Correspondence
applications, and has transformed management of focal hyperhidrosis. The diffusion properties of BoNTA in human tissues vary between different preparations, and have a significant bearing on efficacy and toxicity. This is used to advantage in cosmesis, where greater BoNTA diffusion is ideal for treatment of frontalis wrinkles. Reduced diffusion of the toxin is desirable when injecting the lateral canthus, pretarsal orbicularis and superior orbital rim,1 in order to minimize toxicity resulting in diplopia, ptosis and ectropion.2 Eccrine glands are typically located at the dermis–fat interface and in the deep reticular dermis. They are almost always surrounded by a pad of adipocytes, and are not found alone in the subcutaneous fat. We were interested to read the recent report of Ko et al.3 in comparing efficacy and diffusion of three formulations of BoNTA in two patients with forehead hyperhidrosis. Their choice of intramuscular (IM) rather than the more conventional intradermal or subcutaneous administration of BoNTA was surprising, as IM injection is likely to have unintended effects on facial musculature when the aim is to treat eccrine glands only. In our experience, topical glycopyrrolate (0.5–4% cream, solution or pads) is very effective in treating craniofacial hyperhidrosis.4 In line with local National Health Service recommendations, we reserve BoNTA largely for axillary hyperhidrosis. Goodman reported halving the dose of BoNTA with addition of the enzyme hyaluronidase in treating hyperhidrosis.5 We are investigating whether enhancing diffusion of BoNTA with hyaluronidase can be repeated in a larger group of patients. A. B. Hussain and G. M. Kavanagh Department of Dermatology, University of Edinburgh, Lauriston Building, Edinburgh, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 30 July 2014
5 Goodman G. Diffusion and short -term efficacy of botulinum toxin A after the addition of hyaluronidase and its possible application for the treatment of axillary hyperhidrosis. Dermatol Surg 2003; 29: 533–83.
Actinic lichen planus with milia doi: 10.1111/ced.12551 We read with interest the recent article published in Clinical and Experimental Dermatology by Vink et al.1 regarding a case of bullous acral lichen sclerosus with milia. We report another uncommon association of milia: actinic lichen planus (LP). A 15-year-old girl of Indian origin presented with a 10-month history of an asymptomatic, darkly pigmented patch near her right eye. She was not on any regular medication. On physical examination revealed a darkly pigmented patch measuring approximately 15 mm adjacent to the right lateral canthus. The surrounding edges of the patch were studded with multiple milia (Fig. 1). When the patient returned for a skin biopsy 6 months later, the patch was much lighter in colour, and the number of milia had reduced. The patient consented to only a small biopsy being taken, thus, a 3 mm punch biopsy was taken from the pigmented area to establish the diagnosis. Histological examination showed a band-like lymphohistiocytic infiltrate in the superficial dermis, with overlying basal cell degeneration, lymphocytic exocytosis and colloid body formation (Fig. 2). A diagnosis of actinic LP with milia was made on the basis of the clinical and histological findings. The patient was commenced on topical tacrolimus 0.1% ointment. Unfortunately, the patient failed to attend for further review.
References 1 Moriarty KC. Botulinium Toxin in Facial Rejuvenation. London/New York: Mosby, 2004. 2 Carruthers J, Fagien S, Matarasso SL. Consensus recommendations on the use of botulinum toxin type A in facial aesthetics. Plast Reconstr Surg 2004; 114 (Suppl): S1–22. 3 Ko EJ, Mun SK, Oh IY et al. Comparison of efficacy and diffusion of three formulations of botulinum toxin type A in two patients with forehead hyperhidrosis. Clin Exp Dermatol 2014; 39: 673–5. 4 Mackenzie A, Burns C, Kavanagh G. Topical glycopyrrolate for axillary hyperhidrosis. Br J Dermatol 2013; 169: 483–4.
ª 2014 British Association of Dermatologists
Figure 1 Milia surrounding a pigmented patch adjacent to the
right lateral canthus.
Clinical and Experimental Dermatology (2015) 40, pp570–579
571
Correspondence
References 1 Vink L, Starink TM. Bullous acral lichen sclerosus with milia. Clin Exp Dermatol 2014; 39: 400–1. 2 Langley RG, Walsh NM, Ross JB. Multiple eruptive milia: report of a case, review of the literature, and a classification. J Am Acad Dermatol 1997; 37: 353–6. 3 Epstein W, Kligman AM. The pathogenesis of milia and benign tumors of the skin. J Invest Dermatol 1956; 26: 1–11. 4 Lucke T, Fallowfield M, Burden D. Lichen planus associated with milia. Clin Exp Dermatol 1999; 26: 266–9.
Figure 2 A band-like lymphohistiocytic infiltrate in the super-
ficial dermis with overlying vacuolar basal epidermal degeneration associated with lymphocyte exocytosis and colloid body formation (haematoxylin and eosin, original magnification 9200).
Actinic LP is a photodistributed variant of LP, which most commonly occurs in individuals with dark complexion. The lesions tend to involve sun-exposed areas, most often on the forehead and face, followed by the dorsum of the hands and the neck. In our patient, the finding of milia studded around the patch was an interesting and rare finding. Milia are small benign epidermoid cysts. They are classified into primary milia, which arise spontaneously, and secondary milia, which develop because of a traumatic or inflammatory cutaneous event.2,3 Secondary milia are seen as a sequelae of a subepidermal blistering process, such as bullous pemphigoid, and in genodermatoses such as epidermolysis bullosa. Milia have also been reported to develop after cosmetic procedures such as dermabrasion.1 It has been suggested that the lichenoid inflammation in LP may have disrupted nearby adnexal structures, such as the hair follicles, which initiates the formation of milia.3 Milia have been reported in the different variants of LP: idiopathic, drug-induced, and tumidus.4 They have been described as a transient feature, which signifies a resolving phase of the inflammatory episode.4 This was the case in our patient, because when she later presented for her skin biopsy, the patch had already started lightening, and the number of milia had reduced significantly. In conclusion, we present the first case of milia associated with actinic LP. L. Yeo,1 E. Husain,2 and J. Hewitt1 Departments of 1Dermatology and 2Pathology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 30 July 2014
572
Clinical and Experimental Dermatology (2015) 40, pp570–579
Unilateral chromhidrosis versus unilateral pseudochromhidrosis: an interesting phenomenon doi: 10.1111/ced.12555 A 38-year-old man presented with a 3-month history of abrupt-onset, asymptomatic, red secretions, limited to his right foot. His condition was exacerbated by an increase in exercise or ambient temperature. No other part of the skin was similarly involved. He denied history of contact with any red substances on his foot. His medical history was otherwise uneventful, and he was not taking any medications or any red-coloured substances. Physical examination revealed multiple, round, discrete, red macules located mainly on the patient’s right forefoot and heel, which were partly coalescing into patches and predominating on the dermatoglyphic ridges at the openings of the eccrine glands, with partial sparing of the furrows (Fig. 1a,b). His left foot had normal sweating, and no other discolouration or abnormalities were found. The stains could be removed with alcohol-soaked cotton-wool. Both sides of the patient’s socks and shoes were uniform in appearance, except for red staining in the right sock (Fig. 1c). Laboratory investigations included complete blood count, platelet count, coagulation panel, urinalysis and urinary homogentisic acid levels, which were all within normal limits. Skin bacterial and fungal cultures grew no organisms. Benzidine test for presence of blood in sweat was negative, as was Wood light illumination for corynebacteria or photoactive chemical compounds. A smear taken from the patient’s foot showed no erythrocytes under the microscope, and the patient refused a skin biopsy. Taking these findings with the fact that the soles are the most abundant areas of eccrine glands, a diagnosis of unilateral eccrine chromhidrosis was made. The patient felt reassured to know the diagnosis, and declined any treatment. During a recent telephone follow-up, he reported that his symptoms had begun resolving spontaneously 3 weeks after his first visit, without any change
ª 2015 British Association of Dermatologists
applications, and has transformed management of focal hyperhidrosis. The diffusion properties of BoNTA in human tissues vary between different preparations, and have a significant bearing on efficacy and toxicity. This is used to advantage in cosmesis, where greater BoNTA diffusion is ideal for treatment of frontalis wrinkles. Reduced diffusion of the toxin is desirable when injecting the lateral canthus, pretarsal orbicularis and superior orbital rim,1 in order to minimize toxicity resulting in diplopia, ptosis and ectropion.2 Eccrine glands are typically located at the dermis–fat interface and in the deep reticular dermis. They are almost always surrounded by a pad of adipocytes, and are not found alone in the subcutaneous fat. We were interested to read the recent report of Ko et al.3 in comparing efficacy and diffusion of three formulations of BoNTA in two patients with forehead hyperhidrosis. Their choice of intramuscular (IM) rather than the more conventional intradermal or subcutaneous administration of BoNTA was surprising, as IM injection is likely to have unintended effects on facial musculature when the aim is to treat eccrine glands only. In our experience, topical glycopyrrolate (0.5–4% cream, solution or pads) is very effective in treating craniofacial hyperhidrosis.4 In line with local National Health Service recommendations, we reserve BoNTA largely for axillary hyperhidrosis. Goodman reported halving the dose of BoNTA with addition of the enzyme hyaluronidase in treating hyperhidrosis.5 We are investigating whether enhancing diffusion of BoNTA with hyaluronidase can be repeated in a larger group of patients. A. B. Hussain and G. M. Kavanagh Department of Dermatology, University of Edinburgh, Lauriston Building, Edinburgh, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 30 July 2014
5 Goodman G. Diffusion and short -term efficacy of botulinum toxin A after the addition of hyaluronidase and its possible application for the treatment of axillary hyperhidrosis. Dermatol Surg 2003; 29: 533–83.
Actinic lichen planus with milia doi: 10.1111/ced.12551 We read with interest the recent article published in Clinical and Experimental Dermatology by Vink et al.1 regarding a case of bullous acral lichen sclerosus with milia. We report another uncommon association of milia: actinic lichen planus (LP). A 15-year-old girl of Indian origin presented with a 10-month history of an asymptomatic, darkly pigmented patch near her right eye. She was not on any regular medication. On physical examination revealed a darkly pigmented patch measuring approximately 15 mm adjacent to the right lateral canthus. The surrounding edges of the patch were studded with multiple milia (Fig. 1). When the patient returned for a skin biopsy 6 months later, the patch was much lighter in colour, and the number of milia had reduced. The patient consented to only a small biopsy being taken, thus, a 3 mm punch biopsy was taken from the pigmented area to establish the diagnosis. Histological examination showed a band-like lymphohistiocytic infiltrate in the superficial dermis, with overlying basal cell degeneration, lymphocytic exocytosis and colloid body formation (Fig. 2). A diagnosis of actinic LP with milia was made on the basis of the clinical and histological findings. The patient was commenced on topical tacrolimus 0.1% ointment. Unfortunately, the patient failed to attend for further review.
References 1 Moriarty KC. Botulinium Toxin in Facial Rejuvenation. London/New York: Mosby, 2004. 2 Carruthers J, Fagien S, Matarasso SL. Consensus recommendations on the use of botulinum toxin type A in facial aesthetics. Plast Reconstr Surg 2004; 114 (Suppl): S1–22. 3 Ko EJ, Mun SK, Oh IY et al. Comparison of efficacy and diffusion of three formulations of botulinum toxin type A in two patients with forehead hyperhidrosis. Clin Exp Dermatol 2014; 39: 673–5. 4 Mackenzie A, Burns C, Kavanagh G. Topical glycopyrrolate for axillary hyperhidrosis. Br J Dermatol 2013; 169: 483–4.
ª 2014 British Association of Dermatologists
Figure 1 Milia surrounding a pigmented patch adjacent to the
right lateral canthus.
Clinical and Experimental Dermatology (2015) 40, pp570–579
571
Correspondence
References 1 Vink L, Starink TM. Bullous acral lichen sclerosus with milia. Clin Exp Dermatol 2014; 39: 400–1. 2 Langley RG, Walsh NM, Ross JB. Multiple eruptive milia: report of a case, review of the literature, and a classification. J Am Acad Dermatol 1997; 37: 353–6. 3 Epstein W, Kligman AM. The pathogenesis of milia and benign tumors of the skin. J Invest Dermatol 1956; 26: 1–11. 4 Lucke T, Fallowfield M, Burden D. Lichen planus associated with milia. Clin Exp Dermatol 1999; 26: 266–9.
Figure 2 A band-like lymphohistiocytic infiltrate in the super-
ficial dermis with overlying vacuolar basal epidermal degeneration associated with lymphocyte exocytosis and colloid body formation (haematoxylin and eosin, original magnification 9200).
Actinic LP is a photodistributed variant of LP, which most commonly occurs in individuals with dark complexion. The lesions tend to involve sun-exposed areas, most often on the forehead and face, followed by the dorsum of the hands and the neck. In our patient, the finding of milia studded around the patch was an interesting and rare finding. Milia are small benign epidermoid cysts. They are classified into primary milia, which arise spontaneously, and secondary milia, which develop because of a traumatic or inflammatory cutaneous event.2,3 Secondary milia are seen as a sequelae of a subepidermal blistering process, such as bullous pemphigoid, and in genodermatoses such as epidermolysis bullosa. Milia have also been reported to develop after cosmetic procedures such as dermabrasion.1 It has been suggested that the lichenoid inflammation in LP may have disrupted nearby adnexal structures, such as the hair follicles, which initiates the formation of milia.3 Milia have been reported in the different variants of LP: idiopathic, drug-induced, and tumidus.4 They have been described as a transient feature, which signifies a resolving phase of the inflammatory episode.4 This was the case in our patient, because when she later presented for her skin biopsy, the patch had already started lightening, and the number of milia had reduced significantly. In conclusion, we present the first case of milia associated with actinic LP. L. Yeo,1 E. Husain,2 and J. Hewitt1 Departments of 1Dermatology and 2Pathology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 30 July 2014
572
Clinical and Experimental Dermatology (2015) 40, pp570–579
Unilateral chromhidrosis versus unilateral pseudochromhidrosis: an interesting phenomenon doi: 10.1111/ced.12555 A 38-year-old man presented with a 3-month history of abrupt-onset, asymptomatic, red secretions, limited to his right foot. His condition was exacerbated by an increase in exercise or ambient temperature. No other part of the skin was similarly involved. He denied history of contact with any red substances on his foot. His medical history was otherwise uneventful, and he was not taking any medications or any red-coloured substances. Physical examination revealed multiple, round, discrete, red macules located mainly on the patient’s right forefoot and heel, which were partly coalescing into patches and predominating on the dermatoglyphic ridges at the openings of the eccrine glands, with partial sparing of the furrows (Fig. 1a,b). His left foot had normal sweating, and no other discolouration or abnormalities were found. The stains could be removed with alcohol-soaked cotton-wool. Both sides of the patient’s socks and shoes were uniform in appearance, except for red staining in the right sock (Fig. 1c). Laboratory investigations included complete blood count, platelet count, coagulation panel, urinalysis and urinary homogentisic acid levels, which were all within normal limits. Skin bacterial and fungal cultures grew no organisms. Benzidine test for presence of blood in sweat was negative, as was Wood light illumination for corynebacteria or photoactive chemical compounds. A smear taken from the patient’s foot showed no erythrocytes under the microscope, and the patient refused a skin biopsy. Taking these findings with the fact that the soles are the most abundant areas of eccrine glands, a diagnosis of unilateral eccrine chromhidrosis was made. The patient felt reassured to know the diagnosis, and declined any treatment. During a recent telephone follow-up, he reported that his symptoms had begun resolving spontaneously 3 weeks after his first visit, without any change
ª 2015 British Association of Dermatologists
