Suppurative Folliculitis Research Articles

Aspectos anatomopatológicos e o uso da imuno-histoquímica em suínos abatidos com lesões cutâneas de erisipela

ABSTRACT: Swine erysipelas is a disease of worldwide distribution, responsible for causing economic losses in swine and considered an occupational zoonotic disease. It is estimated that 30% to 50% of pigs are carriers and stress can predispose the appearance of clinical disease. The diagnosis of erysipelas in slaughter pigs becomes a challenge for pathologists, since scalding and dehairing, routine procedures in slaughterhouses, generate histological artifacts that often make the final diagnosis impossible. This study describes the anatomopathological aspects and evaluate the use of immunohistochemistry as a diagnostic tool in these cases. Forty-three cases of erysipelas in slaughter pigs were analyzed. Grossly, the cutaneous lesions were characteristic pink, red, or purple raised rhomboid, rectangular or square lesions (“diamond skin”). Histologically, in the dermis and subcutaneous tissue, there were suppurative vasculitis, hidradenitis and folliculitis, as well as degeneration and necrosis of the vessel wall, thrombosis and multifocal areas of necrosis. Suppurative vasculitis and damage to the blood vessel wall were observed in all cases, with varying degrees of severity. The immunohistochemical technique proved to be an effective complementary method of diagnosis, with positive immunostaining in 93%. In most cases, we observed mild immunostaining (57.5%), moderate in 22.5% and marked in 20%.

Severe and delayed-onset acneiform eruptions as an adverse reaction to regorafenib.

Regorafenib is an oral multikinase inhibitor targeting several tyrosine kinase receptors including BRAF and epidermal growth factor receptor (EGFR) and is approved as a third-line treatment for metastatic gastrointestinal stromal tumor (GIST). While acneiform eruptions have been observed in patients receiving other BRAF and EGFR inhibitors, the commonly reported adverse reactions to regorafenib are fatigue and palmar-plantar erythrodysesthesia. Herein, we report, to the best of our knowledge, the first case who presented with a severe acneiform eruption 24 months after beginning regorafenib for the treatment of GIST. A 61-year-old woman developed GIST with multiple liver metastases, and she was treated with imatinib and sunitinib. However, these therapies were discontinued, and regorafenib was administered. Twenty-four months after beginning regorafenib, she developed an acneiform eruption on her back. Histopathologic analysis of a skin biopsy from the back revealed neutrophilic suppurative folliculitis. Therefore, she postponed regorafenib administration for 2 months and was treated with topical application of clindamycin phosphate hydrate, which was effective. Consistent with reported evidence that the presence of acneiform eruption and the efficacy of EGFR inhibitors are positively associated, regorafenib had good anticancer activity in our patient. Ultimately, we found that although regorafenib- associated skin toxicities usually appear within 1 month of treatment, patients potentially can present with delayed-onset acneiform eruptions even 24 months later.

Severe and delayed-onset acneiform eruptions as an adverse reaction to regorafenib

Regorafenib is an oral multikinase inhibitor targeting several tyrosine kinase receptors including BRAF and epidermal growth factor receptor (EGFR), and is approved as a third-line treatment for metastatic gastrointestinal stromal tumor (GIST). While acneiform eruptions have been observed in patients receiving other BRAF and EGFR inhibitors, the commonly reported adverse reactions to regorafenib are fatigue and palmar-plantar erythrodysesthesia. Herein, we report, to the best of our knowledge, the first case who presented with a severe acneiform eruption 24 months after beginning regorafenib for the treatment of GIST. A 61-year-old woman developed GIST with multiple liver metastases, and she was treated with imatinib and sunitinib. However, these therapies were discontinued, and regorafenib was administered. Twenty-four months after beginning regorafenib, she developed an acneiform eruption on her back. Histopathologic analysis of a skin biopsy from the back revealed neutrophilic suppurative folliculitis. Therefore, she postponed regorafenib administration for 2 months and was treated with topical application of clindamycin phosphate hydrate, which was effective. Consistent with reported evidence that the presence of acneiform eruption and the efficacy of EGFR inhibitors are positively associated, regorafenib had good anticancer activity in our patient. Ultimately, we found that although regorafenib-associated skin toxicities usually appear within 1 month of treatment, patients potentially can present with delayed-onset acneiform eruptions even 24 months later.

Human Polyomavirus 6 Detected in Cases of Eosinophilic Pustular Folliculitis.

Human polyomaviruses (HPyVs) have been associated with several cutaneous inflammatory conditions. More investigation is needed to identify further presentations of cutaneous pathology associated with HPyVs. Our aim was to investigate the possible association of skin-tropic HPyVs with folliculitis, particularly eosinophilic pustular folliculitis (EPF). This study included 55 Japanese patients, comprising 13 patients with EPF and 42 patients with suppurative folliculitis. HPyV DNAs were detected by quantitative polymerase chain reaction. Expression of viral antigen and geographically related viral genotypes were also assessed. Human polyomavirus 6 (HPyV6) DNA was found in 9 of 13 (69%) patients with EPF, a rate significantly higher than that found in suppurative folliculitis (1/42; 2%). Of the 7 HPyV6 DNA-positive EPF specimens analyzed, 4 were positive for HPyV6 small tumor antigen. All the HPyV6 strains detected in this study were of the Asian/Japanese genotype. The predominant detection of HPyV6 DNA and the expression of viral antigen suggest a possible association between HPyV6 infection and EPF in a subset of patients. Worldwide studies are warranted to determine whether Asian/Japanese genotype HPyV6 is associated preferentially with the incidence and pathogenesis of this eosinophil-related skin disease that has an ethnic predilection for the East Asian population.

Acquired cutaneous angiomatosis and Chorioptes species dermatitis in an adult llama

A five‐year‐old male llama was presented for nonpainful, nonpruritic dermatitis of the right pelvic and thoracic limbs, and right pelvic limb lameness of 2 weeks’ duration. Cutaneous lesions were soft to firm, erythematous, raised and plaque‐like with comedones and scale. Histopathology revealed orthokeratotic hyperkeratosis, suppurative and eosinophilic folliculitis and numerous densely packed vascular structures extending throughout the superficial and mid‐dermis. Concurrent Chorioptes species mites were diagnosed via skin scrapings, and parasitic infestation resolved with topical sulphurated lime solution application. Angiomatosis lesions persisted on clinical and histopathological re‐evaluation. PCR on formalin‐fixed paraffin‐embedded tissue was negative for multiple Bartonella species. This is the second report of cutaneous angiomatosis in a llama, but the first case suspected to be secondary to ectoparasite (Chorioptes species) infestation.

Rare, but Serious Extra-intestinal Complication of Inflammatory Bowel Disease

Bowel-associated dermatosis-arthritis syndrome (BADAS) has been linked to Inflammatory Bowel Disease. Classic prodrome includes fever, chills, myalgias, and polyarthralgias that later evolve into inflammatory papules similar to Sweet Syndrome. The papules consist of neutrophilic infiltrate without vessel wall destruction, differentiating it from other neutrophilic dermatoses. We present a case of a patient with Ulcerative Colitis who also underwent gastric sleeve surgery and presented with BADAS. A 38 year-old Caucasian female presented with diffuse rash for one-week duration. Patient reported fever, chills and myalgias for two days. The rash, consisting of blisters and pustules, erupted initially on her face and spread to her trunk and extremities. She denied pruritus, but did report a burning and stinging sensation. Arthralgias were also noted in bilateral shoulders and knees. She denied any changes in bowel habits or recent illness. The patient had previously been on infliximab, but was discontinued approximately six months earlier. The patient was febrile (101.8F), tachycardic (113 bpm), and hypertensive (150/78 mmHg) on admission. She was in slight distress secondary to symptom burden. On examination, her skin demonstrated multiple pustules with peripheral erythema and crusting. These pustules were noted on her head, face, upper and lower extremities sparing the palms and soles. The rash was non-tender. On admission, her white blood cell count was 16.1 (TH/mm3) hemoglobin 13.1 (g/dL), platelets 341 (TH/mm3), total protein 7 (g/dL), AST 50 (U/L), ALT 62 (U/L), CRP 11.13 (mg/dL), ESR 60 (mm/hr). Her pregnancy, HIV, Hepatitis panel, direct streptococcal antigen, mononucleosis antibody, and mycoplasma IgM testing were all negative. Skin biopsy demonstrated mature neutrophilic infiltrate. This involved the dermis and caused papillary dermal edema. There was no noted fibrinoid necrosis or infarction of the vessels. This was consistent with diagnosis of BADAS given the patient's history of UC. The patient was treated with valacyclovir, steroids, anti-histamine agents and responded well. Our case demonstrates extra intestinal manifestation of IBD that is often not considered in differential diagnosis. Our goal is to bring awareness due to its common recurrence and prompt early treatment initiation for resolution.2048_A Figure 1. Abdomen, punch biopsy. Suppurative folliculitis with a ruptured follicle.2048_B Figure 2. Abdomen, punch biopsy demonstrating neutrophilic infiltrate. Suppurative folliculitis with a ruptured follicle.2048_C Figure 3. Abdomen, punch biopsy. Suppurative folliculitis with a ruptured follicle.

Drug Hypersensitivity due to Azathioprine with Elevated Procalcitonin

We present a case of azathioprine hypersensitivity presenting as sepsis with elevated procalcitonin in a 68-year-old man with myasthenia gravis. The patient presented with fever, chills, nausea, vomiting, and headache. He developed numerous 1 cm erythematous papules over his upper torso. Infectious workup including bacteriological tests and microbial cultures was negative and a skin biopsy was performed which revealed suppurative folliculitis with eosinophils, consistent with drug hypersensitivity. Notably, acute phase reactants including C-reactive protein and procalcitonin were elevated upon presentation, likely secondary to drug hypersensitivity.

An Epidemic Outbreak of Cutaneous Leishmaniasis Presenting as Suppurative Folliculitis: A Study of 6 Cases.

Folliculitis is defined as the inflammation of the follicles. The most common cause of folliculitis is infection. Here, we report an unusual cause of suppurative infundibulitis-which had not yet been described in the literature-due to Leishmania infection, and exemplified by 6 cases that occurred in the setting of an epidemic outbreak. The 6 individuals were immigrants from Morocco. Most of them were men (4 men and 2 women), and most of them were less than 30 years old (apart from one 40-year-old woman). In all cases, a cutaneous biopsy was performed. There was a granulomatous folliculitis with suppurative granulomas in all the cases. All cases showed prominence of plasma cells in the inflammatory infiltrate, and leishmanias were found in all cases. They were mainly seen in the abscessified central areas. The amount of organisms varied from a few to a moderate amount. They were stained by the anti-CD1a antibody (Novocastra) and by a polyclonal homemade anti-leishmania antibody. In addition, in 1 case, microbiological culture was performed, and Leishmania major was demonstrated as the causative agent of the infection.

Histopathologic features of erythematous papulopustular eruption to epidermal growth factor receptor inhibitors in cancer patients.

Erythematous papulopustular eruption (EPPE) is the most frequent skin adverse event to epidermal growth factor receptor (EGFR) inhibitors but its histopathologic features have been poorly studied. As EPPE is a strong predictor of patient's treatment response, the EPPE histopathologic features and their correlations with skin eruption severity and involved drug were investigated. An involved skin biopsy was carried out in 39 informed patients treated with EGFR inhibitors (mainly cetuximab and erlotinib). The cutaneous changes in hematoxylin-eosin stained sections were evaluated. The EPPE to EGFR inhibitors is histopathologically characterized by neutrophilic subcorneal or intraepidermal pustules and polymorphous infiltrate of the superficial dermis during the earliest phases and by lymphocytic perifolliculitis and/or suppurative folliculitis at a later phase. The widespread dermis inflammation was more frequent in severe EPPEs and in patients treated with cetuximab, while the hair follicle inflammation was observed only in mild/moderate EPPEs. Our study shows the histopathologic signs of EPPE and their correlation with clinical severity and the offending drug.

Generalized granuloma annulare in a folliculocentric distribution

We present a 69-year-old man with type 2 diabetes mellitus and a five-year history of an eruption of follicular pustules, papules, and nodules, which was identified histopathologically as folliculocentric granuloma annulare (GA). Folliculocentric generalized GA is a rarely reported variant of GA, in which the the palisading histiocytes form focal granulomas in a follicular pattern. In this case, the GA may represent an isotopic phenomenon, with lesions developing in hair follicles that were previously affected by a suppurative folliculitis.

Lupus miliaris disseminatus faciei

Lupus miliaris disseminatus faciei (LMDF) is a rare, inflammatory condition, which is characterized by red-brown and yellow-brown papules on the face, with characteristic involvement of the eyelids and with histopathologic findings of suppurative and granulomatous folliculitis and dermatitis. The etiology of this disease is not known, but retinoids, anti-inflammatory, immunosuppressive, and antimicrobial medications are utilized to treat the condition with variable results. We present the case of a patient with LMDF that has thus far been refractory to treatment.

The clinical features and histopathologic patterns of folliculotropic mycosis fungoides in a series of 38 cases.

The recognition of folliculotropic mycosis fungoides (FMF) may pose diagnostic challenges, owing to the variety of histopathological findings. In this study, our aim is to describe the broad spectrum of the histopathological patterns in a total of 86 biopsies from 38 patients with FMF, together with the clinical features. The most frequent histopathologic pattern was the folliculocentric/folliculotropic pattern, with or without follicular mucinosis. Keratin-filled cysts and comedones were the second most common pattern in the biopsies. Other less common findings included widening of the hair follicle orifis with keratotic plugging, reminiscent of keratosis pilaris, granuloma formation, eosinophilic or suppurative folliculitis and basaloid folliculolymphoid hyperplasia. Coexisting syringotropism was present in some biopsies. The CD4 : CD8 ratio was at least 4 : 1 or more in most biopsies. Grouped follicular papules and patch/plaque lesions with follicular prominence were the most frequent clinical findings. Folliculocentric lesions such as milia, cysts and acneiform lesions, alopecia, loss of hair or eyebrows were also seen. In 6 out of 38 (15.8%) patients, transformation to large-cell lymphoma was observed during the follow-up. The awareness and the identification of the various histopathological presentations of FMF by pathologists, as well as by clinicians, are imperative to prevent diagnostic errors.

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.

Dermatologic toxicities to targeted cancer therapy: shared clinical and histologic adverse skin reactions

Dermatologic toxicities (DT) to targeted cancer therapy may present as inflammatory dermatoses, keratoses, and as benign and malignant squamous proliferations. Published reports of DT with cancer therapy with epidermal growth factor receptor (EGFR), tyrosine kinase (TK), MEK, PI3K, AKT, and BRAF inhibitors were reviewed. DT associated with targeted cancer therapy demonstrated similar reactions and may be grouped as (i) DT as cutaneous inflammation, and (ii) DT as cutaneous epithelial proliferation. EGFR inhibitor, cetuximab, and MEK inhibitors, selumetinib and trametinib, demonstrated papulopustular rash with a suppurative folliculitis in 83%, 93%, and 80% of the patients on therapy, respectively. Common DT with EGFR inhibitors erlotinib and tyrosine kinase inhibitor sorafenib were hand-foot skin reactions in 30-60% of patients on therapy. PI3K inhibitor BKM-120 and AKT inhibitor MK2206 produced maculopapular eruptions seen as dermal hypersensitivity reaction on the skin biopsy. RAF inhibitors vemurafenib and sorafenib were associated with a variety of cutaneous epithelial proliferations (keratosis pilaris, seborrheic keratosis, verruca vulgaris, actinic keratosis, keratoacanthoma, and squamous cell carcinoma. Various anticancer agents may target similar cellular compounds and/or cell signaling pathways thus share similar clinical and histologic features of DT. The knowledge of the overlap of DT with different types of targeted cancer therapy will assist in evaluation of cutaneous reactions.

Neutrophilic Dermatosis After Azathioprine Exposure

Azathioprine hypersensitivity syndrome can present clinically and histopathologically like Sweet syndrome. Shared clinical features include fever, constitutional symptoms, prompt response to systemic corticosteroid therapy, neutrophilia, and abrupt onset of erythematous cutaneous lesions. Histologically, both azathioprine hypersensitivity syndrome and Sweet syndrome are rich in neutrophils. An 81-year-old woman with Crohn disease presented with fever and an acute eruption of plaques on her extremities within 2 weeks of starting treatment with azathioprine. Laboratory evaluation was notable for leukocytosis and neutrophilia. Skin biopsy of an erythematous plaque on the thigh demonstrated a suppurative folliculitis. Azathioprine treatment was discontinued resulting in resolution of the clinical lesions within 5 days. Our case was compared with 18 cases with similar clinical features. We report a case of azathioprine hypersensitivity syndrome and review the literature on azathioprine-induced eruptions with features of Sweet syndrome. Our patient's distribution of lesions on the extremities and the finding of suppurative folliculitis on histopathology were not classical for Sweet syndrome. Azathioprine hypersensitivity syndrome seems to be a neutrophil-driven dermatosis; therefore, many overlapping features with Sweet syndrome are not surprising. Due to the potential for anaphylaxis with azathioprine rechallenge, a better term for a Sweetlike presentation in the setting of azathioprine administration is azathioprine hypersensitivity syndrome.

Textual Research on Chiding Disease and Matixiang Herb in Da he wai ke (External Medicine of Da He)

Recorded in Da he wai ke (The External Medicine of Da He) in the Ming dynasty without a corresponding disease title in contemporary scholarly concepts of Traditional Chinese Medicine (TCM), Chiding disease was described as an acute symptomatic disease with inevitable serious conditions of convulsion-like or mania-like behavior, and as a refractory ailment. It was also considered as an alias of Hongsiding (namely the acute lymphangitis) in few ancient books. Matixiang, a Chinese herb for treatment of Chiding, was regarded as a nonsuch drug by Da he wai ke, and was considered as a take-then-cure drug by Chuang yang jing yan quan shu (Compendium for Experience in Sores Diseases). The present studies about Chiding and Matixiang show that: (1) the name of Chiding was first seen in Zhong zang jing (Master Hua's Classic of the Viscera) ; (2) Chiding was rarely mentioned in medical literature of the Song, Yuan and Qing Dynasty, but mostly seen in the Ming Dynasty; (3) Xinding and Huoyanding were found as synonyms of Chiding ; (4) the distinction between Chiding and Hongsiding (flaming sore) was revealed by comparison analysis of their etiology, affected part(s), symptoms, prognosis and syndromic pictures; (5) Chiding on the tongue is the same as "Tongue Ding" or "Sublingual Ding" in contemporary TCM and as "Sublingual Space Infection" in Western Medicine. Moreover, Chiding on the hands, feet or other skin parts could be classified as "Hands/Feet Ding" in contemporary TCM and as "Furuncle" (i.e., Acute Suppurative Folliculitis and Perifolliculitis or cellulites of the tongue) in Western Medicine; (6) Matixiang is probably deduced as Asarum forbesii Maxim., A. ichangense C. Y. Cheng et C. S. Yang, family Aristolochiaceae, or Valeriana jatamansi Jones., family Valerianaceae.

Majocchi's granuloma in an immunocompetent child

A 12-year-old boy was referred to A+E with a ten day history of a facial rash. He had been treated by his GP with oral flucloxacillin for eight days prior but the rash had worsened. He had no significant past medical history. He lived with his parents who were from Pakistan, four siblings, his cat and four kittens. He had travelled to Pakistan on holiday four months earlier with no problems. On examination in the dermatology department he had an inflammatory eruption over the right periorbital area and dorsal nose. There were small pustules over the right eyebrow with surface scale and smaller lesions on the left temple and frontal hairline. He had marked cervical lymphadenopathy. A 4 mm punch biopsy was taken from the left temple along with skin scrapings. Histological examination showed a deep suppurative folliculitis with fungal hyphae (Majocchi9s granuloma). Skin scrapings confirmed trichophyton mentagrophytes on culture. Following discussion with microbiology he was commenced on 20 mg itraconazole daily. After 6 weeks of therapy the eruption had completely cleared and the lymphadenopathy had resolved. Majocchi9s granuloma is an uncommon deep dermatophyte infection of the dermis and subcutis. It does not respond to topical antifungal therapy and requires systemic therapy. Majocchi9s granuloma is rare in immunocompetent people: in such cases it is usually secondary to trauma. There are two sub-types of trichophyton mentagrophytes: trichophyton mentagrophytes var interdigitale is anthropophilic and is specifically associated with humans; and trichophyton mentragrophytes var. mentagrophytes which is zoophilic. In the later case clinical disease is usually due to animal contact with mice, cats or rabbits. In this case it was not possible to subtype t. mentagrophytes. The patient was referred to medical paediatrics for evaluation of his general health but he failed to attend three appointments. On closer questioning the patient advised that his pet cat regularly caught mice. It was felt that the cats were the likely source of his dermatophyte infection, and they were subsequently treated empirically for this by their vet. The patient remains well twelve months following treatment and has had no similar recurrence since then.

Trichophyton rubrum suppurative tinea of the bald area of the scalp

An 83-year-old man presented with an approximately 1-year history of an extensive inflammatory purulent crusted lesion in the bald area of the scalp diagnosed as tinea caused by Trichophyton rubrum. The scalp biopsy specimen showed suppurative folliculitis with perifollicular abscesses in upper dermis, and periodic acid-Schiff-positive fungal elements within the hair follicles and in the hyperkeratotic horny layer. The infection probably spread from diseased fingernails. A cure of the scalp lesion was achieved 2 months after starting daily oral treatment with 250 mg terbinafine. To our knowledge, the case presented is the first in which a suppurative abscess-forming T. rubrum infection of the bald area of the scalp in an immunocompetent man has been described.

Inflammatory tinea capitis: kerion, dermatophytic granuloma, and mycetoma

Inflammatory tinea capitis is the result of a hypersensitivity reaction to a dermatophytic infection. The usual forms are favus, kerion celsi, dermatophytic Majocchi granuloma, and mycetoma. Inflammatory tinea capitis can be caused by Microsporum canis, Trichophyton mentagrophytes, T tonsurans, T rubrum, and M gypseum. Histopathologic findings include a spectrum from mild suppurative folliculitis to dense granulomatous infiltrates. In mycetoma, grains must be present.

Nontuberculous Mycobacterial Skin Infections

Mycobacterial organisms have re-emerged as an important cause of infectious disease worldwide. Both tuberculosis and nontuberculous mycobacterial infections remain endemic in many parts of the world and are becoming more common in patients with iatrogenic immunosuppression and HIV infection. The nontuberculous mycobacteria, often referred to as mycobacteria other than tuberculosis (MOT), are of special significance to the dermatologist because they often present in the skin, typically after exposure to an aqueous environment. Presentations range from indolent nodules with sporotrichoid spread to acute suppurative folliculitis and abscess formation. Infection with MOT should be considered whenever routine bacterial cultures are negative. Cultures should be obtained, but empiric therapy must often be started while cultures are pending. Some data suggest that clarithromycin may be the best initial empiric therapy.