DOCSLIB.ORG

Adalimumab – Safe and Effective Therapy for an Adolescent Patient with Severe Psoriasis and Immune Thrombocytopenia

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Adalimumab – Safe and Effective Therapy for an Adolescent Patient with Severe Psoriasis and Immune Thrombocytopenia Acta Dermatovenerol Croat 2019;27(2):121-123 CASE REPORT Adalimumab – Safe and Effective Therapy for an Adolescent Patient with Severe Psoriasis and Immune Thrombocytopenia Mariusz Sikora, Patrycja Gajda, Magdalena Chrabąszcz, Albert Stec, Małgorzata Olszewska, Lidia Rudnicka Department of Dermatology, Medical University of Warsaw, Warsaw, Poland Corresponding author: ABSTRACT Psoriasis has been linked to several comorbidities, including metabolic Mariusz Sikora, MD, PhD syndrome, atopy, and celiac disease. However, the association between immune thrombocytopenia and psoriasis has rarely been described. We report the case of an Department of Dermatology adolescent with severe psoriasis and concomitant immune thrombocytopenia who Medical University of Warsaw obtained remission during treatment with adalimumab. Increased concentration of Koszykowa 82A tumor necrosis factor-α seems to be a pathogenic linkage and therapeutic target for 02-008 Warsaw both diseases. Poland KEY WORDS: adalimumab, immune thrombocytopenia, psoriasis, tumor necrosis fac- [email protected] tor-alpha Received: January 16, 2019 Accepted: May 15, 2019 INTRODUCTION CASE PRESENTATION Psoriasis is a chronic inflammatory disease that We present a case of 16-year-old girl with an 8- affects about 2% of the population worldwide. The year history of plaque psoriasis. Over the course of pediatric subset of the psoriasis population is an im- disease, the patient was treated with topical agents, portant subgroup since nearly one third of patients narrow band UVB phototherapy (3 sessions/week for with psoriasis experience disease onset in childhood 4 months), acitretin (0.5 mg/kg bw/day for 5 months), (1,2). The affected children and adolescents face a methotrexate (20 mg/week for 7 months), and cyclo- combination of physical and psychosocial challeng- sporine (3.5 mg/kg bw/day for 6 months); however, es. Pediatric psoriasis is associated with pronounced no clinically meaningful response was observed. The effects on self-esteem, stigmatization, and social rela- patient was also diagnosed with immune thrombo- tionships compared with their disease-free peers (3). cytopenia at the age of 12. Recent research has linked psoriasis to several comor- On admission to our Department, physical ex- bidities, including metabolic syndrome, atopy, celiac amination revealed extensive erythematous scaly disease, vitiligo, and alopecia areata (4). plaques involving 48% of the body surface area Immune thrombocytopenia is one of the most (BSA) (Figure 1). The psoriasis area severity index common acquired bleeding disorders in children sec- (PASI) score was assessed as 34.9. Psoriasis had a pro- ondary to the production of autoantibodies against found negative impact on the patient’s quality of life platelets (5). The association of immune thrombocy- (Children’s Dermatology Life Quality Index – CDLQI topenia and psoriasis has rarely been described (6,7). – 27 points). ACTA DERMATOVENEROLOGICA CROATICA 121 Sikora et al. Acta Dermatovenerol Croat Adalimumab for psoriasis with ITP 2019;27(2):121-123 Figure 1. Diffuse erythematous scaly plaques before treat- Figure 2. Clinical improvement after 12 weeks of therapy ment with adalimumab. with adalimumab. Total blood count test revealed isolated throm- splenectomy (9). Due to potential platelet-lowering ef- bocytopenia (82×103/dL). Kidney and liver function fect of immunosuppressive drugs, systemic treatment tests, fasting blood glucose, and lipid profile showed of pediatric psoriasis concomitant with immune throm- no abnormalities. Serological markers for hepatitis B bocytopenia poses a substantial clinical challenge. and C, human immunodeficiency virus, and interfer- Our patient demonstrated a good clinical response on-γ release assay were negative. to adalimumab, which has been approved in 2015 by Because of the severity of the disease and lack of the European Medicines Agency for the treatment of response to standard systemic therapies, the patient severe plaque psoriasis in children aged 4 years or old- received 40 mg adalimumab subcutaneously every 2 er. Adalimumab is a fully human monoclonal antibody weeks. A rapid improvement was observed after the against tumor necrosis factor α (TNFα), a key cytokine first two injections, with almost complete remission in a number of autoimmune diseases (10). in the following weeks (outcomes at week 12: PASI – 2.4; BSA – 4%; CDLQI – 3; Figure 2). No adverse events Increased blood concentration of TNFα has been were observed during biologic therapy. The platelet reported in patients with immune thrombocytopenia count increased moderately to 121×103/dL. (11). Additionally, single-nucleotide polymorphism in the TNFα gene (308G/A) was reported to affect gene DISCUSSION transcription by increasing TNFα production and was speculated to increase the risk and exacerbate the out- Although pediatric psoriasis generally has a mild come of ITP (12). clinical course, a certain group of patients is refractory to conventional systemic agents. Biological treatment We decided to use adalimumab in our patient due targeting specific immune components in the patho- to inadequate response to conventional treatment, physiological cascade of psoriasis is becoming a prom- relatively short half-life of the drug (in case of adverse ising therapeutic alternative (2,8). We described the events), and the possibility of continuing the therapy case of a 16-year-old girl with severe psoriasis poorly with health care reimbursement after reaching adult- controlled by conventional treatments and concomi- hood. Monocytes and macrophages are considered tant immune thrombocytopenia. to be the main producers of soluble TNFα, although Immune thrombocytopenia is a benign condition activated CD4 T-cells highly express transmembrane and one of the common causes of thrombocytopenia TNFα which provides a co-stimulatory signal for hu- in adults and children that resolves spontaneously. man B-cell activation, a remarkable feature of ITP (13). However, 20-30% of patients develop the chronic form The possibility of neutralizing the soluble and mem- that requires more intensive treatment including corti- brane-bound TNFα was an additional argument for costeroids, intravenous immunoglobulin, rituximab, or starting therapy with adalimumab for both diseases. 122 ACTA DERMATOVENEROLOGICA CROATICA Sikora et al. Acta Dermatovenerol Croat Adalimumab for psoriasis with ITP 2019;27(2):121-123 On the other hand, the literature provides very 6. Aboud N, Depre F, Salama A. Is autoimmune th- few reports of thrombocytopenia in patients with rombocytopenia itself the primary disease in the psoriasis who were treated with biologics such as presence of second diseases data from a long-term etanercept, adalimumab, infliximab, ustekinumab, or observation. Transfus Med Hemother. 2017;44:23- secukinumab (14-16). The exact mechanism by which 8. biological drugs may induce thrombocytopenia in 7. Feudjo-Tepie MA, Le Roux G, Beach KJ, Bennett D, psoriasis remains unclear. This reaction may be due Robinson NJ. Comorbidities of idiopathic thrombo- to the relative excess of Th2 lymphocytes, which may cytopenic purpura: a population-based study. Adv in turn stimulate antiplatelet antibody production, Hematol. 2009;2009:963506. leading to platelet destruction and thrombocytope- nia. Another explanation is that biologics are associ- 8. Madiraca D, Šitum M, Prkačin I, Ožanić Bulić S. Treat- ated with formation of immune complexes, which ment options for pediatric psoriasis. Acta Dermato- in turn bind to the surface of platelets and activate venerol Croat. 2016;24:175-80. the complement cascade. Some authors suggest that 9. Osman ME. Chronic immune thrombocytopenia in thrombocytopenia is an idiosyncratic reaction in ge- a child responding only to thrombopoietin recep- netically predisposed patients (17). tor agonist. Sudan J Paediatr. 2012;12:60-4. It is important for clinicians to be aware of this side 10. Wu JJ, Valdecantos WC. Adalimumab in chronic effect of biological drugs. However, the potential risk plaque psoriasis: A clinical guide. J Drugs Dermatol. of drug-induced thrombocytopenia does not repre- 2017;16:779-90. sent a contraindication for the administration of bio- 11. Del Vecchio GC, Giordano P, Tesse R, Piacente L, Al- logics in psoriasis. Instead, as illustrated by this case, tomare M, De Mattia D. Clinical significance of se- it may be applied as an attractive treatment for both rum cytokine levels and thrombopoietic markers in psoriasis and immune thrombocytopenia. Since all childhood idiopathic thrombocytopenic purpura. agents pose a substantial risk, platelet counts should Blood Transfus. 2012;10:194-9. be regularly monitored in patients receiving anti- TNFα/IL-23/IL-17 biologics to facilitate early recogni- 12. Zhang J, Min QH, Xu YM, Deng LB, Yang WM, Wang tion of thrombocytopenia. Y, et al. Association between TNF-alpha -308G/A polymorphism and risk of immune thrombocyto- concLusion penia: a meta-analysis. Genet Test Mol Biomarkers. 2017;21:80-5. Psoriasis and immune thrombocytopenia are quite common in the pediatric population, but their 13. Talaat RM, Elmaghraby AM, Barakat SS, El-Shahat M. coexistence is rare. We would like to emphasize that Alterations in immune cell subsets and their cyto- altered TNFα expression may be a pathogenic linkage kine secretion profile in childhood idiopathic th- and therapeutic target for both diseases. rombocytopenic purpura (ITP). Clin Exp Immunol. 2014;176:291-300. References 14. Nakahara T, Konishi S, Yasukochi Y,
Load more

Recommended publications
  • Coexistence of Vulgar Psoriasis and Systemic Lupus Erythematosus - Case Report
    doi: http://dx.doi.org/10.11606/issn.1679-9836.v98i1p77-80 Rev Med (São Paulo). 2019 Jan-Feb;98(1):77-80. Coexistence of vulgar psoriasis and systemic lupus erythematosus - case report Coexistência de psoríase vulgar e lúpus eritematoso sistêmico: relato de caso Kaique Picoli Dadalto1, Lívia Grassi Guimarães2, Kayo Cezar Pessini Marchióri3 Dadalto KP, Guimarães LG, Marchióri KCP. Coexistence of vulgar psoriasis and systemic lupus erythematosus - case report / Coexistência de psoríase vulgar e lúpus eritematoso sistêmico: relato de caso. Rev Med (São Paulo). 2019 Jan-Feb;98(1):77-80. ABSTRACT: Psoriasis and Systemic lupus erythematosus (SLE) RESUMO: Psoríase e Lúpus eritematoso sistêmico (LES) são are autoimmune diseases caused by multifactorial etiology, with doenças autoimunes de etiologia multifatorial, com envolvimento involvement of genetic and non-genetic factors. The purpose de fatores genéticos e não genéticos. O objetivo deste relato of this case report is to clearly and succinctly present a rare de caso é expor de maneira clara e sucinta uma associação association of autoimmune pathologies, which, according to some rara de patologias autoimunes, que, de acordo com algumas similar clinical features (arthralgia and cutaneous lesions), may características clínicas semelhantes (artralgia e lesões cutâneas), interfere or delay the diagnosis of its coexistence. In addition, it podem dificultar ou postergar o diagnóstico de sua coexistência. is of paramount importance to the medical community to know about the treatment of this condition, since there is a possibility Além disso, é de suma importância à comunidade médica o of exacerbation or worsening of one or both diseases. The conhecimento a respeito do tratamento desta condição, já que combination of these diseases is very rare, so, the diagnosis existe a possibilidade de exacerbação ou piora de uma, ou de is difficult and the treatment even more delicate, due to the ambas as doenças.
    [Show full text]
  • Acquired Thrombotic Thrombocytopenic Purpura in a Patient with Pernicious Anemia
    Hindawi Case Reports in Hematology Volume 2017, Article ID 1923607, 4 pages https://doi.org/10.1155/2017/1923607 Case Report Acquired Thrombotic Thrombocytopenic Purpura in a Patient with Pernicious Anemia Ramesh Kumar Pandey, Sumit Dahal, Kamal Fadlalla El Jack Fadlalla, Shambhu Bhagat, and Bikash Bhattarai Interfaith Medical Center, Brooklyn, NY, USA Correspondence should be addressed to Ramesh Kumar Pandey; [email protected] Received 14 January 2017; Revised 2 March 2017; Accepted 23 March 2017; Published 4 April 2017 Academic Editor: Kazunori Nakase Copyright © 2017 Ramesh Kumar Pandey et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Acquired thrombotic thrombocytopenic purpura (TTP) has been associated with different autoimmune disorders. However, its association with pernicious anemia is rarely reported. Case Report. A 46-year-old male presented with blood in sputum and urine for one day. The vitals were stable. The physical examination was significant for icterus. Lab tests’ results revealed leukocytosis, macrocytic anemia, severe thrombocytopenia, renal dysfunction, and unconjugated hyperbilirubinemia. He had an elevated LDH, low haptoglobin levels with many schistocytes, nucleated RBCs, and reticulocytes on peripheral smear. Low ADAMTS13 activity (<10%) with elevated ADAMTS13 antibody clinched the diagnosis of severe acquired TTP,and plasmapheresis was started. There was an initial improvement in his hematological markers, which were however not sustained on discontinuation of plasmapheresis. For his refractory TTP, he was resumed on daily plasmapheresis and Rituximab was started. Furthermore, the initial serum Vitamin B12 and reticulocyte index were low in the presence of anti-intrinsic factor antibody.
    [Show full text]
  • Psoriasis and Vitiligo: an Association Or Coincidence?
    igmentar f P y D l o is a o n r r d e u r o s J Solovan C, et al., Pigmentary Disorders 2014, 1:1 Journal of Pigmentary Disorders DOI: 10.4172/jpd.1000106 World Health Academy ISSN: 2376-0427 Letter To Editor Open Access Psoriasis and Vitiligo: An Association or Coincidence? Caius Solovan1, Anca E Chiriac2, Tudor Pinteala2, Liliana Foia2 and Anca Chiriac3* 1University of Medicine and Pharmacy “V Babes” Timisoara, Romania 2University of Medicine and Pharmacy “Gr T Popa” Iasi, Romania 3Apollonia University, Nicolina Medical Center, Iasi, Romania *Corresponding author: Anca Chiriac, Apollonia University, Nicolina Medical Center, Iasi, Romania, Tel: 00-40-721-234-999; E-mail: [email protected] Rec date: April 21, 2014; Acc date: May 23, 2014; Pub date: May 25, 2014 Citation: Solovan C, Chiriac AE, Pinteala T, Foia L, Chiriac A (2014) Psoriasis and Vitiligo: An Association or Coincidence? Pigmentary Disorders 1: 106. doi: 10.4172/ jpd.1000106 Copyright: © 2014 Solovan C, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Letter to Editor Dermatitis herpetiformis 1 0.08% Sir, Chronic urticaria 2 0.16% The worldwide occurrence of psoriasis in the general population is Lyell syndrome 1 0.08% about 2–3% and of vitiligo is 0.5-1%. Coexistence of these diseases in the same patient is rarely reported and based on a pathogenesis not Quincke edema 1 0.08% completely understood [1].
    [Show full text]
  • The Coexistence of Systemic Lupus Erythematosus and Psoriasis: Is It Possible?
    CASE REPORT The Coexistence of Systemic Lupus Erythematosus and Psoriasis: Is It Possible? Hendra Gunawan, Awalia, Joewono Soeroso Department of Internal Medicine, Faculty of Medicine, Airlangga University - Dr. Soetomo Hospital, Surabaya, Indonesia Corresponding Author: Prof. Joewono Soeroso, MD., M.Sc, PhD. Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Airlangga University - Dr. Soetomo Hospital. Jl. Mayjen. Prof. Dr. Moestopo 4-6, Surabaya 60132, Indonesia. email: [email protected]; [email protected]. ABSTRAK Lupus eritematosus sistemik (LES) adalah penyakit autoimun kronik eksaserbatif dengan manifestasi klinis yang beragam. Psoriasis vulgaris adalah penyakit kulit yang menyerang 1-3% dari populasi. Patofisiologi mengenai tumpang tindihnya penyakit tersebut belum sepenuhnya diketahui. Hal ini menyebabkan adanya tantangan tersendiri dalam tatalaksana kedua penyakit tersebut. Dua orang laki-laki dengan LES dan psoriasis vulgaris dilaporkan dengan manifestasi klinis eritroderma berulang dengan fotosensitif. Perbaikan klinis dicapai setelah terapi kombinasi metilprednisolon dengan metotrexat. Adanya LES yang tumpang tindih psoriasis vulgaris merupakan suatu fenomena klinis yang langka. Hubungan kedua penyakit tersebut dapat berupa saling mendahului atau tumpang tindih pada suatu waktu yang sama dan memiliki hubungan dengan adanya anti- Ro/SSA. Adanya tumpang tindih dari dua penyakit tersebut memberikan paradigma baru dalam patofisiologi, diagnosis, dan tatalaksana di masa mendatang. Kata kunci: lupus eritematosus sistemik, psoriasis vulgaris, psoriatic artritis, overlap syndrome. ABSTRACT Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with various clinical disorders and frequent exacerbations. Psoriasis vulgaris is a common skin disorder which affect 1-3% of general populations. The pathophysiology regarding the coexistence of these diseases is not fully understood. Therapeutic challenges arise since the treatment one of these diseases may aggravate the other.
    [Show full text]
  • Acne, Eczema and Psoriasis
    Acne, Eczema and Psoriasis Dr Rebecca Clapham Aims • Classification of severity • Management in primary care – tips and tricks • When to refer • Any other aspects you may want to cover? Acne • First important aspect is to assess severity and type of lesions as this alters management Acne - Aetiology • 1. Androgen-induced seborrhoea (excess grease) • 2. Comedone formation – abnormal proliferation of ductal keratinocytes • 3. Colonisation pilosebaceous duct with Propionibacterium acnes (P.acnes) – esp inflammatory lesions • 4. Inflammation – lymphocyte response to comedones and P. acnes Factors that influence acne • Hormonal – 70% females acne worse few days prior to period – PCOS • UV Light – can benefit acne • Stress – evidence weak, limited data – Acne excoriee – habitually scratching the spots • Diet – Evidence weak – People report improvement with low-glycaemic index diet • Cosmetics – Oil-based cosmetics • Drugs – Topical steroids, anabolic steroids, lithium, ciclosporin, iodides (homeopathic) Skin assessment • Comedones – Blackheads and whiteheads • Inflammed lesions – Papules, pustules, nodules • Scarring – atrophic/ice pick scar or hypertrophic • Pigmentation • Seborrhoea (greasy skin) Comedones Blackheads Whiteheads • Open comedones • Closed comedones Inflammatory lesions Papules/pustules Nodules Scarring Ice-pick scars Atrophic scarring Acne Grading • Grade 1 (mild) – a few whiteheads/blackheads with just a few papules and pustules • Grade 2 (moderate)- Comedones with multiple papules and pustules. Mainly face. • Grade 3 (moderately
    [Show full text]
  • Treatment of Refractory Pityriasis Rubra Pilaris with Novel Phosphodiesterase 4
    Letters Discussion | Acrodermatitis continua of Hallopeau, also Additional Contributions: We thank the patient for granting permission to known as acrodermatitis perstans and dermatitis repens, publish this information. is a rare inflammatory pustular dermatosis of the distal fin- 1. Saunier J, Debarbieux S, Jullien D, Garnier L, Dalle S, Thomas L. Acrodermatitis continua of Hallopeau treated successfully with ustekinumab gers and toes. It is considered a variant of pustular psoriasis and acitretin after failure of tumour necrosis factor blockade and anakinra. or, less commonly, its own pustular psoriasis-like indepen- Dermatology. 2015;230(2):97-100. 1 dent entity. Precise pathophysiology and incidence 2. Kiszewski AE, De Villa D, Scheibel I, Ricachnevsky N. An infant with are unknown. Case literature suggests predominance in acrodermatitis continua of Hallopeau: successful treatment with thalidomide women, but the disease affects both sexes and, rarely, and UVB therapy. Pediatr Dermatol. 2009;26(1):105-106. children.2 3. Jo SJ, Park JY, Yoon HS, Youn JI. Case of acrodermatitis continua accompanied by psoriatic arthritis. J Dermatol. 2006;33(11):787-791. Acrodermatitis continua of Hallopeau initially presents 4. Sehgal VN, Verma P, Sharma S, et al. Acrodermatitis continua of Hallopeau: as erythema overlying the distal digits that evolves into evolution of treatment options. Int J Dermatol. 2011;50(10):1195-1211. pustules.2 The nail bed is often involved, with paronychial 5. Lutz V, Lipsker D. Acitretin- and tumor necrosis factor inhibitor-resistant 3 and subungual involvement and atrophic skin changes. acrodermatitis continua of Hallopeau responsive to the interleukin 1 receptor Most patients experience a chronic, relapsing course involv- antagonist anakinra.
    [Show full text]
  • Successful Treatment of Refractory Pityriasis Rubra Pilaris With
    Letters Discussion | The results of this study reveal important differ- OBSERVATION ences in the microbiota of HS lesions in obese vs nonobese pa- tients. Gut flora alterations are seen in obese patients,4,5 and Successful Treatment of Refractory Pityriasis HS has been associated with obesity. It is possible that altered Rubra Pilaris With Secukinumab gut or skin flora could have a pathogenic role in HS. Pityriasis rubra pilaris (PRP) is a rare inflammatory skin dis- Some of the limitations of the present study include the order of unknown cause. It is characterized by follicular use of retrospective data and the lack of a control group con- hyperkeratosis, scaly erythematous plaques, palmoplantar sisting of patients with no history of HS. Although these cul- keratoderma, and frequent progression to generalized tures were obtained from purulence extruding from HS le- erythroderma.1 Six types of PRP are distinguished, with type sions, the bacterial culture results could represent skin or gut 1 being the most common form in adults. Disease manage- flora contamination. Information about the specific ana- ment of PRP is challenging for lack of specific guidelines. Topi- tomic locations of HS cultures was not available. Because only cal emollients, corticosteroids, and salicylic acid alone or com- the first recorded culture of each patient was analyzed, it is un- bined with systemic retinoids, methotrexate, and tumor known if the culture results would change with time and fur- necrosis factor (TNF) inhibitors are considered to be most ther antibiotic therapy. The use of data obtained from swab- helpful.2,3 Unfortunately, PRP often resists conventional treat- based cultures may also represent a potential limitation because ment.
    [Show full text]
  • A Brighter Future for Psoriasis Patients Melanoma and Skin Cancer Center
    Skin Health FROM THE MOUNT SINAI DEPARTMENT OF DERMATOLOGY FALL 2013 MESSAGE FROM THE CHAIR A Brighter Future for Psoriasis Patients By Mark G. Lebwohl, MD, Sol and Clara Kest Professor and Chair ount Sinai has been at the forefront of psoriasis research since Mthe 1980’s, when we introduced a topical combination regimen that remains the standard of care around the world even today. This consists of both a superpotent corticosteroid and a vitamin-D analog such as calcipotriene (Dovonex®) or calcitriol (Vectical®). The use of combination therapy led to the invention of Taclonex®, a popular and effective psoriasis formula that contains two topical agents. While refining the concept of combination therapy, we discovered that some topical preparations inactivate others, and subsequently we fostered the understanding that two or more ingredients, when applied together, must be shown to be compatible. In recent years this rule has been Dr. Mark G. Lebwohl embraced for all topical medicines, not just for psoriasis drugs. continued on page 4 BREAKING NEWS In This Issue Melanoma and Skin Cancer Center By Philip Friedlander, MD, PhD LASER HAIR REMOVAL Alan Kling, MD Page 2 he Tisch Cancer Institute is pleased to announce the creation of the Melanoma and TSkin Cancer Center, a virtual gathering place designed to provide a full array of medical LOOKING FAB THIS FALL resources to skin cancer patients. As part of its mission to deliver the highest quality of care, David S. Orentreich, MD the Center has assembled a team of leading specialists representing the fields of dermatology, Marina I. Peredo, MD medical oncology, surgery, dermatopathology, podiatry, and social work.
    [Show full text]
  • RESEARCH HIGHLIGHTS Research Highlights Jennifer Tran, Patrick Fleming, Cathryn Sibbald
    RESEARCH HIGHLIGHTS Research Highlights Jennifer Tran, Patrick Fleming, Cathryn Sibbald SATELLITE LESIONS: A NEW PROGNOSTIC SIGN FOR systemic symptoms (fever, malaise, lymphadenopathy, HIGH-RISK HERPES ZOSTER and/or headache), underlying immunosuppression, and el Hayderi, L., Bontems, S., Nikkels-Tassoudji, N., Arrese, J. E., Seidel, L., need for hospitalization. Meex, C., & Nikkels, A. F. (2015). Satellite lesions accompanying herpes zoster: A new prognostic sign for high-risk zoster. The British Journal There were 109 confirmed cases of herpes zoster, of of Dermatology, 172(6), 1530Y1534. which 23 patients (21%) had SLs. Immunocompromised patients had a 3.15-fold increased RR of having SLs and erpes zoster, or shingles, is a painful vesicular were more likely to have higher numbers of SLs compared eruption caused by reactivation of varicella-zoster with immunocompetent patients. SLs were usually located virus (Wilson, 2011). This condition affects almost on the trunk and were not pruritic or painful. The pres- Hone million individuals annually in the United States, with ence of SLs significantly increased risk of systemic signs an estimated lifetime risk of 32% (Harpaz, Ortega-Sanchez, (RR = 2.08, 95% confidence interval [CI] [1.35, 3.30]), & Seward, 2008). Zoster classically affects a single der- underlying immunosuppression (RR = 2.38, 95% CI matome but can occasionally present with satellite lesions [1.46, 3.87]), multistage zoster (RR = 3.30, 95% CI [1.96, (SLs) away from the primary site (Wilson, 2011). Pre- 5.55]), multidermatomal zoster (RR = 10.6, 95% CI [4.72, vious reports have suggested that these SLs may represent 23.8]), increased surface involvement (RR = 3.27, 95% CI hematogenous spread of the virus (Castronovo & Nikkels, [1.89, 5.7]), and hospitalization (RR = 2.94, 95% CI 2012), but the overall clinical significance of these SLs [1.55, 5.58]).
    [Show full text]
  • Pityriasis Rosea
    BMJ 2015;351:h5233 doi: 10.1136/bmj.h5233 (Published 29 October 2015) Page 1 of 6 Practice PRACTICE PRACTICE POINTER Pityriasis rosea Samantha Eisman consultant dermatologist, Rodney Sinclair professor in dermatology Sinclair Dermatology, Melbourne, VIC, 3002, Australia Pityriasis rosea is an acute exanthem that may cause patients great anxiety but is self limiting and resolves within one to three How does pityriasis rosea present? months.1 It is a distinctive erythematous oval scaly eruption of Pityriasis rosea begins in 40-76% of patients with a single herald the trunk and limbs, with minimal constitutional symptoms. patch—an asymptomatic thin oval scaly plaque often on the What causes pityriasis rosea? trunk (fig 1⇓).7 Multiple herald patches may also occur.8 The patch is usually well demarcated, 2-4 cm in diameter, The cause of pityriasis rosea is uncertain but epidemiological erythematous, salmon coloured, or hyperpigmented. A fine (seasonal variation and clustering in communities) and clinical collarette of scale is attached to the periphery of the plaque with features suggest an infective agent. Light and electron its free edge extending internally. Within days to three weeks microscopy findings suggest infection with human herpesviruses 2 the second phase begins—the appearance of numerous smaller 6 and 7 (HHV-6/7). These viral antigens have been detected lesions, which are similar in configuration but occur along the in skin lesions by immunohistochemistry and their DNA has lines of cleavage of the trunk (Christmas tree pattern; figs 2⇓ been isolated from non-lesional skin, peripheral blood 3 and 3⇓). The rash typically lasts five weeks; it resolves within mononuclear cells, serum, and saliva samples.
    [Show full text]
  • Treatment of Psoriasis After Initiation of Nivolumab Therapy for Metastatic Malignant Melanoma: an Ancient Drug Revisited
    LETTER TO THE EDITOR DOI: 10.4274/jtad.galenos.2020.13007 J Turk Acad Dermatol 2020;14(3):93-94 Treatment of Psoriasis After Initiation of Nivolumab Therapy for Metastatic Malignant Melanoma: An Ancient Drug Revisited Gökhan Okan1, Kezban Nur Pilancı2, Cuyan Demirkesen3 1Private Dermatologist, Istanbul, Turkey 2Memorial Bahcelievler Hospital, Clinic of Oncology, Istanbul, Turkey 3Acibadem University Faculty of Medicine, Department of Pathology, Istanbul, Turkey Keywords: Checkpoint inhibitors, Nivolumab, Psoriasis, Melanoma, Sulfasalazine Dear Editor, Checkpoint inhibition can cause various immune-related adverse events in any organ but skin toxicity occurs most frequently [1]. We report de novo development of psoriasis vulgaris in a patient receiving nivolumab for treatment of metastatic melanoma which was controlled with sulfasalazine (SSZ). A 69-year-old male was initiated with nivolumab 3 mg/kg every two weeks for metastatic BRAF-negative melanoma of the back. The patient’s medical history was notable for arterial hypertension and dyslipidemia for which he has been medically treated. There was no personal or family history of psoriasis. One week after the fourth cycle of nivolumab, asymptomatic, sharply bordered, erythematous and scaly plaques were seen on the the anterolateral aspects of shins, dorsa of hands, feet, scalp, and trunk (Figure 1a). A skin biopsy revealed psoriasiform epidermal hyperplasia with prominent orthohyperkeratosis, and mounds of parakeratosis, containing neutrophils. The suprapapillary epidermis was thinned, and there were collections of neutrophils in the spinous layers which were consistent with psoriasis (Figure 1b, 1c). The patient had psoriasis area and severity index score of 12. He did not have psoriatic arthritis. The patient’s melanoma improved with nivolumab therapy but the skin lesions increased.
    [Show full text]
  • History of Psoriasis and Parapsoriasis
    History of Psoriasis and Parapsoriasis By Karl Holubar Summary Parapsoriasis is «oï a disease entity. Jt is an auxiliary term introduced in J 902 to group several dermatoses w>itk a/aint similarity to psoriasis. Tlie liistorical development leading to tlie creation o/ t/ie term parapsoriasis is outlined and t/te Itistory o/psoriasis is 6rie/ly reviewed. Semantic and terminological considerations Obviously, para-psoriasis as a term has been created in analogy to psoriasis. We should remember similar neologisms in medical language, e. g. protein and para-protein; typhoid and para-typhoid, thyroid and para-thyroid, phimosis and para-phimosis, eventually, pemphigus and para-pemphigus (the latter in 1955 this term was to be employed instead of pemphigoid but was not accepted by the dermatological world). Literally, para is a Greek preposition, (with the genitive, dative and accusative), meaning: by the side of, next to something, alongside something. In medicine, para is used often as a prefix to another term, which designates a condition somewhat similar to the one under consideration. The same holds for psoriasis and parapsoria- sis. In detail, though, it is a bit more complicated. Parapsoriasis has more than one "/at/ier", three in fact: ideiurick /Iu.spitz f 1835—1886,), Paul Gerson Luna (A850—1929j and Louis Procç fI856—I928J. Auspitz, in 1881, had published a new system of skin diseases the seventh class of which was called epidermidoses, subdivided into liypcrlcfiratose.s, parakeratoses, kerato/y- ses, the characteristics of which were excessive keratinization, abnormal keratinization and insufficent keratinization. When Unna, in 1890®, pub- lished his two reports on what he called parakeratosis variegata, he referred to Auspitz' system and term when coining his own.
    [Show full text]