Acneiform Research Articles

Instrumental evaluation sensitively detects subclinical skin changes by the epidermal growth factor receptor inhibitors and risk factors for severe acneiform eruption.

Epidermal growth factor receptor inhibitors (EGFRI), EGFR tyrosine kinase inhibitors (TKI) and anti-EGFR antibodies commonly develop skin toxicities including acneiform eruption (AfE). However, precise skin changes and risk factors for severe AfE are still unclear. The objective of the current study was elucidation of the useful parameters for early and sensitive detection of the skin changes by EGFRI. Transepidermal water loss (TEWL), skin surface hydration, skin surface lipid levels and erythema/melanin index were serially measured for 2weeks in 19 EGFR-TKI afatinib/erlotinib-treated patients and for 8weeks in 20 anti-EGFR antibody cetuximab-treated patients. The TEWL levels of the cheek in the patients who developed AfE of grade 2 and more (AfE≥Gr2) were already elevated at 7days after the initiation of afatinib/erlotinib therapy compared with those before therapy as well as in patients with grade 1 or less (AfE≤Gr1). In patients treated with cetuximab, the skin surface hydration on the cheek in AfE≥Gr2 patients significantly decreased compared with that of AfE≤Gr1 patients at the 2nd and 6th week. Baseline skin surface lipid levels and erythema index on the cheek of patients with AfE≥Gr2 were significantly higher than those with AfE≤Gr1. The small sample size of the present study, especially for logistic regression analysis, is a limitation. In conclusion, instrumental evaluation declared rapid inflammatory changes of the skin by EGFRI and elucidated oily skin as a risk for severe AfE.

ADVERSE DRUG REACTION TO ALL PROTON PUMP INHIBITORS EXCEPT ESOMEPRAZOLE IN MEDICALLY COMPLEX PEDIATRIC PATIENT

Introduction Proton-pump inhibitors (PPIs) are commonly used for treatment of gastroesophageal reflux disease (GERD). PPIs have a favourable safety profile; however, immediate and delayed hypersensitivity reactions have been described. Case Description A six-year-old male with hypomyelination with atrophy of the basal ganglia and cerebellum (HABC) and significant medical complexity including seizure disorder, tracheostomy ventilation, severe GERD, and gastro-jejunostomy feeding, developed a papular acneiform eruption 24 hours after administration of omeprazole, lansoprazole, and rabeprazole. The lesions were not evanescent, and did not respond to antihistamine therapy. Skin testing was negative to omeprazole, lansoprazole, rabeprazole, pantoprazole, and esomeprazole. Esomeprazole was started and tolerated well up to 10mg daily, but the patient developed an upper GI bleed due to duodenal ulcer. He was urgently started on pantoprazole infusion. 24 hours later, he developed generalized coalescent erythematous macules, that resolved within 15 minutes of antihistamine administration. Upon discharge, he was continued on pantoprazole with regular antihistamines. Discussion There are three general patterns of hypersensitivity reactions with PPIs: 1) hypersensitivity to one PPI cross-reacting with all other PPIs; 2) cross-reactivity based on structure analogues; and 3) hypersensitivity to single PPI. Other patterns of reactions have been reported; however, tolerance of esomeprazole alone, with clinical reactions to others is uncommon. This was a medically fragile pediatric patient who required PPIs in both acute and chronic settings. This case demonstrates different clinical reactions in the same patient to different PPIs, and the importance of systematically evaluating all PPI options for safe alternatives.

Severe acneiform eruption secondary to cetuximab successfully treated with oral prednisolone

Severe acneiform eruption secondary to cetuximab successfully treated with oral prednisolone

RASopathic comedone‐like or cystic lesions induced by vemurafenib: a model of skin lesions similar but not identical to those induced by dioxins MADISH

Patients treated with vemurafenib for metastatic melanoma often develop skin lesions similar to those observed after exposure to dioxin-like compounds. We previously called these lesions MADISH (metabolizing acquired dioxin-induced skin hamartoma) when analysing a case of acute dioxin poisoning. We performed a clinical trial aimed at comparing the skin lesions observed under vemurafenib treatment with MADISH in order to bring to light a possible crosstalk between vemurafenib and dioxin pathways. In this case series study, we explored the histological aspect of skin lesions in 10 cases treated with vemurafenib for malignant melanoma. We also analysed the ability of vemurafenib and tyrosine kinase inhibitors to induce dioxin-AhR pathway. All patients had skin lesions diagnosed as 'non-inflammatory acneiform eruption' by dermatologists. These were predominantly facial with notable retroauricular involvement and clinically compatible with chloracne/MADISH when assessed by dioxin expert. Histological analysis showed mostly comedone-like lesions and dermal cysts containing epithelial wall with basal or lateral epithelial projections and lamellar keratinization and alterations of remaining sebaceous glands. The expression of CYP1A1, a gene highly induced following dioxin exposure, was not observed in these lesions. Vemurafenib and the tyrosine kinase inhibitors erlotinib and gefitinib did not induce CYP1A1 activity. Although the skin lesions under vemurafenib treatment were morphologically similar to MADISH, the absence of CYP1A1 expression in dermal cysts of patients and the absence of CYP1A1 activation by vemurafenib led us consider that these skin lesions were different from true MADISH and not mediated by a crosstalk of AhR signalling, but rather to a hyperactivation of PI3K-Akt pathway as a consequence of vemurafenib treatment. A strong expression of CYP1A1 in the epithelial wall of dermal cysts must be required, parallel to the morphology of the lesions, to make the diagnosis of MADISH, the hallmark of an exposure to dioxin-like/chloracnegen compounds.

Trisomy 8-Associated Intestinal Behcet’s Disease That Achieved Complete Remission With Mesalazine

A 39-year-old man was referred to our hospital because of ileocecal ulcer and pancytopenia. Past medical history included psoriatic arthritis and acne vulgaris. Physical examination findings showed recurrent oral ulcerations and acneiform eruptions on his body. Colonoscopy confirmed the presence of an ulcer at the ileocecal valve. Human leukocyte antigen was positive for B51. Based on the bone marrow findings of hypercellularity accompanied by trilineage dysplastic changes and cytogenetic findings of 47,XY,dup(1)(q21q32), idem+8, a definite diagnosis of intestinal Behcet’s disease (BD), incomplete type, associated with myelodysplastic syndrome (MDS) with positivity for trisomy 8 was finally confirmed. Treatment of intestinal BD with mesalazine at 3,000 mg daily induced complete ulcer healing after 4 months. Thereafter, two cycles of azacytidine was administered, followed by bone marrow transplantation. The patient has done well with continuous healing of the ulcer for a year. Differentiating episodic MDS with positivity for trisomy 8 from drug-induced MDS by examination of the bone marrow and the cytogenetic changes is indispensable. Intestinal BD patients who develop pancytopenia would probably need sufficient doses of mesalazine for treatment. J Med Cases. 2018;9(8):255-259 doi: https://doi.org/10.14740/jmc3082w

Myths, Truths, and Clinical Relevance of Comedogenicity Product Labeling

he concept of acne cosmetica was first introduced in 1972 to describe low-grade persistent acneiform eruptions in women who use cosmetics daily.1 Although histologically similar to acne vulgaris, which forms from abnormal differentiation and proliferation of keratinocytes in the follicular duct, acne cosmetica comedones are smaller and closed and show less sebaceous gland involution.1 Although sebum composition, follicular hyperkeratosis, androgens, and cytokines are implicated in the pathogenesis of acne vulgaris, acne cosmetica results from the prolonged use of cosmetic compounds that block follicular ducts. In 1972, 28% of adolescents and 4% of women (≥31 years of age) were affected.1 We believe that the prevalence of acne cosmetica is increasing with cosmeceutical industry growth. Thus, comedogenicity is an important consumer consideration.

An update on Chinese herbal medicines as adjuvant treatment of anticancer therapeutics.

Numerous studies have indicated that in cancer treatment Chinese herbal medicines in combination with chemo-, radio-, or targeted-therapy can be used to enhance the efficacy of and diminish the side effects and complications caused by these therapies. Therefore, an understanding of Chinese herbal medicines is needed by physicians and other health care providers. This review provides an update on Chinese herbal medicines as adjuvant treatment of anticancer therapeutics. First, some Chinese herbal medicines (e.g. Astragalus, Ginseng, Scutellaria barbata, TJ-41, TJ-48, PHY906, Huachansu injection, and Kanglaite injection) that are commonly used for treating the cancer and/or reducing the toxicity induced by chemo-, radio-, or targeted-therapy are discussed. These Chinese herbal medicines have been shown to possess great advantages in terms of suppressing tumor progression, increasing the sensitivity of chemo-, radio-, or targeted-therapeutics, improving an organism's immune system function, and lessening the damage caused by these therapeutics. Second, some clinical trials using Chinese herbal medicines as adjuvant improving cancer treatment related side effects and complications are reviewed. Some Chinese herbal medicines have a significant effect on reducing cancer-related fatigue and pain, improving peripheral neuropathy and gastrointestinal side effects including diarrhea, nausea, and vomiting, decrease the incidence of bone marrow suppression, protecting anthracycline-induced cardiotoxicity and radiation-induced pneumonitis, and relieving EGFR-TKIs related acneiform eruptions and other side effects. This review of those medicines should contribute to an understanding of Chinese herbal medicines as adjuvant treatment for cancer and provide useful information for the development of more effective anti-cancer drugs. However, rigorously designed trials on potential Chinese herbal medicine must be further examined involving cancer treatment especially molecular targeted-therapy in the future.

Acneiform eruption associated with the use of vortioxetine

ABSTRACTAcneiform is used to describe eruptions that resemble acne vulgaris, but are not aetiologically similar. A number of drugs that can be responsible for acneiform eruptions exist. Vortioxetine is a multimodal antidepressant molecule that shows an antagonistic effect to the 5HT1D, 5HT3, and 5HT7 receptors, a partial agonistic effect to the 5HT1B receptor and a fully agonistic effect to the 5HT1A receptor, and also is an inhibitor to the serotonin transporter (SERT). In this article, we report a female patient who developed acneiform eruption during vortioxetine treatment.

Dermatological aspects of tularaemia: a study of 168 cases.

Tularaemia is a zoonotic infectious disease caused by Francisella tularensis, an aerobic, uncapsulated, gram-negative coccobacillus. Several case reports have appeared on the dermatological manifestations of tularaemia, but relatively few longer-term studies are available. To identify skin features of tularaemia that aid in its diagnosis. In total, 168 patients (68 male, 100 female) diagnosed with tularaemia were retrospectively examined. All dermatological data for these patients were evaluated. Of the 168 patients, 149 (88.69%) had tularaemia of the oropharyngeal type, 12 (7.73%) had the ulceroglandular type, 5 (2.9%) had the oculoglandular type and 2 (0.59%) had the pulmonary type. Secondary skin manifestations were found in 26 patients (15.47%). Sweet syndrome (SS) was found in 11 patients (6.54%), most of whom presented with the oropharyngeal form, while erythema nodosum (EN) was found in 7 patients (4.16%), dermatitis in 2 (1.19%), urticaria in 2 (1.19%), acneiform eruptions in 1 (0.59%), vasculitis-like eruptions in 1 (0.59%) and SS + EN in 1 (0.59%). Patients with the oropharyngeal form had a statistically significant (P < 0.001) higher number of skin findings than patients with the other forms. In clinical practice, tularaemia may present with various cutaneous manifestations, and dermatologists who work in endemic regions must be aware of the possibility of this disease.

A Clinical Study of Steroid Induced Dermatoses

Introduction: Steroid induced dermatoses on face are one of the common presentations in Dermatological practice.Objectives: 1) Understand the clinical patterns of adverse effects of long term abuse of topical steroid on face and 2) Assess the factor which promotes its abuse.Materials and Methods: This was a descriptive exploratory cross-sectional study carried out from December, 2013 through November, 2014. A total of 39 patients fulfilling the inclusion criteria were enrolled into the study. All the study variables were recorded using preformed structured questionnaire and analyzed.Results: The following effects of steroid abuse on face were seen: pruritus (38.5%), burning (15.4%), eythema (74.4%), telangiectasias (66.7%), acneiform eruptions (59%), comedones (35.9%), xerosis (55.1%), photosensitivity (51.3%), rebound phenomenon (38.5%) and others (38.5%). Most of them used steroids on recommendation of their friends (38.5%) and pharmacists (20.5%). All of them used steroid for different dermatoses on their face.Limitations: This is a hospital-based small-scale study and might not be true picture of problem in the community.Conclusion: Long term use of steroid on face results in different clinical presentations. Most of the patients used steroidon recommendation of their friends facilitated by easy availability of the drug over- the -counter.

Abuse of Topical Corticosteroids and its Consequences: A Prospective Study

Background: Misuse of topical corticosteroids is a widespread among young people in India, especially women. The inadvertent use of topical corticosteroids for various common dermatological conditions is associated with significant adverse effects Aim: To assess the steroid abuse for various common dermatological conditions and its adverse effects. Materials & Methods: Sixty patients who attended OPD dermatology were taken in to study. A detailed clinical history with regard to age, gender, education status, duration and frequency of use of topical steroids, type and formulation of the drug (lotion, cream, ointment), cause for using the drug and the source of the drug (by dermatologist, doctor- physician/Ayurvedic/homeopathic, over the counter (OTC) were taken. Results: Majority of patients were between the age group of 15-30 years and females were in predominance. The common indications were facial pigmentation, dermatophytosis and acne. The source of drug were mostly from pharmacist, friends and family members. Most commonly used steroid were betamethasone valerate, clobetasol propionate and mometasone furoate. The common side effects observed were acneiform eruptions, tinea incognito, and erythema with telangiectasia, cutaneous atrophy and striae. Conclusion: Topical steroids should be used cautiously and judiciously. Awareness should be given regarding the indications and its consequences. Avoidance of self-medication by over the counter purchase should be stressed upon. While treating children extreme care should be given regarding the selection of potency of topical steroids.

Pattern of skin diseases amongst children attending a dermatology clinic in Lagos, Nigeria.

IntroductionSkin diseases constitute a major health problem affecting a large proportion of the population including children causing distress and disability. This study aimed to document the spectrum and frequency of skin diseases of children who attended the dermatology outpatient clinic of the Lagos University Teaching Hospital (LUTH) Lagos, Nigeria.MethodsA cross-sectional study of children (18 years old and below) who attended the dermatology clinic between January 2004 and December 2016. Data obtained from the medical records of the patients included age, gender, clinical features, laboratory features and diagnosis. Skin diseases were classified into various groups.ResultsThere were 6373 children included in the study with a male to female ratio of 1:1.13. The most common disease categories were infections 1795 (26.1%), Eczematous conditions 1711 (24.9%), Infestations 936 (13.6%), papulosquamous disorders 547 (8.0%) and Bullous disorders 254 (3.7%). With respect to individual skin diseases, atopic dermatitis (AD) 1042 (15.1%) was the most common skin condition followed by papular urticaria 705 (10.2%) and tinea capitis 554 (8.1%). Infections were most common among infants and adolescents. Acneiform eruptions were common among adolescents while eczematous disorders were most common among children less than 5 years.ConclusionThe study highlights the common dermatoses seen in children in a specialized dermatology clinic in a developing country such as Nigeria. Most of the skin diseases observed can be controlled by proper environmental sanitation, adequate nutrition, reducing overcrowding, and promoting good health-seeking behavior among parents and caregivers. Information obtained from the study may guide training in dermatology especially among pediatricians.

Recalcitrant Acneiform Eruption Revealing Behçet’s Disease: A Case with Late but Successful Response to Adalimumab

Behçet's disease is a systemic vasculitis with a chronic-relapsing course, which can lead to significant morbidity and mortality. From the often-compelling challenge of making a prompt diagnosis comes the difficulty in its treatment. We report the case of a patient with an acneiform skin eruption revealing Behçet's disease that was refractory to conventional therapy and later completely responded to adalimumab. Although randomized controlled clinical trials are lacking in the literature, there is already significant evidence supporting anti-TNF agents as a major therapeutic advance in Behçet's disease, particularly in cases that are severe, refractory or intolerant to classical immunosuppression.

Severe Hypercortisolism with Hypokalemic Alkalosis Mimicking Ectopic Cushing Syndrome in a Patient with Cushing Disease Due to Pituitary Microadenoma.

Severe Hypercortisolism with Hypokalemic Alkalosis Mimicking Ectopic Cushing Syndrome in a Patient with Cushing Disease Due to Pituitary Microadenoma.

Severe Striae and Steroid Acne as Side Effects of Long-term Systemic Corticosteroid Treatment: A Case Report and Review of The Literature

Background: Systemic corticosteroids are often used in dermatology. The anti-inflammatory and immunosuppressive properties of corticosteroids make this agent as the first-line option in many disorders such as autoimmune and bullous diseases. However, there are also potential side effects and dermatologists who prescribe corticosteroids have to be aware of them. Case Summary: We report a 16-year-old girl with a history of taking oral methylprednisolone in the past 8 months who came with a acne-like eruption on the face, chest, and extremities as well as lines on the skin. Physical examination revealed monomorphic papules on the facial, thorax, and superior and inferior extremities region. Comedones were absent. Striae were found in the bilateral femur, abdomen, and mammary region. The patient was diagnosed with acneiform eruption and striae distensae rubra. Treatment using a combination of topical clindamycin and tretinoin showed clinical improvement of the acneiform eruption after three months of therapy. However, striae did not show improvement despite topical application of tretinoin and Centella asiatica extract. Conclusion: This case demonstrates the importance of understanding the cutaneous side effects that may result from chronic systemic corticosteroids administration as well as the evidence-based management.

Reaccion acneiforme noduloquistica secundaria a vemurafenib con buena respuesta a isotretinoina oralSevere acneiform eruption associated with vemurafenib with response to isotretinoin

Vemurafenib, a kinase inhibitor that targets tumors with the BRAF V600E mutation, is a promising option for unresectable or metastatic melanoma. Cutaneous side-effects have been reported including alopecia, photosensitivity, squamous cell carcinoma, keratoacanthomas, keratosis pilaris-like eruption, and palmoplantar hyperkeratosis. Acneiform eruptions have been reported in 3%-6% of the patients treated with BRAF inhibitors,and 5 cases are described in the literature. Although they responded well to topical therapies, oral antibiotics, or observation, one case required oral etretinate and the withdrawal of vemurafenib because the adverse event reached grade 3. We report one case of a severe acneiform eruption associated with vemurafenib with a good response to isotretinoin allowing continuation of the BRAF inhibitor.

Localized acneiform eruption induced by radiation therapy

Radiation-induced skin changes and dermatoses occur in the majority of patients receiving radiotherapy and may produce significant adverse effects. Radiation-induced acneiform eruption is a rare but likely an underreported cutaneous adverse effect. This is a case of a localized comedonal eruption induced by radiation therapy exposure in a 47-year-old male treated for a malignant tumor. Recognition and proper management of this presentation are important for the optimization of patient health, reassurance of the patient and the treating team, and avoidance of any unnecessary delays in surgical reconstruction planning.

Tofacitinib (Selective Janus Kinase Inhibitor 1 and 3): A Promising Therapy for the Treatment of Alopecia Areata: A Case Report of Six Patients.

Background:Alopecia areata (AA) is a chronic autoimmune disorder characterized by patchy loss of hair from scalp, beard, eyebrows, or rarely even body hair. Rarely, the disease can be widespread and severe leading to loss of entire scalp and body hair causing apprehension and psychological stress in patients. Management of such cases is equally difficult with the available options of topical and systemic immunosuppressant. Tofacitinib, JAK3 inhibitor, is emerging as a promising drug for the management of severe and resistant cases of AA/totalis/universalis.Objective:Our study aims to show the effectiveness of oral tofacitinib in the treatment of alopecia universalis (AU).Methods:Six patients diagnosed with AU/alopecia totalis duration of disease 6 months–15 years refractory to other treatments were selected and were started on oral tofacitinib 5 mg twice daily up to 10 mg BID and were followed up every 4 weeks. The efficacy was measured by hair regrowth using photographic assessment, Severity of Alopecia Tool score, and physical examination. Patients will be followed up for 6 months after stopping treatment for assessing disease relapse.Results:All our six patients showed dramatic response to oral tofacitinib. Patients were followed up every 4 weeks, and results were assessed. Significant hair regrowth was evident in all the patients by the end of 12 weeks. Currently, four of our patients are on oral tofacitinib 10 mg BID and are under follow-up. There was no relapse in one patient after stopping drug for 4 months. Another patient started developed AA patches in the eyebrows within 2 months of stopping tofacitinib. Acneiform eruptions were seen in two patients which were managed with topicals.Conclusion:In our patients, tofacitinib successfully alleviated AU in the absence of significant adverse side effects. We recommend that further controlled studies be required to establish safety and confirm efficacy.

Trisomy 8-Associated Intestinal Behcet’s Disease That Achieved Complete Remission With Mesalazine

A 39-year-old man was referred to our hospital because of ileocecal ulcer and pancytopenia. Past medical history included psoriatic arthritis and acne vulgaris. Physical examination findings showed recurrent oral ulcerations and acneiform eruptions on his body. Colonoscopy confirmed the presence of an ulcer at the ileocecal valve. Human leukocyte antigen was positive for B51. Based on the bone marrow findings of hypercellularity accompanied by trilineage dysplastic changes and cytogenetic findings of 47,XY,dup(1)(q21q32), idem+8, a definite diagnosis of intestinal Behcet’s disease (BD), incomplete type, associated with myelodysplastic syndrome (MDS) with positivity for trisomy 8 was finally confirmed. Treatment of intestinal BD with mesalazine at 3,000 mg daily induced complete ulcer healing after 4 months. Thereafter, two cycles of azacytidine was administered, followed by bone marrow transplantation. The patient has done well with continuous healing of the ulcer for a year. Differentiating episodic MDS with positivity for trisomy 8 from drug-induced MDS by examination of the bone marrow and the cytogenetic changes is indispensable. Intestinal BD patients who develop pancytopenia would probably need sufficient doses of mesalazine for treatment. J Med Cases. 2018;9(8):255-259 doi: https://doi.org/10.14740/jmc3082w

Acneiform eruptions and inflammatory striae as probable reactions to adalimumab

Acneiform eruptions and inflammatory striae as probable reactions to adalimumab