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Recalcitrant cutaneous sarcoidosis causing facial disfigurement: Failure to respond to captopril and allopurinol
P1144
P1146
Changes in rosacea comorbidities and drug utilization over time Brad Yentzer, MD, WFU School of Medicine, Winston Salem, NC, United States; Alan Fleischer, MD, WFU School of Medicine, Winston Salem, NC, United States Background: Rosacea is a chronic skin condition, requiring lifelong treatment and carrying significant morbidity. Given the rise in antibiotic resistant bacteria, many physicians are reevaluating their use of antibiotics for long-term treatment of several dermatoses. Purpose: To examine trends in the treatment of rosacea and the comorbidities associated with this skin condition.
Hyperhydrosis with symptoms of blue pigmented chromhidrosis and bromhidrosis Yitzy Fox, New Age Skin Research Foundation, Fresh Meadows, NY, United States; Joshua Fox, MD, New Age Skin Research Foundation and Advanced Dermatology PC, Fresh Meadows, NY, United States; Rao Saladi, MD, New Age Skin Research Foundation, Fresh Meadows, NY, United States
Methods: The National Ambulatory Medical Care Survey was queried from 2002 to 2006 for drug mentions at visits for rosacea and coexisting diagnoses. Prescribing patterns from dermatologists were compared to other physicians. Results: Over the 5-year study period, 10 million visits made to physicians had the diagnosis of rosacea. Seventy-four percent of rosacea visits were associated with comorbidities, and 49% were dermatologic in nature. Metronidazole, tetracyclines, azelaic acid, and sodium sulfacetamide accounted for the top four medications mentioned at rosacea visits. When examining all physicians, there was an increase in the prescribing of azelaic acid and a decrease in sodium sulfacetamide. Only dermatologists showed a decrease in the prescribing of systemic medications for rosacea. Conclusions: Dermatologists are decreasing their use of systemic antibiotics for rosacea and turning to therapies, such as azelaic acid, that do not induce bacterial resistance and have other nonantimicrobial effects as well. Commercial support: 100% is sponsored by Intendis.
Background: Chromhidrosis, a rare skin disorder characterized by colored sweat, can be subcategorized based on its etiology from sweat producing apocrine or eccrine glands. Bromhidrosis (by definition meaning ‘‘foul-smelling sweat’’), another glandular condition, originates most commonly from apocrine glands and is additionally linked to malodor. Objective: We present a rare case of 63-year-old man with hyperhidrosis involving eccrine pseudochromhidrosis and blue sweat with a coexisting presence of severe bromhidrosis, a unique presentation that has not been reported in the dermatologic literature. Methods: In our further investigation for the culprit of the blue sweat from the patient, we performed chemical analysis of the patient’s belongings. Results: The patient noticed the discharge blue sweat for a period of 2 months before he came to seek treatment. The patient’s medical and medication history is noncontributory except that the patient was taking hypertensive drugs. The conditions were ultimately treated with prescription antiperspirant Xerac-AC and Drysol; they completely eliminated both the smell of bromhidrosis and the discharge of chromhidrosis. This is the first time an antiperspirant deodorant was reported to have significantly diminished both the smell and discharge of bromhidrosis and chromhidrosis, respectively. The patient’s undergarments revealed excessive copper and zinc levels, which may be the cause for the blue color of the sweat. However, the etiology is still unknown, and further research in patients with similar conditions should be investigated. Commercial support: None identified.
P1145 Follicular mucinosis treated with tacrolimus Ana Maria Mosca de Cerqueira, MD, Hospital Municipal Jesus, Rio de Janeiro, Brazil; Camila Caberlon Cruz Oliveira, MD, Hospital Municipal Jesus, Rio de Janeiro, Brazil; Claudia Fernanda Dias Souza, MD, Hospital Municipal Jesus, Rio de Janeiro, Brazil; Cristiane Cassab Sasajima, MD, Hospital Municipal Jesus, Rio de Janeiro, Brazil Folicular mucinosis (FMu) is a relatively rare dermatosis characterized by deposits of mucin in the skin or hairfollicles.There are two forms of the disease: an idiopathic or primary form, and another symptomatic form associated to benign and malignant processes. FMu does not have preference for sex and age, and the etiology is unknown. The clinical manifestation generally presenting as squamous plaques covered by porous pilosebaceous units, follicular papules, and alopecic areas. We present a new and successfully case treated with tacrolimus, a possible effective treatment for FMu. Clinical synopsis: A 12-year-old female patient from Bom Jardim-Rio de Janeiro with black skin, without personal or familiar antecedents, presented with cutaneous lesions in her left side of the face, with tenuous scaling, centrifugal increase, and asymptomatic. It was treated as face tinea for 15 days with topic antimycotic, but the patient returned with intense scaling, hypopigmentation, and infiltration. Histologic and immunohistochemical studies showed follicular mucinous. Finally, the patient was treated with tacrolimus 0.1%, showing total lesion regression after 15 days of treatment. A satisfactory evolution was observed in 9 months of follow-up. Discussion: FMu belongs to the cutaneous mucinoses group and is a chronic dermatosis involving the sebaceous glands and outer root sheaths. Recently, the FMu classification was expanded as follows: (1) primary, short evolution; (2) primary, prolonged course; and (3) secondary, associated with other processes. The first and most common form is a benign condition that affects children and young adults; in this condition, there are fewer lesions and those lesions are limited to the head and neck. These cure spontaneously and generally do not recur. The histopathologic findings are mucin degeneration in the external sheath of the hair follicle and sebaceous gland. Generally, the presence of a high number of eosinophils in the inflammatory infiltrate and marked mucinous alterations in the follicular epithelium speak in favor of a benign form. FMu has been treated with steroids, dapsone, indomethacin, interferons, isotretinoin, minocycline, and ultraviolet A, with variable success. Reason for presentation: The use of tacrolimus has not been reported yet in the treatment of FMu. We report a new and successfully case treated with tacrolimus in children with FMu in her face. Commercial support: None identified.
MARCH 2010
P1147 Recalcitrant cutaneous sarcoidosis causing facial disfigurement: Failure to respond to captopril and allopurinol Anton Alexandroff, MD, PhD, Department of Dermatology, Leicester Royal Infirmary, Leicester, United Kingdom; Karen Harman, MD, MBBCh, Department of Dermatology, Leicester Royal Infirmary, Leicester, United Kingdom Cutaneous sarcoidosis can be an extremely disfiguring and therefore distressing condition. A 48-year-old patient has had pulmonary and cutaneous sarcoidosis for 12 years. The diagnosis was confirmed by skin biopsy, which showed typical noncaseating granulomas, pulmonary function tests, and high-resolution chest computed tomography. She had normal angiotensin-converting enzyme levels and a normal chest radiograph and ECG. The pulmonary involvement was mild and easily controlled by Pulmicort steroid inhalers (taken as required). However, widespread cutaneous involvement with multiple purple indurated patches and plaques (affecting the face, limbs, and body), although they were asymptomatic, proved to be very distressing for our patient because of marked disfigurement; this affected her social life. Over the years, she gained no benefit from or did not tolerate the following treatments: potent and very potent topical corticosteroids with and without occlusion, intralesional corticosteroids, topical tacrolimus, oral prednisolone alone or in combination with oral methotrexate, minocycline, acitretin, hydroxychloroquine, azathioprine, and cyclosporin. In a few reports, it has been suggested that angiotensin-converting enzyme inhibitors and allopurinol may be beneficial in recalcitrant cases of cutaneous sarcoidosis. Our patient attempted treatment with the ACE inhibitor captopril but had to stop it after 6 weeks because of the side effects of a dry cough. She also received no benefit from a 4-month course of allopurinol. Our patient is currently being treated with fumaric acid esters (Fumaderm). No improvement has been noted so far following 6 months of treatment despite developing lymphopenia (0.6 3 109/L) on the maximum dose of Fumaderm (240 mg TDS). If the patient fails to respond to Fumaderm, we are planning to attempt treatment with photodynamic therapy, which has been reported successful in the treatment of three patients with cutaneous sarcoidosis. Commercial support: ABA received P&G Beauty travel reimbursement.
J AM ACAD DERMATOL
AB37
P1146
Changes in rosacea comorbidities and drug utilization over time Brad Yentzer, MD, WFU School of Medicine, Winston Salem, NC, United States; Alan Fleischer, MD, WFU School of Medicine, Winston Salem, NC, United States Background: Rosacea is a chronic skin condition, requiring lifelong treatment and carrying significant morbidity. Given the rise in antibiotic resistant bacteria, many physicians are reevaluating their use of antibiotics for long-term treatment of several dermatoses. Purpose: To examine trends in the treatment of rosacea and the comorbidities associated with this skin condition.
Hyperhydrosis with symptoms of blue pigmented chromhidrosis and bromhidrosis Yitzy Fox, New Age Skin Research Foundation, Fresh Meadows, NY, United States; Joshua Fox, MD, New Age Skin Research Foundation and Advanced Dermatology PC, Fresh Meadows, NY, United States; Rao Saladi, MD, New Age Skin Research Foundation, Fresh Meadows, NY, United States
Methods: The National Ambulatory Medical Care Survey was queried from 2002 to 2006 for drug mentions at visits for rosacea and coexisting diagnoses. Prescribing patterns from dermatologists were compared to other physicians. Results: Over the 5-year study period, 10 million visits made to physicians had the diagnosis of rosacea. Seventy-four percent of rosacea visits were associated with comorbidities, and 49% were dermatologic in nature. Metronidazole, tetracyclines, azelaic acid, and sodium sulfacetamide accounted for the top four medications mentioned at rosacea visits. When examining all physicians, there was an increase in the prescribing of azelaic acid and a decrease in sodium sulfacetamide. Only dermatologists showed a decrease in the prescribing of systemic medications for rosacea. Conclusions: Dermatologists are decreasing their use of systemic antibiotics for rosacea and turning to therapies, such as azelaic acid, that do not induce bacterial resistance and have other nonantimicrobial effects as well. Commercial support: 100% is sponsored by Intendis.
Background: Chromhidrosis, a rare skin disorder characterized by colored sweat, can be subcategorized based on its etiology from sweat producing apocrine or eccrine glands. Bromhidrosis (by definition meaning ‘‘foul-smelling sweat’’), another glandular condition, originates most commonly from apocrine glands and is additionally linked to malodor. Objective: We present a rare case of 63-year-old man with hyperhidrosis involving eccrine pseudochromhidrosis and blue sweat with a coexisting presence of severe bromhidrosis, a unique presentation that has not been reported in the dermatologic literature. Methods: In our further investigation for the culprit of the blue sweat from the patient, we performed chemical analysis of the patient’s belongings. Results: The patient noticed the discharge blue sweat for a period of 2 months before he came to seek treatment. The patient’s medical and medication history is noncontributory except that the patient was taking hypertensive drugs. The conditions were ultimately treated with prescription antiperspirant Xerac-AC and Drysol; they completely eliminated both the smell of bromhidrosis and the discharge of chromhidrosis. This is the first time an antiperspirant deodorant was reported to have significantly diminished both the smell and discharge of bromhidrosis and chromhidrosis, respectively. The patient’s undergarments revealed excessive copper and zinc levels, which may be the cause for the blue color of the sweat. However, the etiology is still unknown, and further research in patients with similar conditions should be investigated. Commercial support: None identified.
P1145 Follicular mucinosis treated with tacrolimus Ana Maria Mosca de Cerqueira, MD, Hospital Municipal Jesus, Rio de Janeiro, Brazil; Camila Caberlon Cruz Oliveira, MD, Hospital Municipal Jesus, Rio de Janeiro, Brazil; Claudia Fernanda Dias Souza, MD, Hospital Municipal Jesus, Rio de Janeiro, Brazil; Cristiane Cassab Sasajima, MD, Hospital Municipal Jesus, Rio de Janeiro, Brazil Folicular mucinosis (FMu) is a relatively rare dermatosis characterized by deposits of mucin in the skin or hairfollicles.There are two forms of the disease: an idiopathic or primary form, and another symptomatic form associated to benign and malignant processes. FMu does not have preference for sex and age, and the etiology is unknown. The clinical manifestation generally presenting as squamous plaques covered by porous pilosebaceous units, follicular papules, and alopecic areas. We present a new and successfully case treated with tacrolimus, a possible effective treatment for FMu. Clinical synopsis: A 12-year-old female patient from Bom Jardim-Rio de Janeiro with black skin, without personal or familiar antecedents, presented with cutaneous lesions in her left side of the face, with tenuous scaling, centrifugal increase, and asymptomatic. It was treated as face tinea for 15 days with topic antimycotic, but the patient returned with intense scaling, hypopigmentation, and infiltration. Histologic and immunohistochemical studies showed follicular mucinous. Finally, the patient was treated with tacrolimus 0.1%, showing total lesion regression after 15 days of treatment. A satisfactory evolution was observed in 9 months of follow-up. Discussion: FMu belongs to the cutaneous mucinoses group and is a chronic dermatosis involving the sebaceous glands and outer root sheaths. Recently, the FMu classification was expanded as follows: (1) primary, short evolution; (2) primary, prolonged course; and (3) secondary, associated with other processes. The first and most common form is a benign condition that affects children and young adults; in this condition, there are fewer lesions and those lesions are limited to the head and neck. These cure spontaneously and generally do not recur. The histopathologic findings are mucin degeneration in the external sheath of the hair follicle and sebaceous gland. Generally, the presence of a high number of eosinophils in the inflammatory infiltrate and marked mucinous alterations in the follicular epithelium speak in favor of a benign form. FMu has been treated with steroids, dapsone, indomethacin, interferons, isotretinoin, minocycline, and ultraviolet A, with variable success. Reason for presentation: The use of tacrolimus has not been reported yet in the treatment of FMu. We report a new and successfully case treated with tacrolimus in children with FMu in her face. Commercial support: None identified.
MARCH 2010
P1147 Recalcitrant cutaneous sarcoidosis causing facial disfigurement: Failure to respond to captopril and allopurinol Anton Alexandroff, MD, PhD, Department of Dermatology, Leicester Royal Infirmary, Leicester, United Kingdom; Karen Harman, MD, MBBCh, Department of Dermatology, Leicester Royal Infirmary, Leicester, United Kingdom Cutaneous sarcoidosis can be an extremely disfiguring and therefore distressing condition. A 48-year-old patient has had pulmonary and cutaneous sarcoidosis for 12 years. The diagnosis was confirmed by skin biopsy, which showed typical noncaseating granulomas, pulmonary function tests, and high-resolution chest computed tomography. She had normal angiotensin-converting enzyme levels and a normal chest radiograph and ECG. The pulmonary involvement was mild and easily controlled by Pulmicort steroid inhalers (taken as required). However, widespread cutaneous involvement with multiple purple indurated patches and plaques (affecting the face, limbs, and body), although they were asymptomatic, proved to be very distressing for our patient because of marked disfigurement; this affected her social life. Over the years, she gained no benefit from or did not tolerate the following treatments: potent and very potent topical corticosteroids with and without occlusion, intralesional corticosteroids, topical tacrolimus, oral prednisolone alone or in combination with oral methotrexate, minocycline, acitretin, hydroxychloroquine, azathioprine, and cyclosporin. In a few reports, it has been suggested that angiotensin-converting enzyme inhibitors and allopurinol may be beneficial in recalcitrant cases of cutaneous sarcoidosis. Our patient attempted treatment with the ACE inhibitor captopril but had to stop it after 6 weeks because of the side effects of a dry cough. She also received no benefit from a 4-month course of allopurinol. Our patient is currently being treated with fumaric acid esters (Fumaderm). No improvement has been noted so far following 6 months of treatment despite developing lymphopenia (0.6 3 109/L) on the maximum dose of Fumaderm (240 mg TDS). If the patient fails to respond to Fumaderm, we are planning to attempt treatment with photodynamic therapy, which has been reported successful in the treatment of three patients with cutaneous sarcoidosis. Commercial support: ABA received P&G Beauty travel reimbursement.
J AM ACAD DERMATOL
AB37