Papulopustular Eruption Research Articles

Dermatologic adverse events to chemotherapeutic agents, Part 2: BRAF inhibitors, MEK inhibitors, and ipilimumab.

The advent of novel targeted chemotherapeutic agents and immunotherapies has dramatically changed the arena of cancer treatment in recent years. BRAF inhibitors, MEK inhibitors, and ipilimumab are among the newer chemotherapy drugs that are being used at an increasing rate. Dermatologic adverse events to these medications are common, and it is important for dermatologists and oncologists alike to learn to recognize and treat such side effects in order to maintain both patients' quality of life and their anticancer treatment. This review describes the cutaneous side effects seen with BRAF inhibitors (eg, maculopapular eruption, photosensitivity, squamoproliferative growths, melanocytic proliferations), MEK inhibitors (eg, papulopustular eruption), and ipilimumab (eg, maculopapular eruption, vitiligo), with a mention of vismodegib and anti-PD-1 agents.

Severe Demodex Infestation of a Coal Miner

We report a case of Demodex infestation in a 35 year old coal miner presenting with a 5 year history of scally papulopustular eruption on his face. He had been working inunderground coal tunnels in a humid- hot- dusty environment and he had been used to bath twice a day with hot water and multiple cleaners. The patient was treated successfully with oral metronidazol, topical permethrin, topical steroids and avoidance of undergraund mining . We believe his occupational environment made him prone to infestation by changes in sebum composition and/or viscosity, his bath habituation facilitated infestation, damaging the epidermal barrier function and his previous treatments exaggerated his infestation. During evaluation of the patient, specific occupational factors and habituations will be related with higher succession rates of treatment. We need to conduct further studies in order to draw a definite conclusion about the effect of the occupational environment on Demodex infestation.

Cetuximab-induced Crusted Pustular Eruption with Patchy Alopecia

A 52-year-old man with recurrent metastatic rectal carcinoma being treated with cetuximab presented to the emergency department with a diffuse papulopustular eruption on the face, scalp, chest, and groin, accompanied by patchy alopecia of the scalp and facial hair.

Isotretinoin for high-grade or refractory epidermal growth factor receptor inhibitor-related acneiform papulopustular eruptions

Isotretinoin for high-grade or refractory epidermal growth factor receptor inhibitor-related acneiform papulopustular eruptions

Perioral dermatitis from high fluoride dentifrice: a case report and review of literature

Perioral dermatitis is a papulopustular eruption, commonly related to the inappropriate application of topical corticosteroids with occasional reports of inhaled corticosteroids and decreased personal hygiene. We present a case of a 45-year-old female with a one-year history of perioral dermatitis related to the use of highly fluoridated toothpaste commenced to control dental caries.

Cutaneous Listeriosis

Cutaneous infections due to Listeria monocytogenes are rare. Typically, infections manifest as nonpainful, nonpruritic, self-limited, localized, papulopustular or vesiculopustular eruptions in healthy persons. Most cases follow direct inoculation of the skin in veterinarians or farmers who have exposure to animal products of conception. Less commonly, skin lesions may arise from hematogenous dissemination in compromised hosts with invasive disease. Here, we report the first case in a gardener that occurred following exposure to soil and vegetation.

Histopathology of acneiform eruptions in patients treated with epidermal growth factor receptor inhibitors

Epidermal growth factor receptor inhibitors (EGFRIs) are anticancer agents that have been approved for use in a variety of solid tumors. EGFR-inhibiting agents produce a variety of cutaneous adverse events: most commonly a follicular papulopustular (acneiform) eruption on the face, scalp, chest and upper back. The goal of this manuscript is to elucidate the histopathologic findings associated with this most common adverse event. The histopathological findings of 10 patients with papulopustular eruptions induced by EGFRIs are described and compared to the four prior published case series of acneiform rashes attributed to EGFRIs. All 10 patients in our case series showed a superficial, predominantly neutrophilic suppurative folliculitis with ectatic follicular infundibula and rupture of the epithelial lining. Similar pathology was found in the four other case series discussing this phenomenon. While the characteristic clinical appearance of this rash precludes the need for a biopsy in most cases, this knowledge promotes our understanding of the pathophysiologic process. As the use of EGFRIs expands, dermatopathologists will see these reactions more commonly and will need to recognize this pattern.

Index of Suspicion

A 5-year-old previously healthy boy presents to the emergency department (ED) with a 2-week history of intermittent left groin pain, usually occurring later in the day. Pain is not related to eating, movement, urination, or stooling. There is no report of trauma or precipitating event. He screams and refuses to stand up during pain episodes, which occur suddenly and last approximately 1 to 2 hours at a time. He otherwise has normal gait and activity when pain free. He does not wake up at night in pain. No recent illnesses or fevers are reported. Review of systems and his examination findings are unremarkable. Two days prior, he was evaluated in the ED for the same issue and had normal urinalysis, urine culture, and scrotal ultrasonogram results. The consulting urologist did not suspect a urologic process. He was discharged home with pain medication. Today, he returns to the ED because of the intense pain. The patient is admitted for further evaluation and pain management. Complete blood cell (CBC) count, C-reactive protein level, urinalysis results, and plain radiographs of the hips are unremarkable. Computed tomography of the abdomen and pelvis reveals a trace amount of nonspecific free fluid in the pelvis. His pain appears to be alleviated with ibuprofen and bed rest. The following day, he has another episode of intense groin pain after returning from the play room. Physical examination at this time demonstrates only point tenderness on palpation over his symphysis pubis area. No swelling, erythema, or increased warmth was noted in that area. An additional imaging study reveals the diagnosis. A 15-year-old girl presents to the clinic with an itchy rash, fever, headache, nausea, and dizziness. A few days earlier she was evaluated for rash on her back and low-grade fevers. She was prescribed amoxicillin clavulanate for suspected streptococcal …

Papulopustular eruption after holiday in a 44-year-old man

Papulopustular eruption after holiday in a 44-year-old man

Steroid Dermatitis Resembling Rosacea: A Clinical Evaluation of 75 Patients

Background. The use of topical steroids on the skin of the face should be carefully evaluated by the dermatologist; however, its misuse still occurs producing dermatological problem resembling rosacea. Objectives. To report the different clinical manifestations of steroid dermatitis resembling rosacea and to discover causes behind abusing topical steroids on the face. Methods. In this prospective observational study, 75 patients with steroid dermatitis resembling rosacea who had history of topical steroid use on their faces for at least 1–3 months were evaluated at the Department of Dermatology, Baghdad Teaching Hospital, between August 2010 and December 2012. Results. The majority of patients were young women who used a combinations of potent and very potent topical steroid for average period of 0.25–10 years. Facial redness and hotness, telangiectasia, and rebound phenomenon with papulopustular eruption were the main clinical presentations. The most common causes of using topical steroid on the face were pigmentary problems and acne through recommendations from nonmedical personnel. Conclusion. Topical steroid should not be used on the face unless it is under strict dermatological supervision.

Unique presentations of epidermal growth factor receptor inhibitor-induced papulopustular eruption related to bacterial superinfection

Epidermal growth factor receptor (EGFR) inhibitors have been reported to induce numerous cutaneous side effects, the most notable of which is a papulopustular eruption on the face, scalp, and central chest. The typical presentation consists of inflamed papules, often with pustules, favoring a seborrheic distribution. The pustules of the EGFR inhibitor-induced papulopustular eruption are commonly sterile but bacterial superinfection is not uncommon. We report two unique presentations of the papulopustular eruption that were found to be associated with Staphylococcus aureus superinfection. One patient presented with an abrupt onset of nearly confluent red plaques on the cheeks, forehead, chin, and neck, with innumerable studded pinpoint pustules. The other patient had a long-standing untreated papulopustular eruption on the scalp, which resulted in widespread erythema, large thick plaques of serous crust, pustular exudate, and associated alopecia. Both patients quickly resolved with non-tetracycline oral antibiotics combined with topical steroid treatment.

Gefitinib-associated vitiligo: report in a man with parotid squamous cell carcinoma and review of drug-induced hypopigmentation

Gefitinib is a tyrosine kinase inhibitor that targets and inhibits epidermal growth factor receptors. It was initially used to treat non-small cell lung cancer but has increasingly been used for other solid tumors such as those in the breast, colorectal sites, and head and neck, as in our patient. Vitiligo is an autoimmune disorder that results in the destruction of melanocytes and subsequent skin depigmentation and hypopigmentation. Previously described mucocutanous side effects of gefitinib at 250-500 mg/day include alopecia, asteatotic dermatitis, desquamation, hyperpigmentation, papulopustular acneiform eruption, pruritus, seborrheic dermatitis, and skin fragility. A 54-year-old man with metastatic squamous cell carcinoma to the parotid gland developed vitiligo within 1 month of starting gefitinib therapy. We retrospectively reviewed the medical literature using PubMed, searching: (1) gefitinib side effects, (2) drugs and (3) vitiligo. The patient with gefitinib-induced vitiligo continued to receive treatment with the drug during which time areas of skin hypopigmentation persisted and progressed. Etiology of drug-induced vitiligo includes alopecia areata therapies, anticonvulsants, antimalarials, antineoplastics, anti-Parkinson medications, and other miscellaneous drugs. No other individuals have been described with gefitinib-induced vitiligo. Albeit rare, gefitinib may be associated with the development of vitiligo.

Corrigendum to “Sebaceous glands as the primary target of EGFR-inhibitors in the development of papulopustular eruption” [J. Dermatol. Sci. 66 (2) (2012) 165–168

The corresponding author regrets to inform that at the time of checking their proofs, they omitted to include Prof. Dr. Christos C. Zouboulis (Departments of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Auenweg 38, 06847 Dessau, Germany), who kindly provided them the SZ95 cells for their research, to the authors list, as initially agreed. The corresponding author would like to apologise for any inconvenience caused.

EL31 - How to Overcome Skin Disorders Caused by Anticancer Agents

ABSTRACT Anticancer agents have been used for individuals having advanced malignant tumors. The targeted chemotherapeutic agents comprise (i) small molecule epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors, gefitinib, erlotinib and lapatinib, (ii) monoclonal anti-EGFR antibodies, cetuximab and panitumumab, and (iii) small molecule multikinase inhibitors, sorafenib and sunitinib. EGFR inhibitors (EGFRI) may cause common mucocutaneous reactions including papulopustular eruption, paronychia with pyogenic granuloma-like tissue, curly hair growth, xerosis, stomatitis/mucositis and hypersensitivity syndrome. Oral small molecule multikinase inhibitors can induce common mucocutaneous reactions such as hand–foot skin reaction, seborrheic dermatitis-like or papulopustular eruption, paronychia with pyogenic granuloma-like tissue, alopecia, xerosis, stomatitis/mucositis, facial swelling, skin discoloration, hair depigmentation, secondary neoplasm of cutaneous squamous cell carcinoma and keratoacanthoma. Repetitive evaluation and treatment is essential to overcome mucocutaneous reactions caused by targeted anticancer agents. The grading for EGFRI-induced papulopustular eruption has been proposed. The agents should be continued, if the reactions are not severe. However, the drugs may induce severe adverse reactions including toxic epidermal necrolysis and Stevens-Johnson syndrome. The agents are recommended to be discontinued, if any sign of severe drug eruption is present. There have been little controlled clinical trials for treatment regimens for EGFRI-associated common mucocutaneous reactions. The current management is based on qualitative evidence, subjective reports and expert opinion. We now need to propose a treatment guideline for adverse mucocutaneous reactions caused by targeted anticancer agents with ongoing research and clinical trials.

Cutaneous and ocular signs of childhood rosacea

AbstractPurpose To describe the clinical features of cutaneous and ocular manifestations of childhood rosacea, to propose diagnostic criteria, and to emphasize the possible severity of ocular complications in this age group.Methods Children aged 1 to 15 years who had received a diagnosis of cutaneous and/or ocular rosacea and were seen between January 1, 1996, and December 31, 2011.Results Of 20 patients, 11 had ocular and cutaneous rosacea, 6 had isolated cutaneous involvement, and 3 had isolated ocular involvement. Dermatologic examination results were sufficient to diagnose rosacea in 12 of the patients (60%). The most common presentation was a papulopustular eruption on a telangiectatic background. In 11 patients (55%), ocular involvement preceded the skin eruption. Among the ophthalmologic manifestations, chalazions and blepharoconjunctivitis were the main presenting symptoms; keratitis was observed in 4 patients and corneal ulcers in 2. Ten patients were treated with oral metronidazole. Intermittent treatment for at least 3 months was used to avoid neurologic toxic effects and to achieve complete remission.Conclusion Although rare, childhood rosacea should be recognized because of the possible severity of ocular involvement.

Recalcitrant eosinophilic pustular folliculitis of Ofuji with palmoplantar pustulosis: dramatic response to narrowband UVB phototherapy

Eosinophilic pustular folliculitis of Ofuji is a recalcitrant disease typified by non-infective eosinophilic spongiosis involving the infundibular region of the hair follicle. We present a case of a 49-year-old Chinese man with known palmoplantar pustulosis and acrodermatitis continua of Hallopeau which was promptly resolved with methotrexate therapy. He returned with an erythematous papulopustular eruption with coalescence to annular plaques, occurring over the face, chest and back with active palmoplantar pustulation. Histology from skin biopsy of the palmar lesion was in keeping with palmoplantar psoriasis, while biopsy of the facial and truncal lesions revealed florid perifollicular eosinophilic congregation diagnostic of eosinophilic pustular folliculitis of Ofuji. Indomethacin was initiated with partial improvement of lesions with cyclical flares. A trial of narrowband ultraviolet-B phototherapy at a frequency of thrice weekly achieved sustained clearance of both eosinophilic pustular folliculitis and palmoplantar lesions. Indomethacin was tailed down and eventually discontinued with maintenance of narrowband ultraviolet-B therapy; this achieved successful control of the disease.

Azithromycin Pulses for the Treatment of Epidermal Growth Factor Receptor Inhibitor-Related Papulopustular Eruption: An Effective and Convenient Alternative to Tetracyclines

Background: Papulopustular eruption (PPE) is the most common cutaneous side effect of epidermal growth factor receptor inhibitors (EGFRIs). Objective: To document the efficacy and safety of pulsed azithromycin doses in the treatment of EGFRI-related PPE. Methods: A retrospective analysis of patients under EGFRIs who exhibited at least grade 2 PPE and were intolerant or resistant to tetracyclines was performed. Treatment consisted of pulsed azithromycin doses of 500 mg daily for 3 consecutive days per week for at least 2 weeks. Results: Treatment with azithromycin showed a significant reduction in the number of lesions in 18/20 patients, with 11 showing complete resolution of the rash. No significant side effects were recorded. We did not observe any interactions with the targeted biological agents or any obvious compromise of the anticancer treatment. Conclusions: Weekly pulses of azithromycin are effective and promote increased patient adhesion to the treatment. A prospective study is needed to confirm efficacy and safety of this convenient treatment.

Manifestations cutanées des thérapies ciblées

Many cutaneous adverse events have been identified with recently developed targeted treatments. Some of them are common and specific, like paradoxical psoriasiform eruptions with anti-TNFα, papulopustular eruptions and paronychias with EGFR inhibitors and peculiar hand-foot skin reactions with multitargeted kinase inhibitors sorefenib and sunitinib. Patients treated with these recently available biologics need a careful monitoring.

Sebaceous glands as the primary target of EGFR-inhibitors in the development of papulopustular eruption

Sebaceous glands as the primary target of EGFR-inhibitors in the development of papulopustular eruption

A novel approach to manage skin toxicity caused by therapeutic agents targeting epidermal growth factor receptor.

636 Background: Inhibition of EGFR represents an important field in cancer therapy.Skin rash is a common adverse reaction in patients receiving EGFR inhibitors. Nicotinamide has been shown to be an effective treatment for skin inflammation in various conditions, since nicotinamide inhibits IL-8 production through the NF-kB and MAPK pathways in an in vitro keratinocytes/P. acnes model of inflammation. Furthermore green tea polyphenols could be useful in attenuation of solar UVB light-induced oxidative stress-mediated and MAPK-caused skin disorders in humans.In this study we evaluated the effect of nicotinamide and green tea polyphenols on skin toxicity EGFRI related. Methods: Patients with skin toxicity induced by EGFRI were enrolled. They underwent a skin biopsy and skin samples for microbiological analyses at first presentation of skin toxicity (T0). Skin toxicity was assessed with NCI-CTACE,EGFR index and Dermatology Life Quality Index (DLQI) test. Therapy protocol consisted in topical application of moisturizing cream containing green tea polyphenols plus oral administration of nicotinamide 200 mg/die for 12 weeks. Topical application of 1% clindamycin gel and/or systemic administration of minocicline were provided in case of superbacterial infection. All treated patients were monitored for at least 12 weeks (T12), across three time points (T0,T6,T12). Results: 24 colorectal cancer patients receiving anti-EGFR monoclonal antibodies (cetuximab or panitumumab) and developing skin toxicity were treated by a multidisciplinary team including oncologists, dermatologists, a pathologist and a nurse. All the patients experienced a significant reduction of skin toxicity according to the NCI-CTACE and EGFR index (p<0.05). Papulo-pustular eruption and itching significantly improved after 6 weeks of treatment and erythema decreased after 12 weeks. A significative improvement of the global score and of DLQI was evident. No toxicity related to the treatment of skin toxicity was observed. Conclusions: Treatment with nicotinamide and green tea polyphenols represent a novel effective approach to manage skin toxicity caused by EGFRI.