396 Correspondence
patients with atypical or poorly responsive leg or cutaneous ulceration. Departments of Dermatology and *Tissue Viability, Royal Hospitals Trust, Grosvenor Road, Belfast, Northern Ireland, U.K. E-mail:
[email protected]
(a)
D.J. MCKENNA J. DONNELLY* D.K.B. ARMSTRONG
References 1 Claeys A, Weber-Muller F, Trechot P et al. Cutaneous, perivulvar and perianal ulcerations induced by nicorandil. Br J Dermatol 2006; 155:494–6. 2 Cooke NS, Tolland JP, Dolan OM. Nicorandil-associated perianal ulceration: a case series of 10 patients. Br J Dermatol 2006; 154:199– 200. 3 Wong T, Swain F, Calonge E. Nicorandil-associated perianal ulceration with prominent elastophagocytosis and flexural ulceration. Br J Dermatol 2005; 152:1360–1. 4 Malik R, Clark C, Blair R et al. Chronic anal ulceration due to nicorandil. Br J Dermatol 2005; 152:809–10. 5 Passeron T, Lacour JP, Mantoux F et al. Chronic anal ulceration due to nicorandil. Br J Dermatol 2004; 150:394–6. 6 Watson A, Al Ozairi O, Fraser A et al. Nicorandil associated anal ulceration. Lancet 2002; 360:546–7. 7 Watson A, Suttie S, Fraser A et al. Nicorandil associated anal ulceration. Colorectal Dis 2004; 6:330–1. 8 Jang HS, Jo JH, Kim BS et al. A case of severe tongue ulceration and laryngeal inflammation induced by low-dose nicorandil therapy. Br J Dermatol 2004; 151:939–40. Conflicts of interest: none declared.
(b)
Paraneoplastic neutrophilic figurate erythema DOI: 10.1111/j.1365-2133.2006.07640.x SIR, Neutrophilic dermatoses are a heterogeneous group of diseases characterized histologically by the presence of a neutrophilic infiltrate in the dermis, epidermis, or both, the absence of identifiable infectious micro-organisms and a positive clinical response to treatment with systemic corticoids.1 They are probably the group of cutaneous disorders most frequently linked to disease of internal organs, and may be associated with neoplasias, especially haematological ones. The cutaneous lesions may precede the development of the neoplasia by months or years, so that follow-up of the patient is essential. We report a 79-year-old woman with a clinical history of cryptogenetic hepatic cirrhosis who was referred to our outpatients department because of generalized cutaneous lesions of 1-month duration. Physical examination revealed the presence of annular, polycyclic purplish erythematous lesions, which were raised, desquamative and had an arciform border. They affected the upper and lower limbs, including the palms
Fig 1. (a) Annular, polycyclic, purplish erythematous lesions on the lower limbs. (b) Detail of the lesion on the sole of the foot where the arciform and desquamative border can be seen.
of the hands and the soles of the feet (Fig. 1a,b). The lesions presented a peripheral growth with central clearing and a progressive extension towards the trunk. The patient did not have a raised temperature or mucosal involvement, and complained only of a slight itching, together with asthenia and hyporexia without weight loss that had developed over the previous 6 months. Laboratory testing showed only a raised lactic dehydrogenase of 456 IU L)1 (normal 91–180). A cutaneous biopsy was performed in which a neutrophilic infiltrate affecting the eccrine excretory duct could be seen 2006 The Authors
Journal Compilation 2006 British Association of Dermatologists • British Journal of Dermatology 2007 156, pp378–410
Correspondence 397
Fig 2. Neutrophilic infiltrate affecting the eccrine excretory duct. Staining and magnification, main figure: haematoxylin and eosin · 10; inset: periodic acid-Schiff staining · 40.
(Fig. 2). The secretory portion was excluded. The infiltrate, although to a lesser degree, also had a perivascular and superficial distribution with oedema in the dermis. No indications of vasculitis were found. Microbiological cultures carried out for fungi, bacteria and mycobacteria were negative. The lesions were treated successfully with oral corticoids. A month after the first consultation, the patient began to suffer from left-sided painful latero-cervical adenopathy, a high temperature that did not respond to antibiotics and the reappearance of the cutaneous lesions. Both the febrile syndrome and the cutaneous symptoms were again resolved with oral corticoid treatment. A first cervical ganglion biopsy was reported as showing a reactive adenitis, but given the persistence of the adenopathy, a second biopsy was carried out which revealed a Hodgkin lymphoma. A study of its extension did not show any other affected sites (stage IA). Radiotherapy was given with complete remission of the lymphoma and with no return of the cutaneous lesions after 2-year follow-up. We present the case of a patient with a cutaneous paraneoplastic clinical picture and an associated Hodgkin lymphoma, with the clinical characteristics of a figurate erythema and histologically compatible with a neutrophilic dermatosis. Erythema gyratum repens is characterized by serpiginous, erythematous lesions that are centrifugal and rapid growing. It may affect the whole body surface, but excludes the palms of the hands and the soles of the feet. In some 82% of cases it is associated with solid tumours. The histopathology is nonspecific and includes a superficial and at times perivascular infiltrate of monocytes, lymphocytes or histiocytes.2 Erythema annulare centrifugum is characterized by erythematous papules with peripheral growth and central clearing that is slower compared with erythema gyratum repens, and forms annular and polycyclic shapes. It has been described in association with infections, drugs, autoimmune diseases and neoplasias. Depending on the clinical and pathology findings it is classified into a superficial and a deep type. The super-
ficial type presents as a superficial spongiotic dermatitis and the deep type with a superficial and deep perivascular lymphocytic infiltrate.3 As we can see, although cutaneous lesions are compatible with figurate erythema, these entities do not present with the histology of neutrophilic dermatosis. We have found only two reported cases named as ‘neutrophilic figurate erythema of infancy’, characterized by annular and arciform lesions with centrifugal growth and central clearing, both in children, with a spontaneous resolution and no association with other pathologies.4 Recently Khan Durani et al.5 have described a case of neutrophilic dermatosis simulating an erythema gyratum repens in a patient with systemic lupus erythematosus not associated with a neoplasia. With respect to the anatomopathological findings, we have to suggest a differential diagnosis with other neutrophilic dermatoses, especially neutrophilic eccrine hidradenitis and Sweet syndrome. Neutrophilic eccrine hidradenitis is characterized by a variable clinical picture of papules, nodules, plaques and erythematous or purplish pustules. Histologically there is a neutrophilic infiltrate with degeneration and necrosis of the eccrine glands. The majority of cases occur in patients with haematological neoplasias who are receiving chemotherapy; exceptionally, cases have been described that were not related to chemotherapy6 and even preceded the development of the neoplasia.7 In our case, the exclusive involvement of the eccrine duct, especially the acrosyringium, is striking, as neutrophilic eccrine hidradenitis is characterized by involvement both of the secretory portion and the duct. However, Scallan et al.,8 in 1988, described a case with involvement of the eccrine duct excluding the secretory portion. Sweet syndrome is classically characterized by raised temperature, neutrophilic leucocytosis, an acute eruption, a massive dermic neutrophilic infiltrate without vasculitis and a good response to treatment with oral corticoids. It should be noted that cases of Sweet syndrome associated with neoplasias may be clinically atypical, with a higher incidence of recurrence and the absence of leucocytosis and raised temperature.9 The diffuse perivascular neutrophilic infiltrate that was seen in our patient was slight, in contrast with the characteristics of Sweet syndrome. Our patient did not have neutrophilia, but did have an episode of high temperature and a good response to treatment with oral corticoids. As noted above, neutrophilic dermatoses associated with haematological neoplasias frequently present atypical or intermediate clinical forms and there have been cases described of the association of several neutrophilic dermatoses in the same patient.10 For this reason it is postulated that the different manifestations may form part of one and the same spectrum.1 It is possible that the clinical picture of our patient corresponds to one of such forms. However, we must point out that we have not found any reported case of paraneoplastic neutrophilic dermatosis with a clinical picture of figurate lesions similar to ours. We therefore propose the name of paraneoplastic neutrophilic figurate erythema based on the
2006 The Authors Journal Compilation 2006 British Association of Dermatologists • British Journal of Dermatology 2007 156, pp378–410
398 Correspondence
clinical and anatomopathological findings to denominate this new entity. Departments of Dermatology and *Pathology, Santiago Apo´stol Hospital, C/Olaguibel no. 27, 01004, Vitoria, A´lava, Spain E-mail:
[email protected]
I . T R E´ B O L R . G O N Z A´ L E Z - P E´ R E Z I . G A R C ´I A - R I O M.A. ARREGUI N. SARACIBAR* L. CARNERO R. SOLOETA
References 1 Hensley CD, Caughman SW. Neutrophilic dermatoses associated with hematologic disorders. Clin Dermatol 2000; 18:355–67. 2 Eubanks LE, McBurney E, Reed R. Erythema gyratum repens. Am J Med Sci 2001; 321:302–5. 3 Weyers W, Diaz-Cascajo C, Weyers I. Erythema annulare centrifugum. Results of a clinicopathologic study of 73 patients. Am J Dermatopathol 2003; 25:451–62. 4 Annesi G, Signoretti S, Angelo C et al. Neutrophilic figurate erythema of infancy. Am J Dermatopathol 1997; 19:403–6. 5 Khan Durani B, Andrassy K, Hartschuh W. Neutrophilic dermatosis with an erythema gyratum repens-like pattern in systemic lupus erythematosus. Acta Derm Venereol 2005; 85:455–6. 6 Roustan G, Salas C, Cabrera R, Simo´n A. Neutrophilic eccrine hidradenitis unassociated with chemotherapy in a patient with acute myelogenous leukemia. Int J Dermatol 2001; 40:144–7. 7 Pierson JC, Helm T, Taylor J. Neutrophilic eccrine hidradenitis heralding the onset of acute myelogenous leukemia. Arch Dermatol 1993; 129:791–2. 8 Scallan PJ, Kettler AH, Levy ML, Tschen JA. Neutrophilic eccrine hidradenitis. Evidence implicating bleomycin as a causative agent. Cancer 1988; 62:2532–6. 9 Cohen PR, Kurzrock R. Sweet syndrome revisited: a review of disease concepts. Int J Dermatol 2003; 42:761–78. 10 Caughman W, Stern R, Haynes H. Neutrophilic dermatosis of myeloproliferative disorders. J Am Acad Dermatol 1983; 9:751–8. Conflicts of interest: none declared.
percentage reduction. Even though this evaluation seems convenient for clinical routine, we propose that efficacy of surgical procedures for axillary hyperhidrosis should be evaluated at least with one objective method (e.g. iodine starch test or gravimetry) if scientific studies are performed. This would facilitate the comparability of different surgical procedures. In their discussion the authors mention the so-called novel surgical techniques for focal axillary hyperhidrosis, with special regard to curettage or liposuction. We agree with the authors’ opinion that sufficient and stable removal of sweat glands is not possible by using standard liposuction cannulas. However, we have shown that with a specially designed, flat-tip rasping cannula an effective long-term reduction of axillary sweating is possible.2 The counterpart to the described scissor snipping of sweat glands is obtained by pushing the axillary skin with adjacent sweat glands into the rasps of the above-mentioned cannula, thus allowing an aggressive curettage (Fig. 1). In their discussion Lawrence and Lonsdale Eccles underline the ongoing disagreement between supporters of open surgery and those who prefer minimally invasive strategies such as suction-curettage. Whereas some authors postulate the higher efficacy of open surgery, others point out that minimally invasive procedures lead to less scarring and complications.2,3 Despite this discordance no side-control studies comparing open surgery and novel techniques (e.g. suction-curettage) are available although these data would be of great interest to physicians specialized in the treatment of focal axillary hyperhidrosis. Our hyperhidrosis study group plans to initiate a study in this regard. We read the histopathological data with great interest. The fact that sweat glands were visible at the bottom of biopsy specimens with a minimum average depth of 3Æ5 mm may support the theory that suction-curettage may not be successful if performed in too superficial a plane.4 Hence prior to curettage a slight superficial liposuction for removal of deep parts of sweat glands could enhance the efficacy of suctioncurettage. Of further interest would be a histopathological study evaluating the pre- and postoperative density of sweat glands and to investigate a possible correlation between histological findings and clinical outcome.
Surgical treatment of axillary hyperhidrosis DOI: 10.1111/j.1365-2133.2006.07637.x SIR, We read with great interest the recent article by Lawrence and Lonsdale Eccles1 on selective sweat gland removal with minimal skin excision in the treatment of axillary hyperhidrosis, which contained fascinating and promising data. Based on our long-standing experience with surgical procedures for the treatment of excessive sweating we would like to add some further comments and information. Lawrence and Lonsdale Eccles observed a notable reduction of axillary hyperhidrosis after surgery.1 However, efficacy was only assessed by the patients themselves, who estimated the
Fig 1. Rasping type cannula. An aggressive curettage is enabled by pressing parts of the dermis into the rasps during surgery. 2006 The Authors
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