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Sneddon–Wilkinson disease associated with seronegative inflammatory polyarthritis
Resolution of radiation-induced acneiform eruption after treatment with minocycline and tretinoin
SneddoneWilkinson disease associated with seronegative inflammatory polyarthritis
(Poster reference number 4618)
(Poster reference number 5088)
Karina Parr, MD, Scott and White Memorial Hospital and Texas A&M University Health Science Center, Temple, TX, United States; Rod Mahmoudizad, UTMB, Galveston, TX, United States; Ronald Grimwood, MD, Scott and White Memorial Hospital and Texas A&M Health Science Center, Temple, TX, United States Postradiation comedogenesis is an uncommon side effect of radiation therapy, with few cases reported in the medical literature. Proposed etiology of this reaction is alteration of pilosebaceous unit secretions and retention of proliferating ductal keratinocytes due to stricture and scarring. We report a case of a 48-year-old white woman treated for infiltrating ductal carcinoma with lumpectomy and radiation, who subsequently developed open and closed comedones as well as tender inflammatory papules and papulopustules in the irradiated areas. Our patient was treated with topical tretinoin cream and oral minocycline, with rapid improvement in symptoms and complete resolution of lesions after 2 months of therapy. We reviewed previous literature on pathogenesis, clinical features, and treatment of postradiation acne. To our knowledge, this is the first reported case of a rapid resolution of a radiation-induced acneiform eruption after combination treatment with minocycline and tretinoin.
Theng Theng Lew, MBBS, Solihull Hospital, Solihull, United Kingdom; Joanne Hague, MBBS, Solihull Hospital, Solihull, United Kingdom; Peter Colloby, MBBS, Solihull Hospital, Solihull, United Kingdom; Stephen Oripin, MBChB, Solihull Hospital, Solihull, United Kingdom A 78-year-old woman previously diagnosed with well controlled mild plaque psoriasis presented to rheumatology with a 5-month history of a symmetric, rheumatoid-like seronegative inflammatory polyarthritis affecting her knees, wrists, and hands. She was diagnosed with psoriatic arthropathy and commenced on oral methotrexate at 12.5 mg weekly with good clinical response. However, she presented to dermatology 10 years later with a pustular eruption in the axillae, groin and abdominal folds. Fluid levels were seen in a few flaccid pustules. Laboratory examinations including full blood count, renal and liver function, ANA and ENA were unremarkable. Serum IgA monoclonal gammopathy was noted, although urinary BenceeJones protein was negative. Histology showed subcorneal neutrophilic infiltrates and direct immunofluorescence was negative for IgA deposition. A diagnosis of subcorneal pustular dermatosis or SneddoneWilkinson disease (SWD) was made based on the clinical and histologic findings. Hematological assessment suggested monoclonal gammopathy of unknown significance (MGUS) requiring biannual review. SWD is a rare, benign inflammatory dermatosis of unknown etiology, which is associated with monoclonal gammopathies and myeloproliferative disorders, and less commonly rheumatoid arthritis. Its association with seronegative arthritis is even rarer, with only a few reported cases in the literature. Interestingly, evolvement of SWD to pustular or plaque psoriasis has been described in children. However, it is unclear if our patient has two separate skin pathologies or if SWD was present at the onset. She was commenced on a potent topical steroid although systemic therapy is likely to be required because of the poor clinical response. The challenge lies in selecting a first-line treatment to be given in combination with methotrexate that has been effective in managing her arthritis. The use of methotrexate together with dapsone, the usual drug of choice in SWD, may result in an increased risk of serious hematologic side effects, although dual therapy is not absolutely contraindicated if strict blood monitoring is observed. In cases where dapsone is ineffective or poorly tolerated, good therapeutic response has been reported with acitretin or phototherapy (both narrow band UVB and psoralen with UVA). The combination of methotrexate with one of these alternative treatments would possibly be a more acceptable option with less risk of hematologic abnormalities.
Commercial support: None identified.
Commercial support: None identified.
Review of the effect of race/ethnicity on medication adherence
(Poster reference number 5401)
Sarah Koch, BBA, Wake Forest University School of Medicine, Winston Salem, NC, United States; Michelle M. Levender, MD, Wake Forest University School of Medicine, Winston Salem, NC, United States; Steve R. Feldman, MD, PhD, Wake Forest University School of Medicine, Winston Salem, NC, United States Background: Medication adherence is generally poor and costs the US health care system billions of dollars annually. Several studies have looked at the relationship between race and adherence to specific medications, or race and adherence among certain subpopulations; however, there appears to be a paucity of studies investigating the general effects of race on adherence. Purpose: To assess the relationship between race and medication adherence. Methods: A PubMed literature search was conducted using the search terms ‘‘race’’ OR ‘‘ethnicity’’ AND ‘‘adherence.’’ Results: Eghty-two of the 103 articles reviewed (79.6%) found a significant relationship between race and adherence. Black race was the most common race/ethnicity to be significantly associated with poor adherence (58 articles), followed by Latino/Hispanic/Mexican American (17 articles). White race was the most common race/ethnicity to be significantly associated with good adherence (6 articles), followed by Japanese (2 articles), and black (1 article). Conclusion: There appears to be substantial evidence of a relationship between race and medication adherence. Further research is needed to understand the confounding variables that may be involved, the full prevalence of this relationship within certain fields of medicine and certain subpopulations, and, most importantly, what providers can do to improve adherence across all races. Commercial support: None identified.
APRIL 2012
Solitary plexiform neurofibroma in the absence of neurofibromastosis type I: A case report
(Poster reference number 5338)
Andrea Hui, MD, Department of Dermatology at SUNY Downstate Medical Center, Brooklyn, Brooklyn, NY, United States; Erin Gilbert, MD, PhD, Department of Dermatology at SUNY Downstate Medical Center, Brooklyn, Brooklyn, NY, United States Background: Plexiform neurofibroma (PNF) is a benign tumor composed of a proliferation of neuromesenchymal tissue, typically involving the trunk. The PNF is considered pathognomonic of neurofibromatosis type I (NF1). This article presents a case of solitary PNF on the abdomen of an adult female, without family history, cutaneous, or systemic features of NF1. Case report: A 30-year-old woman presented with a tender subcutaneous nodule on the left lower abdomen, which had been present since age 12. The patient denied family history of NF1. Physical examination was otherwise normal and did not reveal any other cutaneous features of NF1, and ophthalmologic slit-lamp examination did not reveal Lisch nodules. The lesion was completely removed by excisional biopsy. Histologic examination revealed PNF. Discussion: PNF is considered pathognomonic of NF1. This case was unique in that it describes a solitary PNF in the absence of other features diagnostic for NF1, and without a family history. A review of the literature for solitary PNF demonstrates a paucity of such cases. Commercial support: None identified.
J AM ACAD DERMATOL
AB61
SneddoneWilkinson disease associated with seronegative inflammatory polyarthritis
(Poster reference number 4618)
(Poster reference number 5088)
Karina Parr, MD, Scott and White Memorial Hospital and Texas A&M University Health Science Center, Temple, TX, United States; Rod Mahmoudizad, UTMB, Galveston, TX, United States; Ronald Grimwood, MD, Scott and White Memorial Hospital and Texas A&M Health Science Center, Temple, TX, United States Postradiation comedogenesis is an uncommon side effect of radiation therapy, with few cases reported in the medical literature. Proposed etiology of this reaction is alteration of pilosebaceous unit secretions and retention of proliferating ductal keratinocytes due to stricture and scarring. We report a case of a 48-year-old white woman treated for infiltrating ductal carcinoma with lumpectomy and radiation, who subsequently developed open and closed comedones as well as tender inflammatory papules and papulopustules in the irradiated areas. Our patient was treated with topical tretinoin cream and oral minocycline, with rapid improvement in symptoms and complete resolution of lesions after 2 months of therapy. We reviewed previous literature on pathogenesis, clinical features, and treatment of postradiation acne. To our knowledge, this is the first reported case of a rapid resolution of a radiation-induced acneiform eruption after combination treatment with minocycline and tretinoin.
Theng Theng Lew, MBBS, Solihull Hospital, Solihull, United Kingdom; Joanne Hague, MBBS, Solihull Hospital, Solihull, United Kingdom; Peter Colloby, MBBS, Solihull Hospital, Solihull, United Kingdom; Stephen Oripin, MBChB, Solihull Hospital, Solihull, United Kingdom A 78-year-old woman previously diagnosed with well controlled mild plaque psoriasis presented to rheumatology with a 5-month history of a symmetric, rheumatoid-like seronegative inflammatory polyarthritis affecting her knees, wrists, and hands. She was diagnosed with psoriatic arthropathy and commenced on oral methotrexate at 12.5 mg weekly with good clinical response. However, she presented to dermatology 10 years later with a pustular eruption in the axillae, groin and abdominal folds. Fluid levels were seen in a few flaccid pustules. Laboratory examinations including full blood count, renal and liver function, ANA and ENA were unremarkable. Serum IgA monoclonal gammopathy was noted, although urinary BenceeJones protein was negative. Histology showed subcorneal neutrophilic infiltrates and direct immunofluorescence was negative for IgA deposition. A diagnosis of subcorneal pustular dermatosis or SneddoneWilkinson disease (SWD) was made based on the clinical and histologic findings. Hematological assessment suggested monoclonal gammopathy of unknown significance (MGUS) requiring biannual review. SWD is a rare, benign inflammatory dermatosis of unknown etiology, which is associated with monoclonal gammopathies and myeloproliferative disorders, and less commonly rheumatoid arthritis. Its association with seronegative arthritis is even rarer, with only a few reported cases in the literature. Interestingly, evolvement of SWD to pustular or plaque psoriasis has been described in children. However, it is unclear if our patient has two separate skin pathologies or if SWD was present at the onset. She was commenced on a potent topical steroid although systemic therapy is likely to be required because of the poor clinical response. The challenge lies in selecting a first-line treatment to be given in combination with methotrexate that has been effective in managing her arthritis. The use of methotrexate together with dapsone, the usual drug of choice in SWD, may result in an increased risk of serious hematologic side effects, although dual therapy is not absolutely contraindicated if strict blood monitoring is observed. In cases where dapsone is ineffective or poorly tolerated, good therapeutic response has been reported with acitretin or phototherapy (both narrow band UVB and psoralen with UVA). The combination of methotrexate with one of these alternative treatments would possibly be a more acceptable option with less risk of hematologic abnormalities.
Commercial support: None identified.
Commercial support: None identified.
Review of the effect of race/ethnicity on medication adherence
(Poster reference number 5401)
Sarah Koch, BBA, Wake Forest University School of Medicine, Winston Salem, NC, United States; Michelle M. Levender, MD, Wake Forest University School of Medicine, Winston Salem, NC, United States; Steve R. Feldman, MD, PhD, Wake Forest University School of Medicine, Winston Salem, NC, United States Background: Medication adherence is generally poor and costs the US health care system billions of dollars annually. Several studies have looked at the relationship between race and adherence to specific medications, or race and adherence among certain subpopulations; however, there appears to be a paucity of studies investigating the general effects of race on adherence. Purpose: To assess the relationship between race and medication adherence. Methods: A PubMed literature search was conducted using the search terms ‘‘race’’ OR ‘‘ethnicity’’ AND ‘‘adherence.’’ Results: Eghty-two of the 103 articles reviewed (79.6%) found a significant relationship between race and adherence. Black race was the most common race/ethnicity to be significantly associated with poor adherence (58 articles), followed by Latino/Hispanic/Mexican American (17 articles). White race was the most common race/ethnicity to be significantly associated with good adherence (6 articles), followed by Japanese (2 articles), and black (1 article). Conclusion: There appears to be substantial evidence of a relationship between race and medication adherence. Further research is needed to understand the confounding variables that may be involved, the full prevalence of this relationship within certain fields of medicine and certain subpopulations, and, most importantly, what providers can do to improve adherence across all races. Commercial support: None identified.
APRIL 2012
Solitary plexiform neurofibroma in the absence of neurofibromastosis type I: A case report
(Poster reference number 5338)
Andrea Hui, MD, Department of Dermatology at SUNY Downstate Medical Center, Brooklyn, Brooklyn, NY, United States; Erin Gilbert, MD, PhD, Department of Dermatology at SUNY Downstate Medical Center, Brooklyn, Brooklyn, NY, United States Background: Plexiform neurofibroma (PNF) is a benign tumor composed of a proliferation of neuromesenchymal tissue, typically involving the trunk. The PNF is considered pathognomonic of neurofibromatosis type I (NF1). This article presents a case of solitary PNF on the abdomen of an adult female, without family history, cutaneous, or systemic features of NF1. Case report: A 30-year-old woman presented with a tender subcutaneous nodule on the left lower abdomen, which had been present since age 12. The patient denied family history of NF1. Physical examination was otherwise normal and did not reveal any other cutaneous features of NF1, and ophthalmologic slit-lamp examination did not reveal Lisch nodules. The lesion was completely removed by excisional biopsy. Histologic examination revealed PNF. Discussion: PNF is considered pathognomonic of NF1. This case was unique in that it describes a solitary PNF in the absence of other features diagnostic for NF1, and without a family history. A review of the literature for solitary PNF demonstrates a paucity of such cases. Commercial support: None identified.
J AM ACAD DERMATOL
AB61