Chronic moderate heat dermatitis (erythema ab igne) in five dogs, three cats and one silvered langur

Erythema ab igne, an old and rare disease in the human literature, is an erythematous, often pigmented, reticular, macular dermatosis that occurs at the site of repeated exposure to moderate heat. We identified lesions consistent with erythema ab igne in five dogs, three cats and one silvered langur (Trachypithecus cristatus[Raffles, 1821]). In dogs and cats, the cutaneous lesion distribution typically reflected chronic exposure to moderate heat during lateral or sternal recumbency. The silvered langur developed cutaneous lesions on the dorsal neck from exposure to a heat lamp. Principal clinical lesions consisted of irregular areas of alopecia (7/9) and erythema (7/9), sometimes with hyperpigmentation (3/9). Principal histological features consisted of karyomegaly (9/9) and keratinocyte atypia (4/9), scattered apoptotic or vacuolated basal cells and/or apoptotic keratinocytes (6/9), mild mixed mononuclear interstitial or interface dermatitis (9/9) with adnexal atrophy (8/9), and a variable number of wavy eosinophilic elastic fibres (9/9). The presence of these cutaneous lesions in an animal indicates that the environment should be evaluated for exposure to chronic moderate heat, and the heat source should be eliminated or modified to prevent further exposure and progression of lesions.

Linear and whorled nevoid hypermelanosis with bilateral giant cerebral aneurysms

A 24-year-old woman presented with bilateral giant intracavernous carotid artery aneurysms manifesting as a cavernous sinus syndrome on the left side, and anisocoria, ophthalmic pain, and oculomotor paresis on the left side. Physical examination showed mild hyperextensibility of the metacarpophalangeal joints, amelogenesis imperfecta, and hyperpigmentation following Blaschko lines. Analysis of the NEMO gene for incontinentia pigmenti syndrome and of collagen III for Ehlers-Danlos type IV was normal. Skewed X-inactivation patterns in blood lymphocytes were detected. To the best of our knowledge, this association of linear hyperpigmentation and cerebral aneurysms has never been previously reported.

[Side-effects and risk profile of latanoprost 0.005% (Xalatan)]

BACKGROUND

Latanoprost, a prostaglandin F(2alpha)-analogue, has been widely in use in clinical practice for a period of over 5 years. The side-effects of latanoprost are analyzed and the clinical relevance is discussed.

RESULTS

Hypertrichosis and increased pigmentation of eyelashes will develop in the majority of patients using latanoprost for more than 6 months. Increased pigmentation of the eyelids may also occur. Hyperpigmentation of the iris is seen in 12-18% of caucasians using latanoprost over a period of 1-2 years. Increased iris pigmentation seems more common in asian people and remains unchanged after discontinuation of therapy. Pigmentation of intra- and extraocular structures is caused by increased melanogenesis, not by melanocyte proliferation. Mild conjunctival hyperemia may develop in approximately 30% of patients, but is most often without clinical relevance. Further reported side-effects include anterior uveitis, reactivation of herpes-keratitis/-dermatitis and cystoid macular edema in pseudophakic and aphakic patients. A causal relationship has still not been proven for these side-effects. Systemic side-effects are rare (e.g. headache, facial rash, cardiovascular effects). No experience exists for treatment of glaucoma with latanoprost in childhood.

CONCLUSION

Latanoprost represents a highly effective antiglaucomatous drug, rarely associated with vision-threatening complications. The most common complications are hypertrichosis of eyelashes and increased pigmentation of extra- and intraocular structures. A careful lifetime evaluation of these patients is recommended. Systemic side-effects are rare, but may occur.

Yellow urticaria secondary to hyperbilirubinemia in a patient with end-stage liver disease

Acute urticaria is characterized by pruritic, erythematous, edematous plaques. We report the case of a 48-year-old man with acute urticaria, whose lesions appeared yellow secondary to an elevated bilirubin level.

Nail pigmentation caused by hydroxyurea: report of 9 cases

We report a series of 9 patients, 6 men and 3 women, who presented nail hyperpigmentation arising between 6 and 24 months from the start of hydroxyurea therapy. The most commonly observed clinical pattern was that of longitudinal melanonychia. In only 1 patient, who was affected in all 20 nails, we observed longitudinal melanonychia, diffuse melanonychia, and hyperpigmentation of the skin.

Chronic pigmented purpura associated with odontogenic infection

Five patients with chronic pigmented purpura associated with odontogenic infection are described. Four patients had Schamberg's disease, and one had itching purpura. These patients were resistant to topical corticosteroid treatment, but appearance of purpuric spots ceased after treatment for periodontitis, pulpitis, or both. No circulating immune complexes were detected, and neither immunoglobulin nor complement was deposited in the papillary vessels of the skin. Odontogenic infection might be one of the precipitating factors for chronic pigmented purpura.

Utilization of a high-resolution digital imaging system for the objective and quantitative assessment of hyperpigmented spots on the face

BACKGROUND/AIMS

The aim of this study was to quantify and confirm the efficacy of cosmetic formulations for hyperpigmented spots over a wide area of the face using a high quality digital imaging system that we developed.

METHODS

A total of 120 Japanese female volunteers aged 25-60 years with solar lentigines were treated for 6 months with a skin lightening moisturizer (SLM, thereafter) containing 3% magnesium ascorbyl phosphate on one side of the face and vehicle on the other side. During the course of the study, facial images were collected by the image analysis to measure facial skin colour and the total area of hyperpigmented spots. The evaluation was also conducted by visual grading. Measurements were made before and 1, 3, and 6 months after starting the application, and again 6 months after discontinuing the treatment. Three similar clinical studies using the same protocol were repeated for up to one-month to confirm the reproducibility of the results and to examine seasonal variation.

RESULTS

SLM significantly reduced the total area of hyperpigmented spots (P < 0.005) after one month of treatment compared to the vehicle, with no significant variation in facial skin colour tone in the areas outside the hyperpigmented spots. The results of the visual grading were consistent with those obtained by image analysis. The total area of hyperpigmented spots 6 months after discontinuing the treatment had returned to pre-treatment levels. The reproducibility of these clinical results was demonstrated in three follow-up studies.

CONCLUSIONS

A high-resolution digital imaging method, combined with a split-face clinical protocol is sensitive enough to prove that SLM readily reduces hyperpigmented spots, while maintaining normal facial skin colour.

Graphic analysis of the relationship between skin colour change and variations in the amounts of melanin and haemoglobin

BACKGROUND/AIMS

The L*a*b* coordinate is the most commonly used colour system to measure skin colour in dermatology and cosmetology. In this system, a* and L* are often used for quantification of the degrees of erythema and pigmentation. The aim of this study was to examine whether a* and L* can be used as specific scales to indicate the amount of haemoglobin and melanin, respectively, in the skin.

METHODS

The a* and L* values were examined with a reflectance spectrometer in various skin conditions or lesions caused by a change in the amount of either melanin or haemoglobin, i.e. vitiligo, ultraviolet-induced pigmentation (PG), erythema resulting from slapping (ER), corticosteroid-induced blanching, erythema due to stasis by arm lowering, and a combination of PG and ER. The differences in values between the test sites and the adjacent normal skin, deltaa* and deltaL*, were plotted on the deltaa*-deltaL* plane and analysed statistically and geometrically.

RESULTS

L* depended substantially not only on melanin but also on haemoglobin, especially if the oxygen saturation level was expected to be low. a* was also influenced by melanin. The results of graphic analysis indicated that a linear transformation of (deltaa*, deltaL*) into (deltaHb = 1.68 deltaa* + 0.60 deltaL*, deltaMel =-1.06 deltaa*-1.44 deltaL*) was suitable for separately estimating the change in the amount of haemoglobin (deltaHb) and in that of melanin (deltaMel).

CONCLUSION

The results of this study may be of value for understanding the relationship between colour coordinates of the skin and the quantities of haemoglobin and melanin, and may be of use when pigmented lesions of the face are monitored by tristimulus colourimetry, as facial skin colour is affected considerably by the rich and easily variable cutaneous blood flow.

Supravenous hyperpigmentation, transverse leuconychia and transverse melanonychia after chemotherapy for Hodgkin's disease

Pigmentary abberations of the skin, mucosa and epidermal appendages are common side-effects after systemic treatment with chemotherapeutic agents. These pigment changes appear in different patterns and are partly quite typical for the applied chemotherapeutic drug. The pathogenesis of the different skin pigmentations are not well known. The most often discussed causes are the stimulation of melanocytes, involvement of the tyrosinase enzyme system and thrombophlebitis with postinflammatory hyperpigmentation by the aggressive substances. Nail discolorations are mainly due to direct toxic effects and stimulation of the matrix melanocytes. We report a rare event of supravenous hyperpigmentation, transverse leuconychia and melanonychia after chemotherapy of a patient suffering from Hodgkin's disease.

Drug-induced skin pigmentation. Epidemiology, diagnosis and treatment

Drug-induced pigmentation represents 10 to 20% of all cases of acquired hyperpigmentation and this hypothesis must be systematically raised in unexplained pigmented lesions especially in elderly people. The pathogenesis of drug-induced pigmentation is variable according to the causative medication and can involve an accumulation of melanin, sometimes following a nonspecific cutaneous inflammation and often worsened by sun exposure, an accumulation of the triggering drug itself, a synthesis of special pigments under the direct influence of the drug or deposits of iron following damage to the dermal vessels. The influence of sun exposure is usually obvious in most cases, either by sun-induced melanin synthesis stimulation with formation of complexes between melanin and the causative drug or by transformation of the drug in visible particles usually taken up by dermal macrophages under the influence of sunlight. The main drugs implicated in causing skin pigmentation are nonsteroidal anti-inflammatory drugs, antimalarials, amiodarone, cytotoxic drugs, tetracyclines, heavy metals and psychotropic drugs. Clinical features are very variable according to the triggering molecule, with a large range of patterns and shades which are sometimes more or less reminiscent of the culprit drug. Histological findings are very variable as well but the colored particles are often concentrated within dermal macrophages which are sometimes localized in a distinctive fashion with respect to dermal structures such as vessels or adnexes. Treatment is often limited to sun-avoidance or interruption of treatment with the offending drug but laser therapy recently gave rise to hope of a cure in some cases. These measures are often followed by a fading of the lesions but the pigmentation may last for a long time or may even become permanent in a small percentage of patients.

Laser eradication of pigmented lesions and tattoos

Laser treatment of pigmented lesions can be a rewarding experience when appropriate lesions are treated. Accurate diagnosis of pigmented lesions is needed before treatment. In some lesions, adjuvant topical therapy is greatly beneficial, and for others it may be the only option. The treatment of melanocytic nevi is controversial but worth pursuing. All tattoos respond well to Q-switched lasers; the appropriate wavelength depends on the color of ink. Amateur and traumatic tattoos clear readily with laser treatment. Cosmetic tattoos should be approached with caution. In addition, the use of laser-responsive ink and higher-powered or shorter-pulsed (picosecond) lasers may further enhance the ability to treat tattoos.

Laser resurfacing of darkly pigmented patients

Hyperpigmentation following laser resurfacing in darker-skinned individuals is common but treatable. This pigmentation is usually heralded by persistent erythema and can be prevented in most patients if aggressive laser resurfacing is curtailed and conservative or single-pass techniques are applied. Avoiding excessive intraoperative frictional trauma when removing the desiccated tissue Avoiding excessive intraoperative frictional trauma when removing the desiccated tissue and potentially irritating agents or infections in the pre- or postoperative period is also instrumental in avoiding long-term complications.

Can we use video images to triage pigmented lesions?

BACKGROUND

Advances in telemedicine permit consultations where the doctor and patient are at different sites.

OBJECTIVES

To determine whether this technology could be used to triage referrals of pigmented lesions to a dermatology out-patient clinic, and thereby assist in managing the ever increasing number of lesions being referred.

METHODS

When patients attended clinic, a clinical diagnosis of their pigmented lesion was made and recorded. A still image of each lesion was subsequently taken from a video camera using a PC card, and stored. These images were subsequently viewed in conjunction with the general practitioner's referral information and designated as 'warrants referral' or 'does not warrant referral'. For each lesion this decision was compared with the clinical diagnosis made during the live consultation in the clinic (the 'gold standard'). Clinical diagnoses designated as warranting referral were malignant melanoma, basal cell carcinoma, keratoacanthoma, atypical naevus and pyogenic granuloma (due to the potential clinical confusion with amelanotic melanoma). Lesions that were not considered to warrant referral included benign melanocytic naevus, seborrhoeic keratosis, dermatofibroma, congenital naevus, solar lentigo, actinic keratosis and various other benign conditions.

RESULTS

In total, 819 lesions were evaluated, resulting in a mean sensitivity of 81% and specificity of 73% for the technique.

CONCLUSIONS

We feel that the overall sensitivity of 81% is encouraging as regards the use of such a technique as a triage tool, but that the inability to examine the whole patient or palpate the lesions is a major drawback in the safe triage of patients with pigmented lesions.

Citalopram-induced photopigmentation

Citalopram is one of the newer and most potent selective serotonin re-uptake inhibitor (SSRI) drugs. It has a well-established antidepressive action with a favorable adverse event profile. We present a fifty-year-old woman with diffuse photopigmentation who had been diagnosed as suffering from depression. The patient was given citalopram (40 mg/day) for her psychiatric condition and diffuse photopigmentation was noted thereafter. To our knowledge, such an adverse event has not been reported previously.

The Laugier-Hunziker syndrome

Laugier and Hunziker described a syndrome consisting of asymptomatic benign areas of hyperpigmentation affecting the lips, buccal mucosa and, in 50%, the fingernails. We report a 67-year-old woman with the clinical features of Laugier-Hunziker syndrome in association with vulval pigmentation. Histology, immunohistochemistry and electron microscopy from the various areas of pigmentation on the body confirmed the benign nature of the pigmentation. We review potential causes of oral and genital pigmentation, and suggest an expansion of the original syndrome described by Laugier and Hunziker to include more widespread areas of benign hyperpigmentation, which may associated.

Two cases of unilateral pigmented purpuric dermatosis

Two cases of pigmented purpuric dermatosis showing unusual distribution are reported. Case 1: 35-year-old female. A group of three asymptomatic purpuric macules developed on the ulnar side of the elbow flexure of the left forear 3-6 months before presentation. Histopathological analysis revealed a band-like inflammatory infiltrate in the Uppermost dermis and extravasation of red blood cells just beneath the epidermis, but there was no evidence of lichefaction degeneration in the basal layer of the epidermis. Case 2: 26-year-old female. Asymptomatic purpuric pigmentations developed on the flexure side of the right lower extremity in a linear arrangement 2-3 months before presentation. Histopathological analysis revealed focally perivascular inflammatatory infiltrates consisting mainly of lymphocytes and conspicuous extravasation of red blood cells into the papillary dermis. There was no histological evidence of vasculitis in either case. Hemosiderin deposits were more limited than expected in both patients. Both cases are compatible with diagnoses of pigmented purpuric dermatosis. Case 1 on the left arm was compatible with lichen purpuricus. Case 2 occurred in a linear arrangement on the right leg and had a history of aspirin use for chronic headache. We therefore suspected that medication had been an etiological or contributing factor.

Q-switched Alexandrite laser in the treatment of pigmented macules in Laugier-Hunziker syndrome

We report clearance of pigmented macules on the lips of two subjects with Laugier-Hunziker syndrome using the Q-switched Alexandrite laser. Recurrence of two macules was noticed in one case 6 months after treatment and the lesions were successfully retreated. This report evaluates the efficacy and side-effect profile of the Q-switched Alexandrite laser in the treatment of lentigines in this syndrome.

Frictional amyloidosis: a study of 10 cases

Ten patients with macular amyloidosis were studied with particular reference to the role of friction. All 10 patients had a history of prolonged rubbing over a period of 2-5 years with various objects, such as bath sponges, brushes, towels, plant sticks and leaves. The presence of amyloid was confirmed by histochemical stains in six cases and by electron microscopy in four cases. The study confirms the role of friction in the causation of macular amyloidosis and hence, the term 'frictional amyloidosis' aptly describes the condition. The study also emphasizes the need for electron microscopy in the diagnosis of frictional amyloidosis.

Hemarthrosis as initial presentation of scurvy

Vitamin C deficiency or scurvy is a disease now rarely seen except for certain populations at risk. When it occurs, diagnosis can be difficult as it can mimic other disorders. Its manifestations are primarily due to an abnormality in collagen formation causing bleeding in the skin, joints, muscles, or gastrointestinal tract and dystrophic hair deformities. We describe a case of scurvy in a 43-year-old man who presented with new onset hemarthrosis with no history of bleeding disorder. He was found to have perifollicular hyperpigmentation and corkscrew hairs, highly suggestive of scurvy. He admitted to completely eliminating fruits and vegetables from his diet and his serum vitamin C level was markedly decreased. Treatment with daily vitamin C supplement led to relief of symptoms and resolution of skin changes.

Chronic tophaceous gout presenting as hyperpigmented nodules in the limbs of a patient with coexisting psoriasis

We describe a 53-year-old male renal transplant recipient with hypertension and triglyceridemia, who showed rare manifestations of gout presenting as brownish nodules on the arms and legs as well as chronic tophaceous gouty arthritis of the hands and feet mimicking rheumatoid arthritis, in association with subsequently developed psoriasis of the palms. In elderly Asian men, hypertension and renal insufficiency may be risk factors predisposing to the development of multiple hyperpigmented nodules of tophi in the more proximal extremities.