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Background The National Eczema Association has received increasing numbers of patient inquiries regarding "steroid addiction syndrome," coinciding with the growing presence of social media dedicated to this topic. Although many of the side effects of topical corticosteroids (TCS) are addressed in guidelines, TCS addiction is not. Objective We sought to assess the current evidence regarding addiction/withdrawal. Methods We performed a systematic review of the current literature. Results Our initial search yielded 294 results with 34 studies meeting inclusion criteria. TCS withdrawal was reported mostly on the face and genital area (99.3%) of women (81.0%) primarily in the setting of long-term inappropriate use of potent TCS. Burning and stinging were the most frequently reported symptoms (65.5%) with erythema being the most common sign (92.3%). TCS withdrawal syndrome can be divided into papulopustular and erythematoedematous subtypes, with the latter presenting with more burning and edema. Limitations Low quality of evidence, variability in the extent of data, and the lack of studies with rigorous steroid addiction methodology are limitations. Conclusions TCS withdrawal is likely a distinct clinical adverse effect of TCS misuse. Patients and providers should be aware of its clinical presentation and risk factors.

Demodicosis refers to the infestation byDemodexspp., a saprophytic mite of the pilosebaceous unit. Demodex proliferation can result in a number of cutaneous disorders including pustular folliculitis, pityriasis folliculorum, papulopustular, and granulomatous rosacea, among others. We report the case of a 7-year-old female presenting with pruritic grayish crusted lesions over her nose and cheeks, along with facial erythema, papules, and pustules. The father referred chronic use of topical steroids. A potassium hydroxide mount of a pustule scraping revealed severalD. folliculorummites. Oral ivermectin (200 μg/kg, single dose) plus topical permethrin 5% lotion applied for 3 consecutive nights were administered. Oral ivermectin was repeated every week and oral erythromycin plus topical metronidazole cream was added. The facial lesions greatly improved within the following 3 months. While infestation of the pilosebaceous unit byDemodex folliculorummites is common, only few individuals present symptoms. Demodicosis can present as pruritic papules, pustules, plaques, and granulomatous facial lesions. To our knowledge, this is the first reported case of facial crusted demodicosis in an immunocompetent child. The development of symptoms in this patient could be secondary to local immunosuppression caused by the chronic use of topical steroids.

Perioral dermatitis is a common papulopustular facial eruption in adult, menstrual females. It usually begins around the mouth and spreads slowly to the nasal sidewalls, glabella, and periocular skin. Due to its erythema and progressive spread, it is often misdiagnosed as atopic, allergic, or irritant dermatitis. Dermatitic eruptions show patches and plaques of inflamed skin, rather than papules and pustules, and are frequently pruritic. In photosensitive facial eruptions, the distribution of erythema involves the convex areas, such as the forehead, central cheeks, and nasal bridge. There is relative sparing of shadowed areas, such as the inferior eyelids, proximal upper lip, and proximal chin. Topical steroid use worsens perioral dermatitis. Recommended treatment options include topical metronidazole twice daily and oral cycline antibiotics.

Behcet's disease usually begins with cutaneous manifestations, such as recurrent aphthous stomatitis, genital ulcers, erythema nodosum-like lesions, papulopustular findings, and pathergy phenomenon. Recurrent aphthous stomatitis is generally the first sign, and other findings may develop in the course of the disease. There is no specific diagnostic available for Behcet's disease. It is most prevalent among patients along the ancient Silk Road. The high frequency of HLA-B51 among a wide range of ethnic populations favors the role of genetic factors. Behcet's disease usually appears in the third to fourth decade of life, and is rarely seen in children and adults over 50 years of age. It affects both genders equally, but the course of the disease is more severe in men. Eye involvement leading to loss of vision, plus vascular, articular, and central nervous system involvement are more commonly observed among men. Behcet's disease is a systemic inflammatory disorder. A complex genetic background, coupled with innate and adaptive immune system activation, causes the diverse clinical manifestations that characterize the clinical picture.

Vasculitis is relatively uncommon in lymphoproliferative disease and may predate the diagnosis of lymphoproliferative disease. Many vasculitides have been associated with hairy cell leukemia (HCL), including polyarteritis nodosa (PAN) and leukocytoclastic vasculitis. We herein report a case whose initial presentation was like Behcet's disease (BD) (arthritis, oral and genital ulcerations, papulopustular skin lesions) in addition to pancytopenia, but turned out to have HCL. Because of the overlap between their symptoms, like oral ulcerations, skin lesions, arthritis and constitutional findings, HCL and BD may mimic each other. We should keep in mind other reasons for vasculitis such as lymphoproliferative disease, especially whose who have hematological abnormalities such as pancytopenia.

Acupoint stimulation-including acupuncture, moxibustion, cupping, acupoint injection, and acupoint catgut embedding-has shown a beneficial effect for treating acne. However, comprehensive evaluation of current clinical evidence is lacking.The aim of this review was to assess the effectiveness and safety of all acupoint stimulation techniques used to treat acne vulgaris.A systematic review was conducted. It included only randomized controlled trials on acupoint stimulation for acne. Six electronic databases were searched for English and Chinese language studies. All searches ended in May 2012. Studies were selected for eligibility and assessed for quality. RevMan 5.1 software was used for data analysis with an effect estimate presented as risk ratios (Studies with subjects who were diagnosed with acne vulgaris, or papulopustular, inflammatory, adolescent, or polymorphic acne-regardless of gender, age, and ethnicity-were included.Interventions included any acupoint stimulation technique-such as acupuncture, moxibustion, cupping, acupoint injection, and acupoint catgut embedding-compared with no treatment, placebo, or conventional pharmaceutical medication.Reduction of signs and symptoms and presence of adverse effects were examined.Forty-three trials involving 3453 patients with acne were included. The methodological quality of trials was generally poor in terms of randomization, blinding, and intention-to-treat analysis. Meta-analyses showed significant differences in increasing the number of cured patients between acupuncture plus herbal medicine and herbal medicine alone (Acupoint stimulation therapies combined with other treatments appears to be effective for acne. However, further large, rigorously designed trials are needed to confirm these findings.

We report a case of Demodex infestation in a 35 year old coal miner presenting with a 5 year history of scally papulopustular eruption on his face. He had been working inunderground coal tunnels in a humid- hot- dusty environment and he had been used to bath twice a day with hot water and multiple cleaners. The patient was treated successfully with oral metronidazol, topical permethrin, topical steroids and avoidance of undergraund mining . We believe his occupational environment made him prone to infestation by changes in sebum composition and/or viscosity, his bath habituation facilitated infestation, damaging the epidermal barrier function and his previous treatments exaggerated his infestation. During evaluation of the patient, specific occupational factors and habituations will be related with higher succession rates of treatment. We need to conduct further studies in order to draw a definite conclusion about the effect of the occupational environment on Demodex infestation.

Rosacea is best regarded as an inflammatory facial skin disorder. As already mentioned in previous chapters, it is heralded usually by frequent episodes of flushing (stage I, pre-rosacea, subtype 0) followed in 81 % of patients by persistent erythema (erythrosis) and telangiectasia (stage II, erythematotelangiectatic, subtype 1) in the center of the face, which may proceed in a minority of patients (19 %) to formation of papules and pustules (stage III, papulopustular, subtype 2) and even nodules (stage IV, phymatous, subtype 3) [1, 2]. This variable clinical presentation makes differential diagnosis rather wide according to presenting symptoms and signs (Table 90.1). Sometimes, biopsy is needed to establish the diagnosis.

A 52-year-old man with recurrent metastatic rectal carcinoma being treated with cetuximab presented to the emergency department with a diffuse papulopustular eruption on the face, scalp, chest, and groin, accompanied by patchy alopecia of the scalp and facial hair.

Erlotinib is an epidermal growth factor receptor (EGFR) inhibitor, used as a treatment for advanced stage cancer. The most common side effect is cutaneous toxicity including the already known papulopustular reaction. We herein report a case of erlotinib induced target-like purpura, a peculiar cutaneous adverse event. A 57-year-old patient with advanced non-small cell lung cancer was treated by erolotinib 150 mg daily. After taking the drug for three days, an unusual target-like purpura developed on her lower legs. Skin biopsy specimen taken from the lesion revealed an extravasation of erythrocytes in the upper dermis without destruction of blood vessel walls. This skin eruption cleared after the drug was withdrawn and recurred after erlotinib was re-challenged. The mechanism underlying this cutaneous adverse event remains to be elucidated. Physicians should be aware of the rare side effect of this increasingly used drug.

Clinical trials comparing a test treatment with an active control therapy have become very popular in drug and medical device development in the last decade. An active controlled trial without a placebo, however, exhibits some major challenges in design, analysis, and interpretation, such as the determination of the non-inferiority margin or the assumption of constancy condition. When there are no ethical concerns, the comparison of a test drug with placebo usually provides the most convincing proof of the efficacy of a new treatment. Therefore, it may be advisable to conduct a three-arm trial — including placebo, active control, and the new treatment — if it is ethically justifiable such as a papulopustular acne study and an oral prophylactic antibiotics study. In this paper, we propose a statistical methodology for a three-arm non-inferiority trial with binary outcomes. We adapt the step-down hierarchical hypotheses and give a three-step testing procedure which is more realistic in conducting a clinical trial. We derived an optimal sample size allocation rule in an ethical and reliable manner to minimize the total sample size and hence to shorten the duration of the trials. Real examples from a papulopustular acne study and an oral prophylactic antibiotics study are used to demonstrate our methodology.

Background: Although systemic isotretinoin offers more effective alternatives for treatment, as the drug has several side-effects, physicians are hesitatant to recommend the drug. The aim of this research was to retrospectively evaluate the effectiveness, side-effects and validity of systemic isotretinoin treatment on patients with acne, to thereby present experimental data relevant to future usage by patients suffering from acne.Methods: Patients diagnosed with acne in the Dermatology Polyclinic of the Medical Faculty of KSU between January 2004 and September 2008 was identified from the polyclinic records. Patient data were retrieved from the archives and recorded in the pre-prepared format. A retrospective evaluation was made of the safety and effectiveness of isotretinoin treatment, and the clinical and laboratory test side-effects.Results: A total of 241 patients were prescribed systemic isotretinoin treatment and started treatment. Of these, 129 of these patients attended regular follow-up examinations and completed the treatment. Systemic isotretinoin was determined to be effective on acne during a treatment period of 23.47±4.5 weeks with a total average dose of 113.73±22.4 mg. There were no serious laboratory test or clinical effects of an intolerable level tolerated which would lead to termination of the treatment.Conclusions: Systemic isotretinoin treatment is effective and safe for acne vulgaris patients with nodulocystic and papulopustular types of lesion. However, it is essential that the laboratory parameters of hepatic function tests and the lipid profile are checked regularly.

Summary Background In daily dermatological practice, many dermatologists do not include demodicosis in their differential diagnoses, or the diagnosis of demodicosis is frequently masked by other skin diseases such as papulopustular or erythematotelangiectatic rosacea, seborrhoeic dermatitis, perioral dermatitis and contact dermatitis. There are two methods for measurement of the density of Demodex folliculorum (Dd): standardized skin surface biopsy (SSSB) and direct microscopic examination of fresh secretions from sebaceous glands (DME). No study has been reported in the literature comparing the diagnostic value of these two techniques. Objectives To compare the value of the two techniques, SSSB and DME, for the measurement of Dd in patients with suspected demodicosis. Methods Mite density was investigated using SSSB and DME in 37 patients with facial skin lesions suggesting demodicosis. Two samples, one for SSSB and one for DME, were obtained from a cheek lesion of each patient. Results Twenty-three (62%) patients were diagnosed with demodicosis according to their clinical manifestations combined with a high Dd (Dd > 5 mites cm−2) with SSSB and/or DME. In all the patients, the mean Dd measured with SSSB was higher than that with DME (22·9 ± 5·9 and 2·2 ± 0·8, respectively; P = 0·001). Also, among the 23 patients with demodicosis, the mean Dd measured using SSSB was higher than the mean Dd with DME (36·5 ± 8·3 and 3·4 ± 1·2, respectively; P = 0·0001). Conclusions We recommend the use of SSSB for the measurement of Dd as more patients with demodicosis can be diagnosed with this method compared with the DME method.

BackgroundPseudomonas aeruginosa folliculitis (PF) can develop after exposure to contaminated water in heated swimming pools, whirlpools, and hot-tubes, or after diving suit dressing. Methods We observed and studied 14 cases of PF after shower/bath exposure, an underestimated pathogenic event. Cutaneous and environmental microbiological evaluations were performed. Results In our cases, the clinical expression of dermatitis was constant, PF being a clinically well recognizable skin infection, presenting with follicular, macular, and papulopustular lesions located on the lateral aspect of the trunk, axillary folds, hips, buttocks, and suprapubic area. In all cases, Pseudomonas aeruginosa was isolated from lesional skin; seven cases were serotyped revealing, in three cases, serotype 0 : 1, in two cases 0 : 8, in one case 0 : 10, and in one case 0 : 11. In three families, Pseudomonas aeruginosa was isolated in the well water. In a further three families, Pseudomonas aeruginosa was isolated from bathroom and kitchen components. Conclusions Based on our experience, we suggest that shower/bath exposure should be definitively included amongst the possible pathogenic events causing PF. Pseudomonas aeruginosa is responsible for a number of clinical pictures, e.g. otitis externa, conjunctivitis, toe web intertrigo, green nail syndrome, infection of burns and wounds, and folliculitis. Pseudomonas aeruginosa folliculitis (PF) has been reported to develop as a consequence of exposure to contaminated water in heated swimming pools, whirlpools, and hot-tubes, or related to diving suits and leg waxing. 1–4We observed 14 cases of PF after shower/bath exposure. This is probably an underestimated pathogenic event; to our knowledge, only one case has been reported to date. 5In our patients, the clinical expression of dermatitis was constant, PF being a clinically well recognizable skin condition.

A 50-year-old man was diagnosed with Behçet disease (BD) on the basis of an 8-year history of episodes of recurrent oral aphthous ulcers, papulopustular lesions on physical examination, and a positive pathergy test. Two years prior to diagnosis of BD, vitiligo had also been diagnosed on the basis of hypopigmented lesions on the scrotum following genital ulceration. To our knowledge, this is the first case of incidental coexistence of BD and vitiligo, and, furthermore, the first case of koebnerization of genital ulceration of BD.

Background: Literature reports indicate that phospholipid liposomes facilitate the accumulation of active agents in the infundibulum. Objective: The study hypothesis of an improved antibacterial efficacy of benzoyl peroxide (BPO) in phospholipid liposomes was tested in comparison with a commercial and a pharmacopoeial BPO preparation. Methods: The infundibular bacterial samples were obtained with the Permabond technique from 20 acne patients who had been treated with the test substances (vehicle-controlled) for 2 weeks twice per day in a single-blinded, comparative study on the upper back. Results: A significant antibacterial effect in the infundibula (Propionibacteria and Micrococcaceae, both: p < 0.001) for a BPO phospholipid liposome formulation could be demonstrated. In comparison to the other significantly efficacious BPO formulations which were also tested (commercial product and pharmacopoeial formulation), the BPO phospholipid liposome formulation showed a significantly greater antibacterial efficacy for Propionibacteria and Micrococcaceae (both: p < 0.01). Conclusion: A BPO formulation in phospholipid liposomes may represent an improvement of the conventional external BPO treatment of acne.

Background: Behçet's disease (BD) is an inflammatory multisystem disorder, characterized by recurrent oral and genital ulcers, erythema nodosum-like lesions, papulopustular lesions, uveitis, large vessel thrombosis as well as neurologic and gastrointestinal manifestations. Case Report: A 55-year-old man with BD was admitted to the emergency room with perianal abscess and necrosis. One day after abscess drainage and débridement the patient developed peritonitis, and sepsis ensued. Histopathologic examination of the skin overlaying the débridement area revealed vasculitis and fibrinoid necrosis. Emergency laporatomy revealed multiple 'punchedout' perforations with 0.5-1 cm in diameter over the whole small intestine concentrating in the terminal ileum. Débridement - primary repair and partial ileal resection - of ileostomy was done. The patient died due to sepsis and multiple organ failure on the first postoperative day. Histopathologic examination revealed nonspecific inflammatory cell infiltrates surrounding capillaries and venules, especially in the submucosa and serosa (vasculitis) with no evidence of granulomatous inflammation. Conclusion: Anal abscess or necrosis in a patients with BD may be a clue to the presence of intestinal BD with imminent perforation, representing the widespread vasculitis of the gut in BD. © 2007 S. Karger GmbH.

Background Papulopustular lesions (PPL), the commonest presentation of skin lesions in Behcet’s disease (BD) are cutaneous, sterile folliculitis or acne-like lesions on erythematous base. Our purpose was to determine the true frequency and anatomic location of the PPL and compare this with controls. We also sought to determine whether or not there was any relationship between PPL and either disease activity or other manifestations of BD. Methods Fifty patients with BD, diagnosed according to the criteria of the International Study Group for Behcet’s Disease, were enrolled in the study. The control group consisted of 100 patients with other dermatologic diseases (21 acne and 79 non-acne patients), selected randomly. A dermatologist counted the lesions, in a blind protocol, on seven anatomic locations: scalp, face, neck, trunk, upper and lower extremities and genitalia. Results The frequency of PPL in patients with BD was 96% and the most common location was the trunk, whereas in the control group the frequency was 89% and the most common location was the face. In acne and non-acne patients, the frequency was 100% and 86.1% respectively. The total mean number, and mean numbers of PPL on the location of trunk, upper and lower extremities, and genitalia were higher in patients with BD than in controls. When the PPL in BD patients with a positive pathergy test was compared with that in patients with a negative pathergy test, the difference was significantly higher. Conclusions Our results indicate that PPL appear to be non-specific. In the diagnosis of BD the mean number and anatomic location of the lesions are of more importance than the frequency.

This open study was conducted in 72 outpatients with acne vulgaris, to compare the clinical efficacy and tolerability of azithromycin and minocycline. Azithromycin was administered as a single oral dose (500 mg/day) for 4 days in four cycles every 10 days and minocycline was administered 100 mg daily for 6 weeks. Improvement was assessed 6 weeks after initiation of treatment with a four-graded scale. A satisfactory clinical response was observed in 75.8% of the patients treated with azithromycin and in 70.5% of those treated with minocycline. There were no significant differences between these two acne treatments in terms of reduction of the number of lesions (p> 0.05). Both agents were well tolerated and mild side effects were reported in 10.3% of azithromycin and 11.7% of minocycline treated patients. We conclude that azithromycin is at least as clinically effective and well tolerated as minocycline as treatment of facial comedonic and papulopustular acne.

Oral and genital ulcerative lesions in Behcet’s disease (BD) are regarded as important manifestation for diagnosis. Various kinds of skin lesions appear in patients with BD. They present as orogenital ulcers, papulopustular eruptions, erythema nodosum, superficial thrombophlebitis, necrotizing vasculitis, and pyoderma gangrenosum. All patients with orogenital ulcerations, papulopustular eruptions, and thrombophlebitis should be fully investigated to establish a definitive diagnosis and eliminate the possibility of an underlying BD.

Scabies is commonly seen worldwide, in its usual classic form when afflicting older children and adults. However, neonatal scabies is described as its own entity in the literature. We present a case of a 4-week-old infant with a generalized papulopustular, vesicular, and crusted rash who was diagnosed with scabies. We contrast the differing clinical features of neonatal and classic scabies, describe possible mimickers of this diagnostic dilemma, and review current treatment options available for scabies in this very young age group.

In this retrospective study, 258 patients with BD (F/M: 130/128, mean age: 41.1±11,5 years) classified according to ISG criteria were included. The demographic and clinical data for active organ manifestations and treatment protocols were evaluated, both for the current visit and in the last month. Patients having at least one of any disease manifestations were categorized as active. Results At otal of 1757 visits of 258 patients were overviewed. Mean visit number was 6,8± 2,7 (range:1-10) and mean follow-up duration was 45.8±36.5 months (2-165). One hundred twenty-five patients (48.4%) were of mucocutaneus type, whereas 133 patients (51.6%) had major organ involvement. When all visits combined, 19.843.9% of the patients were using immunosuppressives (IS), whereas 35.3-59.3% was under non-IS therapies such as colchicine or NSAIDs. There was also a group of noncompliant patients (6.4-45%) without any treatment in some visits. Patients were clinically active in 67.2% (n=1182) of the total visits (n=1757). Frequency of clinical activity increased to 75.6% (68.1- 90.3) when the month before the visit was also included. The major cause of the activity was aphthous ulcers (39.4-63.2%) with other mucocutaneous manifestations also commonly present (Genital ulcer: 3.5-27.1 %, erythema nodosum: 8.2-22.5%, papulopustular lesions: 18.2-33.7%, arthritis: 21.3-33.5%, uveitis: 0.5-8.5% and vascular involvement: 2.5-10.8%). No difference was observed between the frequency of activity of patients having ISs or nonIS therapies. Conclusion Although complete remission is the current, primary target in inflammatory rheumatological diseases such as rheumatoid arthritis or vasculitides, it is fairly difficult to achieve complete remission in BD with current therapeutic regimens. The reluctance of the clinicians to be aggressive for some BD manifestations with low morbidity, such as mucocutaneous lesions, might be influencing the continuous, low-disease activity state in BD patients.

First described in Japan by Ofuji in 1970 [1], eosinophilic pustular folliculitis (EPF) is a noninfectious inflammatory skin disease that manifests with coalescing papulopustular plaques. The disease is histologically characterized by eosinophilic infiltration of hair follicles. There are three known variants of EPF: classic (as originally described by Ofuji and predominantly affecting Japanese individuals), HIV-associated, and infantile.

Background The aim of this study is to reveal demographic and clinical features of Behcet's disease (BD) in a Turkish population. Methods We retrospectively evaluated the clinical findings of 521 patients with BD. Results A total of 521 patients (287 female and 234 male) were included in this study. Onset signs: oral ulceration (72.7%) was followed by genital ulceration (3.1%), ocular involvement (1.0%), and erythema nodosum-like lesions (ENLL) (0.2%). In 120 patients (23%), the onset manifestation compromised more than one symptom. During follow-up, in females and males respectively, oral ulceration was found in 100%, genital ulceration in 90.9% and in 82.5%, papulopustular lesions in 52.6% and in 71.4%, positive pathergy test in 45.3% and in 48.7%, ENLL in 43.6% and in 31.6%, ocular involvement in 36.9% and in 58.1%, gastrointestinal involvement in 6.6% and in 5.6%, joint involvement in 4.2% and in 6.4%, vascular involvement in 1.7% and in 10.6%, neurological involvement in 0% and in 4.7% and pulmonary involvement in 0.7% and in 0.7%. Genital ulceration and ENLL were found to be statistically higher in females than males. Papulopustular lesions and ocular, neurological, and vascular involvement were significantly higher in males than females. Conclusions In our study, systemic involvement was higher in males than females, as the disease is more severe in males than females. As the only initial finding of the disease can be genital ulceration or ocular manifestations, gynecologists, urologists, ophthalmologists, and family practitioners must keep in mind BD as a differential diagnosis.

Background Epidermal growth factor receptor inhibitors (EGFRIs) are anticancer agents that have been approved for use in a variety of solid tumors. EGFR-inhibiting agents produce a variety of cutaneous adverse events: most commonly a follicular papulopustular (acneiform) eruption on the face, scalp, chest and upper back. Objective The goal of this manuscript is to elucidate the histopathologic findings associated with this most common adverse event. Methods The histopathological findings of 10 patients with papulopustular eruptions induced by EGFRIs are described and compared to the four prior published case series of acneiform rashes attributed to EGFRIs. Results All 10 patients in our case series showed a superficial, predominantly neutrophilic suppurative folliculitis with ectatic follicular infundibula and rupture of the epithelial lining. Similar pathology was found in the four other case series discussing this phenomenon. Conclusion While the characteristic clinical appearance of this rash precludes the need for a biopsy in most cases, this knowledge promotes our understanding of the pathophysiologic process. As the use of EGFRIs expands, dermatopathologists will see these reactions more commonly and will need to recognize this pattern.

The aim was to compare the treatment effectiveness of intense pulsed light (IPL) and vacuum versus IPL with placebo for mild to moderate comedonal and inflammatory acne.We randomized 180 patients with mild to moderate comedonal and inflammatory acne into three groups: Group A - 60 patients treated with vacuum and IPL, Group V - 60 patients treated with IPL, and Group 0 (control group) - 60 patients who received topical treatment with Sebium H2O Micellaire Solution. We evaluated the results using the Leeds revised acne-grading system and Cardiff Acne Disability Index.There was a significant reduction in the number of papules, pustules, and comedones in Groups A and V compared with those in the control group (p0.001) with a more rapid decrease of the papules from Group A compared with that from Group V. We found an improvement in the clinical aspect (p0.001) when we compared Groups A and V with controls. Patients belonging to Group A were more satisfied compared with those belonging to Group V (p = 0.004) and significantly more satisfied compared with those belonging to Group 0 (p0.001). In conclusion, we consider that both the devices are efficient, the combination of vacuum and IPL representing a therapeutic option for the comedonal acne.

This multicenter, randomized parallel group study investigated the efficacy and tolerability of adapalene 0.1% gel plus nadifloxacin 1% cream (combination therapy) compared with adapalene gel (monotherapy) during 12-week treatment of acne vulgaris. A total of 184 Japanese patients aged above 12 years with moderate to severe acne as indicated by the Japanese severity grading criteria were randomized to combination therapy (n = 84) and monotherapy (n = 100) groups, both having comparable demographic and baseline characteristics. Adapalene was applied only to inflammatory acne lesions in order to minimize skin irritation and ensure the treatment results. Efficacy and safety evaluations, treatment compliance and satisfaction with drug application were periodically monitored. The combination therapy provided a significantly greater efficacy than adapalene in decrement of inflammatory papulopustular lesions at 4 weeks and thereafter (P = 0.0056). The overall judgment of the therapeutic efficacy by the physician at the end of study revealed a significant difference (P = 0.02496) between the groups in favor of combination therapy. Dryness was reported in a greater proportion of patients undergoing monotherapy than combination therapy at weeks 2 and 4 (P = 0.04652). The patient self-assessment in satisfaction with the drug application at the end of study revealed a significant difference (P = 0.00268) between the groups in favor of combination therapy. Among 76 strains of Propionibacterium acnes isolated from 87 patients, no strain was resistant to nadifloxacin. Thus, the simultaneous use of adapalene and nadifloxacin may provide an additive and complementary effect, resulting in clinical superiority and greater patient adherence compared to adapalene monotherapy.

Background: There has been an increasing focus on the extent to which oxidative stress and inflammation are involved in the pathophysiology of acne. The aim of this study is to investigate the effect of oral Silymarin, N-acetylcysteine and Selenium in the treatment of acne vulgaris. Methods: A randomized prospective clinical trial was carried out on 56 patients with acne vulgaris who were examined clinically by dermatologist and classified according to disease severity. Serum levels of Glutathione, Malondialdehyde and Interleukine-8 in the acne patients were measured pre- and eight weeks post-treatment with oral antioxidants and compared to that of 28 healthy volunteers. The clinical follow- up was done every two weeks to assess the changes in the number of inflammatory lesions. Results: Administration of antioxidants to patients with acne vulgaris significantly reduce serum Malondialdehyde level; and increased serum level of Glutathione after eight weeks compared to pre-treatment value, also significantly reduce Interleukine-8 serum levels and the number of inflammatory lesions in patients with acne compared to placebo. Conclusion: The results obtained in this study clearly showed the beneficial effect of Silymarin, N-acetylcysteine and Selenium to patients with acne vulgaris as indicated by the clinical improvement that strongly and positively correlated with improvement in biochemical data.

Dermatologic adverse events (AEs) are frequently observed in patients receiving EGF receptor (EGFR; also known as ErbB1) tyrosine kinase inhibitor therapy. The impact of these AEs goes beyond cosmesis to the discomfort from itching, pain and secondary infections, all of which may significantly impact on patient well-being, adherence and clinical outcomes. Afatinib is a potent, irreversible, oral, ErbB family blocker, inhibiting EGFR (ErbB1), HER2 (ErbB2) and ErbB4 receptor kinases. It also inhibits transphosphorylation of ErbB3. Similar to EGFR inhibitors, dermatologic AEs have been frequently observed in patients treated with afatinib. Papulopustular (acneiform) rash, pruritus, xerosis, paronychia and alopecia will require patient education and proactive treatment interventions. This article summarizes current data on the dermatologic AEs associated with afatinib treatment across the clinical trial program, and provides strategies for their effective management.

Background and Objectives Pharmacological treatment has a fairly good effect on the papulopustular lesions in rosacea, but not as good an effect on the erythema and telangiectases. The aim was to treat rosacea patients with both erythematotelangiectatic and papulopustular lesions with flashlamp pulsed dye laser (FPDL) until telangiectases/erythema disappeared, and to evaluate whether the treatment might also be effective on papulopustular lesions. Study Design/Materials and Methods Ten patients were treated on one side of the face with FPDL. The final examination was blinded and performed on the average 10 months after the last treatment. Results Two of the patients had more lesions after treatment, three were unchanged, three had only slightly less, and two had markedly less papulopustular lesions. Conclusion Our conclusion from this small sample of patients is that FPDL probably has limited value on papulopustular lesions in rosacea. This indicates that the origin of rosacea may not be only vascular. Lasers Surg. Med. 34:266–268, 2004. © 2004 Wiley-Liss, Inc.

Epidermal growth factor receptor (EGFR) is known to be over-expressed in many different types of cancers, including lung cancer, breast cancer, colorectal cancer, and so on (1). Treatments targeting on EGFR signaling pathway provide better responses in these cancer patients harboring mutations in EGFR gene (2,3). However, adverse effects due to these EGFR inhibitors might lead to a poor drug adherence or discontinued usages of these agents (4). Skin toxicities are commonly encountered adverse effects during the treatment of EGFR inhibitors. Four major skin toxicities have been identified, including papulopustular (acneiform) eruptions, xerosis, pruritus, and paronychia. Therefore, management of these skin toxicities has a critical role in reducing patients’ discomforts, improving patients’ quality of life, maintaining usage of these agents, and further having a better prognosis (5).

Background It is well known that menstruation triggers several conditions such as migraine, recurrent aphtous stomatitis and acne vulgaris in otherwise healthy individuals (1). It may exacerbate chronic autoimmune diseases and familial Mediterranean fever (FMF) (2–4). There is also one study that briefly mentions menstruation causes activation in Behcet9s syndrome (BS) (4). Objectives We investigated the relationship between menstruation and specifically the skin-mucosa lesions of BS. As controls, we studied FMF patients. Methods Premenopausal women with BS and FMF seen consecutively at the outpatient clinic of Cerrahpasa Medical Faculty at Istanbul, were interviewed. BS patients were asked whether they experienced increased skin-mucosa lesions during the menstrual period. A similar questionnaire assessing this time the frequency of serositis and fever attacks was given to the patients with FMF. As a control the participants were also asked whether they experienced headaches during the same period as well. Results A total of 140 BS patients with a mean age of 36±8 and mean disease duration of 9±6 years were studied. While 21 (15%) were off treatment, 103 (74%) were using colchicine and the remaining were using other immunosuppressive agents. As shown in the Table, among BS patients, 78 (56%) associated at least one symptom with menstruation. The most commonly reported symptom related with menstruation was the papulopustular involvement (50%), followed by oral (30%) and genital ulcers (21%) and nodular lesions (21%). We also studied 185 patients with FMF. Their mean age was 32±8 and mean disease duration was 12±8 years. All patients were using colchicine for a mean duration of 8±7 years. A total of 138 patients (75%) reported that their attacks overlapped with menstruation. These attacks included mostly peritonitis in 126 patients (68%), pleuritis in 102 (55%), and fever in 73 (40%). Among both BS and FMF patients, similar number of patients (41% and 41%, respectively) reported that menstruation triggered headaches. Conclusions This survey showed that, in about half of the patients with BS at least one skin mucosa lesion is exacerbated with menstruation. Most commonly reported were the papulopustular lesions. Menstruation had a stronger effect on FMF, triggering at least one symptom in about ¾ patients. The main limitation of the study was the self-reported assessment methodology, rather than a prospective diary assessment. Our findings provide further evidence that papulopustular lesions of BS and acne vulgaris are pathologically related (5). References Khanna N et al. Indian J Dermatol Venereol Leprol. 1991; Akar S et al. Rheumatol Int. 2006; Colangelo K et al. Rheumatology (Oxford). 2011; Karadag O et al. Rheumatol Int. 2013; Kutlubay Z et al. Clin Exp Rheumatol. 2015 Disclosure of Interest None declared

Three children will be described who present recurrent episodes of pruritic papulopustular follicular lesions on the face, the extremities and the trunk. The episodes lasted for 1-3 months with intermittent remission. Each flare was accompanied by hypereosinophilia and an increased total IgE titer. RAST and prick tests were positive for Dermatophagoides pteronyssinus (DPT). Laboratory tests disclosed no infectious or parasitic etiology. Histological examination showed eosinophilic pustular folliculitis (EPF) in each of the 3 cases. The lesions responded well to topical corticosteroids. The aim of this article is to underline the importance of hypersensitivity reactions (in these particular cases to DPT) in the pathogenesis of EPF.

Colorectal cancer (CRC) is the third most common cancer, and is the third most common cause of death due to cancer in both women and men. Approximately 20 percent of patients with newly diagnosed colon cancer have distant metastatic disease at the time of diagnosis. Panitumumab is a fully human IgG2 monoclonal antibody targeting the epidermal growth factor receptor (EGFR), and it is commonly used to treat metastatic colorectal cancer (mCRC). Combinations of panitumumab plus an irinotecan or oxaliplatin-based regimen are reasonable both first-line and second-line options for mCRC with RAS wild type tumors. However, it has been associated with various side effects such as papulopustular acneiform rash, hypomagnesemia, and diarrhea. No previous reports on patients who developed tongue pain without stomatitis while treatment with panitumumab exists in the literature. Here we report two cases that developed tongue pain while on panitumumab for mCRC.

Kikuchi-Fujimoto disease commonly presents with cervical lymphadenopathy accompanied by fever, myalgia, neutropaenia, and rarely cutaneous eruption. Most cutaneous lesions present as erythematous macules, papules, plaques, nodules, or ulcers on the upper part of the body such as trunk, upper extremities, and face. We present a case of Kikuchi-Fujimoto disease with a papulopustular eruption on the whole body including the lower extremities.

Background Transient myeloproliferative disorder (TMD) affects up to 10% of patients with Down syndrome (DS). A small proportion of newborns are asymptomatic and only manifest circulating blast cells, with or without leukocytosis, while others present with hepatomegaly, splenomegaly, serous effusions, and liver fibrosis. Few cases in the literature also have skin manifestations, described as crusted, erythematous, vesiculopustular eruptions occurring mainly on the face, with spreading to the trunk and extremities. Materials and methods Four patients with DS and TMD were studied due to the presence of cutaneous eruptions. Systemic involvement, work-up, and follow-up were documented for each patient. Our results were compared with the previously reported cases. Results All patients were males, with ages ranging from 1 to 20 days at the time of diagnosis. In three patients, the eruption was papulopustular, and two of them also had vesicles. In one patient, lesions resembled bullous impetigo. In all, the lesions involved the face, followed by the extremities in three and the trunk in two patients. Pathergy phenomena was present in one patient. Hepatomegaly and a leukemoid reaction were present in all patients. Bone marrow showed an M7 immunophenotype in three patients and normal cellularity in one. Follow-up ranged from 2 to 11 months, during which the patients were healthy. Conclusions Recognition of the cutaneous eruptions associated with TMD in neonate patients with DS may lead to early diagnosis and avoidance of unnecessary chemotherapy. However, because leukemia may develop later, careful follow-up is mandatory in all cases.

A 4-year-old male presented with papulopustular eruption and eczematous dermatitis started in early infancy (Figs. 10.1 and 10.2). He also had recurrent large cutaneous abscesses in both axillae and groin area, with lymphadenopathy, but no fever. He had a history of recurrent bronchitis and pneumonia.

Purpose To describe the clinical features of cutaneous and ocular manifestations of childhood rosacea, to propose diagnostic criteria, and to emphasize the possible severity of ocular complications in this age group. Methods Children aged 1 to 15 years who had received a diagnosis of cutaneous and/or ocular rosacea and were seen between January 1, 1996, and December 31, 2011. Results Of 20 patients, 11 had ocular and cutaneous rosacea, 6 had isolated cutaneous involvement, and 3 had isolated ocular involvement. Dermatologic examination results were sufficient to diagnose rosacea in 12 of the patients (60%). The most common presentation was a papulopustular eruption on a telangiectatic background. In 11 patients (55%), ocular involvement preceded the skin eruption. Among the ophthalmologic manifestations, chalazions and blepharoconjunctivitis were the main presenting symptoms; keratitis was observed in 4 patients and corneal ulcers in 2. Ten patients were treated with oral metronidazole. Intermittent treatment for at least 3 months was used to avoid neurologic toxic effects and to achieve complete remission. Conclusion Although rare, childhood rosacea should be recognized because of the possible severity of ocular involvement.

Helicobacter pylori was incriminated as an etiological factor of rosacea. However, there is still controversy about this association. We conducted a comparative study in order to assess the role of H. pylori in rosacea patients who had dyspeptic symptoms. The study included 68 patients and 54 controls. Screening for H. pylori was performed and positive cases were referred for gastric endoscopy. The inflammatory response and bacterial density were evaluated in gastric biopsy. H. pylori vacA alleles, cagA and iceA genotypes were assessed by polymerase chain reaction. We found that 49 rosacea (72%) and 25 controls (46.3%) were infected with H. pylori. Thirty-one rosacea cases were papulopustular (PPR) while 18 were erythematotelangiectatic (ETR). Gastric ulceration was higher in PPR cases (38.7%) than ETR (11.1%) and controls (12%). A significant inflammatory reaction was observed more in PPR cases (74.2%) compared with 44.4% in ETR (P = 0.04) and 44% in controls (P = 0.02). Analysis of H. pylori genotypes revealed that vacA s1m1 was more identified in PPR cases (54.8%) compared with 22.2% in ETR (P = 0.03) and 16% in controls (P = 0.003). There was a significant elevation of cagA/vacA s1m1 positivity in PPR cases. After the eradication regimen of H. pylori, a significant improvement (P < 0.05) was observed in 15 out of 27 PPR cases (55.6%) compared with three out of 17 ETR (17.6%). We concluded that H. pylori has a significant role in rosacea patients who had dyspeptic symptoms. The PPR type is more influenced by H. pylori and this is regarded as being because of certain virulent strains that increase the inflammatory response in gastric mucosa and also in cutaneous lesions.

There is a variety of adverse effects and toxicities of newer and older chemotherapeutic agents which emerge in the skin, mucosa and adnexa. Common skin reactions while undergoing chemotherapy include alopecia, changes in skin pigmentation, palmoplantar erythrodysesthesia, nail dystrophies and stomatitis. Extravasation injuries or hypersensitivity reactions may be severe. New oncologic agents have led to the development of different, class-specific cutaneous side effects. Epidermal growth factor receptor (EGFR) inhibitors induce papulopustular rashes in a high percentage of patients as well as, to a smaller degree, xerosis cutis, hair and nail changes, hyper pigmentation and enhancement of radiation dermatitis. Multikinase inhibitors will often cause hand-foot syndrome, but may also induce facial erythema, subungual splinter hemorrhages and other less frequent skin changes. BRAF inhibitors can lead to rash and development of cutaneous keratinocytic neoplasias for which patients should be closely monitored. Finally, MEK/ERK inhibitors induce similar skin toxicities to EGFR inhibitors such as papulopustular rashes, xerosis cutis and paronychia. Our chapter will focus on the clinical picture, histopathology and treatment options of these new class-specific cutaneous side effects.

Rosacea is a chronic skin disease affecting up to 10% of the population in some European countries. Rosacea manifests as various combinations of characteristic signs and symptoms in a centrofacial distribution. At present, there is no consensus about the definition or classification of the clinical patterns of rosacea. Initially, four stages were differentiated (pre-rosacea then stages I through III), with several variants (e.g., persistent erythema and edema, rosacea conglobata, and rosacea fulminans). The National Rosacea Society (NRS) in the USA has classified rosacea into four subtypes (erythematotelangiectatic, papulopustular, phymatous, and ocular) and one variant (lupoid or granulomatous rosacea). This classification scheme does not mention progression from one type to another and makes no reference to pathophysiological considerations. It uses major and minor diagnostic criteria based on the physical findings and symptoms. The NRS has also developed criteria for grading disease severity. The classification of rosacea into stages or subtypes, without considering the possibility of progression from one to another, will probably remain controversial until additional knowledge on the pathophysiology of rosacea is obtained.

Background Behcet disease (BD) is prevalent in Central and East Asia and in the Eastern Mediterranean area where most studies have been performed. Few studies have evaluated patients with BD in Brazil. Objectives The objective of the study was to describe clinical manifestations of BD and their therapy in a single center in Brazil. Methods Sixty patients who met the International Study Group Criteria for BD and were under follow-up at the Vasculitis Unit of the Universidade Federal de Sao Paulo were evaluated in a retrospective observational study. Results Mean age at study was 40.0 (SD, 10.7) years, and the female-male ratio was 1.2:1.0. The frequency of disease manifestations was as follows: oral ulcers, 100%; genital ulcers, 93.3%; ocular manifestations, 63.3%; arthritis, 46.7%; cutaneous lesions, 71.7%; positive pathergy test, 22.7%; neurologic involvement, 28.3%; thrombosis, 13.3%; and gastrointestinal involvement, 3.3%. Arthritis and erythema nodosum were more prevalent among women, whereas papulopustular lesions were more common in men. The frequency of each treatment modality was as follows: colchicine, 78.3%; thalidomide, 26.7%; colchicine and penicillin, 21.7%; dapsone, 8.3%; and pentoxyphyline, 8.3%. These treatments were mainly used for mucocutaneous manifestations. Immunosuppressive drugs were prescribed for 70% of the patients, including azathioprine (35.0%), cyclophosphamide (28.3%), cyclosporin A (21.7%), methotrexate (18.3%), and chlorambucil (6.7%). Infliximab was used in 5.0% of refractory patients. No differences were observed between sexes related to severe manifestations of BD. Conclusions Although reported elsewhere, Brazilian men with BD did not have a worse prognosis. Women had a higher frequency of arthritis manifestations.

Rosacea is a common facial disorder characterized by centrofacial erythema, flushing, telangiectasia, edema, papules, pustules, ocular lesions, and rhinophyma in various combinations. The skin lesions most commonly affect the convex areas of the nose, cheeks, chin, and forehead. Rosacea is classified as erythematotelangiectatic (ETR), papulopustular, and phymatous subtypes, and as ocular and granulomatous variants. The ETR subtype is typified by frequent episodes of facial flushing, telangiectasias, and persistent centrofacial erythema and may be accompanied by facial edema, burning, or stinging. Severe flushing can cause significant physical discomfort and emotional stress to the patients, and currently no satisfactory treatments are available.

The conventionally used dose of isotretinoin in acne causes significant dose-related adverse effects. Low-dose isotretinoin has been used successfully in mild to moderate papulopustular acne. Although isotretinoin acts against all mechanisms of acne formation, it has no significant direct antimicrobial effect.To test whether the addition of an antibacterial enables use of isotretinoin in low doses even in moderate to severe acne.This was a preliminary open-label, prospective, non-comparative, single-centre study carried out in a tertiary-care referral hospital. Seventy patients with grade 3 and 4 acne according to the US FDA global score were included in the study between October 2005 and December 2007. These patients were treated with a combination of low-dose isotretinoin (0.3 mg/kg/day) and pulsed oral azithromycin (500 mg/day over three consecutive days every 2 weeks). Response to treatment was assessed at monthly intervals and was recorded as a percentage decrease in overall severity of disease. Treatment was continued to complete clearance of lesions or to 16 weeks, whichever came later.Sixty-two (93.9%) of 66 eligible patients had complete clearance of disease activity after a mean treatment duration of 21 weeks. The mean total cumulative dose of isotretinoin was 49.6 mg/kg. Seven (11.3%) patients had a relapse of disease during the post-treatment follow-up period. Fifty-three adverse effects were observed. Three patients had initial aggravation of disease that was managed with prednisolone and disappeared with continuation of treatment.A combination of low-dose isotretinoin and oral azithromycin pulse is effective in severe acne and has a reasonably acceptable adverse-effect profile and low post-treatment relapse rates.

Rosacea is generally categorized into 4 distinct clinical subtypes: erythematotelangiectatic, papulopustular, phymatous, and ocular.1 Granulomatous rosacea, rosacea fulminans, and perioral dermatitis have been described as additional variants.2 Herein we describe 14 patients with rosacea and prominent neurologic symptoms, who represent another distinct subset of rosacea meriting a unique approach to management.

A standardized skin-surface biopsy (1 cm2) of the cheek was performed in 49 patients with rosacea [13 with erythematotelangiectatic rosacea (ETR), three with squamous rosacea (SR), 33 with papulopustular rosacea (PPR)], and 45 controls. A mean density of 0.7 Demodex folliculorum/cm2 was found in controls, 98% of whom had less than five Demodex/cm2. When all clinical types of rosacea were considered collectively, the density of Demodex was significantly higher in patients with rosacea than in controls (mean = 10.8/cm2; P < 0.001). When the various clinical types of rosacea were considered separately, Demodex density was statistically significantly higher than in controls only in the PPR patients (mean = 12.8/cm2; P < 0.001). The same type of comparison was also made for three other groups of subjects-patients with isolated inflammatory papules (n = 4), rhinophyma (n = 3), and HIV infection (n = 21), respectively: in these groups, the Demodex density did not differ significantly from controls. The present study demonstrates a high density of D. folliculorum in PPR, and supports its pathogenic role in the papulopustular phase of rosacea. The study suggests that standardized surface biopsy could be a useful diagnostic tool for PPR, with a 98% specificity when Demodex density is higher than 5/cm2.