Collagen vascular diseases

Unmet Medical Needs in Chronic, Non-communicable Inflammatory Skin Diseases

An estimated 20-25% of the population is affected by chronic, non-communicable inflammatory skin diseases. Chronic skin inflammation has many causes. Among the most frequent chronic inflammatory skin diseases are atopic dermatitis, psoriasis, urticaria, lichen planus, and hidradenitis suppurativa, driven by a complex interplay of genetics and environmental factors. Autoimmunity is another important cause of chronic skin inflammation. The autoimmune response may be mainly T cell driven, such as in alopecia areata or vitiligo, or B cell driven in chronic spontaneous urticaria, pemphigus and pemphigoid diseases. Rare causes of chronic skin inflammation are autoinflammatory diseases, or rheumatic diseases, such as cutaneous lupus erythematosus or dermatomyositis. Whilst we have seen a significant improvement in diagnosis and treatment, several challenges remain. Especially for rarer causes of chronic skin inflammation, early diagnosis is often missed because of low awareness and lack of diagnostics. Systemic immunosuppression is the treatment of choice for almost all of these diseases. Adverse events due to immunosuppression, insufficient therapeutic responses and relapses remain a challenge. For atopic dermatitis and psoriasis, a broad spectrum of innovative treatments has been developed. However, treatment responses cannot be predicted so far. Hence, development of (bio)markers allowing selection of specific medications for individual patients is needed. Given the encouraging developments during the past years, we envision that many of these challenges in the diagnosis and treatment of chronic inflammatory skin diseases will be thoroughly addressed in the future.

Dermatomyositis as a paraneoplastic phenomenon in oesophageal cancer

Dermatomyositis is a multisystem disease manifesting as an idiopathic inflammatory myopathy, characterised predominantly by cutaneous and muscular abnormalities. Patients with dermatomyositis display characteristic skin changes in addition to muscle weakness. Many consider dermatomyositis a paraneoplastic syndrome, as up to 32% of patients with dermatomyositis will develop cancer. Discussed here is the case of a 69-year-old man with a new diagnosis of dermatomyositis who was referred to a tertiary institution with an 8-month history of rash, proximal muscle weakness, fatigue and weight loss. In the absence of clinical symptoms, negative cancer markers and a negative CT chest, abdomen and pelvis, positron emission tomography-CT prompted a gastroscopy, which led to the discovery of a stage T1b oesophageal adenocarcinoma. The oesophageal adenocarcinoma was treated with a gastrointestinal endoscopic mucosal resection and subsequent oesophajectomy. The patient's dermatomyositis was treated successfully with oral prednisolone and methotrexate.

Pulsed dye laser as an excellent choice of treatment for lupus tumidus: a prospective study

BACKGROUND

Clinical manifestations of cutaneous lupus erythematosus (CLE) vary widely, and different subtypes of this autoimmune disease exist. Tumidus subtype (LT) has been recently separated from the chronic subtypes and is now considered an independent entity due to its particular clinical and histological features. Different treatments are usually prescribed for CLE. Our group has experience of CLE effectively treated with pulsed dye laser (PDL). It was our impression that better responses were achieved in the LT subtype, but no controlled prospective studies with PDL have been specifically performed.

MATERIALS AND METHODS

A prospective study was performed on 10 patients with histologically confirmed LT treated with PDL. All patients were treated with 595 nm PDL using the 10 mm spot size at 0.5 ms pulse width and a fluence of 8 J/cm(2). Biopsies were taken before and 4 weeks after treatment and were stained with haematoxylin-eosin.

RESULTS

Evaluation after PDL treatment showed clinical improvement in all of them without side-effects and reduction of the dermal lymphocytic infiltrate in 9/10 of the patients. Epidermal changes were absent in all patients. Mucin deposition persisted only in one patient. However, 50% of the patients developed new lesions nearby or distant to the treated zones.

CONCLUSIONS

PDL therapy is an effective and fast treatment option for acute flares of LT; however, it does not prevent recurrences. A histological improvement has been confirmed in this study. Purpura seems to be necessary to achieve a good response.

Oral manifestations as important symptoms for juvenile dermatomyositis early diagnosis: a case report

BACKGROUND

Juvenile dermatomyositis (JDM) is an idiopathic inflammatory myopathy of childhood and adolescence, characterized by symmetrical weakness of proximal muscles and classical cutaneous features. Literature reports rarely describe or focus on oral lesions that are associated with this disease.

CASE REPORT

This case describes a 4-year-old girl in whom the oral lesions were the initial manifestations of JDM. Physical examination revealed characteristic skin manifestations, proximal muscle weakness, extensive calcinosis, necrotic ulceration, complicated erysipelas, and diffuse alopecia. The diagnosis was established based on the clinical, histological, electroneuromyography, and biochemical findings.

CONCLUSION

Recognition of gingival telangiectases as an important diagnostic marker of JDM leads us to suggest that identifying oral manifestations, which may be carried out by a paediatric dentist, contributes in establishing an early diagnosis and an immediate treatment of this condition.

Overview of common, rare and atypical manifestations of cutaneous lupus erythematosus and histopathological correlates

The skin is the second most frequently affected organ system in lupus erythematosus. Although only very rarely life threatening--an example is lupus erythematosus-associated toxic epidermal necrolysis--skin disease contributes disproportionally to disease burden in terms of personal and psychosocial wellbeing, vocational disability, and hence in medical and social costs. Since several manifestations are closely associated with the presence and activity of systemic lupus erythematosus, prompt and accurate diagnosis of cutaneous lupus erythematosus is essential. This review aims to cover common, rare, and atypical manifestations of lupus erythematosus-associated skin disease with a detailed discussion of histopathological correlates. Cutaneous lupus erythematosus covers a wide morphological spectrum well beyond acute, subacute and chronic cutaneous lupus erythematosus, which are commonly classified as lupus-specific skin disease. Other uncommon or less well-known manifestations include lupus erythematosus tumidus, lupus profundus, chilblain lupus, mucosal lupus erythematosus, and bullous lupus erythematosus. Vascular manifestations include leukocytoclastic and urticarial vasculitis, livedoid vasculopathy and livedo reticularis/ racemosa. Finally, we discuss rare presentations such as lupus erythematosus-related erythema exsudativum multiforme (Rowell syndrome), Kikuchi-Fujimoto disease, extravascular necrotizing palisaded granulomatous dermatitis (Winkelmann granuloma), and neutrophilic urticarial dermatosis.

Dermatomiosite

Dermatomiosite é doença idiopática inflamatória crônica que afeta a musculatura estriada, a pele e outros órgãos. Apresenta critérios diagnósticos definidos por Bohan & Peter, podendo os pacientes ser classificados em cinco grupos: dermatomiosite juvenil, dermatomiosite primária idiopática, dermatomiosites amiopáticas, dermatomiosite associada a neoplasias e dermatomiosite associada a outras doenças do tecido conectivo. O sexo feminino é mais afetado, e a idade média do diagnóstico é 40 anos. Manifestações cutâneas são observadas em todos os pacientes. Das alterações sistêmicas, a manifestação muscular mais freqüente é a perda de força proximal, e a manifestação pulmonar mais comum é a pneumopatia intersticial. Podem ser observadas neoplasias durante o seguimento da doença, sendo mais freqüentes nos pacientes acima de 60 anos. A desidrogenase lática é a enzima muscular alterada na maioria dos casos. Para diagnóstico da dermatomiosite, pode ser realizado exame anatomopatológico de biópsia cutânea e biópsia muscular, além de eletroneuromiografia. Os corticóides são a terapia mais utilizada. As causas de óbito mais freqüentes são a neoplasia maligna, a septicemia e a infecção pulmonar.

Discoid lupus erythematosus in children--a retrospective study of 34 patients

Discoid lupus erythematosus is much less frequent and studied in children. We undertook a retrospective study of 34 children less than 16 years of age with this disease, seen over a period of 9 years. A female predominance of 2:1 was found. An association between discoid lupus erythematosus and systemic lupus erythematosus was observed in 23.5% of patients, a higher proportion compared to adult discoid lupus erythematosus. Disseminated lesions were much more frequent in patients with criteria for systemic lupus erythematosus (87.5% vs 34%), suggesting that it could be associated with a worse prognosis. Histologic findings were similar to those observed in adult discoid lupus erythematosus.

Lupus eritematoso discóide na infância

OBJETIVO: Realizar revisão da literatura sobre o lupus eritematoso discóide (LED) na infância. FONTES DE DADOS: Livros-texto e artigos de revistas indexadas pelo Medline e SciELO nos últimos dez anos, usando as seguintes palavras-chave: "discoid lupus erythematosus", "chronic cutaneous lupus erythematosus", "lupus erythematosus in childhood", "lupus erythematosus in children", "discoid lupus erythematosus in childhood", "discoid lupus erythematosus in children". SÍNTESEDOS DADOS: A idade de início da doença ocorre predominantemente entre cinco e dez anos e a história familiar de lupus eritematoso está presente em 11 a 35% dos casos. A relação gênero feminino/masculino varia de 1/1 a 2,4/1. Por sua vez, 24 a 27% dos pacientes com LED desenvolvem lupus eritematoso sistêmico (LES). Lesões discóides localizadas (que acometem cabeça e pescoço) são observadas em 56 a 75% dos pacientes. A face é o local mais acometido. O LED localizado e o generalizado apresentam evolução semelhante. Os achados histológicos são típicos, mostrando dermatite de interface. IgM e IgG são os depósitos mais freqüentes na zona da membrana basal da epiderme. Os tratamentos geralmente utilizados são: fotoproteção, corticosteróides tópicos e antimaláricos. Imunossupressores, talidomida, dapsona e retinóides podem ser usados nos casos refratários. CONCLUSÕES: O LED da infância parece ter pequeno predomínio no gênero feminino, alta prevalência de história familiar de lupus eritematoso e elevada proporção que evolui para a forma sistêmica da doença, comparada ao LED do adulto. O LED localizado e o generalizado apresentam prognósticos semelhante. Os achados histológicos não foram diferentes daqueles descritos no LED do adulto.

Rituximab for the treatment of the skin manifestations of dermatomyositis: A report of 3 cases

Three patients suffering from classic dermatomyositis (juvenile and adult-onset) with prominent recalcitrant skin manifestations are described. All patients demonstrated good control of muscle symptoms on immunosuppressive medications, but their cutaneous disease persisted despite treatment with at least 4 different systemic treatments and topical agents. They were given rituximab, a monoclonal anti-CD20 antibody, achieving a response with minimal side effects. We document our experience with this medication for the cutaneous lesions of dermatomyositis.

Update on Connective Tissue Diseases in Dermatology

Recent advances in understanding the pathogenesis of autoimmune diseases, including lupus erythematosus, dermatomyositis, and scleroderma, have allowed for reorganization of the classification of these disorders. With these novel stratifications, early identification of rheumatic skin diseases with systemic implications and consistency in designing and executing therapeutic trials will be enhanced. This review will provide a compilation of updates on epidemiology, pathology, evaluation, and classification with a predominant focus on therapeutics, reflecting the growth is this area.