Management of refractory pityriasis rubra pilaris: challenges and solutions

Resolution of Pityriasis rubra pilaris induced ectropion with oral dexamethasone. A case report

An 82-year-old male presented with generalised Pityriasis rubra pilaris (PRP) managed initially by dermatology team. The patient did not respond to first- and second-line treatment, including oral acitretin, steroid creams, and methotrexate, and developed bilateral cicatricial ectropion, for which he was referred to oculoplastic team for surgical management. A head injury resulting in subacute subdural haematoma, managed with a week course of low dose oral dexamethasone, resulted in the improvement of his skin condition and complete resolution of the cicatricial ectropion within a few weeks. Thus, systemic treatment of PRP with oral dexamethasone may be considered sooner in the treatment of cicatricial ectropion in similar cases.

An Institution Based Cross-Sectional Observational Aetiological Study Correlating the Clinico-Pathological Findings in Patients Presenting with Acquired Palmoplantar Keratoderma

Background

Palmoplantar keratoderma (PPK) is a heterogeneous group of hereditary or acquired disorders characterised by excessive epidermal thickening of the palms and soles. Proper knowledge about the aetiology of the disease and clinico-demographic profile helps in planning management and predicting outcomes.

Aims and Objective

To determine the prevalence of different dermatoses and describe their clinico-histological correlation in acquired palmoplantar keratoderma.

Materials and Methods

An institution-based cross-sectional study conducted after obtaining Ethics-Committee permission and consent from participants. Patients of any age or gender presenting with acquired PPK were recruited. The calculated sample size was 67 by using the prevalence rate (p) of 22.2%, allowable error (L) of 10%, the confidence level of 95% (z = 1.96), and an infinite population size of 20,000. Patients were evaluated by taking demographic and clinical data in a pre-designed case record form, necessary laboratory investigations and histopathological examination that wereevaluated by three blinded experts. The pooled data were analysed with statistical software.

Results

Among the 67 participants, Psoriasis was diagnosed clinically in 39 (58.2%) and histologically in 7 (10.4%), Lichen planus (LP) clinically in 16 (23.9%) and histologically in 9 (13.4%), Pityriasis rubra pilaris (PRP) in 8 (11.9%) patients clinically and 7 (10.4%) histologically and Hyperkeratotic eczema (HKE) in 4 (6%) clinically and 43 (64.2%) histopathologically. There was very poor inter-rater agreement (Kappa = 0.148, SE 0.0047, 95% CI 0.057 to 0.24). The clinico-pathological correlation was found to be agreeable in 17.9% Psoriasis, 56.2% LP and 87.5% PRP. HKE was commonly misdiagnosed as Psoriasis in 65.1% of patients.

Conclusion

Hyperkeratotic lesions of the palm and sole often present with overlapping clinical features and a skin biopsy has to be done to aid in diagnosis.

Limitation

Stratification of the clinical expertise of clinicians was done during the analysis.

Misdiagnosed Pityriasis Rubra Pilaris Successfully Managed With Isotretinoin: A Case Series

Being a rare inflammatory, hyperproliferative dermatosis, diagnosing pityriasis rubra pilaris (PRP) can be a challenge to many clinicians. Our case reports aim to demonstrate that PRP is frequently diagnosed and managed as atopic dermatitis (AD) and that distinguishing features on dermoscopy, and biopsy can help diagnose this rare disease. The study also aims to show that PRP can be successfully treated with Isotretinoin. Our case series aims to describe two cases of PRP, initially diagnosed as AD and managed with topical corticosteroids. Being the first case series in the literature to describe the incidences of diagnosing PRP as AD portrays the significance of utilizing dermoscopy and biopsy as tools to confirm this diagnosis for appropriate management. Although PRP is a rare diagnosis, dermoscopy and biopsy can help confirm the disease. Management with isotretinoin will most likely have successful outcomes in those patients.

A Study of Clinical, Dermoscopic and Histopathological Correlation in Follicular Keratotic Diseases: Preliminary Observations in 30 Cases

Context:

Follicular keratotic disorder is an abnormal keratinization affecting the follicular orifices and clinically characterized by hyperkeratotic follicular papules affecting various sites. Dermoscopy is a non-invasive diagnostic tool and differentiates closely resembling diseases as well as possibly prevents need for an invasive biopsy.

Aim:

This study was aimed to find the correlation between clinical, dermoscopic and histopathological findings in follicular keratotic diseases and to establish the dermoscopic criteria in the diagnosis of primary follicular keratotic diseases.

Materials and Methods:

This was a hospital-based prospective cross-sectional study of 30 consecutive patients clinically diagnosed with follicular keratotic diseases, irrespective of age and duration of the disease.

Results:

The study consisted of 30 patients with a mean age of 19.57 ± 9.69 years. The most common primary follicular keratotic disease observed was phrynoderma and secondary follicular keratotic disease was follicular lichen planus (lichen planopilaris). The predominant dermoscopic finding among all the follicular keratotic diseases was perifollicular scaling 29 (96.7%) followed by keratotic plug 28 (93.3%). The most common histopathological feature was dilated follicular infundibulum 22 (73.3%) followed by follicular plug 15 (50%) and dermal perivascular infiltration 22 (73.3%). The clinical and dermoscopic features showed a significant statistical association with the histopathological findings.

Conclusion:

Dermoscopy is a simple, non-invasive diagnostic tool that helps in differentiating and diagnosing the closely resembling follicular keratotic diseases.

Germline CBM-opathies: From immunodeficiency to atopy

Caspase recruitment domain (CARD) protein-B cell CLL/lymphoma 10 (BCL10)-MALT1 paracaspase (MALT1) [CBM] complexes are critical signaling adaptors that facilitate immune and inflammatory responses downstream of both cell surface and intracellular receptors. Germline mutations that alter the function of members of this complex (termed CBM-opathies) cause a broad array of clinical phenotypes, ranging from profound combined immunodeficiency to B-cell lymphocytosis. With an increasing number of patients being described in recent years, the clinical spectrum of diseases associated with CBM-opathies is rapidly expanding and becoming unexpectedly heterogeneous. Here we review major discoveries that have shaped our understanding of CBM complex biology, and we provide an overview of the clinical presentation, diagnostic approach, and treatment options for those carrying germline mutations affecting CARD9, CARD11, CARD14, BCL10, and MALT1.

Use of Biologics in Pityriasis Rubra Pilaris Refractory to First-Line Systemic Therapy: A Systematic Review [Formula: see text]

Pityriasis rubra pilaris (PRP) is an uncommon, inflammatory, papulosquamous skin disease. Treatment of PRP is challenging as the disease is often refractory to conventional therapies, such as retinoids and methotrexate. There has been an increasing number of studies reporting the successful use of biologic therapy in patients with PRP; however, the data on the efficacy and safety are limited. Our objective was to evaluate the existing evidence for utilizing biologics, whether alone or in combination with established systemic therapies, in patients with treatment-resistant PRP. We systematically reviewed evidence within Medline and Pubmed databases between January 1, 2000, to March 31, 2019. Articles consisted of patients diagnosed with PRP who have failed to respond sufficiently to first-line systemic therapies, or who had comorbidities that precluded their use. In total, 363 unique articles were identified, 56 of which were considered relevant to the clinical question. Of the 56 articles highlighted, 35 met the inclusion criteria and were limited to case series and case studies. Therapy with biologics was found to be successful for both monotherapy (81.1% [27/33]) and when used in combination with existing systemic therapies (87.5% [14/16]). The existing evidence suggests that biologics may be regarded as a tool for PRP treatment alone or in combination therapy with existing treatments, although large-scale randomized clinical trials are necessary to better assess their efficacy and safety.

The management and genetic background of pityriasis rubra pilaris: a single-centre experience

BACKGROUND

Pityriasis rubra pilaris (PRP) is a rare chronic inflammatory dermatosis with multifactorial aetiology. It is known that particular caspase recruitment domain family member 14 (CARD14) gene mutations are associated with familial PRP and certain forms of psoriasis. Additionally, few data are available about the role of CARD14 gene variants in sporadic PRP. The clinical picture is variable for the different types of PRP, therefore choosing the adequate treatment is often difficult, furthermore there are no specific guidelines for therapy.

OBJECTIVE

Our aim was to survey the efficacy of the applied therapies and to screen the CARD14 gene variants in our PRP patients.

METHODS

In this retrospective study, patients diagnosed with PRP between 2006 and 2016 at our clinic were involved. Besides the follow-up study of the treatments, the genetic analysis of CARD14 gene was performed.

RESULTS

We analysed 19 patients, among whom 17 were diagnosed with type I, one with type III, and one with type V PRP. The majority of the patients were successfully treated with acitretin in combination with systemic corticosteroids, and the remaining patients were treated with other systemic therapies with diverse effects. The genetic screening of CARD14 gene revealed two previously described mutations (rs114688446, rs117918077) and six polymorphisms (rs28674001, rs2066964, rs34367357, rs11653893, rs11652075, rs2289541). Ten of 19 patients carried different CARD14 genetic variants either alone or in combination.

CONCLUSION

Based on our experience, we propose that acitretin and an initial combination of short-term systemic corticosteroid therapy could be a successful treatment option for PRP. Although we identified several CARD14 variants in almost half of our cases, we did not find a correlation between the therapeutic response and the genetic background. Our data support the previous observation that CARD14 genetic variants are not specific to PRP, although they may indicate chronic inflammation.

Pityriasis Rubra Pilaris With Extensive Follicular Acantholysis Resembling Pemphigus Vulgaris: A Case Report

Pityriasis rubra pilaris (PRP) is a rare, chronic, heterogeneous, papulosquamous inflammatory dermatosis of unknown etiology. Although erythematous scaly patches characterize the classic presentation of PRP, a broad range of clinical presentations has been reported. Histologically, PRP is characterized by psoriasiform acanthosis with alternating orthokeratosis and parakeratosis and rarely small acantholytic foci. In this article, we report a patient who presented with diffuse erythroderma and extensive acantholysis mimicking pemphigus vulgaris histologically.

Biologics for pityriasis rubra pilaris treatment: A review of the literature

Pityriasis rubra pilaris (PRP) is a rare inflammatory papulosquamous skin disease that is often refractory to conventional therapies. The off-label use of biologics, such as anti-tumor necrosis factor, anti-interleukin (IL) 12/IL-23, and anti-IL-17 agents, has been proven successful in the past 2 decades for PRP treatment. Our aim was to analyse the literature for the use of biologics in PRP treatment. We conducted a review by performing PubMed and ClinicalTrials.gov searches. Sixty-eight articles met our selection criteria and are herein discussed. Out of 86 PRP patients, the vast majority were treated with anti-tumor necrosis factor, anti-IL-12/IL-23, or anti-IL-17 biologics, either alone or in combination therapy. A marked-to-complete response was observed in 50%-78%, a partial response in 11%-25%, and no or poor response in 11%-25%. This review has several limitations, including small sample sizes and the lack of shared study design criteria. In some instances, PRP might have resolved spontaneously. Further, the presence of concomitant therapy or the lack of detailed data on previous treatments, makes it difficult to strictly define a therapeutic role per se of specific biologics in PRP. This review shows that biologics may be regarded as a tool for PRP treatment alone or in combination therapy although clinical trials are needed to better assess their efficacy and safety.