[Cutaneous fissures in collodion babies: incidence and treatment]

BACKGROUND

Collodion baby syndrome (CBS) is a pathological cutaneous condition present at birth and is due to the presence of a thick horny layer of the skin. Exfoliation begins early with drying and cracking of the collodion membrane. The cracks may either remain superficial or they may be deeper and affect the superficial dermis, in which case, fissures form. This study of CBS provides information on the clinical aspect of fissures, their incidence, their pathological consequences and therapeutic approaches.

PATIENTS AND METHODS

In our study, diagnosis of CBS was made clinically based on the presence of neonatal collodion membrane. Identification of typical cracks and fissures was made on clinical examination and their site, chronology and consequences were assessed. Routine bacteriological examination of fissures was performed twice weekly on a clinically infected specimen taken from an inguinal fissure. The therapeutic protocol for CBS has been validated and involved use of sterile vaseline oil. Fissures were disinfected.

RESULTS

Cracks are a constant feature. Fissures were seen in 20 of the 33 cases of CBS with the site of predilection being large skinfolds. Morphine was necessary for pain relief in three cases. Pathogenic organisms were isolated in all cases of inflammatory fissures. Dissemination of septicaemia was confirmed in four cases and the offending organism was isolated from the inflammatory fissures in all cases. Candida albicans was present in all cases of fissures in the inguinal folds or between the buttocks. Keratotic adhesions occurred after healing of digital fissures and a surgical procedure was required in this event.

DISCUSSION

Fissures are lesions occurring secondarily to cracks and they were seen in 20 of the 33 cases of CBS. These secondary lesions are rarely mentioned in the literature and the reasons for this oversight are discussed. Fissures are potential complications in all states of CBS, particularly where the collodion is thick. Topical treatment does not prevent transformation of cracks to fissures in all cases. Where fissures are not inflammatory, routine prescription of oral antibiotics is not always necessary. Regular bacteriological monitoring at several different fissure sites allows selection of appropriate antibiotic therapy. The main therapeutic goal in CBS is to treat painful fissures and superinfection.

Bébé collodion révélant une trichothiodystrophie confondue avec un syndrome de Netherton : réévaluation d’une erreur de diagnostic

BACKGROUND

Reassessment of a previously published case report allowed correction of a misdiagnosis: a neonatal aspect of collodion baby with pilar dystrophy is evocative of trichothiodystrophy and not Netherton syndrome. Other than this published erroneous case report, there have been no other publications concerning Netherton syndrome mentioning this neonatal collodion baby status. It may be clearly stated that Netherton syndrome never begins with collodion baby status.

PATIENTS AND METHODS

The re-examined case concerned a girl with collodion baby syndrome presenting pilar dystrophy. At 2 years, an inaccurate diagnosis of Netherton syndrome was made despite the fact that the pilar dystrophy involved trichorrhexis nodosis with ichthyosis vulgaris. At 8 years, 13 years and 17 years, the diagnosis of trichothiodystrophy was posited in the presence of tiger-striping of the hair visible in polarised light together with low capillary cystine at only 51 p. 100 of the normal level. The phenotype obtained comprised ichthyosis, pilar dystrophy, low IQ and stunted growth of at least two standard deviations despite tall parents. There was no evidence of photosensitivity.

DISCUSSION

The state of baby collodion may or may not herald trichothiodystrophia. A review of 72 articles containing a clinical description of signs at the onset of trichothiodystrophy showed a relationship in 22 cases between this condition and collodion baby syndrome. The collodion baby phenotype is of moderate intensity with little or no facial dysmorphia. Microscopic examination of hair is alone able to orient diagnosis towards trichothiodystrophy. Microscopic examination of the hair with inspection under polarised light is essential to confirm an aetiological diagnosis of collodion baby. Collodion baby syndrome never leads to Netherton syndrome. In some cases, however, it may herald trichothiodystrophy.

Ulcérations cervicofaciales liées à un foyer infectieux dentaire chez l'enfant

In children, chronic cervicofacial ulceration related to dental infection is rare. Thus the diagnosis is often late and the treatment is consequently delayed. We report 2 new cases.

CASES REPORT

A 13-year-old boy presented with a 1-year history of chronic and suppurative ulceration on the right cheek. Culture was positive for actinomycetes. In spite of a prolonged and miscellaneous antibiotherapy, the lesion recured. The ulceration healed after the eradication of infection on a right superior molar. A 12-year-old girl presented with a right sub-mandibular ulceration, which appeared 3 months before. This lesion did not respond to penicillinotherapy given during 3 months. An infection on a right inferior molar was diagnosed on a tomodensitometry. 3 months after the tooth extraction, the ulceration healed without recurrence.

CONCLUSION

These cases emphasize the interest to look for a dental infection at the origin of chronic cervicofacial lesion.

Olmsted syndrome: report of two new cases and literature review

Olmsted syndrome is a rare keratinization disorder; 18 cases have been published so far. It associates a mutilating cogenital palmoplantar keratoderma with periorificial erythematokeratotic lesions. We report herein two new unrelated male children with Olmsted syndrome (OS), one of whom was studied by light and electron microscopy. Our histological, immunohistochemical, and ultrastructural findings suggest that this disease is related to epidermal hyperproliferation. We present herein a review of the twenty cases published so far and discuss the major clinicopathological and genetic features of this disease.

Hailey-Hailey disease is caused by mutations in ATP2C1 encoding a novel Ca(2+) pump

Hailey-Hailey disease (HHD) is an autosomal dominant skin disorder characterized by suprabasal cell separation (acantholysis) of the epidermis. Previous genetic linkage studies localized the gene to a 5 cM interval on human chromosome 3q21. After reducing the disease critical region to <1 cM, we used a positional cloning strategy to identify the gene ATP2C1, which is mutated in HHD. ATP2C1 encodes a new class of P-type Ca(2+)-transport ATPase, which is the homologue for the rat SPLA and the yeast PMR1 medial Golgi Ca(2+)pumps and is related to the sarco(endo)plasmic calcium ATPase (SERCA) and plasma membrane calcium ATPase (PCMA) families of Ca(2+)pumps. The predicted protein has the same apparent transmembrane organization and contains all of the conserved domains present in other P-type ATPases. ATP2C1 produces two alternative splice variants of approximately 4.5 kb encoding predicted proteins of 903 and 923 amino acids. We identified 13 different mutations, including nonsense, frameshift insertion and deletions, splice-site mutations, and non-conservative missense mutations. This study demonstrates that defects in ATP2C1 cause HHD and together with the recent identification of ATP2A2 as the defective gene in Darier's disease, provide further evidence of the critical role of Ca(2+)signaling in maintaining epidermal integrity.

Mutations of PTEN in patients with Bannayan-Riley-Ruvalcaba phenotype

We report three new mutations in PTEN, the gene responsible for Cowden disease in five patients with Bannayan-Riley-Ruvalcaba syndrome from three unrelated families. This finding confirms that Cowden disease, a dominant cancer predisposing syndrome, and Bannayan-Riley-Ruvalcaba syndrome, which includes macrocephaly, multiple lipomas, intestinal hamartomatous polyps, vascular malformations, and pigmented macules of the penis, are allelic disorders at the PTEN locus on chromosome 10q.

[Scleroderma-like patch on the thigh in infants after vitamin K injection at birth: six observations]

INTRODUCTION

Texier's disease or pseudosclerodermatous reaction after intramuscular injection of vitamin K1 is well known in adults although only 1 report of a case in a newborn was found in the literature. We report 6 cases.

CASE REPORTS

Six infants (4 boys, 2 girls) developed "peau d'orange" skin lesions after the age of 6 months which was localized in the lower third of the medial aspect of the thigh. Initial rapid locoregional extension was followed by stabilization and then regression. In all 6 cases, histology showed lesions of the fascia and/or the deep hypoderma associated with variable mononuclear inflammatory infiltration and hyalin fibrosis. When performed, immunological studies (complement fixation, search for autoantibodies) were always negative or normal. No visceral involvement was found.

DISCUSSION

A pseudosclerodermatous lesion of the lower third of the thigh occurred in 6 infants at the site of an intramuscular injection of vitamin K1 administered at birth. The history, clinical manifestations, histology and outcome of these cases are compatible with the diagnosis of Texier's disease. We discuss the role of the solvent in the Roche vitamin K1 injection. The pathogenesis of this side effect remains unknown.

CONCLUSION

Texier's disease in infants after injection of vitamin K1 at birth is a stereotypic dermatosis. Diagnosis is based on history and clinical presentation. The causal effect of injectable vitamin K1 should be entertained whenever pseudosclerodermatous lesions are observed in a young child.

Refined genetic mapping of the darier locus to a <1-cM region of chromosome 12q24.1, and construction of a complete, high-resolution P1 artificial chromosome/bacterial artificial chromosome contig of the critical region

Darier disease (DD) (MIM 124200) is an autosomal dominant skin disorder characterized by loss of adhesion between epidermal cells and by abnormal keratinization. We present linkage analysis showing, in four families, key recombination events that refine the location of the DD locus on chromosome 12q23-24.1 to a region of <1 cM. We have constructed a YAC/P1 artificial chromosome (PAC)/bacterial artificial chromosome (BAC)-based physical map that encompasses this refined DD region. The map consists of 35 YAC, 69 PAC, 16 BAC, and 2 cosmid clones that were ordered by mapping 54 anonymous sequence-tagged sites. The critical region is estimated to be 2.4 Mb in size, with an average marker resolution of 37.5 kb. The refinement of the critical interval excludes the ALDH2, RPL6, PTPN11, and OAS genes, as well as seven expressed sequence tags (ESTs) previously mapped in the DD region. The three known genes (ATP2A2, PPP1CC, and SCA2) and the 10 ESTs mapped within the critical region are not obvious candidates for the DD gene. Therefore, this detailed integrated physical, genetic, and partial transcript map provides an important resource for the isolation of the DD gene and, possibly, other disease genes.

The naevoid basal-cell carcinoma syndrome (Gorlin syndrome) is a chromosomal instability syndrome

The Gorlin syndrome, or naevoid basal-cell carcinoma syndrome (NBCS) is an autosomal dominant cancer prone disease (at risk of multiple basal cell carcinomas, and other malignant or benign proliferations). We have previously reported data from peripheral blood lymphocytes of patients with this condition, showing a significant level of spontaneous chromatid and chromosome rearrangements and an overall lengthening of the cell cycle. In this paper, we confirm this disease to be a chromosome instability syndrome from studies on fibroblasts of 5 patients. Spontaneous chromosomal rearrangements, an increased frequency of sister chromatid exchanges and a slowing of the cell cycle were found, compared to age-matched control material. There was also an increased sensitivity to aberration production by mechlorethamine in patient fibroblasts. The chromosome instability we found was not restricted to a given cell lineage, but appears to be part of the general condition of this syndrome. The recently discovered gene responsible for Gorlin syndrome, PTC (or PTCH), encodes a transmembrane protein with yet poorly known functions. However, the demonstration of Gorlin syndrome as a chromosome instability syndrome suggests that this protein has a role in DNA maintenance, repair and/or replication.

[Febrile toxiderma in children]

Febrile cutaneous drug reactions in the child represent 6% of paediatric hospitalizations for dermatologic reasons. Diagnosis is difficult, for both infectious diseases and drug allergy can induce the same skin reaction. The same eruption can correspond to several drug-induced reactions. In a single child, there may be several causes of skin eruption and several drugs inducing similar cutaneous reactions. Clinical diagnosis and the method of clinical imputability lead to diagnosis. Paraclinical methods are of limited interest. Symptomatic treatment is begun on emergency admission. Upon identification, the responsible drug can be withheld and the authorities responsible for post-marketing surveillance can be notified.

[Hemifacial atrophy. A case report associated with linear scleroderma]

The authors report a case of facial hemiatrophy, secondary to linear scleroderma, and review the various possible causes of facial hemiatrophy. The various treatments proposed to correct facial hemiatrophy are described. The advantages and disadvantages of each technique together with their indications as a function of the severity of the lesions are then discussed. Free flap currently appears to be the treatment of choice in severe forms and the main question concerns the choice of flap. The authors prefer an inverted dermal fat flap because of its advantages (absence of long-term ptosis, better facial contours) and the absence of laparotomy.

[Lesions of the hand and upper limb in children with linear scleroderma. Therapeutic approach in two cases]

The authors report two cases of linear scleroderma (LS) in children, located on the hand and upper limb. LS is rare in children (245 cases reported in the literature). LS initially consists of a sclero-inflammatory lesion, followed by a sclero-atrophic lesion, characterized by its linear arrangement selective involvement of one limb, and its local and regional effects. The onset is generally marked by development of a sclerodermic line, sometimes associated with extra-cutaneous lesions. The active phase of the disease is long (mean: 3 years), with multiplication or extension of the initial lesions (frontal "coup de sabre", hemiatrophy). Systemic complications are rare (Raynaud's phenomenon, glomerulonephritis...). Regional complications (retractile myositis, articular stiffness, shortening) are frequent, severe and persistent (75% of cases). Treatment has not been definitively standardized, but should include:--systemic corticosteroids, quite active in early forms. --physiotherapy and external prostheses during the early and active phase, and finally surgical correction of orthopaedic sequelae. They are often difficult operations, with partial results, but functionally very useful, especially with the addition of cutaneous expansion. Our 2 cases demonstrate the considerable functional improvement achieved in the hand.

Evidence of chromosomal instability in the lymphocytes of Gorlin basal-cell carcinoma patients

The Gorlin syndrome, or naevoid basal-cell carcinoma syndrome (NBCS) is an autosomal dominant disease. It has been suspected for long that this cancer prone disease (multiple basal-cell carcinomas; other malignant or benign proliferations) is a chromosome instability syndrome. We previously reported a lengthening in the cell cycle of lymphocytes from two patients with NBCS. With a larger sample (n = 7), we confirm this disease to be a chromosome instability syndrome, although clearly, expression of this characteristic can vary between patients: (1) spontaneous chromatid breaks occurred more often in a subset of the patients; (2) spontaneous micronuclei were found more frequently in NBCS than in the controls; (3) we confirm the cell cycle to be affected in this disease. As these results were obtained on lymphocytes--a cell lineage not affected in NBCS manifestations--the chromosome instability we found would appear to be part of the general condition of this syndrome.

Shave excision and phenol peeling of generalized verrucous epidermal nevus

BACKGROUND

Generalized verrucous epidermal nevus is a disorder characterized by papulokeratotic and verrucous plaques involving a large area of the skin. This disease has been associated with a number of malformations including osseous, neurological, and ophthalmologic anomalies.

OBJECTIVE

To report clinical and histologic features of verrucous epidermal nevus that developed in association with osseous anomalies, and the surgical technique employed.

METHODS

Treatment consisted of razor blade shaving using a dermatome, followed by phenol peeling on the pigmented areas of the face.

RESULTS

The described procedure resulted in a cure of the verrucous epidermal nevus with good cosmetic outcome.

CONCLUSION

Generalized verrucous epidermal nevus can be successfully managed by surgical excision using a razor blade mounted on a dermatome.

Checks for chromosomal instability in Gorlin and non-Gorlin basal-cell carcinoma patients

The naevoid basal-cell carcinoma syndrome (NBCCS) is an autosomal dominant disorder with multiple basal-cell carcinomas, an increased risk for other neoplasms, and various malformations. Chromosome instability has been implicated in the pathogenesis of this syndrome, but these reports are somewhat contradictory. We have investigated five patients, two with confirmed NBCCS and three suspected. No evidence for chromosome instability was found in lymphocytes at three sample times after stimulation using metaphase aberration analysis, sister-chromatid exchange (SCE) in second division cells, or micronuclei. A significant lengthening of the cell cycle was found for the two confirmed NBCCS patients, but not for the suspected cases.

Aplasia cutis congenita of the scalp in an infant exposed to valproic acid in utero

We report a newborn with isolated aplasia cutis congenita of the scalp whose mother was treated with valproic acid during pregnancy. Aplasia cutis congenita has been described in infants exposed in utero to antithyroid drugs, but has not been related to other tetratogenic agents. Fetal exposure to valproic acid is known to increase the risks of spina bifida and other midline defects. Interestingly, aplasia cutis congenita of the scalp is regarded as a cutaneous marker for neural dysraphism. However, this defect of the scalp and valproic acid intake during pregnancy may be a random association and similar observations are needed to suggest causality.

Repeated skin expansion for excision of congenital giant nevi in infancy and childhood

Three children with giant pigmented nevi were treated by repeated tissue expansion. Five flaps were expanded twice, and one flap was expanded three times. The delay between expansions was 4 to 15 months (mean 9 months). With full inflation, vascularization of the flap remained good. However, every new expansion decreased flap length by 50 percent. Overall results with this technique, especially in two infants with giant pigmented nevi involving respectively 20 and 40 percent of the body surface, have been most impressive. Only one major complication has occurred: erosion of the skin caused by a fold of the expander envelope resulting in exposure of the expander. This technique improves the early surgical management of giant pigmented nevi and may provide better long-term functional and cosmetic results.

Recurrent ctb(7)(q31.3) and possible laminin involvement in a neonatal cutis laxa with a Marfan phenotype

A 6-week-old girl presented with cutis laxa, emphysema, heart anomalies and a diaphragmatic hernia. She died at 22 weeks. A recurrent ctb(7)(q31.3) was found and the laminin gene was suspected to be involved in the disease. Anti-human laminin antiserum showed that this protein was absent from the skin. This case, together with 17 other similar cases, could represent a new type of connective tissue disease.

[Hereditary prolidase deficiency in 2 sisters with therapy-resistant leg ulcers]

Two sisters with hereditary prolidase deficiency are presented. Recurrent and painful leg ulcers are the predominant feature.

[Stevens-Johnson syndrome and pulmonary infection by Mycoplasma pneumonia (author's transl)]

The case-report of an eleven-year-old boy presenting with the association of Stevens-Johnson syndrome and pulmonary symptoms is studied. The course of the disease covered two distinct periods since a one-month interval occurred between the two cutaneo-mucous and pulmonary episodes. Mycoplasma Pneumoniae infection was confirmed by positive seroconversion. The child recovered without sequelae. Indirect immunofluorescence transitorily showed anticytoplasmic antibodies directed against basal epidermic cells. These antibodies were not fixed on the lesions as shown by direct immunofluorescence. The possible connexion between Stevens-Johnson syndrome, Mycoplasma Pneumoniae infection and anticytoplasmic antibodies is under discussion.

[Pemphigus foliaceus in a child. A two years follow-up under steroid. An immunosuppression therapy (author's transl)]

The observation of pemphigus foliaceus out of endemic zone in a six-year-old child is reported. The rate of anti-ICS antibodies is very high (1/6,400). The direct immunofluorescence shows the common aspect of epidermic network between the cells. Fluorescence basement membrane has been found with monospecific anti-C3 sera, and after remission with the monospecific anti-IgG sera. The clinical, histological and immunological relationship between pemphigus foliaceus in its sporadic and endemic forms and pemphigus erythematosus are discussed. The clinical and immunological regression is obtained by association of prednisone and immunodepressive therapy. After two years of treatment the maintenance dosis is not yet reached. A review of ten previous reported cases of pemphigus foliaceus in children in its sporadic form is presented.

[Association of ectodermal dysplasia, cleft of the lip palate and "scrubbing-brush hair". Its situation in "D. E. F. syndromes" (ectodermal dysplasia, cleft of the lip and/or palate (author's transl)]

The "D. E. F.-syndromes" consist of ectodermal dysplasia, cleft of the lip and/or palate (fente labiale et/ou palatine). This group includes the A. E. C.- and the E. E. C.-syndromes. We are reporting two cases of D. E. F.-syndrome, in which there was a very particular hair dysplasia, which we named "scrubbing-brush hair". The first case was a boy. The disease was probably transmitted on the dominant autosomal mode. The ectodermal dysplasia was of hypohidrotic type. The second case was also observed in a boy. There was no similar genetic abnormality in the family. The ectodermal dysplasia was of hidrotic types. The embryological findings account for the association between the ectodermal dysplasia and the medial dysraphia of the face.

[Pachydermatoglyphy. A sign of malignancy for acanthosis nigricans (author's transl)]

The pachydermatoglyphy corresponds from the clinical point of view to a diffuse palmo-plantar keratodermia, of a yellowish color, characterised by a rough thickening of the finger prints. The presence of the pachydermatoglyphy has been pointed out in six cases of malignant acanthosis nigricans. This was already found in previous descriptions. Pachydermatoglyphy is specially found in malignant acanthosis nigricans, but we have also observed such cases in erythrokeratodermia with pilar keratosis and deafness.

[Richner-Hanhart's syndrome or oculo-cutaneous tyrosinosis (about one case) (author's transl)]

Richner-Hanhart's syndrome correspond to an hypertyrosinemia due to a deficiency of a soluble tyrosine amino-transferase. This recently described tyrosinosis has been called oculo-cutaneous tyrosinosis. This disease transmitted on a recessive way in amenable to a treatment by a low tyrosine diet. In an infant, 18 months old, presenting a bilateral dendritic keratitis, a punctiform keratosis of the extremities, a patchy leucokeratosis of the tongue and a mental ketardation, the hypertyrosinemia reached 52 mg per 100 ml and the urine demonstrated the presence of phenyl-atonic acids. There was no hepato-renal involvement. The deferency of soluble amino-transferase was studied on the hepatocytes and confirmed. The low tyrosine diet made the clinical and biological signs disappear. The improvement was noticeable from the first week on and continued during the 16 months of the follow-up. There was no ill effect of the special diet on the weight and height growth. The oculo-cutaneous tyrosinosis is similar to the experimental form obtained by Schweizer on the rat. The occurrence of intracellular tyrosine crystals probably damages lysosine membrane and the release lysomie proteases induce the cellular lesions.

[Acrodermatitis enteropathica. Anatomo-clinical study of 2 familial cases treated with zinc sulfate]

Two familial cases of acrodermatitis enteropathica began at the time of weaning, with characteristic dermatologic lesions and digestive signs, resulting in lack of weight gain: at 13 months of age growth future was evident in the elder child. The anatomic lesions were those of an exophagitis and, in the duodenal mucosa, a dilation of the capillaries of the chorion in the absence of villous atrophy. The ultrastructural study showed inclusions in Paneth's cells, and changes in keratin cells, with intra-cytoplasmic vacuoles and abnormal melanin pigment in the skin. The administration of zinc sulphate induced a rapid recovery of cutaneous lesions and resumption of growth. The interruption of treatment resulted twice in a quite immediate relapse of cutaneous signs in the first patient, which was rapidly reversible with the reintroduction of zinc sulphate.

[Systematized papulosis of the lower scapular areas with ultrastructural anhist bodies: specific cutaneous symptoms of Hunter's disease (author's transl)]

Papulosis of the scapular areas is a characteristic dermatologic sign of Hunter's disease. It has not been described in the other mucopolysaccharidoses. This sign had been detailed by Hunter in 1917 in his princeps observation. We noted it in two cases of the disease. The ultrastructural study showed an accumulation in the connective interstitial substance of anhist bodies of intra-cellular origin.