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Palmoplantar eccrine hidradenitis induced by subacute cold injury: the same entity as childhood pernio?1
P518
P520
PALMOPLANTAR ECCRINE HIDRADENITIS INDUCED BY SUBACUTE COLD INJURY: THE SAME ENTITY AS CHILDHOOD PERNIO? Paula D Zook, MD, University of Washington School of Medicine, Seattle, WA, United States, Robin Hornung, MD, MPH, University of Washington School of Medicine, Seattle, WA, United States, Zsolt Argenyi, MD, University of Washington School of Medicine, Seattle, WA, United States A 12-year-old healthy female added on urgently to clinic for red, painful feet. Three days prior she developed fever, myalgias, fatigue, diarrhea, nausea and vomiting, and painful red bumps on the feet. All symptoms resolved after two days except foot pain, which progressed. The patient complained of burning, aching foot pain with severe TTP and inability to walk. In the past three weeks she had ridden her horse into a cold river on numerous occasions, most recently two days before her skin eruption. She had no prior history of skin disease. Examination revealed swollen, shiny, tense plantar skin bilaterally with numerous ill-defined bluish-red exquisitely tender nodules and macules on the plantar surfaces and sides of her feet. There was a suggestion of blanching around the lesions. The exam was otherwise normal. Routine histology showed superficial and deep perivascular and perieccrine inflammation of lymphocytes, neutrophils and rare eosinophils with extension into subcutaneous fat. The eccrine glands showed necrotic change, and there was an isolated neutrophilic abscess around an eccrine coil. There was also edema and scant inflammation of the papillary dermis. The epidermis was normal. The histologic diagnosis was pernio vs. palmoplantar eccrine hidradenitis. Palmoplantar eccrine hidradenitis is a benign, self-limited though recurrent disease which presents in healthy children as acute onset of tender, erythematous plantar nodules. A seasonal occurrence has been noted, and a wet and cold milieu has been postulated as causative by some authors. PPEH has many features in common with pernio in children, including the clinical presentation, possible connection to subacute cold injury, and similar histologic features. The most comprehensive review of the histology of pernio reports eccrine hidradenitis (primarily lymphocytic), papillary dermal edema, superficial and deep perivascular lymphocytic and neutrophilic inflammation, and mild lichenoid interface dermatitis. Based upon the clinical and histologic features of both entities, PPEH and childhood pernio may represent the same entity. PPEH must also be distinguished clinically and histologically from neutrophilic eccrine hidradenitis, which is seen in children undergoing chemotherapy for cancer.
SURPRISING CASE OF GENERALIZED ALOPECIA IN AN INFANT Hakim D Miriam, MD, BS, Montreal Children’s Hospital, McGill University Health Center, Montreal, QC, Canada, Natalie Nasser, MD, Brenda Moroz, MD Trichosporon, a genus of fungi that is ubiquitous in the environment, is also a member of the normal flora of the mouth, skin, and nails1. Trichosporon beigellii (T. beigellii) has been called the most significant pathogen in its genus2. This species has gained attention over the years as a causative agent of many superficial mycotic infections as well as invasive infections. A fungus native to South America, Africa, Japan, and temperate climates of Central and Eastern Europe3, Trichosporon beigellii is the etiologic agent of white piedra. White piedra is a superficial mycosis that is characterized clinically by greasy involvement of hair shaft(s) on the eyebrows, eyelashes, scalp, axillae and pubic hairs. Microscopic examination reveals soft, white to gray nodules composed of hyphae and arthrospores. In general, the underlying skin is not affected and Wood’s lamp exam does not aid the clinician in making the diagnosis. In children, the majority of infectious scalp alopecias are due to the dermatophyte species Microsporum, Trichophyton and Epidermophyton. We present a surprising and interesting case of generalized scalp alopecia due to T. Beigellii in an infant native to North America and stress the importance of culture and clinical examination in the diagnosis of infectious alopecias in the pediatric population. Furthermore, we discuss the treatments and sequelae of T. Beigellii infections in healthy and immunocompromised infants. Disclosure not available at press time.
Disclosure not available at press time.
Photobiology, Phototherapy & Photosensitivity Diseases P521
P519 MOLLUSCUM CONTAGIOSUM IN CHILDREN-WHO GETS THEM? Lawrence F Eichenfield, MD, Univ. of California, San Diego School of Medicine; Children’s Hospital, San Diego, San Diego, CA, United States, Magdalene Dohil, MD, Amy Paller, MD, Department of Pediatrics, Children’s Memorial Hospital, Northwestern University Medical Center, Chicago, IL, United States, Ann Lucky, MD, Dermatology Associates of Cincinnati, Cincinnati, OH, United States Molluscum contagiosum (MC) is a viral disorder of the skin and mucous membranes characterized by discrete single or multiple, flesh-colored papules. Although MC as a clinical entity is well defined, its epidemiology in children is poorly documented. The purpose of this study was to update epidemiologic data on children with MC with regard to age, gender, race, degree of involvement, relation to pre-existing atopic dermatitis (AD), and immune status. A retrospective chart review of 3 pediatric dermatology practices was conducted. A total of 302 patient charts with the CPT code diagnosis of MC seen over a 6 to 8-month period were reviewed. Most children were ⬍8 years of age, suggesting development of immunity at a young age. The majority of patients presented with ⬍15 lesions, which suggests that treatment with nonpainful destructive therapy (eg, cantharidin) or with topical immunotherapy (eg, imiquimod) is practical. Unlike earlier reports, the number of immunocompromised patients presenting with MC was extremely low. Approximately 25% of patients presented with a history of previous or active AD. Of these patients, 21.2% were using either a topical corticosteroid or calcineurin inhibitor as treatment for their coexistent AD at the time of the clinic visit. No patients were administered systemic immunosuppressive medication or were infected with human immunodeficiency virus. One patient had a diagnosis of immunoglobulin E deficiency. These data provide valuable updated information on the demographics and clinical presentation of MC in pediatric patients in the United States. All authors serve as consultants to 3M Pharmaceuticals. 100% is sponsored by an unrestricted educational grant provided by 3M Pharmaceuticals.
P134
J AM ACAD DERMATOL
CHRONIC ACTINIC DERMATITIS SUCCESSFULLY TREATED WITH MYCOPHENOLATE MOFETIL Michelle Thomson, MBChB, University Hospital Birmingham Department of Dermatology, Birmingham, England, Graeme Stewart, MD, University Hospital Birmingham Department of Dermatology, Birmingham, England, Helen Lewis, MD, University Hospital Birmingham Department of Dermatology, Birmingham, England Chronic actinic dermatitis (CAD) is characterised by abnormal photosensitivity to ultraviolet and often visible wavelengths. The aetiology remains uncertain and the response to standard therapies is unpredictable. Mycophenolate mofetil (MMF) is an immunosuppressant which is being increasingly used for inflammatory skin disorders. We present our recent experience using this novel treatment for refractory CAD. Two male patients, aged 55 years (patient 1) and 49 years (patient 2), presented with an eczematous eruption on photo exposed skin which was present year round with significant worsening in the summer. Phototesting revealed markedly reduced 24-hour minimal erythema dose and exaggerated papular responses to UVB. Patient 1 tested positive to nickel, cobalt and dichromate on patch testing and oxybenzone and Uvistat 30 on photopatch testing. Patient 2 had positive reactions to Balsum of Peru and phosphorous sesquisulphide on patch testing. His photopatch tests were negative. Histology showed epidermal hyperplasia and a dense perivascular infiltrate in the dermis. Porphyria screen, anti-nuclear and anti-Ro antibodies were negative. Both patients had refractory CAD or developed significant side effects to conventional therapies, including prednisolone, PUVA, azathioprine and cyclosporin. They received at least 6 years of these treatments prior to commencing MMF in early 2000. Each noted a significant improvement in symptoms within six weeks and subsequent clearing of the eczematous lesions. Patient 1 requires continuous treatment with MMF 500mg twice daily to prevent relapses. Patient 2 remains in remission using MMF 1g twice daily during the spring and summer months. Both patients have tolerated the treatment well with no abnormalities in blood count or liver biochemistry. Since commencing MMF, their quality of life has significantly improved with pursuit of outdoor activities using sun protection measures. These observations suggest that MMF should be considered as an alternative treatment to conventional therapies for refractory CAD. Disclosure not available at press time.
MARCH 2004
P520
PALMOPLANTAR ECCRINE HIDRADENITIS INDUCED BY SUBACUTE COLD INJURY: THE SAME ENTITY AS CHILDHOOD PERNIO? Paula D Zook, MD, University of Washington School of Medicine, Seattle, WA, United States, Robin Hornung, MD, MPH, University of Washington School of Medicine, Seattle, WA, United States, Zsolt Argenyi, MD, University of Washington School of Medicine, Seattle, WA, United States A 12-year-old healthy female added on urgently to clinic for red, painful feet. Three days prior she developed fever, myalgias, fatigue, diarrhea, nausea and vomiting, and painful red bumps on the feet. All symptoms resolved after two days except foot pain, which progressed. The patient complained of burning, aching foot pain with severe TTP and inability to walk. In the past three weeks she had ridden her horse into a cold river on numerous occasions, most recently two days before her skin eruption. She had no prior history of skin disease. Examination revealed swollen, shiny, tense plantar skin bilaterally with numerous ill-defined bluish-red exquisitely tender nodules and macules on the plantar surfaces and sides of her feet. There was a suggestion of blanching around the lesions. The exam was otherwise normal. Routine histology showed superficial and deep perivascular and perieccrine inflammation of lymphocytes, neutrophils and rare eosinophils with extension into subcutaneous fat. The eccrine glands showed necrotic change, and there was an isolated neutrophilic abscess around an eccrine coil. There was also edema and scant inflammation of the papillary dermis. The epidermis was normal. The histologic diagnosis was pernio vs. palmoplantar eccrine hidradenitis. Palmoplantar eccrine hidradenitis is a benign, self-limited though recurrent disease which presents in healthy children as acute onset of tender, erythematous plantar nodules. A seasonal occurrence has been noted, and a wet and cold milieu has been postulated as causative by some authors. PPEH has many features in common with pernio in children, including the clinical presentation, possible connection to subacute cold injury, and similar histologic features. The most comprehensive review of the histology of pernio reports eccrine hidradenitis (primarily lymphocytic), papillary dermal edema, superficial and deep perivascular lymphocytic and neutrophilic inflammation, and mild lichenoid interface dermatitis. Based upon the clinical and histologic features of both entities, PPEH and childhood pernio may represent the same entity. PPEH must also be distinguished clinically and histologically from neutrophilic eccrine hidradenitis, which is seen in children undergoing chemotherapy for cancer.
SURPRISING CASE OF GENERALIZED ALOPECIA IN AN INFANT Hakim D Miriam, MD, BS, Montreal Children’s Hospital, McGill University Health Center, Montreal, QC, Canada, Natalie Nasser, MD, Brenda Moroz, MD Trichosporon, a genus of fungi that is ubiquitous in the environment, is also a member of the normal flora of the mouth, skin, and nails1. Trichosporon beigellii (T. beigellii) has been called the most significant pathogen in its genus2. This species has gained attention over the years as a causative agent of many superficial mycotic infections as well as invasive infections. A fungus native to South America, Africa, Japan, and temperate climates of Central and Eastern Europe3, Trichosporon beigellii is the etiologic agent of white piedra. White piedra is a superficial mycosis that is characterized clinically by greasy involvement of hair shaft(s) on the eyebrows, eyelashes, scalp, axillae and pubic hairs. Microscopic examination reveals soft, white to gray nodules composed of hyphae and arthrospores. In general, the underlying skin is not affected and Wood’s lamp exam does not aid the clinician in making the diagnosis. In children, the majority of infectious scalp alopecias are due to the dermatophyte species Microsporum, Trichophyton and Epidermophyton. We present a surprising and interesting case of generalized scalp alopecia due to T. Beigellii in an infant native to North America and stress the importance of culture and clinical examination in the diagnosis of infectious alopecias in the pediatric population. Furthermore, we discuss the treatments and sequelae of T. Beigellii infections in healthy and immunocompromised infants. Disclosure not available at press time.
Disclosure not available at press time.
Photobiology, Phototherapy & Photosensitivity Diseases P521
P519 MOLLUSCUM CONTAGIOSUM IN CHILDREN-WHO GETS THEM? Lawrence F Eichenfield, MD, Univ. of California, San Diego School of Medicine; Children’s Hospital, San Diego, San Diego, CA, United States, Magdalene Dohil, MD, Amy Paller, MD, Department of Pediatrics, Children’s Memorial Hospital, Northwestern University Medical Center, Chicago, IL, United States, Ann Lucky, MD, Dermatology Associates of Cincinnati, Cincinnati, OH, United States Molluscum contagiosum (MC) is a viral disorder of the skin and mucous membranes characterized by discrete single or multiple, flesh-colored papules. Although MC as a clinical entity is well defined, its epidemiology in children is poorly documented. The purpose of this study was to update epidemiologic data on children with MC with regard to age, gender, race, degree of involvement, relation to pre-existing atopic dermatitis (AD), and immune status. A retrospective chart review of 3 pediatric dermatology practices was conducted. A total of 302 patient charts with the CPT code diagnosis of MC seen over a 6 to 8-month period were reviewed. Most children were ⬍8 years of age, suggesting development of immunity at a young age. The majority of patients presented with ⬍15 lesions, which suggests that treatment with nonpainful destructive therapy (eg, cantharidin) or with topical immunotherapy (eg, imiquimod) is practical. Unlike earlier reports, the number of immunocompromised patients presenting with MC was extremely low. Approximately 25% of patients presented with a history of previous or active AD. Of these patients, 21.2% were using either a topical corticosteroid or calcineurin inhibitor as treatment for their coexistent AD at the time of the clinic visit. No patients were administered systemic immunosuppressive medication or were infected with human immunodeficiency virus. One patient had a diagnosis of immunoglobulin E deficiency. These data provide valuable updated information on the demographics and clinical presentation of MC in pediatric patients in the United States. All authors serve as consultants to 3M Pharmaceuticals. 100% is sponsored by an unrestricted educational grant provided by 3M Pharmaceuticals.
P134
J AM ACAD DERMATOL
CHRONIC ACTINIC DERMATITIS SUCCESSFULLY TREATED WITH MYCOPHENOLATE MOFETIL Michelle Thomson, MBChB, University Hospital Birmingham Department of Dermatology, Birmingham, England, Graeme Stewart, MD, University Hospital Birmingham Department of Dermatology, Birmingham, England, Helen Lewis, MD, University Hospital Birmingham Department of Dermatology, Birmingham, England Chronic actinic dermatitis (CAD) is characterised by abnormal photosensitivity to ultraviolet and often visible wavelengths. The aetiology remains uncertain and the response to standard therapies is unpredictable. Mycophenolate mofetil (MMF) is an immunosuppressant which is being increasingly used for inflammatory skin disorders. We present our recent experience using this novel treatment for refractory CAD. Two male patients, aged 55 years (patient 1) and 49 years (patient 2), presented with an eczematous eruption on photo exposed skin which was present year round with significant worsening in the summer. Phototesting revealed markedly reduced 24-hour minimal erythema dose and exaggerated papular responses to UVB. Patient 1 tested positive to nickel, cobalt and dichromate on patch testing and oxybenzone and Uvistat 30 on photopatch testing. Patient 2 had positive reactions to Balsum of Peru and phosphorous sesquisulphide on patch testing. His photopatch tests were negative. Histology showed epidermal hyperplasia and a dense perivascular infiltrate in the dermis. Porphyria screen, anti-nuclear and anti-Ro antibodies were negative. Both patients had refractory CAD or developed significant side effects to conventional therapies, including prednisolone, PUVA, azathioprine and cyclosporin. They received at least 6 years of these treatments prior to commencing MMF in early 2000. Each noted a significant improvement in symptoms within six weeks and subsequent clearing of the eczematous lesions. Patient 1 requires continuous treatment with MMF 500mg twice daily to prevent relapses. Patient 2 remains in remission using MMF 1g twice daily during the spring and summer months. Both patients have tolerated the treatment well with no abnormalities in blood count or liver biochemistry. Since commencing MMF, their quality of life has significantly improved with pursuit of outdoor activities using sun protection measures. These observations suggest that MMF should be considered as an alternative treatment to conventional therapies for refractory CAD. Disclosure not available at press time.
MARCH 2004