2014.2

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Paper titled as „Estimation of peroxisome proliferators-activated receptors γ gene expression in inflammatory skin diseases: atopic dermatitis and psoriasis“ represents an original work that point on the importance of decreased expression nucler receptors PPRγ in the pathogenesis of psoriasis and dermatitis atopica. The results of this study indicates that activation of this receptors and its signaling pathways could be very important therapeutic approach for the inflammatory skin diseases such as psoriasis and dermatitis atopica.   Slavic Vjeroslava, MD PhD (Montenegro)

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It is very useful study with very important finding showing efficacy of combination treatment using methotrexate and calcipotriol over methotrexate alone for chronic plaque psoriasis of scalp and palmoplantar area.   Dr. Sudip Parajuli (Nepal)  

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Original article titled as „HLA-DPDQDR is expressed in all lesional skin from patients with autoimmune skin diseases“ is aimed at identifying genetic predispositions for autoimmune skin blistering diseases. The results have indicated that antigen recognition and its presentation to immune system occurs in multiple skin structures. This findings indicate on the existence of a large number of target cells and/or their junctions-like structures that could be very important in achieving better control of inflammation.    Slavic Vjeroslava, MD PhD (Montenegro)  

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This is a very interesting paper that features an in-vivo study of pattern recognition receptors, recently studied by other authors [1,2] in animal models. As far as I am aware is the first in vivo research that evaluates the effect of phototherapy with UVB-NB on TLR 7 and 9.In a recent publication Jian et al1 evaluated an antagonist of TLR 7, 8 and 9 in a mouse model of psoriasis. Their results demonstrated  inhibition of IL-6, IFN-γ, IL-12, IL-23, IL-21, and IL-17. Thus demonstrating reduced reponses of Th1 and Th17. They have also suggested an inhibition of inflammsome activation.It would be interesting to study the TLR 8 response to phototherapy with UVB-NB. As explained by Suarez-Fariñas et al [2], activation of this receptor would activate NFkB responsive pathways with production of IL23 from dendritic cells. References:   1. Jiang W, Zhu FG, Bhagat L, Yu D, Tang JX, Kandimalla ER, et al. A Toll-like receptor 7, 8, and 9 antagonist inhibits Th1 and Th17 responses and inflammasome activation in a model of IL-23-induced psoriasis. J Invest Dermatol. 2013;133:1777-84.   2. Suárez-Fariñas M, Arbeit R, Jiang W, Ortenzio FS, Sullivan T, Krueger JG. Suppression of molecular inflammatory pathways by Toll-like receptor 7, 8, and 9 antagonists in a model of IL-23-induced skin inflammation. PLoS One. 2013;8:e84634.   Dr. Manuel Valdebran (Dominican Republic)

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Fanciful argumentation!Never found before a so complete and lucid statistical study that analyses the single cases of neurological factors inducing and/or aggravating psoriasis: e.g. the death of a dear family member, monetary or matrimonial tensors!Even the revelation of the odd behavior of Koebner’s effect tends to explain so many strange and unusual cases of psoriasis, sometimes  very difficult to diagnosticate.   Lorenzo Martini, M.Sc. (Italy) 

This study analyses in detail the participation of various trigger factors in the onset or exacerbation of psoriasis. It also confirms that stress, drugs and infection are the most common triggers of psoriatic process. Regarding the biochemical parameters which were analyzed in patients with psoriasis (Tabl. IV), it would be interesting to show a biochemical correlation before and after the administration of a particular drug (similar to what is shown in the connection of skin changes before and after the administration of methotrexate, cyclosporine etc., Fig. A1B1-A4B4).   Dr. Nermina Ovčina-Kurtović (Bosnia and Herzegovina)

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 This is a peculiar phenomenon I am most interested. The “isotopic response” implies that the new skin disease appeared at the site of an already healed primary skin disease. It is also essential that the second skin disease to be a new and unrelated one. Here we do not know the vitiliginous area having active disease or not hence to name this skin reaction as a isotopic response is problematic. If vitiligo is stable it falls to this category.If vitiliginous area is active I would like to propose a new term ( If the second skin disease appeared on the site of previous active dermatosus)  -“ Isotopic co- response”Fallowing cases are example to new category. References:   1. Göktay F, Mansur AT, Aydingöz IE. Colocalization of vitiligo and lichen planus on scrotal skin: a finding contrary to the actinic damage theory. Dermatology. 2006;212:390-2.   2. Ujiie H, Sawamura D, Shimizu H. Development of lichen planus and psoriasis on lesions of vitiligo vulgaris.Clin Exp Dermatol. 2006;31:375-7.   Dr. Ajith P. Kannangara (Sri Lanka)

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 Many dermatology problems have atypical presentation, which require skin biopsy and further specific diagnostic methods to differentiates between any similar problems as in this case. Pemphigus vulgaris patients with generalized disease may require more aggressive immunosuppression to suppress blistering, Prednisolone with an adjuvant is the preferred treatment for pemphigus vulgaris rather than steroid only.  Dr Amani Tresh (Libya)

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 Very interesting article focusing 3 cases of this rare disorder of keratinization. The term porokeratosis was coined in 1893, by Italian dermatologist Vittorio Mibelli  who was born in Portoferraio, Elba. The lesion he described was hyperkeratosis originating at the orifice of a sweat duct then the name “poro”. It is a quite typical  well-de? ned lesion with a hyperkeratotic ridge on the border that contains the coronoid lamella.Malignant transformation is a known complication and has been reported as high as 7.5%; therefore, it is advisable to treat these lesions. Successful treatment of these lesions with imiquimod 5% cream has been reported although redness of skin usually complicates patient adherence.  Dr César Bimbi (Brasil)

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A rare clinical picture of tuberculosis presenting as a lip abscess is presented by the authors,that should be considered in the differential diagnosis particularly in a patient with underlying tuberculosis.Prof. Kanthilatha Pai (India) 

Thank you for the nice presentation. Going back to the last statement in the conclusion “Definitive tissue diagnosis along with demonstration of AFB, as in the present case remains the gold standard.”With its easily handled procedure unfortunately the demonstration of AFB by ZN staining method has its limitation as its sensitivity remains obviously low.Different diagnostic modes have been implemented for TB diagnosis.Conventional methods for the diagnosis of tuberculosis include smear andculture for Mycobacterium tuberculosis. Ziehl-Neelsen staining for acid-fast bacilli requires 104-106bacilli/ml of tissue or fluid specimens to give a positive result. Although culture for mycobacterium is more sensitive, it still needs 101-102 bacilli/ml of sample for the diagnostic yield and requires two to four weeks for the growth of M. tuberculosis. Diagnosis of tuberculosis from tissue samples is usually made by histopathological examination (HPE) that depends on the presence of granulomatous inflammation and caseous necrosis. It requires high expertise. Advanced molecular methods such as Polymerase chain reaction (PCR), a type ofnucleic acid amplification system, have shown very promising results for early and rapid diagnosis of the disease due to its detection limit of one to ten bacilli in various clinical samples.   Dr. Mohamed Wael Daboul (Syrian Arab Republic)

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 Reporting interesting case with an atypical presentation of pyogenic granuloma in the glans penis. The approach was correct, beyond all preoperative investigation, the surgical indication was perfect, the procedure, the principle would be diagnosed, eventually becoming therapeutic.  Dr. Roni Leonardo Teixeira (Brazil) 

 This case highlights the unusual presentation of Pyogenic granuloma, which should be kept in mind while encountering a erythematous papule in the urethra.   Prof. Kanthilatha Pai (India)

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Seborrheic keratosis (SK) is a one of the most benign condition in aging skin of either white or skin of colour.Melanocytic naevus also falls to the frequently seeing dermatosus especially in Asian population. Association between Seborrheic keratosis and Melanocytic naevus is most probably a coincidental occurrence because so far there is no documented hard evidence to suggest the co-occurrence is a collision. Dr. Ajith P. Kannangara (Sri Lanka)

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 The authors describe an interesting and still debatable case, when referring to diagnosis, prevalence and terms of definition.A few remarks:Cheilitis granulomatosa  is a chronic swelling of one or both  lips due to granulomatous inflammation. It is a monosymptomatic form or an incomplete variant of Melkersson-Rosenthal syndrome, defined by the triad of recurrent orofacial swelling, facial nerve palsy and fissuring of the tongue (lingua plicata).Wiesenfield [1] introduced the concept of orofacial granulomatosis and cheilitis granulomatosa  and Melkersson-Rosenthal syndrome are considered subsets of this new entity. Cheilitis granulomatosa without lingua plicata or facial palsies also is called Miescher syndrome or Miescher’s Cheilitis [2].The classic triad of Melkersson-Rosenthal syndrome is seen in only 25% of cases [3] and perhaps the syndrome is sometimes over or under diagnosed. Being a granulomatous disease granulomatous inflammation is the histological hallmark of the disease, although some reports have not been so drastic in this regard, as is the case of present communication.Fissured tongue  has been reported in 10% of normal population and in  Melkersson-Rosenthal syndrome,  Coffin-Lowry syndrome, Fraser’s Syndrome, Down’s syndrome,  Oral-Facial-Digital (OFD) Syndrome Type I, Mohr Syndrome (the OFD syndrome, type II), Pierre Robin Syndrome,  Maroteaux Lamy Syndrome,  ECC syndrome [4]. The association with psoriasis is intrigue and confirmed lately in different studies with a  variable prevalence: 6-47.5% [5]We congratulate the authors for the presentation that draws attention to many interesting clinical issues.  References:   1. Wiesenfeld D, Ferguson MM, Mitchell DN, MacDonald DG, Scully C, Cochran K, et al. Oro-facial granulomatosis–a clinical and pathological analysis. Q J Med. 1985;54:101-13.2. van der Waal RI, Schulten EA, van de Scheur MR, Wauters IM, Starink TM, van der Waal. Review Cheilitis granulomatosa.J Eur Acad Dermatol Venereol. 2001;15:519-23.3. Chen C, Huilgol SC, James C, Selva D. Melkersson-Rosenthal syndrome presenting with upper lid edema and facial palsy. Can J Ophthalmol. 2002;37:361-3.4. Gorlin Robert J, Cohen M Michael, Hennekam Raoul CM. Syndromes of head and neck. 4th edition. Oxford University Press Inc; 2001.5. Zargari O. The prevalence and significance of fissured tongue and geographical tongue in psoriatic patients. Clin Exp Dermatol. 2006;31:192-5.  Prof. Anca Chiriac MD, PhD (Romania) 

 Given the unusual association, it would be interesting to watch an intraoral images of the patient (including the tongue), an image of treatment outcome and histopathology.   Dr José López-López (Spain)

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 Comentario:   La esclerodermia localizada linear se caracteriza por lesiones cutáneas en banda o alargadas  que presenta substrato de fibrosis.  En los casos 2 y 3, si bien es factible que comenzarán en forma lineal, en la actual presentación se constata compromiso de la mitad de la cara.  /Hemifacial/  Parece correcto mencionar esta dificultad de ubicación de ambos casos y  referir la clasificación en la cual se han basado los autores.  De esta manera el articulo tendría mayor valor docente.      Comment:    Linear localized scleroderma characterized by skin lesions or elongated strip substrate having fibrosis. In cases 2 and 3, although it is likely to start in a linear fashion, in the current presentation compromise half of the face is found. /hemifacial/  It seems right to mention the difficulty of both location and refer the classification in which the authors have been based. In this way the article would have greater educational value. Dra. María Bibiana Leroux (Argentina) 

 As clinical dermatologist, I have found this article is of great interest and I feel readers will find it so: A brief and good review of the three types of linear scleroderma, which in certain cases may be considered a challenge-to-treat condition. Unfortunately, my personal experience on therapies for this disease is not satisfactory, so there future researches are warranted on this way. Good quality clinical images are accompanied in this easy-to-read, well-structured article.   Dr. Husein Husein-ElAhmed (Spain)

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 A very interesting -up to date- review of thalidomide, a drug labeled pregnancy category X, but many dermatologist around the world are using currently at least in recurrent aphthous, actinic prurigo and prurigo nodularis, but anyone using it should follow the S.T.E.P.S. program, taking account the irreversible peripheral neuropathy as a complication.Now days the only FDA-approved indication is erythema nodosum leprosum and the rest of indications are off-labeled dermatological uses. Prof. Roberto Arenas (Mexico)

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 As noted by the authors it is very important to differentiate between vascular malformations and vascular neoplasms especially infantile hemangiomas. Not only because of its origin but because these entities have different therapeutic approaches. Infantile hemangiomas are benign self-limited neoplasms that are very susceptible to the treatment with systemic and topical propranolol, used in cases of functional or aesthetic compromise. Conversely vascular malformations do not involute and necessitate imaging studies for further categorization. Different modalities of treatment are described for this entity depending on the type of malformation, its location, the areas involved. Certainly it is important for dermatologists to instruct colleagues from other specialties about the difference between vascular malformations and vascular tumors and the recent advances in their therapeutic approaches.   Dr. Manuel Valdebran (Dominican Republic)

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 Clear concepts that unfortunately not all pathologists know and confusion of nomenclature and classification is created. Excellent job. There are several curiosities in this diagnosis:  1. Merkel cell carcinoma shows epithelial and neuroendocrine differentiation. Tumour cells express low molecular weight cytokeratins (detectable by specific or broad spectrum cytokeratins such as AE1/AE3, CAM5.2, pan-cytokeratin), epithelial membrane antigen and the epithelial marker BER-EP4. Cytokeratin 20 is a sensitive and quite specific marker for Merkel cell carcinoma, and was not done in this case. CK20 is useful in combination with thyroid-transcription factor-1 to differentiate between Merkel cell carcinoma (CK20 positive,TTF-1negative) and small cell carcinoma of the lung (<10% CK20 positive, TTF-1 positive). Markers of neuroendocrine differentiation include chromogranin, synaptophysin, neuronspecific enolase, bombesin, somatostatin, calcitonin, gastrin and others.Merkel cell carcinoma also expresses CD117, the KIT receptor tyrosine kinase, and in approximately a third of cases CD99. The tumour cells are negative for leukocyte common antigen and S-100.  2. The epidermis may be involved in a pagetoid fashion as a feature of this tumor, and in exceptional cases the tumour cells are entirely limited to the epidermis. Although most MCCs are entirely dermal or subcutaneous, some of them have an intraepidermal component (epidermotropic MCC). 3. Not infrequently, Merkel cell carcinoma occurs in intimate association with an in situ or invasive squamous cell carcinoma.   Reference: https://www.inkling.com/read/dermatopathology-busam-goldblum-1st/chapter-16/merkel-cell-carcinoma   Prof. Ass. Beatriz Di Martino (Paraguay)