealed that 60% of pressure ulcers is produced. The problem of the UPP in heels is present in all the areas of intervention and particularly in paediatric units intensive care, where the first localization it is the occipital area followed by the heels.

A new classification system for grading the severity of onychomycosis: Onychomycosis Severity Index.

OBJECTIVE: To establish and validate a new system to define the severity of onychomycosis. The Onychomycosis Severity Index (OSI) score is obtained by multiplying the score for the area of involvement (range, 0-5) by the score for the proximity of disease to the matrix (range, 1-5). Ten points are added for the presence of a longitudinal streak or a patch (dermatophytoma) or for greater than 2 mm of subungual hyperkeratosis. Mild onychomycosis corresponds to a score of 1 through 5; moderate, 6 through 15; and severe, 16 through 35. DESIGN: Consensus conference. SETTING: Teleconference. PARTICIPANTS: The consensus group included 5 dermatologists, 1 dermatology resident with an interest in nail disorders, and a statistician. The meetings were held by closed teleconference. MAIN OUTCOME MEASURES: Index reliability. RESULTS: The reliability of the OSI system was assessed in 2 steps. The first assessment included 37 dermatologists who scored 8 photographs of onychomycosis after being taught how to use the OSI. The scoring system showed very high reliability (Cronbach α = 0.99 and intraclass correlation coefficient [ICC] = 0.95). The second assessment entailed evaluation of 49 nails by 3 dermatologists, including an expert in the OSI. This assessment was conducted at the University of Alabama at Birmingham and at the Oregon Dermatology and Research Center, Portland. The scoring system showed very high reliabilities at both sites (Cronbach α = 0.99 and ICC = 0.96 at the University of Alabama at Birmingham, and Cronbach α = 0.98 and ICC = 0.93 at the Oregon Dermatology and Research Center). CONCLUSION: The OSI is a new, simple, objective, reproducible numeric system to grade the severity of onychomycosis.

Nonmutilating palmoplantar and periorificial kertoderma: a variant of Olmsted syndrome or a distinct entity?

BACKGROUND: Olmsted syndrome is a rare keratinization disorder characterized by mutilating palmoplantar and periorificial keratoderma as the two major diagnostic features. Some authors believe that atypical cases without this standard combination may not really belong to Olmsted syndrome. Herein, we describe two familial cases with congenital nonmutilating palmoplantar and periorificial keratoderma, and discuss their similarities and differences with Olmsted syndrome. PATIENTS: The study included two sisters who presented with focal and punctate nonmutilating palmoplantar keratoderma (PPK), periorificial hyperkeratotic plaques, and widely distributed keratotic lesions. Fragile denuded areas of the skin were found in sites exposed to trauma. Fingernails showed a characteristic form of leukonychia. RESULTS: Histopathology of plantar keratoderma showed psoriasiform hyperplasia with marked compact hyperkeratosis, while vicinity of denuded skin revealed thin parakeratotic zone and dissolution of the granular cell layer. Immunohistochemistry demonstrated suprabasal staining pattern for acidic keratin (AE1) and uniform positivity, starting four to six layers above the basal layer, for cytokeratin 10. Electron microscopy showed defective keratinization. Cytogenetic studies revealed normal karyotype and no chromosomal breakage. CONCLUSION: Our cases share Olmsted syndrome in the early onset, and the presence of symmetrical PPK, periorificial keratoderma and keratotic lesions. However, the striking nonmutilating nature of PPK and the presence of unique features in our patients suggest a newly described keratinization disorder.

The hand-foot-syndrome associated with medical tumor therapy - classification and management.

The hand-foot-syndrome (HFS, palmoplantar erythrodysesthesia, chemotherapy-associated acral erythema) is characterized by painful predominantly palmo-plantar lesions. The association with different chemotherapeutic agents has been known for over 20 years. More recently, HFS has been reported in association with regimens using targeted agents, in particular the multikinase inhibitors (MKI) sorafenib and sunitinib. The HFS associated with MKI has a different distribution and clinical appearance than the traditional disorder. In this review, similarities and differences between chemotherapy- and MKI-associated HFS are discussed and current recommendations for their prophylaxis and management are summarized.

Other fungi causing onychomycosis.

Nondermatophyte onychomycosis account for 2% to 12% of all nail fungal infections and can be caused by a wide range of fungi, mainly Scopulariopsis brevicaulis, Aspergillus versicolor, A. flavus, A. niger, A. fumigatus, Fusarium solani, F. oxysporum and Scytalidium spp. Among the predisposing factors are footwear, hyperhidrosis, local trauma, peripheral circulatory disease, and immunosuppression. These nondermatophyte fungi lack the keratinolytic capacity of dermatophytes, but they still can infect alone or in combination with the latter. Because most are considered laboratory contaminants, special criteria have been created for the correct diagnosis of nondermatophyte onychomycosis. The etiologic agent does not determine the clinical pattern of nail invasion, but superficial onychomycosis is frequently observed; leukonychia and melanonychia can also be clinical manifestations.

A dynamic model of hand-and-foot syndrome in patients receiving capecitabine.

For the purpose of developing a longitudinal model to predict hand-and-foot syndrome (HFS) dynamics in patients receiving capecitabine, data from two large phase III studies were used. Of 595 patients in the capecitabine arms, 400 patients were randomly selected to build the model, and the other 195 were assigned for model validation. A score for risk of developing HFS was modeled using the proportional odds model, a sigmoidal maximum effect model driven by capecitabine accumulation as estimated through a kinetic-pharmacodynamic model and a Markov process. The lower the calculated creatinine clearance value at inclusion, the higher was the risk of HFS. Model validation was performed by visual and statistical predictive checks. The predictive dynamic model of HFS in patients receiving capecitabine allows the prediction of toxicity risk based on cumulative capecitabine dose and previous HFS grade. This dose-toxicity model will be useful in developing Bayesian individual treatment adaptations and may be of use in the clinic.

Patterns of lower leg and foot eczema in South India.

BACKGROUND: The pattern of eczema is altered by geography, habits of people and environmental factors and regional variation in skin structure and function. AIMS: Our study was done to estimate frequency and patterns of lower leg and foot eczemas. METHODS: A total of 200 patients with various types of lower leg and foot eczemas were recruited over a period of 2 years. Demographic and clinical characteristics were noted. Suspected cases of allergic contact dermatitis were patch tested. RESULTS: The frequency of these eczemas was 2.5 per 1000 out patients. Mean age of patients was 40.49 years. Female to male ratio was 1.6:1. Sixty (30%) patients were farmers, sixty (30%) were housewives, forty (20%) were students, nineteen (9.5%) were daily laborers, nine had sedentary jobs and three were teachers. Most eczemas were bilateral (72%). Mean duration of eczema was 36.6 months. Most common type of eczema was lichen simplex chronicus (36%) followed by discoid eczema (18.5%), allergic contact dermatitis (14.5%) and stasis eczema (7.5%). Other eczemas noted were juvenile plantar dermatosis, cumulative irritant contact dermatitis, infected eczema, hyperkeratotic eczema, asteatotic eczema, pompholyx, infective eczema and unclassified endogenous eczema. Common sites of involvement were dorsa of feet (49.5%), followed by lateral aspect of lower leg (31%), medial aspect of lower leg (17.5%) and ankle (12%). CONCLUSION: Our study highlights lichen simplex chronicus as the most common eczema affecting the lower legs and feet.

New fungal nail infections.

PURPOSE OF REVIEW: The number of people affected by onychomycosis continues to increase. The prevalence of different pathogens in different areas depends on several factors, such as climate, geography and migration. We reviewed the recent literature to identify new agents responsible for onychomycosis. RECENT FINDINGS: Recent studies performed in different countries are not only reporting molds and yeasts as contaminants, but are increasingly reporting them as pathogens. Infection by novel agents is also being reported, although the individual cases do not necessarily indicate that these are emerging agents. SUMMARY: Clinicians should bear in mind the increased number of case series reporting the role of molds and yeasts in onychomycosis, and should not treat the disease without first examining the mycology results. The question remains as to whether these agents are truly new fungi responsible for onychomycosis, or whether improvement of diagnostic techniques and increasing reference to such species in the literature has resulted in better identification of such agents.

Epidermodysplasia verruciformis and generalized verrucosis: the same disease?

We report a patient with epidermodysplasia verruciformis (EV) who had severe generalized verrucous skin lesions for 50 years without any immunological abnormality. Microscopic examination showed two histopathological features, including seborrhoeic keratosis and common warts. The detected human papilloma virus (HPV) types were found to be HPV 3, 50, 5, and 76, using a degenerate PCR method. EV and generalized verrucosis are distinguished by slight differences in clinical symptoms or HPV types, so there should be no apparent differential points common to both diseases. Therefore, we propose that an abnormal susceptibility specific to HPV, which is the most characteristic feature in EV, should be regarded as a differential point in these two diseases.

Acropustulosis repens.

BACKGROUND: Pustular eruptions of the extremities of the fingers and toes (acropustulosis) have been grouped under the single term "Hallopeau's acrodermatitis continua", which is a severe disease, with uninterrupted course, and successive eruptions that may become generalized. However, there is a form of acropustulosis with few lesions, evolving with remissions and relapses, with a benign course. It is necessary to separate these two forms of acropustulosis. METHODS: I had the opportunity to observe six patients with a mitigated form of acropustulosis that does not fit into the diagnostic criteria of Hallopeau's acrodermatitis continua, which should be considered an independent clinical entity. RESULTS: Sometimes, there is only one lesion in each eruption. The pustules are sterile and appear in small crops, located on the hyponychium or on the nail bed. The result is partial onycholysis or nail detachment. After each eruption there is complete recovery. Histopathology shows a nonspongiform pustule filled with neutrophils, with subcorneal localization. Four patients had follow-up for at least 2 years, and one patient presented psoriasis lesions on the scalp after 11 years. CONCLUSIONS: Acropustulosis as I described it can be differentiated from Halopeau's acrodermatitis continua using the following diagnostic criteria: (1) it is a benign condition; (2) the pustules are located on the hyponychium or nail bed; (3) pustules can be single or occur in small groups; (4) they reccur in flares, with restitutio ad integrum during the periods of remission; (5) the pustules are sterile; (6) microscopic study shows a subcorneal pustule (spongiform aspect is rare). A similar condition to that found in my cases was described by Radcliff-Crocker (H. Radcliff-Crocker, Diseases of the Skin, London: H.K. Lewis, 1888), termed "dermatitis repens".

Alterations of epidermal proliferation and cytokeratin expression in skin biopsies from heavy draught horses with chronic pastern dermatitis.

We report the historical, clinical and histopathological characteristics of skin lesions in biopsies from 37 heavy draught horses with chronic pastern dermatitis. The skin lesions were divided into four macroscopic groups: scaling (group I, n=5), hyperkeratotic and hyperplastic plaque-like lesions (group II, n=14), nodular skin masses (group III, n=16) and verrucous skin lesions (group IV, n=2). The principal histological findings were hyperkeratosis and epidermal hyperplasia. There was a gradual increase in epidermal hyperplasia from groups I to IV, suggesting that the lesions represent different stages of disease. In all cases, there was perivascular dermatitis dominated by T lymphocytes with an increase in MHC class II-positive dendritic-like cells. Immunohistochemical labelling for cytokeratins CK5/6(4), CK10 and CK14 indicated a change in their expression pattern. This correlated with the degree of epidermal hyperplasia, indicating abnormal differentiation of keratinocytes. There was a statistically significant correlation between the severity of skin lesions and several other factors including increasing age, increasing cannon circumference, prominence of anatomical structures such as fetlock tufts of hairs, ergots and chestnuts, and bulges in the fetlock region.

Superficial white onychomycosis revisited.

BACKGROUND: Superficial white onychomycosis (SWO) is a distinct pattern of fungal nail invasion, which is usually treated with topical antifungals. OBJECTIVE: This paper presents a case of SWO with deep penetration and records other similar cases. METHODS: The clues to deep invasion of the nail plate are twofold: an inability to clear the discoloration by scraping the nail and a clinical involvement of the nail plate in the proximal nailfold area. Histology of the nail keratin will confirm deep penetration beyond the superficial layers of the nail plate. RESULTS: In the light of this finding the authors propose a further subdivision of SWO to reflect previously unrecognized variants with therapeutic implications into: (i) the classical SWO type; (ii) the dual invasion of the nail plate, superficial and ventral; and (iii) the pseudo-SWO with deep fungal invasion of the nail plate. CONCLUSIONS: This subdivision of SWO allows the clinician to treat the patient appropriately using topical antifungals when the disease is restricted to the dorsum of the nail. Systemic drugs either in isolation or in combination with topical treatment are mandatory when deep penetration or ventral fungal invasion are observed.

Type IV hypersensitivity from rubber chemicals: a 15-year experience in Taiwan.

BACKGROUND: Allergic contact dermatitis from rubber chemicals is frequent but has not been reported form Asia. OBJECTIVE: To study the pattern of type IV allergy to rubber chemicals in a Chinese-based population. METHODS: A retrospective study was conducted by reviewing the patch test results of 2,235 (604 men, 1,631 women) patients from January 1986 to December 2000. RESULTS: Ninety-nine patients (4.4%) had one or more positive reactions, 42 (6.9%) men and 57 (3.5%) women. The incidence did not increase throughout the study period. Among thiuram, mercapto, carba and black-rubber mix, thiuram is the most potent sensitizer, mostly for the hand and mercapto mix for the foot. Thiuram allergy is considered occupation related, while mercapto allergy, mostly from rubber slippers, is not typically related to an occupation. A negative correlation between thiuram and carba was found despite the frequent association between these two mixes. A high risk of rubber sensitization was noted in construction, health service, transportation, agriculture and hairdressing workers. A high frequency of concomitant sensitivity to cobalt was found. CONCLUSION: This is the first statistically analyzed study of rubber chemical allergy in Asia, which supports major trends concerning rubber chemical allergy from European studies. However, wearing rubber slippers in Taiwan contributes to the high percentage of foot dermatitis. Carba should still be retained in the European standard series because of the coexistence of thiuram and carba in rubber products. The concomitant sensitization to cobalt in rubber-allergic patients needs further evaluations.

Types of onychomycosis.

Onychomycosis may be classified into several types: distal subungual, white superficial, proximal subungual, endonyx, and total dystrophic. Distal subungual onychomycosis (DSO), the most common type, involves the nail bed and, subsequently, the nail plate. White superficial onychomycosis (WSO) usually manifests as superficial white patches with distinct edges on the surface of the nail plate. Proximal subungual onychomycosis results when the fungal organism enters via the cuticle and the ventral aspect of the proximal nail fold. In endonyx onychomycosis, fungal organisms invade the nail plate without resulting nail bed hyperkeratosis, onycholysis, or nail bed inflammatory changes. In total dystrophic onychomycosis, complete dystrophy of the nail plate occurs; these changes may be primary or secondary.

[Eccrine neutrophilic hidradenitis: idiopathic plantar form in children]. / Hidradénite eccrine neutrophilique: forme plantaire idiopathique de l'enfant.

UNLABELLED: In this study, two cases have been reported of idiopathic plantar hidradenitis, an uncommon dermatological pathology with a spontaneous favorable outcome. OBSERVATIONS: Two children aged 12 and 14 years presented with a painful papulo-nodular plantar rash with major functional impairment. The diagnosis of idiopathic plantar hidradenitis was considered, and then confirmed in one case by plantar biopsy. Non-steroidal antiinflammatory drugs, associated with paracetamol in one case were administered. The symptoms disappeared spontaneously within a few days in both cases, without any recurrence. CONCLUSION: A knowledge of the symptoms connected with plantar hidradenitis in the child allows a rapid diagnosis to be made without hospitalization or further medical examination. Analgesic treatment and rest seem to be the only useful approaches. Biopsy to investigate eccrine gland infiltration by neutrophils can only be proposed in the case of an abnormally prolonged duration or an atypical presentation of this pathology.