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Jung F, Sibbald C, Bohdanowicz M, Ingram JR, Piguet V. Systematic review of the efficacies and adverse effects of treatments for pityriasis lichenoides. Br J Dermatol 2020; 183:1026-1032. [PMID: 32112390 DOI: 10.1111/bjd.18977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pityriasis lichenoides (PL) is a papulosquamous dermatosis affecting both children and adults, for which no standard treatment currently exists. OBJECTIVES To characterize different treatment options and develop an evidence-based treatment algorithm for PL. METHODS A systematic search of published literature on PL treatments was performed on 23 December 2017 via the MEDLINE, Embase, CINAHL, CENTRAL, ClinicalTrials.gov and the EU Clinical Trials Register databases. RESULTS Of 1090 abstracts retrieved, 27 full-text articles with 502 participants were included for analysis. Seventeen of the full-text articles were retrospective cohort studies and two were randomized controlled studies. Treatment modalities included in these articles were phototherapy, antibiotics, methotrexate, pyrimethamine and trisulfapyrimidine, corticosteroids and conservative treatment. Of these treatments, phototherapy led to complete remission in the highest proportion of patients, and topical corticosteroids were found to have been trialled in the highest number of patients. CONCLUSIONS The current literature consists almost entirely of uncontrolled studies, and none provides compelling data to support an evidence-based approach to PL treatment. Pityriasis lichenoides chronica and pityriasis lichenoides et varioliformis acuta should be distinguished in response to treatment, and definitions of response to treatment must be standardized. Additional randomized control studies with longer follow-up will help better differentiate between treatment efficacies and adverse effects.
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Affiliation(s)
- F Jung
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada
| | - C Sibbald
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada
| | - M Bohdanowicz
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada
| | - J R Ingram
- Dermatology, Division of Infection & Immunity, Cardiff University, Cardiff, UK
| | - V Piguet
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada.,Dermatology, Division of Infection & Immunity, Cardiff University, Cardiff, UK.,Division of Dermatology, Women's College Hospital, Toronto, ON, Canada
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2
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Fongue J, Amatore F, Benzaquen M, Spadari M, Granel B, Berbis P. Febrile ulceronecrotic Mucha-Habermann disease after levamisole-adulterated cocaine use: an unusual case. Clin Exp Dermatol 2018; 43:846-848. [DOI: 10.1111/ced.13651] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2017] [Indexed: 11/27/2022]
Affiliation(s)
- J. Fongue
- Dermatology Service; Hôpital Nord, Assistance Publique Hôpitaux de Marseille; Aix Marseille Université; Marseille France
| | - F. Amatore
- Dermatology Service; Hôpital Nord, Assistance Publique Hôpitaux de Marseille; Aix Marseille Université; Marseille France
| | - M. Benzaquen
- Dermatology Service; Hôpital Nord, Assistance Publique Hôpitaux de Marseille; Aix Marseille Université; Marseille France
| | - M. Spadari
- Addictovigilance Service; Hôpital de la Timone, Assistance Publique Hôpitaux de Marseille; Marseille France
| | - B. Granel
- Internal Medicine Service; Hôpital Nord, Assistance Publique Hôpitaux de Marseille; Aix Marseille Université; Marseille France
| | - P. Berbis
- Dermatology Service; Hôpital Nord, Assistance Publique Hôpitaux de Marseille; Aix Marseille Université; Marseille France
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3
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Nofal A, Assaf M, Alakad R, Amer H, Nofal E, Yosef A. Febrile ulceronecrotic Mucha-Habermann disease: proposed diagnostic criteria and therapeutic evaluation. Int J Dermatol 2015; 55:729-38. [DOI: 10.1111/ijd.13195] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/13/2015] [Accepted: 08/24/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Ahmad Nofal
- Department of Dermatology; Faculty of Medicine; Zagazig University; Zagazig Egypt
| | - Magda Assaf
- Department of Pathology; Faculty of Medicine; Zagazig University; Zagazig Egypt
| | - Rania Alakad
- Department of Dermatology; Faculty of Medicine; Zagazig University; Zagazig Egypt
| | - Hala Amer
- Al-Haud Al-Marsoud Dermatology Hospital; Cairo Egypt
| | - Eman Nofal
- Department of Dermatology; Faculty of Medicine; Zagazig University; Zagazig Egypt
| | - Ayman Yosef
- Department of Dermatology; Faculty of Medicine; Zagazig University; Zagazig Egypt
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4
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Griffith-Bauer K, Leitenberger SL, Krol A. Febrile Ulceronecrotic Mucha-Habermann Disease: Two Cases with Excellent Response to Methotrexate. Pediatr Dermatol 2015; 32:e307-8. [PMID: 26584702 DOI: 10.1111/pde.12687] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Febrile ulceronecrotic Mucha-Habermann disease (FUMHD), a severe form of pityriasis lichenoides et varioliformis acuta (PLEVA), featuring large, ulcerative, necrotic skin plaques, high fever, and other systemic symptoms, is a rare disorder of unknown etiology. No randomized controlled trials have established treatment guidelines and multiple modalities are often employed, making it difficult to assess the efficacy of any single agent. We report two cases of this condition in which treatment with methotrexate plus antibiotic treatment for superinfection led to rapid improvement.
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Affiliation(s)
- Kelly Griffith-Bauer
- Department of Dermatology, Center for Health and Healing, Oregon Health and Science University, Portland, Oregon
| | - Sabra L Leitenberger
- Department of Dermatology, Center for Health and Healing, Oregon Health and Science University, Portland, Oregon
| | - Alfons Krol
- Department of Dermatology, Center for Health and Healing, Oregon Health and Science University, Portland, Oregon
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5
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Lejuste FX, Michaux C, Lehners C, Calteux N. Febrile ulceronecrotic Mucha-Habermann disease. BMJ Case Rep 2013; 2013:bcr2013009739. [PMID: 24127370 PMCID: PMC3822268 DOI: 10.1136/bcr-2013-009739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The Mucha-Habermann disease is an inflammatory disease of the skin and is a variant of pityriasis lichenoides et varioliformis acuta. We describe the case of a 64-years-old woman who was admitted for erysipelas of the face. Despite treatment, evolution was marked by the appearance of a necrotising ulcerative area in the centre of the erysipelas associated with local oedema and headache. A skin biopsy revealed a pityriasis lichenoides et varioliformis acuta. Corticosteroids led to a rapid stabilisation of lesions, and after 6 months the patient shows only a small area of frontal hypopigmentation. The aetiology remains uncertain. There is no established standard treatment. We would like to draw attention of the medical and surgical specialists to this rare disease. The diagnosis should be considered in a necrotic lesion associated with rapid expansion of systemic and peripheral cutaneous signs. Diagnosis must be considered to avoid unnecessary debridement and extensive scars.
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Affiliation(s)
- F-X Lejuste
- Service de Chirurgie Plastique Reconstructrice et Esthétique, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
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6
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Febrile Ulceronecrotic Mucha-Habermann Disease (Pityriasis Lichenoides et Varioliformis Acuta Fulminans) Associated With Parvovirus Infection. Am J Dermatopathol 2013; 35:503-6. [DOI: 10.1097/dad.0b013e3182770626] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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7
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Gomes Bica BER, Reis Monteiro de Barros MDGC, Junior CS. Doença de Mucha-Habermann. REVISTA BRASILEIRA DE REUMATOLOGIA 2013; 53:314-7. [DOI: 10.1590/s0482-50042013000300011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2011] [Accepted: 02/18/2013] [Indexed: 11/22/2022] Open
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8
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Sharon VR, Konia TH, Barr KL, Fung MA. Assessment of the 'no eosinophils' rule: are eosinophils truly absent in pityriasis lichenoides, connective tissue disease, and graft-vs.-host disease? J Cutan Pathol 2012; 39:413-8. [PMID: 22443393 DOI: 10.1111/j.1600-0560.2012.01891.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Eosinophils are often present in the inflammatory infiltrate of an interface dermatitis, but the diagnostic specificity of eosinophils in interface dermatitis has not been formally evaluated. We retrospectively identified 97 examples of interface dermatitis with clinically confirmed diagnoses, including lupus erythematosus (LE), lichen planus, pityriasis lichenoides (PL), graft-vs.-host disease (GVHD), dermatomyositis (DM) and drug reaction. Diagnoses were clinically confirmed by at least two dermatologists. Slides were reviewed in a blinded fashion by at least two dermatopathologists. The average eosinophil count per 10 ×200 (×20 objective) fields was lowest for PL (0.2), DM (0.3), GVHD (0.4), and LE (0.5) [defined as Group 1] and was higher for lichen planus, drug reactions, erythema multiforme (major and minor) and viral exanthems [defined as Group 2]. Distinction between Group 1 and Group 2 was maximized using an eosinophil count cutoff of 1.1. In conclusion, eosinophils are usually rare to absent in PL, DM, most forms of LE and GVHD. While final interpretation requires a composite assessment of all features, our results suggest that the presence of even a single eosinophil within nine or ten ×20 fields argues against a diagnosis of PL, DM or LE.
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Affiliation(s)
- Victoria R Sharon
- Department of Dermatology, University of California Davis, Sacramento, CA, USA
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9
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Kaufman WS, McNamara EK, Curtis AR, Kosari P, Jorizzo JL, Krowchuk DP. Febrile ulceronecrotic Mucha-Habermann disease (pityriasis lichenoides et varioliformis acuta fulminans) presenting as Stevens-Johnson syndrome. Pediatr Dermatol 2012; 29:135-40. [PMID: 22084981 DOI: 10.1111/j.1525-1470.2011.01608.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We present two pediatric patients with pityriasis lichenoides et varioliformis acuta fulminans whose admitting diagnosis was Stevens Johnson Syndrome. The patients were successfully treated with methotrexate and prednisone. These cases highlight the importance of early recognition and treatment of this disease to prevent further morbidity and a potentially fatal prognosis.
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Affiliation(s)
- William S Kaufman
- Department of Dermatology, Wake Forest Baptist Health, Winston-Salem, NC 27104, USA
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10
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Meziane L, Caudron A, Dhaille F, Jourdan M, Dadban A, Lok C, Chaby G. Febrile Ulceronecrotic Mucha-Habermann Disease: Treatment with Infliximab and Intravenous Immunoglobulins and Review of the Literature. Dermatology 2012; 225:344-8. [PMID: 23391565 DOI: 10.1159/000346245] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 11/26/2012] [Indexed: 11/19/2022] Open
Affiliation(s)
- L Meziane
- Department of Dermatology, Amiens University Medical Centre, South Hospital, and University Picardie Jules Verne, Amiens, France.
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11
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Perrin BS, Yan AC, Treat JR. Febrile ulceronecrotic Mucha-Habermann disease in a 34-month-old boy: a case report and review of the literature. Pediatr Dermatol 2012; 29:53-8. [PMID: 21906156 DOI: 10.1111/j.1525-1470.2011.01531.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a case of febrile ulceronecrotic Mucha-Habermann disease (FUMHD) in a 34-month-old boy. Our patient had a history of biopsy-proven pityriasis lichenoides et varioliformis acuta (PLEVA) since age 2. At 34 months, his skin lesions rapidly progressed to ulceration and necrosis in the setting of high fever. Skin biopsy revealed an intense lichenoid infiltrate with parakeratosis at the edges of areas of epidermal necrosis consistent with FUMHD, which is the severe variant of PLEVA. Despite initial treatment with prednisolone, his disease progressed to involve more than 50% of his body surface area. In addition to corticosteroids, he was treated with intravenous immunoglobulin, dapsone, and acyclovir, without complete resolution of disease. Methotrexate successfully cleared his skin disease and systemic symptoms. This patient highlights the exceptional response of FUMHD to methotrexate. Based on our review of the literature, this also represents the youngest reported case of FUMHD.
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Affiliation(s)
- Bridget S Perrin
- School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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12
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Farnaghi F, Seirafi H, Ehsani A, Agdari ME, Noormohammadpour P. Comparison of the therapeutic effects of narrow band UVB vs. PUVA in patients with pityriasis lichenoides. J Eur Acad Dermatol Venereol 2010; 25:913-6. [DOI: 10.1111/j.1468-3083.2010.03879.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Zhang LX, Liang Y, Liu Y, Ma L. Febrile ulceronecrotic Mucha-Habermann's disease with pulmonary involvement. Pediatr Dermatol 2010; 27:290-3. [PMID: 20609148 DOI: 10.1111/j.1525-1470.2010.01141.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We report a case of febrile ulceronecrotic Mucha-Habermann disease (FUMHD) in a 12-year-old boy. After 1 week of typical cutaneous appearance of pityriasis lichenoides et varioliformis acuta (PLEVA), he was given a percutaneous injection of measles virus vaccine, and then extensive polymorphous, papular, and ulcerohemorrhagic skin lesions developed along with intermittent high temperature, hepatic dysfunction, and hypoalbuminemia. Thoracic CT scan showed parenchymal nodular infiltration at the tip of vascular structures. Skin biopsy showed a combination of the classic features of PLEVA and an allergic vasculitis. We treated him with prednisolone and methotrexate (MTX) successfully. The evolution in our patient suggests that FUMHD may have been triggered by virus vaccination. We also emphasize that FUMHD in children may be successfully treated with a combination of systemic MTX and high-dose corticosteroids.
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Affiliation(s)
- Li-xin Zhang
- Department of Dermatology, Beijing Children's Hospital, Capital Medical University, Beijing, China
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14
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Taylor CR, Gandhi RT, Handwerker J, Duncan LM. Case records of the Massachusetts General Hospital. Case 34-2009. A 20-year-old man with sore throat, fever, and rash. N Engl J Med 2009; 361:1787-96. [PMID: 19864678 DOI: 10.1056/nejmcpc0905543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Charles R Taylor
- Department of Dermatology, Massachusetts General Hospital, and Harvard Medical School, USA
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16
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Abstract
Pityriasis lichenoides (PL) is an uncommon, acquired spectrum of skin conditions that poses various challenges to patients as well as clinicians. It is a difficult and debatable disorder to diagnose, categorize, and treat. Besides these inherent obstacles, PL merits awareness because of its potential to progress to cutaneous lymphoma or an ulceronecrotic presentation, both of which carry a significant risk of mortality. The scope of PL presentations is delineated along a continuum of multiple variants including pityriasis lichenoides et varioliformis acuta (PLEVA), pityriasis lichenoides chronica (PLC), and febrile ulceronecrotic Mucha-Habermann disease (FUMHD). Classification of these presentations as separate subsets is debatable in view of their overlapping clinical, histopathologic, and etiologic features. PLEVA generally presents as an acute-to-subacute skin eruption of multiple, small, red papules that develops into polymorphic lesions and vacillates with periods of varying remissions as well as possible sequelae of hyper/hypopigmentation and varicella-like scars. PLC has a more gradual manifestation of very small red-to-brown flat maculopapules with mica-like scale; it also follows a relapsing course but with long periods of remission. FUMHD is an acute and severe generalized eruption of purpuric and ulceronecrotic plaques with associated systemic involvement and a mortality rate of up to 25%; hence, it should be approached as a dermatologic emergency.Histopathological evaluation of PL usually reveals dermal, wedge-shaped, lymphocytic infiltrate, epidermal spongiosis, parakeratosis, and variable necrosis of keratinocytes. PLC demonstrates more subtle histology whereas, at the other end of the spectrum, febrile ulceronecrotic FUMHD exhibits the most exaggerated histological features. The pathogenic mechanism behind PL is unclear although infectious or drug-related hypersensitivity reactions versus premycotic lymphoproliferative disorder are the mainstay theories. The foremost therapies for PLEVA and PLC are phototherapy, systemic antibacterials, and topical corticosteroids. Aggressive treatment with immunosuppressant and/or immunomodulating agents as well as intensive supportive care are recommended for FUMHD. We first describe a representative case of a 14-year-old boy with PLC who was successfully treated with narrow-band UVB. We then review the pathophysiology, classification, and treatment of PL.
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Affiliation(s)
- Amor Khachemoune
- Department of Dermatology, New York University School of Medicine, New York, NY 10016, USA.
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17
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Bowers S, Warshaw EM. Pityriasis lichenoides and its subtypes. J Am Acad Dermatol 2006; 55:557-72; quiz 573-6. [PMID: 17010734 DOI: 10.1016/j.jaad.2005.07.058] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2005] [Revised: 07/05/2005] [Accepted: 07/23/2005] [Indexed: 11/18/2022]
Abstract
Pityriasis lichenoides represents a unique group of inflammatory skin disorders that include pityriasis lichenoides et varioliformis acuta (PLEVA), febrile ulceronecrotic Mucha-Habermann disease (a subtype of PLEVA), and pityriasis lichenoides chronica. The history, epidemiology, clinical features, pathophysiology, and treatment of this group of conditions are reviewed in this manuscript.
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Pavlotsky F, Baum S, Barzilai A, Shpiro D, Trau H. UVB therapy of pityriasis lichenoides - our experience with 29 patients. J Eur Acad Dermatol Venereol 2006; 20:542-7. [PMID: 16684281 DOI: 10.1111/j.1468-3083.2006.01531.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pityriasis lichenoides comprises a clinical and pathological spectrum of disorders. So far no highly effective treatment has been reported. Previous small studies have suggested that ultraviolet B (UVB) is a good alternative. METHODS This is a retrospective analysis of 29 pityriasis lichenoides patients treated in our institution with broad- or narrow-band UVB during the period 1996-2002. Twenty-one of these patients had one or more previous unsuccessful treatments. RESULTS Complete response was achieved in 93.1% in both treatment groups, with 73% of them still relapse free after a mean follow-up of 58 and 38 months in broad- and narrow-band UVB treatment groups, respectively. Mild side-effects were observed in about one-third of the patients. CONCLUSION We believe both forms of UVB are a good option for pityriasis lichenoides and should be considered as the first line in generalized cases interested in treatment.
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Affiliation(s)
- F Pavlotsky
- Phototherapy Unit, Department of Dermatology, Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel-Aviv University, Israel.
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Malnar T, Milavec-Puretic V, Rados J, Zarkovic K, Dobric I. Febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta with fatal outcome. J Eur Acad Dermatol Venereol 2006; 20:303-7. [PMID: 16503892 DOI: 10.1111/j.1468-3083.2006.01389.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Ulceronecrotic Mucha-Habermann disease is a severe, febrile form of pityriasis lichenoides et varioliformis acuta. The condition may sometimes have a fatal outcome, especially in elderly patients. In this paper, we are reporting on a 60-year-old male patient who suffered from the eruption of erythematous, haemorrhagic, ulceronecrotic papules accompanied by high temperature. Erosions and ulceronecrotic papules covered over 80% of his body. Three weeks after his admittance to our hospital, clinical signs resembling ileus together with the leucocytosis occurred. The patient was transferred to the department of internal medicine and later to the surgery department. The fulminant course of the disease could not be stopped, and the patient died of severe intestinal and colon gangrene caused by the massive thrombosis of superior mesenteric artery. Up to date, only 23 cases of this severe form of the disease have been reported, and even with the early recognition, fulminant course may lead to death.
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Affiliation(s)
- T Malnar
- Dermatovenereology Unit, Cakovec General Hospital, Cakovec, Croatia (Hrvatska).
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Abstract
Chronic wounds often represent a significant medical and economic challenge. Clinicians seek novel therapies poised to foster production of granulation tissue and subsequent healing. Cadaveric allograft remains the mainstay in burn therapy. Research, however, shows that this treatment functions adjunctively in complex nonhealing wounds by manipulating the microenvironment, preventing desiccation of underlying bone and tendon, augmenting wound-bed preparation, and producing rapid closure. The following review presents the rationale for incorporating skin allografts into the wound healing algorithm, including chronic wound biochemistry, wound-bed preparation, current applications, combination therapies, cost considerations, and case studies. Diagnosis and treatment of underlying etiologies remains essential. A multidisciplinary approach using accepted treatment protocols helps reduce morbidity and expense associated with these lesions.
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Affiliation(s)
- Robert J Snyder
- Wound Healing Center, University Hospital and Medical Center, Tamarac, FL 33321, USA.
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Herron MD, Bohnsack JF, Vanderhooft SL. Septic, CD-30 positive febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta. Pediatr Dermatol 2005; 22:360-5. [PMID: 16060878 DOI: 10.1111/j.1525-1470.2005.22418.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We report life-threatening febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta in an 8-year-old girl. Hemorrhagic-crusted papules and plaques covered over 90% of the patient's body, leaving her susceptible to Pseudomonas aeruginosa and Staphylococcus epidermidis bacteremia as well as Candida parapsilosis fungemia. Sepsis delayed definitive treatment of the underlying cutaneous disease for 2 weeks. Combined therapy with methotrexate and cyclosporin caused remission of the process. Although immunohistochemistry revealed CD-30 positive cells, suggesting the diagnosis of lymphomatoid papulosis, the histopathology was most compatible with pityriasis lichenoides et varioliformis acuta. A partial loss of CD2 and CD5 in the predominant CD3 T-cell lymphocytes suggested a clonal proliferation. Elevated soluble interleukin-2 receptor levels reflected marked T-cell activation, and the downward trend of the levels during treatment coincided with clinical regression of this inflammatory dermatosis.
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Affiliation(s)
- Mark D Herron
- Department of Dermatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Tsianakas A, Hoeger PH. Transition of pityriasis lichenoides et varioliformis acuta to febrile ulceronecrotic Mucha-Habermann disease is associated with elevated serum tumour necrosis factor-alpha. Br J Dermatol 2005; 152:794-9. [PMID: 15840118 DOI: 10.1111/j.1365-2133.2005.06485.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Febrile ulceronecrotic Mucha-Habermann disease (FUMHD) represents a fulminant and potentially lethal variant of pityriasis lichenoides. Only 24 cases have been described so far. We report a 9-year-old boy who initially presented with classical pityriasis lichenoides et varioliformis acuta (PLEVA) following a mild enteritis. Three weeks later, his skin lesions started to ulcerate progressively, involving > 90% of his body surface, accompanied by high fever, normal C-reactive protein, but highly elevated serum levels of tumour necrosis factor (TNF)-alpha. Methotrexate 10 mg m(-2) weekly was required to halt disease progression, while oral steroids (initial dose 2.8 mg kg(-1) daily) alone proved insufficient. Sequential histology revealed progressively dense perivascular and intramural lymphocytic inflammation as well as keratinocyte necrosis. Our case demonstrates the clinical and histological continuum between 'classical' PLEVA and FUMHD and points to the potentially pathogenic significance of TNF-alpha. We hypothesize that in future cases, treatment with TNF-alpha antagonists might represent a reasonable alternative to high-dose immunosuppressive therapy.
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Affiliation(s)
- A Tsianakas
- Division of Paediatric Dermatology, Department of Dermatology, University of Hamburg, Martinistr. 52, D-20246 Hamburg, Germany
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Neff P, Meuli-Simmen C, Kempf W, Gaspert T, Meyer VE, Künzi W. Lyell syndrome revisited: analysis of 18 cases of severe bullous skin disease in a burns unit. ACTA ACUST UNITED AC 2005; 58:73-80. [PMID: 15629170 DOI: 10.1016/j.bjps.2004.04.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2003] [Accepted: 04/27/2004] [Indexed: 10/26/2022]
Abstract
Over the last few years, understanding of the pathophysiology of toxic epidermal necrolysis (TEN), or Lyell's disease, has substantially increased. However, differentiation of severe bullous skin disease remains a challenge for the clinician, and one that is often complicated by late patient referral. We performed a retrospective analysis of all patients with severe bullous skin disease, admitted between 1997 and 2002 to the Burn Centre, which is an integrated part of the Division for Plastic, Hand- and Reconstructive Surgery at the University Hospital of Zurich, Switzerland. We present an overview of our strategies and of the diagnostic and therapeutic difficulties encountered. The final diagnoses of the 18 patients referred to the unit were as follows: eight cases of TEN, one case of staphylococcal scalded-skin syndrome (SSSS), two cases of generalised drug eruption, one case of acute generalised exanthematic pustulosis and one case of febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta (PLEVA). In two cases, the diagnosis remained unclear. In three cases, paraneoplastic origins were suspected but not demonstrated. The overall mortality rate was 33% (six of 18 patients). Remarkably, all patients with histologically confirmed TEN survived. Six of these patients were successfully treated with intravenous immunoglobulins (IVIG). The most common single causative drug inducing TEN (four cases out of eight) was Phenytoin. Establishing an accurate diagnosis-based on a skin biopsy, harvested at an early stage-is more important than ever, because more specific and effective therapeutic modalities are available. As these potentially life-threatening bullous skin disorders are rare, we recommend, that care be provided by an experienced interdisciplinary team, comprising a dermatologist, or dermatopathologist, an intensive care specialist and a plastic surgeon.
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Affiliation(s)
- Ph Neff
- Division for Plastic, Hand- and Reconstructive Surgery, Department of Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland.
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Cozzio A, Hafner J, Kempf W, Häffner A, Palmedo G, Michaelis S, Gilliet M, Zimmermann D, Burg G. Febrile ulceronecrotic Mucha-Habermann disease with clonality: A cutaneous T-cell lymphoma entity? J Am Acad Dermatol 2004; 51:1014-7. [PMID: 15583604 DOI: 10.1016/j.jaad.2004.06.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Febrile ulceronecrotic Mucha-Habermann disease (FUMHD) is a severe variant of pityriasis lichenoides et varioliformis acuta (PLEVA). PLEVA patients only very rarely have systemic signs; the cutaneous lesions are usually asymptomatic, but may be pruritic and may heal with scarring. FUMHD often starts out as classic PLEVA, but goes on to develop widespread ulceronecrotic lesions and is associated with a high mortality rate. Whether Pityriasis lichenoides chronica (PLC) and PLEVA form a spectrum rather than single entities of clonal lymphoproliferative diseases has been discussed. Recently, it has been proposed that FUMHD, too, is a clonal lymphoproliferative disorder. Here, we report two cases of FUMHD with monoclonal T-cell population, as detected by Southern blot analysis. We propose that clonal FUMHD represents a cutaneous T-cell lymphoma entity.
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Affiliation(s)
- Antonio Cozzio
- Department of Dermatology, University Hospital of Zurich, Switzerland.
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