Letters to the Editor

496

W.K. Jacyk,1,* W. Baran,1 A. Essop2 1

Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland, 2Department of Dermatology, University of Pretoria, Pretoria, South Africa *Correspondence: W. K. Jacyk. E-mail: [email protected]

References 1 Degos R, Delort J, Civatte J et al. Tumeur epidermique d’aspect particulier: acanthome a cellules claires. Ann Dermatol Syph 1962; 89: 361–371. 2 Wilson Jones E, Wells GC. Degos’ acanthoma (Acanthome a cellules claires). A histological report of nine cases. Arch Dermatol. 1966; 94: 286–294. 3 Pierard GE. Melanocytes in clear cell acanthoma. Am J Dermatopathol 1991; 13: 430. 4 Langer K, Wuketich S, Konrad K. Pigmented clear cell acanthoma. Am J Dermatopathol 1994; 16: 134–139. 5 Tempark T, Shwayder T. Clear cell acanthoma. Clin Exp Dermatol 2012; 37: 831–837. 6 Thorne EG, Fusaro RM. Multiple clear cell acanthomas in a patient with lamellar ichthyosis. Dermatologica 1971; 143: 105–110. 7 Landry M, Winkelmann R. Multiple clear cell acanthomas and ichthyosis. Arch Dematol 1972; 105: 371–383. 8 Zedek DC, Langel DJ, White W. Clear cell acanthoma versus acanthosis: a psoriasiform reaction pattern lacking trichilemmal differentiation. Am J Dermatopathol 2007; 29: 378–384. 9 Finch TM, Tan CY. Clear cell acanthoma developing on a psoriatic plaque: further evidence of an inflammatory aetiology? Br J Dermatol 2000; 142: 842–844. 10 Cota C, Ferrara G, Amantea A et al. Eccrine syringofibroadenoma and clear cell acanthoma: An association by chance? Am J Dermatopathol 2011; 33: 195–198. DOI: 10.1111/jdv.12882

A case of chronic radiodermatitis after transjugular intrahepatic portosystemic shunt Editor Transjugular intrahepatic portosystemic shunt (TIPS) is a non-invasive angiographic technique for achieving portal decompression. We describe one case of fluoroscopy-induced radiodermatitis after TIPS. In December 2012, a 64-year-old man was referred to clinic for dermatological consultation, owing to onset of presence of 20 9 15 cm focally necrotic, ulcerating, hypopigmented, sclerotic and indurated plaque on the mid-right back (Fig. 1). The patient felt a very deep and persistent pain. The patient was affected by HCV-related liver disease, complicated by F1 oesophageal varices and ascites. In October 2011, he was hospitalized for a TIPS. This procedure was successful without complications. Three days after the shunt procedure, the patient developed pain and burning sensation on the mid-right back with the

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Figure 1 Indurated plaque of a 20 9 15 cm on the midright back.

presence of vesicle lesions on the skin. At the initial dermatological examination, the lesions were misdiagnosed, clinical diagnosis was herpes zoster. The therapy yielded no benefit, and there was enduring pain, with subsequent worsening and progression to non-healing ulcerations. Upon referral to our clinic, we carried out two skin biopsies of the lesion that showed epidermal acanthosis. The dermis consisted of scattered stellate fibroblasts, capillary ectasia and deep sclerosis. A magnetic resonance revealed the extension and depth of the plaque. The image of cutaneous and subcutaneous area of the back revealed an extensive in the medium-right side aedematous/inflammatory area of the longissimus muscle of the back. The patient was diagnosed with radiodermatitis post-TIPS based on clinical symptoms, histopathology and instrumental imaging. The patient started pain therapy first with FANS, then for 1 month with morphine without any benefit. In March 2013, a plastic surgeon excised the radiodermitic areas, with a subsequent and resulting decrease in pain. The patient began a close follow-up for monitoring of radiationinduced malignancy. Transjugular intrahepatic portosystemic shunt is a non-surgical procedure used to treat portal hypertension and to prevent and manage its complications. Advantages attributed to TIPS include minimal invasiveness and the ability to provide portosystemic decompression without major surgery. During the procedure, biologically significant doses of ionizing radiation can be adsorbed, resulting in radiodermatitis.1 The development of radiodermatitis after radiation treatment represents a well- known complication, whereas those related with diagnostic procedures are less frequent.2

© 2014 European Academy of Dermatology and Venereology

Letters to the Editor

497

In 1996, Lichtenstein, reported the first four cases of radiodermatitis after cardiac catheterism and in 1997, Knautz described the first case of radiodermatitis after TIPS.3,4 In the literature are reported 12 cases of patients affected by radiodermatits after TIPS: it is a very rare complication, often making for difficult diagnoses. Generally, some weeks or months after the procedure, patients feel a worsening pain and may develop cutaneous manifestations up to 1 year later. The rarity of the complication, as well as the development time of radiodermatitis, makes it difficult to make a solid association with the fluorososcopy procedure. Therefore, incorrect diagnoses such as morfea, fixed drug eruption, lichen scleroatrophicus, panniculitis, are likely to occur. Patients are thus often subjected to unsuitable and ineffective therapies for controlling the throbbing and distressing pain.5 In the case we were able to observe, which because of the rarity of the onset led to diagnosis problems, there was the peculiarity of showing cutaneous lesions just a few days after the procedure. Lack of diagnosis led to it becoming chronic, thus causing not only diagnostic problems but therapeutic ones as well. As involved radiographic procedures such as TIPS became more prevalent, physicians need to be aware of possible risks such as radiodermatitis to prevent side-effects. It is important to initiate an exact and early diagnosis to ensure operative therapeutic strategies and ensure a long-term follow-up for malignancy screening.6 M.A. Montesu,* V. Amadu, R. Satta Department of Surgical, Microsurgical and Medical Sciences – Dermatology, University of Sassari, Sassari, Italy *Correspondence: M.A. Montesu. E-mail: [email protected]

References 1 Nahass GT, Cornelius L. Fluoroscopy-induced radiodermatitis after transjugular intrahepatic portosystemic shunt. Am J Gastroenterol 1998; 93: 1546–1549. 2 Fierens H, Goffette P, Tennstedt D, Lachapelle J. Radiodermatitis after transjugular intrahepatic portosystemic shunt: 4 cases. Ann Dermatol Venereol 2000; 127: 619–623. 3 Knautz MA, Abele DC, Reynolds TL. Radiodermatitis after transjugular intrahepatic portosystemic shunt. South Med J 1997; 90: 352–356. 4 Lichtenstein DA, Klapholz L, Vardy DA et al. Chronic radiodermatitis following cardiac catheterization. Arch Dermatol 1996; 132: 663–667. 5 Boncher J, Bergfeld WF. Fluoroscopy-induced chronic radiation dermatitis: a report of two additional cases and a brief review of the literature. J Cutan Pathol 2012; 39: 63–67. 6 Cante V, Doutre MS. Chronic radiodermatitis after a transjugular intrahepatic portosystemic shunt. Ann Dermatol Venereol 2011; 138: 424–425. DOI: 10.1111/jdv.12885

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A case of erythroplasia of Queyrat successfully treated with combination carbon dioxide laser vaporization and surgery Editor Squamous cell carcinoma in situ on the mucosal or transitional surfaces is known as erythroplasia of Queyrat (EQ). It usually occurs on the glans penis and appears as a well-marginated erythematous patch or plaque.1 Removal of the cancer by partial or total penectomy had been regarded as standard therapy, but radical procedures may cause considerable mental distress. Therefore, development of an alternative non-invasive treatment for EQ has been important. Topical 5% imiquimod cream containing an immune-response modifier has been applied, or methylaminolaevulinic acid photodynamic therapy has been tried; however, both therapeutic effectiveness in EQ are still controversial.2–4 Herein, we report the case of an 87-year-old male with dementia suffering from EQ involving preputial area and glans that underwent combination carbon dioxide laser vaporization and surgery and had a good clinical result. An 87-year-old man, with a history of severe dementia, visited our department for penile redness and slightly bleeding. On physical examination, an asymptomatic, well defined, erythematous, shiny plaque measuring 1.0 9 2.0 cm was observed on the glans penis and extended to the frenulum and the upper part of the penile shaft (Fig. 1a). A skin biopsy specimen revealed atypical keratinocytes with dyskeratosis, hyperchromatism and pleomorphism were seen throughout the epidermis. Intraepidermal dyskeratotic cells were observed as prematurely cornified individual keratinocytes and showed eosinophilic cytoplasm with a dense basophilic nucleus (Fig. 1b). Based on these findings, we made the final diagnosis of EQ. He underwent combination carbon dioxide laser vaporization at the glans and so called partial phimosiotomy (Fig. 1c). The laser (Bel Laser; Takarabelmont, Osaka, Japan) was used in the superpulsed waved and 10 watts of potency. We confirmed that tumour cells were not remained by intraoperative rapid diagnosis (Fig. 1d). At 3 months of follow-up, the patient had maintained a good clinical condition without local recurrence (Fig. 1e). In our case, we considered every treatment options including partial and total penectomy, topical application of imiquimod 5% cream, photodynamic therapy and these combinations; however, the patient’s background having dementia in 87-year-old male patient narrowed therapeutic resources. We speculated that he could not have used topical 5% imiquimod application continuously at his home, and he steadfastly refused total or partial penectomy; he strongly hoped that the shape of his glans should be remained. We finally chose the combination carbon dioxide laser vaporization and surgery. Although resurfacing by carbon dioxide

© 2014 European Academy of Dermatology and Venereology

A case of chronic radiodermatitis after transjugular intrahepatic portosystemic shunt.

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