Plantar Involvement Research Articles

Real-World Clinical Experience of Dupilumab in the Treatment of Chronic Palmo-Plantar Eczema in Patients with Moderate-Severe Atopic Dermatitis: 52-Week Follow-Up.

Background: Hand-foot eczema (HFE) are special locations of dermatitis, which are often associated with atopic dermatitis (AD) and have a significant negative impact on the quality of life, demanding a clinically relevant improvement. Objectives: To evaluate the effectiveness and safety of dupilumab in the treatment of eczema localized in hands and/or feet in patients with moderate-to-severe AD. Methods: Retrospective multicenter study of adult patients with HFE treated with dupilumab for their AD. Patients with other concomitantly systemic immunosuppressive treatments did not undergo a washout period. The severity of palmar and/or plantar involvement was assessed using the Physician Global Assessment (PGA) scale on a scale of 0 ( = clear) to 5 ( = very severe). Eczema Area and Severity Index (EASI) and NRS-pruritus scales were also evaluated. One hundred percent of patients reached week 16, while 67/84 reached week 52 of follow-up. Results: A total of 84 patients were included 86.69% of patients showed a reduction in PGA-Hand, and 80.34% in PGA-Foot at week 52, EASI improvement was reached by 83.55% of patients at week 16 and 87.35% at week 52. Reduction of pruritus (≥4 points in NRS-pruritus scale) was 73.01% at week 16 and 80.67% at week 52. No differences in response to dupilumab were observed in the different subtypes of palmo-plantar dermatitis. Conclusions: The results obtained in our study suggest that dupilumab may be an effective and safe therapeutic option for the treatment of dermatitis localized in hands and/or feet.

32481 Mycosis fungoides palmaris et plantaris: A case series

Mycosis fungoides palmaris et plantaris (MFPP) is a rare subtype, presenting with palm or sole involvement. Less than 30 cases have been previously reported, and there are no guidelines for management. We describe the clinical and histopathologic features, treatments, and treatment responses in patients with MFPP treated at Memorial Sloan Kettering Cancer Center. Retrospective review from 2000-2019 identified 302 patients with acral involvement and 4 patients with MFPP. Median age of our patients was 64 years old, with 3 males and 1 female. One patient had palmar involvement, 1 patient had plantar involvement, and 2 had both regions affected. Three patients had patches and 1 patient had plaques. On histology of all patients, atypical infiltrates of epidermotropic lymphocytes were seen. The median number of treatments used were five, and included skin-directed (topical nitrogen mustard, topical steroids, phototherapy – NB-UVB, PUVA), local radiation, and systemic therapy (bexarotene). All 4 patients were initially treated with skin-directed therapy with no or partial response. One patient had complete response to bexarotene while another patient had partial response to bexarotene and subsequently received radiation therapy. Of the 3 patients who received local radiation, 1 had partial response and 2 had complete response. MFPP is a rare MF subtype that may be challenging to treat. Based on evidence from our case series, radiation therapy shows the most promise with oral retinoid showing some efficacy. Similarly, radiation therapy has been reported as effective treatment of MFPP in the literature, with other treatments including immunotherapy and PUVA photochemotherapy.

Hemidesmosomal Reactivity and Treatment Recommendations in Immune Checkpoint Inhibitor-Induced Bullous Pemphigoid-A Retrospective, Monocentric Study.

Immune checkpoint inhibitors (ICI) induce T-cell-mediated antitumour responses. While ICI were initially successfully applied in metastasized melanoma, they are now approved for several tumour entities. Numerous autoimmune disorders have been reported to occur as adverse events of the treatment, among them bullous pemphigoid (BP), with less than 1% of the patients experiencing ICI-induced BP. This number is higher than the estimated prevalence of autoimmune bullous diseases in the general population of Germany, which lies around 0.05%. We here describe our cohort of eight patients, who developed a bullous pemphigoid under or shortly after ICI treatment. Half of them had a severe subtype (as shown by BPDAI >57) and showed a median onset of ICI-BP after 10 months of ICI initiation. Six patients had a palmar and/or plantar involvement, while oral involvement occurred in one case. All patients had linear epidermal IgG depositions in split skin in the indirect immunofluorescence. In four out of five biopsies available for direct immunofluorescence, linear IgG and C3 depositions were detected at the basement membrane, while one patient showed linear IgM staining. Moderate to high levels of FLBP180 autoantibodies were found in seven of eight cases. The disease can still be active after ICI discontinuation, while rituximab might be required for remission. Finally, four tumour samples were stained histochemically for collagen XVII (BP180), but no enhanced expression was found.

Plantar involvement correlates with obesity, pain and impaired mobility in epidermolysis bullosa simplex: a retrospective cohort study.

Epidermolysis bullosa simplex (EBS) is the most common type of EB, a group of rare genodermatoses. Affected individuals suffer from skin blistering and report a high disease burden. In some EBS subtypes, plantar keratoderma (PK) has been described. This study investigated the presence and correlation of PK with body mass index, pain and mobility in EBS. Individuals (n=157) with genetically characterized EBS were included in this retrospective cohort study, and clinical data were collected over 16years (referral patients to the largest German EB centre). Descriptive statistics and mixed linear models were used to assess correlations. PK was found in 75.8% of patients beginning at a mean age of 4.3years. Both focal and diffuse PK were observed, and 60% of adults with localized and severe EBS were preobese or obese, with ˜30% of patients reporting severely reduced mobility. The presence of PK, especially diffuse PK, correlated significantly with local infections, obesity, pain and requirement of a wheelchair. Along with treating skin fragility and blistering, PK should be considered a potential marker of increased morbidity and may represent a target of EBS therapy development.

How frequently does palmoplantar psoriasis affect the palms and/or soles? A systematic review and meta-analysis.

IntroductionPalmoplantar psoriasis (PPP) is a variant of psoriasis that affects the palms and/or soles. Although PPP is a disabling and therapeutically challenging condition, its epidemiology is poorly defined.AimTo assess the prevalence of PPP locations (palms, soles or both), and to analyse epidemiological and clinical characteristics of the disease.Material and methodsTwo bibliographic databases (MEDLINE and SCOPUS) were used as data sources searched from inception to October 2017. The selection of articles was limited to human subjects and English or French languages.ResultsA search resulted in a total of 293 articles, out of which 24 were utilized for the current systematic review and 21 for meta-analysis. All listed studies comprised a total of 2083 patients with PPP, with more males than females. According to the results of meta-analysis, majority of patients had the highest prevalence of both palms and soles involvement (95% CI: 47–67), with an almost equal prevalence showing palmar (21%; 95% CI: 13–30) or plantar (20%; 95% CI: 12–29) involvement. The most prevalent type of PPP was plaque/hyperkeratotic, followed by the pustular type.ConclusionsAlmost three-fifths (59%) of all PPP patients had involvement of both palms and soles, while exclusive palmar or plantar involvement was seen in 21% and 20% of patients, respectively. Future research should be performed to elucidate basic epidemiological and clinical characteristics of PPP, which would be helpful for proper consideration of this condition.

Paradoxical reversed plantar involvement during ixekizumab therapy for psoriasis

Palmoplantar psoriasis is a particularly challenging variant of psoriasis. Psoriasis at this location has a significant impact on health-related quality of life and is often recalcitrant. However, difficult cases may respond to biologic therapies. Paradoxical reactions during treatment with biological agents have been described, mostly during anti-tumor necrosis factor therapy. These typically present as a change in morphology or distribution of lesions. We present a patient with palmoplantar psoriasis treated with ixekizumab who achieved a favorable response that was coupled with a rare paradoxical reaction, reversed plantar involvement. The reason for this phenomenon and its clinical course are uncertain, but these new lesions are proving recalcitrant to complementary therapies. Provided the increasingly widespread use of biologic therapies, the incidence and diversity of paradoxical reactions are expected to increase.

Mycosis fungoides with plantar involvement and bowenoid changes

Mycosis fungoides with plantar involvement and bowenoid changes

Spotting Zika spots: descriptive features of the rash used in 66 published cases.

Zika virus (ZV) is an important emerging infection. Rash is a key feature, but the summative literature lacks description of the rash beyond 'maculopapular'. Our aim was to identify the cutaneous features described in the published literature. A literature search using defined terms for ZV cases reports and series was performed on the OVID, Clinical Key and University of Dundee's e-library journals databases in December 2016; a later case report was included while the paper was under review. Diagnosis in all cases was via PCR. Exclusion criteria were Zika cases without rash or omitting any description of the rash. Ocular features (conjunctivitis) were not included. In total, 42 publications with 66 cases met the criteria. The most frequent descriptive features included maculopapular (59%), lower limb petechial purpura (11%) and erythematous/red (9%). Pruritus was described in 44% and tenderness in 3%. Lesions were located on the trunk (29%), limbs (5% arms, 11% both arms and legs), face (17%) and extremities (14%) or were diffuse/generalized (12%). There was facial sparing in 3%. Other features were centrifugal spread (6%), palmar and/or plantar involvement (6%), palmoplantar desquamation (2%) and malar erythema with oedema (2%). Mucosal features included gingival bleeding (11%), oral haemorrhagic blisters (8%) and painful blisters/vesicles (4%). Oedema/swelling was described in the upper limbs (5%), lower limbs (5%) and both (3%). Mean rash duration was 6 days (range 3-11 days). The ZV exanthema is most frequently maculopapular, pruritic, sometimes with centrifugal spread from the trunk to extremities. This may include lower limb petechial purpura, palmoplantar lesions, oedema of limb extremities, and gingival bleeding or painful oral bullae. As ZV becomes more prevalent, recognition of the clinical features will enable earlier diagnosis and appropriate testing.

A case of erosive lichen planus with plantar involvement

A case of erosive lichen planus with plantar involvement

Benign dermoscopic parallel ridge pattern in plantar hyperpigmentation due to capecitabine.

We report the case of a 37-year-old woman (phototype II) who presented at our outpatient clinic with a two-month history of hyperpigmented plantar macules. Medical history revealed that the patient had taken capecitabine in the past three months as adjuvant chemotherapy for recurrent breast cancer. Dermoscopic examination of the plantar macules showed parallel ridge pattern with pigmentation in the furrows without obliteration of eccrine gland apertures. Besides in acral melanoma, parallel ridge pattern can also be observed in benign plantar lesions, such as congenital or acquired acral nevi, subcorneal hemorrhage, dye-related pigmentation and drug-induced hyperpigmentation, especially in patients with phototypes III–VI. The few reported cases of capecitabine-induced hyperpigmentation have been associated with hand and foot syndrome in patients with phototypes IV–V and palmar as well as plantar involvement.

Schamberg disease with plantar involvement

Schamberg disease with plantar involvement

Association of Morbus Ledderhose With Dupuytren’s Contracture

Fibromatous nodules in the sole of the foot are often called Ledderhose disease. It is a benign nodular formation in the plantar aponeurosis, typically at the distal medial border. A lump forms and it can be a few centimeters in diameter. It is frequently seen as an isolated disease, but a relationship to Dupuytren's has been noted in some patients. The study was a part of a large cohort study, the Reykjavík study. Men with Dupuytren's disease (n = 122) were invited to follow-up 18 years after the initial observation. An equal number of controls, matched for age and smoking habits, were also invited. A total of 92 Dupuytren's patients and 101 control subjects attended for follow-up and were examined for plantar nodules. Statistical evaluation was carried out using chi-square test and presented as odds ratio (OR) and 95% confidence interval (95% CI). Ledderhose disease was identified in 14 of the 92 (15.2%) men with Dupuytren's disease, while it was only in 4 of the 101 (3.9%) matched controls (OR = 4.35, 95% CI, 1.3-16.7, P < 0.01). Men operated for Dupuytren's disease or with finger contractures were more likely to have plantar nodules than those with only nodules or strings in the palms (OR = 6.1, 95% CI, 1.8-27.1, P < 0.001). The plantar involvement was related to family history of Dupuytren's disease (OR = 3.1, 95% CI, 1.1-8.5, P = 0.02). Men with manifestations of finger contractures or who need surgery for Dupuytren's disease are more likely to also develop plantar fibromas. Level III, retrospective comparative series.

Solitary Cutaneous Myofibroma on the Sole: An Unusual Localization

Dear Editor: A 61-year-old man presented with several years of history of a solitary cutaneous mass on his left sole. A clinical examination revealed a 26×22 mm sized, skin-colored, firm, asymptomatic subcutaneous nodule (Fig. 1). General laboratory screening, including a complete blood count, renal and liver function tests and lipid levels, were within normal limits. A histopathological examination showed a well-circumscribed mass composed of spindle cells that were arranged in interlacing fascicles or whorls. The spindle cells had elongated nuclei, inconspicuous nucleoli and eosinophilic cytoplasm, resembling smooth muscle cells (Fig. 2). As a result of immunohistochemical staining, these cells were found to be positive for smooth muscle actin, but negative for S-100 protein and desmin. On Masson trichrome staining, many spindle cells with red cytoplasmic stain were found to be dispersed among the blue collagen bundles. Based on both clinical and histological features, a diagnosis of solitary cutaneous myofibroma was made. Fig. 1 26×22 mm sized, skin-colored, firm, asymptomatic subcutaneous nodule on the left sole. Fig. 2 (A) Skin biopsy showed a relatively well-circumscribed tumor in the dermis (H&E, Scanning view). (B) The tumor consists of spindle cells arranged in interlacing fascicles or whorls (H&E, ×100). (C) These spindle cells had pale ... Solitary cutaneous myofibroma is a circumscribed benign neoplasm of superficial soft tissue in adolescents and adults; it represents the adult counterpart of infantile myofibromatosis1. Clinically, it typically presents as a painless, slow-growing, firm cutaneous or subcutaneous nodule with an occasional bluish hue. There is a predilection for it to occur on the head and neck, shoulder girdle, lower extremity and hand2,3. Oral and genital solitary cutaneous myofibromas have also been identified. Plantar involvement is exceptionally rare, and there has been only one case of solitary cutaneous myofibroma affecting the sole in the literature3. Histological findings reveal a distinctive appearance, well recognized in children but much less so in adults. It manifests as a biphasic pattern or a zoning arrangement of two cell types4. Among them, the hemangiopericytomatous components, which are typical of infantile myofibromatosis, may sometimes be inconspicuous or even absent in adult lesions, as in our case3. Spindle cells have eosinophilic cytoplasm arranged in short bundles and fascicles resembling leiomyoma. These cells demonstrate features of both myofibroblasts and fibroblasts. Myofibroblastic differentiation of the tumor cells is supported by their immunophenotype. The spindle cells are desmin negative, but smooth muscle actin positive. The Masson trichrome stain, in which thick fibrous bundles with random, irregularly intersecting angles are prominent, can be used to assist in differentiating myofibromas from smooth muscle lesions5. In contrast, smooth muscle lesions show delicate fibrous tissues surrounding the smooth muscle cells and in the septa between the smooth muscle masses. The limited follow-up of solitary cutaneous myofibromas suggests that they tend to follow a benign clinical course with no evidence of recurrence or metastasis1-3. To our knowledge, our case represents only the second report of a solitary cutaneous myofibroma occurring on the sole. We suggest, even though it is very rare, that solitary cutaneous myofibroma should be considered in the differential diagnosis of solitary lesions involving the sole.

Subcutaneous Sarcoidosis with Plantar Involvement

Sarcoidosis is a multisystem granulomatous disorder of an unknown etiology. Subcutaneous sarcoidosis is a rare manifestation of sarcoidosis, and plantar involvement is extremely rare and there is only one such case report in the medical literature. Herein we present an interesting case of a patient who was diagnosed as having subcutaneous sarcoidosis at a plantar localization because plantar involvement is extremely rare and also because of the successful outcome after performing intralesional corticosteroid therapy.

With This Eruption, There Is Not a Second to Lues

A 28-year-old white man presented to the Emergency Department with a 24-hour history of an eruption on his extremities, trunk, and face. The patient was known to be HIV positive with a CD4 count of 527 and a viral load of 20,300. He denied fever, chills, malaise, and headache. His social history was significant for the fact that he was in a monogamous homosexual relationship. He had no recent travel, pet exposures, or sick contacts. Physical examination revealed stable vital signs and no documented fever. A maculopapular eruption was present on his face, trunk, and extremities (Figures 1 and 2). There was no palmar or plantar involvement. He was treated with diphenhydramine and topical 2.5% hydrocortisone and advised to return if his condition did not improve. Twelve days after the initial evaluation, the patient consulted us again due to progression of his dermatitis. He had no additional complaints other than an eruption on both palms but neither sole. (Figure 3). The eruption now demonstrated erythematous pink-red oval macules and papules 1-2 cm in size distributed on his scalp, face, trunk, and arms. A few papules contained fine collarettes of scale. Further questioning revealed that the patient had experienced a tender rectal ulcer 2 months previously. A punch biopsy and rapid plasma reagin were performed. The histopathologic examination revealed interface dermatitis with lymphocytes, plasma cells, occasional neutrophils, and a prominent lymphoplasmacytic perivascular dermatitis with infiltration of the vessel walls. Warthrin-Starry and Steiner methods demonstrated spirochetes at the dermal-epidermal junction and in vessel walls, consistent with Treponema pallidum (Figure 4). Rapid plasma reagin and fluorescent Treponema antibody were both reactive with a Venereal Disease Research Laboratory (VDRL) of 1:16. The patient was diagnosed as having secondary syphilis and treated with 2.4 million units of IM benzathine penicillin for 3 weeks. His eruption resolved after the initial treatment and he did not experience a Jarisch-Herxheimer reaction.

T- and B-lymphocyte subsets in patients with Dupuytren's disease: Correlations with disease severity

Previous reports have indicated that inflammatory mechanisms may be involved in the pathogenesis of Dupuytren's disease and it has even been suggested that this condition is a T-cell mediated autoimmune disorder. We investigated peripheral blood lymphocyte subsets from 21 patients with Dupuytren's disease and compared them with ten healthy blood donors. The Dupuytren's patients had an increase in DR+ T-cells compared with healthy controls. Furthermore, patients with both palmar and plantar involvement had a higher percentage of DR+ T-cells than those with only the palm affected. The percentage of circulating CD5+ B-cells was lower in the Dupuytren's patients compared with the control group; this feature was marginally significant for the whole group of Dupuytren's patients but was strongest in the group of patients with both palmar and plantar involvement. These findings support previous suggestions that immunological mechanisms, involving activated T-cells and probably also B-cells, are involved in the pathogenesis of Dupuytren's disease.

Macrodystrophia lipomatosa: radiographic observations.

23 cases of macrodystrophia lipomatosa (MDL) are reported showing a wide spectrum of radiographic findings. Typical findings were hypertrophy of all the mesodermal tissues of the affected digits with dramatic overgrowth of fat. Phalanges were enlarged both in length and transverse diameter, but the trabecular pattern was maintained. In one patient, the phalanges and metatarsals were elongated but thinned. In another case, all the phalanges and metatarsals of the great toe were small. The little toe was also involved in two cases. Articular surfaces were slanting. There was a high incidence of palmar and plantar involvement. In a few cases the forearm and leg were also involved. Other uncommon features observed were early maturation of epiphyseal centres of ossification of phalanges and metatarsals, syndactyly, polydactyly, brachydactyly and symphalangism. Angiography was uncharacteristic.

Azathioprine. An effective, corticosteroid-sparing therapy for patients with recalcitrant cutaneous lupus erythematosus or with recalcitrant cutaneous leukocytoclastic vasculitis

Azathioprine sodium has been reported to be effective therapy for chronic cutaneous lupus erythematosus (LE) but rarely for chronic cutaneous leukocytoclastic vasculitis (LV). We used azathioprine in the treatment of six patients with cutaneous LE, four of whom had subacute cutaneous (nonscarring) LE and two of whom had chronic cutaneous (scarring, discoid) LE, and six patients with chronic cutaneous LV. The conditions of all patients had been resistant to conventional therapy, and they required long-term oral corticosteroid therapy for control of their disease. Two of the patients with LE had prominent palmar and/or plantar involvement. Three patients with LE had an excellent response to azathioprine, with near complete clearing of the skin lesions, allowing a decrease in prednisone dosage. One patient with LE initially demonstrated significant improvement, but azathioprine therapy had to be discontinued because of pancreatitis. The treatment failed in two patients with LE; one had nausea and the other repeatedly developed a drug-induced fever. Five of the six patients with LV had improved conditions, with complete control of the disease occurring in two patients and partial control in three patients. Azathioprine is effective for some patients with cutaneous LE and chronic cutaneous LV, but it should be reserved for patients with severe disease in whom more conventional treatment fails.

Dupuytren's contracture: Plantar involvement

Dupuytren's contracture: Plantar involvement