Prurigo pigmentosa (Nagashima) associated with anorexia nervosa

Prurigo Pigmentosa Induced by a Ketogenic Diet

Prurigo pigmentosa is an important cause of reticular pruritic rash that has been under-reported in the United States. To ensure proper patient care, it is important for dermatologists to be aware of its presentations and associated factors. Here, we present an uncommon case of prurigo pigmentosa induced by a ketogenic diet and discuss the links between this condition and the state of ketosis, a relationship every provider should be conscious of.

Use of minocycline for the treatment of prurigo pigmentosa with intraepidermal vesiculation: a case report

Pruritus pigmentosa is a skin disease mainly characterized by pruritus, inflammatory rash and reticular and macular pigmentation. The disease more commonly affects young women and may persist for several years. In this article, we report a case of a 20-year-old female patient who presented with erythema and blisters on the neck and trunk with pruritus for 20 days. Dermatological examination revealed a reticular distribution of erythema on the chest and abdomen and some areas of erythema covered with crusts. Additionally, blisters and bullae with clear fluid and negative Nikolsky's sign were noted. On the neck and back, erythema was also in a reticular distribution, and erythema secondary to erosion and/or crusts was present. In addition, histopathological analysis of the lesions showed hyperkeratosis and intraepidermal multilocular vesiculation and confirmed increased migration of inflammatory cells into the epidermis and infiltration of inflammatory cells, including lymphocytes, histiocytes and eosinophils, in the superficial dermis. The expression levels of IgG, IgM, IgA and C3 were all negative. This patient was diagnosed with prurigo pigmentosa, and the condition improved after treatment with minocycline.

Prurigo Pigmentosa: Demographics and Characteristics in 14 Caucasian Patients

BACKGROUND

Prurigo pigmentosa (PP) is an inflammatory dermatosis typically reported in young Asian women and characterized by recurrent papulovesicular lesions resolving with a postinflammatory reticulated hyperpigmentation.

METHODS

We have included all consecutive patients with PP diagnosed in our tertiary center between 2013 and 2020. The clinical information was retrospectively collected from medical records.

RESULTS

We identified 14 patients with PP. The median age at the time of diagnosis was 29.5 years (range 17-43 years), while the female-to-male ratio was 13:1. Diagnostic delay varied from 10 days to 10 years (mean of 25 months). Light microscopy studies consistently showed presence of a lymphohistiocytic infiltrate in combination in 40% of cases with neutrophils. Interface changes were found in 60% of cases. In 6 (43%) of 14 cases, there was a chronological relationship between the starting of a new diet and the development of the first flares. Treatment with doxycycline in 9 patients resulted in a complete regression of the lesions.

LIMITATION

This was a retrospective study in a tertiary referral hospital.

CONCLUSIONS

Our observations indicate that PP is not so rare in Europe as previously thought and is often diagnosed after a long delay. Demographics, clinical characteristics and triggering factors in Caucasian patients are similar to those described in the Asian population. Diagnosis is based on the peculiar recurrent course and distinctive clinicopathological features. Tetracyclines represent the first-line therapy in PP.

[Prurigo pigmentosa during pregnancy]

INTRODUCTION

Prurigo pigmentosa is a rare inflammatory dermatosis characterized by pruritic and reticulate papules on the trunk leaving hyperpigmentation. This dermatosis has been rarely described outside Asia. The pathophysiology remains obscure.

CASE REPORT

We report the case of a 21-year-old North-African woman presenting with a highly pruritic eruption with numerous erythematous macules and papules coalescing in a reticular pattern on the trunk. The eruption occurred during the first trimester of pregnancy, which was marked by severe vomiting resulting in weight loss of 13kg with ketonemia and ketonuria. Taking into account the characteristic pattern of the eruption, the absence of differential diagnosis, and the histological examination, we concluded on a diagnosis of prurigo pigmentosa. Progression of the disease exhibited phases of decreased inflammation and of pruritus alternating with episodes of inflammatory flares triggered by relapses of ketonemia. The symptoms finally resolved during the 2nd trimester of pregnancy after vomiting ceased. Secondary reticulated hyperpigmentation was observed.

CONCLUSION

Although rare, the highly evocative clinical presentation of the eruption should help clinicians in diagnosing prurigo pigmentosa. While pathophysiology remains undetermined, prurigo pigmentosa was reported in cases of intense fasting, anorexia, type-1 diabetes, and in two other cases of pregnancy with severe vomiting. Our case underlines the need to screen for and treat underlying ketonemia to achieve control of the inflammatory flares of prurigo pigmentosa.

Prurigo Pigmentosa-Report of 3 Cases From Brazil and Literature Review

Prurigo pigmentosa (PP) is a rare inflammatory disease of the skin of uncertain etiology first reported in Japan. It is typified by recurrent eruptions of itching urticarial macules, papules, vesicopapules, and plaques with a reticular arrangement that quickly resolve leaving a net-like pigmentation. The disease presents specific histopathological features. Herein, 3 cases of PP in Brazilians with no Japanese ancestry are reported and a revision of all previous English-language case reports indexed on PubMed is provided. Two articles with original case reports not listed on PubMed were also included. Our patients are 2 women and 1 man at the ages of 39, 33, and 22 years, respectively. All 3 presented findings in consonance with previous cases of PP and were diagnosed based on clinicopathological correlation. They were successfully treated with oral minocycline or doxycycline. In our literature review, a total of 210 previously reported cases were included. Although PP seemed to be restricted to Japanese patients in the first years after its recognition, the geographic boundaries of the disease are continuously expanding. Korea responded for 83 previous cases and Japan for 53. The mean age was 24.4 years, with 84.3% of the cases occurring between 11 and 30 years of age. The female/male rate was 2.6 and the most affected anatomical sites were back, chest, and neck. We do believe that the rarity of case reports in western countries may represent lack of awareness about the disease by dermatologists and dermatopathologists in these regions.

Prurigo Pigmentosa: Literature Review

Prurigo pigmentosa, also referred to as Nagashima's disease, is a rare inflammatory skin condition of unknown etiology. It typically presents as pruritic erythematous papules, papulovesicles, and vesicles appearing in a reticular pattern on the back, chest, or neck. The histological features of prurigo pigmentosa vary according to the stage of the disease. Early-stage disease is characterized by a superficial perivascular infiltrate of neutrophils; spongiosis and necrotic keratinocytes commonly appear in later stages. The etiology of prurigo pigmentosa has yet to be determined. Oral minocycline is usually the first-line therapy for prurigo pigmentosa. However, doxycycline, macrolide antibiotics, and/or dapsone (diaminodiphenyl sulfone) may be indicated for some patients. We describe the key features of prurigo pigmentosa, including the epidemiology, clinical and histologic presentation, differential diagnosis, postulated pathogenesis, and treatment options for this condition.

Prurigo pigmentosa after a strict ketogenic diet

Prurigo pigmentosa (PP) is a rare inflammatory dermatosis of unknown cause characterized by a predominantly truncal eruption of pruritic erythematous papules in a reticular pattern, resolving with hyperpigmentation. PP is twice as common in girls and women, and the mean age at onset is 25 years. Diagnosis of PP is challenging and is aided by characteristic histopathologic findings. We report a case of PP in a 17-year-old white boy. The eruption arose during strict adherence to a ketogenic diet.

Reticulate dermatoses

The term "reticulate" is used for clinical description of skin lesions that are configured in a net-like pattern. Many primary and secondary dermatoses present in such patterns involving specific body sites. Certain cutaneous manifestations of systemic diseases or genodermatoses also present in such manner. This review classifies and describes such conditions with reticulate lesions and briefly, their associated features.

Identification of Helicobacter pylori in skin biopsy of prurigo pigmentosa

A 23-year-old Chinese man presented with a 3-year history of a pruritic eruption. On examination, pink urticarial papules associated with hyperpigmented reticulated patches were noted on his neck, back, and upper chest. Histopathology revealed vacuolar interface dermatitis and numerous gram-negative rods within a dilated hair follicle. The organisms were reactive with anti-Helicobacter pylori immunohistochemisty. The histologic findings and clinical presentation support the diagnosis of prurigo pigmentosa. Additional testing demonstrated a positive urease breath test and serum H. pylori IgG antibodies. The patient was referred to gastroenterology and treated with appropriate antibiotics. After treatment, esophagogastroduodenoscopy revealed chronic gastritis without evidence of H. pylori infection and his skin showed reticulated hyperpigmented patches without evidence of active inflammatory papules. Although previous reports have associated prurigo pigmentosa to H. Pylori gastritis, this is the first report of H. pylori organisms identified in a skin biopsy of prurigo pigmentosa.

Prurigo pigmentosa in Korea: clinicopathological study

BACKGROUND

Prurigo pigmentosa (PP) is an inflammatory dermatosis characterized by recurrent pruritic erythematous papules, mainly located on the trunk. It was first described by Nagashima in 1971 in Japan. Since then, more than 300 cases have been reported in Japan, but reports from other parts of the world are quite rare.

MATERIALS AND METHODS

We studied clinical and histopathological data from six patients with PP diagnosed in our hospital and 43 patients (18 reports) who were diagnosed with PP in Korea between 1988 and 2008.

RESULTS

The number of Korean patients reported in recent years is higher than the number of other non-Japanese patients reported. Clinicopathological characteristics in Korean patients were not significantly different from those previously reported. Therapeutic results with minocycline were successful in our patients.

CONCLUSIONS

We suspect that PP is not uncommon in Korea, and the disease may be underestimated. Strict restriction of diet as well as known associated factors like wet condition are suggested as one of the important factors contributing to the occurrence of PP in Korea.

Prurigo pigmentosa associated with an atopic diathesis in a 13-year-old girl

We report an Italian prepubescent girl with the typical clinical and histologic features of prurigo pigmentosa associated with an atopic diathesis. The dermatitis disappeared after treatment with minocycline, leaving a brown, reticulated hyperpigmentation, with no recurrence. The association with an atopic diathesis could justify, in this instance, the major susceptibility to environmental factors claimed by some authors as triggering factors for prurigo pigmentosa. To our knowledge, this is only the second occurrence of this disease in a prepubescent patient reported in the literature.

Prurigo pigmentosa: not an uncommon disease in the Turkish population

BACKGROUND

Prurigo pigmentosa (PP) is a rare inflammatory dermatosis of unknown etiology. It is characterized by erythematous papules of the trunk that resolve leaving a reticulate hyperpigmentation. The original report from Japan in 1971 was followed by new cases, mostly of Japanese origin.

METHODS

We scrutinized PP cases diagnosed in our clinic and reviewed the English, German, French, and Turkish language literature.

RESULTS

We report six additional Turkish patients. We found more than 40 cases reported from various countries outside Japan. The patients had different racial origins. The number of Turkish patients reported in recent years is higher than the number of other non-Japanese patients reported.

CONCLUSIONS

The disease is not uncommon in the Turkish population. It may be underestimated in other countries with Caucasian populations. Therapeutic results with tetracycline and doxycycline was successful in our patients.

[Prurigo pigmentosa]

Prurigo pigmentosa is an infrequent inflammatory dermatosis of unknown etiology, characterized by recurrent episodes of pruritic erythematous papules which develop into intense reticulated pigmentation. It has been referenced most frequently in young women in Japan. Only thirty cases have been described outside of Japan. We describe a 32-year-old Spanish female who developed a pruritic dermatosis with the clinical characteristics and histopathological findings of prurigo pigmentosa. We review the epidemiological, clinical and histopathological characteristics of this peculiar skin disease.

Prurigo pigmentosa in a patient with primary biliary cirrhosis and Sjögren syndrome

A 44-year-old Japanese woman suddenly developed severely pruritic erythematous papules on her trunk in a symmetrical distribution. Biopsy specimens showed the typical histopathological findings of prurigo pigmentosa. She had had recurrent episodes of high fever spikes for several years, and lost 10 kg in the last year. She was diagnosed as primary biliary cirrhosis (PBC) associated with subclinical Sjögren syndrome (SjS). Predonisolone (60 mg/day) for two weeks was effective for the PBC and fever, but not for the prurigo pigmentosa. PBC may be involved in the pathogenesis of this rare skin disease.

The hypomagnesic rat model: dermatitis-prone hairless rats with mild magnesium depletion fed a diet low in lipids did not develop pruritic dermatitis

BACKGROUND/PURPOSE

In the hypomagnesic dermatosis of rats, low-dietary magnesium leads to lowered serum Mg2+, universal dermatitis and scratching. The model is postulated to work better if the diet also has a low content of lipids. Pruritus is seen in patients suffering from anorexia nervosa and resolves on weight restoration. Lipid depletion of the diet and/or lowered body weight may therefore be important in developing pruritus. The purpose of the present study was to investigate whether a diet low in lipids can induce pruritus in dermatitis prone rats because of mild magnesium depletion thereby focusing on the role of lipids in the hypomagnesic dermatosis rat model.

METHODS

Fourteen male hairless rats, 3 weeks of age, were fed a diet deficient in lipids and with a lower content of magnesium for a 4-week period and compared with 11 controls fed a normal diet. The skin was inspected daily and transepidermal water loss (TEWL), serum Mg2+ and scratching activity were measured. At the end, skin biopsies were taken from the flank and ears.

RESULTS

Serum Mg2+ was significantly lowered in the diet group (P<0.001) but the rats developed no dermatitis or increased TEWL compared with 11 rats in a control group. Biopsies were normal with no sign of inflammation. Rats in the diet group had inferior weight gain, were less active and spent more time asleep than control rats (P<0.01). Furthermore, scratching activity monitored in the last week of the study as the number of scratch-sequences per awake minute was reduced in the diet group (P<0.001).

CONCLUSION

The lipid-deficient diet was not able to induce pruritic dermatitis despite the fact that the rats were dermatitis prone because of mild magnesium depletion. It is not confirmed that dietary lipid depletion plays any significant role in the hypomagnesic dermatitis rat model. The dermatitis and the model appear to be strictly dependent on efficient magnesium depletion manufactured with very low magnesium levels.

Prurigo: diagnosis and management

Prurigo is a condition of nodular cutaneous lesions that itch (pruire) intensely. Although the acute form can be caused by insect stings, most of the subacute and chronic forms appear to be idiopathic. Toxic agents deposited in the skin by exogenous factors such as parasites, bacteria, or topically or orally administered drugs can induce itch. In susceptible individuals, physical mechanisms such as UV light can induce changes in epidermal innervation that result both in itch generally and in prurigo lesions. Prurigo is sometimes associated with atopy, pregnancy, internal diseases, malabsorption, or malignancy. Some forms of prurigo may be secondary to scratching. Emotional factors can also influence the perception of itch and induce prurigo by provoking scratching. These are the various specialized forms of prurigo, and there are certain others, such as prurigo pigmentosa, that have some ethnic preference. Topical treatments by corticosteroids, coal tar, bath photochemotherapy, UVB, cryotherapy, or capsaicin, as well as systemic regimens involving use of psoralen + UVA (PUVA), erythromycin, arotinoid acid, cyclosporine, chloroquine, dapsone, minocycline, naltrexone, azathioprine or thalidomide are used for the treatment of this condition. Psychotherapeutic agents to treat problems of mood that deteriorate prurigo are also prescribed. Combined sequential treatments for generalized, therapy-resistant cases need to be tailored to the exacerbations that occur and to provide maintenance treatment in order to enable the patient to withstand the intolerable itch.

Prurigo pigmentosa: a distinctive inflammatory disease of the skin

More than 200 patients with prurigo pigmentosa, a disease described first by Nagashima in 1971, have been reported on in Japan, but only 28 non-Japanese patients have come to notice as of today. In order to establish reliable, repeatable criteria for diagnosis of the disease, we studied 25 patients with prurigo pigmentosa and reviewed the literature pertaining to it as recorded in another 182 patients.Clinically, prurigo pigmentosa presents itself as pruritic urticarial papules, papulovesicles, and vesicles arranged in reticular pattern and distributed symmetrically on the back, neck, and chest. Lesions involute in a matter of days, leaving behind netlike pigmentation. Exacerbations and recurrences are the rule. Histopathologically, prurigo pigmentosa begins with a superficial perivascular infiltrate of neutrophils. Shortly thereafter, neutrophils are scattered in dermal papillae and then sweep rapidly through an epidermis in which spongiosis, ballooning, and necrotic keratocytes are accompaniments. En route, abscesses may form in the surface epithelium. Very soon, eosinophils and lymphocytes come to predominate over neutrophils in a dermal infiltrate that assumes a patchy lichenoid pattern. Intraepidermal vesiculation follows on spongiosis and ballooning and, sometimes, subepidermal vesiculation on vacuolar alteration at the dermo-epidermal junction. As the epidermis becomes hyperplastic, parakeratotic, and slightly hyperpigmented, melanophages begin to appear in the dermis. Studies by immunofluorescence are negative invariably. Dapsone or minocyclin are effective treatments; both of those agents inhibit migration and/or function of neutrophils. The cause and pathogenesis have yet to be determined. Prurigo pigmentosa is unique among inflammatory diseases of the skin and the singularity of it is manifest both clinically and histopathologically.

Cutaneous manifestations of eating disorders

BACKGROUND AND OBJECTIVE

No complete review of the cutaneous manifestations of eating disorders exists. We therefore, set out to review and systematically describe the clinical and histopathologic features of dermatologic conditions associated with anorexia nervosa, bulimia nervosa, and obesity. Differential diagnosis, pathophysiology, laboratory studies, and treatment are also reviewed.

METHODS

Index Medicus review (1966 to present) using Ovid-MEDLINE. Search terms included eating disorders, anorexia nervosa, bulimia nervosa, eating disorders not otherwise specified (ED-NOS), and obesity, as well as the terms dermatology skin and cutaneous manifestations, with cross-referencing sources. These were combined with our own clinical experience. All relevant publications, including case reports, case series, cohort studies, and histopathologic studies giving at least Level II-3 evidence (evidence from comparisons between times or places with or without the intervention, including dramatic results in uncontrolled experiments), were selected.

CONCLUSION

Forty dermatological signs have been reported in eating disorder patients. Eating disorders have many cutaneous manifestations and cutaneous signs may lead to the diagnosis of an occult eating disorder. The resolution of skin eruptions in eating disorder patients often depends on treatment of the underlying disorder.