Issue 2016.2

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 1) Governments vary on what restrictions they put on caring and prescribing for displaced persons but as referenced by Fuller et al 2013 in this article the carer  will always have United Nations backing. In Rome the legality of the recipient of care is always recorded, but after ticking the appropriate box, therapy can go ahead.   2) As described in this Dresden experience interpreters are needed. Sometimes they are required urgently and always communication and counselling is in itself therapeutic. It is therefore helpful to have one site allocated for volunteer interpreters so one does not have to waste time looking for them. It can also provide to the interpreter some guidance on confidentiality.   3)Whether it is an emergency  as described or at the site of a disaster such as an earthquake ,a single known site to accept  sort and distribute medicines and devises will help to avoid the chaotic availability of multiple donations, and assessment of their safety.   4) Ivermectin was prescribed for treatment of scabies affecting whole families. It is not normally prescribed for under fives and for the pregnant.   Prof. Terence J. Ryan (United Kingdom)  

 The paper did not question hygiene measurements at the camp. nor the environment at the camp itself, i.e. Laundry, bathrooms, toilets.  The paper should include a set of proposals and recommendations stating the need of dermatology service as a first mandatory health service before establishing a shelter for displaced people. What did they do with the patients infected with scabies, mycosis ….etc.   Dr. Samar Al-Nahhas (Liban)    

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 Arsenic is a human carcinogen and is known to be accompanied by Bowen’s disease, squamous cell carcinoma and basal cell carcinoma. In addition, association of arsenic poisoning and Merkel cell carcinoma (MCC) has also reported since Ohnishi et al. and we first reported in late 90’s [1,2]. Ohnishi et al. reported 81-year-old Japanese male and we reported 72-year-old Japanese male of MCC associated with Bowen’s disease who had histories of arsenic exposure. After that Taiwanese case series were followed [3,4]. If such a carcinoma is also prevented by retinoids, it would be desirable.   References:  1. Ohnishi Y, Murakami S, Ohtsuka H, Miyauchi S, Shinmori H, Hashimoto K. Merkel cell carcinoma and multiple Bowen’s disease: incidental association or possible relationship to inorganic arsenic exposure? J Dermatol 1997;24:310-6.  2. Tsuruta D, Hamada T, Mochida K, Nakagawa K, Kobayashi H, Ishii M. Merkel cell carcinoma, Bowen’s disease and chronic occupational arsenic poisoning. Br J Dermatol 1998;139:291-4.  3. Lien HC, Tsai TF, Lee YY, Hsiao CH. Merkel cell carcinoma and chronic arsenicism. J Am Acad Dermatol. 1999;41:641-3.  4. Ho SY, Tsai YC, Lee MC, Guo HR. Merkel cell carcinoma in patients with long-term ingestion of arsenic. J Occup Health. 2005;47:188-92.   Daisuke Tsuruta, MD, PhD (Japan)  

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 Thank you for this well explained case report of a Pilomatricoma found in an unusual site like the orbit. In my opinion, it would be also interesting to understand why it was performed a computed tomography  as first imaging examination; I think that ultrasound  could represent an alternative choice in this case with optimal results.   Dr Francesco Maria Solivetti (Italy) Dr. Francesco Maria Solivetti thank you for reading our article „fibrolipoma of the orbit”, and in order to answer your comment, let me indicate that the pattient came to our clinic asking evaluation due that he was with orbit tumor. In this first evaluation, the patient showed a computed tomography of the orbit that he had taken previosly. So, we decided there was no necessary to make another image diagnosis. Certainly, we agreed with you that the ultrasonography is an important alternative for better diagnosis    Dr. Rafael Corredor-Osorio 

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 With the increase in lifespan, we are now facing a functional, rather than cosmetic, dimension of skin aging, where the protective mechanical functions of the skin are lost. Dermatoporosis is a novel term proposed to describe the chronic cutaneous insufficiency/fragility syndrome characterized by an extreme skin atrophy [1,2]. Dermatoporosis is principally due to chronological aging and long-term and unprotected sun exposure, but it may also result from the chronic use of topical and systemic corticosteroids [3]. Besides skin lacerations and ulcerations, deep dissecting hematoma (DDH) is an emerging severe complication of dermatoporosis [4]. Secondary to a minor traumatic event, rupture of the fragile dermatoporotic skin vessels exposed to skin surface due to epidermal and dermal atrophy and to the loss of viscoelasticity seems to be the pathogenetic mechanism underlying this complication. Prompt diagnosis by clinical examination and radiologic imaging, and immediate surgical evacuation of the hematoma and the necrotic tissue are critical to save the life of the patient [4-6]. In this issue, Re Domínguez et al. report another case of DDH as a complication of stage IV dermatoporosis and underline the importance of the awareness of this emerging syndrome by health care professionnals, especially by dermatologists and geriatricians [7].   We have recently proposed a membrane organelle, hyalurosome, composed of molecules involved in hyaluronate (HA) metabolism and cell signaling in the keratinocytes, such as principal HA receptor CD44, heparin-binding epidermal growth factor (HB-EGF), HB-EGF receptor erbB1 and HA synthase 3 (HAS3), which is functionally defective in dermatoporosis and may be a target for intervention [8]. Several lines of evidence suggest that hyalurosome is located in keratinocyte filopodia, thin, actin-rich plasma membrane protrusions implicated in cell motility. We have recently shown that keratinocyte filopodia are downregulated by corticosteroids in vitro [8]. Uncovering the molecular mechanisms implicating hyalurosome seems to be crucial to better understand the pathogenesis of dermatoporosis and to develop new therapeutic and preventive strategies [9-12].     References:   1. Kaya G, Saurat JH. Dermatoporosis – A chronic cutaneous insufficiency/fragility syndrome: Clinico-pathological features, mechanisms, prevention and potential treatments.  Dermatology. 2007;215:284-94.  2. Saurat JH. Dermatoporosis. The functional side of skin aging. Dermatology. 2007 ;215:271-2.  3. Kaya G, Saurat JH. Dermatoporosis: A new concept in skin aging. Eur Ger Med. 2010;1: 216-9.  4. Kaya G, Jacobs F, Prins C, Viero D, Kaya A, Saurat JH. Deep dissecting hematoma: An emerging severe complication of dermatoporosis. Arch Dermatol. 2008;144:1303-8. 5. Toutous Trellu L, Weiss L, Tarteaut MH, Kaya A, Cheretakis A, Kaya G. Deep dissecting hematoma: A plaidoyer for an early and specialized management. Eur Ger Med. 2010;1:228-30.  6. Toutous Trellu L, Herrmann FR, Tarteaut MH, Kaya A, Cheretakis A, Kaya G. Post-traumatic cutaneous hematomas in geriatrics hospital: A neglected disease? Eur Ger Med. 2012;3:107-111.  7. Re Domínguez ML, Di Martino Ortiz B, Rodríguez Masi M, Knopfelmacher Domínguez O, Bolla de Lezcano L. Dermatoporosis, an emerging disease: case report. Our Dermatol Online 2016;7:191-4.  8. Barnes L, Ino F, Jaunin F, Saurat JH, Kaya G. Inhibition of putative hyalurosome platform in keratinocytes as a mechanism for corticosteroid-induced epidermal atrophy. J Invest Dermatol. 2013;133:1017-26.  9. Kaya G, Tran C, Sorg O, Hotz R, Grand D, Carraux P, et al. Hyaluronate fragments reverse skin atrophy by a CD44-dependent mechanism. PLoS Med. 2006;3:e493.  10. Kaya G. New therapeutic targets in dermatoporosis. J Nutr Health Aging. 2012;16:220-34.  11. Darbellay B, Barnes L, Boehncke WH, Saurat JH, Kaya G. Reversal of murine epidermal atrophy by topical modulation of calcium signaling. J Invest Dermatol. 2014;134:1599-608.  12. Nikolic DS, Ziori C, Kostaki M, Fontao L, Saurat JH, Kaya G. Hyalurosome gene regulation and dose-dependent restoration of skin atrophy by retinaldehyde and defined-size hyaluronate fragments in dermatoporosis. Dermatology. 2014;229:110-5.   Prof Gürkan Kaya (Switzerland)  

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 In the recent case report published by Satoh and colleagues, another case of Staphylococcus aureus associated Henoch-Schonlein purpura (HSP) is described in an adult patient after sternotomy wound infection. Like the case reported by us, this patient also developed presumed renal involvement with increased serum creatinine as well as nephrotic range proteinuria. This case is important to the literature because it continues to highlight the necessary addition of HSP to the differential diagnosis of adult patients with lower extremity purpura. Classically taught as a disease of childhood, increasing numbers of cases of adult patients have been published in recent years. Close communication between Rheumatology and Dermatology specialists is necessary to ensure that direct immunoflourescense is obtained on skin biopsy specimens suspicious of vasculitis. This is especially important after a recent infection and in community hospital settings where it may not be routinely done. As the literature on this subject grows, Staphylococcus aureus appears to be playing a larger role in HSP, and may be important to the pathogenesis of worsening renal outcomes in adult patients.   Thank you for this interesting addition to the medical literature.  Reference:  1. Berquist JB, Bartels CM. Rare association of Henoch-Schönlein Purpura with recurrent endocarditis. WMJ. 2011;110:38-40.   Dr Jilaine Bolek Berquist (USA)