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The article describes the case of a 19-year-old Caucasian woman who presented with intense pain and edema in the right buttock and livedoid patches in the entire right lower limb and is unable to move her right foot following benzathine benzyl penicillin injection for tonsillitis. Topics covered include the findings of a pelvis computed tomography (CT) scan and biopsy, the diagnosis of Nicolau syndrome and the response of the patient to hyperbaric oxygen therapy.

During the last decades, the incidence of opportunistic fungal infections has been increasing, namely in the context of immunosuppression. The Scedosporium apiospermum is a ubiquitous filamentous fungus in soil, decaying vegetation, sewers and polluted waters. Can cause infections in immunocompetent patients after trauma and severe and potentially fatal infections in immunocompromised patients. The authors describe a case of an infection by S. apiospermum on the dorsum of the left foot of a patient under prolonged systemic corticosteroid therapy combined with methotrexate due to the diagnosis of giant cell arteritis. Treatment of these infections can be a challenge due to the inherent resistance to many of the available systemic antifungal agents, including amphotericin B. In the case described, therapy with voriconazole was performed, with complete resolution of the lesions. [ABSTRACT FROM AUTHOR]

Introduction: Actinic keratosis is the most common premalignant lesion. The therapeutic approach to patients with multiple lesions involves field-directed treatment. Objective: To evaluate the efficacy and safety of ingenol mebutato, a new drug treatment for topical field-directed treatment of actinic keratosis. Design: Systematic review and meta-analysis of randomized controlled trials (RCTs) trials. Data sources: Medline and Cochrane Library (June 2014). Study selection: Two reviewers independently searched for studies and retrieved their characteristics and data estimates. Data synthesis: Random-effects meta-analysis. Heterogeneity was assessed with the I2 test. Results: Six trials (n = 1,492) versus placebo were included. The odds of a patient experiencing complete removal of the lesions was 17 (95%CI: 9 to 31, I2 = 0%) and 8.5 (95% CI: 5 to 15, I2 = 0%) times higher, compared to placebo, in the face/scalp and trunk/extremities, respectively. The incidence of adverse events related to treatment was higher in the group of mebutato ingenol (+23%, 95%CI: 11 to 35%), with no differences between groups in the discontinuation rate due to adverse events. Conclusions: Mebutato of ingenol is efficacious in the treatment of actinic keratosis. Compared to other field-directed treatments available in Portugal, its therapeutic value comes from the favourable safety profile and tolerability, simplicity and short duration of the treatment regimen and the possibility of different treatment to injuries according to anatomical location (individualization of therapy). Future studies should directly compare the different therapeutic options and evaluate the effectiveness of the same in the real world. [ABSTRACT FROM AUTHOR]

Measurement of the concentration of iron in the skin, if correlated with total body iron stores, may enable better informed decisions on when to initiate, change or stop therapy in hereditary heamochromatosis. Naive haemochromatosis patients with iron overload and with C282Y and/or H63D HFE mutations were evaluated at the following time-points: disease diagnosis, end of the therapy programme, and 6 months after the end of therapy. The distribution and concentration of iron in the skin were assessed by quantitative nuclear microscopy methods, in parallel with serum and plasma iron concentration. Iron content in the liver was determined by nuclear magnetic resonance. Iron accumulated in the epidermis; its concentration increased from outer to inner layers, being maximal in the basal layer (7.33±0.98 μmol/g). At all 3 time-points, most of the iron was associated with the extracellular space. During the phlebotomy programme the iron content of the skin and the liver decreased by a factor of 2. These data suggest that measurements of iron concentration in the epidermis, which is a readily accessible tissue, reflect iron overload in the liver. [ABSTRACT FROM AUTHOR]

Dipeptidyl-peptidase IV inhibitor-associated bullous pemphigoid efficiently treated with omalizumab Serum IgG against BP180 titers dropped during omalizumab treatment, but remained elevated (from above 200 UI/mL before treatment to 89 UI/mL after 6 months and to 46 UI/mL after 12 months). Since Fairley et al described the first case of a BP patient efficiently treated with omalizumab, an increasing number of cases of successful treatment has been reported.4 Criteria to select the ideal candidate to anti-IgE-directed therapy remain uncertain. [Extracted from the article]

Systemic lupus erythematosus (SLE) is a multiorgan autoimmune disease of unknown etiology with many clinical manifestations. The skin is one of the target organs most variably affected by the disease. The American College of Rheumatology (ACR) established 11 criteria as a classificatory instrument to operationalise the definition of SLE in clinical trials. They were not intended to be used to diagnose individuals and do not do well in that capacity. Cutaneous lesions account for four of these 11 revised criteria of SLE. Skin lesions in patients with lupus may be specific or nonspecific. This paper covers the SLE-specific cutaneous changes: malar rash, discoid rash, photosensitivity, and oral mucosal lesions as well as SLE nonspecific skin manifestations, their pathophysiology, and management. A deeper thorough understanding of the cutaneous manifestations of SLE is essential for diagnosis, prognosis, and efficient management. Thus, dermatologists should cooperate with other specialties to provide optimal care of SLE patient. [ABSTRACT FROM AUTHOR]

Systemic lupus erythematosus (SLE) is a multiorgan autoimmune disease of unknown etiology with many clinical manifestations. The skin is one of the target organs most variably affected by the disease. The American College of Rheumatology (ACR) established 11 criteria as a classificatory instrument to operationalise the definition of SLE in clinical trials. They were not intended to be used to diagnose individuals and do not do well in that capacity. Cutaneous lesions account for four of these 11 revised criteria of SLE. Skin lesions in patients with lupus may be specific or nonspecific. This paper covers the SLE-specific cutaneous changes: malar rash, discoid rash, photosensitivity, and oral mucosal lesions as well as SLE nonspecific skin manifestations, their pathophysiology, and management. A deeper thorough understanding of the cutaneous manifestations of SLE is essential for diagnosis, prognosis, and efficient management. Thus, dermatologists should cooperate with other specialties to provide optimal care of SLE patient. [ABSTRACT FROM AUTHOR]

Psoriasis is a lifelong, chronic, and immune-mediated systemic disease, which affects approximately 1-3% of the Caucasian population. The different presentations of psoriasis require different approaches to treatment and appropriate prescriptions according to disease severity. The use of topical therapy remains a key component of the management of almost all psoriasis patients, and while mild disease is commonly treated only with topical agents, the use of topical therapy as adjuvant therapy in moderate-to-severe disease may also be helpful. This paper focuses on the cutaneous mechanisms of action of corticosteroids and on the currently available topical treatments, taking into account adverse effects, bioavailability, new combination treatments, and strategies to improve the safety of corticosteroids. It is established that the treatment choice should be tailored to match the individual patient's needs and his/her expectations, prescribing to each patient the most suitable vehicle. [ABSTRACT FROM AUTHOR]

As previously described, Psoralen plus UVA (PUVA) therapy induces chromosome damage in psoriatic patients. This study evaluates whether these effects are transitory or persistent. In addition, we studied these effects after narrowband UVB (nUVB) and anti-tumor necrosis factor (TNF)-α treatments. Among 40 responder patients, 10 received PUVA, 10 nUVB, 10 Infliximab and 10 Etanercept. Disease activity was determined with Psoriasis Area and Severity Index. Chromosomal breakage was evaluated by the clastogenic factor (CF) test. Potential clastogenic agents, malondialdehyde (MDA) and TNF-α were measured. Before treatment, the plasma-adjusted clastogenic scores (ACS) of patients were increased. During treatment, a further increase in ACS was observed in both phototherapy groups. Chromosome damage persisted for PUVA patients at week 32, while it diminished after nUVB to ACS values lower than before treatment. MDA and TNF-α values were also increased at baseline. MDA decreased during treatment in all groups, but without reaching normal levels. Plasma TNF-α remained unchanged in PUVA and nUVB but decreased in both anti-TNF-α treatment groups. Psoriasis is accompanied by CF-induced chromosomal breakage that increases during PUVA and nUVB treatments. Plasma clastogenic activity persisted in the follow-up after PUVA, while after nUVB ACS returned to values even lower than baseline. Clastogenic activity during the induction phase with anti-TNF-α remained unchanged. [ABSTRACT FROM AUTHOR]

Background: Acute generalized pustular psoriasis (AGPP) is a rare variant of psoriasis that can be lethal without proper treatment. It can be caused by the withdrawal of corticosteroids and, among its extracutaneous manifestations, liver abnormalities are frequently under-reported or attributed to drugs. Objective: The aim of this study was to assess the clinical and laboratory data, treatment options, and disease outcome in patients with AGPP and to search for significant differences between subgroups of these patients. Study Design: This was a retrospective analysis of the clinical files from inpatients with AGPP observed in our department between 1973 and 2008. Statistical tests were performed at a significance level of 5%. Setting: This was an inpatient, single-center study. Main Outcome Measures: Outcome measures were a previous history of psoriasis, corticosteroid use before admittance, mortality rate, white blood cell count, absolute neutrophil count, and abnormalities in liver enzymes. Results: Atotal of 34 patients fulfilled the inclusion criteria, of whom 61% were men and 65% had a previous history of psoriasis vulgaris. Topical corticosteroids were applied by 50% of patients before admittance. Skin lesions remitted with methotrexate, etretinate, or acitretin treatment in all but two patients who died of sepsis. Abnormalities in liver enzymes were present in 47% of patients. Patients without a previous history of psoriasis had a significantly younger age at the first episode of AGPP. In the comparison between the groups of patients with and without liver abnormalities, a male preponderance and higher leukocyte counts were found in the former, with a positive correlation between the absolute neutrophil count and total bilirubin also being observed. Previous use of retinoids or methotrexate was not associated with these hepatic alterations. Limitations: Limitations of the data were that this was a single-center, retrospective study with a small sample size. Conclusions: Withdrawal of systemic or topical corticosteroids can precipitate or worsen AGPP and these agents should not be used in these patients. Liver abnormalities can be considered an extra-cutaneous manifestation of AGPP. As in other series, no association between the use of drugs and changes in liver tests was found and therefore the deleterious withdrawal of efficient drugs, namely acitretin and methotrexate, should be avoided. [ABSTRACT FROM AUTHOR]

Abstract: Photodynamic therapy (PDT) is a poor treatment option for nodular basal cell carcinomas and squamous cell carcinomas. As a result, the search for new photosensitizers with better effectiveness is of current interest. The photocytotoxicity of conjugates (P-R) of a water-soluble tri-cationic porphyrin (P-H) having similar efficiency of production of singlet oxygen, the PDT cytotoxin, has been assessed in vitro. Links between uptake, intracellular localization, photooxidative stress, photocytotoxicity and ability to induce programmed cell death are established. Conjugates bearing methyl (P-Me), Di-O-isopropylidene-(-d-galactopyranosyl (P-OGal) or N,N′-dicyclohexylureidooxycarbonyl (P-DDC) chains are efficiently taken-up by proliferating NCTC 2544 keratinocytes. The relative order of photocytotoxicity is P-OGal >P-DDC=P-Me≫P-H. The photocytotoxic potential of P-Me, P-OGal and P-DDC equals that of endogenous protoporphyrin IX induced by δ-aminolevulinic acid or its esters, the pro-drugs currently employed for PDT of skin lesions. Microfluorometry shows that P-Me, P-OGal, and P-DDC localize in endocytotic or pinocytotic vesicles but not in mitochondria or nucleus. Absence of annexin V binding, caspase activation or chromatin condensation suggests that cell photosensitization by P-R does not induce apoptosis. On the other hand, P-OGal photocytotoxicity correlates with appearance of multiple vesicles that have hallmarks of autophagy compartments, being decorated with the marker LC3 in cells transfected with an expression vector encoding GFP-LC3. p38 and JNK phosphorylation and inhibition of ERK1/2 phosphorylation suggest close relationship between mortality of NCTC 2544 keratinocytes and MAPK pathway impairment. Given their potentially easy formulation, water-soluble P-R are promising powerful photosensitizers for PDT of skin lesions. [Copyright &y& Elsevier]

Bullous dermatoses are a variety of autoimmune skin diseases that are characterized by the presence of bullae or blisters. Most of these diseases are associated with substantial morbidity, and a few may result in death. Although most general approaches to the treatment and diagnosis of these entities are similar, the diagnosis of the specific disease is important, because the most appropriate dosage and timing of some commonly used medications vary considerably. The review covers the management of main autoimmune bullous dermatoses, including bullous pemphigoid and pemphigus vulgaris, linear IgA dermatosis, dermatitis herpetiformis, and bullous systemic lupus erythematosus. [ABSTRACT FROM AUTHOR]

We report on a comparative study by Transmission Electron Microscopy (HRTEM) and Scanning Transmission Ion Microscopy (STIM) combined with Rutherford Backscattering Spectrometry (RBS) and Particle Induced X-Ray Emission (PIXE) on ultra-thin and thin cross-sections, respectively, of various skin samples (porcine skin, healthy human skin, human skin grafted on a severe combined immuno-deficient mouse model) to which we applied topically various formulations containing titanium dioxide (TiO2) nanoparticles with primary particle sizes in the range from 20-100 nm. Whereas the HRTEM and STIM/PIXE images reveal clear differences - mainly related to the different thickness of the cross-sections - they unambiguously show that penetration of TiO2 nanoparticles is restricted to the topmost 3-5 corneocyte layers of the stratum corneum (SC). [ABSTRACT FROM AUTHOR]

Dear Editor A 16-year-old Caucasian adolescent with no relevant prior medical history was referred to our dermatology consultation due to classical pyoderma gangrenosum refractory to therapy. In the context of chronic herpetic infection, the ulcers do not resolve spontaneously, and the infection may spread to adjacent areas, as was the case of this patient. [Extracted from the article]

The high number of patients submitted to radiotherapy contrasts with the few reports of postirradiation pseudosclerodermatous panniculitis, suggesting that it is an underdiagnosed clinical entity, probably because of the low number of skin biopsies performed.[4] Postirradiation pseudosclerodermatous panniculitis is an overlooked but increasingly reported entity that must be considered in the differential diagnosis of a malignancy recurrence in an anatomic body area submitted to radiotherapy. [Extracted from the article]

Porphyria cutanea tarda (PCT) can occur in HIV patients. Current evidence suggests that HIV infection may interfere with the hepatic cytochrome oxidase system, leading to porphyrin metabolism impairment. Moreover, chronic hemodialysis in renal failure may be a risk factor for PCT. In addition to the contributory factors for PCT associated to HIV infection, it is possible that porphyrin accumulation secondary to renal failure may play a role in the expression of this disease. We report a case of PCT in an HIV-1 infected patient under blood dialysis, refractory to antimalarials and controlled with desferrioxamine. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 39-year-old homosexual patient with AIDS who was observed in the emergency department for non-pruritic erythematous macules, patches, and papules. The patient was diagnosed with post-kala-azar dermal leishmaniasis (PKDL) caused by Leishmania donovani. He was given liposomal amphotericin B 4 mg/kg per day IV as treatment for the disease.

Background Sweet's syndrome is the most common neutrophilic dermatosis, but its pathophysiology is still largely unknown and different subgroups can be defined. Objectives To assess the clinical/laboratory factors in a series of patients with Sweet's syndrome and search for significant differences between defined subgroups. Methods A retrospective study of inpatient files with this diagnosis was made, and patients were included if they fulfilled the classical diagnostic criteria. Data were analyzed with the SPSS package, with a significance level of 5%. Results Forty-two patients fulfilled the inclusion criteria, with a median age of 50 years. Females comprised 88% of patients, and disease onset occurred in autumn or spring in over 70% of cases. A previous oropharyngeal infection was described by 38% of patients, and a previous or concomitantly diagnosed neoplasm by 10%. In contrast with the literature, the lower extremities were also involved in the majority of patients, and arthralgia was the most frequent extracutaneous manifestation. On bivariate analysis, in patients who reported a previous oropharyngeal infection, the lesions were significantly more frequent in autumn, and a shorter inpatient stay as well as a lower temperature on admission and lower prevalence of arthralgia were observed in the same group. Conclusions The subgroup of patients with a previous oropharyngeal infection had a less severe form of this syndrome. [ABSTRACT FROM AUTHOR]

The article talks about effectiveness of motivational phone-calls (MPCs) in treatment of psoriasis. It is mentioned that MPCs were shown to improve adherence to skin topical treatments and how it impacted the subjective wellbeing or objective improvement in patients. The article adds that the patients were divided into two group and one received three calls and other didn't, revealed that less number of MPC were not sufficient for improvement in treatment.

A letter to the editor is presented related to case study of a 59-year-old white female suffering with prorkeratosis and malignant melonoma, and had 18 years history of erythematous scaly papules on lower and upper limbs.

The article presents a case study of a 29-year-old white woman with a history of severe plaque psoriasis for 16 years. A pigmented macule was noted in the patient's right thigh, who received adalimumab, a tumour necrosis factor (TNF)-α blocker. The lesion was found to have atypical irregular borders and discoloration. A diagnosis of irritated dysplastic spitzoid compound naevus was made based on the presence of Kamino bodies and homogeneous upregulation of both p16 and p21 proteins.