Acantholytic dermatosis in chronic renal failure.

Abstract

A 53‐year‐old Chinese man with chronic renal failure complained of persistent small raised papules behind the ears and on the nape of the neck for the past 6 months. These lesions were slightly pruritic but nontender. He was diagnosed as having chronic renal failure secondary to chronic glomerulonephritis and had been on maintenance hemodialysis for the past 9 years. He had pulmonary tuberculosis 18 months earlier and had completed a full course of antituberculous therapy consisting of 2 months of 800 mg/day ethambutol, and 9 months of 450 mg/day rifampicin and 300 mg/day isoniazid. His present medications included 100 mg/day asprin, 0.25 μg/day calcitriol, daily calcium, and multivitamin supplements which he had been taking for the past 3 years. He worked mainly on a night shift as a cab driver for the past 20 years and gave no history of excessive sun exposure. There was no family history of any acantholytic disorder.Physical examination revealed an anemic patient with pallor and the sallow discoloration of chronic renal failure. Multiple discrete, brownish scaly papules (approximately 20 in number), measuring between 2 and 6 mm in diameter, were clustered behind both ears and on the nape of the neck just below the hairline (Fig. 1). Some of the firm papules had a central depression. The rest of the body was unaffected. There were no signs of significant sun damage present. Laboratory tests showed the following: hemoglobin 7.6 g/dL, white blood cell count 8000/mm3, platelets 234,000/mm3, urea 21.0 mmol/L, Na 135 mmol/L, K4.8 mmol/L, Cl 101 mmol/L, HCO320.0 mmol/L, blood glucose 5.9 mmol/L, creatinine 1176 nmol/L, total calcium 2.39 mmol/L, and inorganic phosphate 2.29 mmol/L.On biopsy, the papular lesions showed suprabasal clefts, focal acantholysis with corps ronds, and grains (Fig. 2). The adjacent dermis showed patchy infiltrates of lymphocytes and mononuclear cells. The histologic findings resembled Darier's disease.Most of the skin lesions were excised and followed by primary skin closure. No recurrence was noted after 6 months of follow‐up.