disease and that it is, therefore, impossible to determine whether the development of MDF is induced by aggravation of the underlying disease or by the use of drugs [4]. The aetiology of dermatofibromas is controversial. Cytogenetic studies demonstrating clonality suggest that the lesion may in fact be neoplastic. Some prefer to think of it as a reactive process or dermal response to injury following an insult such as an insect bite or non-specific inflammatory conditions. In this case, histopathological findings of degenerated hair follicles were observed in the vicinity of the MDF lesions, suggesting the possibility that MDF developed secondarily to folliculitis. There is a reported case of solitary sclerotic fibroma similarly stemming from folliculitis [5]. Although there is no report as yet suggesting that MDF can be caused by folliculitis, it seems very likely that folliculitis may represent one cause, in addition to immune-mediated diseases. In some cases, the onset of MDF preceded the onset and diagnosis of the associated immune-mediated disease [6]. Further continued caution against the development of an immune-mediated disease is needed in the present case as well.
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Disclosure. Financial support: none. Conflict of interest: none. 1
Department of Dermatology Department of Pathology, Toho University Ohashi Medical Center, Ohashi 2-17-6, Meguro-ku, Tokyo, 153-8515 Japan 2
Kosuke WATANABE1 Hidetsugu FUKUDA1 Shiro NIIYAMA1 Toshiaki OHARASAKI2 Hideki MUKAI1
1. Niiyama S, Happle R, Hoffmann R. Multiple disseminated dermatofibromas in a woman with systemic lupus erythematosus. Eur J Dermatol 2001; 11: 475-6. 2. Kimura Y, Kaneko T, Akasaka E, Nakajima K, Aizu T, Nakano H, Sawamura D. Multiple eruptive dermatofibromas associated with Hashimoto’s thyroiditis and myasthenia gravis. Eur J Dermatol 2010; 20: 538-9. 3. Kanitakis J, Carbonnel E, Delmonte S, Livrozet JM, Faure M, Claudy A. Multiple eruptive dermatofibromas in a patient with HIV infection: case report and literature review. J Cutan Pathol 2000; 27: 54-6. 4. Niiyama S, Katsuoka K, Happle R, Hoffmann R. Multiple eruptive dermatofibromas: a review of the literature. Acta Derm Venereol 2002; 82: 241-4. 5. Chang SN, Chun SI, Moon TK, Park WH. Solitary sclerotic fibroma of the skin: degenerated sclerotic change of inflammatory conditions, especially folliculitis. Am J Dermatopathol 2000; 22: 22-5. 6. Murphy SC, Lowitt MH, Kao GF. Multiple eruptive dermatofibromas in an HIV-positive man. Dermatology 1995; 190: 309-12. doi:10.1684/ejd.2013.2164
Treatment of segmental lichen aureus with a pulsed-dye laser: new treatment options for lichen aureus Lichen aureus is a localized variant of pigmented purpuric dermatosis (PPD) and is characterized by discrete or confluent lichenoid macules and papules that are very persistent. EJD, vol. 23, n◦ 6, November-December 2013
Figure 1. A) Golden-brown macules and lichenoid papules on the anterior shin of the right leg. B) Complete remission of the lesions at 4 weeks after three sessions of pulsed-dye laser treatment. C) Biopsy showing lichenoid infiltrate and endothelial cell swelling with red blood cell extravasation in the upper dermis (hematoxylin and eosin staining; ×200).
The underlying cause of lichen aureus remains unknown and consequently there is no cure [1]. Here, we report a case of segmental lichen aureus that significantly improved after three treatment sessions with a 595 nm pulsed-dye laser (PDL). A 33-year-old woman presented with a 3 year history of multiple golden-brown macules and patches on her lower right leg (figure 1A). She had no history of drug use, skin irritation or disease and showed no subjective symptoms. A histopathological examination demonstrated superficial perivascular lymphocytic infiltration and endothelial cell swelling with red blood cell extravasation (figure 1C). Based on clinical and histopathologic features, we diagnosed the patient with segmental lichen aureus. The patient received various treatments including topical steroids, tacrolimus, oral pentoxyfylline and narrow-band ultraviolet B-light; however, none was effective. Finally, we decided to treat the lesions with a 595 nm PDL (V-beam perfecta, Candela Corporation, MA). The patient was treated with PDL three times over a period of 3 weeks, using a 7 mm spot, a fluence of 9–11 J/cm2 , and a pulse duration of 10 ms. A dynamic cooling device delivered a 30 ms spurt of cryogen at 30 ms prior to the laser pulse. There was a marked improvement in the lesions after the first treatment, and there was complete remission after three sessions
891
(figure 1B). There was no evidence of recurrence of the lesions during the 6 month follow-up period. PPD constitutes a group of cutaneous lesions that are characterized by petechiae and bronze discoloration of the skin. A number of clinical variants of PPD are recognized that may represent different clinical presentations. These include Schamberg’s disease, Majocchi’s disease, lichen aureus, pigmented purpuric lichenoid dermatosis of Gougerot and Blum and eczematid-like purpura of Doucas and Kapetanakis. Lichen aureus is a rare subtype of PPD that affects young adults and is characterized by chronic, stable or slowly-progressing lesions. Lichen aureus may exhibit a segmental pattern that follows venous drainage or the lines of Blaschko [2, 3]. In the case presented here, the lesions were composed of numerous golden-brown macules and lichenoid papules with a segmental distribution. Although there are various treatment options for lichen aureus, such as topical and systemic steroids, phototherapy, pentoxyphylline and prostacyclin, there is no cure for this condition [2-4]. We used a PDL that emitted light at a wavelength of 595 nm, which is selectively absorbed by oxyhemoglobin. There is an underlying vascular disturbance in lichen aureus; therefore, we thought that 595 nm PDL might be an effective treatment for this condition [5]. Additionally, 595 nm PDL penetrates approximately 1.2 mm into the skin, which is sufficient to treat lichen aureus limited to the superficial dermis [6]. To our knowledge, the clinical use of PDL for the treatment of lichen aureus has not been reported previously. We believe that this novel therapeutic modality might offer a new strategy in the treatment of lichen aureus, which is a chronic and treatment-resistant condition. Further larger studies with long term follow up are needed to establish its efficacy, to determine the optimal settings and the duration of treatment.
Visceral leishmaniasis with cutaneous dissemination in a renal transplant recipient A 34-year-old male was referred for multiple papules on his face and neck, present for two weeks. He underwent renal transplantation 7 years previously and been on prednisolone, sirolimus and mycophenolate mofetil since then. He was admitted three months earlier with fever, malaise and cough. As his sputum culture had grown Pseudomonas aeruginosa, he took meropenem (3 g/day, intravenously) and had no symptoms on follow-up visits. Three months later, he presented with fever, abdominal pain, cough, dysphagia, hoarseness and splenomegaly. Dermatological examination revealed multiple skin-colored papules on the face and neck with a 2-week history (figure 1A). Laboratory examination showed pancytopenia, increased aspartate aminotransferase, blood urea nitrogen, creatinine and C-reactive protein. Blood, sputum, and urine cultures for bacteria were negative. Ultrasonography confirmed splenomegaly. Chest X-ray and computed tomography showed bacterial pneumonia and meropenem (3 g/day, intravenously) was started. Bronchoalveolar lavage grew Acinetobacter baumannii and colistin was administered (150 mg/day, intravenously). Magnetic resonance imaging of the neck disclosed enlargement of the left nasopharyngeal area (figure 1B). Histopathological examination
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Disclosure. Financial support: none. Conflict of interest: none. Department of Dermatology, Chungnam National University Hospital, 33 Munhwa-ro, Daejeon, 301-747, Korea
Dong-kyun HONG In-kyu CHANG Young LEE Young-joon SEO Chang-deok KIM Jeung-hoon LEE Myung IM
1. Moche J, Glassman S, Modi D, Grayson W. Segmental lichen aureus: A report of two cases treated with methylprednisolone aceponate. Australas J Dermatol 2011; 52: 15-8. 2. Ruiz-Esmenjaud J, Dahl MV. Segmental lichen aureus: onset associated with trauma and puberty. Arch Dermatol 1988; 124: 1572-4. 3. Lee HW, Lee DK, Chang SE, et al. Segmental lichen aureus: combination therapy with pentoxyfilline and prostacycline. J Eur Acad Dermatol Venereol 2006; 20: 1378-80. 4. Basak PY, Ergin S. Should pentoxifylline be regarded as an effective treatment for Schamberg’s disease? J Am Acad Dermatol 2001; 44: 548-9. 5. D’Ambrosia RA, Rajpara VS, Glogau RG. The successful treatment of Schamberg’s disease with the 595nm vascular laser. Dermatol Surg 2011; 37: 100-1. 6. Zachary CB, Rofagha R. Laser therapy. In: Bolognia JL, Jorizzo JL, Schaffer JV, eds. Dermatology. 3rd edn. Elsevier, 2012: 2261-2. doi:10.1684/ejd.2013.2166
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Figure 1. Multiple, skin-colored papules of 2 to 4 mm diameter on the face and neck. (Inset: close-up view of the papules) (A). Magnetic resonance imaging of the neck shows edema and enlargement of the left nasopharyngeal area (arrow) (B). Bone marrow aspiration biopsy reveals extracellular leishmania amastigotes (arrows) (Hematoxylin-eosin stain; original magnification ×1000) (C). Cytology of the skin lesions disclose multiple round to oval intracytoplasmic Leishman-Donovan bodies (arrows) inside the histiocytes.(Inset: close-up view of the amastigotes. Small ovoid bodies with an eccentric nucleus) (May Grünwald-Giemsa stain; original magnification ×1000) (D). EJD, vol. 23, n◦ 6, November-December 2013
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Disclosure. Financial support: none. Conflict of interest: none. 1
Department of Dermatology Department of Pathology, Toho University Ohashi Medical Center, Ohashi 2-17-6, Meguro-ku, Tokyo, 153-8515 Japan 2
Kosuke WATANABE1 Hidetsugu FUKUDA1 Shiro NIIYAMA1 Toshiaki OHARASAKI2 Hideki MUKAI1
1. Niiyama S, Happle R, Hoffmann R. Multiple disseminated dermatofibromas in a woman with systemic lupus erythematosus. Eur J Dermatol 2001; 11: 475-6. 2. Kimura Y, Kaneko T, Akasaka E, Nakajima K, Aizu T, Nakano H, Sawamura D. Multiple eruptive dermatofibromas associated with Hashimoto’s thyroiditis and myasthenia gravis. Eur J Dermatol 2010; 20: 538-9. 3. Kanitakis J, Carbonnel E, Delmonte S, Livrozet JM, Faure M, Claudy A. Multiple eruptive dermatofibromas in a patient with HIV infection: case report and literature review. J Cutan Pathol 2000; 27: 54-6. 4. Niiyama S, Katsuoka K, Happle R, Hoffmann R. Multiple eruptive dermatofibromas: a review of the literature. Acta Derm Venereol 2002; 82: 241-4. 5. Chang SN, Chun SI, Moon TK, Park WH. Solitary sclerotic fibroma of the skin: degenerated sclerotic change of inflammatory conditions, especially folliculitis. Am J Dermatopathol 2000; 22: 22-5. 6. Murphy SC, Lowitt MH, Kao GF. Multiple eruptive dermatofibromas in an HIV-positive man. Dermatology 1995; 190: 309-12. doi:10.1684/ejd.2013.2164
Treatment of segmental lichen aureus with a pulsed-dye laser: new treatment options for lichen aureus Lichen aureus is a localized variant of pigmented purpuric dermatosis (PPD) and is characterized by discrete or confluent lichenoid macules and papules that are very persistent. EJD, vol. 23, n◦ 6, November-December 2013
Figure 1. A) Golden-brown macules and lichenoid papules on the anterior shin of the right leg. B) Complete remission of the lesions at 4 weeks after three sessions of pulsed-dye laser treatment. C) Biopsy showing lichenoid infiltrate and endothelial cell swelling with red blood cell extravasation in the upper dermis (hematoxylin and eosin staining; ×200).
The underlying cause of lichen aureus remains unknown and consequently there is no cure [1]. Here, we report a case of segmental lichen aureus that significantly improved after three treatment sessions with a 595 nm pulsed-dye laser (PDL). A 33-year-old woman presented with a 3 year history of multiple golden-brown macules and patches on her lower right leg (figure 1A). She had no history of drug use, skin irritation or disease and showed no subjective symptoms. A histopathological examination demonstrated superficial perivascular lymphocytic infiltration and endothelial cell swelling with red blood cell extravasation (figure 1C). Based on clinical and histopathologic features, we diagnosed the patient with segmental lichen aureus. The patient received various treatments including topical steroids, tacrolimus, oral pentoxyfylline and narrow-band ultraviolet B-light; however, none was effective. Finally, we decided to treat the lesions with a 595 nm PDL (V-beam perfecta, Candela Corporation, MA). The patient was treated with PDL three times over a period of 3 weeks, using a 7 mm spot, a fluence of 9–11 J/cm2 , and a pulse duration of 10 ms. A dynamic cooling device delivered a 30 ms spurt of cryogen at 30 ms prior to the laser pulse. There was a marked improvement in the lesions after the first treatment, and there was complete remission after three sessions
891
(figure 1B). There was no evidence of recurrence of the lesions during the 6 month follow-up period. PPD constitutes a group of cutaneous lesions that are characterized by petechiae and bronze discoloration of the skin. A number of clinical variants of PPD are recognized that may represent different clinical presentations. These include Schamberg’s disease, Majocchi’s disease, lichen aureus, pigmented purpuric lichenoid dermatosis of Gougerot and Blum and eczematid-like purpura of Doucas and Kapetanakis. Lichen aureus is a rare subtype of PPD that affects young adults and is characterized by chronic, stable or slowly-progressing lesions. Lichen aureus may exhibit a segmental pattern that follows venous drainage or the lines of Blaschko [2, 3]. In the case presented here, the lesions were composed of numerous golden-brown macules and lichenoid papules with a segmental distribution. Although there are various treatment options for lichen aureus, such as topical and systemic steroids, phototherapy, pentoxyphylline and prostacyclin, there is no cure for this condition [2-4]. We used a PDL that emitted light at a wavelength of 595 nm, which is selectively absorbed by oxyhemoglobin. There is an underlying vascular disturbance in lichen aureus; therefore, we thought that 595 nm PDL might be an effective treatment for this condition [5]. Additionally, 595 nm PDL penetrates approximately 1.2 mm into the skin, which is sufficient to treat lichen aureus limited to the superficial dermis [6]. To our knowledge, the clinical use of PDL for the treatment of lichen aureus has not been reported previously. We believe that this novel therapeutic modality might offer a new strategy in the treatment of lichen aureus, which is a chronic and treatment-resistant condition. Further larger studies with long term follow up are needed to establish its efficacy, to determine the optimal settings and the duration of treatment.
Visceral leishmaniasis with cutaneous dissemination in a renal transplant recipient A 34-year-old male was referred for multiple papules on his face and neck, present for two weeks. He underwent renal transplantation 7 years previously and been on prednisolone, sirolimus and mycophenolate mofetil since then. He was admitted three months earlier with fever, malaise and cough. As his sputum culture had grown Pseudomonas aeruginosa, he took meropenem (3 g/day, intravenously) and had no symptoms on follow-up visits. Three months later, he presented with fever, abdominal pain, cough, dysphagia, hoarseness and splenomegaly. Dermatological examination revealed multiple skin-colored papules on the face and neck with a 2-week history (figure 1A). Laboratory examination showed pancytopenia, increased aspartate aminotransferase, blood urea nitrogen, creatinine and C-reactive protein. Blood, sputum, and urine cultures for bacteria were negative. Ultrasonography confirmed splenomegaly. Chest X-ray and computed tomography showed bacterial pneumonia and meropenem (3 g/day, intravenously) was started. Bronchoalveolar lavage grew Acinetobacter baumannii and colistin was administered (150 mg/day, intravenously). Magnetic resonance imaging of the neck disclosed enlargement of the left nasopharyngeal area (figure 1B). Histopathological examination
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Disclosure. Financial support: none. Conflict of interest: none. Department of Dermatology, Chungnam National University Hospital, 33 Munhwa-ro, Daejeon, 301-747, Korea
Dong-kyun HONG In-kyu CHANG Young LEE Young-joon SEO Chang-deok KIM Jeung-hoon LEE Myung IM
1. Moche J, Glassman S, Modi D, Grayson W. Segmental lichen aureus: A report of two cases treated with methylprednisolone aceponate. Australas J Dermatol 2011; 52: 15-8. 2. Ruiz-Esmenjaud J, Dahl MV. Segmental lichen aureus: onset associated with trauma and puberty. Arch Dermatol 1988; 124: 1572-4. 3. Lee HW, Lee DK, Chang SE, et al. Segmental lichen aureus: combination therapy with pentoxyfilline and prostacycline. J Eur Acad Dermatol Venereol 2006; 20: 1378-80. 4. Basak PY, Ergin S. Should pentoxifylline be regarded as an effective treatment for Schamberg’s disease? J Am Acad Dermatol 2001; 44: 548-9. 5. D’Ambrosia RA, Rajpara VS, Glogau RG. The successful treatment of Schamberg’s disease with the 595nm vascular laser. Dermatol Surg 2011; 37: 100-1. 6. Zachary CB, Rofagha R. Laser therapy. In: Bolognia JL, Jorizzo JL, Schaffer JV, eds. Dermatology. 3rd edn. Elsevier, 2012: 2261-2. doi:10.1684/ejd.2013.2166
892
Figure 1. Multiple, skin-colored papules of 2 to 4 mm diameter on the face and neck. (Inset: close-up view of the papules) (A). Magnetic resonance imaging of the neck shows edema and enlargement of the left nasopharyngeal area (arrow) (B). Bone marrow aspiration biopsy reveals extracellular leishmania amastigotes (arrows) (Hematoxylin-eosin stain; original magnification ×1000) (C). Cytology of the skin lesions disclose multiple round to oval intracytoplasmic Leishman-Donovan bodies (arrows) inside the histiocytes.(Inset: close-up view of the amastigotes. Small ovoid bodies with an eccentric nucleus) (May Grünwald-Giemsa stain; original magnification ×1000) (D). EJD, vol. 23, n◦ 6, November-December 2013
