- Email: [email protected]
Dermatitis herpetiformis flare associated with use of triiodomethane packing strips for alveolar osteitis
352 Letters
J AM ACAD DERMATOL FEBRUARY 2009
CASE Dermatitis herpetiformis flare associated with use of triiodomethane packing strips for alveolar osteitis To the Editor: Dermatitis herpetiformis (DH) is an autoimmune blistering disease associated with gluten sensitivity that typically presents with extremely pruritic erythematous, urticarial papules and plaques containing herpetiform vesicles on the extensor aspects of the elbows and knees, the buttocks, and the back. We report a case of a DH flare following exposure to triiodomethane in a 19-year-old white woman. The patient presented with a 6-year history of DH, confirmed by histopathology and immunofluorescence and controlled with a gluten-free diet and dapsone 50 mg daily. Three days after undergoing extraction of six molar teeth, she complained of increasing mouth pain and was diagnosed with alveolar osteitis in two sockets. The involved sockets were packed with packing strips containing triiodomethane (Curity Iodoform Packing Strips; Tyco Healthcare/Kendall, Mansfield, MA) and a paste containing chlorobutanol, guaiacol, eugenol, and balsam of Peru (Dry Socket Paste; Sultan Healthcare, Engelwood, NJ). One day later, she experienced an eruption of extremely pruritic papules and vesicles on the shoulders, elbows, knees, and buttocks. The eruption was more severe than eruptions occurring during previous exacerbations. Dapsone was increased to 75 mg daily without improvement. In light of the packing strips’ temporal association with the flare, they were removed. One day later, the skin lesions and symptoms began resolving and resolved entirely within 2 weeks. At that time, dapsone was decreased to 50 mg daily. Since then, she has experienced occasional mild DH exacerbations associated with gluten ingestion. The observation that iodine and related compounds can trigger DH onset or flares dates to 1891,1 although the pathophysiology of these reactions has not been well characterized. Historically, provocative tests using oral iodine or iodides or topical iodides have been used in the diagnosis of DH.1-4 Potassium idodide, contrast media, iodine-containing diets (including seafood), and thyroid disorders (with and without treatment with iodine compounds) have also been associated with DH onset or flares.1,5,6 To our knowledge, only one previous report has linked triiodomethane exposure to a DH flare.7 That patient was a 60-year-old female with a
LETTERS 3-year history of DH whose disease became refractory to treatment (including dapsone 100 mg daily and a sulfonamide and a corticosteroid) after she had a triiodomethane-containing filling material placed in an endodontically treated tooth. After extraction of that tooth, her symptoms were eliminated with dapsone 50 mg daily. DH flares have not been associated with iodine-containing products applied to the skin, such as surgical antiseptics, which might be related to the lower systemic absorption through keratinized, compared to nonkeratinized, squamous epithelium. DH flares have also not been associated with chlorobutanol, guaiacol, eugenol, or balsam of Peru, although given the temporal association between use of these compounds and the DH flare, they cannot be ruled out as a cause. DH patients and their physicians and dentists should be aware that exposure to iodine-containing products such as triiodomethane might lead to a disease flare. Physicians and dentists should consider using alternatives to iodine-containing products in DH patients. The authors thank Frederick N. Hyman, DDS, MPH, for his helpful comments during the preparation of this manuscript.
Kenneth A. Katz, MD, MSc, MSCE,a Julie E. Roseman,b Robert L. Roseman, MD,c and Stephen I. Katz, MD, PhDd From San Francisco, Californiaa; Emory University,b Atlanta, Georgia; Vitreo Retinal Associates,c Gainesville, Florida; and the Dermatology Branch,d National Cancer Institute, National Institutes of Health, Bethesda, Maryland Funding sources: None. Conflicts of interest: None declared. Correspondence to: Kenneth A. Katz, MD, MSc, MSCE, 1360 Mission St, Ste 401, San Francisco, CA 94103 E-mail: [email protected]
REFERENCES 1. From E, Thomsen K. Dermatitis herpetiformis. A case provoked by iodine. Br J Dermatol 1974;91:221-4. 2. Charlesworth EN, Backe JT, Garcia RL. Iodide-induced immunofluorescence in dermatitis herpetiformis. Arch Dermatol 1976; 112:555.
Letters 353
J AM ACAD DERMATOL VOLUME 60, NUMBER 2
3. Haffenden GP, Blenkinsopp WK, Ring NP, Wojnarowska F, Fry L. The potassium iodide patch test in dermatitis herpetiformis in relation to treatment with a gluten-free diet and dapsone. Br J Dermatol 1980;103:313-7. 4. Salo OP, Laiho K, Blomqvist K, Mustakallio KK. Papillary deposition of fibrin in iodide reactions in dermatitis herpetiformis. Ann Clin Res 1970;2:19-21. 5. Sciallis GF. Dermatitis herpetiformis and iodine. Br J Dermatol 1976;94:343. 6. Douglas WS, Alexander JOD. Dermatitis herpetiformis, iodine compounds, and thyrotoxicosis. Br J Dermatol 1975;92:596-8. 7. Landes E. Therapy resistance of a dermatitis herpetiformis Duhring to sulones, sulfonamides and steroids caused by iodoform dental filling [in German]. Z Haut Geschlechtskr 1960;28:306-7. doi:10.1016/j.jaad.2008.08.041
The use of dermatoscopy to differentiate vestibular papillae, a normal variant of the female external genitalia, from condyloma acuminata To the Editor: Vestibular papillae of the vulva are very small asymptomatic filiform or soft, frond-like projections on the vestibular epithelium or the inner aspect of the labia minora.1,2 This normal variant has a smooth surface and similar color to the adjacent mucosa.2 Although common, the condition may be unfamiliar to clinicians and may be misdiagnosed as condyloma acuminata.3
A 39-year-old female presented with multiple papillary projections on the vulva. Three months earlier, she had complained of vulvodynia after childbirth and first recognized multiple grouped papillary projections on the inner left side of the labia minora. These had smooth surfaces and were the same color as the adjacent mucosa (Fig 1, A). At an obstetrics/gynecologic clinic, she was diagnosed as having condyloma acuminata, and at dermatologic clinic she was believed to have Bartholin adenitis. She was prescribed a first-generation cephalosporin (an oral dose of cephradine 1 g a day for 7 days) for the presumed Bartholin adenitis. The vulvodynia improved, but the objective findings remained unchanged without associated itching or tenderness. Dermatoscopy with the DermLite II Pro (3Gen, San Juan, Capistrano, CA) demonstrated a regular, often symmetrical and linear, array of papillae over the vestibule. Individual vestibular papillae were juxtaposed, and their respective bases remained separate. Abundant, irregular vascular channels were observed in the transparent core of the papillae (Fig 1, B). Routine laboratory investigations and potassium hydroxide examinations were normal or negative. An excisional biopsy was performed; this showed anastomosing vascular projections covered by a normal epithelium with no histologic features of viral infection (Fig 2). Polymerase chain reaction
Fig 1. A, Multiple skin-colored, soft, frond-like projections on the left inner aspect of the labia minora. B, Dermatoscopic findings include multiple filiform projections with abundant vascular structures. The bases of the individual projections remain separate.
J AM ACAD DERMATOL FEBRUARY 2009
CASE Dermatitis herpetiformis flare associated with use of triiodomethane packing strips for alveolar osteitis To the Editor: Dermatitis herpetiformis (DH) is an autoimmune blistering disease associated with gluten sensitivity that typically presents with extremely pruritic erythematous, urticarial papules and plaques containing herpetiform vesicles on the extensor aspects of the elbows and knees, the buttocks, and the back. We report a case of a DH flare following exposure to triiodomethane in a 19-year-old white woman. The patient presented with a 6-year history of DH, confirmed by histopathology and immunofluorescence and controlled with a gluten-free diet and dapsone 50 mg daily. Three days after undergoing extraction of six molar teeth, she complained of increasing mouth pain and was diagnosed with alveolar osteitis in two sockets. The involved sockets were packed with packing strips containing triiodomethane (Curity Iodoform Packing Strips; Tyco Healthcare/Kendall, Mansfield, MA) and a paste containing chlorobutanol, guaiacol, eugenol, and balsam of Peru (Dry Socket Paste; Sultan Healthcare, Engelwood, NJ). One day later, she experienced an eruption of extremely pruritic papules and vesicles on the shoulders, elbows, knees, and buttocks. The eruption was more severe than eruptions occurring during previous exacerbations. Dapsone was increased to 75 mg daily without improvement. In light of the packing strips’ temporal association with the flare, they were removed. One day later, the skin lesions and symptoms began resolving and resolved entirely within 2 weeks. At that time, dapsone was decreased to 50 mg daily. Since then, she has experienced occasional mild DH exacerbations associated with gluten ingestion. The observation that iodine and related compounds can trigger DH onset or flares dates to 1891,1 although the pathophysiology of these reactions has not been well characterized. Historically, provocative tests using oral iodine or iodides or topical iodides have been used in the diagnosis of DH.1-4 Potassium idodide, contrast media, iodine-containing diets (including seafood), and thyroid disorders (with and without treatment with iodine compounds) have also been associated with DH onset or flares.1,5,6 To our knowledge, only one previous report has linked triiodomethane exposure to a DH flare.7 That patient was a 60-year-old female with a
LETTERS 3-year history of DH whose disease became refractory to treatment (including dapsone 100 mg daily and a sulfonamide and a corticosteroid) after she had a triiodomethane-containing filling material placed in an endodontically treated tooth. After extraction of that tooth, her symptoms were eliminated with dapsone 50 mg daily. DH flares have not been associated with iodine-containing products applied to the skin, such as surgical antiseptics, which might be related to the lower systemic absorption through keratinized, compared to nonkeratinized, squamous epithelium. DH flares have also not been associated with chlorobutanol, guaiacol, eugenol, or balsam of Peru, although given the temporal association between use of these compounds and the DH flare, they cannot be ruled out as a cause. DH patients and their physicians and dentists should be aware that exposure to iodine-containing products such as triiodomethane might lead to a disease flare. Physicians and dentists should consider using alternatives to iodine-containing products in DH patients. The authors thank Frederick N. Hyman, DDS, MPH, for his helpful comments during the preparation of this manuscript.
Kenneth A. Katz, MD, MSc, MSCE,a Julie E. Roseman,b Robert L. Roseman, MD,c and Stephen I. Katz, MD, PhDd From San Francisco, Californiaa; Emory University,b Atlanta, Georgia; Vitreo Retinal Associates,c Gainesville, Florida; and the Dermatology Branch,d National Cancer Institute, National Institutes of Health, Bethesda, Maryland Funding sources: None. Conflicts of interest: None declared. Correspondence to: Kenneth A. Katz, MD, MSc, MSCE, 1360 Mission St, Ste 401, San Francisco, CA 94103 E-mail: [email protected]
REFERENCES 1. From E, Thomsen K. Dermatitis herpetiformis. A case provoked by iodine. Br J Dermatol 1974;91:221-4. 2. Charlesworth EN, Backe JT, Garcia RL. Iodide-induced immunofluorescence in dermatitis herpetiformis. Arch Dermatol 1976; 112:555.
Letters 353
J AM ACAD DERMATOL VOLUME 60, NUMBER 2
3. Haffenden GP, Blenkinsopp WK, Ring NP, Wojnarowska F, Fry L. The potassium iodide patch test in dermatitis herpetiformis in relation to treatment with a gluten-free diet and dapsone. Br J Dermatol 1980;103:313-7. 4. Salo OP, Laiho K, Blomqvist K, Mustakallio KK. Papillary deposition of fibrin in iodide reactions in dermatitis herpetiformis. Ann Clin Res 1970;2:19-21. 5. Sciallis GF. Dermatitis herpetiformis and iodine. Br J Dermatol 1976;94:343. 6. Douglas WS, Alexander JOD. Dermatitis herpetiformis, iodine compounds, and thyrotoxicosis. Br J Dermatol 1975;92:596-8. 7. Landes E. Therapy resistance of a dermatitis herpetiformis Duhring to sulones, sulfonamides and steroids caused by iodoform dental filling [in German]. Z Haut Geschlechtskr 1960;28:306-7. doi:10.1016/j.jaad.2008.08.041
The use of dermatoscopy to differentiate vestibular papillae, a normal variant of the female external genitalia, from condyloma acuminata To the Editor: Vestibular papillae of the vulva are very small asymptomatic filiform or soft, frond-like projections on the vestibular epithelium or the inner aspect of the labia minora.1,2 This normal variant has a smooth surface and similar color to the adjacent mucosa.2 Although common, the condition may be unfamiliar to clinicians and may be misdiagnosed as condyloma acuminata.3
A 39-year-old female presented with multiple papillary projections on the vulva. Three months earlier, she had complained of vulvodynia after childbirth and first recognized multiple grouped papillary projections on the inner left side of the labia minora. These had smooth surfaces and were the same color as the adjacent mucosa (Fig 1, A). At an obstetrics/gynecologic clinic, she was diagnosed as having condyloma acuminata, and at dermatologic clinic she was believed to have Bartholin adenitis. She was prescribed a first-generation cephalosporin (an oral dose of cephradine 1 g a day for 7 days) for the presumed Bartholin adenitis. The vulvodynia improved, but the objective findings remained unchanged without associated itching or tenderness. Dermatoscopy with the DermLite II Pro (3Gen, San Juan, Capistrano, CA) demonstrated a regular, often symmetrical and linear, array of papillae over the vestibule. Individual vestibular papillae were juxtaposed, and their respective bases remained separate. Abundant, irregular vascular channels were observed in the transparent core of the papillae (Fig 1, B). Routine laboratory investigations and potassium hydroxide examinations were normal or negative. An excisional biopsy was performed; this showed anastomosing vascular projections covered by a normal epithelium with no histologic features of viral infection (Fig 2). Polymerase chain reaction
Fig 1. A, Multiple skin-colored, soft, frond-like projections on the left inner aspect of the labia minora. B, Dermatoscopic findings include multiple filiform projections with abundant vascular structures. The bases of the individual projections remain separate.