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Cuperus E, Bygum A, Boeckmann L, Bodemer C, Bolling MC, Caproni M, Diociaiuti A, Emmert S, Fischer J, Gostynski A, Guez S, van Gijn ME, Hannulla-Jouppi K, Has C, Hernández-Martín A, Martinez AE, Mazereeuw-Hautier J, Medvecz M, Neri I, Sigurdsson V, Suessmuth K, Traupe H, Oji V, Pasmans SGMA. Proposal for a 6-step-approach for differential diagnosis of neonatal erythroderma. J Eur Acad Dermatol Venereol 2022; 36:973-986. [PMID: 35238435 PMCID: PMC9310754 DOI: 10.1111/jdv.18043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 12/15/2021] [Accepted: 02/03/2022] [Indexed: 11/28/2022]
Abstract
The broad differential diagnosis of neonatal erythroderma often poses a diagnostic challenge. Mortality of neonatal erythroderma is high due to complications of the erythroderma itself and the occasionally severe and life-threatening underlying disease. Early correct recognition of the underlying cause leads to better treatment and prognosis. Currently, neonatal erythroderma is approached by a case by case basis. The purpose of this scoping review was to develop a diagnostic approach in neonatal erythroderma. After a systematic literature search in Embase (January 1990 - May 2020, 74 cases of neonatal erythroderma were identified, and 50+ diagnoses could be extracted. Main causes were the ichthyoses (40%) and primary immunodeficiencies (35%). Congenital erythroderma was present in 64% (47/74) of the cases, predominantly with congenital ichthyosis (11/11; 100%), Netherton syndrome (12/14, 86%), and Omenn syndrome (11/23, 48%). Time until diagnosis ranged from 102 days to 116 days for cases of non-congenital erythroderma and congenital erythroderma respectively. Among the 74 identified cases a total of 17 patients (23%) died within a mean of 158 days and were related to Omenn syndrome (35%), graft versus host disease (67%), and Netherton syndrome (18%). Disease history and physical examination are summarized in this paper. Age of onset and a collodion membrane can help to narrow the differential diagnoses. Investigations of blood, histology, hair analysis, genetic analysis and clinical imaging are summarized and discussed. A standard blood investigation is proposed and the need for skin biopsies with Lympho-Epithelial Kazal-Type related Inhibitor-staining is highlighted. Overall, this review shows that diagnostic procedures narrow the differential diagnosis in neonatal erythroderma. A 6-step flowchart for the diagnostic approach for neonatal erythroderma during the first month of life is proposed. The approach was made with the support of expert leaders from international multidisciplinary collaborations in the European Reference Network Skin-subthematic group Ichthyosis.
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Affiliation(s)
- E Cuperus
- Erasmus MC University Medical Center Rotterdam-Sophia Children's Hospital, Department of Dermatology, Center of Pediatric Dermatology, The Netherlands
| | - A Bygum
- University of Southern Denmark, Clinical Institute, Denmark & Odense University Hospital, Department of Clinical Genetics, Denmark
| | - L Boeckmann
- University Medical Center Rostock. Clinic and Policlinic for Dermatology and Venereology. Rostock, Germany
| | - C Bodemer
- Department of Dermatology, Reference Center for Genodermatoses (MAGEC), Necker-Enfants Malades Hospital (AP-HP5), Paris-Centre University, Imagine Institute, INSERM, Paris, France
| | - M C Bolling
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Groningen, the Netherlands
| | - M Caproni
- Department of Health Sciences, Section of Dermatology, USL Toscana Centro, Rare Diseases Unit, University of Florence, Florence, Italy
| | - A Diociaiuti
- Dermatology Unit and Genodermatosis Unit, Genetics and Rare Diseases Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - S Emmert
- University Medical Center Rostock. Clinic and Policlinic for Dermatology and Venereology. Rostock, Germany
| | - J Fischer
- Institute of Human Genetics, Medical Faculty and Medical Center, University of Freiburg, Freiburg, Germany
| | - A Gostynski
- Department of Dermatology, Maastricht University Medical Center, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S Guez
- Pediatrics Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - M E van Gijn
- University of Groningen, University Medical Center Groningen, Department of Genetics, Groningen, the Netherlands
| | - K Hannulla-Jouppi
- Department of Dermatology and Allergology, University of Helsinki and Helsinki University Central Hospital, HUS, Helsinki, Finland
| | - C Has
- Department of Dermatology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - A E Martinez
- Pediatric Dermatology, NHS Foundation Trust, Great Ormond Street, London, UK
| | - J Mazereeuw-Hautier
- Dermatology Department, Reference Center for Rare Skin Diseases, Toulouse, France
| | - M Medvecz
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - I Neri
- Dermatology - IRCCS Policlinico di Sant'Orsola - Department of Experimental, Diagnostic and Specialty Medicine (DIMES) Alma Mater, Studiorum University of Bologna, Bologna, Italy
| | - V Sigurdsson
- University Medical Center Utrecht and Utrecht University, Department of Dermatology, Utrecht, The Netherlands
| | - K Suessmuth
- Department of Dermatology, University Hospital of Münster, Münster, Germany
| | - H Traupe
- Department of Dermatology, University Hospital of Münster, Münster, Germany
| | - V Oji
- Department of Dermatology, University Hospital of Münster, Münster, Germany
| | - S G M A Pasmans
- Erasmus MC University Medical Center Rotterdam-Sophia Children's Hospital, Department of Dermatology, Center of Pediatric Dermatology, The Netherlands
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Plachouri K, Georgiou S. Paraneoplastic erythroderma: an insight on the existing data. Int J Dermatol 2020; 59:1429-1436. [DOI: 10.1111/ijd.14970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 04/17/2020] [Accepted: 05/04/2020] [Indexed: 11/29/2022]
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Eczematous dermatitis in primary immunodeficiencies: A review of cutaneous clues to diagnosis. Clin Immunol 2020; 211:108330. [DOI: 10.1016/j.clim.2019.108330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/24/2019] [Accepted: 12/27/2019] [Indexed: 11/23/2022]
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Ghariani Fetoui N, Boussofara L, Hmida D, Mokni S, Mekki N, Ben Mustapha I, Belajouza C, Ghariani N, Picard C, Denguezli M. [Ichtyosiform erythroderma revealing a severe combined immunodeficiency]. Ann Dermatol Venereol 2020; 147:131-134. [PMID: 31973905 DOI: 10.1016/j.annder.2019.09.611] [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] [Received: 01/20/2019] [Revised: 05/15/2019] [Accepted: 09/27/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Severe combined immunodeficiency (SCID) is a the most severe form of primary immunodeficiency and is highly heterogeneous. We report an atypical form of SCID revealed by exfoliative erythroderma. PATIENTS AND METHODS A 3-month-old boy, born to consanguineous parents, was admitted to the dermatology department with exfoliative erythroderma associated with eczematous patches and alopecia of the scalp, eyelashes, and eyebrows, but with no lymphadenopathy or hepatosplenomegaly. He displayed chronic diarrhea and recurrent infection since birth. A complete blood count showed marked leukocytosis with eosinophilia and lymphocytosis. These clinical and biological findings improved partly with topical steroids. The patient no longer had erythroderma and showed regrowth of hair, eyelashes and eyebrows. The subsequent CBC showed less marked eosinophilia with mild lymphopenia and no leukocytosis. Immunoglobulin levels were undetectable. Primary immunodeficiency was discussed. Immunological investigations concluded on a diagnosis of T-B-NK+ SCID. Mutation analysis revealed a homozygous c.1338C>G (pCys446Trp) mutation in the RAG2 gene. Hematopoietic stem cell transplantation is planned in the near future. CONCLUSION This case illustrates atypical T-B-NK+ SCID revealed by severe exfoliative erythroderma in a 3-month-old boy with RAG2 gene mutation. Neonatal erythroderma must be considered a warning sign of primary immunodeficiency requiring immediate immunological phenotyping as well as genetic testing for a definitive diagnosis.
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Affiliation(s)
- N Ghariani Fetoui
- Service de dermatologie, hôpital universitaire Farhat Hached, Sousse, Tunisie.
| | - L Boussofara
- Service de dermatologie, hôpital universitaire Farhat Hached, Sousse, Tunisie
| | - D Hmida
- Laboratoire d'immunobiologie des infections, institut Pasteur de Tunis, Tunisie
| | - S Mokni
- Service de dermatologie, hôpital universitaire Farhat Hached, Sousse, Tunisie
| | - N Mekki
- Laboratoire de cytogénétique, hôpital universitaire Farhat Hached, Sousse, Tunisie
| | - I Ben Mustapha
- Laboratoire de cytogénétique, hôpital universitaire Farhat Hached, Sousse, Tunisie
| | - C Belajouza
- Service de dermatologie, hôpital universitaire Farhat Hached, Sousse, Tunisie
| | - N Ghariani
- Service de dermatologie, hôpital universitaire Farhat Hached, Sousse, Tunisie
| | - C Picard
- Institut Imagine, Paris Descartes-Sorbonne, cité universitaire de Paris, 75015 Paris, France; Centre d'étude des déficits immunitaires (CEDI), hôpital Necker-Enfants malades, Assistance publique-Hôpitaux de Paris (AP-HP), 75015 Paris, France
| | - M Denguezli
- Service de dermatologie, hôpital universitaire Farhat Hached, Sousse, Tunisie
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Ott H. Guidance for assessment of erythroderma in neonates and infants for the pediatric immunologist. Pediatr Allergy Immunol 2019; 30:259-268. [PMID: 30702169 DOI: 10.1111/pai.13032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 11/24/2018] [Accepted: 11/26/2018] [Indexed: 12/25/2022]
Abstract
Neonatal and infantile erythroderma (NIE) represents the common clinical phenotype of heterogeneous diseases ranging from benign and transient skin conditions to fatal multiorgan disorders. NIE regularly demands a comprehensive diagnostic workup in a multiprofessional setting, especially if newborns and young infants with the disease develop a failure to thrive and concomitant infectious, neurologic, or metabolic complications. By obtaining a detailed medical history and performing a thorough clinical examination, targeted diagnostic steps can be scheduled for most affected children. If NIE occurs in the early neonatal period, lesional skin biopsy and histology are often indicated. Likewise, if monogenic skin or immunologic diseases are suspected, genetic testing with customized panels of potentially underlying genes is mandatory. Of note, if acute symptoms such as severe infections, metabolic acidosis, or seizures occur, rapid microbiologic and metabolic investigations are warranted to rule out immunodeficiency and inborn errors of metabolism.
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Affiliation(s)
- Hagen Ott
- Division of Pediatric Dermatology, Children's Hospital AUF DER BULT, Hannover, Germany.,Epidermolysis bullosa Centre, Hannover, Germany
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Patrizi A, Neri I, Ricci G, Cipriani F, Ravaioli GM. Advances in pharmacotherapeutic management of common skin diseases in neonates and infants. Expert Opin Pharmacother 2017; 18:717-725. [PMID: 28429969 DOI: 10.1080/14656566.2017.1316371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION neonatal and infantile skin diseases are frequently encountered in the clinical practice and represent worldwide a socioeconomic issue. They encompass a wide range of acquired or congenital conditions, including infections, vascular lesions and inflammatory diseases and can present with different degrees of severity, leading in some cases to dramatic complications. Areas covered: In this paper we report the most recent evidences on the management of some common skin diseases in neonates and infants. Hemangiomas, viral, fungal and bacterial infections, omphalitis, atopic and seborrhoeic dermatitis, napkin disease will be treated and discussed. Expert opinion: The majority of the dermatologic alterations in neonates are physiological, transient and do not require any treatment, thus the parents can be reassured about the good prognosis. However, in some cases, serious conditions must be excluded. In particular neonatal and infantile infections should be promptly recognized and properly managed, to avoid severe complications. The therapeutic options include traditional and, although few, innovative medical treatments, which will be carefully taken into consideration by the expert Dermatologists and Paediatricians.
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Affiliation(s)
- Annalisa Patrizi
- a Dermatology, Department of Experimental, Diagnostic and Specialty Medicine , Sant'Orsola-Malpighi Hospital, University of Bologna , Bologna , Italy
| | - Iria Neri
- a Dermatology, Department of Experimental, Diagnostic and Specialty Medicine , Sant'Orsola-Malpighi Hospital, University of Bologna , Bologna , Italy
| | - Giampaolo Ricci
- b Division of Pediatrics, Department of Medical and Surgical Sciences , Sant'Orsola-Malpighi Hospital, University of Bologna , Bologna , Italy
| | - Francesca Cipriani
- b Division of Pediatrics, Department of Medical and Surgical Sciences , Sant'Orsola-Malpighi Hospital, University of Bologna , Bologna , Italy
| | - Giulia Maria Ravaioli
- a Dermatology, Department of Experimental, Diagnostic and Specialty Medicine , Sant'Orsola-Malpighi Hospital, University of Bologna , Bologna , Italy
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Burden‐Teh E, Thomas K, Ratib S, Grindlay D, Adaji E, Murphy R. The epidemiology of childhood psoriasis: a scoping review. Br J Dermatol 2016; 174:1242-57. [DOI: 10.1111/bjd.14507] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2016] [Indexed: 12/13/2022]
Affiliation(s)
- E. Burden‐Teh
- Centre of Evidence Based Dermatology University of Nottingham Nottingham U.K
| | - K.S. Thomas
- Centre of Evidence Based Dermatology University of Nottingham Nottingham U.K
| | - S. Ratib
- Centre of Evidence Based Dermatology University of Nottingham Nottingham U.K
| | - D. Grindlay
- Centre of Evidence Based Dermatology University of Nottingham Nottingham U.K
| | - E. Adaji
- Division of Epidemiology & Public Health University of Nottingham Nottingham U.K
| | - R. Murphy
- Sheffield Teaching Hospitals NHS Foundation Trust Sheffield U.K
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Campione E, Diluvio L, Terrinoni A, Orlandi A, Latino MP, Torti C, Pietroleonardo L, Botti E, Chimenti S, Bianchi L. Severe erytrodermic psoriasis in child twins: from clinical-pathological diagnosis to treatment of choice through genetic analyses: two case reports. BMC Res Notes 2014; 7:929. [PMID: 25520159 PMCID: PMC4300562 DOI: 10.1186/1756-0500-7-929] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 11/25/2014] [Indexed: 02/05/2023] Open
Abstract
Background Pediatric erythroderma is a severe cutaneous disorder, which may pose diagnostic and therapeutic challenges. Psoriasis, ichthyoses, atopy, seborrhoeic dermatitis, pityriasis rubra pilaris, infections, metabolic diseases, drugs reaction, may cause erythroderma. The therapy should be tailored on each aetiology, if possible. The biochemical and metabolic imbalance should be corrected, and particular attention should be paid to the psychosocial behavior often related to this disfiguring disease. Case presentation Two 3 year-old Caucasian twins have been suffering from an unmanageable erythroderma since the age of 8 months. The diagnosis of psoriasis, already remarkably expressed in the father’s family in three cases of fraternal twins, could be enforced for several points. Major histocompatibility complex, class I, Cw*06 was detected in both twins; we found no transglutaminase-1, no corneodesmosin, nor any Interleukin-36 receptor antagonist gene mutations. We performed a cutaneous histology, positive immunostaining for Lympho-epithelial Kazal-type-related inhibitor, dermoscopy and reflectance confocal microscopy. The twins had previously received systemic steroids, short cycles of low-dosage ciclosporine, followed by etanercept at the dosage of 0,8 mg/kg, without reliable results. Cyclosporine was then reconsidered at a dosage of 5 mg/kg/day with close blood monitoring. After three months of treatment, consistent clearing and significant improvement of their social and psychological behaviour were achieved. After over one year of continuous therapy with cyclosporine, the twins have still maintained the result obtained. Conclusion Pediatric erythroderma may pose a great challenge as a potentially life-threatening condition causing extreme distress in children, parents and pediatricians. In young patients it is mandatory to establish correct clinical and instrumental procedures, possibly supplemented by genetic analyses such as those we required, in order to determine an effective and safe therapy in terms of cost-benefit and put patients and family in the best condition to perform common daily activities.
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Affiliation(s)
- Elena Campione
- Department of Dermatology, Tor Vergata University of Rome, Rome, Italy.
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Abstract
Cutaneous manifestations are common in primary immune deficiency diseases, affecting between 40 % and 70 % of patients with diagnosed primary immune deficiency. Skin infections characterize many primary immune deficiencies, but there are also frequent noninfectious cutaneous manifestations seen in many of these disorders, including eczematous lesions, erythroderma, cutaneous granulomas, dysplasia of skin, hair, and nails, autoimmune conditions, and frank vasculitis. For the patient with suspected primary immunodeficiency, much can be inferred by evaluating the presenting cutaneous findings, including various infectious susceptibilities, presence of atopy, and evidence of impaired or overactive inflammatory response. The skin manifestations of primary immune deficiency diseases are often early or heralding findings of the underlying immunologic disease. Therefore, awareness of associations between skin findings and immune deficiency may aide in the early detection and treatment of serious or life-threatening immunologic defects. This review summarizes the common skin manifestations of primary immune deficiency diseases and provides the reader with a differential diagnosis of primary immune defects to consider for the most common skin manifestations.
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Bender AM, Levy ML. The child with recalcitrant dermatitis: when to worry? Dermatol Clin 2013; 31:223-8. [PMID: 23557651 DOI: 10.1016/j.det.2012.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Dermatitis is a frequent cause for referral to the pediatric dermatologist. In this article, a brief overview is given of common childhood dermatoses as well as some rarer dermatoses that may give the clinician cause for concern. Widespread scaling and erythema, described as erythroderma, are a cause of frustration for patients, families, and their physician(s). Both unusual and common skin disorders can present in this fashion. Just as recognizing common dermatoses is important, it is also important to recognize when a dermatitis fails to fit the common pattern and may prompt further investigation.
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Affiliation(s)
- Anna M Bender
- Division of Pediatric Dermatology, Department of Dermatology, Johns Hopkins University, 200 North Wolfe Street, Suite 2107, Baltimore, MD 21287, USA
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Sampaio ALSB, Mameri ÂCA, Vargas TJDS, Ramos-e-Silva M, Nunes AP, Carneiro SCDS. Dermatite seborreica. An Bras Dermatol 2011; 86:1061-71; quiz 1072-4. [DOI: 10.1590/s0365-05962011000600002] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 03/24/2011] [Indexed: 01/14/2023] Open
Abstract
A dermatite seborreica é uma doença eritêmato-escamativa de caráter crônico-recidivante que acomete entre 1 e 3% da população geral dos Estados Unidos. Possui dois picos de incidência - o primeiro, durante os três primeiros meses de vida, e o segundo, a partir da puberdade, atingindo seu ápice entre os 40 e 60 anos de idade. Os indivíduos HIV positivos têm maior prevalência da doença, que apresenta maior intensidade e tendência à refratariedade ao tratamento. Doenças neurológicas e outras doenças crônicas também estão associadas ao desenvolvimento da dermatite seborreica. Como mecanismo fisiopatogênico, reconhece-se que o fungo Malassezia sp., presente na pele de indivíduos suscetíveis, leve a uma irritação não-imunogênica a partir da produção de metabólitos à base de ácidos graxos insaturados deixados na superfície cutânea. Este artigo faz uma revisão da literatura sobre dermatite seborreica, com ênfase nos aspectos imunogenéticos, formas clínicas e tratamento.
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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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Ott H, Hütten M, Baron JM, Merk HF, Fölster-Holst R. Neonatal and infantile erythrodermas. J Dtsch Dermatol Ges 2008; 6:1070-85; quiz 1086. [DOI: 10.1111/j.1610-0387.2008.06891.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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