Erythematous Eruption Research Articles

Understanding and Managing Vulvar Psoriasis in Girls: Findings From a Cohort Study.

Pediatric vulvar psoriasis in girls is under-recognized and under-treated due to its nonspecific clinical appearance. This paper aims to describe the signs and symptoms of pediatric vulvar psoriasis and treatment strategies used by our group. A retrospective cohort study was undertaken at a private pediatric dermatology referral practice from January 2016 to December 2022. Clinical data were prospectively collected and recorded in an online patient database. Treatment regimens were individualized and titrated to clinical response. In 100 girls with vulvar psoriasis, the most common presentation was an erythematous vulvar eruption (97%) which was well-demarcated in 52% of children and appeared as a plaque in one-fourth. The perianal skin was involved in 48% of cases. Extragenital psoriasis was present in 69% of patients. Most children responded to initial induction treatment with moderate-potency topical corticosteroid ointment followed by maintenance with topical tar solution. Systemic treatment was not required for purely vulvar psoriasis compared with 3% of children with extragenital psoriasis. Vulvar psoriasis in girls presents as a chronic erythematous vulvitis, with perianal involvement inhalfthecases,but without vaginitis. It is a remitting and relapsing skin condition that requires long-term topical management.

Onychomadesis and Beau’s Lines- Rare Complications of Handfoot- and-mouth Disease

Hand-foot-and-mouth disease (HFMD) is a common self-limiting viral infection in children caused by Coxsackievirus A16 and human enterovirus 71, presenting with fever, erythematous papulovesicular eruptions/ blisters on the palms, soles, knees, buttocks, and oral mucosa. Although rare, complications may arise in nails e. g. onychomadesis (nail separation) and Beau’s lines (transverse lines on the nails). These typically appear within four to eight weeks of HFMD and persist for around 5-6 weeks. No active treatment is required and these nail changes resolve spontaneously within few weeks as the nail bed remain intact. We present here a boy of 4 years who presented with such nail changes after around 5 weeks of HFM disease and diagnosed as onychomadesis and Beau’s lines after ruling out other possible causes of nail changes. BANGLADESH J CHILD HEALTH 2023; VOL 47 (1) : 47-50

Severe distributive shock, neutrophilic dermatosis, and ST-elevation myocardial infarction in the setting of azathioprine hypersensitivity syndrome

BackgroundAzathioprine is a purine synthesis inhibitor used as an immunosuppressive therapy for many immune-mediated diseases. Azathioprine hypersensitivity reaction is a rare, life-threatening adverse reaction characterized by a range of multisystem manifestations including fever, abdominal pain, arthralgias, erythematous cutaneous eruption, acute renal failure, neutrophilia, and more rarely, distributive shock. Although acute heart failure has been rarely described in association with azathioprine hypersensitivity syndrome, myocardial infarction has, to our knowledge, never been associated with this entity.Case PresentationWe describe a case of a 59-year-old male with Crohn’s disease who developed severe azathioprine hypersensitivity syndrome that included distributive shock, neutrophilic dermatosis, and acute coronary syndrome with ST-elevation. Clinical improvement was seen after cessation of azathioprine and administration of glucocorticoid therapy.ConclusionPrompt recognition of azathioprine hypersensitivity syndrome, which can manifest as shock and neutrophilic dermatosis, is key to ensure rapid azathioprine cessation.

Cutaneous adverse events following COVID-19 vaccination: A case series of 30 Japanese patients and a review of 93 Japanese studies.

In Japan, cutaneous adverse events (AEs) following the coronavirus disease 2019 (COVID-19) vaccination have been frequently described; however, a larger case series and literature review are lacking. There is an urgent need for an extensive investigation of new cases and previous reports to provide a thorough body of information about post-COVID-19 immunization cutaneous AEs. We aimed to analyze patients with cutaneous AEs after COVID-19 vaccination in our hospital and review previous studies of cutaneous AEs. We analyzed post-COVID-19 vaccination cutaneous AEs in our department, the Japanese Registry, and previous literature. We enrolled 30 patients with cutaneous post-vaccination AEs in our department over 2 years (April 1, 2021, to March 31, 2023). We also confirmed cases registered in the Ministry of Health, Labor, and Welfare COVID-19 vaccine side effect reporting system (February 17, 2021-March 12, 2023). A total of 587 records were retrieved and 93 articles were included for data extraction. A total of 28 non-injection-site cutaneous AEs and two injection-site AEs were identified. Six (20.0%) patients developed new-onset erythematous eruptions, and five (16.7%) patients developed urticaria. Pruritic eruption, eczema, shingles, and sweating symptoms have also been reported. In previous studies on non-injection-site cutaneous AEs, individuals who received the BNT162b2 vaccine were older than those who received mRNA-1273 (P < 0.01). Cutaneous AEs were mostly nonsignificant and self-limiting reactions; however, rare, severe, or life-threatening AEs were also reported. Physicians should be aware of the various possible cutaneous AEs associated with the COVID-19 vaccination.

Anti‐TIF‐1γ dermatomyositis: Erythematous eruption with weakness and normal creatine kinase

AbstractWe describe a case of a previously well 76‐year‐old woman who presented with 9 months of a generalised pruritic rash alongside fatigue, weight‐loss and a symmetrical weakness of the legs.

A case of a patient with cutaneous 'frog spawn'.

A 60-year-old woman presented with a 7-year history of an erythematous cutaneous eruption involving the right submammary area. She described asymptomatic, small blisters that would exude clear fluid intermittently.

Stevens-Johnson syndrome secondary to massive inflammatory hyperplasia of bilateral lingual margins: a case report and literature review.

Stevens-Johnson syndrome (SJS), also known as the multifactorial erythematous drug eruption, is a class of adverse reactions of the skin and mucous membranes primarily caused by drug allergy often involving the oral cavity, eyes, and external genital mucosa, generally accompanied by fever, and can be life-threatening in severe cases. In February 2022, the Department of Stomatology, the First Affiliated Hospital of Zhengzhou University admitted a patient with huge inflammatory hyperplasia of bilateral lingual margins secondary to SJS. Upon admission, no other obvious symptoms were observed except for tongue hyperplasia. The patient suffered from a severe adverse drug reaction caused by acetaminophen 2 months ago and was complicated by liver dysfunction and pulmonary infection. After 1 month of treatment and rehabilitation, he developed a secondary tongue mass and was subsequently admitted to Dept. of Oral and Maxillofacial Surgery Ward 2, the First Affiliated Hospital of Zhengzhou University. After completing the examination, the tongue mass was surgically removed. After a follow-up of 11 months, the patient's condition was satisfactory and no temporary discomfort was observed. The case of tongue mass secondary to SJS is extremely rare. If a stomatologist encounters a similar case, we should carefully inquire about the drug allergy history and recent medication history, and be alert to whether or not they had adverse drug reactions recently.

A case of disseminated erythematous drug eruption caused by favipiravir in a patient with COVID‐19

A case of disseminated erythematous drug eruption caused by favipiravir in a patient with <scp>COVID</scp>‐19

The Dermatological Effects of Box Jellyfish Envenomation in Stinging Victims in Thailand: Underestimated Severity

The dermatological effects of box jellyfish envenomation among stinging victims in Thailand are not well reported, particularly concerning chronic effects. For first aid, different recommendations indicate the necessity for the removal of tentacles in life-threatening situations. This study aimed to describe the dermatological effects of box jellyfish envenomation and propose recommendations regarding first aid for victims in urgent care or life-threatening situations. Surveillance systems and Toxic Jellyfish Networks were established to improve detection and investigation. The networks investigated all severe victims of jellyfish envenomation. A retrospective study was conducted, and victims of stinging by box jellyfish investigated from 1999 to 2021 were included. One hundred and twenty-four victims were recorded. The majority of victims were males (55%), tourists (69%), and Thai nationals (49%). Direct contact had more severe consequences than indirect contact. Dermatological effects included edema, erythematous caterpillar track-like rash, blistering, bullae, papular eruption, necrosis, digital gangrene, recurrent dermatitis, dermal hypersensitivity, numbness, lichenification, hyperpigmentation, keloids, and scarring. Suffering and healing continued from several weeks to many years. Victims with multiple-tentacle box jellyfish stings had papular eruptions and greater severity of skin issues. All fatally envenomed victims collapsed within a few minutes and received incorrect/no first aid. The proposed first aid for life-threatening box jellyfish stings is continuous irrigation of the wound with vinegar for at least 30 s and initiation of cardiopulmonary resuscitation if there is no respiration or heartbeat. Tentacles often detach spontaneously, and removal is not always necessary, thus saving time. The findings provide input for improving diagnosis and treatment guidelines.

Pigmenting Purpuric Dermatoses: Striking But Not a Manifestation of COVID-19 Infection.

Purpuric or erythematous eruptions of the lower extremities can be perplexing, especially because this clinical sign has been associated with COVID-19 infection. Since the start of the pandemic, COVID-19 often has been the first differential diagnosis for many clinical findings; however, pigmented purpuric dermatoses (PPDs) are distinctive, reassuring, eponymous, and not linked to this virus. In this article, we differentiate the PPDs and delineate them from potentially serious differential diagnoses, including inflammatory retiform purpura, leukocytoclastic vasculitis, stasis dermatitis, and cellulitis.

Evaluation of Cutaneous Adverse Drug Reactions Reported in a Teaching Hospital of Coastal Andhra

Adverse drug reactions (ADR) can be manifested in different forms, among these cutaneous adverse drug reactions (CADRs) are the commonest. They have been steadily gaining importance and constitute a major proportion of all ADRs. As available data on CADRs is very less, more research is required to have reliable data, hence the current study was undertaken. This prospective study was carried out to evaluate the age and gender distribution, presenting complaints, spectrum of CADRs, causative drugs, causality, severity, and outcomes in patients with or suspected CADRs attending the department of Dermatology of Konaseema Institute of Medical Sciences &amp; Research Foundation Hospital between January 2014 and June 2015. In cooperation with the Dermatologist, patients’ reactions were analyzed based on morphology, and laboratory investigations. Causality was assessed as per the World Health Organization- Uppsala Monitoring Centre (WHO-UMC)causality assessment scale. Modified Hartwig and Siegel Scale was used for the severity assessment of reactions. CADRs occurred most commonly in the 31-40 years age group (32%) with no sign of the difference in both sexes. The most common complaint of CADRs by the patients was skin rash (42%) anddiagnoses were Erythematous drug eruption (ERDE) and Fixed drug eruption (FDE) (28%). The commonest causative drug categories were antimicrobials (52%) and Non-Steroidal Anti-inflammatory Drugs (NSAIDs) (24%).Among antimicrobials, ciprofloxacin, and in NSAIDs, diclofenac were the commonest causative drugs. In causality, majority of the cases were under possible category(42%). Most of the reactions were mild (46%), and moderate (46%) in severity. The majority of the cases showed good recovery without any mortality or disability. The limitations of this study were the relatively small sample size, inability to confirm the particular causative drug in majority of the patients. Future research should focus on the genetic factors concerning to CADRs and molecular-level evaluation should be done for a better understanding of the pathophysiology of various ADRs.

Pemphigus vulgaris mimicking Steven-Johnson syndrome/toxic epidermal necrolysis: report of an unusual case.

Pemphigus vulgaris (PV) is an autoimmune blistering disease affecting the skin and mucosa. It clinically presents as painful erosions, mainly in the oral cavity, and flaccid blisters and erosions on the skin. Steven-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a severe mucocutaneous drug hypersensitivity reaction characterized by painful, dusky, erythematous eruptions that often progress to blisters, erosions, and extensive epidermal detachment accompanied by systemic symptoms. Herein, we report the case of a 48-year-old man who presented with extensive skin and mucosal lesions following the ingestion of an unknown medication. The patient's symptoms clinically mimicked SJS, and accordingly, a preliminary diagnosis of SJS/TEN was made. However, clinical investigation of skin biopsy and direct immunofluorescence assay results indicated PV, and a final diagnosis of PV was established.

Continuous hemicrania as the initial manifestation of Ramsay Hunt syndrome: a case report

IntroductionRamsay-Hunt syndrome, also called otic zoster, is a rare complication of herpes zoster. The syndrome is characterized by peripheral facial nerve palsy and an erythematous vesicular eruption in the ear or mouth. Preceding the appearance of the vesicles, unilateral otalgia or neck pain may occur more commonly. However, persistent hemicrania is infrequent in the pre-eruptive phase.ObjectivesTo present an atypical case of Ramsay Hunt syndrome with continuous unilateral headache preceding the onset of other symptoms and signs of the syndrome.Case reportReport of a 69-year-old woman who presented subacute onset of moderate to severe left hemicrania with no autonomic signs. Eight days after the start and continuous headache maintenance, she presented with peripheral facial paralysis. After four days, she noticed the presence of vesicles in the left ear and odynophagia. She developed nausea with several episodes of vomiting and severe imbalance that made it impossible for her to walk unassisted. On physical examination, she presented vesicles in the left ear and oropharynx, left peripheral facial palsy (House Brackmann grade IV), left hypoacusis, nystagmus, and vestibular gait. Diagnostic tests for screening several metabolic diseases and diagnosis of infection (including HIV) were unremarkable. Brain computed tomography and cerebrospinal fluid analysis showed no abnormalities.ConclusionsRamsay-Hunt syndrome mainly involves the facial and vestibulocochlear nerves, causing peripheral facial palsy, otalgia, hypoacusis, and, less frequently, imbalance. Although pain is a frequent manifestation of the pre-eruptive phase of RHS, unilateral headache is not common in this scenario. On the other hand, it is a prevalent complaint in the emergency department and has several different etiologies. Hence, diagnosing RHS when patients present exclusively unilateral headaches is challenging for clinicians. Physicians must consider RHS a vital differential diagnosis of sided-locked headaches, avoiding diagnostic errors and treatment delays.

Changing a Life in Medical Missions: Chronic Actinic Dermatitis

A 47-year-old male was seen in a rural Nicaraguan community for difficulty shaving his beard. The patient stated his face changed roughly 10 years ago and since has never looked the same. He presented at the clinic with an eczematous rash confined to the sun exposed surfaces on his skin. His face and posterior neck were covered in a confluent lichenified erythematous eruption sparing only the forehead and eyelids. The upper chest, forearms, and dorsal hands were hyperpigmented with various hypertrophic and hyperkeratotic lesions. The diagnosis of chronic actinic dermatitis was made due to the overall clinical picture along with limitations in further diagnostic capabilities. After initial therapy, the patient ecstatically returned to the clinic with greatly improved skin.

Histopathological Patterns of Cutaneous Adverse Reaction to Anti-SARS-CoV-2 Vaccines: The Integrative Role of Skin Biopsy.

The advent of vaccines represented a milestone to allow the slowing down and then containing of the exponential increase in ongoing infections and deaths of COVID-19. Since the first months of the vaccination campaign in various continents, there has been a certain number of reports of adverse events, including skin reactions. We conducted a systematic review, searching on PubMed, Web of Science, Scopus, and Cochrane Library for the words: COVID vaccine, dermatopathology, skin, eruptions, rash, cutaneous, BNT162b2 (Pfizer-BioNTech), ChAdOX1 (AstraZeneca), and mRNA-1273 (Moderna). A total of 28 records were initially identified in the literature search of which two were duplicates. After screening for eligibility and inclusion criteria, 18 publications were ultimately included. Various clinical cutaneous manifestations and histopathological patterns following vaccination have been described in literature. The most frequent clinical-pathological presentations were erythematous maculo-papular eruptions in different way of distribution with histopathological pictures mostly represented by interface changes and mixed peri-vascular and peri-adnexal cell infiltrate. Other presentations included new onset of pemphigoid bullous disease (n = 15), delayed T-cell-mediated hypersensitivity reaction (injection site reactions) (n = 10), purpuric skin rash (n = 13), mostly localized on the legs bilaterally and symmetrically with histological pictures characterized by extravasation of erythrocytes in the superficial and middle dermis, and other types of reactions. New studies with large case series and further literature reviews are needed to improve the clinical management of patients and optimize the timeline for carrying out histological biopsy for confirmatory, supportive, and differential diagnosis purposes.

Undermining Ulcers in Juvenile Dermatomyositis.

A 6-year-old boy with a history of refractory anti–transcription intermediary factor 1-γ (anti–TIF1-γ) juvenile dermatomyositis presented to the rheumatology clinic with skin ulcers of 10 days in duration. Physical examination revealed normal muscle for strength. Heliotrope rash, Gottron sign, and diffuse erythematous eruption on the neck, trunk, and buttocks were observed (Figs. 1A, B). No calcinosis cutis, and 2 ulcers (4 × 3 cm, 1 × 1 cm) on the left upper arm deep into the underlying biceps with well-circumscribed margins were observed (Fig. 2). Laboratory studies including muscle enzymes were unremarkable. Patients with anti–TIF1-γ juvenile dermatomyositis tend to have chronic or treatment-resistant disease course. Undermining ulcer is a severe cutaneous manifestation associated with vasculitis or vascular damage due to panniculitis or calcinosis. After 2 cycles of monthly intravenous immunoglobulin therapy (~1.7 g/kg/month) along with continuing use of prednisone and thalidomide at previous dose, the ulcers healed completely (Fig. 3), and other skin lesions improved significantly as well.FIGURE 1: Gottron sign (A) and diffuse erythematous eruption on the buttocks (B).FIGURE 2: Undermining ulcers on the left upper arm.FIGURE 3: The ulcers healed completely after 2 months of treatment.Differential diagnosis: Pyoderma gangrenosum Pressure ulcer Buruli ulcer Dermatomyositis (anti–TIF1-γ, anti-MDA5)

Skin Rash and Mild Bruising: Is Montelukast a Safe Drug?

Montelukast is one of the commonly used drugs in asthma patients. It is prescribed along with inhalational corticosteroids. Although a relatively safe drug, there is a probability of occurrence of skin rashes and skin bruising. Authors present a case report of a 64-year-old chronic asthmatic woman, reporting widespread erythematous eruptions with mild skin bruising and generalized pruritus mostly affecting her lower abdomen and upper extremities. The rash appeared 28 days after introduction of montelukast (10 mg OD). The physician excluded other attributable factors such as trauma, autoimmune disorders such as Churg-Strauss syndrome, and food allergy. Reappearance of rashes after montelukast introduction and complete resolution of the skin rashes after discontinuing it confirms montelukast as offending drug. Naranjo causality assessment score also revealed a “certain/definite” relationship to the montelukast. Long-term safety of montelukast needs to be reviewed by prescribing physicians to prevent adverse reaction.

Hyperkeratotic flexural erythema (more commonly known as granular parakeratosis) with use of laundry sanitizers containing benzalkonium chloride.

Hyperkeratotic flexural erythema (HKFE), also known as granular parakeratosis, is a scaly, erythematous or brown eruption, which usually occurs in the intertriginous and flexural areas. It has been linked to the use of benzalkonium chloride (BAK). To review the clinical presentation of patients diagnosed with HKFE who had been exposed to laundry sanitizer containing BAK, and the therapies trialled to treat these patients. This was a retrospective cases series of 45 patients seen by dermatologists in Victoria, Australia. Information was collected on clinical presentation, investigation and management. The patients varied in age from 18 months to 89 years. The rash typically presented as a symmetrical erythema with characteristic multilayered brownish epidermal scaling. The most common location of the rash was the inguinal/anogenital area (32 of 45 patients; 71.1%) and there was a female predominance. Regarding treatment, topical corticosteroids were frequently prescribed and antibiotics were trialled in 11 patients; however, the condition resolved spontaneously over time in all patients with use of emollients, along with cleaning of the washing machine by running an empty wash, and repeated washing or sometimes disposal of BAK-contaminated clothing. This large case series highlighted the characteristic clinical presentation of HKFE in the setting of BAK used in laundry sanitizer, demonstrating a potential causal link. Further studies are required to evaluate the role of the skin microbiome.

Shiitake Flagellate Dermatitis

A man in his early 70s presented with a 3-day history of intensely pruritic erythematous papules and papular vesicular eruption arranged in a flagellate pattern on his neck, trunk, (Figure 1), and extremities with no general symptoms. On questioning, he had eaten undercooked shiitake mushrooms 2 days before the onset of the cutaneous lesions. Laboratory investigation was unremarkable. A skin biopsy revealed spongiosis, marked papillary dermal edema, and a dermal perivascular inflammatory infiltrate mainly composed of lymphocytes and eosinophils.

Erythematous flexural eruption in a young man.

A young man presented with a 2-week history of well-defined erythematous plaques symmetrically distributed in multiple intertriginous areas. He had received topical corticosteroids, antifungals and oral prednisolone without improvement. Histopathological examination revealed confluent parakeratosis with retention of basophilic keratohyalin granules within the stratum corneum. Click here for the corresponding questions to this CME article.