The clinical manifestations of psoriasis commonly include red, scaly annular plaques on the extensor surfaces. Ulceration is not typical in any psoriasis subtypes. In this case series, Weenig et al describe 3 patients who were referred for evaluation and management of “ulcerative” psoriasis that ultimately was determined to be aggressive, cytotoxic, cutaneous lymphoma. The authors emphasize that psoriasis vulgaris does not ulcerate, and the presence of ulceration within psoriasiform plaques should prompt a biopsy. Given the possible role of potent systemic immunosuppressive agents in the pathogenesis of these lymphomas, these agents should be reserved for only biopsy-proven cases.
Pediatric organ transplant recipients routinely receive long-term treatment with immunosuppressants, many of which have cutaneous adverse effects. In this case report, Strahan and Burch describe a 9-month-old boy who received a heart transplant and developed multiple erythematous, fluctuant, tender facial cysts while being treated with an immunosuppressant regimen of cyclosporine and azathioprine. These lesions responded quickly and dramatically to cessation of cyclosporine treatment and initiation of isotretinoin therapy. Although infantile acne is commonly associated with fluctuations in circulating androgens that stabilize during the initial maturation of the adrenal gland, this case highlights the fact that medications such as cyclosporine may induce this condition. A multidisciplinary approach is necessary to manage these medication-induced adverse effects.
Pyoderma gangrenosum (PG) is a rare cutaneous ulcerative disease. In addition to local wound care and management of secondary infection, therapy commonly includes systemic corticosteroids or other immunomodulatory agents. In this case series, Eaton and Callen describe the safety and efficacy of mycophenolate mofetil, in combination with other agents, for the treatment of 7 patients with PG. Because of the retrospective nature of this study, the authors suggest that placebo-controlled, double-blind studies are warranted to further assess the efficacy of this therapeutic option in treating PG.
Ultrasonography of subcutaneous tumors is useful for acquiring information about the nature, size, and depth of the lesions as well as their relationship to adjacent vessels and other structures. In this retrospective study of 183 patients with subcutaneous lesions who underwent preoperative ultrasonography, Kuwano et al demonstrate that the diagnostic accuracy of ultrasonography compared with pathologic diagnosis was much greater than the diagnostic accuracy after palpation alone. These data reinforce that ultrasonography of subcutaneous benign lesions increases the reliability of preoperative diagnosis.
Superficial vein thrombosis (SVT) most commonly involves the greater and lesser saphenous veins. Risk factors for SVT parallel those for deep vein thrombosis (DVT): varicose veins, thrombophilia, oral contraceptive use, immobilization, malignancy, direct trauma, and a history of thromboembolism. In this prospective study, Binder et al demonstrate that 9% of patients with sonographically proven SVT had a concomitant DVT. The DVTs were mainly asymptomatic, usually in the SVT-affected leg, and associated with elevated D-dimer levels, leading the authors to conclude that the deep veins should be assessed by color-coded duplex sonography when an SVT affects the lower leg. Evaluation of the contralateral leg is also suggested in cases of SVT with a substantially elevated D-dimer level and any symptoms of DVT.
Fatal Cytotoxic Cutaneous Lymphoma Presenting as Ulcerative Psoriasis. Arch Dermatol. 2009;145(7):745. doi:10.1001/archdermatol.2009.146