Case 22 RC F32. 18wks pregnant lady with widespread pruritic nodules.

DD Case 22 RC

• Papular and urticated pruritic plaques of pregnancy (PUPPP) • Folliculitis • Pregnancy induced atopic eczema • Reactive perforating collagenosis Treatments to date….

• Diprosalic / Aknemycin (> 3 months) • Dermovate oint (> 3 months) • Acitretin 10-25mg OD (initial good response, now less effective) • TL01 Phototherapy – 4 sessions only

5 6 Perforating Disorders

Skin disorders in which material is eliminated from the dermis by extrusion through the epidermis to the skin surface by a process of transepidermal elimination.

• Reactive perforating collagenosis ACQUIRED • Kyrle disease PERFORATING • Elastosis perforans serpinginosum DERMATOSIS • Perforating follicultitis -> recommendation to abandon term

7 Rare Perforating Disorders

• Familial Reactive Perforating Dermatosis (< 50 case reports in literature). Onset in childhood. Perforating substance: collagen. Usually spontaneously resolves.

• Perforating calcific elastosis. Onset: adulthood. Site: Abdomen, peri-umbilical. Perforating substance: calcified elastic tissue. Associations: multiparity, obesity, HTN Acquired perforating dermatosis

It is strongly associated with diabetes and chronic disease.

Can also occur in conjunction with other causes of pruritus – from insect bites and to lymphoma and hepatobiliary diseases, including primary biliary cirrhosis and malignancies. Acquired perforating dermatosis- Pathophysiology

• The underlying cause is unknown.

• It has been suggested that mild superficial trauma (e.g. scratching) in genetically susceptible individuals leads to of papillary dermis collagen that is subsequently eliminated by a transepidermal route. Acquired perforating dermatosis - Treatment

Treatment of lesions is often unsatisfactory; in many cases, the lesions are self-healing, but usually are recurrent.

Retinoids (topical/oral) Allopurinol Doxycycline Methotrexate UVB/PUVA Intralesional steroids Emollients and antihistamines seem helpful in controlling pruritus

Saray Y, Seçkin D, Bilezikçi B. Acquired perforating dermatosis: clinicopathological features in twenty-two cases. Journal of the European Academy of Dermatology and Venereology. 2006 Jul 1;20(6):679-88.