Letters to the Editor
Persons who have undergone tick removal should be monitored for up to 30 days for signs and symptoms of tick-borne diseases. Tick numbers and tick-borne diseases should be regularly monitored in areas with a high risk of tick attacks.
Cui-Cui Liu, Lilla Landeck1, Min Zheng Departments of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 1University of Osnabrueck, Osnabrueck, Lower Saxony, Germany Address for correspondence: Prof. Min Zheng, Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou - 310009, Zhejiang Province, China. E-mail: [email protected]
a
REFERENCES 1. 2.
b Figure 1: (a) A live tick stuck to the skin of right clavicle area (b) Histological examination of the tick in the skin (H and E, ×4)
it completely. Histopathological examination showed a tick body full of blood with the mouthpart embedded in the upper dermis, with necrotized skin tissue around it [Figure 1b]. Vessel dilatation and neutrophil infiltrate in the dermis were also observed [Figure 1b]. Ticks are blood feeding external parasites which can cause local and systemic complications, including Lyme disease, tick-borne-encephalitis, tick-borne lymphadenopathy, secondary bacterial skin infection, reactive manifestations against tick allergens and granuloma formation.[1] During 3 months of follow-up, our patient did not show any systemic symptoms indicating that she just suffered a tick bite but did not acquire any tick-transmitted diseases. Any tick found should be immediately and completely removed alive. Many methods of tick removal have been reported in the literature. Topical application of 2% erythromycin and 3% tetracycline preparations are ineffective in eliminating Borrelia burgdorferi from the tick bite site or in preventing dissemination to other tissues.[2] Limited surgical excision is an appropriate and safe tick removal technique and could remove the tick completely[3] without provoking the escape of infective body fluids from the tick into the wound site.
270
3.
Roupakias S, Mitsakou P, Nimer AA. Tick removal. J Prev Med Hyg 2011;52:40-4. Wormser GP, Daniels TJ, Bittker S, Cooper D, Wang G, Pavia CS. Failure of topical antibiotics to prevent disseminated Borrelia burgdorferi infection following a tick bite in C3H/HeJ mice. J Infect Dis 2012;205:991-4. Roupakias S, Mitsakou P, Nimer AA. Surgical tick removal. Wilderness Environ Med 2012;23:97-9. Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.132265 PMID: *****
Lipedematous scalp Sir, Lipedematous scalp is a rare clinico-pathologic entity characterized by an abnormal diffuse thickening of the subcutaneous tissue. There are fewer than 50 previous reports of the condition. Patient 1: A 57-year-old lady presented with itching and swelling over the scalp for 2 years. She had a shaven, diffusely thickened scalp thrown into involutions [Figure 1a] with prominences over the left parietal, vertex and occipital areas of scalp. There were no areas of alopecia, scaling or erythema on the scalp. The scalp had a boggy and spongy consistency. X-ray skull (lateral view) showed
Indian Journal of Dermatology, Venereology and Leprology | May-June 2014 | Vol 80 | Issue 3
Letters to the Editor
a
b
Figure 1: (a) Involutions seen over shaven scalp. (b) Lateral skull radiograph showing diffuse thickening over the entire scalp, with prominence over the frontal (12.3 mm) and occipital scalp (16.2 mm)
diffuse thickening over the entire scalp, with prominences over the frontal (12.3 mm) and occipital scalp (16.2 mm) [Figure 1b]. Patient 2: A 40-year-old lady presented with itching, headache and soft swelling over the scalp for the past 6 years. On examination, she had thickening of the skin over the vertex and left parietal area. Examination of the hair revealed no abnormaliy. Computed tomography (CT) of the head showed a diffuse peri-cranial soft swelling, with the prominence over the vertex measuring a maximum of 22.4 mm in thickness [Figure 2a]. Both patients had no features of acromegaly, pachydermoperiostosis or myxedema. Histopathology of the scalp lesions of both these patients showed mild to focal moderate perivascular infiltrates of lymphocytes and histiocytes. There was no atrophy of hair follicles and pilosebaceous units. The subcutis was thickened, edematous and showed disruption of adipocyte architecture and integrity. It appeared to encroach into the dermis [Figure 2b]. A diagnosis of lipedematous scalp was made in these patients based on the clinical finding of boggy soft swelling of the scalp without alopecia, which on histopathology showed encroachment of thickened subcutis into the dermis. It was first described by Cornbleet in 1935. Coskey et al. introduced the term “lipoedematous alopecia” for a disorder which is characterised by an acquired, non-scarring, permanent alopecia or short hair that is unable to grow beyond a few centimetres, overlying thickened boggy subcutaneous tissue of the scalp.[1,2] Recently Müller et al. proposed the term “localized lipomatosis of the scalp with or without alopecia” and suggested its classification within the group of conventional lipomatosis.[3]
a
b
Figure 2: (a) Computed tomography of the brain showing a diffuse pericranial soft-tissue swelling and prominence over the vertex measuring up to 22.4 mm thickness. (b) Biopsy of the scalp showing encroachment of thickened subcutis into the dermis, H and E, ×5
The condition is characterized by boggy, soft, spongy or doughy thickening of the scalp that is predominantly located at the vertex and occiput, which is better palpated than visualized. Most of the reports are among women with rare reports in Caucasian men. A series of lipedematous scalp in ten Egyptian women who use tight head covers has been reported[4] The presenting symptoms in patients include diffuse pain, paraesthesias, headache, burning, aymptomatic scalp thickening and localised or generalized scalp tenderness or itching. Increased scalp thickness is a characteristic feature resulting from increased thickening in the subcutaneous layer. Kavak et al. in their study have reported the average subcutaneous adipose tissue thickness between the galea aponeurotica and dermis in 78 Turkish subjects as 4.0 ± 0.94 mm by ultrasound.[5] The scalp thickness in patients with lipedematous scalp ranged from 9.2 to 16 mm.[5] Since there was no normative data available on scalp thickness in Indian subjects, we studied normal scalp thickness measured on the CT brain images of 30 patients including 16 males and 14 females with a mean age of 47.2 years (18-83 years). The mean scalp thickness at the frontal, parietal and occipital areas was 5.5 mm (2.8-8.1 mm), 7.1 mm (4-11 mm) and 7.75 mm (5-11 mm) respectively. These measurements were consistent with previous reports from other countries. Going by this data, scalp thickness in both our patients was greater than twice that of the normal population. The histopathological changes include thickening of the subcutaneous tissue with encroachment into
Indian Journal of Dermatology, Venereology and Leprology | May-June 2014 | Vol 80 | Issue 3
271
Letters to the Editor
the dermis and distortion of fat architecture, dermal edema and ectatic lymphatics.[2] The pathogenesis remains unknown although mechanical factors like prolonged use of tight head gear and hormonal factors have been implicated.[4] Incidental associations include diabetes mellitus, renal failure, joint and skin hyperelasticity, Sjogren’s syndrome, hyperlipidemia and ovarian cysts.[2,5] There is no definitive option for treatment or to halt progression of the condition. Our patients were initiated on antihistamines. In conclusion, lipedematous scalp is a possible cause of dysesthetic syndrome of the scalp. In patients with no obvious cause for dysesthesia of the scalp, it is advisable that the scalp be palpated to identify this rare presentation that may otherwise be missed.
C.V. Dincy Peter, Anne Jennifer1, Tanumay Raychaudhury, Laxmisha Chandrashekhar, Sophia Merilyn1, Sadashiv Gowda2, Aparna Shyam2 1
Departments of Dermatology, Venereology and Leprosy, Pathology, and 2Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
Address for correspondence: Dr. C.V. Dincy Peter, Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore, India, Tamil Nadu, India. E-mail: [email protected].
REFERENCES 1. 2.
3. 4. 5.
Cornbleet T. Cutis verticis gyrata? Lipoma? Arch Derm Syphilol 1935;32:688. Martín JM, Monteagudo C, Montesinos E, Guijarro J, Llombart B, Jordá E. Lipedematous scalp and lipedematous alopecia: A clinical and histologic analysis of 3 cases. J Am Acad Dermatol 2005;52:152-6. Müller CS, Niclou M, Vogt T, Pföhler C. Lipedematous diseases of the scalp are not separate entities but part of a spectrum of lipomatous lesions. J Dtsch Dermatol Ges 2012;10:501-7. El Darouti MA, Marzouk SA, Mashaly HM, El Nabarawi EA, Abdel-Halim MR, El Komy MM, et al. Lipedema and lipedematous alopecia: Report of 10 new cases. Eur J Dermatol 2007;17:351-2. Kavak A, Yuceer D, Yildirim U, Baykal C, Sarisoy HT. Lipedematous scalp: A rare entity. J Dermatol 2008;35:102-5. Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.132266 PMID: *****
272
Rosacea fulminans Sir, Rosacea fulminans is an intensely inflammatory facial eruption that affects young women. It can be mistaken for cutaneous infections and inappropriately treated with surgery or short courses of antibiotics. Accurate diagnosis and treatment reduces the potential for scarring. A 32-year-old woman presented with a painful facial eruption which started 2 years ago as a carbuncle. The first culture from pus grew Enterobacter but the rash responded only partially to incision and drainage and various antibiotics including cephalexin, cloxacillin, co-amoxiclav and ciprofloxacin. The patient was then suspected to have nodulocystic acne vulgaris and isotretinoin at 15 mg daily initially led to resolution, but she relapsed after 7 months of treatment. She was afebrile and had no relevant medical or drug history. Physical examination showed erythema, edema and multiple pustules over most of the face [Figure 1]. The total white cell count was 10.9 × 109/L with neutrophilia (81.3%). Erythrocyte sedimentation rate was 59 mm/h. Repeat cultures for bacteria, fungi and mycobacteria were negative and serum antinuclear antibody was non-reactive. Skin biopsy from a pustule on an erythematous, edematous plaque on the cheek showed a folliculo-centric infiltrate of neutrophils within the upper to mid-dermis with a ruptured hair follicle, upper dermal edema and superficial and mid-dermal perivascular lymphocytic infiltrate [Figure 2]. Rosacea fulminans was diagnosed and she was treated with doxycycline 100 mg twice a day, topical metronidazole gel and 2 weeks of indomethacin. The facial erythema and edema improved with cessation of new pustule formation. After 5 months of doxycycline and topical metronidazole, she achieved complete resolution [Figure 3]. Rosacea fulminans (synonym: pyoderma faciale) is a rare, inflammatory dermatosis that predominantly afflicts women in the 2nd to 3rd decades of life. A recent review found about 60 published articles since 1978.[1] It presents as an acute facial eruption of coalescing nodules, pustules and draining sinuses with pronounced erythema and edema. Men are uncommonly affected and extra-facial involvement is rare.[1,2] A history of seborrhea or sudden increase in oiliness prior to eruption may be elicited. Notwithstanding the fulminant nature of the outbreak, systemic symptoms are uncommon. The etiopathogenesis of rosacea fulminans remains unknown. Plewig et al. in their study classified it
Indian Journal of Dermatology, Venereology and Leprology | May-June 2014 | Vol 80 | Issue 3
Copyright of Indian Journal of Dermatology, Venereology & Leprology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Persons who have undergone tick removal should be monitored for up to 30 days for signs and symptoms of tick-borne diseases. Tick numbers and tick-borne diseases should be regularly monitored in areas with a high risk of tick attacks.
Cui-Cui Liu, Lilla Landeck1, Min Zheng Departments of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 1University of Osnabrueck, Osnabrueck, Lower Saxony, Germany Address for correspondence: Prof. Min Zheng, Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou - 310009, Zhejiang Province, China. E-mail: [email protected]
a
REFERENCES 1. 2.
b Figure 1: (a) A live tick stuck to the skin of right clavicle area (b) Histological examination of the tick in the skin (H and E, ×4)
it completely. Histopathological examination showed a tick body full of blood with the mouthpart embedded in the upper dermis, with necrotized skin tissue around it [Figure 1b]. Vessel dilatation and neutrophil infiltrate in the dermis were also observed [Figure 1b]. Ticks are blood feeding external parasites which can cause local and systemic complications, including Lyme disease, tick-borne-encephalitis, tick-borne lymphadenopathy, secondary bacterial skin infection, reactive manifestations against tick allergens and granuloma formation.[1] During 3 months of follow-up, our patient did not show any systemic symptoms indicating that she just suffered a tick bite but did not acquire any tick-transmitted diseases. Any tick found should be immediately and completely removed alive. Many methods of tick removal have been reported in the literature. Topical application of 2% erythromycin and 3% tetracycline preparations are ineffective in eliminating Borrelia burgdorferi from the tick bite site or in preventing dissemination to other tissues.[2] Limited surgical excision is an appropriate and safe tick removal technique and could remove the tick completely[3] without provoking the escape of infective body fluids from the tick into the wound site.
270
3.
Roupakias S, Mitsakou P, Nimer AA. Tick removal. J Prev Med Hyg 2011;52:40-4. Wormser GP, Daniels TJ, Bittker S, Cooper D, Wang G, Pavia CS. Failure of topical antibiotics to prevent disseminated Borrelia burgdorferi infection following a tick bite in C3H/HeJ mice. J Infect Dis 2012;205:991-4. Roupakias S, Mitsakou P, Nimer AA. Surgical tick removal. Wilderness Environ Med 2012;23:97-9. Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.132265 PMID: *****
Lipedematous scalp Sir, Lipedematous scalp is a rare clinico-pathologic entity characterized by an abnormal diffuse thickening of the subcutaneous tissue. There are fewer than 50 previous reports of the condition. Patient 1: A 57-year-old lady presented with itching and swelling over the scalp for 2 years. She had a shaven, diffusely thickened scalp thrown into involutions [Figure 1a] with prominences over the left parietal, vertex and occipital areas of scalp. There were no areas of alopecia, scaling or erythema on the scalp. The scalp had a boggy and spongy consistency. X-ray skull (lateral view) showed
Indian Journal of Dermatology, Venereology and Leprology | May-June 2014 | Vol 80 | Issue 3
Letters to the Editor
a
b
Figure 1: (a) Involutions seen over shaven scalp. (b) Lateral skull radiograph showing diffuse thickening over the entire scalp, with prominence over the frontal (12.3 mm) and occipital scalp (16.2 mm)
diffuse thickening over the entire scalp, with prominences over the frontal (12.3 mm) and occipital scalp (16.2 mm) [Figure 1b]. Patient 2: A 40-year-old lady presented with itching, headache and soft swelling over the scalp for the past 6 years. On examination, she had thickening of the skin over the vertex and left parietal area. Examination of the hair revealed no abnormaliy. Computed tomography (CT) of the head showed a diffuse peri-cranial soft swelling, with the prominence over the vertex measuring a maximum of 22.4 mm in thickness [Figure 2a]. Both patients had no features of acromegaly, pachydermoperiostosis or myxedema. Histopathology of the scalp lesions of both these patients showed mild to focal moderate perivascular infiltrates of lymphocytes and histiocytes. There was no atrophy of hair follicles and pilosebaceous units. The subcutis was thickened, edematous and showed disruption of adipocyte architecture and integrity. It appeared to encroach into the dermis [Figure 2b]. A diagnosis of lipedematous scalp was made in these patients based on the clinical finding of boggy soft swelling of the scalp without alopecia, which on histopathology showed encroachment of thickened subcutis into the dermis. It was first described by Cornbleet in 1935. Coskey et al. introduced the term “lipoedematous alopecia” for a disorder which is characterised by an acquired, non-scarring, permanent alopecia or short hair that is unable to grow beyond a few centimetres, overlying thickened boggy subcutaneous tissue of the scalp.[1,2] Recently Müller et al. proposed the term “localized lipomatosis of the scalp with or without alopecia” and suggested its classification within the group of conventional lipomatosis.[3]
a
b
Figure 2: (a) Computed tomography of the brain showing a diffuse pericranial soft-tissue swelling and prominence over the vertex measuring up to 22.4 mm thickness. (b) Biopsy of the scalp showing encroachment of thickened subcutis into the dermis, H and E, ×5
The condition is characterized by boggy, soft, spongy or doughy thickening of the scalp that is predominantly located at the vertex and occiput, which is better palpated than visualized. Most of the reports are among women with rare reports in Caucasian men. A series of lipedematous scalp in ten Egyptian women who use tight head covers has been reported[4] The presenting symptoms in patients include diffuse pain, paraesthesias, headache, burning, aymptomatic scalp thickening and localised or generalized scalp tenderness or itching. Increased scalp thickness is a characteristic feature resulting from increased thickening in the subcutaneous layer. Kavak et al. in their study have reported the average subcutaneous adipose tissue thickness between the galea aponeurotica and dermis in 78 Turkish subjects as 4.0 ± 0.94 mm by ultrasound.[5] The scalp thickness in patients with lipedematous scalp ranged from 9.2 to 16 mm.[5] Since there was no normative data available on scalp thickness in Indian subjects, we studied normal scalp thickness measured on the CT brain images of 30 patients including 16 males and 14 females with a mean age of 47.2 years (18-83 years). The mean scalp thickness at the frontal, parietal and occipital areas was 5.5 mm (2.8-8.1 mm), 7.1 mm (4-11 mm) and 7.75 mm (5-11 mm) respectively. These measurements were consistent with previous reports from other countries. Going by this data, scalp thickness in both our patients was greater than twice that of the normal population. The histopathological changes include thickening of the subcutaneous tissue with encroachment into
Indian Journal of Dermatology, Venereology and Leprology | May-June 2014 | Vol 80 | Issue 3
271
Letters to the Editor
the dermis and distortion of fat architecture, dermal edema and ectatic lymphatics.[2] The pathogenesis remains unknown although mechanical factors like prolonged use of tight head gear and hormonal factors have been implicated.[4] Incidental associations include diabetes mellitus, renal failure, joint and skin hyperelasticity, Sjogren’s syndrome, hyperlipidemia and ovarian cysts.[2,5] There is no definitive option for treatment or to halt progression of the condition. Our patients were initiated on antihistamines. In conclusion, lipedematous scalp is a possible cause of dysesthetic syndrome of the scalp. In patients with no obvious cause for dysesthesia of the scalp, it is advisable that the scalp be palpated to identify this rare presentation that may otherwise be missed.
C.V. Dincy Peter, Anne Jennifer1, Tanumay Raychaudhury, Laxmisha Chandrashekhar, Sophia Merilyn1, Sadashiv Gowda2, Aparna Shyam2 1
Departments of Dermatology, Venereology and Leprosy, Pathology, and 2Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
Address for correspondence: Dr. C.V. Dincy Peter, Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore, India, Tamil Nadu, India. E-mail: [email protected].
REFERENCES 1. 2.
3. 4. 5.
Cornbleet T. Cutis verticis gyrata? Lipoma? Arch Derm Syphilol 1935;32:688. Martín JM, Monteagudo C, Montesinos E, Guijarro J, Llombart B, Jordá E. Lipedematous scalp and lipedematous alopecia: A clinical and histologic analysis of 3 cases. J Am Acad Dermatol 2005;52:152-6. Müller CS, Niclou M, Vogt T, Pföhler C. Lipedematous diseases of the scalp are not separate entities but part of a spectrum of lipomatous lesions. J Dtsch Dermatol Ges 2012;10:501-7. El Darouti MA, Marzouk SA, Mashaly HM, El Nabarawi EA, Abdel-Halim MR, El Komy MM, et al. Lipedema and lipedematous alopecia: Report of 10 new cases. Eur J Dermatol 2007;17:351-2. Kavak A, Yuceer D, Yildirim U, Baykal C, Sarisoy HT. Lipedematous scalp: A rare entity. J Dermatol 2008;35:102-5. Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.132266 PMID: *****
272
Rosacea fulminans Sir, Rosacea fulminans is an intensely inflammatory facial eruption that affects young women. It can be mistaken for cutaneous infections and inappropriately treated with surgery or short courses of antibiotics. Accurate diagnosis and treatment reduces the potential for scarring. A 32-year-old woman presented with a painful facial eruption which started 2 years ago as a carbuncle. The first culture from pus grew Enterobacter but the rash responded only partially to incision and drainage and various antibiotics including cephalexin, cloxacillin, co-amoxiclav and ciprofloxacin. The patient was then suspected to have nodulocystic acne vulgaris and isotretinoin at 15 mg daily initially led to resolution, but she relapsed after 7 months of treatment. She was afebrile and had no relevant medical or drug history. Physical examination showed erythema, edema and multiple pustules over most of the face [Figure 1]. The total white cell count was 10.9 × 109/L with neutrophilia (81.3%). Erythrocyte sedimentation rate was 59 mm/h. Repeat cultures for bacteria, fungi and mycobacteria were negative and serum antinuclear antibody was non-reactive. Skin biopsy from a pustule on an erythematous, edematous plaque on the cheek showed a folliculo-centric infiltrate of neutrophils within the upper to mid-dermis with a ruptured hair follicle, upper dermal edema and superficial and mid-dermal perivascular lymphocytic infiltrate [Figure 2]. Rosacea fulminans was diagnosed and she was treated with doxycycline 100 mg twice a day, topical metronidazole gel and 2 weeks of indomethacin. The facial erythema and edema improved with cessation of new pustule formation. After 5 months of doxycycline and topical metronidazole, she achieved complete resolution [Figure 3]. Rosacea fulminans (synonym: pyoderma faciale) is a rare, inflammatory dermatosis that predominantly afflicts women in the 2nd to 3rd decades of life. A recent review found about 60 published articles since 1978.[1] It presents as an acute facial eruption of coalescing nodules, pustules and draining sinuses with pronounced erythema and edema. Men are uncommonly affected and extra-facial involvement is rare.[1,2] A history of seborrhea or sudden increase in oiliness prior to eruption may be elicited. Notwithstanding the fulminant nature of the outbreak, systemic symptoms are uncommon. The etiopathogenesis of rosacea fulminans remains unknown. Plewig et al. in their study classified it
Indian Journal of Dermatology, Venereology and Leprology | May-June 2014 | Vol 80 | Issue 3
Copyright of Indian Journal of Dermatology, Venereology & Leprology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
