Pretibial Area Research Articles

7854 Ablation Aberration: A Case of Thyroid Dermopathy Exacerbation in a Filipino Male Following Radioactive Iodine Ablation and Total Thyroidectomy Improved by Weekly Intradermal Long-Acting Glucocorticoid Injection

Abstract Disclosure: K.T. Lim: None. O.C. Dampil: None. Ablation Aberration: A Case of Thyroid Dermopathy Exacerbation in a Filipino Male Following Radioactive Iodine Ablation and Total Thyroidectomy Improved by Weekly Intradermal Long-Acting Glucocorticoid Injection Introduction: Thyroid dermopathy (TD) represents an unusual extrathyroidal presentation of Graves' disease (GD), impacting about 0.5–4% of patients. RAI treatment for hyperthyroidism is known to progress Graves' ophthalmopathy. RAI-induced TD exacerbation, however, is rare in literature. Here, we present a case of worsening TD and ophthalmopathy in a Filipino patient with GD who underwent definitive therapy for persistent hyperthyroidism. Clinical Case: A 44-year-old man with GD had bilateral lower extremity indurated, mildly erythematous plaques for 4 years. Hyperthyroidism persisted despite methimazole compliance, so he underwent RAI ablation two years earlier, total thyroidectomy a year later, and has been on levothyroxine since. Despite definitive treatment, his extrathyroidal symptoms worsened. A punch biopsy of the skin lesions revealed upper and mid-lower dermis mucin deposition, with occasional spindle-shaped and stellate fibroblasts, and mast cells. These histopathologic findings were consistent with pretibial myxedema. We assessed his thyroid function and found he was euthyroid with normal TSH (3.1 μIU/mL; reference range 0.27-4.20) and an elevated TRAb (35.73 IU/L; reference range <1.75). Physical examination revealed thickened skin, cobblestone-like plaques, and non-pitting edema on the pretibial, ankle, and pedal areas. A 3.5-cm-diameter, circumscribed, orange-peel-textured, indurated plaque covered his left ankle. Fluocinolone acetonide 0.025% w/w ointment was initiated. After 3 weeks, his cutaneous symptoms improved by 35%, albeit his left ankle circumscribed plaque improved marginally. Triamcinolone acetonide 40 mg/mL was injected into this and other nodular lesions at 4mg (0.1 mL) per 1-cm-diameter circular region. Each dose was equally dispersed by multipoint intradermal injections using a 1 mL syringe with a 0.5”x 25G needle. A week after intralesional triamcinolone injection and continuous topical steroid application on the non-nodular lesions, a 70% improvement in cutaneous manifestations was observed (from baseline) with the plaques becoming thinner and softer. After three weekly intradermal steroid injections, the circumscribed plaque had flattened (with residual hyperpigmentation), and the other plaques and nonpitting edema dissipated. Conclusion: Our experience with this patient highlights a paradoxical TD exacerbation following RAI ablation and definitive surgery for persistent hyperthyroidism in GD. It also reveals that weekly administration of multiple subcutaneous injections of a long-acting glucocorticoid alleviates lesions where topical ointment does not. Presentation: 6/1/2024

Rapid Efficacy of riSankizumab in pretibial psoriasis invOLVEment: RESOLVE.

Despite extraordinary improvements in the management of psoriasis in recent times, some areas of the body, such as the pretibial area, still show an unsatisfactory response and a more significant impact on patient quality of life. This multicentre study focuses on psoriasis affecting sensitive areas (particularly the pretibial area), its impact on quality of life and the therapeutic response to risankizumab. This multicentre prospective observational study recruited patients with moderate-to-severe psoriasis with pretibial area involvement. All patients underwent treatment with risankizumab (150 mg every 3 weeks), and efficacy was assessed after 24 weeks. The study included 128 patients with a mean age of 51 years, suffering from moderate-to-severe psoriasis with involvement of the pretibial area with median total Psoriasis Area Severity Index score of 17.05 and Dermatology Life Quality Index of 16.27. The group was further divided into two sub-groups: the 'mother patch' group, in whom the very first psoriatic plaque appeared in the pretibial region (45 patients), and the 'non-mother patch' group, in whom the psoriatic lesion in the pretibial region was present but not as the first manifestation (83 patients). In order to better assess the involvement of psoriasis in the pretibial area, the pretibial plaque lesion severity index was also calculated at baseline in all patients: extent 2.75, erythema 2.64, infiltration 2.45 and desquamation 2.38. All participants in this study showed a good therapeutic response, with a reduction in all scores. The pretibial area is becoming an object of therapeutic interest due to some resistance to clearance and the consequent impairment of patient quality of life. This study showed that risankizumab can give favourable therapeutic results not only in patients with moderate-to-severe psoriasis with involvement of the difficult-to-treat areas but particularly in patients with recalcitrant plaques in the pretibial area.

Usefulness of the Keystone Flap in Lower Extremity Reconstruction in Patients with Anterior Tibial Artery Variation: A Case Report

Reconstruction of lower extremity wounds in patients with abnormalities in vascular anatomy is often challenging. A 71-year-old man was admitted to our hospital after sustaining two contact burns on his right leg while sleeping on an electric blanket. Fourth-degree burns amounting to approximately 3% of total body surface area were confirmed, with eschar formation on the right instep and pretibial area. Both wounds on the lower leg required flap reconstruction. In addition, the patient had anterior tibial artery hypoplasia. We considered a two-flap reconstruction method that should leave the source artery and muscle intact and generally has a good prognosis. A peroneal artery perforator-based keystone flap was used on the right lower leg, and a right dorsalis pedis island flap on the foot dorsum. Surgery was performed successfully, and at 8 months postoperatively, the patient walked naturally and had no complaints of discomfort. Additionally, cosmetic results were satisfactory. Accordingly, we introduce a surgical method that is useful in cases similar to that described.

FRI554 Pretibial Myxedema Associated With Hashimoto Thyroiditis Treated With Teprotumumab

Abstract Disclosure: E.M. Niedzialkowska: None. B. Ajaz: None. A. Pokharel: None. Introduction: Pretibial myxedema (PTM) is a localized thyroid-associated dermopathy characterized by local thickening of the skin of the lower extremities. It mostly develops after the onset of thyroid eye disease (TED). Majority of the cases are associated with Graves disease (GD) but infrequently it can occur in Hashimoto thyroiditis (HT) in the presence of thyroid stimulating immunoglobulins (TSIs). Orbital fibroblasts and the pretibial dermis share antigenic sites that underlie autoimmune thyroid disease. IGF-1 has been reported to potentiate the effects of TSH and TSI on TSHR signaling and fibroblast proliferation. Teprotumumab, a novel monoclonal antibody that blocks IGF-1R receptors, is registered for TED treatment. It is plausible it also improves outcomes in PTM through the same mechanism. Clinical case: 52 year old female reported to our Endocrinology clinic with proptosis and myxedema. The patient was diagnosed with hypothyroidism at the age of 21 and was on substitutional dose of levothyroxine, 125 mcg daily. She developed TED 7 years prior with bilateral exophthalmos with medial rectus muscle infiltration. She underwent 5 decompression surgeries and steroid courses due to concern for optic nerve compression. 4 years prior to the visit she developed bilateral, erythematous pitting edema of the lower extremities with involvement of the pretibial areas, ankles and toes and underwent excess left toe callus excision. Despite multiple courses of intralesional steroid injections and topical ammonium lactate use the patient reported persistent edema, pruritus, and restriction of motion. Laboratory results were significant for TSH of 1.73 uIU/mL (n 0.40 - 4.50 uIU/mL), TRAB >40 IU/L (0.00 - 1.75 IU/L), TSI 4.95 (n <0.10 IU/L), TPO antibody <=35 IU/mL, free ft3 2.5 pg/ml (1.7 - 3.7 pg/mL), free ft4 1.0 (0.7 - 1.5 ng/dL). The patient underwent thyroidectomy with pathology results consistent with Hashimoto thyroiditis (thyroiditis with thyroid follicles, Hurthle cell change, marked lymphoid and fibroadipose tissue). Following the procedure she experienced PTM and TED flare up. Subsequent orbital decompression and orbital steroid injections provided minimal improvement. The patient was started on Teprotumumab (8 infusions every 3 weeks) with marked improvement of orbitopathy (CAS reduction from 6/10 to 1/10) and significant reduction of lower extremity edema and rash. Conclusion: We present the case of Hashimoto thyroiditis associated with TED with PTM successfully treated with Teprotumumab. In TED, TSI binds to IGF-1R creating a complex that promotes orbital inflammation. Teprotumumab is believed to degrade antibody-receptor complex and downregulate fibroblast activation and glycosaminoglycans deposition. We postulate the same process may occur in dermal fibroblasts in the light of PTM improvement after teprotumumab treatment. Presentation: Friday, June 16, 2023

Opening a window to skin biomarkers for diabetes stage with optoacoustic mesoscopy

Being the largest and most accessible organ of the human body, the skin could offer a window to diabetes-related complications on the microvasculature. However, skin microvasculature is typically assessed by histological analysis, which is not suited for applications to large populations or longitudinal studies. We introduce ultra-wideband raster-scan optoacoustic mesoscopy (RSOM) for precise, non-invasive assessment of diabetes-related changes in the dermal microvasculature and skin micro-anatomy, resolved with unprecedented sensitivity and detail without the need for contrast agents. Providing unique imaging contrast, we explored a possible role for RSOM as an investigational tool in diabetes healthcare and offer the first comprehensive study investigating the relationship between different diabetes complications and microvascular features in vivo. We applied RSOM to scan the pretibial area of 95 participants with diabetes mellitus and 48 age-matched volunteers without diabetes, grouped according to disease complications, and extracted six label-free optoacoustic biomarkers of human skin, including dermal microvasculature density and epidermal parameters, based on a novel image-processing pipeline. We then correlated these biomarkers to disease severity and found statistically significant effects on microvasculature parameters as a function of diabetes complications. We discuss how label-free RSOM biomarkers can lead to a quantitative assessment of the systemic effects of diabetes and its complications, complementing the qualitative assessment allowed by current clinical metrics, possibly leading to a precise scoring system that captures the gradual evolution of the disease.

Erythema nodosum as a manifestation of many systemic diseases

Introduction and purpose: Erythema nodosum is a most frequent form of panniculitis and it appears as erythematous, painful rounded, nodules typically localized on the pretibial area. The purpose of our review is to present diseases that can be underlying causes of erythema nodosum and to draw attention to accompanying symptoms that can guide us to the appropriate diagnosis. Brief description of the state of knowledge: Currently, erythema nodosum is thought to be a symptom associated with hypersensitivity reactions to various antigens. Although the majority of the causes are considered idiopathic, erythema nodosum may be caused by many etiological factors. Summary: Erythema nodosum is usually an acute condition that resolves without treatment. However, it can sometimes be the first sign of a serious condition - autoimmune diseases, infections or malignancy. In such cases it is essential to observe it carefully and implement appropriate diagnostics that allow us to make a correct diagnosis.

Pain or Weakness? An Immunocompromised Patient Presenting with Inability to Walk

IntroductionErythema nodosum (EN) appears as tender erythematous nodules, mainly on the pretibial areas. The causes are varied including medication side effects, infections, autoimmune conditions, malignancy, and is idiopathic in 50% of cases. The pathophysiology is not completely understood but may involve an immunologic response or hypersensitivity reaction to various stimuli, leading to immune complex deposition in the venules of septae in subcutaneous fat. Case Presentation17-year-old male with right mandible ameloblastoma (positive for BRAF V600E mutation), who was diagnosed in May 2022, and has been semi-compliant with dabrafenib, BRAF V600E mutation kinase inhibitor, for the previous 6 months and was off for about 1 week when he presented with fever, followed by painful rash of extremities, including soles and palms, and ascending weakness with inability to walk, concerning for neurological insult. The rash was confluent, macular patches, non-pruritic, blanching with a needle-like tenderness. We questioned whether the inability to walk was neurological or related to pain. Brain Magnetic Resonance Imaging (MRI) was unremarkable. Extensive infectious disease testing yielded rhinovirus/enterovirus positive Polymerase Chain Reaction (PCR) but was negative for all other pathogens, including Streptococcus A infection. Rheumatologic workup was negative. He was treated with Non-Steroidal Anti-Inflammatory Drugs and triamcinolone cream which provided improvement of rash and presenting symptoms. Skin biopsy showed granulomatous panniculitis compatible with EN. Dabrafenib was discontinued. DiscussionPatient’s initial presentation was concerning for acute onset of ascending weakness in an immunocompromised patient, suggestive of Guillain-Barré syndrome. Muscular strength was difficult to examine upon initial physical exam likely due to patient effort versus experienced symptoms and patient’s need for assistance to ambulate. However, detailed neurological examination and having normal brain MRI led to the conclusion that the acute change was EN-related pain, rather than weakness. After extensive infectious and rheumatological work up, we concluded that the patient’s EN was likely secondary to Dabrafenib use even if adherence was suboptimal. Clinicians should be aware that EN is an adverse reaction which has been reported in relation to Dabrafenib, as evidenced by a retrospective chart review and case report.

Erythema Nodosum Associated with Staphylococcus Species Infection in a Child

Abstract Erythema nodosum (EN) is a poly-etiological disease with an acute flow that is characterized by symmetric emergence of painful nodules often in pretibial areas. A twenty-month-old male child was admitted to hospital for evaluation of the eruptive skin changes in the lower extremities and forearms. The disease began 10 days before getting febricity and loose stools. The laboratory analysis showed an elevated erythrocyte sedimentation rate and leukocytosis. Blood cultures demonstrated the presence of coagulase-negative Staphylococcus, while Proteus vulgaris was isolated in urine cultures. After initiation of the empiric antibiotic therapy and then, the targeted antibiotic therapy according to the antibiogram, there was a significant improvement in a general condition and regression of cutaneous lesions. Erythema nodosum in the present case, is the result of staphylococcal bacteremia although Proteus vulgaris cannot be excluded as a cause.

A Clinicopathological Study of Primary Cutaneous Amyloidosis in Tertiary Care Center, Hubballi

Background: Cutaneous amyloidosis has a varied clinical presentations. Clinically, it is difficult to distinguish different subtypes of PCA. Objectives: This study was been taken up to correlate clinicohistological profile of all three forms of primary cutaneous amyloidosis (PCA) and to study various factors affecting the disease. Materials and Methods: A total number of 85 patients of PCA attending Skin and STD in tertiary care center in Hubballi were included in the study. A detailed history was taken, complete general physical, systemic, and cutaneous examination was done, and details of skin lesions were noted. Patient was subjected to skin biopsy from the affected area. Clinicohistological findings so obtained were analyzed, and results were correlated. Results: Out of 85 cases, 36 (42.35%) were macular amyloidosis (MA), 43 (50.58%) lichen amyloidosis (LA), and 6 (7.05%) were biphasic amyloidosis (BA). Majority of the patients were in the age group of 21–50, with a male: female ratio of 1:1.3. History of scrubbing while taking bath was given by 90.58%. Housewives were the most frequently involved group (38.82%). In MA, most frequently involved sites were upper back (58.33%) and extensor aspect of arm (55.55%). In LA, majority had involvement of the pretibial area (86.04%). The dermal changes seen in MA and LA were almost the same, while the epidermal changes were less frequent in MA. Conclusions: In the present study, most of the patients of macular and LA had clinical and histopathological correlation. There is not much difference in the demographic profile and histopathological characteristics between LA and MA. The findings confirm that the two forms of primary localized cutaneous amyloidosis are closely related variants of one disease. Histological examination will help in confirming the diagnosis.

Pretibial myxedema exhibiting prominent asymmetrical manifestations

Pretibial myxedema (PTM) is an uncommon cutaneous manifestation of Graves’ disease. A 62-year-old obese Japanese man treated for Graves’ disease presented with nodular lesions symmetrically on both pretibial areas. Systemic corticosteroid therapy targeted against simultaneously developing severe Graves’ ophthalmopathy almost completely cleared his skin symptoms. About ten years later, edema of both lower legs recurred, and the right lower leg showed an elephantiasis-like condition with nodules. However, the left leg had less edema and only a few nodular lesions. The skin lesions gradually improved with oral prednisolone. We speculate that our patient’s habit of lying on the right side of the body induced prominent asymmetry of skin lesions by pooling some immune mediators.

Application of perforator propeller flap sequential transfer technique in repair of soft tissue defect of distal lower extremity

To explore the feasibility and effectiveness of perforator propeller flap sequential transfer technique in repair of soft tissue defect of distal lower extremity. Between July 2015 and July 2021, 10 patients with soft tissue defect of distal lower extremity were treated with perforator propeller flap sequential transfer technique. There were 8 males and 2 females, with a median age of 47 years (range, 6-71 years). The etiologies included malignant tumor in 5 cases, trauma in 3 cases, postburn scar contracture in 1 case, and diabetic foot ulcer in 1 case. The defects were located at the pretibial area in 1 case, the distal lower extremity and Achilles tendon in 3 cases, the dorsum of foot and lateral malleolar area in 4 cases, the heel in 1 case, and the plantar foot in 1 case. The size of the defect ranged from 5 cm×3 cm to 8 cm×8 cm. Peroneal artery perforator propellor flaps (the 1st flap) in size of 14 cm×4 cm to 29 cm×8 cm were used to repair the defects of distal lower extremity. The donor site defects were repaired with the other perforator propeller flaps (the 2nd flap) in size of 7 cm×3 cm to 19 cm×7 cm. The donor site of the 2nd flap was directly closed. All the operations were successfully completed and all of the 2nd flaps were elevated within 1 hour. Eight the 1st flaps survived completely; 2 had venous congestion. Among the 2 patients with venous congestion, 1 had necrosis of the distal end of the flap, and the secondary wound was repaired by skin grafting; 1 recovered spontaneously after 7 days. The 2nd flaps totally survived. No complication such as hematoma or infection occurred. Primary closure was achieved in all the recipient and donor sites. All patients were followed up 2-39 months，with a median of 15.5 months. The color, texture, and thickness of the flaps matched well with those of recipient sites. The normal contour of the leg was preserved. During follow-up, no recurrence of malignance or ulcer was observed. The scar contracture was completely released. All patients were satisfied with the reconstructive outcomes. The application of the perforator propeller flap sequential transfer technique can improve the repair ability of the lower extremity perforator propeller flap while ensuring the first-stage closure of the donor site, thereby improving the effectiveness.

Pre tibial myxedema associated with hypothyroid Hashimioto’s thyroiditis

Pretibial myxedema (PTM) is an infiltrative dermopathy due to accumulation of glycosaminoglycans in the dermis and sub cutis. It is commonly associated with Grave’s disease. However, it is infrequently associated with Hashimoto’s thyroiditis and primary hypothyroidism. It often presents as an asymptomatic diffuse non pitting edema, nodule or plaque involving both pretibial areas. Pretibial myxedema may undergo partial or complete remission and is primarily a cosmetic concern for the patient. Apart from treatment of the primary thyroid abnormality, topical or intralesional steroids remain the mainstay of treatment. We report a case of a 72-year-old lady who presented with non pitting edema on both legs. Her thyroid function tests were suggestive of hypothyroidism and thyroid auto antibody profile, ultrasonography and fine needle aspiration cytology favored Hashimoto’s thyroiditis. Histopathology of the pretibial skin was in consistent with pretibial myxedema. A paradox of pretibial myxedema in a patient with Hashimoto’s thyroiditis is a rare clinical entity.

183 Dystrophic epidermolysis bullosa pruriginosa: a new case series of a rare phenotype unveils skewed Th2 immunity

Dystrophic epidermolysis bullosa pruriginosa (DEB-Pr) is a rare subtype of hereditary epidermolysis bullosa, with a poorly understood pathogenesis and no satisfactory treatment. Our objective was to assess the clinical, biological features and genetic basis, to better characterize this rare genodermatosis. We conducted a retrospective study, reviewing the clinical presentation, genetic diagnosis, biological analyses and management of patients with DEB-Pr seen between 2010 and 2020. Seven patients were included, average age of 50.1 years. Pruriginous lichenified papules or nodules appeared at 27.6 years on average on pretibial areas and forearms, associated with milia and toenails dystrophy. All patients received multiple therapies but none could sustainably reduce pruritus. Immunohistopathological analysis of lesion skin revealed subepidermal blister with fibrosis, milia and mast cell infiltration. Serum TNFα, IL1β and IL6 levels were elevated in 2/6 patients. Total serum IgE levels were increased in 7/7 patients. Immunophenotyping of circulating T-cells revealed an increased Th2 subset in 4/4 patients, with reduced Th1 and Th17 subpopulations. Genetic analysis of COL7A1 identified 8 distinct causative mutations, 6 of which were new. Intra-familial clinical variability was documented in 5/7 patients and was associated with the co-inheritance of a recessive COL7A1 mutation or an FLG2 mutation in 2 families. Our study confirms the stereotyped presentation of DEB-Pr with large intra-familial variability in disease expression. Mast cell infiltration, elevated IgE and increased Th2 subset without atopy strongly support a role of Th2-mediated immunity in DEB-Pr, and further argue for new targeted therapeutic options such as dupilumab.

Restoration of middle third leg soft tissue defects using a distally based hemigastrocnemius flap

Background Traumatic wounds, burns, tumor resections, and tibial fractures frequently lead to exposure of the tibia. Due to limited mobility and a paucity of overlying skin, flap coverage is generally required even for a small defect in the pretibial area. Soft tissue coverage of these defects is a must as any exposed bone that is not covered by vascularized soft tissue is at risk of osteomyelitis, bone necrosis, and sepsis. Objective This study aimed to evaluate the coverage of middle third defects of the leg using an inferiorly based hemigastrocnemius muscle flap. Patients and methods This prospective study was carried out at the Plastic, Reconstructive and Burn Department, Al-Azhar University Hospitals. This study included 20 patients with soft tissue defects at the middle third leg. Results In our study, 90% of the patients underwent reconstruction with a medial head distally based gastrocnemius flap, while the rest, 10%, underwent reconstruction with a lateral head distally based gastrocnemius flap. The majority of our patients, 65%, did not develop any complications. Unfortunately, 10% of the patients developed graft rejection and 10% developed partial flap necrosis, while 5% developed wound infection, 5% developed hematoma and 5% showed delayed graft take; all of these patients were managed early, and in terms of complications, only 5% of the patients had a hypertrophic scar of the donor site and 5% of the patients had hyperkeratosis. Most of our patients, 90%, were satisfied with the results, with only 10% being unsatisfied with the shape of postreconstructive recipient or donor sites. Conclusion The inferiorly based hemigastrocnemius muscle flap based on the vascular bundles between the two heads can be useful for reconstruction of the middle third of the leg. It is a simple technique allowing rapid, durable, and reliable coverage of these defects without sacrificing a nerve or a major vessel to the foot.

Erythema Nodosum: A Practical Approach and Diagnostic Algorithm.

Erythema nodosum is the most common form of panniculitis and is characterized by tender erythematous nodules mainly in the lower limbs on the pretibial area. The exact cause of erythema nodosum is unknown, although it appears to be a hypersensitivity response to a variety of antigenic stimuli. Although the etiology is mostly idiopathic, ruling out an underlying disease is imperative before diagnosing primary erythema nodosum. Erythema nodosum can be the first sign of a systemic disease that is triggered by a large group of processes, such as infections, inflammatory diseases, neoplasia, and/or drugs. The most common identifiable causes are streptococcal infections, primary tuberculosis, sarcoidosis, Behçet disease, inflammatory bowel disease, drugs, and pregnancy. We propose a diagnostic algorithm to optimize the initial work-up, hence initiating prompt and accurate management of the underlying disease. The algorithm includes an initial assessment of core symptoms, diagnostic work-up, differential diagnosis, and recommended therapies. Several treatment options for the erythema nodosum lesions have been previously reported; nevertheless, these options treat the symptoms, but not the triggering cause. Making an accurate diagnosis will allow the physician to treat the underlying cause and determine an optimal therapeutic strategy.

Reconstruction of Pretibial Defect Using Bone-Anchored Advancement Flap

While free flaps have been widely used for reconstruction of pretibial defects, the extended operation times are known to be a major drawback. This report presents a case of successful lower leg reconstruction for a large pretibial defect with a bone-anchored advancement flap and split-thickness skin graft. A 59-year-old female patient underwent wide excision of sarcoma on the pretibial area. The skin defect measured 14×6 cm with a 10×2 cm exposure of the tibia in the medial aspect of the defect. An advancement flap was elevated from the medial side of the tibia to cover the exposed bone. The bone defect was reconstructed by the advancement flap with the aid of an anchoring suture to the tibia. Remaining defect with exposed muscles was covered using split-thickness skin graft. No immediate postoperative complication developed. One year after the operation, well-contoured reconstruction was achieved without functional morbidities. In reconstruction of pretibial defects, bone-anchored advancement flap can be considered in patients who are reluctant to or have risk factors for free flap reconstruction.

Pyoderma Gangrenosum of the Chest Wall in a Male Patient with Ulcerative Colitis

Ulcerative colitis, an inflammatory bowel disease, often exhibits extra-intestinal manifestations including various dermatological problems. Pyoderma gangrenosum (PG) is a painful ulcerative cutaneous disorder characterized by the development of rapidly enlarging nodules. The lesion may become aggravated when ulcerative colitis is active, and it commonly affects the extensor surfaces of the lower extremities but rarely the upper extremities, face, periauricular area, anterior chest, back, or buttocks. We encountered a rare case of PG of the chest wall near the left breast, on the face and pretibial area of a male patient with ulcerative colitis. He had not undergone breast surgery and had no history of trauma. The lesion and symptoms were successfully treated by steroid and mesalazine; there was no need for surgery or more potent drugs.

A comparison of the efficacy of 50% trichloroacetic acid (TCA) application and dermabrasion in patients with idiopathic guttate hypomelanosis (IGH): a pilot study

Background: Idiopathic guttate hypomelanosis (IGH) is characterized by discrete, multiple, round-to-oval hypopigmented macules of approximately 2-5 mm diameter, especially on the forearms and pretibial area,which increase in number with aging. Recent focus has been on therapeutic wounding, which stimulates melanocytes from the periphery and surrounding hair follicles to proliferate, migrate, and repigment the lesions. This study aimed to evaluate and compare the efficacy of trichloroacetic (TCA) 50% application and dermabrasion in IGH patients.Methods: Twenty patients of IGH were enrolled after considering various inclusion and exclusion criteria. IGH lesions over the right side were treated with trichloroacetic acid (TCA) 50% witha cotton-tipped applicator. IGH lesions over the left side were treated with dermabrasion.Results: Of the 153 macules in 20 patients, all 81 macules in the dermabrasion group showed some repigmentation, whereas 7 (9.7%) out of 72 macules treated with 50% TCA Touch™ showedno improvement. At the end of 3 months, repigmentation up to 25%, between 25–50%, and between 51–75% was seen in 18.5%, 66.7%, and 14.8% of lesions treated with dermabrasion, respectively. This is while TCA 50% touch-treated macules showed up to 25% and between 25–50% repigmentation in 48.6% and 41.7% of instances, respectively.Conclusion: The analysis suggested that both dermabrasion and TCA 50% Touch are effective in the treatment of IGH. Dermabrasion proved to be more effective than TCA peel and can be tried before or with the medical line of therapy in the treatment of IGH.

Pedicled perforator flaps for mid-tibial soft tissue reconstruction in medically compromised patients

BackgroundThe soft tissue of the central pretibial area is difficult to reconstruct often requiring free tissue transfer. Especially medically compromised patients are not ideal candidates for free tissue transfer and may benefit from expeditiously harvested local flaps with limited donor site morbidity. As muscle flaps are rare, pedicled flaps based on lateral perforators represent an alternative as the arc of rotation can often be limited to 90°. Material and MethodsA retrospective analysis of patient data was conducted to identify patients over the age of 60 years with comorbidities that underwent pretibial soft tissue reconstruction with a single-pedicle perforator flap. Patient demographics, size and cause of the defect, flap dimension, arc of rotation and complications were recorded. ResultsFive patients with an average age of 71.4 years were included. The arc of rotation was 69°, all flaps healed. There were two recurrences of osteomyelitis. ConclusionLateral perforators originating from the anterior tibial artery or peroneal artery are adequate source vessels for single pedicled perforator flaps even in medically compromised patients. A perforator located proximal to the defect allows limiting the arc of rotation to less than 90°, which increases the safety of the flap. Patients benefit from a simple procedure without a microvascular anastomosis and a donor site confined to one extremity.

Crusted Plaque on Pretibial Area in an Adult Male.

Crusted Plaque on Pretibial Area in an Adult Male.