Viewpoints in dermatology • Correspondence
Correspondence
Unilateral laterothoracic or asymmetric periflexural exanthem: is time to change the name of the disease? doi: 10.1111/ced.12486 We read with interest the article by Niedermeier et al.1 about ‘superimposed lateralized exanthem of childhood related to adenovirus infection’, and we would like to make a few comments on it. This exanthem is also known as ‘unilateral laterothoracic exanthema’ (ULE) or ‘asymmetrical periflexural exanthema of childhood’ (APEC). Both denominations, however, are inaccurate, as they do not match the clinical features of the exanthem fully. First, although the exanthem is prevalent in childhood, it is not exclusive to it, as several cases have been reported in adults.2,3 Second, the eruption does not always remain unilateral, and may involve, even primarily, the groin and the legs. Accordingly, we endorse the title suggested by Happle et al.4 that is ‘superimposed lateralized exanthem’ (SLEx). We also agree with their hypothesis explaining the unilateral preponderance of this exanthem as increased responsiveness of a polygenic predisposed side of the body to various infectious agents. Doctors are accustomed to the idea that an infectious disease is caused by a single infectious agent. However, the same infectious agent may cause different types of exanthems, and the same exanthem may be caused by different infectious agents. In addition, different infectious agents may cooperate with each other simultaneously or in temporal succession to produce the clinical manifestations. It seems probable that this also occurs in some cases of drug reactions. In fact, an association with adenovirus, parainfluenza virus, parvovirus B19, human herpes virus (HHV)6 and HHV-7, and Epstein–Barr virus has been reported in SLEx.5 Some of these viruses provide particular features to the exanthem while keeping it mainly lateralized. For example, as we reported years ago,3 Parvovirus B19 may be responsible for an evident purpuric component of the exanthem. An asymmetrical presentation may also be observed in pityriasis rosea (PR). In our updated series of 578 PR cases, an atypical presentation starting from the axilla or presenting a strictly asymmetrical involvement was observed in nine patients (1.5%; seven adults and two children), and in seven of them, an endogenous HHV-6 or
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Clinical and Experimental Dermatology (2015) 40, pp570–579
HHV-7 systemic reactivation was detected, giving a virological confirmation of the diagnosis of PR.6 In fact, we believe the clinical differential diagnosis of SLEx should also include atypical PR, and probably certain cases of SLEx might be atypical presentations of PR. Consequently, we consider that it is time to adopt ‘superimposed lateralized exanthem’ as the most suitable term for this condition. F. Drago, G. Ciccarese and A. Rebora Department of Dermatology, DISSAL, IRCCS AOU San Martino-IST, Genoa, Italy E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 5 May 2014
References 1 Niedermeier A, Pfutzner W, Ruzicka T et al. Superimposed lateralized exanthem of childhood: report of a case related to adenovirus infection. Clin Exp Dermatol 2014; 39: 351–3. 2 Bauza A, Redondo P, Fernandez J. Asymmetric periflexural exanthem in adults. Br J Dermatol 2000; 143: 198–233. 3 Drago F, Semino M, Rampini P et al. Parvovirus B19 infection associated with acute hepatitis and a purpuric exanthem. Br J Dermatol 1999; 141: 154–79. 4 Happle R. Superimposed segmental manifestations of polygenic skin disorders. J Am Acad Dermatol 2007; 57: 690–9. 5 Duarte AF, Cruz MJ, Baudrier T et al. Unilateral laterothoracic exanthem and primary Epstein-Barr virus infection: case report. Pediatr Infect Dis J 2009; 28: 549–50. 6 Broccolo F, Drago F, Careddu AM et al. Additional evidence that pityriasis rosea is associated with reactivation of human herpesvirus-6 and -7. J Invest Dermatol 2005; 124: 1234–40.
Site of botulinum toxin type A administration in craniofacial hyperhidrosis doi: 10.1111/ced.12558 Over recent years, botulinum toxin type A (BoNTA) has been used in an increasing number of clinical
ª 2014 British Association of Dermatologists
Correspondence
applications, and has transformed management of focal hyperhidrosis. The diffusion properties of BoNTA in human tissues vary between different preparations, and have a significant bearing on efficacy and toxicity. This is used to advantage in cosmesis, where greater BoNTA diffusion is ideal for treatment of frontalis wrinkles. Reduced diffusion of the toxin is desirable when injecting the lateral canthus, pretarsal orbicularis and superior orbital rim,1 in order to minimize toxicity resulting in diplopia, ptosis and ectropion.2 Eccrine glands are typically located at the dermis–fat interface and in the deep reticular dermis. They are almost always surrounded by a pad of adipocytes, and are not found alone in the subcutaneous fat. We were interested to read the recent report of Ko et al.3 in comparing efficacy and diffusion of three formulations of BoNTA in two patients with forehead hyperhidrosis. Their choice of intramuscular (IM) rather than the more conventional intradermal or subcutaneous administration of BoNTA was surprising, as IM injection is likely to have unintended effects on facial musculature when the aim is to treat eccrine glands only. In our experience, topical glycopyrrolate (0.5–4% cream, solution or pads) is very effective in treating craniofacial hyperhidrosis.4 In line with local National Health Service recommendations, we reserve BoNTA largely for axillary hyperhidrosis. Goodman reported halving the dose of BoNTA with addition of the enzyme hyaluronidase in treating hyperhidrosis.5 We are investigating whether enhancing diffusion of BoNTA with hyaluronidase can be repeated in a larger group of patients. A. B. Hussain and G. M. Kavanagh Department of Dermatology, University of Edinburgh, Lauriston Building, Edinburgh, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 30 July 2014
5 Goodman G. Diffusion and short -term efficacy of botulinum toxin A after the addition of hyaluronidase and its possible application for the treatment of axillary hyperhidrosis. Dermatol Surg 2003; 29: 533–83.
Actinic lichen planus with milia doi: 10.1111/ced.12551 We read with interest the recent article published in Clinical and Experimental Dermatology by Vink et al.1 regarding a case of bullous acral lichen sclerosus with milia. We report another uncommon association of milia: actinic lichen planus (LP). A 15-year-old girl of Indian origin presented with a 10-month history of an asymptomatic, darkly pigmented patch near her right eye. She was not on any regular medication. On physical examination revealed a darkly pigmented patch measuring approximately 15 mm adjacent to the right lateral canthus. The surrounding edges of the patch were studded with multiple milia (Fig. 1). When the patient returned for a skin biopsy 6 months later, the patch was much lighter in colour, and the number of milia had reduced. The patient consented to only a small biopsy being taken, thus, a 3 mm punch biopsy was taken from the pigmented area to establish the diagnosis. Histological examination showed a band-like lymphohistiocytic infiltrate in the superficial dermis, with overlying basal cell degeneration, lymphocytic exocytosis and colloid body formation (Fig. 2). A diagnosis of actinic LP with milia was made on the basis of the clinical and histological findings. The patient was commenced on topical tacrolimus 0.1% ointment. Unfortunately, the patient failed to attend for further review.
References 1 Moriarty KC. Botulinium Toxin in Facial Rejuvenation. London/New York: Mosby, 2004. 2 Carruthers J, Fagien S, Matarasso SL. Consensus recommendations on the use of botulinum toxin type A in facial aesthetics. Plast Reconstr Surg 2004; 114 (Suppl): S1–22. 3 Ko EJ, Mun SK, Oh IY et al. Comparison of efficacy and diffusion of three formulations of botulinum toxin type A in two patients with forehead hyperhidrosis. Clin Exp Dermatol 2014; 39: 673–5. 4 Mackenzie A, Burns C, Kavanagh G. Topical glycopyrrolate for axillary hyperhidrosis. Br J Dermatol 2013; 169: 483–4.
ª 2014 British Association of Dermatologists
Figure 1 Milia surrounding a pigmented patch adjacent to the
right lateral canthus.
Clinical and Experimental Dermatology (2015) 40, pp570–579
571
Correspondence
Unilateral laterothoracic or asymmetric periflexural exanthem: is time to change the name of the disease? doi: 10.1111/ced.12486 We read with interest the article by Niedermeier et al.1 about ‘superimposed lateralized exanthem of childhood related to adenovirus infection’, and we would like to make a few comments on it. This exanthem is also known as ‘unilateral laterothoracic exanthema’ (ULE) or ‘asymmetrical periflexural exanthema of childhood’ (APEC). Both denominations, however, are inaccurate, as they do not match the clinical features of the exanthem fully. First, although the exanthem is prevalent in childhood, it is not exclusive to it, as several cases have been reported in adults.2,3 Second, the eruption does not always remain unilateral, and may involve, even primarily, the groin and the legs. Accordingly, we endorse the title suggested by Happle et al.4 that is ‘superimposed lateralized exanthem’ (SLEx). We also agree with their hypothesis explaining the unilateral preponderance of this exanthem as increased responsiveness of a polygenic predisposed side of the body to various infectious agents. Doctors are accustomed to the idea that an infectious disease is caused by a single infectious agent. However, the same infectious agent may cause different types of exanthems, and the same exanthem may be caused by different infectious agents. In addition, different infectious agents may cooperate with each other simultaneously or in temporal succession to produce the clinical manifestations. It seems probable that this also occurs in some cases of drug reactions. In fact, an association with adenovirus, parainfluenza virus, parvovirus B19, human herpes virus (HHV)6 and HHV-7, and Epstein–Barr virus has been reported in SLEx.5 Some of these viruses provide particular features to the exanthem while keeping it mainly lateralized. For example, as we reported years ago,3 Parvovirus B19 may be responsible for an evident purpuric component of the exanthem. An asymmetrical presentation may also be observed in pityriasis rosea (PR). In our updated series of 578 PR cases, an atypical presentation starting from the axilla or presenting a strictly asymmetrical involvement was observed in nine patients (1.5%; seven adults and two children), and in seven of them, an endogenous HHV-6 or
570
Clinical and Experimental Dermatology (2015) 40, pp570–579
HHV-7 systemic reactivation was detected, giving a virological confirmation of the diagnosis of PR.6 In fact, we believe the clinical differential diagnosis of SLEx should also include atypical PR, and probably certain cases of SLEx might be atypical presentations of PR. Consequently, we consider that it is time to adopt ‘superimposed lateralized exanthem’ as the most suitable term for this condition. F. Drago, G. Ciccarese and A. Rebora Department of Dermatology, DISSAL, IRCCS AOU San Martino-IST, Genoa, Italy E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 5 May 2014
References 1 Niedermeier A, Pfutzner W, Ruzicka T et al. Superimposed lateralized exanthem of childhood: report of a case related to adenovirus infection. Clin Exp Dermatol 2014; 39: 351–3. 2 Bauza A, Redondo P, Fernandez J. Asymmetric periflexural exanthem in adults. Br J Dermatol 2000; 143: 198–233. 3 Drago F, Semino M, Rampini P et al. Parvovirus B19 infection associated with acute hepatitis and a purpuric exanthem. Br J Dermatol 1999; 141: 154–79. 4 Happle R. Superimposed segmental manifestations of polygenic skin disorders. J Am Acad Dermatol 2007; 57: 690–9. 5 Duarte AF, Cruz MJ, Baudrier T et al. Unilateral laterothoracic exanthem and primary Epstein-Barr virus infection: case report. Pediatr Infect Dis J 2009; 28: 549–50. 6 Broccolo F, Drago F, Careddu AM et al. Additional evidence that pityriasis rosea is associated with reactivation of human herpesvirus-6 and -7. J Invest Dermatol 2005; 124: 1234–40.
Site of botulinum toxin type A administration in craniofacial hyperhidrosis doi: 10.1111/ced.12558 Over recent years, botulinum toxin type A (BoNTA) has been used in an increasing number of clinical
ª 2014 British Association of Dermatologists
Correspondence
applications, and has transformed management of focal hyperhidrosis. The diffusion properties of BoNTA in human tissues vary between different preparations, and have a significant bearing on efficacy and toxicity. This is used to advantage in cosmesis, where greater BoNTA diffusion is ideal for treatment of frontalis wrinkles. Reduced diffusion of the toxin is desirable when injecting the lateral canthus, pretarsal orbicularis and superior orbital rim,1 in order to minimize toxicity resulting in diplopia, ptosis and ectropion.2 Eccrine glands are typically located at the dermis–fat interface and in the deep reticular dermis. They are almost always surrounded by a pad of adipocytes, and are not found alone in the subcutaneous fat. We were interested to read the recent report of Ko et al.3 in comparing efficacy and diffusion of three formulations of BoNTA in two patients with forehead hyperhidrosis. Their choice of intramuscular (IM) rather than the more conventional intradermal or subcutaneous administration of BoNTA was surprising, as IM injection is likely to have unintended effects on facial musculature when the aim is to treat eccrine glands only. In our experience, topical glycopyrrolate (0.5–4% cream, solution or pads) is very effective in treating craniofacial hyperhidrosis.4 In line with local National Health Service recommendations, we reserve BoNTA largely for axillary hyperhidrosis. Goodman reported halving the dose of BoNTA with addition of the enzyme hyaluronidase in treating hyperhidrosis.5 We are investigating whether enhancing diffusion of BoNTA with hyaluronidase can be repeated in a larger group of patients. A. B. Hussain and G. M. Kavanagh Department of Dermatology, University of Edinburgh, Lauriston Building, Edinburgh, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 30 July 2014
5 Goodman G. Diffusion and short -term efficacy of botulinum toxin A after the addition of hyaluronidase and its possible application for the treatment of axillary hyperhidrosis. Dermatol Surg 2003; 29: 533–83.
Actinic lichen planus with milia doi: 10.1111/ced.12551 We read with interest the recent article published in Clinical and Experimental Dermatology by Vink et al.1 regarding a case of bullous acral lichen sclerosus with milia. We report another uncommon association of milia: actinic lichen planus (LP). A 15-year-old girl of Indian origin presented with a 10-month history of an asymptomatic, darkly pigmented patch near her right eye. She was not on any regular medication. On physical examination revealed a darkly pigmented patch measuring approximately 15 mm adjacent to the right lateral canthus. The surrounding edges of the patch were studded with multiple milia (Fig. 1). When the patient returned for a skin biopsy 6 months later, the patch was much lighter in colour, and the number of milia had reduced. The patient consented to only a small biopsy being taken, thus, a 3 mm punch biopsy was taken from the pigmented area to establish the diagnosis. Histological examination showed a band-like lymphohistiocytic infiltrate in the superficial dermis, with overlying basal cell degeneration, lymphocytic exocytosis and colloid body formation (Fig. 2). A diagnosis of actinic LP with milia was made on the basis of the clinical and histological findings. The patient was commenced on topical tacrolimus 0.1% ointment. Unfortunately, the patient failed to attend for further review.
References 1 Moriarty KC. Botulinium Toxin in Facial Rejuvenation. London/New York: Mosby, 2004. 2 Carruthers J, Fagien S, Matarasso SL. Consensus recommendations on the use of botulinum toxin type A in facial aesthetics. Plast Reconstr Surg 2004; 114 (Suppl): S1–22. 3 Ko EJ, Mun SK, Oh IY et al. Comparison of efficacy and diffusion of three formulations of botulinum toxin type A in two patients with forehead hyperhidrosis. Clin Exp Dermatol 2014; 39: 673–5. 4 Mackenzie A, Burns C, Kavanagh G. Topical glycopyrrolate for axillary hyperhidrosis. Br J Dermatol 2013; 169: 483–4.
ª 2014 British Association of Dermatologists
Figure 1 Milia surrounding a pigmented patch adjacent to the
right lateral canthus.
Clinical and Experimental Dermatology (2015) 40, pp570–579
571
