Tumour necrosis factor (TNF) blockers represent an exciting advance in the management of psoriasis. However, the safety profile of these drugs is not completely established. We present a review of the literature, and report on eight patients: two with the unexpected appearance of psoriasis, and the remaining six with exacerbation and change in morphology of their existing psoriasis, all of which occurred during treatment with the TNF blockers adalimumab, etanercept and infliximab. The two new cases, neither of whom had any personal or family history of psoriasis, developed pustular psoriasis on the palms and/or soles. The other six patients, previously diagnosed with severe chronic plaque psoriasis (four patients), generalized pustular psoriasis (one) and erythrodermic psoriasis (one), developed eruptive guttate psoriasis between 15 days and 18 months after the beginning of therapy. These patients had never before presented guttate-type psoriatic lesions, and the lesions appeared in areas of the body that were free of psoriatic plaques at baseline.
Alopecia is one of the clinical manifestations of secondary syphilis. It is uncommon for hair loss to be the sole or predominant manifestation, as hair loss is the chief clinical and histologic differential diagnosis of alopecia areata. The main difference between these two entities is the detection of Treponema pallidum in syphilis. We present the case of a 24-year-old Hispanic man, human immunodeficiency virus seropositive in treatment, with tiny patches of non-cicatricial alopecia in the parieto-occipital regions of his scalp. The patient denied previous history of genital or other skin lesions. A biopsy from an alopecic patch was performed which showed an inflammatory non-scarring alopecia with a discrete lymphocytic type inflammatory infiltrate localized in the peribulbar region. There was lymphocyte exocytosis into the matrix, associated with vacuolar degeneration, and scattered apoptotic cells were observed. Plasma cells were scattered. Immunohistochemical studies showed the presence of T. pallidum limited to the peribulbar region and penetrating into the follicle matrix. To the authors' knowledge, this is the first time that spirochetes have been shown in the hair follicle in alopecia syphilitica, suggesting that the spirochetes may be pathogenetic and responsible for the alopecia.
Reed et al. 1 reported the first drug-induced subacute cutaneous lupus erythematosus (SCLE) cases in 1985. These cases were related to the intake of thiazidic diuretics and were accompanied by positive anti-Ro antibodies. Multiple cases related to different drugs have been published since then. Typical clinical and histological features of SCLE were present with positive anti-Ro antibodies in most cases. 2 The most commonly implicated drugs were anti-hypertensive drugs (thiazide diuretics, angiotensin-converting enzyme inhibitors, beta-blockers and calcium channel blockers), terbinafine and bupropion. [3][4][5] Until now, only a case series of four patients with chemotherapy-induced SCLE have been published. These four patients were treated with taxanes (paclitaxel and docetaxel 6 ). We describe a patient who was treated with cyclofosfamide and adriamycine for a relapse of her breast carcinoma and developed a few days later cutaneous lesions, both clinical and histological, compatible with SCLE and positive anti-Ro antibodies.A 58-year-old female who had been diagnosed with breast cancer in 1997. The cancer was excised, and she was treated with tamoxifen for 5 years. In September 2001, a relapse was detected with bone, breast, lung and liver metastasis. One month later, she started a chemotherapy regimen with adriamycine 100 mg and ciclofosfamide 1000 mg every 21 days (three doses). She developed an erythematous and scaling plaque on her right forearm 2 weeks after the first dose. After the second dose similar lesions appeared on both forearms, the legs and the chest and upper part of the back (Figure 1). There was no history of prior photoexposure.A cutaneous biopsy was performed showing vacuolar interface changes with marked mucinosis in the dermis, features consistent with SCLE. Routine blood tests including blood cells count, biochemistry and autoantibodies revealed only positive ANA (1/160) and anti-Ro antibodies. Antihystone antibodies were negative. Systemic involvement was ruled out. Despite finishing the chemotherapy regimen, cutaneous lesions continued to appear.
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