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Annular pustular psoriasis induced by UV radiation from tanning salon use
Journal of the American Academy of Dermatology
336 Brief communications mine. aldan blue. and silver-methenamine, with a thin peripheral capsule. Such structures. easily identifiable as cryptococci, were not simply circumscribed in the epidermis, but appeared to infiltrate massively the surrounding dermis and subcutaneous fat with no definite limits. An inflammatory reaction was completely absent (Fig. I. B). In the second case, skin lesions resembling molIuscum contagiosum appeared on the face and neck during a fatal relapse of a cryptococcal meningoencephalitis. only a few days before death. A postmortem skin biopsy specimen of a lesion showed a massive cryptococcal infiltration of the skin with a multinucleated giant cell reaction. On admission, the third patient showed clinical signs of lung and liver involvment with only mild neurologic symptoms. Four large pustular lesions (3 t05 cmjn diameter) were observed on his face and neck. This patient reported the onset of these lesions 5 weeks before in the a bsence of any other symptoms. Histologic examination of a lesion revealed a local massivecryptococcal invasion. After 7 days, the patient died of cryptococcal meningoencephalitis but no autopsy was performed.
Discussion. To our knowledge, these are the fourth and fifth described cases of cutaneous cryptococcosis resembling molluscum contagiosum. This clinical presentation should be carefully considered in any HIV-positive patient, particularly in the presence of an already existing immune depression. In immunocompromised patients, cryptococcal skin lesions have been considered as signs of disseminated infection and therefore appearing only in the late stages of the disease. In two of our three cases, the skin lesions preceded the systemic disease and, if the diagnosis had been made earlier, therapy for cryptococcal sepsis might have stopped the progression of the lifethreatening disease. In our experience, an early diagnosis was hindered because patients having only skin lesions did not come to us for further diagnostic procedures. In all cases, however, skin lesions were followed by a fairly rapid and fatal course (4,1, and 5 weeks). Moreover, if we consider that molluscum contagiosum-like lesions or more nonspecific skin lesions may appear weeks before lifethreatening cryptococcal sepsis, it would be wise to perform a skin biopsy of all cutaneous lesions resembling molluscum contagiosum or that might not be clearly related to HIV infection.
bling molluscum contagiosum in a patient with AIDS. Arch Dermatol1985;121:901-2. 7. Calzavara Pinton PG, Scalzini A, Carlino A, et aJ. Cutaneous cryptococcosis resembling molluscum contagiosum. G Ital Dermatol VenereoI1987;122:523-6. 8. Cancus AP, Helfand RF, Imber MJ, et at Cutaneous cryptococcosis mimicking molluscum contagiosum in a patient with AIDS. 1 Infect Dis 1988;158:897-8.
Annular pustular psoriasis induced by UV
radiation from tanning salon use Robert M. Rosen, DO Moline, Illinois UV radiation is usually beneficial for psoriasis. Overexposure, however, rarely leads to generalized pustular psoriasis ofvon Zumbusch (GPPZ). GPPZ is characterized by repetitive waves of pustules, fiery red erythema, and marked systemic toxicity. Annular pustular psoriasis (APP) differs from GPPZ by its more subacute and limited course and lack of toxicity.! A patient was recently encountered in whom APP developed after a burn in a tanning salon, a finding not previously reported. Case report. A 67-year-old white man had chronic stationary plaque psoriasis. He treated this in a tanning salon until he increased his exposure time and received a partial-thickness burn. After this, a recurrent eruption on his trunk and proximal extremities developed. A prodrome of malaise and burning hyperFrom Quad City Skin Clinic. Reprint requests: Robert M. Rosen, DO, Quad City Skin Clinic, 1588 37th Ave., Moline, IL 61265.
16/4/28544
REFERENCES I. Cryptococcosis and AIDS [Editorial]. Lancet 1988;I: 1434-6. 2. Zuger A, Louie E, Holzman RS, et al. Cryptococcal disease in patients with the acquired immunodeficiency syndrome. Ann Intern Med 1986;104:234-40. 3. Dismukes WE. Cryptococcal meningitis in patients with AIDS. J Infect Dis 1988;157:624-8. 4. Chuck SL, Sande MA. Infections with Cryptococcus neoformans in the acquired immunodeficiency syndrome. N Engl J Med 1989;321:794-9. 5. Kovacs lA, Kovacs AA, Polis M, et al. Cryptococcosis in the acquired immunodeficiency syndrome. Ann Intern Med 1985;103:533-8. 6. Rico MJ, Penneys NS. Cutaneous cryptococcosis resem-
Fig. 1. Annular and figurate erythematous bands with central clearing.
Volume 25 Number 2, Part 1 August 1991
Brief communications 337
Fig. 2. Photomicrograph of biopsy specimen from resolving lesion. Psoriasiform hyperplasia, parakeratosis, acanthosis, and some areas of decreased granular layer are seen. There is a sparse lymphocyte-predominant perivascular infiltrate and a condensed collection of inflammatory cells in the stratum corneum. esthesia was followed by an erythematous annular eruption. These expanded rapidly to plaques 3 to 15 cm in diameter with central clearing (Fig. 1). Small pustules were seen on the edge with the first eruption but rarely in later episodes. By7 to 10 days the eruption began to fade. A broad desquamation of palms and soles began at approximately 14 days. The eruptions were completely resolved by 21 days, followed by recurrence 3 to 6 weeks later. About the same areas were affected each time. The following laboratory studies were negative or normal: complete blood cell count, automated chemistry panel, total hemolytic complement, anti-streptolysin 0 titer, antinuclear antibody, fungal and bacterial cultures, and urinalysis. A skin biopsy specimen showed psoriasiform hyperplasia with focal collections of neutrophils condensed in a parakeratotic stratum corneum (Fig. 2). After 1 year, there were no further recurrences. His original plaque-type psoriasis remained. Discussion. APP is a rare condition of recurrent erythema annulare-like lesions with psoriasiform histopathologic features. APP, also called erythema circine recidivant,2 Lapiere-type psoriasis,3 and erythema annulare centrifugum-type psoriasis,4-6 typically runs a cyclically recurrent course that may span decades. I ,4 As with other atypical forms ofpsoriasis, onset is most common by the first decade or beyond the fifth decade and a family history of psoriasis vulgaris is typically absent. l , 7 APP develops, often rapidly, into annular or gyrate bands with central clearing. Pustules are present on the leading edge, but these may last less than 24 hours6 and are often not seen. I, 2, 4 Complete resolution of an episode usually occurs in days6 to weeks, but it can last many months. l Symptoms are variable and include mild pruritus, malaise, or irritability.3, 6, ,8. 9 Low-grade fever, scarlatiniform desquamation of palms and soles, modest leukocytosis, and increased erythrocyte sedimentation rate have also been reported. 1, 2. 6 In some, the eruption is la-
bile and recurrences have been reported to be induced by, pharyngitis,S menses,4 pregnancy,S feelings of psychological stress,8, 9 or episodes of manic psychosis. 10 Diagnosis should be confirmed by a biopsy specimen of the leading edge ofthe eruption because this is most likely to show a spongiform pustule,9 the most characteristic histopathologic feature. Psoriasiform hyperplasia, acanthosis, and parakeratosis are often present. 2 , 4-6 Pustules may be transient and, if a biopsy specimen is obtained from an older lesion as in the present case, neutrophils may have a subcorneal position with loss of spongiform changes. 9 REFERENCES 1. Baker H, Ryan TJ. Generalized pustular psoriasis: a clinical and epidemiological study of 104 cases. Br J Dermatol 1968;80:771-93. 2. Basex A, Dupre A, Christol B, et al. Psoriasis a type d'erythema circine recidivant de Bloch. Bull Soc Fr Dermato! Syphiligr 1967;74:689-95. 3. Clavert HT. Pustular psoriasis (type Lapiere). Br J Dermatol 1967;79:719-21. 4. Degos R, Civatte J, Arroux M. Psoriasis et psoriasis pustuleaux a type de erytheme annuJaire centrifuge. Bull Soc Fr Dermatol Syphiligr 1966;73:356-8. 5. Rajka G, Thune PO. On erythema annulare centrifugumtype of psoriasis. Acta Derm Venereal (Stockh) 1979;59 (suppl 85):143-5. 6. Resneck JS, Cram DL. Erythema annulare-like pustular psoriasis. Arch Dermatol1973;108:687-8. 7. Lyons JH. Generalized pustular psoriasis. Int J Dcrrnatol 1987;26:409-17. 8. Marks R, Gold Sc. Erythema annulare-like pustular pso· riasis. Br J Dermatol 1968;80:379-90. 9. Adler DJ, Rower JM, Hashimoto K. Annular pustular psoriasis. Arch Dermatol 1981;117:313. 10. Shimamoto Y, Shimamoto H. Annular pustular psoriasis associated with affective psychosis. Cutis 1990;45:439-42.
336 Brief communications mine. aldan blue. and silver-methenamine, with a thin peripheral capsule. Such structures. easily identifiable as cryptococci, were not simply circumscribed in the epidermis, but appeared to infiltrate massively the surrounding dermis and subcutaneous fat with no definite limits. An inflammatory reaction was completely absent (Fig. I. B). In the second case, skin lesions resembling molIuscum contagiosum appeared on the face and neck during a fatal relapse of a cryptococcal meningoencephalitis. only a few days before death. A postmortem skin biopsy specimen of a lesion showed a massive cryptococcal infiltration of the skin with a multinucleated giant cell reaction. On admission, the third patient showed clinical signs of lung and liver involvment with only mild neurologic symptoms. Four large pustular lesions (3 t05 cmjn diameter) were observed on his face and neck. This patient reported the onset of these lesions 5 weeks before in the a bsence of any other symptoms. Histologic examination of a lesion revealed a local massivecryptococcal invasion. After 7 days, the patient died of cryptococcal meningoencephalitis but no autopsy was performed.
Discussion. To our knowledge, these are the fourth and fifth described cases of cutaneous cryptococcosis resembling molluscum contagiosum. This clinical presentation should be carefully considered in any HIV-positive patient, particularly in the presence of an already existing immune depression. In immunocompromised patients, cryptococcal skin lesions have been considered as signs of disseminated infection and therefore appearing only in the late stages of the disease. In two of our three cases, the skin lesions preceded the systemic disease and, if the diagnosis had been made earlier, therapy for cryptococcal sepsis might have stopped the progression of the lifethreatening disease. In our experience, an early diagnosis was hindered because patients having only skin lesions did not come to us for further diagnostic procedures. In all cases, however, skin lesions were followed by a fairly rapid and fatal course (4,1, and 5 weeks). Moreover, if we consider that molluscum contagiosum-like lesions or more nonspecific skin lesions may appear weeks before lifethreatening cryptococcal sepsis, it would be wise to perform a skin biopsy of all cutaneous lesions resembling molluscum contagiosum or that might not be clearly related to HIV infection.
bling molluscum contagiosum in a patient with AIDS. Arch Dermatol1985;121:901-2. 7. Calzavara Pinton PG, Scalzini A, Carlino A, et aJ. Cutaneous cryptococcosis resembling molluscum contagiosum. G Ital Dermatol VenereoI1987;122:523-6. 8. Cancus AP, Helfand RF, Imber MJ, et at Cutaneous cryptococcosis mimicking molluscum contagiosum in a patient with AIDS. 1 Infect Dis 1988;158:897-8.
Annular pustular psoriasis induced by UV
radiation from tanning salon use Robert M. Rosen, DO Moline, Illinois UV radiation is usually beneficial for psoriasis. Overexposure, however, rarely leads to generalized pustular psoriasis ofvon Zumbusch (GPPZ). GPPZ is characterized by repetitive waves of pustules, fiery red erythema, and marked systemic toxicity. Annular pustular psoriasis (APP) differs from GPPZ by its more subacute and limited course and lack of toxicity.! A patient was recently encountered in whom APP developed after a burn in a tanning salon, a finding not previously reported. Case report. A 67-year-old white man had chronic stationary plaque psoriasis. He treated this in a tanning salon until he increased his exposure time and received a partial-thickness burn. After this, a recurrent eruption on his trunk and proximal extremities developed. A prodrome of malaise and burning hyperFrom Quad City Skin Clinic. Reprint requests: Robert M. Rosen, DO, Quad City Skin Clinic, 1588 37th Ave., Moline, IL 61265.
16/4/28544
REFERENCES I. Cryptococcosis and AIDS [Editorial]. Lancet 1988;I: 1434-6. 2. Zuger A, Louie E, Holzman RS, et al. Cryptococcal disease in patients with the acquired immunodeficiency syndrome. Ann Intern Med 1986;104:234-40. 3. Dismukes WE. Cryptococcal meningitis in patients with AIDS. J Infect Dis 1988;157:624-8. 4. Chuck SL, Sande MA. Infections with Cryptococcus neoformans in the acquired immunodeficiency syndrome. N Engl J Med 1989;321:794-9. 5. Kovacs lA, Kovacs AA, Polis M, et al. Cryptococcosis in the acquired immunodeficiency syndrome. Ann Intern Med 1985;103:533-8. 6. Rico MJ, Penneys NS. Cutaneous cryptococcosis resem-
Fig. 1. Annular and figurate erythematous bands with central clearing.
Volume 25 Number 2, Part 1 August 1991
Brief communications 337
Fig. 2. Photomicrograph of biopsy specimen from resolving lesion. Psoriasiform hyperplasia, parakeratosis, acanthosis, and some areas of decreased granular layer are seen. There is a sparse lymphocyte-predominant perivascular infiltrate and a condensed collection of inflammatory cells in the stratum corneum. esthesia was followed by an erythematous annular eruption. These expanded rapidly to plaques 3 to 15 cm in diameter with central clearing (Fig. 1). Small pustules were seen on the edge with the first eruption but rarely in later episodes. By7 to 10 days the eruption began to fade. A broad desquamation of palms and soles began at approximately 14 days. The eruptions were completely resolved by 21 days, followed by recurrence 3 to 6 weeks later. About the same areas were affected each time. The following laboratory studies were negative or normal: complete blood cell count, automated chemistry panel, total hemolytic complement, anti-streptolysin 0 titer, antinuclear antibody, fungal and bacterial cultures, and urinalysis. A skin biopsy specimen showed psoriasiform hyperplasia with focal collections of neutrophils condensed in a parakeratotic stratum corneum (Fig. 2). After 1 year, there were no further recurrences. His original plaque-type psoriasis remained. Discussion. APP is a rare condition of recurrent erythema annulare-like lesions with psoriasiform histopathologic features. APP, also called erythema circine recidivant,2 Lapiere-type psoriasis,3 and erythema annulare centrifugum-type psoriasis,4-6 typically runs a cyclically recurrent course that may span decades. I ,4 As with other atypical forms ofpsoriasis, onset is most common by the first decade or beyond the fifth decade and a family history of psoriasis vulgaris is typically absent. l , 7 APP develops, often rapidly, into annular or gyrate bands with central clearing. Pustules are present on the leading edge, but these may last less than 24 hours6 and are often not seen. I, 2, 4 Complete resolution of an episode usually occurs in days6 to weeks, but it can last many months. l Symptoms are variable and include mild pruritus, malaise, or irritability.3, 6, ,8. 9 Low-grade fever, scarlatiniform desquamation of palms and soles, modest leukocytosis, and increased erythrocyte sedimentation rate have also been reported. 1, 2. 6 In some, the eruption is la-
bile and recurrences have been reported to be induced by, pharyngitis,S menses,4 pregnancy,S feelings of psychological stress,8, 9 or episodes of manic psychosis. 10 Diagnosis should be confirmed by a biopsy specimen of the leading edge ofthe eruption because this is most likely to show a spongiform pustule,9 the most characteristic histopathologic feature. Psoriasiform hyperplasia, acanthosis, and parakeratosis are often present. 2 , 4-6 Pustules may be transient and, if a biopsy specimen is obtained from an older lesion as in the present case, neutrophils may have a subcorneal position with loss of spongiform changes. 9 REFERENCES 1. Baker H, Ryan TJ. Generalized pustular psoriasis: a clinical and epidemiological study of 104 cases. Br J Dermatol 1968;80:771-93. 2. Basex A, Dupre A, Christol B, et al. Psoriasis a type d'erythema circine recidivant de Bloch. Bull Soc Fr Dermato! Syphiligr 1967;74:689-95. 3. Clavert HT. Pustular psoriasis (type Lapiere). Br J Dermatol 1967;79:719-21. 4. Degos R, Civatte J, Arroux M. Psoriasis et psoriasis pustuleaux a type de erytheme annuJaire centrifuge. Bull Soc Fr Dermatol Syphiligr 1966;73:356-8. 5. Rajka G, Thune PO. On erythema annulare centrifugumtype of psoriasis. Acta Derm Venereal (Stockh) 1979;59 (suppl 85):143-5. 6. Resneck JS, Cram DL. Erythema annulare-like pustular psoriasis. Arch Dermatol1973;108:687-8. 7. Lyons JH. Generalized pustular psoriasis. Int J Dcrrnatol 1987;26:409-17. 8. Marks R, Gold Sc. Erythema annulare-like pustular pso· riasis. Br J Dermatol 1968;80:379-90. 9. Adler DJ, Rower JM, Hashimoto K. Annular pustular psoriasis. Arch Dermatol 1981;117:313. 10. Shimamoto Y, Shimamoto H. Annular pustular psoriasis associated with affective psychosis. Cutis 1990;45:439-42.