Mona Abdel-Halim

The exact aetiology of pityriasis lichenoides chronica (PLC) remains unknown. While phototherapy is the most investigated therapeutic modality, azithromycin has been used scarcely. The aim of this study is to evaluate the therapeutic efficacy of azithromycin in the treatment of PLC compared to NB-UVB and evaluating the presence of streptococcal infection as a possible etiological factor in PLC patients. The study was designed as a randomised controlled trial. Twenty-four patients with PLC were randomly allocated into either azithromycin (n = 13, standard dose every 10 days) or NB-UVB (n = 11, thrice weekly) groups. End of study (EOS) was either complete clearance of lesions or a maximum of 8 weeks. Therapeutic efficacy was defined as percent reduction in lesions and was calculated for the rash as a whole, erythematous papules alone, and hypopigmented lesions alone and graded into complete, very-good, good, poor or no response. Anti-streptolysin O titre (ASOT), anti-deoxyribonuclease B titre (anti-DNaseB) and throat culture were evaluated at day 0. No significant difference existed between both groups as regards therapeutic efficacy. At EOS, NB-UVB achieved significantly more percent reduction in the extent of hypopigmented lesions and consequently in the rash as a whole (p = 0.001, p = 0.034, respectively). The extent of the rash as a whole was significantly less in the NB-UVB at EOS (p = 0.029, respectively). The effect of NB-UVB on hypopigmented lesions appeared early at week 4 of treatment. Only two patients, one from each group, relapsed during the 3 month follow-up. Evidence of recent streptococcal infection was present in 79% of the cases, mainly in the form of elevated ASOT (94.7%). It was significantly more encountered in young children (< 13 years) (p = 0.03) and was associated with more extent of erythematous papules and consequently with more extent of the rash as a whole (p = 0.05 and p = 0.01, respectively). It did not affect outcome of therapy at EOS. Azithromycin did not show more favorable response in patients with recent streptococcal infection. Therapeutic efficacy of azithromycin is comparable to NB-UVB in treatment of PLC; however, NB-UVB is superior in management of hypopigmented lesions. It is highly suggested that PLC could be a post streptococcal immune mediated disorder.Registration number: ClinicalTrials.gov, NCT03831269.

BACKGROUND/OBJECTIVES: Pityriasis lichenoides chronica (PLC) lesions are reported to subside with post-inflammatory hypopigmentation (PIH); hence, the most widely perceived nature of hypopigmented macules in PLC is PIH. However, to the best of our knowledge, no studies describing histopathological findings in these lesions are reported in literature. The aim of this study is to evaluate the hypopigmented lesions encountered in PLC patients and to shed light on their histopathological features.

METHODS: A cross-sectional observational study included twenty-one patients with PLC recruited in a period of twelve months. Clinical characteristics of each patient were collected. A skin biopsy from hypopigmented lesions whenever present was taken and assessed with routine haematoxylin and eosin stain.

RESULTS: Seventeen patients (81%) were less than 13 years old. Most patients (85.7%) demonstrated diffuse distribution of lesions. Hypopigmented lesions were present on the face in 12 (57.14%) patients. Histopathologically, hypopigmented lesions showed features of post-inflammatory hypopigmentation in 19% of patients, residual PLC in 52.4% and active PLC 28.6% of patients.

CONCLUSION: Hypopigmented lesions in PLC were noted mainly in younger ages, histopathologically they may show features of active or residual disease, beyond post-inflammatory hypopigmentation. Consequently active treatment for patients presenting predominantly with hypopigmented lesions could be required to control the disease.

Background: Skin involvement in granulomatosis with polyangiitis (GPA) is common and can appear as an initial presentation of the disease or more commonly through its course.

Case presentation: We report a case of a 24-year-old male patient, previously diagnosed as having GPA, admitted with fever, hemoptysis, generalized hemorrhagic blisters associated with arthralgia, fatigue, myalgia, nasal crusting, and vertigo. Three weeks prior to admission, he developed erythematous papules on both elbows, and purpuric papules on both lower limbs. Histopathological examination revealed: interstitial granulomatous dermatitis (elbows) and foci of dermal hemorrhage, foci of interstitial histiocytes and zones of altered necrobiotic collagen (lower limbs) consistent with cutaneous lesions of GPA. Two weeks later, his rash progressed to widespread purpura associated with hemorrhagic blisters. Another biopsy revealed leukocytoclastic vasculitis with fibrinoid necrosis of the vessel walls associated with perivascular infiltrate of neutrophils, nuclear dust and extravasated erythrocytes without an associated granulomatous inflammation or necrobiosis. The constellation of the results of the three biopsies together with clinical correlation pointed to a flare of GPA.

Conclusion: Skin involvement in GPA is quite common, and it can manifest in different forms in the same patient. Our patient developed three different skin pathologies within a short period of time.

Fractional CO laser rejuvenation of scars offers a high safety profile. Laser marks usually disappear clinically within 1 week. The authors observed occasional persistence of the laser marks on the scar surface. The purpose of this study is to report the incidence and to describe the clinical, dermoscopic, and histological features of a novel observed complication of fractional CO laser scar rejuvenation "Persistent Pixel Stamping Marks (PPSM)".One hundred seventy-one cases were consecutively recruited from patients assigned for fractional CO laser scar rejuvenation. Patients who developed the phenomenon 1 month post laser session were recorded and subjected to clinical photography, dermoscopy, and optical coherence tomography (OCT) as well as a 4-mm punch biopsy from pixelated scars. The evolution of PPSM was followed up for 6 months. PPSM developed in 16 patients (9.4%), 15 of which were post burn hypertrophic scars. PPSM was significantly related to darker skin type, darker scar color, and longer scar duration. Histopathological findings included characteristic holes in stratum corneum and superficial dermis, thick collagen bundles perpendicular to the skin surface with loss of elastic tissue, focal interface changes, and triangular focus of fibroblastic proliferation. The marks disappeared in 5 and lasted in 11 patients. Their longevity was significantly related to longer dwell times and lower densities. PPSM represent miniature scarring at the sites of the microscopic thermal zones or a sign of their delayed healing. They tend to follow fractional CO laser resurfacing of hyperpigmented, long-standing burn scars. Longer dwell times and lower densities make them last longer.

A 77-year-old female patient presented with bilateral tender, swollen, erythematous, focally crusted cheeks with a discharge of pus and necrotic material, which had developed one month after autologous fat transfer and a corrective injection procedure conducted to correct an overdone fat transfer. Histopathological examination of the discharged material using routine hematoxylin and eosin staining revealed degenerated collagen admixed with three different filler materials. Scattered all throughout the specimen were numerous thick-walled, basophilic, nonbudding spherical bodies of variable sizes. The bodies stained positively with Periodic acid-Schiff and Alcian blue and showed internal septation and sporangia with a morula-like appearance. The morphology of these bodies was characteristic of a infection. The patient was treated by surgical drainage accompanied by itraconazole 200mg daily for six months, ultimately showing marked improvement.

Mycosis fungoides (MF) is the most common form of cutaneous T cell lymphoma (CTCL) with many clinical variants including papular and pityriasis lichenoides chronica (PLC)-like variants. During psoralen and ultraviolet A (PUVA) treatment of MF, PLC-like papular lesions were observed to appear. The exact nature of these lesions is not fully understood. This work aimed to study PLC-like papular lesions arising in MF patients receiving PUVA therapy clinically, histopathologically and immunohistochemically (using monoclonal antibodies against CD4 and CD8) and to compare them with lesions in classic PLC patients. Fifteen MF patients with PLC-like papular lesions arising during PUVA treatment were included and 15 patients with classic PLC served as controls. While the extent of these lesions significantly correlated with their duration (p < 0.05), it showed no significant correlation with the TNMB stage of MF, number of phototherapy sessions or cumulative UVA dose at which they started to appear. The response status of MF to PUVA did not affect their development. Compared to classic PLC, these lesions showed significantly more acute onset (p = 0.003). None of these lesions showed histopathological features essential to diagnose papular/PLC-like MF and no significant difference existed with regard to their histopathological and CD4/CD8 phenotypic features compared to classic PLC. Papular lesions mimicking PLC in MF patients receiving PUVA mostly represent an upgrading reaction with possible good prognostic implication.

Hypopigmented interface T-cell dyscrasia (HITCD) is a distinct form of lymphoid dyscrasia that may progress to hypopigmented mycosis fungoides (HMF). We compared both diseases as regards their CD4/CD8 phenotype and expression of granzyme B and tumor necrosis factor-alpha (TNF-α) and how these are affected by narrow-band UVB (nb-UVB). The study included 11 patients with HITCD and 9 patients with HMF. They received nb-UVB thrice weekly until complete repigmentation or a maximum of 48 sessions. Pretreatment and posttreatment biopsies were stained using anti CD4, CD8, TNF-α, and granzyme B monoclonal antibodies. Epidermal lymphocytes were CD8 predominant in 54.5% and 66.7% of HITCD and HMF cases, respectively, whereas dermal lymphocytes were CD4 predominant in 63.6% and 66.7%, respectively. Significantly, more dermal infiltrate was encountered in HMF (P = 0.041). In both diseases, granzyme B was only expressed in the dermis, whereas TNF-α was expressed both in the epidermis and dermis. No difference existed as regards the number of sessions needed to achieve repigmentation or cumulative nb-UVB dose reached at end of study. (P > 0.05). Narrow-band UVB significantly reduced only the epidermal lymphocytes in both diseases (P ≤ 0.05) with their complete disappearance in 8 (72.7%) HITCD and 6 (66.7%) HMF cases. In both diseases, nb-UVB did not affect granzyme B or TNF-α expression (P > 0.05). In conclusion, both diseases share the same phenotype, with HITCD being a milder form of T-cell dysfunction. In both diseases, epidermal lymphocytes are mainly CD8-exhausted cells lacking cytotoxicity, whereas dermal cells are mostly reactive cells exerting antitumor cytotoxicity. Tumor necrosis factor-alpha mediates hypopigmentation in both diseases and prevents disease progression. Repigmentation after nb-UVB in both diseases occurs before and independently from disappearance of the dermal infiltrate.

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