Eczema en los pies en una consulta de alergia cutánea: estudio retrospectivo de 13 años / Foot Eczema in a Skin Allergy Unit: Retrospective Study of 13 Years

Introducción: La dermatitis de pies es un motivo frecuente de consulta en las Unidades de Alergia Cutánea. Objetivos: Conocer las características demográficas, el diagnóstico y los alérgenos más frecuentemente implicados en los pacientes a los que se les han practicado pruebas epicutáneas. Material y métodos: Estudio observacional transversal en un Servicio de Dermatología con todos los pacientes estudiados con la batería estándar española durante 13 años (2004-2016). Comparamos los resultados de las pruebas epicutáneas y los diagnósticos finales entre los distintos subgrupos de pacientes con eczema de pies. Resultados: Estudiamos un total de 3.265 pacientes; 308 (9,4%) presentaban eczema en los pies, 176 (57,9%) tenían afectación solo en los pies y 132 (42,1%) afectación concomitante en manos y pies. En el subgrupo con afectación exclusiva en los pies se observó un mayor porcentaje de pacientes con pruebas epicutáneas positivas (61,5% solo pies, 53,4% manos y pies). En el subgrupo de afectación concomitante de manos y pies se observó un menor porcentaje de pruebas epicutáneas positivas entre los menores de 18 años (51,3% en menores y 64,4% en mayores). El alérgeno con relevancia presente más frecuente en todos los subgrupos fue el dicromato potásico. La dermatitis de contacto alérgica (49,1%) fue el diagnóstico más frecuente en los pacientes con afectación exclusiva de los pies, mientras que en los pacientes con eczema en manos y pies fue la psoriasis (33,6%) en los adultos y la dermatitis atópica en los menores de 18 años (60,0%). Conclusión: La realización de pruebas epicutáneas es de gran utilidad tanto en los pacientes con eczema de afectación exclusiva de los pies como en aquellos con afectación concomitante de manos y pies

Introduction: Foot eczema is a common complaint encountered by skin allergists. Objective: To study a series of patients with foot eczema who underwent patch testing and describe their demographic profile, diagnoses, and the main allergens involved. Material and methods: Cross-sectional observational study of all patients tested with the standard Spanish patch test series at a dermatology department over a period of 13 years (2004-2016). We studied patch test results and definitive diagnoses by comparing different subgroups of patients with foot eczema. Results: Of the 3,265 patients included in the study, 308 (9.4%) had foot eczema, 176 (57.9%) had foot eczema only and 132 (42.1%) had concomitant foot and hand eczema. Positive patch test results were more common in patients with foot eczema only (positivity rate of 61.5% vs. 53.4% for foot and hand eczema). In the subgroup of patients with concomitant foot and hand involvement, patients aged under 18 years had a lower rate of positive results (51.3% vs. 64.6% for patients >18 years). Potassium dichromate was the most common allergen with current relevance in all subgroups. The main diagnosis in patients with foot involvement only was allergic contact dermatitis (49.1%). In the subgroup of patients with concomitant hand and foot eczema, the main diagnoses were psoriasis in adults (33.6%) and atopic dermatitis in patients aged under 18 years (60.0%). Conclusion: Patch tests are a very useful diagnostic tool for patients with foot eczema with or without concomitant hand involvement

Foot allergic contact dermatitis to mixed dialkyl thioureas.

A 12-year-old boy presented with severe, bilateral foot dermatitis. Extended patch testing was performed, revealing a significant positive reaction to mixed dialkyl thioureas. A thorough review of his history revealed that he was likely being exposed through his neoprene taekwondo shoes. After implementation of allergen avoidance measures, his dermatitis resolved. This case emphasizes awareness of potential allergen exposures and offers helpful avoidance strategies.

Importance of Preexisting Physical Factors in the Development of Dermatological and Muscular Lesions During Hiking.

Hiking has become very popular due to the physical and mental health benefits it provides. Skin lesions may occur with hiking and various factors contribute to their development. Although some lesions may appear to have little importance, something as simple as chaffing can cause serious ulcers in people with at-risk feet. Few studies have analyzed preexisting physical characteristics in hiking and addressed the development of lesions in hikers. This observational and longitudinal study examines the development of foot lesions during hiking, taking into account the influence of existing skin disorders, nail disorders, and/or toe deformities and other intrinsic factors of participants. The feet of 109 hikers doing a 29.6-km hike were analyzed, considering the intrinsic factors of participants and the possible influence of these factors in the development of foot lesions during the walk. The results show that some preexisting physical factors of participants such as gender, existing systemic disease, preexisting keratosis, dermatosis, nontraumatic and traumatic onychopathies, and toe deformities significantly predispose to the development of skin lesions. These factors also predispose to muscle lesions except for nontraumatic and traumatic onychopathies and toe deformities. Due to the influence of preexisting physical factors, such as preexisting keratosis, dermatosis, and toe deformities, in the development of foot lesions in hikers, it is worthwhile and advisable to check these factors before a hike to reduce the incidence of foot disorders. Ensuring adequate podiatry treatment a few days before the walk and warmup of muscles properly before starting are recommended.

Impact of the mechanical hyperkeratotic lesions and its association with quality of life: An observational case-control study.

BACKGROUND: Mechanical hyperkeratotic lesions (MHL) are common condition amongst population of all ages. Such problems may be associated with pain, reduction in mobility, changes of gait and risk of falls and is believed to affect the quality of life (QoL), general health and optimal foot health. OBJECTIVE: The main aim of this study was to describe and compare both foot and general health-related QoL in two groups of participants: (i) with MHL and (ii) healthy controls. METHOD: A total sample of 150 patients, mean age 49.50 ± 36.50 years, was recruited from an outpatient clinic. Demographic data, medical history and clinical characteristics of overall health were determined, and the obtained values were compared by the Foot Health Status Questionnaire (FHSQ). RESULTS: The FHSQ scores of the sample with MHL showed lower scores than control subjects in sections one and two for footwear, general and foot health, foot pain, foot function and physical activity (P < 0.01), but not for social capacity and vigour (P > 0.01). CONCLUSIONS: People with MHL showed a decrease in QoL, based on FHSQ scores, regardless of gender.

Apremilast for the treatment of moderate-to-severe palmoplantar psoriasis: results from a double-blind, placebo-controlled, randomized study.

BACKGROUND: Palmoplantar psoriasis is a variant of psoriasis vulgaris which can severely impair quality of life. OBJECTIVES: The main objectives of this double-blind, placebo-controlled, randomized study were to assess the efficacy and impact on quality of life and work productivity of apremilast for the treatment of moderate-to-severe palmoplantar psoriasis. METHODS: A total of 100 patients with moderate-to-severe palmoplantar psoriasis were randomized to either apremilast 30 mg bid or placebo for 16 weeks. At Week 16, all patients received apremilast 30 mg bid until Week 32. The primary endpoint was the proportion of patients who achieved a Palmoplantar Psoriasis Physician Global Assessment (PPPGA) of 0/1 at Week 16. RESULTS: There was no significant difference in the proportion of patients who achieved a PPPGA of 0/1 at Week 16 between patients randomized to apremilast (14%) and placebo (4%; P = 0.1595). After 32 weeks of treatment with apremilast, 24% of patients achieved a PPGA of 0/1. In addition, apremilast was superior to placebo in achieving Palmoplantar Psoriasis Area Severity Index (PPPASI) 75 (apremilast: 22%; placebo: 8%; P = 0.0499), in improving PPPASI (apremilast: -7.4 ± 7.1; placebo: -3.6 ± 5.9; P = 0.0167), Dermatology Life Quality Index score (apremilast: -4.3 ± 5.1; placebo: -0.8 ± 4.5; P = 0.0004) and in reducing activity impairment (apremilast: -11.0 ± 22.3; placebo: 2.5 ± 25.5; P = 0.0063). CONCLUSION: Despite the absence of a significant difference between apremilast and placebo in proportion of patients achieving a PPPGA of 0/1, the presence of significant differences observed for several secondary endpoints suggests that apremilast may have a role in the treatment of moderate-to-severe palmoplantar psoriasis.

Sensitive skin and the influence of female hormone fluctuations: results from a cross-sectional digital survey in the Dutch population.

Sensitive skin is a widespread condition, which is most frequently reported by women. Changing hormone levels during the menstrual cycle and menopause have been suggested among the stimuli triggering sensitive skin. To investigate the perceived influence of fluctuating hormone levels on self-assessed sensitive skin, including symptoms and stimuli linked to skin sensitivity, as well as potential changes in facial and body skin and sensitive body parts, depending on hormonal status. A digital questionnaire was distributed to a population of women aged 20-65 years old. A total of 278 women were included in the analysis. About 42% premenopausal women declared a perception of (increased) skin sensitivity just before and during the menstrual cycle, while this was reported by almost 32% of peri- and postmenopausal women following the menopause. The majority of reported symptoms included the presence of bumps/pimples, dryness, itching, and redness, and the majority of reported stimuli were shaving, weather, toiletries, and emotions. No differences emerged regarding characteristics of facial and body skin across different hormonal status. Significant differences in sensitivity of body parts emerged for the face and feet, reported by a larger percentage of premenopausal women and peri- and postmenopausal women, respectively. The prevalence of the perceived effects of fluctuating hormone levels on self-assessed sensitive skin in women is high. These effects should be taken into consideration in skin testing and dermatological practice, and support the need for selecting personal care routine or treatment during the menstrual cycle and menopause.

Serratia marcescens Bullous Cellulitis in a Splenectomized Patient: A Case Report and Review of the Literature.

Serratia marcescens is a Gram-negative bacillus belonging to the Enterobacteriaceae family. Cutaneous infection with Serratia is rare, and usually occurs in immunocompromised individuals. Primary cutaneous infections are uncommon, but they are typically severe and are associated with significant morbidity and mortality. The pathogenetic factors leading to S. marcescens infection are not fully understood, but contributing virulence factors include proteases, secreted exotoxins, and the formation of biofilm. We report a case of cellulitis occurring in a splenectomized patient, which led to multiple wound debridements and a transmetatarsal amputation. This dramatic case led us to review the published literature on soft tissue infections caused by S. marcescens.

Broad-band UVB versus paint PUVA for palmoplantar psoriasis treatment.

BACKGROUND: Plaque-type palmoplantar psoriasis (PPTP) is a chronic recalcitrant dermatosis with treatment modalities ranging through topical, phototherapy or systemic. Phototherapy options include various forms of ultraviolet B (UVB) and ultraviolet A with prior psoralen sensitization (PUVA). Currently, few comparative studies have been reported. PURPOSE: To compare Broad-Band UVB (BB-UVB) versus paint PUVA (p-PUVA) in regard to efficacy and safety in the treatment of PPTP. METHODS: A retrospective non-randomized cohort study comprised of all the patients with PPTP treated in our phototherapy centre during 2010-2012, either with BB-UVB or p-PUVA. RESULTS: Among the 248 patients included in this study, 122 received BB-UVB and 126 followed p-PUVA treatment. About 36 (30%) and 53 (42%) had complete remission, 29 (24%) and 59 (47%) responded partially and 57 (47%) and 14 (11%) patients did not improve with BB-UVB and p-PUVA, respectively. The odds ratio for remission (p-PUVA: BB-UVB) was 7.9. Duration of remission was 21.9 ± 1.34 months for p-PUVA and 16.75 ± 1.83 months for BB-UVB. CONCLUSION: Both BB-UVB and p-PUVA are good therapeutic options for PPTP. P-PUVA emerges as the superior treatment modality, yielding a better and more extended response. BB-UVB represents a feasible alternative in patients with milder disease or possible contraindications for p-PUVA.

Hand, foot and scrotal blisters in a patient with cancer receiving oral chemotherapy.

Tyrosine kinase inhibitors are novel antineoplastic drugs that make use of the molecular abnormalities that have been discovered in certain types of tumours. These agents are associated with important dermatological side effects. This case report discusses an atypical presentation of the hand-foot syndrome in one patient treated with sorafenib. A 78-year-old man, recently started on sorafenib for the treatment of hepatocarcinoma with lung metastasis, presented to the emergency room with painful blistering lesions on the palms, soles and scrotum for 1 week. A punch biopsy was performed and sorafenib was withheld. Direct immunofluorescence study was negative for an autoimmune blistering disorder and histopathology stains did not show any microorganisms. A diagnosis of hand-foot syndrome was made. After 2 weeks, the patient showed marked improvement and the plan was to restart sorafenib at a lower dosage.

Opportunistic toenail onychomycosis. The fungal colonization of an available nail unit space by non-dermatophytes is produced by the trauma of the closed shoe by an asymmetric gait or other trauma. A plausible theory.

Opportunistic onychomycosis is defined, when a non-dermatophyte mould is cultured from an abnormal nail unit in the absence of a dermatophyte. The presumption is that the mould has caused the abnormal clinical appearance of the nail unit, yet there are no data available to substantiate this claim. Reports have only identified the mould being recovered from the nail unit niche. A review of the published dermatologic literature describing toenail opportunistic onychomycosis by non-dermatophyte fungi has shown toenails with onycholysis, nail bed (NB) keratosis and nail plate surface abnormalities. The appearance of these clinical changes is indistinguishable from the diagnosis of the Asymmetric Gait Nail Unit Signs (AGNUS). AGNUS is produced by the friction of the closed shoe in patients with an asymmetric gait, resulting primarily from the ubiquitous uneven flat feet. Most commonly, species of Acremonium (Cephalosporium), Aspergillus, Fusarium, Scopulariopsis and rarely species of many different fungi genera are capable of surviving and reproducing in a keratinous environment and change the clinical appearance of the involved nail unit. AGNUS toenails predispose to the colonization by the non-dermatophyte opportunistic fungi but not by dermatophyte fungi.

The effect of hydration on the risk of friction blister formation on the heel of the foot.

BACKGROUND: Friction blister research has focused on prevention and treatment approaches rather than exploring the pathophysiology of the friction blister. Increased skin hydration has been purported to be a key risk factor in friction blister development. This study aimed to test the effect of increased skin surface hydration on the risk of friction blister creation. METHODS: The skin on one foot was hydrated by soaking the foot in water. Intermittent loading was carried out until an observable change of 3°C was evident using infrared thermography. The contra lateral foot acted as a control. Skin hydration and elasticity was measured using electrical capacitance and negative pressure respectively. RESULTS: The rate of temperature change of the hydrated group was significantly greater than that of the non-hydrated foot group (P = 0.001) and showed a strong positive correlation (r = 0.520) with skin surface hydration. Weak negative correlations were seen between skin elasticity and rate of temperature change in response to load application (r = -0.166) and skin surface hydration and elasticity at baseline (r = -0.195). CONCLUSION: In controlled experimental conditions increased skin surface hydration increases the rate of temperature change of the skin in response to load application and consequently increases the risk of blister creation.

[Graves' dermopathy on the big toe]. / Dermopathie basedowienne localisée aux hallux.

BACKGROUND: Localized myxoedema is a rare dermopathy in patients with Graves' disease. The pretibial area is the most commonly affected region but herein we present a case of myxoedema of the big toe. PATIENTS AND METHODS: A 44-year-old male with Graves' disease ongoing for seven years presented bilateral ophthalmopathy and myxoedema of the big toes. The myxoedema was treated successfully with intralesional steroids. DISCUSSION: The physiopathology of myxoedema involves fibroblast activation and glycosaminoglycan production. This activation could result from stimulation of TSH receptors at their surface by TSH receptor antibodies (TRAK) or from an inflammatory process. The pretibial topography may be related to the high frequency in this area of microtrauma, with modulation of the cytokine microenvironment. CONCLUSION: The atypical localization seems to correlate with a Koebner phenomenon. Treatment of Graves' disease is generally insufficient to resolve the cutaneous problems. Topical corticosteroid therapy generally results in rapid improvement of recent lesions.

Association between peripheral vascular endothelial dysfunction and livedoid vasculopathy.

BACKGROUND: Livedoid vasculopathy (LV) is a disease characterized by multiple painful and recurrent ulcerations on the feet, accompanied by atrophic scars. Many researchers suggest that a hypercoagulable status is the pathogenetic factor for LV. However, the cause of LV remains elusive. OBJECTIVE: We sought to determine if endothelial dysfunction is present in patients with LV. METHODS: This prospective study included 16 patients with LV and active ulcers and 16 matched control subjects. We reviewed detailed clinical parameters, including antinuclear antibody, high-sensitivity C-reactive protein, protein C, protein S, homocysteine, anti-SSA, anti-SSB, anticardiolipin antibody, and serum lipid profiles. Flow-mediated vasodilation of the brachial artery was used as an indicator of vascular endothelial function using high-resolution 2-dimensional ultrasonic imaging. RESULTS: Blood pressure, blood biochemistry, high-sensitivity C-reactive protein, and homocysteine were not significantly different in patients with LV and control subjects. Nitroglycerin-mediated vasodilation was not significantly different in patients with LV and control subjects. However, flow-mediated vasodilation was much less in patients with LV than in the control group (3.58 ± 2.32% vs 7.51 ± 2.40%, P < .001). LIMITATIONS: The study was performed at a single site with a limited sample size. CONCLUSION: Peripheral vascular endothelial dysfunction was demonstrated in patients with LV by reduction of brachial flow-mediated vasodilation.

Capecitabine and hand-foot syndrome.

Hand-foot syndrome (HFS), or palmar-plantar erythrodysesthesia, is a common side effect in patients taking long-term 5-fluorouracil treatment and is the most frequently reported side effect of oral capecitabine therapy (≥ 50% of patients). Although the pathogenesis of HFS is not fully understood, it may be due to damaged deep capillaries in the soles of the feet and palms of the hands, leading to a COX inflammatory-type reaction, or related to enzymes involved in the metabolism of capecitabine, namely, thymidine phosphorylase and dihydropyrimidine dehydrogenase. Ethnic variations in the clinical manifestation of HFS warrant further attention, and an alternative system for grading HFS in non-white patients has been proposed. In addition to treatment interruption and dose reduction, supportive treatments can help alleviate symptoms. Because capecitabine is an oral therapy administered at home, it is crucial that patients understand the importance of complying with treatment, be aware of the possibility of HFS, and inform the doctor or nurse immediately if symptoms of HFS develop. Several cases of HFS are presented.

Palmoplantar nonpustular psoriasiform dermatitis in a rhesus macaque.

A case of psoriasiform dermatitis in an adult male rhesus macaque is reported. Appearing spontaneously, the condition presented the clinical and histopathological features of human palmoplantar nonpustular psoriasis. The animal developed multiple scaly plaques on his palms and soles, as well as nail hyperkeratosis and widening of the nail root. Microscopically, the skin lesions showed epidermal hyperkeratosis with multifocal parakeratosis, neutrophil microabscesses in the stratum corneum, a loss of granule cell layer under the microabscesses, acanthosis, and elongation of the rete ridges; the superficial dermis showed a dense inflammatory infiltrate containing lymphocytes, macrophages and neutrophils, as well as dilated and tortuous blood vessels. The lesions improved for 15 days after intramuscular corticosteroid depot therapy and worsened slightly afterwards. Later, a spontaneous, progressive remission coincided with the beginning of spring and lasted until the end of summer; the skin lesions practically disappeared during this period, and the nails looked nearly normal. During the next autumn and winter only nail hyperkeratosis was present. Serum analyses showed hyperproteinaemia and hyperglobulinaemia during the outbreak phase and normal values during remission. The clinical and histopathological features of this case, as well as its evolution, are compared with the three other reported cases of psoriasiform skin lesions in nonhuman primates. To the authors' knowledge, this is the first report of a definite palmoplantar nonpustular psoriasiform dermatitis in a rhesus macaque.