Erythematous Base Research Articles

Ayurvedic Management of Vicharchika (Lichen Simplex Chronicus) - A Case Report

ABSTRACT Lichen simplex chronicus (LSC) consists of lichenified scaly plaque due to chronic scratching. The available conventional treatments are various topical antipruritic agents and corticosteroids, which are associated with high rates of treatment failure and complications because trans-epidermal drug absorption is limited. LSC manifests as a significant challenge to a physician due to persistent itching and therapeutic resistance. In Ayurveda, this condition has a close resemblance to Vicharchika. Vicharchika is a type of Kshudra kustha with dominancy of Kapha dosha characterized by redness, itching, pain, cracks, and dryness. In this case report, a 48 year old female reported complaints of multiple black-colored patches on the dorsum surface of bilateral feet with severe itching for 6 years. Local examination revealed lichenified hyperpigmented plaques with erythematous bases and well-defined edges covered by white scales with central excoriation. Plaques were found bilaterally over the dorsum of feet and malleolus. Based on symptoms and signs, the case of LSC was diagnosed. This case was managed effectively with Ayurvedic internal medications such as Arogyavardhini Vati, Kaishore Guggulu, Nishaamlaki Vati, Triphala churna, Khadirarishta, and local application of Brihat Marichyadi oil and Sudha Gandhak. The outcome assessment was based on improvement in the size of skin patches, hyperpigmentation, thickening, and itching. Complete improvement has been observed in symptoms after 4 months of regular treatment. No adverse effect pertaining to the prescribed drug was reported during the study period. Ayurvedic medicines offer a good approach to managing LSC.

Surgical Excision on Recurrent Furunculosis with Plasmacytosis: a Case Report

Introduction : Furunculosis is a skin inflammation of hair follicle which may become chronic and recurrence. Plasmacytosis is a rare lymphoproliferative disorder involving skin and systemic organs. Here in we report a case of reccurent furunculosis with plasmacytosis treated with surgical excision.
 Case : A 57-years-old woman presented to our outpatient clinic with a recurrent lumps filled with pus on her left cheek since 2 years ago. Dermatological examination obtained a solitary nodule on the erythematous base skin filled with pus. Laboratory findings did not indicate the monoclonality of electrophoretic serum protein. Histopathological features of skin biopsy showed inflammatory cells aggregate in the perifollicular area consisting neutrophils, lymphocytes, monocytes, eosinophils, and plasma cells mainly in the dermal layer. The CD 138 immunostaining was positive, hence we diagnosed the patient with recurrent furunculosis with plasmacytosis. Surgical excision was conducted and no recurrence has been reported since then.
 Discussion : Chronic and recurrent furunculosis leads to plasma reactivity against inflammation, promoting plasma cell deposition as the risk of cutaneous plasmacytosis. Histopathological examination and immunostaining may helpful to establish the diagnosis of plasmacytosis occuring in chronic skin infections. Surgical intervention can be performed on furunculosis cases with fluctuated and solitary lesion resulting in less recurrence.

Infections with Herpes simplex and Varicella zoster virus.

Human herpes viruses belong to the DNA viruses and are among the most common viral pathogens. Currently, eight human herpes viruses have been characterized. Primary infection is typically followed by virus latency. Viral reactivations are more often symptomatic than primary infections and lead more often to medical consultation. In daily practice, infections with herpes simplex virus (HSV) and varicella zoster virus (VZV) are the most common. If HSV primary infections become clinically manifest, they are often accompanied by systemic symptoms whereas manifest HSV reactivations are usually harmless, self-limiting and present as grouped vesicles on an erythematous base (herpetiform). Primary VZV infection leads to the clinical picture of varicella (chickenpox). VZV reactivation manifests clinically as shingles and can be accompanied by severe acute neuralgiform pain. In immunosuppression, complicated (necrotizing, ulcerative, hemorrhagic, generalized) manifestations may occur. The diagnosis is usually made clinically. Therapeutic options include topical agents and systemic antivirals. Adequate therapeutic management includes the recognition and treatment of complications such as the possible involvement of other organ systems and pain. Infection during pregnancy may result in transmission to the unborn child.

Pustular lesions and itching in a couple of young migrants

Two teenage illegal migrants from Bangladesh coming from a Libyan port arrived at Lampedusa Island-Italy. The health authorities, having noticed the presence of pustules on the limbs and genitals, suspecting a monkeypox virus infection, have urgently transferred them to the University Hospital of Palermo. They mentioned itching and prior sexual contact. On inspection, itching lesions and pustular lesions with central crusted umbilication and erythematous bases were detected. One of them had also fever and increased c-reactive protein. A real-time polymerase chain reaction assay on vesicle swabs to research monkeypoxvirus DNA and HIV serology was performed for both patients.

Monkeypox: Cutaneous clues to clinical diagnosis

Monkeypox: Cutaneous clues to clinical diagnosis

Cutaneous vesicles in an infant after bone marrow transplantation.

Eight-month-old infant who recently received a matched unrelated donor transplant for malignant infantile osteopetrosis was admitted on T+48 for the evaluation of fevers. Her complete blood count (CBC) on admission showed a neutrophil count of 8940 × 109/L and Hb of 7.1 g/dl. Patient was started on cefepime and vancomycin while awaiting results of blood culture that grew methicillin-susceptible Staphylococcus aureus. She continued treatment with cefepime and had her central line removed. On T+50 parents reported the appearance of a new blistering rash on her hands. Skin examination demonstrated multiple 1–2 mm deep seated noninflammatory vesicles located on the distal digits and metacarpophalangeal joints of both hands and pad of the right thumb (Figure 1). During this admission, our patient's Epstein–Barr virus (EBV) polymerase chain reaction (PCR) test in whole blood became positive and she also had diarrhea that tested positive for norovirus. In an early posttransplant (<100 days) patient, our major concern was acute graft versus host disease (GVHD). Due to the limited distribution of rash and the lack of systemic symptoms, it became less likely. Although GVHD can present as bullous skin lesions, it is associated with severe disease presentation. Second in our list were infectious causes. There are reports of norovirus-related urticaria presenting with generalized erythematous wheals associated with pruritus. Dermatologic manifestations of EBV are reported more commonly in patients with infectious mononucleosis (IM). IM patients more commonly develop a faint erythematous macular rash early in the course or a maculopapular rash associated with the inappropriate use of amoxicillin. There are reports of IM presenting with erythematous papulovesicules, but it is uncommon. Vesicular lesions associated with Herpes simplex 1 or 2 infection are characterized by grouped vesicles on an erythematous base ring. In severely immunocompromised patients with deficient cellular immunity, the risk of extensive mucocutaneous disease and disseminated infection is higher. Transplant patients are at risk of developing herpes simplex virus (HSV) infection due to reactivation. Lastly, sucking blisters are noninflammatory vesicles with thick walls that contain sterile fluid. Lesions are usually located on dorsal areas of fingers, hands or wrists and can be bilateral. The observation of the infant sucking the involve areas helped guiding with the diagnosis. In the absence of lesions in other areas and with lack of systemic symptoms sucking blisters became the most likely diagnosis. No biopsy was performed due to well apearing baby. Fever subsided and antibiotics were stopped after 10 days with negative blood culture. Rash is persistent with a healthy looking infant without other manifestations. Kristen Nagle, PNP; Linda Cabral, PA. The authors declare they have no conflicts of interest. The authors received no specific funding for this work. A written informed consent was obtained from the parents of the patient to publish the case and images in a medical journal.

Irritant contact dermatitis treated with constitutional homoeopathic medicine – A case report

Contact dermatitis (CD) is a skin disorder characterised by papules and vesicles on an erythematous base. It is often precipitated by an exogenous cause and has a global prevalence of 1.7–6.3%. Irritant CD (ICD) is a type of CD caused by repeated exposure to irritants such as acids, alkalis and oxidants (chemical burns) or low-grade irritants such as soaps, detergents and solvents. Cases of ICD have been reported to be treated successfully with homoeopathic medicines. In this case, a male patient aged 55 years presented with the complaints of blackish-brown discolouration and thick lichenified lesion on the dorsal aspect of the left forearm with sticky thick discharge. Case taking and repertorisation done on the basis of totality of symptoms led to prescription of the constitutional homoeopathic medicine Sepia. The dose and the potency were modified per the patient’s requirements. The patient reported relief in all complaints; there was a significant change in the visual analogue scale for the itching and the dermatology life quality index. This case illustrates the utility of homoeopathic constitutional medication in treating chronic allergic dermatological conditions. Further, larger scale studies are required to enable generalisation of the findings.

An enlarging painful nodule on the upper portion of the thigh

An 87-year-old man was referred to dermatology with a 4-month history of a rapidly growing, painful, brown, 4.5×5.0-cm nodule on an erythematous base on his left thigh (Fig 1). He had experienced a dry cough in the preceding months and had a remote history of tobacco use and an occupation in manufacturing. Basic laboratory studies were unremarkable. An incisional biopsy, a histopathologic examination (Fig 2), and immunostainings were performed. The sample stained positive for thyroid transcription factor 1 (Fig 3), cytokeratin 7, and programmed death-ligand 1 (PD-L1) and nonreactive for CDX2, SOX10, NKX3.1, p40, synaptophysin, and cytokeratin 20.

Brunsting-Perry pemphigoid: a systematic review.

Brunsting-Perry pemphigoid (BPP) is a rare, autoimmune bullous skin disorder classified within the spectrum of mucous membrane pemphigoid (MMP). An a priori protocol was designed based on PRISMA guidelines. PubMed and Scopus databases were searched for English-language articles concerning BPP published between 1950 and July 2021. Thirty-six articles including 63 BPP patients were analyzed. The mean age at diagnosis was 62.9 years (range: 27-86). BPP was shown to be characterized by vesiculobullous lesions (46/63, 73.0%) on an erythematous base, erosions or ulcerations (27/63, 42.9%), atrophic scars (49/63, 77.8%), and milia (4/63, 6.3%). Exclusive oral mucosal involvement was documented in 22.2% of cases, usually manifesting after the cutaneous onset of the disease. Subepidermal blistering was a constant finding, often with an eosinophil-rich inflammatory infiltrate (21/58, 36.2%). Positive direct immunofluorescence was found in 92.0% of patients, almost always with linear IgG ± C3 deposits along the basement membrane (43/46, 93.5%). BP180 (12/15, 80.0%), BP230 (5/15, 33.3%), and laminin 332 (3/15, 20.0%) were the most frequently identified target antigens. BPP nosologic position remains uncertain, given the overlap with other autoimmune bullous diseases, such as MMP, bullous pemphigoid, and epidermolysis bullosa acquisita, particularly in its BPP-like variant. Nonpredominant oral mucosal lesions may appear during the course of the disease, generally after cutaneous manifestations. Positivity of DIF and anti-BP180/230 autoantibodies detected on ELISA/immunoblotting in the absence of anticollagen VII antibodies may provide guidance in diagnosing BPP.

Paradoxical Perforating Folliculitis in a Newly Transplanted Kidney Recipient: Case Study

We report on a rare case of perforating folliculitis with a paradoxical presentation. An 18-year-old patient with end-stage kidney failure was undergoing continuous ambulatory peritoneal dialysis following 1 year of hemodialysis treatment. While being treated with continuous ambulatory peritoneal dialysis, he developed an itchy papular eruption on an erythematous base over his face and chest, which was diagnosed as chicken pox and treatedwith acyclovir.He also underwent successful deceased donor kidney transplant 1 year later. On day 10 posttransplant, he presented with a papular eruption over the chest, face, and forearms. A skin biopsy revealed a perforating folliculitis lesion. He was treated with prednisone and tacrolimus, as part of the kidney transplant treatment. The skin lesions resolved progressively. His urea, creatinine, and electrolyte levels remained normal and on an ever-improving trend at each visit. By 4 months posttransplant, the skin lesions had resolved almost completely.

Led astray by serology

A 27-year-old man of South Asian ethnicity presented with abdominal pain, nausea and constipation. Eight months earlier he had undergone myeloablative, haplo-identical, allogeneic stem cell transplantation (SCT) for acute lymphoblastic leukaemia. Immunosuppression had been stopped 4 months before presentation; he had continued prophylactic aciclovir, co-trimoxazole and phenoxymethylpenicillin. He was febrile and abdominal imaging revealed oedematous pancreatitis and non-obstructive cholecystitis. Despite fluids and antibiotics (co-amoxiclav, gentamicin), he deteriorated and two days later, a painless, non-pruritic rash emerged, spreading from the face to trunk and limbs. He also developed profuse diarrhoea, melaena and anaemia. His abdomen was soft with generalised tenderness and active bowel sounds. A diffuse rash affected face, trunk and limbs, sparing palms and soles. Lesions were dark, 1–4 mm haemorrhagic vesicles over an erythematous base. Pigmented, ulcerating lesions were noted over the hard palate. An endoscopy showed multiple gastric ulcers. Methylprednisolone was commenced for possible acute Graft-versus-Host Disease, and disseminated infection was treated empirically with piperacillin-tazobactam, ivermectin and aciclovir. Disseminated varicella zoster virus (VZV) infection was confirmed by identifying VZV viraemia and positive VZV PCR from lesion swabs. Pre- and post-SCT VZV IgG titres were > 150mIU/ml. There was CD4 + lymphopenia (56 x106/L). As no additional cause was identified, the pancreatitis and small bowel inflammation was felt most likely to be due to visceral reactivation of VZV. Take-home messages: 1. VZV reactivation may still occur despite aciclovir prophylaxis. 2. Immune reconstitution post-SCT is highly variable. 3. Seemingly adequate VZV IgG titres do not necessarily prevent infection if there is immunosuppression. Abstract without diagnosis A 27-year-old man of South Asian ethnicity presented with abdominal pain, nausea and constipation. Eight months earlier he had undergone myeloablative, haplo-identical, allogeneic stem cell transplantation (SCT) for acute lymphoblastic leukaemia. Immunosuppression had been stopped 4 months before presentation; he had continued prophylactic aciclovir, co-trimoxazole and phenoxymethylpenicillin.

Pityriasis rubra pilaris like eruption following Sinopharm – SARS COVID-19 vaccine

Pityriasis rubra pilaris (PRP) is an uncommon papulosquamous disorder, first described in 1835 by Claudia’s Tarral1 which is characterized by the presence of follicular papules on an erythematous base and orange-red plaques with islands of sparing. Six main types of PRP are described with classic adult being the most commonly seen variant. PRP can be associated with infections, autoimmunity, malignancies, drugs, etc. However, most cases are idiopathic.

Tinea incognito-like generalized pustular psoriasis: A case report

Pustular psoriasis is a rare, immune-mediated systematic skin disorder characterized by yellowish pustules on an erythematous base with multiform clinical presentations and distribution patterns. There are many forms of skin lesions in patients with pustular psoriasis. In this article, we report a case of a male patient having skin lesions very similar to tinea incognito, however definitely diagnosed with pustular psoriasis.

Exanthem and enanthem with fever and dyspnea.

The patient presented with high fever, productive cough, dyspnea, generalized myalgias, conjunctivitis, and whitish elevations with an erythematous base on the buccal mucosa.

Pustular Psoriasis: From Pathophysiology to Treatment.

Pustular psoriasis (PP) is a clinicopathological entity encompassing different variants, i.e., acute generalized PP (GPP), PP of pregnancy (impetigo herpetiformis), annular (and circinate) PP, infantile/juvenile PP, palmoplantar PP/palmoplantar pustulosis, and acrodermatitis continua of Hallopeau (ACH), which have in common an eruption of superficial sterile pustules on an erythematous base. Unlike psoriasis vulgaris, in which a key role is played by the adaptive immune system and interleukin (IL)-17/IL-23 axis, PP seems to be characterized by an intense inflammatory response resulting from innate immunity hyperactivation, with prominent involvement of the IL-36 axis. Some nosological aspects of PP are still controversial and debated. Moreover, owing to the rarity and heterogeneity of PP forms, data on prognosis and therapeutic management are limited. Recent progresses in the identification of genetic mutations and immunological mechanisms have promoted a better understanding of PP pathogenesis and might have important consequences on diagnostic refinement and treatment. In this narrative review, current findings in the pathogenesis, classification, clinical features, and therapeutic management of PP are briefly discussed.

Hemorrhagic Varicella in a 41-Year-Old Woman with Evans Syndrome : Case Report

Background: Varicella is an infection caused by the varicella-zoster virus (VZV) with symptomsof an exanthematous vesicular rash and systemic symptoms. Hemorrhagic varicella commonlyseen in immunocompromised patients. Evans syndrome (ES) is an autoimmune with two or morecytopenias,including autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP).Case: 41-year-old woman complains of swelling filled with reddish fluid almost all over herbody,sometimes painful and accompanied by fever. Patient also experienced vaginal bleeding resultingin anemia (Hb 8.8 g/DL) and thrombocytopenia (platelets 34,000/uL). Dermatological status of thegeneralized,multiple hemorrhagic vesicles with an erythematous base,partially ruptured. Tzank testrevealed multinucleated giant cells. Patient suffered AIHA and received therapy with methylprednisolone4 mg/day and mycophenolic acid 2x500 mg/day.Conclusion: We report a case of hemorrhagic varicella in a 41-year-old woman with Evan’s syndromewith concurrent features of AIHA and ITP. Dermatological status of the generalized, multiplehemorrhagic vesicles with an erythematous base,some of ruptured with erosions. Tzank test revealedmultinucleated giant cells. Patient was treated with acyclovir 5x800 mg for 7 days,2% salicylic acid and0.5% menthol applied every 12 hours and mupirocin 2% ointment applied twice a day on the erosionarea and clinical improvement was found after 17 days of therapy.

M011 HYPERSENSITIVITY TO AMOXICILLIN-CLAVULANATE MANIFESTING AS ACUTE LOCALIZED EXANTHEMATOUS PUSTULOSIS

In 2005, Prange and colleagues identified a localized variant of acute generalized exanthematous pustulosis (AGEP) they termed ‘acute localized exanthematous pustulosis’ (ALEP). ALEP is characterized by sterile pinhead-sized nonfollicular pustules over an erythematous base typically distributed on the face, neck, or chest. Over 80% of cases are in response to medications, with beta-lactam antibiotics being frequently implicated. We describe a case of facial ALEP that developed three days after initiating amoxicillin-clavulanate therapy.

Steroid-resistant Acute Generalized Exanthematous Pustulosis Mimicking Generalized Pustular Psoriasis Successfully Treated by Methotrexate

Acute generalized exanthematous pustulosis is a rare drug-induced eruption that is characterized by sterile non-follicular pustules arising on an often edematous diffuse erythematous background. Generalized pustular psoriasis is an acute and severe clinical form of psoriasis presenting as pustular eruption with erythematous base. Differentiating both diseases is often challenging because of their clinical and histopathological similarities. A 62-year-old woman presented with pustular eruption and fever three days after taking propyphenazone. Laboratory findings revealed leukocytosis and neutrophilia. Histopathological findings revealed a subcorneal spongiform pustule filled with neutrophils and perivascular inflammatory cell infiltration with neutrophils in the dermis. She was initially treated with systemic steroids, however, the lesions showed insignificant improvement. Treatment was then shifted to methotrexate which resulted in a dramatic clinical improvement.

Rash in an immunocompromised patient

A 47-year-old man presented to the emergency department with rapidly worsening skin lesions and malaise. The patient had scattered pink papules, some with overlying ulceration and hemorrhagic crust, that had started on his back and chest and spread to his face, buttocks, and extremities. Closer examination of his abdomen and neck revealed vesicles on an erythematous base. The patient had a history of Hodgkin lymphoma and a bone marrow transplant complicated by graft versus host disease.What’s your diagnosis?

Diffuse Geometric Erosions on the Skin of a Premature Infant, Fraternal Twin Unaffected

Diffuse Geometric Erosions on the Skin of a Premature Infant, Fraternal Twin Unaffected