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Moledina M, Davison S, Malik A. Ophthalmic complication of pityriasis rubra pilaris. BMJ Case Rep 2024; 17:e256445. [PMID: 38806396 DOI: 10.1136/bcr-2023-256445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024] Open
Abstract
Pityriasis rubra pilaris (PRP) is a rare dermatological condition which may present with ocular manifestations. We report a case of recurrent cicatricial ectropion (CE) with topical beta-blocker use in the rare dermatological condition PRP. The patient underwent release of scar tissue, lateral tarsal strip and full-thickness supraclavicular skin graft for CE following immunosuppression with methotrexate for 3 months. Postoperatively, CE recurred, with skin graft shrinkage and resumption of periocular disease activity, 8 weeks following the introduction of topical timolol. The patient was referred for further immunosuppression and substitution of timolol before consideration for further surgery. PRP has a variety of potential ocular complications. Surgery has a high risk of recurrence and should be performed when the overall disease is quiescent and drugs, which could trigger reactivation, have been discontinued and/or substituted. Skin grafts should be oversized to off-set shrinkage.
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Affiliation(s)
- Malik Moledina
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, UK
| | - Simon Davison
- Barking Havering and Redbridge University Hospitals NHS Trust, Romford, London, UK
| | - Adeela Malik
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, UK
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2
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Iznardo H, Puig L. Beyond plaque psoriasis - pathogenesis and treatment of other psoriasis phenotypes. Curr Opin Rheumatol 2022; 34:225-234. [PMID: 35699337 DOI: 10.1097/bor.0000000000000882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Psoriasis vulgaris is the commonest presentation of psoriatic disease, but morphologic variants such as pustular psoriasis (PP) and a closely related disease, pityriasis rubra pilaris (PRP), have been known for a long time, have been associated with rheumatologic manifestations indistinguishable from psoriatic arthritis (PsA) that may go unrecognized, and often represent a therapeutic conundrum. There is recent evidence that underlying genetic and pathogenetic differences may provide the basis for newer therapeutic approaches. RECENT FINDINGS This narrative review highlights the clinical, genetic and pathogenetic characteristics of PP and PRP, their association with PsA and recent developments in their treatment, especially with biologic agents targeting IL-36 and other cytokines of pathogenic relevance. SUMMARY The clinical manifestations of PP and PRP are less well known to rheumatologists than those of psoriasis, and recent advances in our insight on their pathogenesis may eventually overcome the therapeutic difficulties faced by dermatologists and rheumatologists in the management of these diseases and their rheumatologic manifestations.
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Affiliation(s)
- Helena Iznardo
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma, Barcelona, Spain
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3
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Mellett M. Regulation and dysregulation of CARD14 signalling and its physiological consequences in inflammatory skin disease. Cell Immunol 2020; 354:104147. [DOI: 10.1016/j.cellimm.2020.104147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 04/17/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022]
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Abstract
Pityriasis rubra pilaris (PRP) is a rare inflammatory skin disorder of unknown etiology, initially described in 1835. It is characterized by keratotic follicular papules, well-demarcated salmon-colored erythematous scaly plaques interspersed with distinct islands of uninvolved skin, and palmoplantar keratoderma. Is PRP a systemic disease? Skin is mainly affected in PRP. Despite its clinical heterogeneity, PRP could be associated with a variety of rheumatologic, infectious, neoplastic, and other extracutaneous manifestations. We accept the hypothesis of not only an association but also a causative relation between skin and systemic manifestations with possible common underlying pathomechanisms such as systemic immunologic processes and superantigen mimicry.
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Kromer C, Sabat R, Celis D, Mössner R. Systemische Therapien bei Pityriasis rubra pilaris: eine systematische Übersicht. J Dtsch Dermatol Ges 2019; 17:243-260. [DOI: 10.1111/ddg.13718_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/29/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Christian Kromer
- Klinik für DermatologieVenerologie und AllergologieUniversitätsmedizin Göttingen Göttingen Deutschland
| | - Robert Sabat
- Interdisiplinäre Gruppe für Molekulare Immunpathologie, Dermatologie/Medizinische Immunologie, Charité – Universitätsmedizin Berlin Berlin Deutschland
- Psoriasis Forschungs‐ und BehandlungsCentrum, Klinik für Dermatologie, Venerologie und Allergologie und Institut für Medizinische Immunologie, Charité – Universitätsmedizin Berlin Berlin Deutschland
| | - Daniel Celis
- Wirtschaftswissenschaftliche Fakultät, Universität Göttingen Göttingen Deutschland
| | - Rotraut Mössner
- Klinik für DermatologieVenerologie und AllergologieUniversitätsmedizin Göttingen Göttingen Deutschland
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6
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Kromer C, Sabat R, Celis D, Mössner R. Systemic therapies of pityriasis rubra pilaris: a systematic review. J Dtsch Dermatol Ges 2018; 17:243-259. [PMID: 30520557 DOI: 10.1111/ddg.13718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/29/2018] [Indexed: 02/03/2023]
Abstract
Pityriasis rubra pilaris (PRP) is a rare papulosquamous disorder. Treatment is challenging; the armamentarium consists of topical corticosteroids, phototherapy, classic systemic treatments such as retinoids or immunosuppressive drugs, and most recently biologicals. However, the relative effectiveness of therapies is unclear. Our objective was to review the published literature on systemic treatment of PRP. A systematic review was conducted on PubMed and the Cochrane Library up to 5 September 2017. Studies evaluating any systemic treatments of PRP (except for historical treatments) were included. Overall, 182 studies met the predefined inclusion criteria, and reported on 475 patients and 652 courses of treatment. 42.0 % (225/514) of all patients treated with retinoids achieved an excellent response (isotretinoin: 61.1 % [102/167], etretinate: 47 % [54/115], and acitretin: 24.7 % [43/174]) compared to an excellent response rate of 33.1 % (53/160) with methotrexate. Therapy with biologicals was successful in 51.0 % of patients (71/133) (ustekinumab: 62.5 % [10/16], infliximab: 57.1 % [28/49], etanercept: 53.3 % [16/30], and adalimumab: 46.4 % [13/28]). This review balances effectiveness, side effects, experience, and drug costs in order to suggest a treatment regimen starting with isotretinoin as first-line, methotrexate as second-line and biologicals as third-line treatment for this difficult-to-treat dermatosis.
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Affiliation(s)
- Christian Kromer
- Department of Dermatology, Venereology, and Allergology, University Medical Centre, Göttingen, Germany
| | - Robert Sabat
- Interdisciplinary Group of Molecular Immunopathology, Dermatology/Medical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Psoriasis Research and Treatment Center, Department of Dermatology and Allergy and Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Celis
- Faculty of Economic Sciences, Göttingen University, Göttingen, Germany
| | - Rotraut Mössner
- Department of Dermatology, Venereology, and Allergology, University Medical Centre, Göttingen, Germany
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7
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Abstract
Pityriasis rubra pilaris (PRP) is an idiopathic, papulosquamous inflammatory dermatosis. It is characterized by hyperkeratotic follicular papules coalescing into orange-red scaly plaques, islands of sparing, and palmoplantar keratoderma. PRP can be subdivided into six clinical subtypes according to Griffiths' classification, based on age of onset, disease extent, prognosis, and other associated features. The sixth subtype of PRP occurs in individuals affected by HIV infection, and retroviral screening in all de novo cases of PRP is advised. Other reported associations include various infections, autoimmunity, drugs, and malignancies, although the true significance of these is still unclear. The genetic basis for familial cases, most commonly categorized under the fifth subtype, has been mapped to gain of function mutations in the caspase recruitment domain family, member 14 (CARD14) gene. Treatment of PRP remains a challenge to this day due to a paucity of high-quality evidence. Therapeutic regimens have been guided mostly by case reports and case series, with the mainstay of treatment being oral retinoids. Recently, biologics have emerged as a promising treatment for PRP. We present a review of the clinicopathologic features, pathogenesis, associated disorders, and treatment of PRP, with an emphasis and critical appraisal of the existing literature on the latter.
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8
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Roenneberg S, Biedermann T. Pityriasis rubra pilaris: algorithms for diagnosis and treatment. J Eur Acad Dermatol Venereol 2018; 32:889-898. [DOI: 10.1111/jdv.14761] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 11/30/2017] [Indexed: 12/11/2022]
Affiliation(s)
- S. Roenneberg
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Germany Munich
| | - T. Biedermann
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Germany Munich
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9
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Drosou A, Kirsner RS, Welsh E, Sullivan TP, Kerdel FA. Use of Infliximab, an Anti-Tumor Necrosis Alpha Antibody, for Inflammatory Dermatoses. J Cutan Med Surg 2016. [DOI: 10.1177/120347540300700503] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Infliximab is a monoclonal antibody against tumor necrosis factor alpha currently approved by the U.S. FDA for the treatment of Crohn's disease and rheumatoid arthritis. Recently, a controlled trial reported its effectiveness for psoriasis. Objective: The object of our study was to evaluate the efficacy and safety of infliximab for inflammatory or autoimmune cutaneous disorders. Methods: A retrospective chart review was performed for patients who received infliximab at the University of Miami, Cedars Medical Center. Results: Patients with various disease, including panniculitis, pityriasis rubra pilaris, eosinophilic fasciitis, discoid lupus erythematosus, and necrobiosis lipoidica diabeticorum, received infliximab infusion at a dose of 5 mg/kg. All patients had refractory disease or adverse effects to previous therapy, which included cyclosporine, systemic steroids, azathioprin, clofazimine, mycophenolate mofetil, acitretin, UVB, and thalidomide. Six out of the seven patients improved after treatment. Conclusions: Infliximab was well tolerated in most patients and the majority benefited from the use of infliximab.
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Affiliation(s)
- Anna Drosou
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Robert S. Kirsner
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida, USA
- Department of Epidemiology and Public Health, University of Miami School of Medicine, Miami, Florida, USA
- Veterans Administration Medical Center, Miami, Florida, USA
| | - Esperanza Welsh
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Tory P. Sullivan
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Francisco A. Kerdel
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida, USA
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11
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Lin CY, Maurice PDL, Cross NB. A case of pityriasis rubra pilaris associated with membranous nephropathy. Australas J Dermatol 2011; 54:e1-3. [DOI: 10.1111/j.1440-0960.2011.00807.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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12
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Liu PY, Prete PE. Arthritis associated with pityriasis rubra pilaris. BMJ Case Rep 2010; 2010:2010/aug17_1/bcr1220092565. [PMID: 22766575 DOI: 10.1136/bcr.12.2009.2565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pityriasis rubra pilaris (PRP) is a rare papulosquamous disease of unknown aetiology, with an estimated prevalence of 2.5 per million.1 It is clinically characterised by the presence of follicular hyperkeratotic papules, but the histopathology is usually non-specific. An interesting case of asymmetric, inflammatory arthritis of the hand in a patient who also presented with PRP is presented, along with a review of the few previously reported cases the literature.
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Affiliation(s)
- Paul Y Liu
- Department of Medicine, Division of Rheumatology, University of California, Irvine, Orange, California, USA
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13
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Abstract
Pityriasis rubra pilaris (PRP) is a rare inflammatory dermatosis of unknown etiology, and finding a successful therapy can be challenging. PRP occurs equally in men and women. In some patients, associated autoimmune diseases, infections, or malignancies are possible trigger factors. PRP shows a bimodal age distribution, peaking in the first as well as in the fifth to sixth decade. Its classification into five subgroups is based on age at onset, clinical course, morphologic features, and prognosis. More than 50% of patients are best classified as type I with adult-onset PRP. This form is also characterized by high spontaneous remission rates (80%) within 1-3 years. Clinically, the classical adult (type I) and classical juvenile (type III) forms appear to be the same except for the patient's age. Recently, the designation of a new category of PRP (type VI) has been proposed that is characterized by the presence of HIV infection with different clinical features and a poorer prognosis. Typical morphologic features of PRP are erythematosquamous salmon-colored plaques with well demarcated islands of unaffected skin. Often, keratoderma of the palms and soles is present. In patients with extensive disease, ectropion is a dreaded complication. Histology shows hyperkeratosis, alternating orthokeratosis and parakeratosis in a checkerboard pattern, and focal acantholytic dyskeratosis. Descriptions and therapeutic experiences are mainly based on case reports. Mostly, systemic retinoids, methotrexate, and other immunosuppressive agents as well as UV light therapy are applied, with varying response rates. In recent years, treatment with so-called 'biologics' is becoming more and more popular for treating recalcitrant PRP. We present a review of the clinical features, histopathologic findings, classification, differential diagnoses, and treatment of PRP.
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Affiliation(s)
- Annette Klein
- Department of Dermatology, University of Regensburg, Regensburg, Germany.
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14
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Müller H, Gattringer C, Zelger B, Höpfl R, Eisendle K. Infliximab monotherapy as first-line treatment for adult-onset pityriasis rubra pilaris: case report and review of the literature on biologic therapy. J Am Acad Dermatol 2009; 59:S65-70. [PMID: 19119128 DOI: 10.1016/j.jaad.2008.05.037] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 04/08/2008] [Accepted: 05/27/2008] [Indexed: 10/21/2022]
Abstract
Pityriasis rubra pilaris (PRP) is a rare, chronic papulosquamous disorder of unknown etiology that often progresses to disabling palmoplantar keratoderma and erythroderma. There is currently no universally effective treatment for PRP, and some cases are resistant to multiple topical and systemic therapies. Systemic retinoids, methotrexate, several immunosuppressive agents, fumaric acid esters, stanozolol, and phototherapy have all been used with varying degrees of success. Recently, a few reports have appeared in the literature concerning the use of biologics in combination therapies and/or in refractory PRP cases. We report a case of type I adult-onset PRP successfully treated with infliximab monotherapy as initial systemic therapy, and provide a comprehensive literature review on biologic therapy for PRP. The complete and persistent response to infliximab in our patient and in the previously reported cases confirms a role for anti-tumor necrosis factor-alfa therapy as an effective option in the treatment of PRP. Further studies are warranted to evaluate possible differences in efficacy among the different biologics.
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Affiliation(s)
- Hansgeorg Müller
- Department of Dermatology and Venerology, Innsbruck Medical University, Innsbruck, Austria.
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15
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Gül Ü, Gönül M, Kılıç A, Soylu S, Koçak O, Gönen B, Bodur H, Güler S. A case of pityriasis rubra pilaris associated with sacroileitis and autoimmune thyroiditis. J Eur Acad Dermatol Venereol 2008; 22:889-90. [PMID: 18031492 DOI: 10.1111/j.1468-3083.2007.02502.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Centre, Sehgal Nursing Home, Delhi, India. in
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Manoharan S, White S, Gumparthy K. Successful treatment of type I adult-onset pityriasis rubra pilaris with infliximab. Australas J Dermatol 2006; 47:124-9. [PMID: 16637810 DOI: 10.1111/j.1440-0960.2006.00247.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 59-year-old woman presented with a painful, pruritic eruption that had commenced as an erythematous, dry patch on the upper back but progressed to erythroderma. Examination revealed orange-tinged erythroderma, scalp scaling, ectropion, palmoplantar keratoderma and nail changes. A diagnosis of type I adult-onset pityriasis rubra pilaris was made, and a subsequent skin biopsy was consistent with this. She was treated with a number of topical and systemic agents with minimal improvement or major side-effects. The patient was then treated with intravenous infliximab 5 mg/kg. She improved dramatically within 2 weeks and was no longer erythrodermic. Five further infusions resulted in additional improvement. Methotrexate was briefly added to the regime, but was ceased owing to nausea. Topical tar and keratolytics were used on the scalp. The patient was left with minimal disease activity and was maintained on emollients.
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Affiliation(s)
- Shobhan Manoharan
- Department of Dermatology, Wirral Hospital NHS Trust, Clatterbridge Hospital, Bebington Wirral, England, UK.
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Ohashi H, Takahashi H, Obara M, Suzuki C, Yamamoto M, Yamamoto H, Makiguchi Y, Tamagawa M, Saga K, Murakami E, Imai K. [A case of pityriasis rubra pilaris associated with rapidly progressive finger joint destruction]. NIHON RINSHO MEN'EKI GAKKAI KAISHI = JAPANESE JOURNAL OF CLINICAL IMMUNOLOGY 2004; 27:407-13. [PMID: 15678895 DOI: 10.2177/jsci.27.407] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 40-year-old female noticed edema of the lower limbs in March 1995. Nephrotic syndrome due to membranous nephropathy was diagnosed and administration of high-dose corticosteroids resulted in incomplete remission. Progressively enlarging, red scaling skin lesions developed concomitantly from the scalp to the extremities. Pityriasis rubra pilaris (PRP) was diagnosed in 1996 in the Department of Dermatology at Sapporo Medical University hospital. Various treatments proved ineffective. Arthritis of the finger joints developed in July 1999, and proteinuria recurred in April 2000. She was admitted to our department in August 2000. Physical examination on admission revealed marked swelling of both distal interphalangeal (DIP) joints and the right fourth proximal interphalangeal (PIP) joint. Results of testing for antinuclear antibody, rheumatoid factor, and HLA-B27 were all negative. Radiography of the hands revealed destruction of the DIP and PIP joints where MRI indicated the presence of synovitis. Bone scintigraphy demonstrated accumulation in bilateral metatarso-phalangeal joints and the left sacroiliac joint. Arthritis associated with PRP was diagnosed, as both PRP and psoriasis represent keratinizing disorders of the skin and clinical features in the present case resembled those of psoriatic arthritis. Despite administration of high-dose corticosteroids, destruction of finger joints progressed rapidly. Administration of cyclosporine in April 2002 improved arthritic symptoms. Cases of PRP accompanied by arthritis need to be accumulated to allow analysis of the pathogenesis and clinical picture of this association.
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Affiliation(s)
- Hirokazu Ohashi
- First Department of Internal Medicine, School of Medicine, Sapporo Medical University
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Behr FD, Bangert JL, Hansen RC. Atypical pityriasis rubra pilaris associated with arthropathy and osteoporosis: a case report with 15-year follow-up. Pediatr Dermatol 2002; 19:46-51. [PMID: 11860571 DOI: 10.1046/j.1525-1470.2002.00004.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pityriasis rubra pilaris (PRP) is an idiopathic papulosquamous disease that clinically presents with palmoplantar keratoderma and follicular hyperkeratotic papules that coalesce into scaly erythematous plaques. We report a unique case of atypical PRP beginning at 1 year of age with associated severe arthropathy and osteoporosis. We further discuss the clinical and histopathologic aspects of PRP, its possible etiology, and other associated conditions.
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Affiliation(s)
- Fiona D Behr
- Section of Dermatology, University of Arizona College of Medicine, Tucson, Arizona, USA.
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20
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Abstract
Psoriasis and psoriatic arthritis have been recognized for more than 100 years. Neither the link between psoriasis of the skin or nails and arthritis of the joints nor the pathogenesis of either condition alone or in combination has yet been explained. Our understanding of the mechanisms of inflammation of the skin and the joints has improved over the past 30 years and there are some interesting common threads of knowledge that may bring us closer to understanding psoriasis and psoriatic arthritis. This article will explore further the areas of immunogenetics, infection, autoimmunity, vascular morphology/angiogenesis, trauma and the nervous system in respect of psoriasis and psoriatic arthritis highlighting in particular those aspects that previously have not received due reference.
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Affiliation(s)
- U Fearon
- Department of Rheumatology, St Vincent's University Hospital, Elm Park, Dublin, Ireland
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