Letters to the Editor
375
References 1 Muro Y, Sugiura K, Akiyama M. Limitations of a single-point evaluation of anti-MDA5 antibody, ferritin, and IL-18 in predicting the prognosis of interstitial lung disease with anti-MDA5 antibody-positive dermatomyositis. Clin Rheumatol 2013; 32: 395–398. 2 Mimori T, Nakashima R, Hosono Y. Interstitial lung disease in myositis: clinical subsets, biomarkers, and treatment. Curr Rheumatol Rep 2012; 14: 264–274. 3 Fujimoto M, Hamaguchi Y, Kaji K et al. Myositis-specific anti-155/140 autoantibodies target transcription intermediary factor 1 family proteins. Arthritis Rheum 2012; 64: 513–522. 4 Kang HJ, Park JS, Kim DW et al. Adverse pulmonary reactions associated with the use of monoclonal antibodies in cancer patients. Resp Med 2012; 106: 443–450. DOI: 10.1111/jdv.12797
Figure 1 Pigmented macule of the anterior aspect of the neck surrounded by a halo-phenomenon.
Lichen sclerosus mimicking halo-naevus comedonicus Editor Lichen sclerosus (LS) is a chronic inflammatory skin disease, which more frequently involves females in the genital area. Extragenital LS is less common than the genital variant. We reported a particular extragenital LS mimicking a halo-naevus comedonicus. A 50-year-old man presented with a pigmented lesion of the anterior aspect of the neck of 1 year duration. At examination, the lesion was a well-defined plaque, 4 9 3 cm in diameter, with multiple comedones developed on a light brown pigmented macule. The pigmented area was delineated by a surrounding white ring without comedones (Fig. 1). The lesion was moderately indurated on palpation. The patient was free of any other skin lesion, no vitiligo or other halo-phenomenon was noticed. No topical treatment was applied. The patient was healthy and did not report any other disease or medication intake. The
(a)
histological examination from a biopsy taken in the comedones bearing area showed a dilated pore (open comedone) associated with a dense compact infiltrate of corneocytes with hyperkeratosis of the walls of the follicular channel (Fig. 2a). A compact orthohyperkeratosis of the stratum corneum was found, thicker than the atrophic underlying epidermis (Fig. 2a–b). The papillary dermis was moderately oedematous in some areas associated with a moderate inflammatory infiltrate (Fig. 2c), and homogenized and sclerotic in others areas (Fig. 2a). A lichenoid infiltrate was found in localized areas (Fig. 2c). Thus, the diagnosis of lichen sclerosus mimicking a halo-naevus comedonicus in an adult patient was made. The patient denied any further investigation and was lost of follow-up. LS is most common on the neck, the shoulders and the upper part of the trunk.1 It is generally asymptomatic but pruritus may be present. Our patient was asymptomatic. Extragenital LS generally appears as white or ivory multiple macules associated with skin atrophy. The lesion of the present patient was particular as the peripheral ivory ring was delineating a central slight brown
(b)
(c)
Figure 2 (a) Histology of a comedone-like structure, with homogenized papillary dermis and atrophic epidermis with orthohyperkeratosis (haematin and eosin staining, original magnification 9400). (b) Densification of the papillary dermis, with horizontalization of the elastic fibres (orcein staining, original magnification 9400). (c) Oedema and moderate inflammatory infiltrate of the papillary dermis associated with dermal-epidermal lichenoid pattern (orcein staining, original magnification 9400).
JEADV 2016, 30, 320–386
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
376
pigmented area containing open comedones, mimicking a halo-naevus comedonicus. Additionally, the present lesion was isolated, increasing a possible confusion with halo-naevus comedonicus. In our case, the diagnosis of extragenital LS was based on histological findings. Indeed, histology of LS typically shows atrophy of epidermis with vacuolar degeneration of the basal layer and orthohyperkeratosis of the stratum corneum, as observed in the present case (Fig. 2a–b). The papillary dermis exhibits typical morphologic changes with homogenization and oedema at early stages and sclerotic in latter stages of the disease.1 These typical dermal changes were observed in the present lesion on different slides sections (Fig. 2a–c). Comedone-like structures in our patient were also compatible with the diagnosis of LS. Indeed, the orthohyperkeratosis of the follicle walls in LS can lead to the formation of open pores containing multiple corneocytes layers and keratin debris (Fig. 2a). This aspect may also be observed in naevus comedonicus. Whereas the location to the neck is common to both conditions, the age of onset is a strong argument in favour of LS. As reported elsewhere, LS occurs typically between the 5th and 7th decade while naevus comedonicus affects mostly children and young adults less than 20 years.2 Many physical or chemical treatments have been used in LS with variable efficacy. In localized LS, topical retinoids, corticosteroids or calcineurin inhibitors, photodynamic therapy or surgery might be considered.3 T. Jouary,1,* S. Guillet,1 C. Droitcourt,1 C. Dutriaux,1 K. Ezzedine,1 J.F. Goussot,2 A. Taieb1 ^pital Saint Andre, Bordeaux, France, Service de Dermatologie, Ho ^pital Haut-Le v e ^que, Pessac, France Service d’Anatomopathologie, Ho *Correspondence: Dr. Thomas Jouary. E-mail: [email protected] 1
2
References 1 Meffert JJ, Davis BM, Grimwood RE. Lichen sclerosus. J Am Acad Dermatol 1995; 32: 393–416. 2 Lefkowitz A, Schwartz RA, Lambert WC. Nevus comedonicus. Dermatology 1999; 199: 204–207. 3 Fistarol SK, Itin PH. Diagnosis and treatment of lichen sclerosus: an update. Am J Clin Dermatol 2013; 14: 27–47. DOI: 10.1111/jdv.12800
Is isotretinoin treatment safe in patients with known peanut allergy? Reply Editor We read with interest the contribution of Pierret et al. who used isotretinoin to treat a patient with severe acne vulgaris
JEADV 2016, 30, 320–386
and previous anaphylaxis to peanuts.1 We would like to report a second case facing a similar treatment challenge. An 18-year-old man was referred for a second opinion on the use of isotretinoin for the treatment of severe facial acne vulgaris. The patient had a history of nausea and throat tightness following ingestion of peanuts, classified as Ring and Messmer severity grade 2.2 Our patient was not allergic to soybean. Skin prick tests for peanuts were positive. Total serum IgE was elevated (817 kIU/L). ImmunoCAP results were positive for Ara h2 (4.12 kIU/L) and Ara h8 (9.74 kIU/L) and negative for Ara h1, Ara h3 and Ara h9 (
375
References 1 Muro Y, Sugiura K, Akiyama M. Limitations of a single-point evaluation of anti-MDA5 antibody, ferritin, and IL-18 in predicting the prognosis of interstitial lung disease with anti-MDA5 antibody-positive dermatomyositis. Clin Rheumatol 2013; 32: 395–398. 2 Mimori T, Nakashima R, Hosono Y. Interstitial lung disease in myositis: clinical subsets, biomarkers, and treatment. Curr Rheumatol Rep 2012; 14: 264–274. 3 Fujimoto M, Hamaguchi Y, Kaji K et al. Myositis-specific anti-155/140 autoantibodies target transcription intermediary factor 1 family proteins. Arthritis Rheum 2012; 64: 513–522. 4 Kang HJ, Park JS, Kim DW et al. Adverse pulmonary reactions associated with the use of monoclonal antibodies in cancer patients. Resp Med 2012; 106: 443–450. DOI: 10.1111/jdv.12797
Figure 1 Pigmented macule of the anterior aspect of the neck surrounded by a halo-phenomenon.
Lichen sclerosus mimicking halo-naevus comedonicus Editor Lichen sclerosus (LS) is a chronic inflammatory skin disease, which more frequently involves females in the genital area. Extragenital LS is less common than the genital variant. We reported a particular extragenital LS mimicking a halo-naevus comedonicus. A 50-year-old man presented with a pigmented lesion of the anterior aspect of the neck of 1 year duration. At examination, the lesion was a well-defined plaque, 4 9 3 cm in diameter, with multiple comedones developed on a light brown pigmented macule. The pigmented area was delineated by a surrounding white ring without comedones (Fig. 1). The lesion was moderately indurated on palpation. The patient was free of any other skin lesion, no vitiligo or other halo-phenomenon was noticed. No topical treatment was applied. The patient was healthy and did not report any other disease or medication intake. The
(a)
histological examination from a biopsy taken in the comedones bearing area showed a dilated pore (open comedone) associated with a dense compact infiltrate of corneocytes with hyperkeratosis of the walls of the follicular channel (Fig. 2a). A compact orthohyperkeratosis of the stratum corneum was found, thicker than the atrophic underlying epidermis (Fig. 2a–b). The papillary dermis was moderately oedematous in some areas associated with a moderate inflammatory infiltrate (Fig. 2c), and homogenized and sclerotic in others areas (Fig. 2a). A lichenoid infiltrate was found in localized areas (Fig. 2c). Thus, the diagnosis of lichen sclerosus mimicking a halo-naevus comedonicus in an adult patient was made. The patient denied any further investigation and was lost of follow-up. LS is most common on the neck, the shoulders and the upper part of the trunk.1 It is generally asymptomatic but pruritus may be present. Our patient was asymptomatic. Extragenital LS generally appears as white or ivory multiple macules associated with skin atrophy. The lesion of the present patient was particular as the peripheral ivory ring was delineating a central slight brown
(b)
(c)
Figure 2 (a) Histology of a comedone-like structure, with homogenized papillary dermis and atrophic epidermis with orthohyperkeratosis (haematin and eosin staining, original magnification 9400). (b) Densification of the papillary dermis, with horizontalization of the elastic fibres (orcein staining, original magnification 9400). (c) Oedema and moderate inflammatory infiltrate of the papillary dermis associated with dermal-epidermal lichenoid pattern (orcein staining, original magnification 9400).
JEADV 2016, 30, 320–386
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
376
pigmented area containing open comedones, mimicking a halo-naevus comedonicus. Additionally, the present lesion was isolated, increasing a possible confusion with halo-naevus comedonicus. In our case, the diagnosis of extragenital LS was based on histological findings. Indeed, histology of LS typically shows atrophy of epidermis with vacuolar degeneration of the basal layer and orthohyperkeratosis of the stratum corneum, as observed in the present case (Fig. 2a–b). The papillary dermis exhibits typical morphologic changes with homogenization and oedema at early stages and sclerotic in latter stages of the disease.1 These typical dermal changes were observed in the present lesion on different slides sections (Fig. 2a–c). Comedone-like structures in our patient were also compatible with the diagnosis of LS. Indeed, the orthohyperkeratosis of the follicle walls in LS can lead to the formation of open pores containing multiple corneocytes layers and keratin debris (Fig. 2a). This aspect may also be observed in naevus comedonicus. Whereas the location to the neck is common to both conditions, the age of onset is a strong argument in favour of LS. As reported elsewhere, LS occurs typically between the 5th and 7th decade while naevus comedonicus affects mostly children and young adults less than 20 years.2 Many physical or chemical treatments have been used in LS with variable efficacy. In localized LS, topical retinoids, corticosteroids or calcineurin inhibitors, photodynamic therapy or surgery might be considered.3 T. Jouary,1,* S. Guillet,1 C. Droitcourt,1 C. Dutriaux,1 K. Ezzedine,1 J.F. Goussot,2 A. Taieb1 ^pital Saint Andre, Bordeaux, France, Service de Dermatologie, Ho ^pital Haut-Le v e ^que, Pessac, France Service d’Anatomopathologie, Ho *Correspondence: Dr. Thomas Jouary. E-mail: [email protected] 1
2
References 1 Meffert JJ, Davis BM, Grimwood RE. Lichen sclerosus. J Am Acad Dermatol 1995; 32: 393–416. 2 Lefkowitz A, Schwartz RA, Lambert WC. Nevus comedonicus. Dermatology 1999; 199: 204–207. 3 Fistarol SK, Itin PH. Diagnosis and treatment of lichen sclerosus: an update. Am J Clin Dermatol 2013; 14: 27–47. DOI: 10.1111/jdv.12800
Is isotretinoin treatment safe in patients with known peanut allergy? Reply Editor We read with interest the contribution of Pierret et al. who used isotretinoin to treat a patient with severe acne vulgaris
JEADV 2016, 30, 320–386
and previous anaphylaxis to peanuts.1 We would like to report a second case facing a similar treatment challenge. An 18-year-old man was referred for a second opinion on the use of isotretinoin for the treatment of severe facial acne vulgaris. The patient had a history of nausea and throat tightness following ingestion of peanuts, classified as Ring and Messmer severity grade 2.2 Our patient was not allergic to soybean. Skin prick tests for peanuts were positive. Total serum IgE was elevated (817 kIU/L). ImmunoCAP results were positive for Ara h2 (4.12 kIU/L) and Ara h8 (9.74 kIU/L) and negative for Ara h1, Ara h3 and Ara h9 (
