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Khan AS, Badar Q, Siddiqui K, Hanif S, Lakhan H. Reverse Koebner Phenomenon in a Vitiligo Patient Treated With Radiotherapy. Cureus 2024; 16:e60771. [PMID: 38903331 PMCID: PMC11188008 DOI: 10.7759/cureus.60771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2024] [Indexed: 06/22/2024] Open
Abstract
Radiation-induced hypopigmentation resulting in a skin condition similar to vitiligo is evident in limited studies. In contrast to the typical Koebner phenomenon where new lesions develop at the site of injury, the trauma-induced disappearance of a specific rash in a patient with an already-developed skin disease is seen very rarely. This phenomenon is called "reverse Koebnerization" or "Koebner non-reaction." Herein, we submit a case of a 51-year-old female with already-developed vitiligo who came for treatment for carcinoma of the tongue with radiation therapy. Later, after the treatment, the patient developed a re-pigmentation of her skin.
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Affiliation(s)
- Asma S Khan
- Department of Radiation Oncology, Dr. Ziauddin Hospital, Karachi, PAK
| | - Quratulain Badar
- Department of Radiation Oncology, Dr. Ziauddin Hospital, Karachi, PAK
| | - Kaynat Siddiqui
- Department of Radiation Oncology, Dr. Ziauddin Hospital, Karachi, PAK
| | - Shoaib Hanif
- Department of Radiation Oncology, Dr. Ziauddin Hospital, Karachi, PAK
| | - Hafeez Lakhan
- Department of Radiation Oncology, Dr. Ziauddin Hospital, Karachi, PAK
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Woodruff CM, Botto N. The Role of Patch Testing in Evaluating Delayed Hypersensitivity Reactions to Medications. Clin Rev Allergy Immunol 2022; 62:548-561. [PMID: 35113364 PMCID: PMC9156465 DOI: 10.1007/s12016-022-08924-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/19/2022]
Abstract
Confirming drug imputability is an important step in the management of cutaneous adverse drug reactions (CADR). Re-challenge is inconvenient and in many cases life threatening. We review the literature on ideal patch testing technique for specific CADRs. Testing should be performed approximately 3 months after the resolution of the eruption using standard patch testing techniques. Commercially available patch test preparations are available for a minority of drugs, so in most cases, testing should be performed with the drug at various recommended concentrations and in different vehicles. Testing to all known excipients, such as dyes, vehicles and preservatives is also important. Immunosuppressive medications should be discontinued or down titrated to the lowest tolerable dose to decrease the risk of false negative reactions. We provide an overview of expert recommendations and extant evidence on the utility of patch testing for identifying the culprit drug in common CADRs and for specific drug or drug classes. Overall, there appears to be significant variability in the patch test positivity of different drugs, which is likely the result of factors intrinsic to the drug such as dermal absorption (as a function of lipophilicity and molecular size) and whether the drug itself or a downstream metabolite is implicated in the immune reaction. Drugs with high patch test positivity rates include beta-lactam antibiotics, aromatic anticonvulsants, phenytoin, and corticosteroids, among others. Patch testing positivity varies both as a function of the drug and type of CADR. The sum of the evidence suggests that patch testing in the setting of morbilliform eruptions, fixed drug eruption, acute generalized exanthematous pustulosis, and possibly also drug-induced hypersensitivity syndrome, photoallergic and eczematous reactions may be worthwhile, although utility of testing may vary on the specific drug in question for the eruption. It appears to be of limited utility and is not recommended in the setting of other complex CADR, such as SJS/TEN and leukocytoclastic vasculitis.
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Affiliation(s)
| | - Nina Botto
- University of California San Francisco, San Francisco, CA, USA
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Masuria BL, Baniya GC, Galgali S. Remote Reverse Koebner Phenomenon in Atypical Granuloma Annulare. Indian J Dermatol 2021; 66:551-552. [PMID: 35068514 PMCID: PMC8751699 DOI: 10.4103/ijd.ijd_31_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Bhanwar L Masuria
- Department of Dermatology, Government Medical College, Barmer, Rajasthan, India
| | - Girish C Baniya
- Department of Psychiatry, Government Medical College, Barmer, Rajasthan, India
| | - Shraddha Galgali
- Department of Obstetrics and Gynaecology, Government Medical College, Barmer, Rajasthan, India E-mail:
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Reverse Kőbner response in lichen striatus: the first case described in the literature. Postepy Dermatol Alergol 2018; 35:434-435. [PMID: 30206462 PMCID: PMC6130129 DOI: 10.5114/ada.2018.75840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 06/11/2017] [Indexed: 11/17/2022] Open
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Smith K, Norwood C, Skelton H. Do the Physical and Histologic Features and Time Course in Acute Generalized Exanthematous Pustulosis Reflect a Pattern of Cytokine Dysregulation? J Cutan Med Surg 2016. [DOI: 10.1177/120347540300700102] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Acute generalized exanthematous pustulosis (AGEP) is characterized by fever and an indurated erythematous eruption early, with the development of nonfollicular pinhead sterile pustules on an erythematous background. The eruption progresses and resolves relatively rapidly. Although drugs are believed to be the major etiologic agents, other immune modulators, including infections, heavy metals, and radiation, have been implicated. Objective: The purpose of this study was to document underlying diseases in patients with AGEP and to determine if this data and the histologic features suggested an underlying pattern of immune dysregulation. Methods: Twenty-one patients with new or recurrent episodes of AGEP were questioned concerning underlying diseases. The histopathologic features seen in the biopsy sections and the approximate time of biopsy during the course of their eruptions were recorded. Results: Two patients had a history of psoriasis and one patient had a family history of psoriasis, two patients had diagnoses of sarcoid, two patients had inflammatory bowel disease, one had autoimmune thyroiditis, and one patient had multiple sclerosis. Biopsies done at the onset of the eruption showed marked to moderate papillary dermal edema and a mixed dermal inflammatory infiltrate. Shortly thereafter, biopsies showed spongiform pustules within the epidermis and occasional dyskeratotic cells with residual perivascular dermal edema. Although no definitive vasculitis was seen, there was leukocytoclasis within the dermal infiltrate in the majority of biopsy specimens performed more than 48 hours after the onset of the eruption. Conclusion: The histologic features seen in AGEP and the disease associations suggest that patients who develop this eruption may have an underlying tendency for development of a pattern of immune dysregulation characterized by a T helper-1 cytokine pattern.
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Affiliation(s)
- Kathleen Smith
- Departments of Dermatology and Pathology, University of Alabama, Birmingham, Alabama, USA
| | - Christopher Norwood
- Department of Dermatology, National Naval Medical Center, Bethesda, Maryland, USA
| | - Henry Skelton
- Departments of Dermatology and Pathology, University of Alabama, Birmingham, Alabama, USA
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Five-Year Retrospective Review of Acute Generalized Exanthematous Pustulosis. Dermatol Res Pract 2015; 2015:260928. [PMID: 26783390 PMCID: PMC4689982 DOI: 10.1155/2015/260928] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/22/2015] [Accepted: 11/23/2015] [Indexed: 11/30/2022] Open
Abstract
Background. Acute generalized exanthematous pustulosis (AGEP) is an acute pustular eruption characterized by widespread nonfollicular sterile pustules. The aim of this study is to characterize the etiology, clinical features, laboratory findings, management, and outcome of patients with AGEP in Asians. Patient/Methods. A retrospective analysis was performed on patient who presented with AGEP between August 2008 and November 2012 in a tertiary center in Thailand. Results. Nineteen patients with AGEP were included. AGEP was generally distributed in seventeen patients (89.5%) and localized in two (10.5%). Fever and neutrophilia occurred in 52.6% and 68.4%, respectively. Hepatitis was found up to 26.3%. The most common etiology was drugs (94.7%), comprising of antibiotics (73.6%), proton pump inhibitors (10.5%), nonsteroidal anti-inflammatory drugs (5.3%), and herbal medicine (5.3%). Beta-lactams were the most common causal drug, particularly carbapenems and cephalosporins. This is the first report of Andrographis paniculata as an offending agent for AGEP. We found no differences between various treatment regimens (topical corticosteroid, systemic corticosteroid, and supportive treatment) regarding the time from drug cessation to pustules resolution (P = 0.171). Conclusions. We have highlighted the presentation of AGEP among Asians. We found high association with systemic drugs. Carbapenems were one of the leading culprit drugs. Finally, a localized variant was observed.
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Chen CA, Mikailov A, Faulkner-Jones B, Wu PA. Leukocytoclastic vasculitis sparing a tattoo with halo effect. JAAD Case Rep 2015; 1:269-71. [PMID: 27051750 PMCID: PMC4809221 DOI: 10.1016/j.jdcr.2015.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
| | - Anar Mikailov
- Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Peggy A Wu
- Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Naveen KN, Pai VV, Athanikar SB, Gupta G, Parshwanath HA. Remote reverse Koebner phenomenon in generalized granuloma annulare. Indian Dermatol Online J 2014; 5:219-21. [PMID: 24860769 PMCID: PMC4030362 DOI: 10.4103/2229-5178.131137] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Kikkeri N Naveen
- Department of Dermatology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - Varadraj V Pai
- Department of Dermatology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - Sharatchandra B Athanikar
- Department of Dermatology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - Gaurang Gupta
- Department of Dermatology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - Hassan A Parshwanath
- Department of Pathology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
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Pinal-Fernandez I, Solans-Laqué R. The ‘Sparing Phenomenon' of Purpuric Rash over Tattooed Skin. Dermatology 2013; 228:27-30. [DOI: 10.1159/000356779] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 10/18/2013] [Indexed: 11/19/2022] Open
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Abstract
Stability is taken as the most important parameter before opting for any transplantation technique to treat vitiligo. But, simultaneous donor site repigmentation and depigmentation of grafts at the recipient site has been noted. Similarly donor site depigmentation with complete repigmentation of the recipient area with pigment growing out from each graft has been observed. Successful repigmentation after regrafting in previous punch failure cases has also been reported. Koebner's phenomenon from history (Kp-h) and test grafting were the only available indicators to assess stability. It is quite ironic to note that even after four decades of experience in vitiligo surgery, there seems to be little consensus among workers regarding the optimal required period of stability. Moreover, the exact concept of stability in vitiligo is itself still not transparent and defined beyond doubt Overdependence on KpH or TG may be sometimes misleading in vitiligo. These two reveal the apparent clinical stability only and that may not be the true reflection of stability status of the disease at the molecular level. Antimelanocyte cytotoxic reactivity was observed among CD8+ TCC isolated from perilesional biopsies of patients with vitiligo. An attempt should be made to clearly fathom and define stability, not merely only on clinical ground but along with electron microscopy and histoenzymological analysis of the perilesional and nonlesional skin of vitiligo patients. Probably some growth factors which are responsible for both mitogenic and melanogenic stimulation of melanocytes should also be taken into account. Some serological test(s) could guide us to measure these growth factors.
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Affiliation(s)
- Koushik Lahiri
- From the Pigmentary Disorder Unit, Rita Skin Foundation, GD 381 Sector III, Salt Lake, Kolkata, India
| | - Subrata Malakar
- From the Pigmentary Disorder Unit, Rita Skin Foundation, GD 381 Sector III, Salt Lake, Kolkata, India
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Yadav S, De D, Kanwar AJ. Reverse koebner phenomenon in leukocytoclastic vasculitis. Indian J Dermatol 2011; 56:598-9. [PMID: 22121292 PMCID: PMC3221237 DOI: 10.4103/0019-5154.87169] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- S Yadav
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail:
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Kim HJ, Jung KD, Lee KT, Byun JY, Lee DY, Lee JH, Yang JM, Lee ES. Acute generalized exanthematous pustulosis caused by diltiazem. Ann Dermatol 2011; 23:108-10. [PMID: 21738378 DOI: 10.5021/ad.2011.23.1.108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 05/09/2010] [Accepted: 05/11/2010] [Indexed: 11/08/2022] Open
Abstract
Acute generalized exanthematous pustulosis is clinically characterized by fever, pruritus and an acute pustular eruption. It can be described as having an abrupt onset and then spontaneous resolution occurs shortly after the start of symptoms, and there is usually only a single episode. Most cases have been triggered by the ingestion of drugs. Diltiazem hydrochloride is a calcium channel blocker that is commonly used for treating hypertension and angina. This drug was found to be the responsible agent in our current patient. There have been 9 such case reports in the English medical literature, yet this is the first such report in the Korean medical literature. We present the case of a 51-year-old male who experienced an acute generalized exanthematous pustulosis due to diltiazem hydrochloride and we review the relevant literature.
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Affiliation(s)
- Hyun-Je Kim
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Vitiligo is a result of disrupted epidermal melanization with an undecided etiology and incompletely understood pathogenesis. Various treatment options have resulted in various degrees of success. Various surgical modalities and transplantation techniques have evolved during the last few decades. Of them, miniature punch grafting (PG) has established its place as the easiest, fastest, and least expensive method. Various aspects of this particular procedure have been discussed here. The historical perspective, the instruments, evolution of mini grafting down the ages, and the methodology, advantages, and disadvantages have been discussed. A detailed discussion on the topic along with a review of relevant literature has been provided in this article.
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Affiliation(s)
- Koushik Lahiri
- Department of Dermatology, Apollo Gleneagles Hospital and Pigmentary Disorder Unit, Rita Skin Foundation, India.
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Sidoroff A, Dunant A, Viboud C, Halevy S, Bavinck JNB, Naldi L, Mockenhaupt M, Fagot JP, Roujeau JC. Risk factors for acute generalized exanthematous pustulosis (AGEP)-results of a multinational case-control study (EuroSCAR). Br J Dermatol 2007; 157:989-96. [PMID: 17854366 DOI: 10.1111/j.1365-2133.2007.08156.x] [Citation(s) in RCA: 306] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Acute generalized exanthematous pustulosis (AGEP) is a disease characterized by the rapid occurrence of many sterile, nonfollicular pustules usually arising on an oedematous erythema often accompanied by leucocytosis and fever. It is usually attributed to drugs. OBJECTIVES To evaluate the risk for different drugs of causing AGEP. PATIENTS AND METHODS A multinational case-control study (EuroSCAR) conducted to evaluate the risk for different drugs of causing severe cutaneous adverse reactions; the study included 97 validated community cases of AGEP and 1009 controls. Results Strongly associated drugs, i.e. drugs with a lower bound of the 95% confidence interval (CI) of the odds ratio (OR) > 5 were pristinamycin (CI 26-infinity), ampicillin/amoxicillin (CI 10-infinity), quinolones (CI 8.5-infinity), (hydroxy)chloroquine (CI 8-infinity), anti-infective sulphonamides (CI 7.1-infinity), terbinafine (CI 7.1-infinity) and diltiazem (CI 5.0-infinity). No significant risk was found for infections and a personal or family history of psoriasis (CI 0.7-2.2). CONCLUSIONS Medications associated with AGEP differ from those associated with Stevens-Johnson syndrome or toxic epidermal necrolysis. Different timing patterns from drug intake to reaction onset were observed for different drugs. Infections, although possible triggers, played no prominent role in causing AGEP and there was no evidence that AGEP is a variant of pustular psoriasis.
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Affiliation(s)
- A Sidoroff
- Department of Dermatology and Venereology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
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Gensch K, Hodzic-Avdagic N, Megahed M, Ruzicka T, Kuhn A. Akute generalisierte exanthematische Pustulose bei nachgewiesener Typ-IV-Allergie. Hautarzt 2007; 58:250-2, 254-5. [PMID: 16691372 DOI: 10.1007/s00105-006-1161-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Acute generalized exanthematous pustulosis (AGEP) is characterized by an acute disseminated eruption of multiple, non-follicular pustules. In addition, it can be associated with fever, elevated erythrocyte sedimentation rate, and leukocytosis. The pathogenesis of AGEP is still unknown; however, medications appear a likely cause in most cases. We report on 3 patients with AGEP demonstrating characteristic clinical and histologic features after taking amoxicillin, ampicillin, or diltiazem. All patients had positive patch test reactions to the suspected drugs.
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Affiliation(s)
- K Gensch
- Hautklinik, Heinrich-Heine-Universität Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf.
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Lahiri K, Malakar S, Sarma N, Banerjee U. Repigmentation of vitiligo with punch grafting and narrow-band UV-B (311 nm)--a prospective study. Int J Dermatol 2006; 45:649-55. [PMID: 16796620 DOI: 10.1111/j.1365-4632.2005.02697.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Phototherapy is already established as an effective mode of therapy in vitiligo. An evidence-based study was carried out of the effect of narrow-band (311 nm) ultraviolet-B (NB-UV-B) radiation in 66 surgically treated patients with recalcitrant vitiligo in whom autologous mini-punch grafting was deployed. METHODS A total of 2613 grafts were placed over 108 lesions on 17 regions in 66 individuals (39 females and 27 males) with stable, refractory vitiligo. The age range was 21-48 years. Postsurgically, they were exposed to a suberythemal dose of NB-UV-B (311 nm). Different parameters of surgical repigmentation were documented. RESULTS Successful repigmentation was achieved in 57 (86.36%) cases. The appearance of repigmentation (AOR) time in different regions varied between 14 and 32 days, with an overall average of approximately 20.6 days. Maximum pigment spread (MPS) reached 12 mm with an average of 6.5 mm. The relationship between the donor graft area and area of surgical repigmentation was also calculated. Cobblestoning was the most common (31.8%) complication, but improved with time and/or interference. CONCLUSIONS Punch grafting in combination with phototherapy (NB-UV-B, 311 nm) was found to be an easy, safe, inexpensive, and effective method of repigmenting static and stubborn vitiligo. Different facets of punch grafting-induced and phototherapy-aided surgical repigmentation were taken into consideration. The area of repigmentation, MPS, and relationship between the donor graft area and area of surgical repigmentation were documented.
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Affiliation(s)
- Koushik Lahiri
- Pigmentary Disorder Unit, Rita Skin Foundation, Calcutta, India.
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LAXMISHA CHANDRASHEKAR, KUMARI RASHMI, THAPPA DEVINDERMOHAN. Satellite Repigmentation (Remote Reverse Koebner Phenomenon). Dermatol Surg 2006. [DOI: 10.1097/00042728-200604000-00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hausermann P, Scherer K, Weber M, Bircher AJ. Ciprofloxacin-induced acute generalized exanthematous pustulosis mimicking bullous drug eruption confirmed by a positive patch test. Dermatology 2006; 211:277-80. [PMID: 16205075 DOI: 10.1159/000087024] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2004] [Accepted: 12/20/2004] [Indexed: 11/19/2022] Open
Abstract
We report the case of an 80-year-old woman presenting with ciprofloxacin-induced acute generalized exanthematous pustulosis (AGEP) confirmed by a positive patch test. Cutaneous morphology, course and histological findings were consistent with a definite diagnosis according to the AGEP validation score of the EuroSCAR study group. We point to the rarity of quinolone-induced AGEP and discuss immunological mechanisms, the value of in vivo and in vitro tests as well as the main differential diagnosis. Furthermore, we highlight in this particular case the challenging differentiation from bullous drug eruption.
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Affiliation(s)
- P Hausermann
- Department of Dermatology, University Hospital Basel, Switzerland
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Keller M, Spanou Z, Schaerli P, Britschgi M, Yawalkar N, Seitz M, Villiger PM, Pichler WJ. T Cell-Regulated Neutrophilic Inflammation in Autoinflammatory Diseases. THE JOURNAL OF IMMUNOLOGY 2005; 175:7678-86. [PMID: 16301678 DOI: 10.4049/jimmunol.175.11.7678] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Previous studies of acute generalized exanthematous pustulosis, a peculiar drug hypersensitivity reaction, suggested that CXCL8-producing T cells regulate sterile, polymorphonuclear neutrophil-rich skin inflammations. In this study, we test the hypothesis of whether CXCL8-producing T cells are present in autoinflammatory diseases like pustular psoriasis and Behçet's disease. Immunohistochemistry of normal skin revealed few CD4+ and CD8+ T cells, few CXCL8+ cells, and no neutrophilic infiltration, whereas in acute exacerbations of atopic dermatitis, numerous CD4+ T cells but few CD8+ T cells, neutrophils, or CXCL8+ cells were detected. In contrast, a pronounced infiltration of neutrophils and of predominantly CD4+ T cells was observed in skin biopsies from pustular psoriasis, Behçet's disease, and acute generalized exanthematous pustulosis, with infiltrating T cells strongly positive for CXCL8 and the chemokine receptor CCR6. Skin-derived T cell clones from pustular skin reactions were positive for CCR6 but negative for CCR8 and secreted high amounts of CXCL8 and GM-CSF, often together with IFN-gamma and TNF-alpha after in vitro stimulation. Moreover, some skin-derived T cell clones from Behçet's disease and from pustular psoriasis predominantly produced CXCL8 and GM-CSF, but failed to secrete IL-5 and IFN-gamma. These cells might represent a particular subset as they differ from both Th1 as well as Th2 T cells and are associated with a unique, neutrophil-rich sterile inflammation. Our findings suggest that CXCL8/GM-CSF-producing T cells may orchestrate neutrophil-rich pathologies of chronic autoinflammatory diseases like pustular psoriasis and Behçet's disease.
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Affiliation(s)
- Monika Keller
- Division of Allergology, Clinic of Rheumatology and Clinical Immunology/Allergology, Inselspital, University of Bern, Bern, Switzerland
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Malakar S, Lahiri K. Spontaneous repigmentation in vitiligo: why it is important. Int J Dermatol 2005. [DOI: 10.1111/j.1365-4632.2005.02657.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Girardi M, Duncan KO, Tigelaar RE, Imaeda S, Watsky KL, McNiff JM. Cross-Comparison of Patch Test and Lymphocyte Proliferation Responses in Patients With a History of Acute Generalized Exanthematous Pustulosis. Am J Dermatopathol 2005; 27:343-6. [PMID: 16121058 DOI: 10.1097/01.dad.0000160982.75176.6c] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
An adverse cutaneous reaction to a systemically administered drug may rarely manifest as acute generalized exanthematous pustulosis (AGEP). Several recent reports have documented positive patch test results in patients with a history of AGEP, while two have demonstrated drug-specific in vitro lymphocyte proliferative responses. These findings suggest that drug-specific T cells mediate AGEP. We describe two patients with a history of AGEP who each demonstrated positive patch test results specific for the inciting drug: Patient #1 to the antibiotic metronidazole, and Patient #2 to the calcium channel-blocker diltiazem. Histologic examination of biopsy specimens taken from the patch test sites of these patients revealed spongiotic dermatitis and perivascular lymphocytes consistent with a delayed-type hypersensitivity reaction, rather than demonstrating subcorneal neutrophilic pustules more typical of AGEP. In vitro testing by measuring peripheral T cell proliferative responses to chemically purified drug correlated with the clinical response. In a direct cross-comparison, patch test results were shown to correlate with in vitro lymphocyte proliferative responses in two patients with a history of AGEP to different drugs. These findings provide additional evidence that the pathogenesis of AGEP involves a T cell-mediated immune response.
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Affiliation(s)
- Michael Girardi
- Departments of Dermatology, Yale University School of Medicine, New Haven, CT 06520, USA
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Beltraminelli HS, Lerch M, Arnold A, Bircher AJ, Haeusermann P. Acute generalized exanthematous pustulosis induced by the antifungal terbinafine: case report and review of the literature. Br J Dermatol 2005; 152:780-3. [PMID: 15840114 DOI: 10.1111/j.1365-2133.2005.06393.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Cutaneous drug reactions occur with a frequency of 1-8% and can be higher for certain classes of drugs. They can range from mild morbilliform eruptions to more severe forms such as drug-hypersensitivity syndrome, toxic epidermal necrolysis or anaphylaxis. Acute generalized exanthematous pustulosis (AGEP) is considered to be a clinical reaction pattern, which is induced in over 90% of the cases by systemic drugs. It is a rare presentation of an adverse drug reaction most frequently triggered by anti-infectious drugs. A high proportion of these cases have been attributed to aminopenicillins and macrolides. We report a terbinafine-induced AGEP in a 68-year-old male confirmed by lymphocyte stimulation in vitro, and review the published cases induced by antimycotic drugs with special emphasis on terbinafine-triggered cases.
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Affiliation(s)
- H S Beltraminelli
- Department of Dermatology, Kantonsspital Basel, University of Basel, Petersgraben 4 CH-4031 Basel, Switzerland.
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Schaerli P, Britschgi M, Keller M, Steiner UC, Steinmann LS, Moser B, Pichler WJ. Characterization of Human T Cells That Regulate Neutrophilic Skin Inflammation. THE JOURNAL OF IMMUNOLOGY 2004; 173:2151-8. [PMID: 15265952 DOI: 10.4049/jimmunol.173.3.2151] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
It is unknown whether neutrophilic inflammations can be regulated by T cells. This question was analyzed by studying acute generalized exanthematous pustulosis (AGEP), which is a severe drug hypersensitivity resulting in intraepidermal or subcorneal sterile pustules. Recently, we found that drug-specific blood and skin T cells from AGEP patients secrete high levels of the potent neutrophil-attracting chemokine IL-8/CXCL8. In this study, we characterize the phenotype and function of CXCL8-producing T cells. Supernatants from CXCL8(+) T cells were strongly chemotactic for neutrophils, CXCR1, and CXCR2 transfectants, but not for transfectants expressing CXCR4, CX3CR1, human chemokine receptor, and RDC1. Neutralization experiments indicated that chemotaxis was mainly mediated by CXCL8, but not by granulocyte chemotactic protein-2/CXCL6, epithelial cell-derived neutrophil attractant-78/CXCL5, or growth-related oncogene-alpha,beta,gamma/CXCL1,2,3. Interestingly, approximately 2.5% of CD4(+) T cells in normal peripheral blood also produced CXCL8. In addition to CXCL8, AGEP T cells produced large amounts of the monocyte/neutrophil-activating cytokine GM-CSF, and the majority released IFN-gamma and the proinflammatory cytokine TNF-alpha. Furthermore, apoptosis in neutrophils treated with conditioned medium from CXCL8(+) T cells could be reduced by 40%. In lesional skin, CXCL8(+) T cells consistently expressed the chemokine receptor CCR6, suggesting a prominent role for CCR6 in early inflammatory T cell recruitment. Finally, our data suggest that CXCL8-producing T cells facilitate skin inflammation by orchestrating neutrophilic infiltration and ensuring neutrophil survival, which leads to sterile pustular eruptions found in AGEP patients. This mechanism may be relevant for other T cell-mediated diseases with a neutrophilic inflammation such as Behçet's disease and pustular psoriasis.
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MESH Headings
- Acute Disease
- Animals
- B-Lymphocytes/immunology
- CD4-Positive T-Lymphocytes/drug effects
- CD4-Positive T-Lymphocytes/immunology
- CD4-Positive T-Lymphocytes/metabolism
- CX3C Chemokine Receptor 1
- Cell Survival
- Cells, Cultured/immunology
- Cells, Cultured/metabolism
- Chemokines, CXC/analysis
- Chemokines, CXC/physiology
- Chemotaxis, Leukocyte/drug effects
- Chemotaxis, Leukocyte/physiology
- Culture Media, Conditioned/pharmacology
- Drug Eruptions/etiology
- Drug Eruptions/immunology
- Exanthema/chemically induced
- Exanthema/immunology
- Humans
- Intercellular Signaling Peptides and Proteins/analysis
- Intercellular Signaling Peptides and Proteins/physiology
- Interferon-gamma/metabolism
- Interleukin-4/metabolism
- Ionomycin/pharmacology
- Membrane Proteins/genetics
- Mice
- Neutrophils/drug effects
- Neutrophils/physiology
- Receptors, CXCR
- Receptors, CXCR4/genetics
- Receptors, Chemokine/genetics
- Receptors, G-Protein-Coupled/genetics
- Receptors, Interleukin-8A/genetics
- Receptors, Interleukin-8B/genetics
- Skin/immunology
- Skin Diseases, Vesiculobullous/chemically induced
- Skin Diseases, Vesiculobullous/immunology
- T-Lymphocyte Subsets/immunology
- T-Lymphocyte Subsets/metabolism
- Tetradecanoylphorbol Acetate/pharmacology
- Transfection
- Tumor Necrosis Factor-alpha/metabolism
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Affiliation(s)
- Patrick Schaerli
- Division of Allergology, Clinic of Rheumatology and Clinical Immunology/Allergology, Inselspital, and Theodor-Kocher-Institute, University of Bern, Switzerland
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Cholez C, Trechot P, Schmutz JL, Faure G, Bene MC, Barbaud A. Maculopapular rash induced by diltiazem: allergological investigations in four patients and cross reactions between calcium channel blockers. Allergy 2003; 58:1207-9. [PMID: 14616146 DOI: 10.1034/j.1398-9995.2003.00222.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- C Cholez
- Fournier Hospital, University Hospital of Nancy, Department of Dermatology, 36, quai de la bataille, 54000 Nancy, France
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Britschgi M, Pichler WJ. Acute generalized exanthematous pustulosis, a clue to neutrophil-mediated inflammatory processes orchestrated by T cells. Curr Opin Allergy Clin Immunol 2002; 2:325-31. [PMID: 12130947 DOI: 10.1097/00130832-200208000-00006] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Circumstantial evidence exists that certain neutrophilic inflammatory processes are regulated by T cells, but how this occurs is not well understood. The present review presents data on how T cells may directly orchestrate a neutrophilic inflammation by specific release of the neutrophil-attracting chemokine CXCL8 (formerly known as interleukin-8). RECENT FINDINGS Acute generalized exanthematous pustulosis (AGEP) is an uncommon cutaneous eruption that is most often provoked by drugs, by acute infections with enteroviruses, or by mercury. It is characterized by acute, extensive formation of nonfollicular sterile pustules on an erythematous background, fever and elevated numbers of blood neutrophils. Involvement of T cells in drug-induced AGEP was suggested by positive patch tests and lymphocyte transformation tests. Moreover, drug-specific CD4+ and CD8+ T cells could be isolated and propagated in vitro from patch test sites and blood from AGEP patients. Their main characteristic is a high level of CXCL8 production. SUMMARY T cells are involved even in some neutrophil-rich inflammatory responses, and they may orchestrate the immune reaction directly by high CXCL8 production or indirectly via interleukin-17 production, which induces CXCL8 production in various cell types. AGEP serves as a valuable model for characterizing T cells with a particular function--namely production of CXCL8--leading to neutrophilic inflammation. It is tempting to speculate that elucidation of this pathomechanism will help to improve our understanding of similar neutrophilic eruptions (e.g. pustular psoriasis) and may reveal new targets for pharmacotherapeutic interventions in such diseases.
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Affiliation(s)
- Markus Britschgi
- Division of Allergology, Clinic for Rheumatology and Clinical Immunology/Allergology, PKT2 D572, Inselspital, University of Bern, CH-3010 Bern, Switzerland
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Britschgi M, Steiner UC, Schmid S, Depta JP, Senti G, Bircher A, Burkhart C, Yawalkar N, Pichler WJ. T-cell involvement in drug-induced acute generalized exanthematous pustulosis. J Clin Invest 2001; 107:1433-41. [PMID: 11390425 PMCID: PMC209321 DOI: 10.1172/jci12118] [Citation(s) in RCA: 243] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Acute generalized exanthematous pustulosis (AGEP) is an uncommon eruption most often provoked by drugs, by acute infections with enteroviruses, or by mercury. It is characterized by acute, extensive formation of nonfollicular sterile pustules on erythematous background, fever, and peripheral blood leukocytosis. We present clinical and immunological data on four patients with this disease, which is caused by different drugs. An involvement of T cells could be implied by positive skin patch tests and lymphocyte transformation tests. Immunohistochemistry revealed a massive cell infiltrate consisting of neutrophils in pustules and T cells in the dermis and epidermis. Expression of the potent neutrophil-attracting chemokine IL-8 was elevated in keratinocytes and infiltrating mononuclear cells. Drug-specific T cells were generated from the blood and skin of three patients, and phenotypic characterization showed a heterogeneous distribution of CD4/CD8 phenotype and of T-cell receptor Vbeta-expression. Analysis of cytokine/chemokine profiles revealed that IL-8 is produced significantly more by drug-specific T cells from patients with AGEP compared with drug-specific T cells from patients that had non-AGEP exanthemas. In conclusion, our data demonstrate the involvement of drug-specific T cells in the pathomechanism of this rather rare and peculiar form of drug allergy. In addition, they indicate that even in some neutrophil-rich inflammatory responses specific T cells are engaged and might orchestrate the immune reaction.
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Affiliation(s)
- M Britschgi
- Clinic of Rheumatology and Clinical Immunology/Allergology, Inselspital, Bern, Switzerland
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