Allopurinol in the treatment of acquired reactive perforating collagenosis

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.

Case for diagnosis. Hyperpigmented and excoriated papules and nodules in a diabetic patient

Reactive perforating collagenosis is a rare perforating dermatosis clinically characterized by intensely pruritic hyperpigmented papules, plaques, and nodules with a central keratotic plug. Histopathology reveals transepidermal elimination of collagen fibers. Its pathophysiology is still under investigation, but the acquired form has been linked to systemic conditions such as diabetes mellitus and chronic kidney disease. However, it has also been described as a paraneoplastic syndrome. The authors present the case of a 65-year-old diabetic patient in which a myeloproliferative neoplasm was suspected.

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.

Elastosis perforans serpiginosa induced by d-penicillamine treated with cyclosporine and allopurinol

Elastosis perforans serpiginosa (EPS) is a rare condition within the group of perforating dermatoses. It is characterized by the synthesis of anomalous elastic fibers that are eliminated through perforating channels (transepidermal elimination). It is classified into three subtypes. One of them is drug-induced by prolonged treatment with d-penicillamine. This drug is a heavy metal chelator used to treat diseases such as rheumatoid arthritis, cystinuria, and Wilson's disease. Years of treatment with d-penicillamine at high doses are required for developing EPS, with occasional slow regression after drug withdrawal. There is no established treatment for EPS, with described cases using various treatment options such as corticoids, retinoids, tazarotene, cryotherapy, imiquimod, photodynamic therapy, electrosurgery, and CO2 laser among others with inconsistent results. We present a case of EPS induced by d-penicillamine with favorable response to cyclosporine and allopurinol in a patient with a history of Wilson's disease since childhood. They maybe considered as possible therapeutic options not described so far for an entity with variable response to current treatments. We highlight the extensive involvement of the case with progression, despite the suspension of d-penicillamine and failure to previous treatments with photodynamic therapy and retinoids.

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.