Correspondence
(a)
(b)
demonstrated histology suggestive of a neutrophilic dermatosis, as well as pustules, which are also often seen in this disease spectrum. We postulate that the overlapping pathological features of our case of shiitake dermatitis with neutrophilic dermatoses may explain the unusual clinical features of pustulation and oral aphthous ulceration in this case. Our patient had complete resolution of the rash and mouth ulcers at the 1-month follow-up. We advised him to cook shiitake mushrooms more thoroughly in future. S. E. Hamer,1 K. Kulkarni,2 and S. N. Cohen1 1 Departments of Dermatology and 2Histopathology, Queen’s Medical Centre, Nottingham, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 4 May 2014
References 1 Nakamura T. Toxicoderma caused by shiitake (Lentinus edodes). Jpn J Clin Dermatol 1977; 28: 65–8. 2 Garg S, Cockayne S. Shiitake dermatitis diagnosed after 16 years! Arch Dermatol 2008; 144: 1241–2. 3 Lippert U, Martin V, Schwertfeger C et al. Shiitake dermatitis. Br J Dermatol 2003; 148: 178–9. 4 Shimizu R. A case of drug eruption caused by lentinan (in Japanese). Rinsho Derma (Toyko) 1990; 32: 1065–8. 5 Yamamoto T, Nishioka K. Flagellate erythema. Int J Dermatol 2006; 45: 627–31. Figure 2 (a) Spongiosis of the epidermis, neutrophil exocytosis,
papillary dermal oedema and a heavy dermal neutrophilic infiltrate; (b) subcorneal pustule with numerous neutrophils and some histiocytes in the dermis. Haematoxylin and eosin, original magnification (a,b) 9 40.
disorders (dermatomyositis and adult-onset Still disease).5 Diagnosing shiitake dermatitis can be complicated by the delay between eating the mushrooms and the appearance of the rash. One report described a patient who developed this rash on multiple occasions over 16 years before the connection was finally made.2 We are not aware of any previous cases of oral involvement in shiitake dermatitis, nor are pustules generally noted. Aphthous ulceration is common, and minor aphthae represent merely a nuisance for many people. The pathogenesis of these ulcers is not well understood, but lesions have been variably attributed to stress, viral infection and trauma. Aphthae can also be a manifestation of systemic disease, including Behcßet syndrome, coeliac disease, inflammatory bowel disease and systemic lupus erythematosus. Drugs such as nicorandil can also be responsible. Aphthae have also been reported as a feature of the neutrophilic dermatosis, Sweet syndrome. Our case
ª 2015 British Association of Dermatologists
Efficacy of combination light-emitting diode (635 and 830 nm) therapy in treating local injection-site reactions after filler doi: 10.1111/ced.12480 Over the past decade, the use of injectable cosmetic fillers has steadily increased, with hyaluronic acid (HA) preparations being the most frequently utilized. Complication rates with injections of HA fillers have been reported to be up to 5%. The most common reaction to HA is a local injection-site reaction, which consists of swelling, erythema and induration at the implant site.1 Although these reactions are predominantly mild or moderate in intensity, and do not result in severe sequelae, new treatment methods promoting rapid healing with high patient compliance are highly desirable because of safety concerns regarding the use of topical steroid agents as anti-inflammatory agents.1 Consequently, researchers have sought other treatment options. Light and laser therapies have attracted atten-
Clinical and Experimental Dermatology (2015) 40, pp331–338
333
Correspondence
(a)
(b)
(c)
(d)
Figure 1 (a,b) Before and (c,d) after
treatment with light-emitting diode therapy.
tion as promising new treatment methods for this condition.2 Light-emitting diode (LED) photomodulation is a nonthermal technology used to modulate cellular activity with light. Photomodulation refers to a photorejuvenation effect using nonthermal cellular stimulation at specific pulse sequences and durations.3 Previous animal and human studies have demonstrated that LED treatment induces reduction in wound size and protects against skin inflammation. LED therapy using a variety of red, blue, and yellow wavelengths has been reported to accelerate cutaneous wound healing after various
334
Clinical and Experimental Dermatology (2015) 40, pp331–338
injuries, including inflammatory situations.4 To date, no studies have been published on the specific evaluation of the efficacy of LED for the treatment of local injection site reactions after filler. In the present study, we utilized a combination LED (635 and 830 nm) therapy for treatmen. A 32-year-old woman received an injection of crosslinked HA filler (Restylane Perlane; Q-MED, Uppsala, Sweden) into the glabellar area in an attempt to plump up this area. The HA concentration in the filler was 20 mg/mL, and the total volume used was 1 mL. Two days after the injection, the patient returned with an
ª 2015 British Association of Dermatologists
Correspondence
inflammatory reaction in the injection area with an itching sensation without pain or tenderness (Fig. 1a,b). The patient was worried about the cosmetic appearance of her forehead. We diagnosed the patient as having a local injectionsite reaction to the filler, and we decided on prompt treatment using combination LED (Smartlux FX; Medmix, Seoul, Korea), because she did not want to be treated with anti-inflammatory agents such as topical steroids. During treatment, the LED device delivered 635 and 830 nm light with a concomitant power density of 75 mW/cm2. The recommended distance between the lesion and LED device was 150–200 mm. The patient was treated for 15 min with continuous (not pulsed) light every day for 7 days. Both the patient and operator wore safety goggles during treatment to protect their eyes. No pain or discomfort was reported by the patient during the treatment period. The inflammatory reaction gradually disappeared over the next 7 days (Fig. 1c,d). Low-intensity light therapy using light in the far-red to near-infrared region of the spectrum (630–1000 nm) can modulate numerous cellular functions. Several recent studies have demonstrated the anti-inflammatory effects of LED therapy.3,4 A study conducted with human gingival fibroblasts treated with arachidonic acid showed that 635 nm irradiation inhibits prostaglandin 2 synthesis in a manner similar to inhibition by cyclooxygenase inhibitors. Another study demonstrated that LED therapy has beneficial effects on the prevention of postinflammatory hyperpigmentation and scarring.3 A further recent study found that LED inhibits several inflammatory cells, improves skin barrier function, and may potentially contribute to the treatment of patients with atopic dermatitis.5 Furthermore, at the cellular level, LED can upregulate procollagen and collagen synthesis in human fibroblast cultures. Irradiation at 830 nm accelerates fibroblast transformation, downregulation of matrix metalloproteinases and mast cell degranulation.3 In addition, the chemotaxis and phagocytic activity of leucocytes and macrophages was shown to be enhanced with cellular stimulation at this wavelength.3 The Smartlux FX is a new LED device, which has 1200 output lamps (635 nm red: 700; 830 nm infrared: 500) and an dual-wavelength output light that produces concomitant red light at 635 nm (58%)and infrared light at 830 nm (42%). This dual-wavelength effect may be the reason why more rapid wound healing and decreased inflammation occur without side effects and patient discomfort. Although we could not histologically confirm inflammatory reaction of the injection area as the patient refused permission for a biopsy, we believe the present study supports the clinical application of LED (635 and 830 nm) as a new treatment option for local injection site reactions after HA filler. We consider that it is likely this LED tech-
ª 2015 British Association of Dermatologists
nique could also be applied for various inflammatory conditions with excellent clearance in a safe manner with high patient compliance. K. H. Yoo,1,2 I. K. Yeo,1 M. Y. Hyun,1 C. K. Hong,1 and B. J. Kim1 1 Department of Dermatology, Chung-Ang University Hospital, Seoul, Korea; and 2Department of Dermatology, Catholic Kwandong University International St.Mary’s Hospital, Incheon, Korea E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 3 May 2014
References 1 Monheit GD, Coleman KM. Hyaluronic acid fillers. Dermatol Ther 2006; 19: 141–50. 2 Pk MinGooBL. The 830 nm light-emitting diode low level light therapy (LED-LLLT) enhances wound healing: a preliminary study. Laser Ther 2013; 22: 43–9. 3 Oh IY, Kim BJ, Kim MN et al. Efficacy of light-emitting diode photomodulation in reducing erythema after fractional carbon dioxide laser resurfacing: a pilot study. Dermatol Surg 2013; 39: 1171–6. 4 Dougal G, Lee SY. Evaluation of the efficacy of low-level light therapy using 1072 nm infrared light for the treatment of herpes simplex labialis. Clin Exp Dermatol 2013; 38: 713–8. 5 Kim CH, Cheong KA, Lee AY. 850 nm light-emittingdiode phototherapy plus low-dose tacrolimus (FK-506) as combination therapy in the treatment of Dermatophagoides farinae-induced atopic dermatitis-like skin lesions in NC/Nga mice. J Dermatol Sci 2013; 72: 142–8.
Subacute cutaneous lupus erythematosus: a paraneoplastic phenomenon in oropharyngeal squamous cell carcinoma doi: 10.1111/ced.12498 A 74-year-old man presented with a 4-week history of an enlarging mass involving his right submandibular region and of weight loss. These features coincided with a mildly pruritic eruption. The patient had a history of hypertension, and had been on metoprolol for 8 years. On physical examination, the eruption was found to consist of eroded papules and plaques on the patient’s forehead, chest and back (Fig. 1a). Mild periungual erythema and nicotine staining were noted on his fingers. A biopsy was taken from the mass (Fig. 1b), and histology showed vacuolar degeneration of the basal layer, and papillary oedema with marked periadnexal and perivascular lymphocytic infiltrate in the dermis. Other findings
Clinical and Experimental Dermatology (2015) 40, pp331–338
335
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
(a)
(b)
demonstrated histology suggestive of a neutrophilic dermatosis, as well as pustules, which are also often seen in this disease spectrum. We postulate that the overlapping pathological features of our case of shiitake dermatitis with neutrophilic dermatoses may explain the unusual clinical features of pustulation and oral aphthous ulceration in this case. Our patient had complete resolution of the rash and mouth ulcers at the 1-month follow-up. We advised him to cook shiitake mushrooms more thoroughly in future. S. E. Hamer,1 K. Kulkarni,2 and S. N. Cohen1 1 Departments of Dermatology and 2Histopathology, Queen’s Medical Centre, Nottingham, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 4 May 2014
References 1 Nakamura T. Toxicoderma caused by shiitake (Lentinus edodes). Jpn J Clin Dermatol 1977; 28: 65–8. 2 Garg S, Cockayne S. Shiitake dermatitis diagnosed after 16 years! Arch Dermatol 2008; 144: 1241–2. 3 Lippert U, Martin V, Schwertfeger C et al. Shiitake dermatitis. Br J Dermatol 2003; 148: 178–9. 4 Shimizu R. A case of drug eruption caused by lentinan (in Japanese). Rinsho Derma (Toyko) 1990; 32: 1065–8. 5 Yamamoto T, Nishioka K. Flagellate erythema. Int J Dermatol 2006; 45: 627–31. Figure 2 (a) Spongiosis of the epidermis, neutrophil exocytosis,
papillary dermal oedema and a heavy dermal neutrophilic infiltrate; (b) subcorneal pustule with numerous neutrophils and some histiocytes in the dermis. Haematoxylin and eosin, original magnification (a,b) 9 40.
disorders (dermatomyositis and adult-onset Still disease).5 Diagnosing shiitake dermatitis can be complicated by the delay between eating the mushrooms and the appearance of the rash. One report described a patient who developed this rash on multiple occasions over 16 years before the connection was finally made.2 We are not aware of any previous cases of oral involvement in shiitake dermatitis, nor are pustules generally noted. Aphthous ulceration is common, and minor aphthae represent merely a nuisance for many people. The pathogenesis of these ulcers is not well understood, but lesions have been variably attributed to stress, viral infection and trauma. Aphthae can also be a manifestation of systemic disease, including Behcßet syndrome, coeliac disease, inflammatory bowel disease and systemic lupus erythematosus. Drugs such as nicorandil can also be responsible. Aphthae have also been reported as a feature of the neutrophilic dermatosis, Sweet syndrome. Our case
ª 2015 British Association of Dermatologists
Efficacy of combination light-emitting diode (635 and 830 nm) therapy in treating local injection-site reactions after filler doi: 10.1111/ced.12480 Over the past decade, the use of injectable cosmetic fillers has steadily increased, with hyaluronic acid (HA) preparations being the most frequently utilized. Complication rates with injections of HA fillers have been reported to be up to 5%. The most common reaction to HA is a local injection-site reaction, which consists of swelling, erythema and induration at the implant site.1 Although these reactions are predominantly mild or moderate in intensity, and do not result in severe sequelae, new treatment methods promoting rapid healing with high patient compliance are highly desirable because of safety concerns regarding the use of topical steroid agents as anti-inflammatory agents.1 Consequently, researchers have sought other treatment options. Light and laser therapies have attracted atten-
Clinical and Experimental Dermatology (2015) 40, pp331–338
333
Correspondence
(a)
(b)
(c)
(d)
Figure 1 (a,b) Before and (c,d) after
treatment with light-emitting diode therapy.
tion as promising new treatment methods for this condition.2 Light-emitting diode (LED) photomodulation is a nonthermal technology used to modulate cellular activity with light. Photomodulation refers to a photorejuvenation effect using nonthermal cellular stimulation at specific pulse sequences and durations.3 Previous animal and human studies have demonstrated that LED treatment induces reduction in wound size and protects against skin inflammation. LED therapy using a variety of red, blue, and yellow wavelengths has been reported to accelerate cutaneous wound healing after various
334
Clinical and Experimental Dermatology (2015) 40, pp331–338
injuries, including inflammatory situations.4 To date, no studies have been published on the specific evaluation of the efficacy of LED for the treatment of local injection site reactions after filler. In the present study, we utilized a combination LED (635 and 830 nm) therapy for treatmen. A 32-year-old woman received an injection of crosslinked HA filler (Restylane Perlane; Q-MED, Uppsala, Sweden) into the glabellar area in an attempt to plump up this area. The HA concentration in the filler was 20 mg/mL, and the total volume used was 1 mL. Two days after the injection, the patient returned with an
ª 2015 British Association of Dermatologists
Correspondence
inflammatory reaction in the injection area with an itching sensation without pain or tenderness (Fig. 1a,b). The patient was worried about the cosmetic appearance of her forehead. We diagnosed the patient as having a local injectionsite reaction to the filler, and we decided on prompt treatment using combination LED (Smartlux FX; Medmix, Seoul, Korea), because she did not want to be treated with anti-inflammatory agents such as topical steroids. During treatment, the LED device delivered 635 and 830 nm light with a concomitant power density of 75 mW/cm2. The recommended distance between the lesion and LED device was 150–200 mm. The patient was treated for 15 min with continuous (not pulsed) light every day for 7 days. Both the patient and operator wore safety goggles during treatment to protect their eyes. No pain or discomfort was reported by the patient during the treatment period. The inflammatory reaction gradually disappeared over the next 7 days (Fig. 1c,d). Low-intensity light therapy using light in the far-red to near-infrared region of the spectrum (630–1000 nm) can modulate numerous cellular functions. Several recent studies have demonstrated the anti-inflammatory effects of LED therapy.3,4 A study conducted with human gingival fibroblasts treated with arachidonic acid showed that 635 nm irradiation inhibits prostaglandin 2 synthesis in a manner similar to inhibition by cyclooxygenase inhibitors. Another study demonstrated that LED therapy has beneficial effects on the prevention of postinflammatory hyperpigmentation and scarring.3 A further recent study found that LED inhibits several inflammatory cells, improves skin barrier function, and may potentially contribute to the treatment of patients with atopic dermatitis.5 Furthermore, at the cellular level, LED can upregulate procollagen and collagen synthesis in human fibroblast cultures. Irradiation at 830 nm accelerates fibroblast transformation, downregulation of matrix metalloproteinases and mast cell degranulation.3 In addition, the chemotaxis and phagocytic activity of leucocytes and macrophages was shown to be enhanced with cellular stimulation at this wavelength.3 The Smartlux FX is a new LED device, which has 1200 output lamps (635 nm red: 700; 830 nm infrared: 500) and an dual-wavelength output light that produces concomitant red light at 635 nm (58%)and infrared light at 830 nm (42%). This dual-wavelength effect may be the reason why more rapid wound healing and decreased inflammation occur without side effects and patient discomfort. Although we could not histologically confirm inflammatory reaction of the injection area as the patient refused permission for a biopsy, we believe the present study supports the clinical application of LED (635 and 830 nm) as a new treatment option for local injection site reactions after HA filler. We consider that it is likely this LED tech-
ª 2015 British Association of Dermatologists
nique could also be applied for various inflammatory conditions with excellent clearance in a safe manner with high patient compliance. K. H. Yoo,1,2 I. K. Yeo,1 M. Y. Hyun,1 C. K. Hong,1 and B. J. Kim1 1 Department of Dermatology, Chung-Ang University Hospital, Seoul, Korea; and 2Department of Dermatology, Catholic Kwandong University International St.Mary’s Hospital, Incheon, Korea E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 3 May 2014
References 1 Monheit GD, Coleman KM. Hyaluronic acid fillers. Dermatol Ther 2006; 19: 141–50. 2 Pk MinGooBL. The 830 nm light-emitting diode low level light therapy (LED-LLLT) enhances wound healing: a preliminary study. Laser Ther 2013; 22: 43–9. 3 Oh IY, Kim BJ, Kim MN et al. Efficacy of light-emitting diode photomodulation in reducing erythema after fractional carbon dioxide laser resurfacing: a pilot study. Dermatol Surg 2013; 39: 1171–6. 4 Dougal G, Lee SY. Evaluation of the efficacy of low-level light therapy using 1072 nm infrared light for the treatment of herpes simplex labialis. Clin Exp Dermatol 2013; 38: 713–8. 5 Kim CH, Cheong KA, Lee AY. 850 nm light-emittingdiode phototherapy plus low-dose tacrolimus (FK-506) as combination therapy in the treatment of Dermatophagoides farinae-induced atopic dermatitis-like skin lesions in NC/Nga mice. J Dermatol Sci 2013; 72: 142–8.
Subacute cutaneous lupus erythematosus: a paraneoplastic phenomenon in oropharyngeal squamous cell carcinoma doi: 10.1111/ced.12498 A 74-year-old man presented with a 4-week history of an enlarging mass involving his right submandibular region and of weight loss. These features coincided with a mildly pruritic eruption. The patient had a history of hypertension, and had been on metoprolol for 8 years. On physical examination, the eruption was found to consist of eroded papules and plaques on the patient’s forehead, chest and back (Fig. 1a). Mild periungual erythema and nicotine staining were noted on his fingers. A biopsy was taken from the mass (Fig. 1b), and histology showed vacuolar degeneration of the basal layer, and papillary oedema with marked periadnexal and perivascular lymphocytic infiltrate in the dermis. Other findings
Clinical and Experimental Dermatology (2015) 40, pp331–338
335
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
