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Open Access Publications from the University of California

Dermatology Online Journal

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Dermatology Online Journal is an open-access, refereed publication intended to meet reference and education needs of the international dermatology community since 1995. Dermatology Online Journal is supported by the Department of Dermatology UC Davis, and by the Northern California Veterans Administration.

Volume 19, Issue 7, 2013


Tachyphylaxis to topical glucocorticoids; what is the evidence?

Background: Common belief holds that as topical glucocorticoids are used over time the less effective they become, a phenomenon called tolerance or tachyphylaxis.

Objective: To determine what evidence supports the concept of tachyphylaxis to glucocorticoids.

Methods: We searched Medline and Google Scholar for articles on tachyphylaxis to glucocorticoids published through October 2012.

Results: Rapid tolerance, tachyphylaxis, to non-clinical effects of glucocorticoids has been reported in literature. However, clinically significant tolerance to topical glucocorticoids has not been identified in clinical trials. We did not identify any evidence that clinical efficacy of glucocorticoids in inflammatory skin diseases significantly diminishes during long term continuous use.

Limitations: Tachyphylaxis or tolerance to clinical effects of topical glucocorticoids in inflammatory skin diseases is not fully characterized or well studied.

Conclusion: Based on available data in literature, there is no clinical trial supporting the concept that topical glucocorticoids lose effectiveness over time, nor that intermittent use of topical glucocorticoids is more effective than continuous use.

Case Report

Acquired perforating dermatosis: a clinical and dermatoscopic correlation

Acquired Perforating Dermatosis (APD) is a perforating disease characterized by transepidermal elimination of dermal material [1,2]. This disease usually develops in adulthood. APD has been reported to occur in association with various diseases, but is most commonly associated with dialysis-dependent chronic renal failure (CRF) or diabetes mellitus (DM) [1,2,3,4]. Morton et al found that APD occurs in up to 10% of patients undergoing hemodialysis [5]. Additionally, Saray et al found that sixteen of twenty-two cases with APD were associated with CRF [3].

Case Presentation

Pseudomonas folliculitis in arabian baths

A 35-year-old man presented with a painful cutaneous skin eruption that was localized on the upper trunk. He stated that the previous weekend he had attended an Arabian bath. The physical examination revealed multiple hair follicle-centered papulopustules surrounded by an erythematous halo. A clinical diagnosis of pseudomonas folliculitis was made and treatment was prescribed. Afterwards Pseudomonas aeruginosa was isolated from a pustule culture. Pseudomonas folliculitis is a bacterial infection of the hair follicles. The most common reservoirs include facilities with hot water and complex piping systems that are difficult to clean, such as hot tubs and bathtubs. Despite adequate or high chlorine levels, Pseudomonas aeruginosa can grow within a biofilm.

Extraordinarily long linear cutaneous lupus erythematosus along the lines of blaschko

Linear cutaneous lupus erythematosus (LCLE) is a rare subtype of cutaneous lupus erythematosus. We describe a 22-year-old Japanese man who had an 11-year history of asymptomatic linear erythema from the right upper back to the dorsum of the right hand. The lesions followed the lines of Blaschko and spread over three large joints. Histological findings were compatible with discoid lupus erythematosus. Although the most common site for LCLE is the face, a few cases of LCLE on the extremities have been reported. To our knowledge, this is the first reported case of an extraordinarily long, continuous LCLE skin lesion.

A case of cutaneous leishmaniasis found in Indiana

Cutaneous leishmaniasis was diagnosed in an Indiana resident, an 80-year-old man who had visited Afganistan 7 months earlier. Although cultures were negative, skin biopsy demonstrated round to oval bodies that stained strongly positive with Giemsa staining. His ulcerated plaques cleared readily with oral ketoconazole.

Universal acquired melanosis: carbon baby

We report a 3-year-old boy born with light brown skin that progressively became much darker. The color change was insidious in onset at the age of 3 months, asymptomatic, and progressive involving the entire body surface. Hyperpigmentation may be congenital or acquired, hereditary or nonhereditary, localized or universal, of known or unknown origin. Universal acquired melanosis is a rare form of hyperpigmentation, which has been synonymously referred to as ‘‘carbon baby.’’

Necrosis digital en la mano por mecanismo infrecuente

A 43-year-old, non-smoking man presented with acute ischemic lesions of his left hand. He had been taking beta-blockers for his arterial hypertension. The day before the occurrence of these acute lesions, he self medicated with a drug containing ergotamine and caffeine because of a headache. About one hour after mild trauma to the hand, he noticed intense cyanosis accompanied by severe pain in the fingers that progressed to digital necrosis. Hematological tests, hand radiography, echo Doppler, and nailfold videocapillaroscopy were performed. Digital necrosis owing to an unusual combination of ischemic mechanisms is assumed.

Fellatio-associated petechiae of the palate: report of purpuric palatal lesions developing after oral sex

Fellatio—a sexual act in which the penis is placed into the mouth of another person—can result in submucosal hemorrhage of the palate. A young woman with fellatio-associated palatal petechiae is reported and the features of irrumation-induced oral lesions of the palate are reviewed. Fellatio-associated petechiae and purpura can potentially occur in anyone who engages in receptive penile oral sex. The lesions are asymptomatic and typically appear on the soft palate. Because the fellatrix or fellator may be unaware of the etiology of the lesions or may be reluctant to provide these details of the sexual history, the clinician needs to have a high index of suspicion based on the patient’s clinical presentation and collaborating history of preceding fellatio.

Erythema nodosum and pernicious anemia

Erythema nodosum (EN) often presents as a sudden onset of tender, erythematous, subcutaneous nodules on the legs and ankles. Although rare, pernicious anemia may be related to vitamin B12 deficiency. Discussion of this association in the context of a particular patient is presented.

A propósito de un caso atípico de histiocitosis eruptiva generalizada

Las histiocitosis son un heterogéneo grupo de enfermedades que se caracterizan por la proliferación de histiocitos en los diferentes tejidos. Actualmente se clasifican en tres grupos: I) Histiocitosis de células de Langerhans; II) Histiocitosis de células no Langerhans; e III) Histiocitosis malignas. Presentamos el caso de un varón de 12 años con pápulas normocoloreadas, múltiples y generalizadas de años de evolución. Se realizó un análisis sangre, orina y un estudio de extensión cuyos resultados estuvieron dentro de la normalidad. La biopsia mostró abundantes histiocitos positivos para CD68, factor XIIIa y negativos para S-100 y CD1a. Basándonos en el cuadro clínico y las pruebas complementarias se estableció el diagnóstico de Histiocitosis eruptiva generalizada (HEG). La HEG es una entidad muy rara que afecta principalmente a la población adulta. Clínicamente se manifiesta como cientos de pápulas distribuidas por cara, tronco y extremidades, de carácter autoinvolutivo, por lo que no suele requerir tratamiento.


Unknown: Bluish-gray macules on the hands of a healthy 34 year-old man

A 34 year-old man presented with asymptomatic bluish-gray macules on his hands that had developed over the previous 2 years. He was otherwise healthy and was on no regular medication. A detailed clinical history and histologic examination allowed the diagnosis.Histopathologic examination showed deposits of aggregated granules of black pigment in the dermis, localized preferentially around the sweat glands. This was consistent with the deposition of silver salts. Given the absence of systemic complaints or other signs and symptoms, a conservative approach was adopted. The lesions remain unchanged after one year of follow up.The wide range of uses for silver allows exposure to its compounds (metal, soluble and insoluble compounds) through different routes of entry, namely direct contact, ingestion, inhalation, and puncture. [1] This exposure is usually occupational, iatrogenic, or accidental. [1] Argyria is an exceedingly rare disease that became uncommon because medications containing silver are no longer used and occupational protection has evolved significantly. [2] It is caused by the deposition of silver grains in the skin and is further divided into localized and generalized forms, according to the route of entry. [1-4] Localized argyria is caused by direct contact with silver (the tiny particles penetrate the skin through the sweat glands) or puncture. [1, 3, 4] These deposits remain indefinitely in the skin and are characterized by a bluish gray color, more prominent in the photo-exposed areas. [3, 4] In the localized forms, patients usually don’t have systemic symptoms and the problem is cosmetic. [1-4] Given the improvement in the safety of working conditions, occupational argyria cases are becoming quite uncommon. [1-4]

Photo Vignette

Cutaneous congenital candidiasis in a full-term newborn from an asymptomatic mother

A male infant of 2,900 g was born at term to a 19-year-old primigravida woman who had adequate prenatal care and no major complications detected during the pregnancy. The only reported medical event was an episode of urinary tract infection by E. coli one month before delivering, which resolved without complications using nitrofurantoin. There was no history of maternal herpes simplex infection and her serologic screening was negative for syphilis.

Hypohidrotic and hidrotic ectodermal dysplasia: a report of two cases

Ectodermal dysplasias are a large group of syndromes characterized by anomalies in the structures of ectodermal origin. There are 2 major types of this disorder, based on clinical findings: hypohidrotic ectodermal dysplasia and hidrotic ectodermal dysplasia. This clinical classification is very important because clinical professionals involved with this disease need first a clear and practical method of diagnosis. The main oral manifestation of ectodermal dysplasia may be expressed as hypodontia. Thus, dental professionals may be the first to diagnose ectodermal dysplasia. The present article reports one case of each of the main types (hypohidrotic and hidrotic) of ectodermal dysplasia and the authors review the literature regarding the pathogenesis, clinical features, and therapeutic management of this condition.

Molluscum contagiosum of the areola and nipple: case report and literature review

Molluscum contagiosum is a common cutaneous infection caused by a double-stranded DNA poxvirus. Skin lesions classically present as small, flesh-colored papules with central umbilication. Lesions are frequently seen on the face, trunk, and extremities of children, or on the genitals of young adults as a sexually transmitted infection. Molluscum contagiosum on the nipple or areola has only been previously described in 4 women. We describe a woman with molluscum contagiosum on the left areola and review the clinical characteristics and histological findings of patients who developed molluscum contagiosum of the nipple or areola.

Three paraneoplastic signs in the same patient with gastric adenocarcinoma

This is the report of a 76-year-old male with typical lesions of acanthosis nigricans maligna (ANM), florid cutaneous papillomatosis (FCP), and tripe palms (TP) for 2 years. He did not have any gastrointestinal complaints. Pathologic findings of skin supported the diagnosis of ANM. Because gastric adenocarcinoma is the most common neoplasm associated with these paraneoplastic dermatoses, further tests were carried out. Endoscopic examination was performed and an adenocarcinoma of the esophagogastric junction was confirmed. Meanwhile, multiple small polyps in the middle and the lower thirds of the esophagus were observed. The patient was referred for further evaluation and subsequent surgical resection of the tumor.Acanthosis nigricans (AN) is a hyperkeratotic mucocutaneous eruption of heterogenous etiology, which is characterized by hyperpigmentation, velvety cutaneous thickening, intensified skin markings, and development of verrucous excrescences typically involving the intertriginous areas. AN is classified into benign and malignant forms on the basis of clinical associations. Malignant acanthosis nigricans (MAN) tends to be extensive and involves mucosal surfaces, mostly in elderly people. Florid cutaneous papillomatosis (FCP), also known as the Schwartz-Burgess syndrome, is characterized by the rapid appearance of multiple verrucous lesions that are clinically indistinguishable from common warts [1]. Tripe palms (TP) is characterized by diffuse, yellowish palmar hyperkeratosis, with enhancement of the epidermal ridges on the hands (dermatoglyphics), resembling intestinal villosities [1]. The association of these three paraneoplastic dermatoses (FCP, ANM and TP) in the same patient has been reported. Herein, we report an elderly male with three paraneoplastic dermatoses for two years. On the initial presentation, he did not report any systemic complaints; diagnostic tests confirmed the presence of a gastric adenocarcinoma.


Multiple eruptive keratoacanthomas associated with leflunomide

A 78-year-old woman diagnosed with rheumatoid arthritis without a history of skin tumors or immunosuppressive medication, started treatment with leflunomide. One month after the introduction of the drug, and for two consecutive years, she developed multiple crateriform nodules and papules on her lower extremities . Biopsy specimens showed keratoacanthomas and squamous-cell carcinomas. Owing to suspicion that the drug could be implicated in the appearance of these tumors, the patient decided to suspend the drug. No new skin lesions have appeared in seventeen months of clinical follow-up. There have been several published case reports of multiple keratoacanthomas associated with immunosuppressive therapy such as sorafenib and imiquimod. However, we found no mention in the literature of the eruption of multiple keratoacanthomas in patients with rheumatoid arthritis treated with leflunomide. We suggest, that the the sudden appearance of skin tumors in our patient is related to the introduction of leflunomide, but additional case reports are required to confirm this association.

Sunscreen regulations and use of anti-inflammatory agents in sunscreens

The Food and Drug Administration (FDA) has been more proactive in regulating sunscreen products. In 2011, the FDA publicized a set of new requirements for marketing over-the-counter sunscreens in the United States. The primary goal of the new FDA requirements was to provide consumers with a clear understanding of the level of protection actually provided by a sunscreen. Furthermore, information about protection against ultraviolet A radiation, associated with early aging and skin cancer, was to be clarified. With the new regulations, sunscreen products that provide protection against ultraviolet A and ultraviolet B would be allowed to be marketed as broad-spectrum sunscreen [1].

Squamous cell carcinoma of the penis and topical combination corticosteroid products: a cautionary case

Squamous cell carcinoma of the penis is fairly uncommon, but an important clinical entity with significant patient morbidity. Early diagnosis is important to allow for conservative management and to avoid aggressive surgical resection. We present a case of an invasive squamous cell carcinoma of the glans penis, which was treated with topical anti-fungals and corticosteroids for 2 years prior to diagnosis, necessitating partial glansectomy.