Correspondence
References
(a)
(b)
Figure 2 (a) Closely aggregated, dilated capillaries are visible just
under the surface ridge. (b) The crista profunda intermedia is sandwiched between the aggregated capillaries, corresponding to the red dots on the side of surface ridge observed under dermoscopy. Haematoxylin and eosin, original magnification (a) 9 100; (b) 9 200.
1 Saida T, Miyazaki A, Oguchi S et al. Significance of dermoscopic patterns in detecting malignant melanoma on acral volar skin: results of a multicenter study in Japan. Arch Dermatol 2004; 140: 1233–8. 2 Tanioka M. Benign acral lesions showing parallel ridge pattern on dermoscopy. J Dermatol 2011; 38: 41–4. 3 Toyonaga E, Inokuma D, Abe Y et al. Pagetoid dyskeratosis with parallel ridge pattern under dermoscopy. JAMA Dermatol 2013; 149: 109–11. 4 Bernabeu-Wittel J, Domınguez-Cruz J, Zulueta T et al. Hemorrhagic parallel-ridge pattern on dermoscopy in ‘Playstation fingertip’. J Am Acad Dermatol 2011; 65: 238–9. 5 Abe R, Yamagishi S, Fujita Y et al. Topical application of anti-angiogenic peptides based on pigment epithelium-derived factor can improve psoriasis. J Dermatol Sci 2010; 57: 183–91.
Scar sarcoidosis on a hypertrophic scar doi: 10.1111/ced.12417
the epidermal structures, and the anatomical distribution of these vessels seems to be independent of the covering epidermis. Cytokines such as keratinocyte-derived vascular endothelial growth factor may induce angiogenesis in the papillary dermis,5 and this kind of reaction might produce a unique distribution of vascular lesions along the epidermal structures. In our case, we speculate that physical irritation from the patient’s habitual walking might have stimulated the keratinocytes or appendages of the skin, possibly causing the cells to release some cytokine-like signals that induced neoplastic vascular proliferation under the surface ridge. To our knowledge, this is the first case of a vascular lesion showing the red PRP pattern under dermoscopy, with a characteristic distribution of abnormal vessels seen histopathologically. The reason why proliferative capillaries are distributed around the crista profunda intermedia remains unclear. No vascular lesions showing a parallel furrow pattern similar to this case have been reported. Further dermoscopy studies of vascular lesions, as well as of pigmented lesions, are needed to elucidate the meaning of the volar parallel pattern in vascular lesions. R. Moriuchi, K. Kikuchi, T. Ito and S. Shimizu Department of Dermatology, Sapporo City General Hospital, North 11, West 13, Chuo-ku, Sapporo 060-8604, Japan E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 24 February 2014
ª 2014 British Association of Dermatologists
Scar sarcoidosis is a rare but specific form of cutaneous sarcoidosis in which old scars become infiltrated with noncaseating epitheloid cell granulomas.1 Trauma, injection, skin injury, venepuncture, tuberculin test site, and local skin injury scars have been known to develop scar sarcoidosis.2 The exact incidence is unknown; however, two recent studies have estimated the incidence of cutaneous sarcoidosis in adults to be 5.4% and 13.8%.3
Figure 1 A single, firm, erythematous, indurated nodule,
8 9 10 mm in size, on the dorsal aspect of the left thumb.
Clinical and Experimental Dermatology (2014) 39, pp944–948
945
Correspondence
(a)
Figure 2 (a) Numerous, noncaseating epitheloid cell granulomas
with multinucleated giant cells and (b) giant cells containing asteroid bodies (black arrow) and star-shaped eosinophilic structures. Haematoxylin and eosin, original magnification (a) 9 40; (b) 9 100. (c) Reticulin staining showed a network of reticulum fibres surrounding and permeating the epitheliod cell granuloma (original magnification 9 40).
A 56-year-old female presented to our outpatient dermatology clinic with a 2-year history of a tender erythematous nodule, which had appeared on a 10-year-old scar on her left thumb. The scar first appeared after a knife-related skin injury, and improved after intralesional steroid injection. Physical examination revealed a single, firm, erythematous, indurated nodule, 8 9 10 mm in size, on the dorsal aspect of the left thumb (Fig. 1). The patient had no other scars on her body, and no other lesions were found on the skin. A biopsy was taken from the nodule, and histology revealed numerous noncaseating epitheloid cell granulomas with multinucleated giant cells (Fig. 2a,b). Stains for mycobacteria and fungi were negative, and polariscopic examination for foreign-body materials was negative. Reticulin staining demonstrated a network of reticulum fibres surrounding and permeating the epitheliod cell granuloma (Fig. 2c). No tissue culture was carried out. Although the patient had no respiratory symptoms and examination of the chest revealed normal breath sounds, plain radiography and computed tomography of the chest showed hilar lymphadenopathy without necrosis or calcification, and numerous tiny, diffuse, well-defined nodules in both lungs. Angiotensin-converting enzyme was raised at 85 U/L (normal range 25–82 U/L). Other laboratory tests, including complete blood count, electrolytes, liver and renal function tests, and urinary analysis, were within normal limits. Mantoux test and sputum for acidfast bacilli were negative. On ophthalmological examination, there were no symptoms or signs of eye involvement. Therefore, a diagnosis of scar sarcoidosis with pulmonary involvement was confirmed. This patient exhibited the typical features of scar sarcoidosis, which developed on a 10-year-old hypertrophic scar. The aetiology of scar sarcoidosis is unknown, although it has been hypothesized that infectious agents or contamination by foreign material in scars can trigger sarcoidosis in individuals with a genetic susceptibility for this disease.2,4 The majority of patients with scar sarcoidosis have systemic disease, and scar inflammation is considered an activity index for this condition.5 In our patient, pulmonary involvement was confirmed through systemic evaluation after diagnosis of scar sarcoidosis. She was treated successfully with three injections of triamcinolone acetonide 5 mg/mL into the skin lesion, and will undergo continued surveillance via pulmonary exam-
(b)
(c)
946
Clinical and Experimental Dermatology (2014) 39, pp944–948
ª 2014 British Association of Dermatologists
Correspondence
ination and chest radiography every 2 months as well as periodic monitoring for other systemic manifestations. S. Y. Choi, M. Y. Hyun, Y. A. No, K. Y. Park, K. Li, B. J. Kim, S. J. Seo, M. N. Kim and C. K. Hong Department of Dermatology, Chung-Ang University Hospital, Seoul, Korea E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 5 March 2014
References 1 Caro I. Scar sarcoidosis. Cutis 1983; 32: 531–3. 2 Yesudian PD, Azurdia RM. Scar sarcoidosis following tattooing of the lips treated with mepacrine. Clin Exp Dermatol 2004; 29: 552–4. 3 Mana J, Marcoval J, Graells J et al. Cutaneous involvement in sarcoidosis. Relationship to systemic disease. Arch Dermatol 1997; 133: 882–8. 4 Singal A, Thami GP, Goraya JS. Scar sarcoidosis in childhood: case report and review of the literature. Clin Exp Dermatol 2005; 30: 244–6. 5 Scarfi F, Arunachalam M, Galeone M et al. Nodular lesions on post-surgical scars: scar sarcoidosis. Acta Derm Venereol 2013; 93: 255–6.
A potentially rare and serious consequence of ciclosporin therapy for psoriasis doi: 10.1111/ced.12451 Ciclosporin is commonly used in dermatological practice to treat a wide range of inflammatory and immunemediated skin disorders. A recent consultation has highlighted a rare complication of ciclosporin therapy, which we believe should be made known to all dermatologists. A 35-year-old white woman with a 10-year history of chronic plaque psoriasis had started ciclosporin for a third time, following two previous, highly successful, 6-month courses of treatment with this drug. At routine review after 4 weeks of treatment, there was a significant reduc-
Figure 1 Fundoscopic images from our patient, demonstrating
tion in active psoriasis, and the patient’s renal function, liver enzymes, white cell counts and blood pressure were all within normal ranges. As the consultation came to a close, the patient mentioned that she had been getting headaches, which were not terribly severe in nature, and was planning to visit her general practitioner. Subsequently, over the course of treatment, the headaches became more frequent and much more severe. The patient then began to report symptoms of blurred vision in her left eye, which an urgent ophthalmic examination revealed to be due to papillo-oedema (Fig. 1). Cranial magnetic resonance imaging excluded the presence of venous thrombosis or intracranial mass. Lumbar puncture demonstrated a cerebrospinal fluid (CSF) opening pressure of 420 mm, while cytology and cultures were all normal. A diagnosis of benign intracranial hypertension (BIH) was made, which was considered by the neurology and ophthalmology departments to be related to ciclosporin use. The patient was commenced on acetozolamide, with an almost immediate improvement in symptoms and CSF pressure. Subsequently, all active treatment was stopped, without recurrence of headaches or visual symptoms. Ciclosporin is a calcineurin inhibitor,1 which inhibits both autoimmune and allogeneic T cell-mediated immune responses.2 BIH, also known as pseudotumour cerebri, is a condition of raised intracranial pressure of unknown cause.3 Patients can present with tinnitus, chronic daily headache, transient visual disturbance, diplopia and papillo-oedema, causing a reduction in visual acuity.3 The reported upper limit of normal for CSF pressure in adults is 200–250 mm.4 A recent report from Stiebel-Kalish et al.5 suggested a role for the upregulation of the water pore protein aquaporin 1 in the development of BIH in patients taking glucocorticoids and retinoids. Further research may reveal a similar mechanism underlying BIH associated with ciclosporin. Ciclosporin-induced BIH is an extremely rare complication. It is possible that our patient developed the idiopathic form of BIH. She is the right age and sex, and is slightly overweight, all features strongly associated with this disorder, although the fairly rapid improvement in symptoms and the discontinuation of active treatment on withdrawal of the drug point to ciclosporin being the cause. Other drugs commonly used in dermatological practice, including isotretinoin, acitretin and tetracyclines, can also give rise to BIH. Given the complete lack of reporting within the dermatology literature and the serious morbidity that this condition can cause, we feel it is vital to bring it the attention of all of our colleagues. It is, therefore, a prerequisite for the prescribing physician to be alert to the symptoms of BIH when using ciclosporin to treat psoriasis or other skin disease, as this condition can lead to permanent visual loss.3
grade 2 papillo-oedema.
ª 2014 British Association of Dermatologists
Clinical and Experimental Dermatology (2014) 39, pp944–948
947
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.
References
(a)
(b)
Figure 2 (a) Closely aggregated, dilated capillaries are visible just
under the surface ridge. (b) The crista profunda intermedia is sandwiched between the aggregated capillaries, corresponding to the red dots on the side of surface ridge observed under dermoscopy. Haematoxylin and eosin, original magnification (a) 9 100; (b) 9 200.
1 Saida T, Miyazaki A, Oguchi S et al. Significance of dermoscopic patterns in detecting malignant melanoma on acral volar skin: results of a multicenter study in Japan. Arch Dermatol 2004; 140: 1233–8. 2 Tanioka M. Benign acral lesions showing parallel ridge pattern on dermoscopy. J Dermatol 2011; 38: 41–4. 3 Toyonaga E, Inokuma D, Abe Y et al. Pagetoid dyskeratosis with parallel ridge pattern under dermoscopy. JAMA Dermatol 2013; 149: 109–11. 4 Bernabeu-Wittel J, Domınguez-Cruz J, Zulueta T et al. Hemorrhagic parallel-ridge pattern on dermoscopy in ‘Playstation fingertip’. J Am Acad Dermatol 2011; 65: 238–9. 5 Abe R, Yamagishi S, Fujita Y et al. Topical application of anti-angiogenic peptides based on pigment epithelium-derived factor can improve psoriasis. J Dermatol Sci 2010; 57: 183–91.
Scar sarcoidosis on a hypertrophic scar doi: 10.1111/ced.12417
the epidermal structures, and the anatomical distribution of these vessels seems to be independent of the covering epidermis. Cytokines such as keratinocyte-derived vascular endothelial growth factor may induce angiogenesis in the papillary dermis,5 and this kind of reaction might produce a unique distribution of vascular lesions along the epidermal structures. In our case, we speculate that physical irritation from the patient’s habitual walking might have stimulated the keratinocytes or appendages of the skin, possibly causing the cells to release some cytokine-like signals that induced neoplastic vascular proliferation under the surface ridge. To our knowledge, this is the first case of a vascular lesion showing the red PRP pattern under dermoscopy, with a characteristic distribution of abnormal vessels seen histopathologically. The reason why proliferative capillaries are distributed around the crista profunda intermedia remains unclear. No vascular lesions showing a parallel furrow pattern similar to this case have been reported. Further dermoscopy studies of vascular lesions, as well as of pigmented lesions, are needed to elucidate the meaning of the volar parallel pattern in vascular lesions. R. Moriuchi, K. Kikuchi, T. Ito and S. Shimizu Department of Dermatology, Sapporo City General Hospital, North 11, West 13, Chuo-ku, Sapporo 060-8604, Japan E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 24 February 2014
ª 2014 British Association of Dermatologists
Scar sarcoidosis is a rare but specific form of cutaneous sarcoidosis in which old scars become infiltrated with noncaseating epitheloid cell granulomas.1 Trauma, injection, skin injury, venepuncture, tuberculin test site, and local skin injury scars have been known to develop scar sarcoidosis.2 The exact incidence is unknown; however, two recent studies have estimated the incidence of cutaneous sarcoidosis in adults to be 5.4% and 13.8%.3
Figure 1 A single, firm, erythematous, indurated nodule,
8 9 10 mm in size, on the dorsal aspect of the left thumb.
Clinical and Experimental Dermatology (2014) 39, pp944–948
945
Correspondence
(a)
Figure 2 (a) Numerous, noncaseating epitheloid cell granulomas
with multinucleated giant cells and (b) giant cells containing asteroid bodies (black arrow) and star-shaped eosinophilic structures. Haematoxylin and eosin, original magnification (a) 9 40; (b) 9 100. (c) Reticulin staining showed a network of reticulum fibres surrounding and permeating the epitheliod cell granuloma (original magnification 9 40).
A 56-year-old female presented to our outpatient dermatology clinic with a 2-year history of a tender erythematous nodule, which had appeared on a 10-year-old scar on her left thumb. The scar first appeared after a knife-related skin injury, and improved after intralesional steroid injection. Physical examination revealed a single, firm, erythematous, indurated nodule, 8 9 10 mm in size, on the dorsal aspect of the left thumb (Fig. 1). The patient had no other scars on her body, and no other lesions were found on the skin. A biopsy was taken from the nodule, and histology revealed numerous noncaseating epitheloid cell granulomas with multinucleated giant cells (Fig. 2a,b). Stains for mycobacteria and fungi were negative, and polariscopic examination for foreign-body materials was negative. Reticulin staining demonstrated a network of reticulum fibres surrounding and permeating the epitheliod cell granuloma (Fig. 2c). No tissue culture was carried out. Although the patient had no respiratory symptoms and examination of the chest revealed normal breath sounds, plain radiography and computed tomography of the chest showed hilar lymphadenopathy without necrosis or calcification, and numerous tiny, diffuse, well-defined nodules in both lungs. Angiotensin-converting enzyme was raised at 85 U/L (normal range 25–82 U/L). Other laboratory tests, including complete blood count, electrolytes, liver and renal function tests, and urinary analysis, were within normal limits. Mantoux test and sputum for acidfast bacilli were negative. On ophthalmological examination, there were no symptoms or signs of eye involvement. Therefore, a diagnosis of scar sarcoidosis with pulmonary involvement was confirmed. This patient exhibited the typical features of scar sarcoidosis, which developed on a 10-year-old hypertrophic scar. The aetiology of scar sarcoidosis is unknown, although it has been hypothesized that infectious agents or contamination by foreign material in scars can trigger sarcoidosis in individuals with a genetic susceptibility for this disease.2,4 The majority of patients with scar sarcoidosis have systemic disease, and scar inflammation is considered an activity index for this condition.5 In our patient, pulmonary involvement was confirmed through systemic evaluation after diagnosis of scar sarcoidosis. She was treated successfully with three injections of triamcinolone acetonide 5 mg/mL into the skin lesion, and will undergo continued surveillance via pulmonary exam-
(b)
(c)
946
Clinical and Experimental Dermatology (2014) 39, pp944–948
ª 2014 British Association of Dermatologists
Correspondence
ination and chest radiography every 2 months as well as periodic monitoring for other systemic manifestations. S. Y. Choi, M. Y. Hyun, Y. A. No, K. Y. Park, K. Li, B. J. Kim, S. J. Seo, M. N. Kim and C. K. Hong Department of Dermatology, Chung-Ang University Hospital, Seoul, Korea E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 5 March 2014
References 1 Caro I. Scar sarcoidosis. Cutis 1983; 32: 531–3. 2 Yesudian PD, Azurdia RM. Scar sarcoidosis following tattooing of the lips treated with mepacrine. Clin Exp Dermatol 2004; 29: 552–4. 3 Mana J, Marcoval J, Graells J et al. Cutaneous involvement in sarcoidosis. Relationship to systemic disease. Arch Dermatol 1997; 133: 882–8. 4 Singal A, Thami GP, Goraya JS. Scar sarcoidosis in childhood: case report and review of the literature. Clin Exp Dermatol 2005; 30: 244–6. 5 Scarfi F, Arunachalam M, Galeone M et al. Nodular lesions on post-surgical scars: scar sarcoidosis. Acta Derm Venereol 2013; 93: 255–6.
A potentially rare and serious consequence of ciclosporin therapy for psoriasis doi: 10.1111/ced.12451 Ciclosporin is commonly used in dermatological practice to treat a wide range of inflammatory and immunemediated skin disorders. A recent consultation has highlighted a rare complication of ciclosporin therapy, which we believe should be made known to all dermatologists. A 35-year-old white woman with a 10-year history of chronic plaque psoriasis had started ciclosporin for a third time, following two previous, highly successful, 6-month courses of treatment with this drug. At routine review after 4 weeks of treatment, there was a significant reduc-
Figure 1 Fundoscopic images from our patient, demonstrating
tion in active psoriasis, and the patient’s renal function, liver enzymes, white cell counts and blood pressure were all within normal ranges. As the consultation came to a close, the patient mentioned that she had been getting headaches, which were not terribly severe in nature, and was planning to visit her general practitioner. Subsequently, over the course of treatment, the headaches became more frequent and much more severe. The patient then began to report symptoms of blurred vision in her left eye, which an urgent ophthalmic examination revealed to be due to papillo-oedema (Fig. 1). Cranial magnetic resonance imaging excluded the presence of venous thrombosis or intracranial mass. Lumbar puncture demonstrated a cerebrospinal fluid (CSF) opening pressure of 420 mm, while cytology and cultures were all normal. A diagnosis of benign intracranial hypertension (BIH) was made, which was considered by the neurology and ophthalmology departments to be related to ciclosporin use. The patient was commenced on acetozolamide, with an almost immediate improvement in symptoms and CSF pressure. Subsequently, all active treatment was stopped, without recurrence of headaches or visual symptoms. Ciclosporin is a calcineurin inhibitor,1 which inhibits both autoimmune and allogeneic T cell-mediated immune responses.2 BIH, also known as pseudotumour cerebri, is a condition of raised intracranial pressure of unknown cause.3 Patients can present with tinnitus, chronic daily headache, transient visual disturbance, diplopia and papillo-oedema, causing a reduction in visual acuity.3 The reported upper limit of normal for CSF pressure in adults is 200–250 mm.4 A recent report from Stiebel-Kalish et al.5 suggested a role for the upregulation of the water pore protein aquaporin 1 in the development of BIH in patients taking glucocorticoids and retinoids. Further research may reveal a similar mechanism underlying BIH associated with ciclosporin. Ciclosporin-induced BIH is an extremely rare complication. It is possible that our patient developed the idiopathic form of BIH. She is the right age and sex, and is slightly overweight, all features strongly associated with this disorder, although the fairly rapid improvement in symptoms and the discontinuation of active treatment on withdrawal of the drug point to ciclosporin being the cause. Other drugs commonly used in dermatological practice, including isotretinoin, acitretin and tetracyclines, can also give rise to BIH. Given the complete lack of reporting within the dermatology literature and the serious morbidity that this condition can cause, we feel it is vital to bring it the attention of all of our colleagues. It is, therefore, a prerequisite for the prescribing physician to be alert to the symptoms of BIH when using ciclosporin to treat psoriasis or other skin disease, as this condition can lead to permanent visual loss.3
grade 2 papillo-oedema.
ª 2014 British Association of Dermatologists
Clinical and Experimental Dermatology (2014) 39, pp944–948
947
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.
