[Vulvar lymphangioma circumscriptum: diagnosis and treatment]

BACKGROUND

The vulvar form of lymphangioma circumscriptumis a rare condition. It is part of the acquired lymphangiectasia and arises secondary, for example, after surgery, radiotherapy for malignancies in the pelvic region, inflammation in which vulvar lymphedema occurs or Morbus Crohn.

CASE DESCRIPTION

A 44-year-old woman presented to the gynaecology outpatient department with a vulvar abnormality that was accompanied by pain and pruritus. Her medical history consisted of premalignant cervical abnormalities and a vulvar lichen simplex chronicus. A biopsy was taken and the diagnosis lymphangioma circumscriptum was made. Due to the growth and the complaints, the decision was made to remove the lesion in the operating room.

CONCLUSION

Lymphangioma circumscriptum is a rare condition that is often misdiagnosed. This case may describe the development of lymphangioma circumscriptum from a lichen simplex chronicus, which has not been described before. It also demonstrates that surgical treatment appears to be a good treatment with few complications in the postoperative course.

Impact of Chronic Kidney Disease Severity on the Risk of Prurigo Nodularis: A Population-Based Cohort Study

While dialysis is linked with prurigo nodularis, little is known about the impact of non-dialysis chronic kidney disease on prurigo nodularis. The influence of chronic kidney disease on development of prurigo nodularis was measured using the Korean National Health Insurance and National Health Screening Program data, identifying 17,295,576 individuals without prior prurigo nodularis. Chronic kidney disease severity was determined by the estimated glomerular filtration rate (in ml/min/1.73 m²) calculated from serum creatinine, and proteinuria detected with urine dipstick. Prurigo nodularis incidence during follow-up was determined. Over a median follow-up period of 9.72 years, 58,599 individuals developed prurigo nodularis, with an incidence rate of 3.59 per 10,000 person-years. Among different variables, estimated glomerular filtration rate was the strongest risk factor for prurigo nodularis. Compared with estimated glomerular filtration rate ≥ 90, estimated glomerular filtration rate 15–29 (hazard ratio 1.31, 95% confidence interval 1.05–1.62) and end-stage renal disease (hazard ratio 1.46, 95% confidence interval 1.25–1.69) were associated with higher risks. The presence of proteinuria independently increased the risk of prurigo nodularis, increased risks associated with estimated glomerular filtration rate 15–29 and endstage renal disease, and caused risk associated with estimated glomerular filtration rate 30–59 to become significant. With differential impact of chronic kidney disease severity on the risk of prurigo nodularis, preservation of renal function would potentially translate into lower risk of prurigo nodularis.

Human Papillomavirus-Independent Squamous Lesions of the Vulva

The pathogenesis of vulvar squamous neoplasia has 2 pathways: human papillomavirus (HPV)-dependent and HPV-independent. The HPV-dependent pathway in the vulva follows the same progression as HPV-dependent lesions elsewhere in the gynecologic tract-HPV infection results in high-grade squamous intraepithelial lesion with subsequent progression to basaloid squamous cell carcinoma. The HPV-independent pathway is more complex, with a variety of precursor lesions and molecular alterations. Although the most recognized form of HPV-independent vulvar lesion is differentiated vulvar intraepithelial neoplasia, recent explorations have elucidated new precursors. This review provides an update on HPV-independent risk factors and precursor lesions for squamous cell carcinoma of the vulva.

[Vulvar pruritus: determination of the most common causes and their treatments]

Vulvar pruritus can be caused by a wide spectrum of diseases, that depend on age, environmental and genetic factors. The most common causes are candidiasis, contact dermatitis and lichen simplex chronicus. Candidiasis is the most common cause of acute vulvar pruritus and is characterized by burning, itching and vaginal whitish secretion. Contact dermatitis is caused by irritants or allergens that are in contact with the genital area, which causes imbalance in the skin barrier causing irritation, swelling, burning, among other manifestations. Lichen simplex chronicus is characterized by lichenification (thickening of the skin) secondary to the chronic itch-scratch cycle in vulvar area. It is an illnes with a tendency to chronicity, but with topical corticosteroids treatment usually might be controlled. Prompt treatment, multidisciplinary and careful attention to irritants and secondary infections prevent these entities become an important and permanent problem.

A retrospective study of relevant diagnostic procedures in vulvodynia

OBJECTIVE

To identify objective clinical signs of vulvodynia and determine specific diagnostic tests for vulvodynia in women referred to a vulvar outpatient clinic for vulval complaints.

STUDY DESIGN

A retrospective study was performed of the medical records of 201 consecutive Danish patients suspected of suffering from vulvodynia who were referred to a vulvar outpatient clinic (Department of Gynecology, Rigshospitalet University Hospital) between October 2003 and January 2006.

RESULTS

Of 201 women, 117 were diagnosed with vulvodynia and 84 had other diagnoses. Of the women diagnosed with vulvodynia in the vulvar clinic, 88.9% were correctly diagnosed before referral. The women with vulvodynia were more likely to report dyspareunia (chi2 = 7.89, p = 0.005) and stinging pain (chi2 = 3.74, p = 0.05). The nonvulvodynia group was more likely to report a tendency toward fissures (chi2 = 5.94, p < 0.05).

CONCLUSION

Self-reported dyspareunia and stinging pain are strongly associated with vulvodynia. Self-reported pruritus and a tendency toward fissures are not likely to be associated with vulvodynia. Whether vulvar biopsies should be performed regularly when redness and pain is present must be explored further in prospective studies.

Sexual dysfunctions in patients with neurodermatitis and psoriasis

We investigated sexual dysfunction and accompanying depression in patients with neurodermatitis and psoriasis. Patients with neurodermatitis (n = 31) and psoriasis (n = 24) were compared to control cases (n = 33) with Beck depression scale (BDS) and Arizona Sexual Experience Scale (ASEX). Beck Depression Scale and ASEX scores varied between three groups. In two group comparisons, the neurodermatitis group had more sexual problems than the psoriasis group and the control group. Patients with neurodermatitis and psoriasis have sexual dysfunction and depression in the course of these chronic diseases and the higher frequency of sexual problems was seen in patients with neurodermatitis.

Psychopathology, depression and dissociative experiences in patients with lichen simplex chronicus

OBJECTIVE

Psychogenic factors may play a contributory role in the development or persistence of lichen simplex chronicus (LSC). The objective of this study was to evaluate the psychiatric profile of patients with LSC including depression and dissociative experiences.

METHOD

Dermatology outpatients with a LSC (n=30) were compared with outpatients with tinea in which psychological factors are regarded as negligible (n=30). All subjects were given psychiatric scales including the Symptom Checklist-90-Revised (SCL-90-R), Hamilton Rating Scale for Depression (HAM-D) and Dissociative Experience Scale (DES).

RESULTS

All mean SCL-90 scores for general psychopathology were higher in the LSC compared to the control group. HAM-D and DES scores were significantly higher in the LSC group (P<.05) as well. In addition, the number of patients whose total DES score of 30 and above was higher in the LSC group.

CONCLUSIONS

Psychiatric symptoms appear relatively common among patients with LSC. Further research is needed to confirm the possible role of dissociative tendencies in the etiology of LSC.

Eosinophilic neuritis and eosinophilic panniculitis in a patient with advanced acquired immunodeficiency syndrome

The pruritic, papular eruption of human immunodeficiency virus with associated peripheral eosinophilia is well documented. We describe a 32-year-old African American man with advanced acquired immunodeficiency syndrome; a generalized painful, pruritic, papular rash; peripheral blood eosinophilia; and perineural eosinophilic infiltrates with eosinophilic panniculitis. To our knowledge, the latter 2 features have not been previously described in the literature on human immunodeficiency virus dermatoses. We propose that eosinophilic neuritis and eosinophilic panniculitis may represent additional findings in the spectrum of cutaneous disease seen in patients with advanced acquired immunodeficiency syndrome.

Sleep Disturbance in Patients with Lichen Simplex Chronicus and Its Relationship to Nocturnal Scratching: A Case Control Study

BACKGROUND

Lichen simplex chronicus (LSC) is a common pruritic disorder resulting from repeated rubbing and scratching. Nighttime pruritus is a common feature in LSC and may disrupt the sleep pattern. The aim of this study is to determine whether there are sleep abnormalities in patients with LSC.

PATIENTS AND METHODS

Fifteen patients with LSC and 15 age-, sex- and body mass index-matched control subjects were enrolled in the study. No participant had any other medical or psychiatric illness. All subjects were evaluated by overnight polysomnography, scratch electrodes, Epworth sleepiness scale and a general questionnaire for demographic data and sleep problems.

RESULTS

There were no significant differences in the groups for total sleep time, sleep efficiency, sleep latency, rapid eye movement (REM) latency, percentage of stage 1 non-REM sleep and REM sleep. The percentage of stage 2 non-REM sleep was higher (P < 0.05) and the percentage of slow wave sleep (stages 3 and 4) was lower in the study group (P < 0.05) than in the controls. The patient group had a mean of 15.9 +/- 7.5 arousal index and 22.8 +/- 14.1 awakenings compared with 9.5 +/- 3.1 and 10.4 +/- 3.9, respectively, in the controls (P < 0.05, P < 0.01, respectively). Arousals of patients were mainly observed in non-REM sleep. The number of scratching bouts ranged from 6 to 20 per night. Scratching episodes were observed frequently during stage 2 non-REM sleep.

CONCLUSION

Polysomnographic findings of patients with LSC demonstrated that sleep structure is disturbed by arousals and awakenings related to scratching bouts during sleep.

Neurodermitis

Squamous cell conjunctival carcinomas (SCCC) are rare. We report on a 34-year-old patient with neurodermatitis and chronic conjunctivitis who presented with a therapy-resistant corneal ulcer induced by mechanical irritation diagnosed as SCCC. Chronic blepharoconjunctivitis seems to sustain the development of SCCC in patients with neurodermatitis because of their insufficient immune response.

Allergic contact dermatitis from hair dye and development of lichen simplex chronicus

Those who dye their hair frequently manifest allergic contact dermatitis (ACD) from p-phenylenediamine (PPD)-containing hair dye. PPD is known to be the most frequent sensitizer in hair dye, but there has been no documentation of this sensitizer having a role in chronic dermatologic conditions. Our department experienced a case of a 62-year-old woman with lichen simplex chronicus (LSC), who complained of aggravation after hair dyeing and made such an association. We conducted a prospective and retrospective study to further evaluate the clinical associations between the two. In our prospective study, patch testing was performed in selected patients who regularly carried out hair dyeing and also had clinical manifestations of LSC. Also a retrospective examination was conducted in cases where patch testing had been performed with PPD in the past for suspected ACD and further selected cases with concurrent LSC and/or other neurodermatitis. 11 and 14 patients in our prospective and retrospective study, respectively, presented with both LSC and positive findings to PPD. 5 (45.5%) and 4 (28.6%) patients in our prospective and retrospective study showed clinical relevance from clinical improvement after stopping use and rechallenge. We report several cases of patients diagnosed as having LSC and/or prurigo nodularis who showed clinical improvement after discontinuing the use of hair dye. The suggestion can therefore be made that hair dye could be a possible aetiologic agent causing LSC in those using hair dyes.

Atopic disease and childhood acute lymphoblastic leukemia

Our objective was to test the hypothesis that the risk of childhood leukemia is associated with allergies or a family history of allergy. We used a German population-based case-control study with self-reported information on allergies of the children and their first-degree relatives. Our study included a total of 1,130 cases of acute lymphoblastic leukemia (ALL), 164 cases of acute myeloid leukemia (AML) and 2,957 controls. A major finding of our study is that hay fever, neurodermatitis and contact eczema are underrepresented within the group of children with ALL, with respective odds ratios (OR) of 0.45 (95% confidence interval [CI] 0.31-0.66) for hay fever, of 0.49 (CI 0.34-0.71) for neurodermatitis and of 0.62 (CI 0.39-0.99) for eczema, respectively. Atopic diseases, comprising hay fever, neurodermatitis and asthma, are much stronger related with a reduced risk of ALL than other allergies (OR 0.52, CI 0.40-0.67 vs. OR 0.89, CI 0.66-1.21). The strongest association is seen with an atopy in the index child; however, ALL risk is also reduced if one of the parents or a sibling had an atopic disease. No such consistent pattern is seen for AML. Our data suggest that atopy or a family history of atopy are associated with a reduced risk of childhood ALL. Recall bias remains a concern, but sensitivity analysis provided some evidence that the protective effect is unlikely to be attributable to this bias in its entirety.

Unusual case presentation of lichen simplex chronicus, Hodgkin's lymphoma, and nonpuerperal hyperprolactinemia-galactorrhea

OBJECTIVE

To report the association of nonpuerperal galactorrhea and severe pruritus with clinical stage IIB Hodgkin's lymphoma.

METHODS

We present a detailed history, findings on physical examination, laboratory data, and results of diagnostic imaging in a 25-year-old woman. A review of the related literature and speculations about possible etiologic factors for this association are provided.

RESULTS

Dermatologic evaluation of the patient revealed lichen simplex chronicus with multiple excoriations on the anterior chest area and lower extremities. High serum prolactin concentrations and easily expressible galactorrhea were present. Magnetic resonance imaging of the sella with 1-mm cuts, however, revealed a normal pituitary gland. Computed tomography showed multiple enlarged mediastinal lymph nodes, and a left supraclavicular lymph node biopsy revealed the presence of Reed-Sternberg cells and lymphocyte alterations consistent with the diagnosis of Hodgkin's lymphoma. After one cycle of chemotherapy for management of the lymphoma, parallel reductions in serum prolactin concentrations and galactorrhea were noted.

CONCLUSION

Possible causes for this syndrome include afferent mammary nerve stimulation resulting from scratching of pruritic skin and cytokine-induced hypersecretion of prolactin attributable to the lymphoma. Although uncommon, this syndrome may serve as an important harbinger of developing Hodgkin's lymphoma, and its disappearance may signify a therapeutic response.

Transmittance properties of flurandrenolide tape for psoriasis: helpful adjunct to phototherapy

BACKGROUND

Flurandrenolide tape is a valuable agent in the treatment of lichen simplex chronicus and in psoriasis. The corticosteroid is helpful for reducing the symptoms and induration of the lichen simplex chronicus lesion, and occlusion of the lesion with the tape reduces the patient's opportunity to rub and scratch the affected area.

OBJECTIVES

The purpose of this study was to determine to what extent flurandrenolide tape may block ultraviolet (UV) light and interfere with phototherapy of psoriasis.

METHODS

Flurandrenolide tape was applied to quartz spectroscopy cuvettes, and the absorption spectrum was determined using a Beckman DU-600 spectrophotometer. The effect of the tape on UV light transmission was also determined using our UVA-UVB office phototherapy unit.

RESULTS

Flurandrenolide tape has considerable UV absorption in the UVC range with less absorption in the UVB and UVA range. The transmittance is greater (less absorption) with longer wavelengths. There was greater UV absorption in the UVB range than in the UVA range.

CONCLUSION

Although flurandrenolide tape may be left in place during PUVA therapy, adjustment of UV dose or removal of the tape is probably needed during UVB phototherapy.

Vulvar vestibulitis is rarely associated with human papillomavirus infection types 6, 11, 16, or 18

Vulvar vestibular biopsy specimens from 31 women with clinical and pathologic findings of vulvar vestibulitis were studied using polymerase chain reaction (PCR) for the identification of human papilloma virus (HPV). The PCR technique specifically probed for HPV types 6, 11, 16, and 18. Of the 31 subjects, three were found to have HPV within the biopsy specimens; two had HPV type 11 and one had HPV 16. Five of the 31 cases had histopathologic features of koilocytosis consistent with HPV effect; three of these five were found to have HPV. The findings support the hypothesis that HPV types 6, 11, 16, and 18 are rarely associated with vulvar vestibulitis. The frequencies identified were similar to those seen with control patients. True koilocytosis is the most useful pathologic feature distinguishing HPV-related cases; it is rarely identified in typical vulvar vestibulitis. Nonspecific changes in the vestibular epithelium associated with glycogen effect should not be interpreted as koilocytosis.

[Neurodermatitis in childhood. Differential diagnosis--complications-- therapy]

The incidence of atopic dermatitis of 2-5% makes it one of the most common chronic diseases of childhood. In 80% of the patients, the skin symptoms first appear within one year of birth. In the differential diagnosis in infants, consideration must be given to candidiasis, seborrhoeic eczema and scabies; bacterial and viral superinfections are common complications. Approximately 80% of the victims have a disposition for atopy; in 50-80%, allergic rhinoconjunctivitis and/or bronchial asthma develops in addition. Despite recent progress in the understanding of the etiopathogenesis of atopic dermatitis, causal treatment is not yet in sight. For this reason, rational symptomatic treatment combined with exhaustive informative talks with and supervision of the children and their parents are of major importance for the management of this disease.

Pityriasis amiantacea and psoriasis. A follow-up study

59 patients with pityriasis amiantacea (PA) were followed up after 8 years on average. 15% had suffered from psoriasis and 19% were aware of psoriasis in their relatives. The incidence of psoriasis was significantly higher (p less than 0.01) than in the Scandinavian population, and the predisposition to psoriasis was significantly higher than in the population (p less than 0.001), but significantly lower (p less than 0.01) than in psoriatic patients. PA seems to be a manifestation of psoriasis in many cases.

Perforating folliculitis in association with hemodialysis

Five patients developed pruritic, keratotic, perforating follicular papules and nodules within 2 months of starting maintenance hemodialysis. Clinically and histologically, the papules and nodules showed the features of perforating folliculitis with superimposed prurigo nodularis, a condition not previously described in patients on maintenance dialysis. The patients with perforating folliculitis constituted 10% of our patients on dialysis during the period of this study. Notably, all five patients were black and had chronic renal failure secondary to diabetic nephropathy. The precise pathogenesis of perforating folliculitis in these patients is unclear at this time.

[Results of and experience with immunotherapy in children with asthma or allergic rhinitis (author's transl)]

Specific hyposensitization in 165 children with inhalant allergy was successful in 82.4%. Children with pollen-allergy showed statistically better results than those with other inhalant-allergies. In the latter group, the failure rate was significantly higher when polyvalent antigen-combinations were used. Age, and duration of the allergic disorder before therapy apparently have no significant influence on the therapeutic success. Children hyposensitized for more than one or two years achieved significantly better short-term results. Patients with atopic dermatitis showed worse results in both groups. Where there is no success after one year of therapy, antigen-determinations should be controlled by repeated cutaneous-vascular tests. In the non-pollen-allergies the prevalent antigen should be determined by provocation-tests. Longterm results after hyposensitization are less favourable than those shortly after a therapeutic course. Three years after discontinuation of therapy success diminished by 35.7%, the recurrence rate was higher in the 1st year than after 2 or 3 years. Frequent local and systemic adverse reactions demand a high responsibility of the physician performing the hyposensitization regimen. In pharmaceutical brochures up to 10,000 PNU are recommended, but this may result in dangerous overdoses.

[Atypical pulmonary stenosis in certain polymalformative syndromes. Prevalence of associated hypertrophique myocardiopathy]

Certain pulmonary stenoses differ markedly from the usual types of isolated valvular stenosis in their clinical features (maximal murmur situated lower down), their radiological signs (absence of a prominent median arc), the electrocardiograph (atypical electrical axis), the haemodynamic findings (usually a poor gradient), and especially the angiocardiography (valvular dysplasia, lack of a post-stenotic dilatation). They are encountered especially in the multiple malformations, as shown by this series of 23 cases comprising the syndrome of Noonan (9), of Gorlin or 'leopard' (7), of Watson or 'café-au-lait spots' (3), or those defying classification, but always having a disorder of facial structure and mental deficiency, sometimes with deafness (4). The frequent finding of a gradually progressive hypertrophic cardiomyopathy is a feature of these syndromes, and usually accounts for the abnormal ECG findings. It leads to a discussion of the pathogenesis, and of the place of these syndromes in a wider context, alongside the phacomatoses and the hereditary forms of neuromuscular degeneration.

[Neurodermatitis and psyche]

The clinical term "constitutional eczematoid" (synonyms: neurodermite, eczema flexuarum, atopic dermatitis e. g.) with/without bronchial asthma and/or allergic rhinitis is presented in its multifactorial dimensions from an overlooking point of view. There are different clinical types, the neurodermite --, the prurigo, the seborrheic and the mixed type of atopic dermatitis. The psychic way of behaviour of these patients which is the neurodermite structure of personality is presented thoroughly. This way of behaviour can especially be seen in patients of neurodermite and prurigo type of atopic dermatitis. In about 10% so called extreme case can be stated presenting this abnormal psychic way of behaviour. Wether in patients with atopic dermatitis a genetic caused psycho-dermatosis has to be discussed, cannot be answered, because there is no allround valid conception of ethology and pathogenesis for this multifactorial disease.

[Radioimmunologic determination of total IgE and allergen-specific IgE-antibodies in diffuse neurodermitis]

Total IgE levels in sera of 165 patients with atopic dermatitis and 79 patients with dermatoses as well as normal control patients were determined by radioimmunoassay (Phadebas, Pharmacia). Although the mean value for patients with atopic dermatitis was found far above the mean value for normal controls, 38% of patients showed total IgE serum levels within the normal range. Highest IgE serum levels were observed in patients with the generalized form of the disease and in patients with asthma and allergic rhinitis. No direct correlation however, to severity of disease could be found. In a series of 50 patients prick tests were compared to total IgE serum levels and to levels of allergen specific antibodies determined by radioallergosorbent-test (RAST). Extracts of grass pollens and of animal dandruff were used. There was complete agreement between results of skin testing and RAST in at least 80%. While cross reactions were common with grass pollen extracts in RAST, there was no cross-over with animal dandruff. No correlation was found between titer of allergen specific antibody and severity of skin lesions. IgE specific antibody could be detected in 48% of patients with normal total IgE serum levels and in 82% of patients with elevated values.