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Bowel-associated dermatosis-arthritis syndrome: A case report
P1178
P1180
An open-label investigation of naftifine hydrochloric acid cream 1% for cutaneous candidiasis Boni E. Elewski, University of Alabama at Birmingham Department of Dermatology, Birmingham, AL, United States; Raj Varma, MD, University of Alabama at Birmingham, Birmingham, AL, United States; Shellie Marks, MD, University of Alabama at Birmingham, Birmingham, AL, United States; Wendy Cantrell, CNP, University of Alabama at Birmingham, Birmingham, AL, United States Background: Cutaneous candidiasis is a common infection often occurring in intertriginous areas. Risk factors include obesity, diabetes, and warm ambient temperature. Frequently, cutaneous candidiasis occurs in conjunction with an irritant dermatitis (complication of intertrigo), secondary bacterial, or dermatophytic infection (dermatophytosis complex). Naftifine, a topical allylamine, is fungicidal against a broad spectrum of dermatophyte fungi and is also effective against Gram-negative and -positive bacteria. In vitro data for naftifine have shown good activity against Candida spp., but the agent is not currently indicated for this type of infection. Objective: An open-label, monocentered, single-arm pilot study to determine the efficacy and patient satisfaction of naftifine cream as a treatment for cutaneous candidiasis. Methods: Fourteen subjects diagnosed with cutaneous candidiasis were instructed to apply naftifine cream to affected areas twice daily (labeled dosage is once-daily) for a total of 4 weeks with a 2-week follow-up. Assessments measuring maceration, scaling, erythema (using a 0-3 scale), and the clinical presence of Candida were performed at baseline and weeks 2, 4, and 6. Photographs were performed at those same time points. Cultures were performed at baseline and weeks 2 and 4. At week 4, a questionnaire was given to patients to assess their satisfaction with the treatment and relief of pruritus (using a 0-3 scale). Results: Naftifine cream twice daily for 4 weeks led to significant improvement in target area lesion assessments measuring maceration, scaling, and erythema. Erythema scores improved from 2.43 6 0.51 at baseline to 1.64 6 0.63 at week 4 (P \.001). Scaling scores improved from 1.07 6 0.92 at baseline to 0.5 6 0.76 at week 4 (P \.0402). Maceration scores improved from 1.64 6 0.84 at baseline to 0.64 6 0.93 at week 4 (P\.0019). Based upon the investigator’s assessment, clinical resolution of infection occurred in 9 out of 14 (64%) patients. Itching improved in all patients and resolved completely in six (43%) patients. Twelve out of 14 patients indicated satisfaction with the study medication. Conclusion: Although naftifine is traditionally considered a potent antidermatophyte drug, our data confirm its utility in cutaneous candidiasis based on symptom improvement and good patient tolerability.
Innovative treatment options for pityriasis versicolor Boni E. Elewski, PhD, University of Alabama at Birmingham Department of Dermatology, Birmingham, AL, United States; Shelley Cathcart, MD, University of Alabama at Birmingham, Birmingham, AL, United States; Shellie Marks, MD, University of Alabama at Birmingham, Birmingham, AL, United States; Wendy Cantrell, CNP, University of Alabama at Birmingham, Birmingham, AL, United States Pityriasis versicolor (PV) is a common chronic superficial fungal infection caused by Malassezia globosa, M sympodialis, M sloofiae, and M furfur. Lesions appear as discrete and confluent hypopigmented, hyperpigmented, or salmon-colored patches with fine scale on the upper trunk and proximal arms. Diagnosis depends on demonstration of small yeast cells and short, stubby hyphae in potassium hydroxide mounts of skin scrapings. Although many conventional therapies have been successful in treating PV, improvements could be made upon the cosmetic appeal and ease of use associated with these therapies. We review the newer PV pathogens and the topical, oral, and preventive treatment options. The lipophilic yeasts of the genus Malassezia have recently become a focus of attention. Although M fufur was believed for decades to be the causative agent in PV, multiple studies have shown that M globosa is the most common isolated species either alone or in combination with M sympodialis, M furfur, or M slooffiae. Ketoconazole has the best MIC of all antifungals against Malassezia spp., but its use is hampered by the messy cream formula. A new 2% ketoconazole foam that was shown to be equivalent to ketoconazole cream has been approved for the topical treatment of seborrheic dermatitis, but may be useful for patients with PV. The foam vehicle improves absorption, adherence, and drug distribution and is easy to use and can be applied on wet or dry skin and on hairy and nonhairy areas. Additional topical antifungals in the azole family, such as clotrimazole or miconazole, are also effective. Terbinafine, an allylamine with fungicidal activity against dermatophytes, is less effective against yeasts such as Malassezia. Other topical therapies include 2.5% selenium sulfide shampoo, 2% zinc pyrithione shampoo, 40% to 60% propylene glycol in water solution, and ciclopiroxamine cream 1%, gel, or shampoo. Although there are no oral agents for PV approved by the US Food and Drug Administration, systemic therapy with ketoconazole, fluconazole, or itraconazole is useful for the treatment of recalcitrant cases or those with extensive involvement. Oral terbinafine and griseofulvin are not effective treatments. PV has a high tendency to recur after being treated successfully. Oral ketoconazole and itraconazole alone and in combination with topical therapies have a significant prophylactic effect. Regardless of treatment type, follow-up after treatment is essential to allow accurate assessment of clinical response. Commercial support: None identified.
Commercial support: Sponsored by an unrestricted educational grant provided by Merz Pharmaceuticals.
P1181
P1179 Bowel-associated dermatosis-arthritis syndrome: A case report Abba Alkali, MBBCh, Department Of Dermatology, Broadgreen Hospital, Liverpool, Merseyside, United Kingdom; Clodagh King, MD, Department Of Dermatology, Broadgreen Hospital, Liverpool, Merseyside, United Kingdom; Niamh Leonard, MD, Department Of Histopathology, Royal Liverpool Hospital, Liverpool, Merseyside, United Kingdom
Superficial acral fibromyxoma: A case report Francisca Regina Oliveira Carneiro, MD, PhD, University of State of Para´, Belem, Brazil; Alena Margareth Darwich Mendes, MD, University of State of Para´, Belem, Brazil; Caroline Martins Brand~ao, University of State of Para´, Belem, Brazil; Maria Ame´lia Lopes Dos Santos, University of State of Para´, Belem, Brazil; Mario Fernando Ribeiro De Miranda, Federal University of Para´, Belem, Brazil
Discussion: It is important to distinguish BADAS from Behc¸et disease (BD) because both may include oral aphthosis and lesions of pustular vasculitis. Histopathology does not differentiate BADAS from BD or early lesions of either pyoderma gangrenosum or Sweet syndrome. In order to definitively diagnose BADAS, an evaluation of the bowel including barium studies and endoscopy should follow a thorough history and physical examination. Treatment of BADAS depends on the etiology. Surgical correction of bowel anatomy often eliminates signs and symptoms following bowel bypass surgery. In other cases, symptoms of BADAS may be effectively controlled with systemic steroids, tetracycline, metronidazole, or erythromycin. In difficult cases, colchicine, dapsone, and thalidomide have been used.
Introduction: Superficial acral fibromyxoma (SAF) is a rare soft tissue tumor first recognized as a distinct histopathologic entity in 2001 by Fetsch et al when they described the clinicopathologic features and immunohistochemical findings identified in 37 cases of this neoplasm. SAF occurs most frequent in male middle-aged patients. Clinically, SAF is characterized as a slow-growing painless rounded tumor localized on toes and fingers, especially in the nail areaa. Palms and soles are rarely compromised. On histologic examination, the lesion is a moderately cellular neoplasm composed of spindle- and stellate-shaped fibroblast-like cells embedded in myxoid, myxocollagenous, or collagenous matrix. Immunoreactivity for CD34, EMA, and C99 can be observed with no reactivity for actin, desmin, cytokeratin, and HMB45. The differential diagnosis includes other myxoid neoplasms with a predilection of distal extremities like fibrous histiocytoma, myxoid dermatofibrosarcoma protuberans, superficial angiomyxoma, acquired digital, fibrokeratoma, sclerosing perineurioma, and others. SAF usually has a benign course, and surgical excision is a successful therapy. Case report: A 54-year-old male presented with a firm, round-shaped tumor on the nail bed of left big toe. The lesion had been slowly enlarging for 8 years. No subjective symptoms had been observed. Histologic examination showed a well circumscribed tumor with stellate cells in collagenous and myxoid matrix. A vascular proliferation was observed with a great number of mast cells. No immunoreactivity for CD34, EMA, C99, cytokeratin, and HMB45 was observed. A radiographic exam of the left big toe showed a localized enlargement of soft tissue. A surgical excision was recommended and the patient is now waiting for this intervention. Discussion: The authors related a case with clinicopathologic features of SAF as male predilection, localization on the big toe, a slowly growing course, and histologic aspects like presence of stelalte-shaped cells embedded in a collagenous matrix. No reactivity for a CD34, EMA, C99, cytokeratin, and HMB45 was observed. In summary, it is very important to recognize this entity and determine the difference between this and other myxoid tumors to avoid unnecessary aggressive treatment to a neoplasm with a benign course.
Commercial support: None identified.
Commercial support: None identified.
Background: Bowel-associated dermatosis-arthritis syndrome (BADAS) is a rare neutrophilic dermatosis first described by Shagrin et al in 1971 as pustular vasculitic cutaneous lesions and serum sicknesselike reactions in patients who had undergone jejunoileal bypass surgery for morbid obesity. The definition is now extended to include the same syndrome in patients with inflammatory bowel disease or blind loop following peptic ulcer surgery. We present a patient with this syndrome and highlight the importance of differentiating BADAS from other neutrophilic dermatoses. Observations: We describe a 49-year-old male with a history of Crohn disease who presented with a rash associated with fever, joint pains, sore eyes, abdominal pain, and diarrhea. A physical examination revealed multiple erythematous papulopustules and plaques on his limbs, trunk, head, and neck. Episcleritis, oral apthouselike and genital ulcers were noted. Laboratory tests were unremarkable apart from raised inflammatory markers. A skin biopsy revealed normal epidermis and superficial dermis and a mixed inflammatory cell infiltrate in the subcutaneous fat in lobular distribution. Based on the clinicopathological findings a diagnosis of BADAS was made. The rash rapidly cleared on high dose corticosteroid therapy.
MARCH 2009
J AM ACAD DERMATOL
AB59
P1180
An open-label investigation of naftifine hydrochloric acid cream 1% for cutaneous candidiasis Boni E. Elewski, University of Alabama at Birmingham Department of Dermatology, Birmingham, AL, United States; Raj Varma, MD, University of Alabama at Birmingham, Birmingham, AL, United States; Shellie Marks, MD, University of Alabama at Birmingham, Birmingham, AL, United States; Wendy Cantrell, CNP, University of Alabama at Birmingham, Birmingham, AL, United States Background: Cutaneous candidiasis is a common infection often occurring in intertriginous areas. Risk factors include obesity, diabetes, and warm ambient temperature. Frequently, cutaneous candidiasis occurs in conjunction with an irritant dermatitis (complication of intertrigo), secondary bacterial, or dermatophytic infection (dermatophytosis complex). Naftifine, a topical allylamine, is fungicidal against a broad spectrum of dermatophyte fungi and is also effective against Gram-negative and -positive bacteria. In vitro data for naftifine have shown good activity against Candida spp., but the agent is not currently indicated for this type of infection. Objective: An open-label, monocentered, single-arm pilot study to determine the efficacy and patient satisfaction of naftifine cream as a treatment for cutaneous candidiasis. Methods: Fourteen subjects diagnosed with cutaneous candidiasis were instructed to apply naftifine cream to affected areas twice daily (labeled dosage is once-daily) for a total of 4 weeks with a 2-week follow-up. Assessments measuring maceration, scaling, erythema (using a 0-3 scale), and the clinical presence of Candida were performed at baseline and weeks 2, 4, and 6. Photographs were performed at those same time points. Cultures were performed at baseline and weeks 2 and 4. At week 4, a questionnaire was given to patients to assess their satisfaction with the treatment and relief of pruritus (using a 0-3 scale). Results: Naftifine cream twice daily for 4 weeks led to significant improvement in target area lesion assessments measuring maceration, scaling, and erythema. Erythema scores improved from 2.43 6 0.51 at baseline to 1.64 6 0.63 at week 4 (P \.001). Scaling scores improved from 1.07 6 0.92 at baseline to 0.5 6 0.76 at week 4 (P \.0402). Maceration scores improved from 1.64 6 0.84 at baseline to 0.64 6 0.93 at week 4 (P\.0019). Based upon the investigator’s assessment, clinical resolution of infection occurred in 9 out of 14 (64%) patients. Itching improved in all patients and resolved completely in six (43%) patients. Twelve out of 14 patients indicated satisfaction with the study medication. Conclusion: Although naftifine is traditionally considered a potent antidermatophyte drug, our data confirm its utility in cutaneous candidiasis based on symptom improvement and good patient tolerability.
Innovative treatment options for pityriasis versicolor Boni E. Elewski, PhD, University of Alabama at Birmingham Department of Dermatology, Birmingham, AL, United States; Shelley Cathcart, MD, University of Alabama at Birmingham, Birmingham, AL, United States; Shellie Marks, MD, University of Alabama at Birmingham, Birmingham, AL, United States; Wendy Cantrell, CNP, University of Alabama at Birmingham, Birmingham, AL, United States Pityriasis versicolor (PV) is a common chronic superficial fungal infection caused by Malassezia globosa, M sympodialis, M sloofiae, and M furfur. Lesions appear as discrete and confluent hypopigmented, hyperpigmented, or salmon-colored patches with fine scale on the upper trunk and proximal arms. Diagnosis depends on demonstration of small yeast cells and short, stubby hyphae in potassium hydroxide mounts of skin scrapings. Although many conventional therapies have been successful in treating PV, improvements could be made upon the cosmetic appeal and ease of use associated with these therapies. We review the newer PV pathogens and the topical, oral, and preventive treatment options. The lipophilic yeasts of the genus Malassezia have recently become a focus of attention. Although M fufur was believed for decades to be the causative agent in PV, multiple studies have shown that M globosa is the most common isolated species either alone or in combination with M sympodialis, M furfur, or M slooffiae. Ketoconazole has the best MIC of all antifungals against Malassezia spp., but its use is hampered by the messy cream formula. A new 2% ketoconazole foam that was shown to be equivalent to ketoconazole cream has been approved for the topical treatment of seborrheic dermatitis, but may be useful for patients with PV. The foam vehicle improves absorption, adherence, and drug distribution and is easy to use and can be applied on wet or dry skin and on hairy and nonhairy areas. Additional topical antifungals in the azole family, such as clotrimazole or miconazole, are also effective. Terbinafine, an allylamine with fungicidal activity against dermatophytes, is less effective against yeasts such as Malassezia. Other topical therapies include 2.5% selenium sulfide shampoo, 2% zinc pyrithione shampoo, 40% to 60% propylene glycol in water solution, and ciclopiroxamine cream 1%, gel, or shampoo. Although there are no oral agents for PV approved by the US Food and Drug Administration, systemic therapy with ketoconazole, fluconazole, or itraconazole is useful for the treatment of recalcitrant cases or those with extensive involvement. Oral terbinafine and griseofulvin are not effective treatments. PV has a high tendency to recur after being treated successfully. Oral ketoconazole and itraconazole alone and in combination with topical therapies have a significant prophylactic effect. Regardless of treatment type, follow-up after treatment is essential to allow accurate assessment of clinical response. Commercial support: None identified.
Commercial support: Sponsored by an unrestricted educational grant provided by Merz Pharmaceuticals.
P1181
P1179 Bowel-associated dermatosis-arthritis syndrome: A case report Abba Alkali, MBBCh, Department Of Dermatology, Broadgreen Hospital, Liverpool, Merseyside, United Kingdom; Clodagh King, MD, Department Of Dermatology, Broadgreen Hospital, Liverpool, Merseyside, United Kingdom; Niamh Leonard, MD, Department Of Histopathology, Royal Liverpool Hospital, Liverpool, Merseyside, United Kingdom
Superficial acral fibromyxoma: A case report Francisca Regina Oliveira Carneiro, MD, PhD, University of State of Para´, Belem, Brazil; Alena Margareth Darwich Mendes, MD, University of State of Para´, Belem, Brazil; Caroline Martins Brand~ao, University of State of Para´, Belem, Brazil; Maria Ame´lia Lopes Dos Santos, University of State of Para´, Belem, Brazil; Mario Fernando Ribeiro De Miranda, Federal University of Para´, Belem, Brazil
Discussion: It is important to distinguish BADAS from Behc¸et disease (BD) because both may include oral aphthosis and lesions of pustular vasculitis. Histopathology does not differentiate BADAS from BD or early lesions of either pyoderma gangrenosum or Sweet syndrome. In order to definitively diagnose BADAS, an evaluation of the bowel including barium studies and endoscopy should follow a thorough history and physical examination. Treatment of BADAS depends on the etiology. Surgical correction of bowel anatomy often eliminates signs and symptoms following bowel bypass surgery. In other cases, symptoms of BADAS may be effectively controlled with systemic steroids, tetracycline, metronidazole, or erythromycin. In difficult cases, colchicine, dapsone, and thalidomide have been used.
Introduction: Superficial acral fibromyxoma (SAF) is a rare soft tissue tumor first recognized as a distinct histopathologic entity in 2001 by Fetsch et al when they described the clinicopathologic features and immunohistochemical findings identified in 37 cases of this neoplasm. SAF occurs most frequent in male middle-aged patients. Clinically, SAF is characterized as a slow-growing painless rounded tumor localized on toes and fingers, especially in the nail areaa. Palms and soles are rarely compromised. On histologic examination, the lesion is a moderately cellular neoplasm composed of spindle- and stellate-shaped fibroblast-like cells embedded in myxoid, myxocollagenous, or collagenous matrix. Immunoreactivity for CD34, EMA, and C99 can be observed with no reactivity for actin, desmin, cytokeratin, and HMB45. The differential diagnosis includes other myxoid neoplasms with a predilection of distal extremities like fibrous histiocytoma, myxoid dermatofibrosarcoma protuberans, superficial angiomyxoma, acquired digital, fibrokeratoma, sclerosing perineurioma, and others. SAF usually has a benign course, and surgical excision is a successful therapy. Case report: A 54-year-old male presented with a firm, round-shaped tumor on the nail bed of left big toe. The lesion had been slowly enlarging for 8 years. No subjective symptoms had been observed. Histologic examination showed a well circumscribed tumor with stellate cells in collagenous and myxoid matrix. A vascular proliferation was observed with a great number of mast cells. No immunoreactivity for CD34, EMA, C99, cytokeratin, and HMB45 was observed. A radiographic exam of the left big toe showed a localized enlargement of soft tissue. A surgical excision was recommended and the patient is now waiting for this intervention. Discussion: The authors related a case with clinicopathologic features of SAF as male predilection, localization on the big toe, a slowly growing course, and histologic aspects like presence of stelalte-shaped cells embedded in a collagenous matrix. No reactivity for a CD34, EMA, C99, cytokeratin, and HMB45 was observed. In summary, it is very important to recognize this entity and determine the difference between this and other myxoid tumors to avoid unnecessary aggressive treatment to a neoplasm with a benign course.
Commercial support: None identified.
Commercial support: None identified.
Background: Bowel-associated dermatosis-arthritis syndrome (BADAS) is a rare neutrophilic dermatosis first described by Shagrin et al in 1971 as pustular vasculitic cutaneous lesions and serum sicknesselike reactions in patients who had undergone jejunoileal bypass surgery for morbid obesity. The definition is now extended to include the same syndrome in patients with inflammatory bowel disease or blind loop following peptic ulcer surgery. We present a patient with this syndrome and highlight the importance of differentiating BADAS from other neutrophilic dermatoses. Observations: We describe a 49-year-old male with a history of Crohn disease who presented with a rash associated with fever, joint pains, sore eyes, abdominal pain, and diarrhea. A physical examination revealed multiple erythematous papulopustules and plaques on his limbs, trunk, head, and neck. Episcleritis, oral apthouselike and genital ulcers were noted. Laboratory tests were unremarkable apart from raised inflammatory markers. A skin biopsy revealed normal epidermis and superficial dermis and a mixed inflammatory cell infiltrate in the subcutaneous fat in lobular distribution. Based on the clinicopathological findings a diagnosis of BADAS was made. The rash rapidly cleared on high dose corticosteroid therapy.
MARCH 2009
J AM ACAD DERMATOL
AB59