e350
Correspondence
been described to date.4–6 The patients were infants in all four cases. Black henna tattoos represent a source of sensitization to PPD that has potentially severe medium- and long-term consequences. Reactions can cause scars, cheloids, and hypopigmentation at the site of the tattoo. These temporary tattoos can cause significant and lifelong sensitization, which is likely to lead to future reactivity to permanent hair dyes, chemicals in rubber products, inks, clothing dyes, and some medications (sulfonamides and hydroclorothiazides).7 This sensitization might affect a subject’s future choice of occupation, particularly with reference to hairdressing and photography. In conclusion, we describe a case of erythema multiforme-like eruption that occurred after the administration of a paint-on tattoo. Temporary tattoos are considered to be safer than permanent tattoos because they disappear within a few weeks. Permanent tattooing is associated with inflammatory reactions to tattoo pigments, photoallergic reactions, and inoculation by certain infectious agents. However, the practice of skin painting is not devoid of risk, and thus public education programs that divulge the dangers of exposure to higher concentrations of PPD are required. Nuria Barrientos, MD Patricia Abajo, MD Marıa Moreno de Vega, MD Jose Dominguez, MD Department of Dermatology University Hospital of Henares
Vascular structure absence under dermoscopy in two cases of angiosarcoma on the scalp
Cutaneous angiosarcoma (AS) is a rare malignant tumor of soft tissue and is known to have three clinical subtypes: classical AS (head and neck type), Stewart–Treves syndrome, and post-radiation AS.1 Few dermoscopic features of AS have been reported and it has not yet been examined in detail. Here, we describe two cases of AS located on the scalp and discuss their dermoscopic features. Case 1 is an 81-year-old Japanese man with previous trauma on the scalp who presented with a purple nodule, 2.5 cm in diameter, on the left parietal region surrounded by poorly marginated purpuric macules (Fig. 1a). Dermoscopic findings showed pink to purple erythema with white or skin-colored perifollicular areas on the macular lesion, and a purple to black homogeneous area covered with a whitish veil on the nodular lesion (Fig. 1b,c). Red to brown hemorrhage was observed beside the nodule. Although linear and ring-shaped erythema was diffusely International Journal of Dermatology 2014, 53, e347–e366
University of Alcal a Alcal a de Henares Spain E-mail: [email protected]
References 1 Balato A, Patruno C, Balato N, et al. Erythema multiforme-like eruption because of paraphenylenediamine. Contact Dermat 2008; 58: 65–66. 2 European Scientific Committee on Cosmetic Products and Non-Food Products. http://ec.europa.eu/consumers/sectors/ cosmetics/documents/directive/index_en.htm #h2-consolidated-version-of-cosmetic-directive-76/768/eec. [Accessed May 26, 2011]. 3 Brancaccio RR, Brown LH, Chang YT, et al. Identification and quantification of para-phenylenediamine in a temporary black henna tattoo. Am J Contact Dermat 2002; 13: 15–18. 4 Sidwell RU, Francis ND, Basarab T, et al. Vesicular erythema multiforme-like reaction to paraphenylenediamine in a henna tattoo. Pediatr Dermatol 2008; 25: 201–204. 5 Jappe U, Bj€ orn M, Petzoldt H. Erythema multiforme-like eruption and depigmentation following allergic contact dermatitis from a paint-on henna tattoo, due to paraphenylenediamine contact hypersensitivity. Contact Dermat 2001; 45: 249–250. 6 Mikkelsen CS, Liljefred F, Mikkelsen DB. Erythema multiforme like reaction to paraphenylendiamine. Ugeskr Laeger 2011; 173: 51–52. 7 Jacob SE, Brod BA. Paraphenylenediamine in black henna tattoos. J Clin Aesthet Dermatol 2011; 12: 46–47.
presented in the background, neither vessels nor lacunae/ lagoons were found within the lesion (Fig. 1d). In case 2, a 75-year-old Japanese man presented with a relatively poorly marginated brownish erythema on the right temple without any symptoms (Fig. 2a). The center of the lesion was slightly elevated and covered with white scales. Dermoscopically, diffuse purplish erythema was observed together with keratin plugs in the hair follicles (Fig. 2b). The elevated lesion was covered with thick, white scales (Fig. 2c). Neither vessels nor lacunae/lagoons were detected by dermoscopy. Both cases were diagnosed as AS histopathologically and immunohistochemically. AS often begins as an erythematous macule and gradually evolves into papules and nodules. It was reported that AS occasionally mimics inflammatory diseases and other skin tumors, including amelanotic melanoma, leiomyosarcoma, and skin metastasis.2 Recently, De Giorgi et al.3 described a steam-like area as a characteristic dermoscopic feature of AS. Further, Oiso et al.4 stressed various color gradations within the lesion. Our cases ª 2014 The International Society of Dermatology
Correspondence
(a)
(c)
(b)
(d)
Figure 1 Case 1. (a) A purple nodule, sized 2.5 cm in diameter, was surrounded by a poorly marginated purpuric macule on the left parietal region of an 81-year-old Japanese man. (b) Dermoscopically, the macular lesion showed pink to purple erythema with white or skin-colored perifollicular areas. (c) The nodular lesion presented purple to black homogeneous area covered with whitish veil. (d) Red to brown hemorrhages was observed beside the nodule. Original magnification: (b–d) 910
(a)
(b)
(c)
Figure 2 Case 2. (a) Relatively poorly marginated brownish erythema on the right temple of a 75-year-old Japanese man. The center of the lesion was slightly elevated and covered with white scales. (b) Dermoscopically, diffuse purplish erythema was observed together with keratin plugs in the hair follicles. (c) Elevated lesion was covered with thick, white scales. Original magnification: (b,c) 910
showed red–purple erythema sparing hair follicles in areas, which was similar to previous reports. Of note was an absence of vascular structures, including vessels and lacunae/lagoons, in our series. Lacunae/lagoons are usually observed by dermoscopy in vascular tumors, including angioma and pyogenic granuloma, even if not highly elevated. Amelanotic melanoma generally shows irreguª 2014 The International Society of Dermatology
larly shaped vessels.5 Psoriasis is characterized by dotted vessels in a regular arrangement.6 The absence of dermoscopic vascular structures can be attributed to random proliferation of AS tumor cells without forming normal vascular structures. This dermoscopic feature can be helpful to distinguish AS from other vascular tumors, amelanotic melanoma, and psoriasis. International Journal of Dermatology 2014, 53, e347–e366
e351
e352
Correspondence
Akane Minagawa, MD Hiroshi Koga, MD Ryuhei Okuyama, MD, PhD Department of Dermatology Shinshu University School of Medicine Matsumoto Japan E-mail: [email protected] Funding sources: None. Conflicts of interest: None. References 1 Donghi D, Kerl K, Dummer R, et al. Cutaneous angiosarcoma: own experience over 13 years. Clinical features, disease course and immunohistochemical profile. J Eur Acad Dermatol Venereol 2010; 24: 1230–1234.
Skin manifestations of celiac disease: not always dermatitis herpetiformis
We read with great interest the recent article by Huber et al.1 about two patients with cutaneous signs suggestive for dermatitis herpetiformis (DH) but with nonspecific histology and negative direct immunofluorescence. In our opinion, both reported cases represent nodular prurigo associated with celiac disease (CD). In the first case, clinical images may be suggestive of DH and gastroduodenoscopy of CD, but the data reported are not sufficient for the diagnosis. Indeed, clinical suspicions and positivity of antibody test alone cannot be considered as sufficient criteria for the diagnosis of DH,2 as positive IgA antiendomysium antibodies, IgA tissue transglutaminase antibodies, and antigliadin antibodies are found in patients with CD without DH. Moreover, even the therapeutic response to dapsone should not be regarded as pathognomonic of DH, as dapsone is effective in many other skin diseases, such as those in which neutrophil granulocytes are involved in the development of the lesions. In a recent paper, we reviewed all mucocutaneous extraintestinal manifestations of CD,3 modifying the classification proposed by Humbert et al.4 in 2006 and stressing the importance of a correct diagnosis even through a close collaboration between gastroenterologists and dermatologists. According to the literature and our experience, mucocutaneous diseases can often be diagnosed in patients with CD; among them, psoriasis, atopic dermatitis, urticaria, nodular prurigo, alopecia areata, or chronic ulcerative stomatitis are the most frequent. Notably, their diagnosis is often complicated because of atypical clinical presentation, sometimes associated with resistance to standard therapies and response to glutenfree diet.3–5 International Journal of Dermatology 2014, 53, e347–e366
2 Grazzini M, Stanganelli I, Rossari S, et al. Dermoscopy, confocal laser microscopy, and hi-tech evaluation of vascular skin lesions: diagnostic and therapeutic perspectives. Dermatol Ther 2012; 25: 297–303. 3 De Giorgi V, Grazzini M, Rossari S, et al. Dermoscopy pattern of cutaneous angiosarcoma. Eur J Dermatol 2011; 21: 113–114. 4 Oiso N, Matsuda H, Kawada A. Various colour gradations as a dermatoscopic feature of cutaneous angiosarcoma of the scalp. Australas J Dermatol 2013; 54: 36–38. 5 Menzies SW, Kreusch J, Byth K, et al. Dermoscopic evaluation of amelanotic and hypomelanotic melanoma. Arch Dermatol 2008; 144: 1120–1127. 6 Lallas A, Kyrgidis A, Tzellos TG, et al. Accuracy of dermoscopic criteria for the diagnosis of psoriasis, dermatitis, lichen planus and pityriasis rosea. Br J Dermatol 2012; 166: 1198–1205.
As a result, not all the skin conditions occurring during CD, showing positivity to CD-specific antibodies and responding to dapsone or to a gluten-free diet, should be diagnosed as DH. On the other hand, we agree with Huber et al.1 about the need for a revision of the diagnostic criteria of DH and the role of IgA deposits, as not only cases with atypical immunopathological findings are increasingly described in the literature,6 but also patients with CD without any skin manifestations have been reported to show granular IgA deposits in perilesional skin.7 Veronica Bonciolini, MD Emiliano Antiga, MD Paolo Fabbri, MD Marzia Caproni, MD Section of Dermatology Department of Surgery and Translational Medicine University of Florence Florence Italy E-mail: [email protected] Conflicts of interest: None.
References 1 Huber C, Tr€ ueb RM, French LE, et al. Negative direct immunofluorescence and nonspecific histology do not exclude the diagnosis of dermatitis herpetiformis Duhring. Int J Dermatol 2013; 52: 248–249. 2 Caproni M, Antiga E, Melani L, et al. Guidelines for the diagnosis and treatment of dermatitis herpetiformis. J Eur Acad Dermatol Venereol 2009; 23: 633–638. 3 Caproni M, Bonciolini V, DErrico A, et al. Celiac disease and dermatologic manifestations: many skin clue to unfold ª 2014 The International Society of Dermatology
Correspondence
been described to date.4–6 The patients were infants in all four cases. Black henna tattoos represent a source of sensitization to PPD that has potentially severe medium- and long-term consequences. Reactions can cause scars, cheloids, and hypopigmentation at the site of the tattoo. These temporary tattoos can cause significant and lifelong sensitization, which is likely to lead to future reactivity to permanent hair dyes, chemicals in rubber products, inks, clothing dyes, and some medications (sulfonamides and hydroclorothiazides).7 This sensitization might affect a subject’s future choice of occupation, particularly with reference to hairdressing and photography. In conclusion, we describe a case of erythema multiforme-like eruption that occurred after the administration of a paint-on tattoo. Temporary tattoos are considered to be safer than permanent tattoos because they disappear within a few weeks. Permanent tattooing is associated with inflammatory reactions to tattoo pigments, photoallergic reactions, and inoculation by certain infectious agents. However, the practice of skin painting is not devoid of risk, and thus public education programs that divulge the dangers of exposure to higher concentrations of PPD are required. Nuria Barrientos, MD Patricia Abajo, MD Marıa Moreno de Vega, MD Jose Dominguez, MD Department of Dermatology University Hospital of Henares
Vascular structure absence under dermoscopy in two cases of angiosarcoma on the scalp
Cutaneous angiosarcoma (AS) is a rare malignant tumor of soft tissue and is known to have three clinical subtypes: classical AS (head and neck type), Stewart–Treves syndrome, and post-radiation AS.1 Few dermoscopic features of AS have been reported and it has not yet been examined in detail. Here, we describe two cases of AS located on the scalp and discuss their dermoscopic features. Case 1 is an 81-year-old Japanese man with previous trauma on the scalp who presented with a purple nodule, 2.5 cm in diameter, on the left parietal region surrounded by poorly marginated purpuric macules (Fig. 1a). Dermoscopic findings showed pink to purple erythema with white or skin-colored perifollicular areas on the macular lesion, and a purple to black homogeneous area covered with a whitish veil on the nodular lesion (Fig. 1b,c). Red to brown hemorrhage was observed beside the nodule. Although linear and ring-shaped erythema was diffusely International Journal of Dermatology 2014, 53, e347–e366
University of Alcal a Alcal a de Henares Spain E-mail: [email protected]
References 1 Balato A, Patruno C, Balato N, et al. Erythema multiforme-like eruption because of paraphenylenediamine. Contact Dermat 2008; 58: 65–66. 2 European Scientific Committee on Cosmetic Products and Non-Food Products. http://ec.europa.eu/consumers/sectors/ cosmetics/documents/directive/index_en.htm #h2-consolidated-version-of-cosmetic-directive-76/768/eec. [Accessed May 26, 2011]. 3 Brancaccio RR, Brown LH, Chang YT, et al. Identification and quantification of para-phenylenediamine in a temporary black henna tattoo. Am J Contact Dermat 2002; 13: 15–18. 4 Sidwell RU, Francis ND, Basarab T, et al. Vesicular erythema multiforme-like reaction to paraphenylenediamine in a henna tattoo. Pediatr Dermatol 2008; 25: 201–204. 5 Jappe U, Bj€ orn M, Petzoldt H. Erythema multiforme-like eruption and depigmentation following allergic contact dermatitis from a paint-on henna tattoo, due to paraphenylenediamine contact hypersensitivity. Contact Dermat 2001; 45: 249–250. 6 Mikkelsen CS, Liljefred F, Mikkelsen DB. Erythema multiforme like reaction to paraphenylendiamine. Ugeskr Laeger 2011; 173: 51–52. 7 Jacob SE, Brod BA. Paraphenylenediamine in black henna tattoos. J Clin Aesthet Dermatol 2011; 12: 46–47.
presented in the background, neither vessels nor lacunae/ lagoons were found within the lesion (Fig. 1d). In case 2, a 75-year-old Japanese man presented with a relatively poorly marginated brownish erythema on the right temple without any symptoms (Fig. 2a). The center of the lesion was slightly elevated and covered with white scales. Dermoscopically, diffuse purplish erythema was observed together with keratin plugs in the hair follicles (Fig. 2b). The elevated lesion was covered with thick, white scales (Fig. 2c). Neither vessels nor lacunae/lagoons were detected by dermoscopy. Both cases were diagnosed as AS histopathologically and immunohistochemically. AS often begins as an erythematous macule and gradually evolves into papules and nodules. It was reported that AS occasionally mimics inflammatory diseases and other skin tumors, including amelanotic melanoma, leiomyosarcoma, and skin metastasis.2 Recently, De Giorgi et al.3 described a steam-like area as a characteristic dermoscopic feature of AS. Further, Oiso et al.4 stressed various color gradations within the lesion. Our cases ª 2014 The International Society of Dermatology
Correspondence
(a)
(c)
(b)
(d)
Figure 1 Case 1. (a) A purple nodule, sized 2.5 cm in diameter, was surrounded by a poorly marginated purpuric macule on the left parietal region of an 81-year-old Japanese man. (b) Dermoscopically, the macular lesion showed pink to purple erythema with white or skin-colored perifollicular areas. (c) The nodular lesion presented purple to black homogeneous area covered with whitish veil. (d) Red to brown hemorrhages was observed beside the nodule. Original magnification: (b–d) 910
(a)
(b)
(c)
Figure 2 Case 2. (a) Relatively poorly marginated brownish erythema on the right temple of a 75-year-old Japanese man. The center of the lesion was slightly elevated and covered with white scales. (b) Dermoscopically, diffuse purplish erythema was observed together with keratin plugs in the hair follicles. (c) Elevated lesion was covered with thick, white scales. Original magnification: (b,c) 910
showed red–purple erythema sparing hair follicles in areas, which was similar to previous reports. Of note was an absence of vascular structures, including vessels and lacunae/lagoons, in our series. Lacunae/lagoons are usually observed by dermoscopy in vascular tumors, including angioma and pyogenic granuloma, even if not highly elevated. Amelanotic melanoma generally shows irreguª 2014 The International Society of Dermatology
larly shaped vessels.5 Psoriasis is characterized by dotted vessels in a regular arrangement.6 The absence of dermoscopic vascular structures can be attributed to random proliferation of AS tumor cells without forming normal vascular structures. This dermoscopic feature can be helpful to distinguish AS from other vascular tumors, amelanotic melanoma, and psoriasis. International Journal of Dermatology 2014, 53, e347–e366
e351
e352
Correspondence
Akane Minagawa, MD Hiroshi Koga, MD Ryuhei Okuyama, MD, PhD Department of Dermatology Shinshu University School of Medicine Matsumoto Japan E-mail: [email protected] Funding sources: None. Conflicts of interest: None. References 1 Donghi D, Kerl K, Dummer R, et al. Cutaneous angiosarcoma: own experience over 13 years. Clinical features, disease course and immunohistochemical profile. J Eur Acad Dermatol Venereol 2010; 24: 1230–1234.
Skin manifestations of celiac disease: not always dermatitis herpetiformis
We read with great interest the recent article by Huber et al.1 about two patients with cutaneous signs suggestive for dermatitis herpetiformis (DH) but with nonspecific histology and negative direct immunofluorescence. In our opinion, both reported cases represent nodular prurigo associated with celiac disease (CD). In the first case, clinical images may be suggestive of DH and gastroduodenoscopy of CD, but the data reported are not sufficient for the diagnosis. Indeed, clinical suspicions and positivity of antibody test alone cannot be considered as sufficient criteria for the diagnosis of DH,2 as positive IgA antiendomysium antibodies, IgA tissue transglutaminase antibodies, and antigliadin antibodies are found in patients with CD without DH. Moreover, even the therapeutic response to dapsone should not be regarded as pathognomonic of DH, as dapsone is effective in many other skin diseases, such as those in which neutrophil granulocytes are involved in the development of the lesions. In a recent paper, we reviewed all mucocutaneous extraintestinal manifestations of CD,3 modifying the classification proposed by Humbert et al.4 in 2006 and stressing the importance of a correct diagnosis even through a close collaboration between gastroenterologists and dermatologists. According to the literature and our experience, mucocutaneous diseases can often be diagnosed in patients with CD; among them, psoriasis, atopic dermatitis, urticaria, nodular prurigo, alopecia areata, or chronic ulcerative stomatitis are the most frequent. Notably, their diagnosis is often complicated because of atypical clinical presentation, sometimes associated with resistance to standard therapies and response to glutenfree diet.3–5 International Journal of Dermatology 2014, 53, e347–e366
2 Grazzini M, Stanganelli I, Rossari S, et al. Dermoscopy, confocal laser microscopy, and hi-tech evaluation of vascular skin lesions: diagnostic and therapeutic perspectives. Dermatol Ther 2012; 25: 297–303. 3 De Giorgi V, Grazzini M, Rossari S, et al. Dermoscopy pattern of cutaneous angiosarcoma. Eur J Dermatol 2011; 21: 113–114. 4 Oiso N, Matsuda H, Kawada A. Various colour gradations as a dermatoscopic feature of cutaneous angiosarcoma of the scalp. Australas J Dermatol 2013; 54: 36–38. 5 Menzies SW, Kreusch J, Byth K, et al. Dermoscopic evaluation of amelanotic and hypomelanotic melanoma. Arch Dermatol 2008; 144: 1120–1127. 6 Lallas A, Kyrgidis A, Tzellos TG, et al. Accuracy of dermoscopic criteria for the diagnosis of psoriasis, dermatitis, lichen planus and pityriasis rosea. Br J Dermatol 2012; 166: 1198–1205.
As a result, not all the skin conditions occurring during CD, showing positivity to CD-specific antibodies and responding to dapsone or to a gluten-free diet, should be diagnosed as DH. On the other hand, we agree with Huber et al.1 about the need for a revision of the diagnostic criteria of DH and the role of IgA deposits, as not only cases with atypical immunopathological findings are increasingly described in the literature,6 but also patients with CD without any skin manifestations have been reported to show granular IgA deposits in perilesional skin.7 Veronica Bonciolini, MD Emiliano Antiga, MD Paolo Fabbri, MD Marzia Caproni, MD Section of Dermatology Department of Surgery and Translational Medicine University of Florence Florence Italy E-mail: [email protected] Conflicts of interest: None.
References 1 Huber C, Tr€ ueb RM, French LE, et al. Negative direct immunofluorescence and nonspecific histology do not exclude the diagnosis of dermatitis herpetiformis Duhring. Int J Dermatol 2013; 52: 248–249. 2 Caproni M, Antiga E, Melani L, et al. Guidelines for the diagnosis and treatment of dermatitis herpetiformis. J Eur Acad Dermatol Venereol 2009; 23: 633–638. 3 Caproni M, Bonciolini V, DErrico A, et al. Celiac disease and dermatologic manifestations: many skin clue to unfold ª 2014 The International Society of Dermatology
