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
Correspondence
(a)
(b)
Figure 2 Magnetic resonance scan showing an enhanced mass
(65 9 48 9 85 mm) with necrotic centre arising from the base of the tongue, and infiltrating the right masticator space, parapharyngeal space and right piriform fossa.
Figure 1 (a) Erythematous and eroded papules and plaques on
the back. (b) Scale crust formation, atrophy and necrotic keratinocytes in the epidermis, with vacuolar degeneration of the basal layer, papillary oedema with marked periadnexal and perivascular lymphocytic infiltrate in the dermis. Haematoxylin and eosin staining; original magnification 910.
included scale crust formation, prominent epidermal atrophy and necrotic keratinocytes. Direct immunofluorescence of the skin tissue was negative. Magnetic resonance imaging of the patient’s neck revealed an enhanced mass (65 9 48 9 85 mm) with a
336
Clinical and Experimental Dermatology (2015) 40, pp331–338
necrotic centre, which arose from the base of the tongue, and infiltrated the right masticator space, parapharyngeal space and right piriform fossa (Fig. 2). A biopsy taken from the submandibular mass demonstrated a poorly differentiated squamous cell carcinoma (SCC). There was no evidence of metastatic disease. Laboratory investigations were positive for nucleolar pattern antinuclear antibodies and anti-Ro antibody (163 U/mL; normal range < 10.0). Other results, including those for double-stranded DNA, C3, C4, anti-La, antiJo-1, creatine kinase, and renal and liver function, were either normal or negative. Although the patient’s presentation was not typical of subacute cutaneous lupus erythematosus (SCLE), we felt that his eruption, in conjunction with the histological features and serology, was most consistent with a paraneoplastic SCLE secondary to a tongue SCC. Mucosal oropharyngeal carcinoma is the most common head and neck malignancy, and has a high mortality rate. Paraneoplastic syndrome secondary to head and neck cancers, and in particular, oropharyngeal SCC, is very rare. The criteria published by McLean1 for paraneoplastic syndrome state that the dermatosis should arise after the development of the malignant tumour, but it may or may not precede the diagnosis of the tumour. Both the malignant tumour and dermatosis should follow a parallel course. Since the 1980s, several paraneoplastic SCLE cases have been reported in relation to malignancy involving the lung, breast, uterus, liver and lymphoma.2,3 The first case of head and neck malignancy associated
ª 2015 British Association of Dermatologists
Correspondence
with paraneoplastic SCLE was a supraglottic laryngeal SCC, reported by Chaudhry et al. in 2005.4 Other cutaneous paraneoplastic syndromes that have been associated with head and neck malignancies include acrokeratosis paraneoplastica, dermatomyositis and eruptive seborrhoeic keratoses.5 Regression of skin eruptions usually occurs after treatment of the primary malignancy. In our case, the patient underwent palliative radiotherapy for a locally advanced SCC that was not amenable tor surgery. His rash improved with topical betamethasone valerate 0.1% ointment and photoprotection. He did not require any systemic treatment, and was still in remission at follow-up 3 months later. A. Murad,1 B. O’Donnell,1 H. Rowley,2 and N. Mulligan3 Departments of 1Dermatology, 2Ear, Nose and Throat, and 3 Histopathology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 16 May 2014
References 1 McLean DJ. Cutaneous paraneoplastic syndromes. Arch Dermatol 1986; 122: 765–7. 2 Evans KG, Heymann WR. Paraneoplastic subacute cutaneous lupus erythematosus: an underrecognized entity. Cutis 2013; 91: 25–9. 3 McKenna KE, Hayes D, McMillen JC. Subacute cutaneous lupus erythematosus-like gyrate erythema and hypertrichosis lanuginosa acquisita associated with uterine adenocarcinoma. Br J Dermatol 1992; 127: 443– 4. 4 Chaudhry SI, Murphy LA, White IR. Subacute cutaneous lupus erythematosus: a paraneoplastic dermatosis? Clin Exp Dermatol 2005; 30: 655–8. 5 Li M, Yang LJ, Zhu XH et al. The Leser-Trelat sign is associated with nasopharyngeal carcinoma: case report and review of cases reported in China. Clin Exp Dermatol 2009; 34: 52–4.
Tap water iontophoresis may be ineffective for axillary hyperhidrosis doi: 10.1111/ced.12485 Focal hyperhidrosis is usually idiopathic, and affects mainly the palms, soles and axillae in an otherwise healthy person. It can have a marked negative effect on patients’ quality of life.1 Therapy for hyperhidrosis is limited. Lifestyle advice and aluminium chloride preparations are the first-line recommendations for management in the primary care
ª 2015 British Association of Dermatologists
setting. Botulinum toxin type A injections and systemic anticholinergic treatment are available treatment options in secondary care. Surgical options such as axillary clearance and endoscopic thoracosympathectomy are reserved for those patients who have not responded to conservative measures.1 Iontophoresis is promoted as a treatment option for hyperhidrosis. The exact mode of its action remains unclear. One hypothesis suggests that charged ions are driven into the skin by the current, and inhibit the function of sweat glands.1 Axillary hyperhidrosis is most common after the onset of puberty, when the axillary apocrine glands begin to proliferate.2 In iontophoresis for axillary hyperhidrosis, foam pads are soaked in tap water, and electrodes are inserted into the pads, which are then placed in the axillae. A low-intensity (5–10 mA) pulsed electric current is run through the electrodes for 10 min, and the polarity of the current is then reversed, and run through for a further 10 min. A course of therapy consists of seven 20-min sessions over 4 weeks. Data supporting the use of tap water iontophoresis for axillary hyperhidrosis is sparse. Anecdotally, Sharpe et al., in a sub-group analysis, noted improvement in only one out of four patients treated for axillary hyperhidrosis with tap water iontophoresis.3 Recently, we assessed the effectiveness of a course of tap water iontophoresis in the management of axillary hyperhidrosis in a more substantial cohort, to inform a decision on whether the service should be continued. Discussion among local dermatologists suggested that tap water iontophoresis needed to be effective in over 30% of cases for it to be considered a worthwhile treatment option. We performed a retrospective survey of 17 patients (12 female, 5 male; median age 30 years, range 15–71) who had received solely axillary iontophoresis between January 2012 and October 2013. Responsiveness was assessed by reviewing the medical entries in patients’ notes and treatment cards, and the summary outcome letter to the patients’ general practitioners. Treatment effectiveness was recorded as successful/adequate clinical response, clinically inadequate improvement or no change or worsening. Results showed that only 4 of the 17 patients (24%) deemed the treatment successful and reported an adequate clinical response, while 6 (35%) reported clinically inadequate improvement, and 7 (41%) reported no change or worsening of their symptoms. As < 30% of patients showed an adequate clinical response to tap water iontophoresis, this treatment for the management of axillary hyperhidrosis has been withdrawn. We would recommend others to reconsider this treatment option for axillary hyperhidrosis, in the absence of evidence of substantial benefit.
Clinical and Experimental Dermatology (2015) 40, pp331–338
337
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
Correspondence
(a)
(b)
Figure 2 Magnetic resonance scan showing an enhanced mass
(65 9 48 9 85 mm) with necrotic centre arising from the base of the tongue, and infiltrating the right masticator space, parapharyngeal space and right piriform fossa.
Figure 1 (a) Erythematous and eroded papules and plaques on
the back. (b) Scale crust formation, atrophy and necrotic keratinocytes in the epidermis, with vacuolar degeneration of the basal layer, papillary oedema with marked periadnexal and perivascular lymphocytic infiltrate in the dermis. Haematoxylin and eosin staining; original magnification 910.
included scale crust formation, prominent epidermal atrophy and necrotic keratinocytes. Direct immunofluorescence of the skin tissue was negative. Magnetic resonance imaging of the patient’s neck revealed an enhanced mass (65 9 48 9 85 mm) with a
336
Clinical and Experimental Dermatology (2015) 40, pp331–338
necrotic centre, which arose from the base of the tongue, and infiltrated the right masticator space, parapharyngeal space and right piriform fossa (Fig. 2). A biopsy taken from the submandibular mass demonstrated a poorly differentiated squamous cell carcinoma (SCC). There was no evidence of metastatic disease. Laboratory investigations were positive for nucleolar pattern antinuclear antibodies and anti-Ro antibody (163 U/mL; normal range < 10.0). Other results, including those for double-stranded DNA, C3, C4, anti-La, antiJo-1, creatine kinase, and renal and liver function, were either normal or negative. Although the patient’s presentation was not typical of subacute cutaneous lupus erythematosus (SCLE), we felt that his eruption, in conjunction with the histological features and serology, was most consistent with a paraneoplastic SCLE secondary to a tongue SCC. Mucosal oropharyngeal carcinoma is the most common head and neck malignancy, and has a high mortality rate. Paraneoplastic syndrome secondary to head and neck cancers, and in particular, oropharyngeal SCC, is very rare. The criteria published by McLean1 for paraneoplastic syndrome state that the dermatosis should arise after the development of the malignant tumour, but it may or may not precede the diagnosis of the tumour. Both the malignant tumour and dermatosis should follow a parallel course. Since the 1980s, several paraneoplastic SCLE cases have been reported in relation to malignancy involving the lung, breast, uterus, liver and lymphoma.2,3 The first case of head and neck malignancy associated
ª 2015 British Association of Dermatologists
Correspondence
with paraneoplastic SCLE was a supraglottic laryngeal SCC, reported by Chaudhry et al. in 2005.4 Other cutaneous paraneoplastic syndromes that have been associated with head and neck malignancies include acrokeratosis paraneoplastica, dermatomyositis and eruptive seborrhoeic keratoses.5 Regression of skin eruptions usually occurs after treatment of the primary malignancy. In our case, the patient underwent palliative radiotherapy for a locally advanced SCC that was not amenable tor surgery. His rash improved with topical betamethasone valerate 0.1% ointment and photoprotection. He did not require any systemic treatment, and was still in remission at follow-up 3 months later. A. Murad,1 B. O’Donnell,1 H. Rowley,2 and N. Mulligan3 Departments of 1Dermatology, 2Ear, Nose and Throat, and 3 Histopathology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 16 May 2014
References 1 McLean DJ. Cutaneous paraneoplastic syndromes. Arch Dermatol 1986; 122: 765–7. 2 Evans KG, Heymann WR. Paraneoplastic subacute cutaneous lupus erythematosus: an underrecognized entity. Cutis 2013; 91: 25–9. 3 McKenna KE, Hayes D, McMillen JC. Subacute cutaneous lupus erythematosus-like gyrate erythema and hypertrichosis lanuginosa acquisita associated with uterine adenocarcinoma. Br J Dermatol 1992; 127: 443– 4. 4 Chaudhry SI, Murphy LA, White IR. Subacute cutaneous lupus erythematosus: a paraneoplastic dermatosis? Clin Exp Dermatol 2005; 30: 655–8. 5 Li M, Yang LJ, Zhu XH et al. The Leser-Trelat sign is associated with nasopharyngeal carcinoma: case report and review of cases reported in China. Clin Exp Dermatol 2009; 34: 52–4.
Tap water iontophoresis may be ineffective for axillary hyperhidrosis doi: 10.1111/ced.12485 Focal hyperhidrosis is usually idiopathic, and affects mainly the palms, soles and axillae in an otherwise healthy person. It can have a marked negative effect on patients’ quality of life.1 Therapy for hyperhidrosis is limited. Lifestyle advice and aluminium chloride preparations are the first-line recommendations for management in the primary care
ª 2015 British Association of Dermatologists
setting. Botulinum toxin type A injections and systemic anticholinergic treatment are available treatment options in secondary care. Surgical options such as axillary clearance and endoscopic thoracosympathectomy are reserved for those patients who have not responded to conservative measures.1 Iontophoresis is promoted as a treatment option for hyperhidrosis. The exact mode of its action remains unclear. One hypothesis suggests that charged ions are driven into the skin by the current, and inhibit the function of sweat glands.1 Axillary hyperhidrosis is most common after the onset of puberty, when the axillary apocrine glands begin to proliferate.2 In iontophoresis for axillary hyperhidrosis, foam pads are soaked in tap water, and electrodes are inserted into the pads, which are then placed in the axillae. A low-intensity (5–10 mA) pulsed electric current is run through the electrodes for 10 min, and the polarity of the current is then reversed, and run through for a further 10 min. A course of therapy consists of seven 20-min sessions over 4 weeks. Data supporting the use of tap water iontophoresis for axillary hyperhidrosis is sparse. Anecdotally, Sharpe et al., in a sub-group analysis, noted improvement in only one out of four patients treated for axillary hyperhidrosis with tap water iontophoresis.3 Recently, we assessed the effectiveness of a course of tap water iontophoresis in the management of axillary hyperhidrosis in a more substantial cohort, to inform a decision on whether the service should be continued. Discussion among local dermatologists suggested that tap water iontophoresis needed to be effective in over 30% of cases for it to be considered a worthwhile treatment option. We performed a retrospective survey of 17 patients (12 female, 5 male; median age 30 years, range 15–71) who had received solely axillary iontophoresis between January 2012 and October 2013. Responsiveness was assessed by reviewing the medical entries in patients’ notes and treatment cards, and the summary outcome letter to the patients’ general practitioners. Treatment effectiveness was recorded as successful/adequate clinical response, clinically inadequate improvement or no change or worsening. Results showed that only 4 of the 17 patients (24%) deemed the treatment successful and reported an adequate clinical response, while 6 (35%) reported clinically inadequate improvement, and 7 (41%) reported no change or worsening of their symptoms. As < 30% of patients showed an adequate clinical response to tap water iontophoresis, this treatment for the management of axillary hyperhidrosis has been withdrawn. We would recommend others to reconsider this treatment option for axillary hyperhidrosis, in the absence of evidence of substantial benefit.
Clinical and Experimental Dermatology (2015) 40, pp331–338
337
