Acquired perforating dermatosis: clinicopathological features in twenty-two cases

Acquired Perforating Dermatosis: Clinical and Histopathological Analysis of 95 Patients From One Center

INTRODUCTION

Acquired perforating dermatosis (APD) is a disease group characterized by transepidermal elimination of dermal connective tissue materials such as collagen, elastic fibers, and keratin through the epidermis and observed with pruritic skin lesions.

OBJECTIVES

In this study, we aim to clarify the clinical, histopathological, and dermoscopic characteristics of APD, identify the associated systemic disease, and figure out treatment options.

METHODS

This study was designed as a single-center retrospective, observational, cross-sectional study. We evaluated all accessible APD cases between January 2004 and June 2022 in a tertiary care hospital.

RESULTS

A total of 95 patients with confirmed APD were included in the study. Sixty percent of the patients were women and 40% were men. The median age at diagnosis was 63.1 years (35-85 years). The most common site of lesions was the lower extremities which were detected in 86.31% of the patients. The concomitant systemic disease was identified in 84.21% of the patients. The most common systemic disease was type 2 diabetes mellitus (65.26%). Antihistamines and topical corticosteroids were the most commonly prescribed treatment agents.

CONCLUSIONS

Transepidermal elimination of dermal connective tissue components is a feature of APD and the disease usually presents with pruritic papules and nodules with central keratotic crust or plug. The diagnosis of APD requires a clinical examination and histological investigation. APD is usually accompanied by systemic comorbidities. There are several topical and systemic medications available for APD, however, sometimes the therapy might be challenging.

Evaluation of the histopathological spectrum of skin biopsies in patients with chronic kidney disease: A single-center experience

BACKGROUND AND AIM

Patients with chronic kidney disease (CKD), particularly those with end-stage renal disease (ESRD), frequently experience skin problems. Here, we present and discuss the histopathology results of skin biopsies performed on renal patients at our facility.

MATERIALS AND METHODS

We retrospectively reviewed all histopathological reports and slides of skin biopsies taken from CKD patients for the last 5 years at the Pathology Department of King Saud University Medical City, King Saud University in Riyadh.

DESIGN

This is a retrospective cross-sectional study.

RESULTS

Patients were 19 (43.2%) males and 25 (56.8%) females, with a mean age of 53.4 19.8 years. Diabetic nephropathy, hypertensive nephropathy, and lupus nephritis were the three most common kidney pathologies (59.1%, 11.4%, and 11.4%, respectively). Seventeen patients (38.5%) were receiving hemodialysis. Acquired perforating collagenosis (APC), which was observed in 16 (36.4%) of our patients, was the most prevalent skin pathology, followed by bullous drug reactions in nine (20.5%), leukocytoclastic vasculitis (LCV) in eight (18.2%), calciphylaxis in six (13.6%), and prurigo nodularis in five (11.4%) patients. Erythematous plaques and papules were the most prevalent skin conditions at the time of presentation in 12 patients (27.3%), followed by pruritus in six (13.6%) and ulcerations in six (13.6%) patients. Collected data were analyzed using the Statistical Package for Social Sciences (SPSS) version 26.0.

CONCLUSION

A spectrum of skin conditions may be seen in CKD patients. The quality of life of CKD patients will be significantly improved by identifying and managing these conditions. Pathologists' familiarity with this spectrum is important, as a correct histopathologic diagnosis will lead to a better outcome.

Perforating dermatosis in a patient on haemodialysis successfully treated with nemolizumab

We present a case of perforating dermatosis in a patient with uraemic pruritus who was on haemodialysis and who was successfully treated with nemolizumab, a humanized monoclonal antibody targeted against interleukin-31 receptor A. Nemolizumab may be a treatment option for perforating dermatosis with a uraemic pruritus background. To our knowledge, this is the first report to show the effect of nemolizumab on perforating dermatosis.

Acquired perforating dermatosis: A clinicopathologic study, and the features of dermoscopy and reflective confocal microscopy of 37 cases

BACKGROUND

Acquired perforating dermatosis (APD) is a rare skin condition characterized by degenerated materials eliminated from the dermis. Several retrospective studies on APD have been reported; however, few data are available on Chinese APD and their features on dermoscopy and reflective confocal microscope (RCM) assays.

OBJECTIVE

The aim of this study was to retrospectively evaluate the clinical and histopathologic data of 37 acquired perforating dermatosis cases, and assess their features on dermoscopy and RCM.

METHODS

Thirty-seven APD patients were retrospectively enrolled in our study. We characterized the clinical histopathological features, concomitant diseases, treatment responses, and the dermoscopy and RCM findings.

RESULTS

Pruritus was the most common symptom, with the lower extremities as the most predilection sites (86.5%, n = 32; 91.9%, n = 34, respectively). Concomitant diseases were found in 34 patients (92.6%), among which diabetes mellitus was the most common, followed by thyroid nodules, allergic dermatosis, and chronic renal insufficiency. Dermoscopy and RCM assays were performed in 11 patients. The typical RCM images were hyperreflective cord-like structures from the epidermis to dermis. Dermoscopy features of fully developed lesions showed central ulceration with peripheral hairpin-like or loop-like capillaries with characteristic garland arrangements.

CONCLUSION

APD is an uncommon skin disorder associated with various systemic conditions in Chinese individuals. Thyroid disorders are an overlooked complication and may play an important role in the development of APD. The results of this study indicate that noninvasive dermoscopy and RCM examination are helpful in the rapid diagnosis and early intervention of APD.

Uncharted surgical therapy for acquired perforating dermatoses

Acquired perforating dermatoses represent an uncommon group of chronic papulonodular dermatoses of unknown aetiology, characterized clinically by intense itching; and histopathologically by transepidermal elimination of dermal components. Definitive targeted pharmacological approaches are lacking, and the disease is usually refractory to therapy. We report here a case of rapid remission of acquired perforating dermatosis following simple thymectomy. If a role for the thymus in the pathogenesis of acquired perforating dermatoses was to be established, this could pave the way for a yet uncharted surgical therapy for these debilitating conditions.

Acquired Perforating Dermatosis as a Paraneoplastic Feature: A Case Report, Literature Review, and Novel Association

Kyrle's disease is an uncommon form of acquired transepidermal elimination dermatosis frequently associated with diabetes mellitus and chronic kidney disease. An association with malignancy has been sporadically reported in the literature. Here, we describe the clinical course of a diabetic patient with end-stage renal disease who developed this disorder as a herald to a regionally advanced renal cell carcinoma. We provide a focused literature review and rationale for the definitive categorization of acquired perforating dermatosis as a potential paraneoplastic manifestation of systemic malignancies. Clinicopathological correlation and prompt communication among clinicians for occult malignancies are always warranted. Furthermore, we describe a novel association of one of the subtypes of acquired perforating dermatosis with such malignancies.

Acquired Reactive Perforating Collagenosis Occurring in Association With Nonred Ink Tattoo

ABSTRACT

Perforating dermatosis is a group of skin conditions in which there is transdermal elimination of collagen, elastic fibers, or other dermal connective tissue. Perforating dermatosis can be genetic or acquired, known as acquired perforating dermatosis (APD). When collagen is the primary extruded material in acquired cases, the disease is designated as acquired reactive perforating collagenosis (RPC). We report a case of acquired RPC occurring in a new tattoo. One week after having a new tattoo placed on the left forearm, a 38-year-old gentleman presented to the emergency room with pruritic, crusted plaques and erosions in the regions of red and green inks of the tattoo. Histopathologic examination of the biopsy revealed an ulceration with transepidermal elimination of collagen bundles accompanied by basophilic debris, scattered dermal tattoo pigment, and a superficial to deep perivascular lymphohistiocytic infiltrate with scattered neutrophils and eosinophils. There have been 2 reported cases of tattoo-associated RPC, both in association with red tattoo ink. This present case is the first reported APD to occur in association with nonred tattoo ink. This case reaffirms the conclusions of others in recognizing APD as a potential tattoo-associated complication.

Cutaneous Manifestations of Chronic Kidney Disease, Dialysis and Post-Renal Transplant: A Review

Skin serves as the mirror of underlying systemic problems. The early diagnosis of subtle cutaneous clinical pointers often helps in identifying renal disorders, obviating the delay in diagnosis and treatment. Cutaneous changes can be observed from the beginning of renal impairment until the evolution to terminal stage, in uremia, hemodialysis, and after kidney transplantation. In the review, we have discussed the cutaneous changes, its implicated etiopathogenesis, and their treatment options, as encountered in chronic kidney disease, hemodialysis and post-renal transplantation.

Evaluation of clinicopathological and treatment characteristics of 80 patients with acquired perforating dermatosis

Acquired perforating dermatosis (APD) is a group of a rare dermatological disorder characterized by elimination of dermal connective tissue through epidermis. We aimed to evaluate the characteristics of patients diagnosed with APD and to determine the differences in comorbidities according to subtypes of APD. A retrospective, observational, cross-sectional study was designed. Patients diagnosed with APD between January 2008 and January 2019 were reviewed. Eighty patients were included in the study. 61.2% (n = 49) of the patients were female and 38.8% (n = 31) were male with a mean age of 58.4 ± 12.5 years. 82.5% (n = 66) of the patients were diagnosed with reactive perforating collagenosis (RPC) and 17.5% (n = 14) of perforating folliculitis (PF). The most common concomitant disease was diabetes mellitus (82.5%). 5.0% of the patients had malignancy. The comorbidity rate in RPC group was higher than PF (P < .05). Topical steroid was the most frequently (90.0%) used treatment. Complete response was obtained 55.0% of patients. Exitus was observed in 23.8% (n = 19) of patients in a mean 17.6 ± 25.7 months follow-up period. APD may be associated with many diseases. Comorbidities are more frequent in RPC group. This situation warns us to evaluate patients with RPC in more detail for underlying diseases. High mortality rate related to the underlying systemic diseases suggests being careful in terms of mortality in patients diagnosed with APD.

Paraneoplastische reaktiv perforierende Kollagenose nach transienter akantholytischer Dermatose Grover

Wir berichten über einen 90-jährigen Patienten mit Prostata-Karzinom, bei dem initial ein Morbus Grover bestand, welcher einen Wandel der klinischen Morphe hin zu einer erworbenen reaktiv perforierenden Kollagenose im Kontext eines paraneoplastischen Geschehens zeigte. Die detaillierte Pathogenese der transienten akantholytischen Dermatose Grover sowie der reaktiv perforierenden Kollagenose ist derzeit unklar. Während die reaktiv perforierende Kollagenose sporadisch in den paraneoplastischen Kontext gerückt wird, ist der Morbus Grover bisher nicht als paraneoplastische Erscheinung eingeordnet worden. Wir diskutieren die klinischen und histologischen differenzialdiagnostischen Überlegungen und empfehlen auf Basis dieser Beobachtungen bei Auftreten eines auffälligen Morbus Grover an fakultative Paraneoplasien zu denken.

Reactive Perforating Collagenosis; An Uncontrolled Pruritus That Left You Scratching Your Head

Acquired perforating collagenosis is a rare disease of altered collagen formation that is extruded through the epidermis. It is most commonly seen in patients with microvascular disease including longstanding diabetes and chronic kidney disease (CKD). Due to the rarity of the disease, no large randomized clinical studies have been performed to determine the most efficacious method of treatment. Therefore, most of the knowledge available for treatment is secondary to the information collected through case reports, case series, and retrospective analyses.

In this report, we present the case of a 68-year-old male with history of stage IV CKD who presented with a severe skin rash that was present over his body, including the chest, arms, back, neck, and buttocks. It did not involve the mouth, legs, palms or soles of the feet. He did not have a significant history of diabetes and had been placed on steroids with the concern that this rash may have been secondary to a drug reaction, erythema multiforme, or bullous pemphigoid. Two skin biopsies were performed as the patient was not responding to systemic and topical steroid or oral antibiotic therapy. The final biopsy ultimately revealed a diagnosis of acquired perforating collagenosis.

This is unusual in our case because although our patient had advanced CKD, he was not on dialysis, and had no significant longstanding history of diabetes. Additionally, as the prevalence of CKD is increasing in the population, it becomes more pertinent for providers to be aware of dermatological conditions associated with advanced CKD. This case report seeks to raise awareness of this disease. Furthermore, as the initial skin biopsy was unrevealing, this case also emphasizes the importance of repeating a biopsy to reduce the chance of sampling error.

Acquired reactive perforating collagenosis: A case report and review of the literature

INTRODUCTION

Acquired reactive perforating collagenosis (ARPC) is a rare skin disorder, which is associated with various internal diseases and even malignant neoplasms. A comprehensive knowledge of the concomitant diseases in ARPC patients is helpful to decrease the misdiagnosis. Although the treatment of ARPC is challenging, systemic assessment of existing regimens is not available.

PATIENT CONCERNS

A 50-year-old woman was admitted to the hospital due to cutaneous pruritus and papules all over the body.

DIAGNOSIS

Physical examination showed various sized papules on the lower limbs, buttocks, back, chest, and upper arms with keratotic plugs in the center. Histopathology showed typical collagenous fiber perforation. The diagnosis of ARPC was made according to histopathology, onset age and typical skin lesions. Type 2 diabetes mellitus (T2DM), chronic renal failure (CRF), and hypothyroidism simultaneously presented in this patient.

INTERVENTIONS

This patient was initially treated with topical corticosteroids and oral antihistamines for the skin lesion and pruritus. Medications for glucose control and recovery of renal and thyroid functions were also applied. On the second admission, the combined therapy of topical retinoic acid, Chinese medicinal herb-Qingpeng ointment, and Zinc oxide ointment was added.

OUTCOMES

Papules and pruritus were improved significantly after the second hospitalization.

CONCLUSION

We present a case of ARPC associated with T2DM, CRF, and hypothyroidism, which has rarely been described. There is no standardized treatment for ARPC. Co-administration of two or more agents for dermatologic interventions and treatment for associated diseases may help to improve skin symptoms.

Clinical characteristics and prognosis of acquired perforating dermatosis: A case report

Acquired perforating dermatosis (APD) is an uncommon skin disease characterized by umbilicated hyperkeratotic lesions, and involves the transepidermal elimination of dermal components, including collagen and elastic fibers. The disease can affect patients with systemic disorders, especially those with chronic renal failure or diabetes mellitus. The current paper described four cases of patients with APD and investigated the clinical characteristics and prognosis of APD, as well as its possible link with systemic disorders. In each of the four cases, the patient had systemic disorders before the onset of APD, three had concomitant renal and thyroid disorders and one had hepatocirrhosis secondary to chronic hepatitis C. The results of the present study showed that APD occurred after the transient worsening of the original systemic disease. Furthermore, it was revealed that dermatosis symptoms were alleviated upon remission of the original systemic disorder, without specific dermatological treatment. Dermatosis symptoms improved in all four patients, indicating that the management of the associated systematic diseases was essential for the successful clinical outcomes of APD.

Acquired reactive perforating collagenosis in association with prostate adenocarcinoma, chronic lymphocytic leukemia, and Graves' disease

Acquired reactive perforating collagenosis is a rare skin disorder characterized by the presence of umbilicated pruritic papules and nodules. Transepidermal elimination of altered and perforating bundles of basophilic collagen from the epidermis is a characteristic histologic feature of acquired reactive perforating collagenosis. Along with its well-known association with systemic diseases such as diabetes mellitus, chronic renal failure, and dermatomyositis, there are reports of acquired reactive perforating collagenosis being associated with malignancies. Herein, we present a case of acquired reactive perforating collagenosis associated with chronic lymphocytic leukemia, prostate adenocarcinoma, and Graves's disease. Clinicians are required to be more vigilant in evaluating patients with acquired reactive perforating collagenosis due to its unique association with malignancies and other systemic diseases.

Chronic prurigo: A retrospective study of 168 cases

Chronic prurigo is classified into two clinical subtypes: prurigo nodularis (PN) and prurigo chronica multiformis (PCM) in Japan. In this study, we retrospectively investigated the clinical features of 168 patients with chronic prurigo (103 with PN and 65 with PCM) diagnosed at the Tokyo Medical and Dental University, and compared age, sex, prevalence of comorbidities, blood test results, histology and treatment efficacy in both groups. We found that patients with PCM were significantly older than those with PN. Males were more frequently diagnosed with PCM than females; however, both sexes were similarly affected by PN. Chronic infection was more prevalent in PN, whereas diabetes was more common in PCM. For both subtypes, serum immunoglobulin E levels were elevated above the normal range. However, serum thymus and activation-regulated chemokine/CCL17 levels and the number of blood eosinophils were significantly higher in patients with PCM than in those with PN. Histologically, much higher numbers of CD4⁺ cells than CD8⁺ cells were distributed in the lesions of both subtypes. Eosinophils were distributed predominantly in intracollagenous lesions in PCM but were observed mainly in perivascular lesions in PN. There were no differences in basophil and mast cell distributions in the lesions of the two groups. Treatment efficacy was also similar in both subtypes. Together, both subtypes exhibit inflammation patterns predominantly driven by T-helper 2 cells. With respect to PCM, elevated numbers of blood eosinophils and the recruitment of these cells into intracollagenous areas may be important for pathogenesis.

Acquired perforating dermatosis: clinicopathologic study of a 10-year period at a tertiary teaching hospital

BACKGROUND

Acquired perforating dermatosis (APD) comprises an uncommon group of skin disorders that develop in adulthood in association with systemic diseases. The aim of this study was to characterize clinicopathologic features and treatment outcomes in a series of patients diagnosed with APD.

METHODS

Retrospective study of all patients diagnosed with an APD over a 10-year period (2009-2018) at a tertiary teaching hospital in Lisbon, Portugal.

RESULTS

Fifty-seven patients with APD were identified. Thirty-five patients presented lesions in multiple anatomic areas (61.4%), and the lower limbs were the most common location. Forty-six patients reported pruritus (80.7%), which was classified as severe in 21 of them (36.8%). An underlying systemic disease was identified in 53 patients (93.0%). Diabetes mellitus (DM) and chronic kidney disease (CKD) were the most common associated systemic diseases, but psychiatric disorders, malignancies, and chronic infections were present in a significant number of patients. The combination of topical steroids with antihistamines was the most prescribed initial treatment, but only 37.8% of the patients had a complete response. Acitretin, systemic steroids, and phototherapy were the treatments associated with the best outcome.

CONCLUSION

Acquired perforating dermatosis can be associated with many systemic disorders that have pruritus as a common factor. Chronic viral infections and an occult malignancy should be sought, particularly in the absence of DM and CKD. The management of APD is challenging and is best achieved with the control of the underlying systemic diseases.

Diagnostic histochemistry in non-neoplastic skin diseases

Non-neoplastic skin lesions comprise a sizable group of disorders with variable etiologies and clinical manifestations. They can be grouped into vesiculopustular dermatitides; spongiotic and psoriasiform diseases; lichenoid dermatitides; lymphoid infiltrates of the dermis; granulomatous processes; bullous disorders; vasculopathies; panniculitides; deposition disorders; and defects in maintenance of dermal connective tissue. The use of histochemical methods continues to be an indispensable adjunct to conventional microscopy in the further characterization of such lesions. This review considers that topic.

Acquired Perforating Dermatosis in a Patient on Peritoneal Dialysis: A Case Report and Review of the Literature

Acquired perforating dermatosis (APD) is a debilitating and itchy skin disease. Its diagnosis is based on biopsy and the treatment is not very clear. It is not well established as to how wide spread it is in patients on peritoneal dialysis (PD) and its implications in this population have not been well studied. Here we present a case of APD that developed in a patient on PD. Its pathology and treatment options are reviewed. More studies are needed to assess the prevalence of APD in PD population.

Acquired perforating dermatosis in a patient with chronic renal failure

Perforating dermatoses are a group of skin diseases characterized by transepidermal elimination of dermal material. The disease is divided into two groups: the primary group and the secondary group. The classical or primary perforating dermatoses are subdivided into four types according to the eliminated dermal materials: Kyrle disease, perforating reactive collagenosis, elastosis perforans serpiginosa, and perforating folliculitis. The secondary form is known as acquired perforating dermatosis. The term was proposed in 1989 by Rapini to designate the perforating dermatoses affecting adult patients with systemic disease, regardless of the dermal materials eliminated. This report describes a case of the disease with elimination of collagen and elastic fibers in a patient with chronic renal failure.

Acquired perforating dermatosis: clinicopathological study of 31 cases, emphasizing pathogenesis and treatment

BACKGROUND

Acquired perforating dermatosis (APD) is a rare group of skin disorders of unknown aetiology and pathogenesis and is associated with several systemic diseases.

OBJECTIVE

We review the clinicopathological features, associated systemic diseases and treatment response in a series of APD patients.

METHODS

We conducted a retrospective observational study of all patients histologically diagnosed with APD in Hospital San Jorge (Huesca, Spain) between 2002 and 2014. Demographic and clinical features were collected from medical records. Statistical analyses were carried out using SPSS software (version 20.0; IBM Corp, Armonk, NY, USA).

RESULTS

The study population consisted of 31 patients (19 women and 12 men), with a mean age of 54 years. Reactive perforating collagenosis (n = 15, 45%) was the most common histopathologic type. The most frequently affected area was the lower limbs (66.6%, n = 22), and pruritus was present in 19 patients (61.3%, P = 0.005). Arterial hypertension (30.3%) was the most common associated condition. Five patients were receiving treatment with infliximab when diagnosed with APD. Most patients responded to topical steroids and oral antihistamines (n = 15).

LIMITATIONS

This study is retrospective, and the sample size is limited.

CONCLUSION

Acquired perforating dermatosis is an underdiagnosed dermatosis frequently associated with systemic disorders. Its pathogenesis may involve vascular damage, not only in patients with diabetes, but also in those with arterial hypertension and chronic venous insufficiency. Control of pruritus and underlying extracutaneous disorders, as well as discontinuation of the treatment with biologics, are important aspects of the management of this dermatosis.

Non-Healing Perianal Ulcers in a Healthy Elderly Male: An Unusual Case of Perforating Dermatosis

BACKGROUND

Perforating dermatoses are a rare group of dermatologic conditions characterized by transepidermal elimination of dermal material that can be primary or acquired secondary to systemic disease.

OBJECTIVE

We present an atypical case of perforating dermatosis resembling elastosis perforans serpiginosa (EPS) presenting with perianal ulcers in an elderly male with no systemic disease or medications and outline his successful treatment course.

CONCLUSIONS

Perianal ulcers in an otherwise healthy individual is an unusual presentation for perforating disorders but should be considered in cases not responding to traditional treatment options.

Bullous pemphigoid arising in a patient with acquired perforating dermatosis

A middle-aged Japanese man who had been on haemodialysis treatment for diabetic nephropathy developed multiple itchy papules and nodules, which were histopathologically diagnosed as acquired perforating dermatosis. Two years later he developed oral lesions and subsequently numerous erosive plaques with necrotic crusts on the trunk and extremities. Histopathology of a papule showed a parakeratotic plug intermingled with basophilic, necrotic debris and collagen bundles, along with penetration of collagen bundles across the epidermis and subepidermal blister. Immunoblotting studies revealed IgG autoantibodies in the patient's serum, which reacted with the C-terminal and the NC16a domains of bullous pemphigoid (BP)180, indicating presence of BP. We searched the literature and found no other cases of an autoimmune blistering disease occurring in association with a perforating disorder. Possible injury to the basement membrane zone induced during the process of transepidermal elimination might be involved in the pathogenesis of the pemphigoid disease.

Diabetes mellitus and the skin

Diabetes is a debilitating, life-threatening disease accounting in 2015 for the death of 5 million people worldwide. According to new estimations, 415 million adults currently suffer from the disease, and this number is expected to rise to 642 million by 2040. High glucose blood levels also affect the skin among systemic organs, and skin disorders can often predict the onset of this metabolic disorder. In this review, we address the pathomechanistic effects of diabetes on the skin and give an overview on the most common skin diseases associated with diabetes.

Cutaneous Markers of Systemic Disease in the Lower Extremity

The skin of the lower extremity can be a helpful diagnostic tool for systemic disease. Diabetes, renal disease, genetic disorders, and even cancer can have cutaneous manifestations in the legs and feet; moreover, proper diagnosis can facilitate earlier treatment of these diseases and not only clear up the skin symptoms but also bring about resolution of the systemic disease causing them. Although not comprehensive, this article discusses many of these disorders presenting with integumentary manifestations in the lower extremities. Where appropriate, it also enumerates the treatments involved, both systemic and localized.

Acquired reactive perforating collagenosis: A report of a typical case

BACKGROUND

Reactive perforating collagenosis (RPC) is a rare form of transepithelial elimination, in which altered collagen is extruded through the epidermis. There are 2 types of RPC, acquired RPC (ARPC) and inherited RPC, while the latter is extremely rare. Here we report on 1 case of ARPC.

METHODS

A 73-year-old female was presented with strongly itchy papules over her back and lower limbs for 3 months. She denied the history of oozing or vesiculation. A cutaneous examination showed diffusely distributed multiple well-defined keratotic papules, 4 to 10 mm in diameter, on the bilateral lower limbs and back as well as a few papules on her chest and forearm. Scratching scars were over the resolved lesions while Koebner phenomenon was negative. The patient had a history of type 2 diabetes for 15 years. Laboratory examinations showed elevated blood glucose level. Skin lesion biopsy showed a well-circumscribed area of necrosis filled with a keratotic plug. Parakeratotic cells and lymphocytic infiltration could be seen in the necrosed area. In dermis, sparse fiber bundles were seen perforating the epidermis. These degenerated fiber bundles were notarized as collagen fiber by elastic fiber stain, suggesting a diagnosis of RPC.

RESULTS

Then a diagnosis of ARPC was made according to the onset age and the history of diabetes mellitus. She was treated with topical application of corticosteroids twice a day and oral antihistamine once a day along with compound glycyrrhizin tablets 3 times a day. And the blood glucose was controlled in a satisfying range. Two months later, a significant improvement was seen in this patient.

CONCLUSION

Since there is no efficient therapy to RPC, moreover, ARPC is considered to be associated with some systemic diseases, the management of the coexisting disease is quite crucial. The patient in this case received a substantial improvement due to the control of blood glucose and application of compound glycyrrhizin tablets.

Kyrle's Disease Presenting in an Extensive Distribution along Lines of Blaschko

A 24-year-old lady presented with the complaints of asymptomatic dark, raised lesions over her body since past 4 years. Dermatological examination revealed hyperkeratotic, hyperpigmented papules in a Blaschkoid distribution over trunk and extremities. The hyperkeratotic lesions could be removed leaving behind a small crater. Skin biopsy revealed hyperkeratosis, parakeratosis with epidermal invagination, focal cornified plug with basophilic degenerated material and dyskeratotic keratinocytes. Dermis showed dilated capillaries with moderate amount of perivascular lymphocytic infiltrate and granulomatous lymphocytic infiltrate in the deep dermis. A diagnosis of Kyrle's disease was made and patient was started on oral acitretin 25 mg daily with satisfactory response to therapy. This is the first reported instance of Kyrle's disease occurring in an extensive Blaschkoid distribution.

Kyrle's disease in a patient of diabetes mellitus and chronic renal failure on dialysis

Kyrle's disease (KD) is an acquired perforating dermatosis associated with an underlying disorder such as diabetes mellitus or chronic renal failure. It presents as multiple discrete, eruptive papules with a central crust or plug, often on the lower extremities. A keratotic plug is seen histologically in an atrophic epidermis and may penetrate the papillary dermis with transepidermal elimination of keratotic debris without collagen or elastic fibers. Various therapies have been reported that include cryotherapy, laser therapy, narrow-band ultraviolet B and use of topical or systemic retinoids. Hereby a case of 64-year-old male, a known case of diabetes mellitus, hypertension and chronic renal failure who developed KD is presented.