- Email: [email protected]
Treatment of perioral dermatitis with topical pimecrolimus
Letters 529
J AM ACAD DERMATOL VOLUME 56, NUMBER 3
CASE
LETTERS
Treatment of perioral dermatitis with topical pimecrolimus To the Editor: Perioral dermatitis is a chronic facial eruption characterized by grouped reddish papules, papulovesicles, and papulopustules over an erythematous area around the mouth. Although perioral is the most frequent location, periocular areas, nasolabial folds, and glabella may also be affected.1 Perioral dermatitis usually occurs in children and in young women between the ages of 20 and 45 years. Nevertheless, the number of adult male patients is assumed to be increasing because of changes in their cosmetic habits. The etiology is still unknown, although many factors have been proposed: contact allergy, hormonal factors, cosmetics, topical or systemic steroids, pregnancy, malabsorption, infective agents (eg, Candida, Demodex, Fusobacterium species), skin barrier disorders, or atopia.2-3 Differential diagnosis of perioral dermatitis includes rosacea, seborrhoeic dermatitis, papular sarcoid, acne vulgaris, contact dermatitis (allergic or irritant), eruptive syringomas, xanthomas, glucagonoma syndrome, or lupus miliaris disseminatus faciei.4-5 The use of all topical steroids should be avoided because they have been implicated in perioral dermatitis pathogenesis.2 Topical metronidazole or erythromycin and oral tetracyclines have been used as conventional treatments. Liquid nitrogen, benzoyl peroxide, ‘‘zero-therapy’’ (observation without medical or cosmetic treatments), radiotherapy, azelaic acid, adapalene, and oral isotretinoin have also been reported as alternative treatments.6-7 We present one case of perioral dermatitis with rapid response to topical pimecrolimus 1% cream. A 22-year-old white man presented with a 3-month history of cutaneous lesions around his mouth. A burning sensation was also noted. Medical history disclosed only Crohn’s disease. At physical examination, multiple erythematous papulopustules ranging in size from 1 mm to 3 mm could be observed around his mouth (Fig 1). Topical steroids (Methylprednisolone aceponate 0.1% cream) had been applied after the eruption began without improvement of the lesions for 2 weeks. A diagnosis of steroid-damaged perioral dermatitis was made. Topical steroids were suspended and replaced with pimecrolimus 1% cream twice daily. The patient denied oral treatment. A complete clearance of the lesions was observed after
Fig 1. Before treatment: multiple millimetric erythematous papules and papulovesicules around the mouth.
Fig 2. Complete clearance of the lesions after 2 weeks with topical pimecrolimus.
2 weeks (Fig 2). No adverse effects or recurrence have been noted at 4 months. Pimecrolimus is the most recently approved calcineurin inhibitor drug. It has been shown to be effective in several cutaneous inflammatory diseases, such as atopic dermatitis, inverse psoriasis, vitiligo, and oral lichen planus by inhibiting inflammatory cytokines in T cells.8-10 Nevertheless, the long-term safety of topical immunomodulators, such as tacrolimus or pimecrolimus, remains to be determined. An abnormality of the stratum corneum with an impairment of skin barrier functions is observed in perioral dermatitis, with an increasing penetration of exogenous agents, leading to contact dermatitis and irritant reactions. These are considered primary triggers of the disease.3 In recent reports, these triggers of perioral dermatitis have been considered similar to those in atopic dermatitis.3 This led us to suppose that pimecrolimus could be effective in our case. In fact, complete and rapid resolution of the lesions was achieved with topical pimecrolimus 1% cream, without adverse effects.
530 Letters
J AM ACAD DERMATOL MARCH 2007
Marina Rodrı´guez-Martı´n, MD, Miguel Sa´ezRodrı´guez, MD, Ana Carnerero-Rodrı´guez, MD, Fernando Rodrı´guez-Garcı´a, MD, Roberto Cabrera de Paz, MD, Miriam Sidro-Sarto, MD, Francisco Guimera´, PhD, Rosalba Sa´nchez, PhD, Marta Garcı´a-Bustı´nduy, PhD, and Antonio Noda-Cabrera, PhD Departments of Dermatology and Pathology, Hospital Universitario de Canarias, University of La Laguna, Tenerife, Spain Correspondence to: Marina Rodrı´guez Martı´n, MD, Servicio de Dermatologı´a, Hospital Universitario de Canarias, Ofra s/n. La Laguna, Santa Cruz de Tenerife, 38320, Canary Islands, Spain
Fig 1. Clinical presentation of lymphangiosarcoma as indurated mass on right cheek.
E-mail: [email protected] REFERENCES 1. Yung A, Highet AS. Perioral dermatitis and inadvertent topical corticosteroid exposure. Br J Dermatol 2002;147:1264-81. 2. Hafeez ZH. Perioral dermatitis: an update. Int J Dermatol 2003;42:514-7. 3. Dirschka T, Tronnier H, Fo¨lster-Holst R. Epithelial barrier function and atopic diathesis in rosacea and perioral dermatitis. Br J Dermatol 2004;150:1136-41. 4. Hall Smith P. Unusual facial xanthoma. Clin Exp Dermatol 1978;3:451-3. 5. Kasper CS. Necrolytic migratory rythema: unresolved problems in diagnosis and pathogenesis. A case report and literature review. Cutis 1992;49:120-2. 6. Array, Jansen T. Azelaic acid as a new treatment for perioral dermatitis results from an open study. Br J Dermatol 2004; 151:933-4. 7. Array, Jansen T. Perioral dermatitis successfully treated with topical adapalene. J Eur Acad Dermatol Venereol 2002;16:175-7. 8. Grassberger M, Steinhoff M, Schneider D, Luger TA. Pimecrolimus—an anti-inflammatory drug targeting the skin. Exp Dermatol 2004;13:721-30. 9. Esquivel-Pedraza L, Ferna´ndez-Cuevas L, Ortiz-Pedroza G, Reyes-Gutierrez E, Orozco-Topete R, et al. Treatment of oral lichen planus with topical pimecrolimus 1% cream. Br J Dermatol 2004;150:771-3. 10. Amichai B. Psoriasis of the glans penis in a child successfully treated with Elidel (pimecrolimus) cream. J Eur Acad Dermatol Venereol 2004;18:742-3. doi:10.1016/j.jaad.2005.03.011
Lymphangiosarcoma presenting as asymptomatic swelling of the cheek To the Editor: An 80-year-old man was referred for evaluation of asymptomatic swelling over the right malar region for 5 months. On physical examination, a 6.5- 3 3.5-cm indurated but soft, mobile mass was palpated. No facial or cervical lymphadenopathy was palpated and cranial nerves were grossly intact (Fig 1). A 4-mm punch biopsy specimen was obtained from the center of the mass and the periphery. The specimen displayed infiltrating cords
Fig 2. A, Punch biopsy displaying jagged, pseudovascular-type structures with cytologically atypical epithelioid and focally spindled cells. (Hematoxylin-eosin stain; original magnification: 340.) B, Punch biopsy displaying epithelioid and spindled cells staining positive for lymphatic stain D2-40. (Original magnification: 340.)
of cytologically atypical epithelioid and focally spindled cells with scattered mitotic figures. Focal discohesive growth showing pseudovascular-type structures were rare and there was an associated lymphoplasmacytic inflammatory infiltrate (Fig 2, A). The malignant cells of interest were positive for CD31, Factor VIII, and the lymphatic stain D2-40 (Fig 2, B). Given the morphology and immunohistochemistry, angiosarcoma (AS) was favored; because of the D2-40 positivity, the malignancy was
J AM ACAD DERMATOL VOLUME 56, NUMBER 3
CASE
LETTERS
Treatment of perioral dermatitis with topical pimecrolimus To the Editor: Perioral dermatitis is a chronic facial eruption characterized by grouped reddish papules, papulovesicles, and papulopustules over an erythematous area around the mouth. Although perioral is the most frequent location, periocular areas, nasolabial folds, and glabella may also be affected.1 Perioral dermatitis usually occurs in children and in young women between the ages of 20 and 45 years. Nevertheless, the number of adult male patients is assumed to be increasing because of changes in their cosmetic habits. The etiology is still unknown, although many factors have been proposed: contact allergy, hormonal factors, cosmetics, topical or systemic steroids, pregnancy, malabsorption, infective agents (eg, Candida, Demodex, Fusobacterium species), skin barrier disorders, or atopia.2-3 Differential diagnosis of perioral dermatitis includes rosacea, seborrhoeic dermatitis, papular sarcoid, acne vulgaris, contact dermatitis (allergic or irritant), eruptive syringomas, xanthomas, glucagonoma syndrome, or lupus miliaris disseminatus faciei.4-5 The use of all topical steroids should be avoided because they have been implicated in perioral dermatitis pathogenesis.2 Topical metronidazole or erythromycin and oral tetracyclines have been used as conventional treatments. Liquid nitrogen, benzoyl peroxide, ‘‘zero-therapy’’ (observation without medical or cosmetic treatments), radiotherapy, azelaic acid, adapalene, and oral isotretinoin have also been reported as alternative treatments.6-7 We present one case of perioral dermatitis with rapid response to topical pimecrolimus 1% cream. A 22-year-old white man presented with a 3-month history of cutaneous lesions around his mouth. A burning sensation was also noted. Medical history disclosed only Crohn’s disease. At physical examination, multiple erythematous papulopustules ranging in size from 1 mm to 3 mm could be observed around his mouth (Fig 1). Topical steroids (Methylprednisolone aceponate 0.1% cream) had been applied after the eruption began without improvement of the lesions for 2 weeks. A diagnosis of steroid-damaged perioral dermatitis was made. Topical steroids were suspended and replaced with pimecrolimus 1% cream twice daily. The patient denied oral treatment. A complete clearance of the lesions was observed after
Fig 1. Before treatment: multiple millimetric erythematous papules and papulovesicules around the mouth.
Fig 2. Complete clearance of the lesions after 2 weeks with topical pimecrolimus.
2 weeks (Fig 2). No adverse effects or recurrence have been noted at 4 months. Pimecrolimus is the most recently approved calcineurin inhibitor drug. It has been shown to be effective in several cutaneous inflammatory diseases, such as atopic dermatitis, inverse psoriasis, vitiligo, and oral lichen planus by inhibiting inflammatory cytokines in T cells.8-10 Nevertheless, the long-term safety of topical immunomodulators, such as tacrolimus or pimecrolimus, remains to be determined. An abnormality of the stratum corneum with an impairment of skin barrier functions is observed in perioral dermatitis, with an increasing penetration of exogenous agents, leading to contact dermatitis and irritant reactions. These are considered primary triggers of the disease.3 In recent reports, these triggers of perioral dermatitis have been considered similar to those in atopic dermatitis.3 This led us to suppose that pimecrolimus could be effective in our case. In fact, complete and rapid resolution of the lesions was achieved with topical pimecrolimus 1% cream, without adverse effects.
530 Letters
J AM ACAD DERMATOL MARCH 2007
Marina Rodrı´guez-Martı´n, MD, Miguel Sa´ezRodrı´guez, MD, Ana Carnerero-Rodrı´guez, MD, Fernando Rodrı´guez-Garcı´a, MD, Roberto Cabrera de Paz, MD, Miriam Sidro-Sarto, MD, Francisco Guimera´, PhD, Rosalba Sa´nchez, PhD, Marta Garcı´a-Bustı´nduy, PhD, and Antonio Noda-Cabrera, PhD Departments of Dermatology and Pathology, Hospital Universitario de Canarias, University of La Laguna, Tenerife, Spain Correspondence to: Marina Rodrı´guez Martı´n, MD, Servicio de Dermatologı´a, Hospital Universitario de Canarias, Ofra s/n. La Laguna, Santa Cruz de Tenerife, 38320, Canary Islands, Spain
Fig 1. Clinical presentation of lymphangiosarcoma as indurated mass on right cheek.
E-mail: [email protected] REFERENCES 1. Yung A, Highet AS. Perioral dermatitis and inadvertent topical corticosteroid exposure. Br J Dermatol 2002;147:1264-81. 2. Hafeez ZH. Perioral dermatitis: an update. Int J Dermatol 2003;42:514-7. 3. Dirschka T, Tronnier H, Fo¨lster-Holst R. Epithelial barrier function and atopic diathesis in rosacea and perioral dermatitis. Br J Dermatol 2004;150:1136-41. 4. Hall Smith P. Unusual facial xanthoma. Clin Exp Dermatol 1978;3:451-3. 5. Kasper CS. Necrolytic migratory rythema: unresolved problems in diagnosis and pathogenesis. A case report and literature review. Cutis 1992;49:120-2. 6. Array, Jansen T. Azelaic acid as a new treatment for perioral dermatitis results from an open study. Br J Dermatol 2004; 151:933-4. 7. Array, Jansen T. Perioral dermatitis successfully treated with topical adapalene. J Eur Acad Dermatol Venereol 2002;16:175-7. 8. Grassberger M, Steinhoff M, Schneider D, Luger TA. Pimecrolimus—an anti-inflammatory drug targeting the skin. Exp Dermatol 2004;13:721-30. 9. Esquivel-Pedraza L, Ferna´ndez-Cuevas L, Ortiz-Pedroza G, Reyes-Gutierrez E, Orozco-Topete R, et al. Treatment of oral lichen planus with topical pimecrolimus 1% cream. Br J Dermatol 2004;150:771-3. 10. Amichai B. Psoriasis of the glans penis in a child successfully treated with Elidel (pimecrolimus) cream. J Eur Acad Dermatol Venereol 2004;18:742-3. doi:10.1016/j.jaad.2005.03.011
Lymphangiosarcoma presenting as asymptomatic swelling of the cheek To the Editor: An 80-year-old man was referred for evaluation of asymptomatic swelling over the right malar region for 5 months. On physical examination, a 6.5- 3 3.5-cm indurated but soft, mobile mass was palpated. No facial or cervical lymphadenopathy was palpated and cranial nerves were grossly intact (Fig 1). A 4-mm punch biopsy specimen was obtained from the center of the mass and the periphery. The specimen displayed infiltrating cords
Fig 2. A, Punch biopsy displaying jagged, pseudovascular-type structures with cytologically atypical epithelioid and focally spindled cells. (Hematoxylin-eosin stain; original magnification: 340.) B, Punch biopsy displaying epithelioid and spindled cells staining positive for lymphatic stain D2-40. (Original magnification: 340.)
of cytologically atypical epithelioid and focally spindled cells with scattered mitotic figures. Focal discohesive growth showing pseudovascular-type structures were rare and there was an associated lymphoplasmacytic inflammatory infiltrate (Fig 2, A). The malignant cells of interest were positive for CD31, Factor VIII, and the lymphatic stain D2-40 (Fig 2, B). Given the morphology and immunohistochemistry, angiosarcoma (AS) was favored; because of the D2-40 positivity, the malignancy was