Morphology
Crusted erythematous plaques over scalp with hair palisades Keshavamurthy Vinay1, MBBS, Dipankar De1, MD, Savita Yadav1, MD, Uma N. Saikia2, 1 MD, and Amrinder J. Kanwar , MD, FRCP
Departments of 1 Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India, and 2 Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India Correspondence Prof. Amrinder J. Kanwar Department of Dermatology, Venereology and Leprology Postgraduate Institute of Medical Education and Research Sector 12, Chandigarh 160012, India E-mail: [email protected] Funding source: None.
Annular pustular psoriasis (APP) is an uncommon form of pustular psoriasis characterized by annular and polycyclic lesions with erythematous scaly pustular margins. Herein we describe an unusual presentation of APP presenting as crusted erythematous plaques on the scalp with hair palisades. Case report A 24-year-old male farmer presented with multiple, erythematous, mildly itchy lesions over the scalp with pus discharge for 15 days. There was no history of drug intake, photosensitivity, joint pain, fever, any systemic symptoms, or similar lesions at other body sites. He denied use of any topical medications. On examination, annular and polycyclic erythematous plaques covered with yellowish crust in the center and matting of hairs in the periphery with apparent arrangement in palisades were noted (Fig. 1a). A few discrete pustules were seen at the edge of the lesion. The remaining cutaneous examination and examination of the mucosae and nails was unremarkable. Gram stain of pus showed neutrophils without any organisms. KOH mount and Tzanck smear showed negative results. A punch biopsy was taken from the edge of a lesion and submitted for histopathological examination. Skin biopsy showed parakeratosis, inconspicuous granular layer, acanthosis, and elongation of rete ridges.
There was focal accumulation of neutrophils in stratum malpighii with infiltration of neutrophils and lymphomononuclear cells in the upper dermis. Increased vascularity was also noted in the papillary dermis (Fig. 1b). Direct immunofluorescence of perilesional skin did not reveal any immune deposits. Other hematological and biochemical investigations were normal, and antinuclear antibody was negative. Based on the clinical features and histological examination, a diagnosis of APP localized to the scalp was made, and the patient was treated with topical clobetasol lotion twice daily. On the 10th day follow-up visit, the pustules and matting of hair follicles had decreased to reveal annular erythematous scaly plaques of psoriasis (Fig. 2). On continuing the treatment for another four weeks, there was complete remission of the scalp lesions. During his final visit, after a further four weeks, the patient had no active lesions and continued to be in clinical remission. Discussion Annular pustular psoriasis (APP), also known as erythema circine recidivants, Lapiere-type psoriasis, and erythema annulare centrifugum-type psoriasis, is an uncommon form of pustular psoriasis characterized by annular and polycyclic lesions with erythematous scaly pustular margins.1 It is considered to be a variant of generalized pus-
70 International Journal of Dermatology 2014, 53, 70–72
ª 2013 The International Society of Dermatology
Vinay et al.
Annular pustular psoriasis
Morphology
(a)
(b) Figure 2 Post-treatment clinical photography showing erythematous scaly plaque of psoriasis. Hair palisades can still be appreciated at the periphery
Figure 1 (a) Multiple, crusted, erythematous, annular plaques over the scalp showing matting of hairs in the periphery with apparent arrangement in palisades. (b) Photomicrography of the skin biopsy showing parakeratosis, inconspicuous granular layer and acanthosis with elongation of rete ridges. Focal accumulation of neutrophils in the epidermis and increased vascularity in the papillary dermis is also seen. (Hematoxylin and eosin 9 200)
tular psoriasis occurring commonly in children with a slight male predominance.1 Occasional case reports of localized APP confined to thighs, forehead extending to scalp, and dorsum of foot have been described.2,3 Our case is unique in that APP localized only to the scalp has not been described previously. Such a presentation is rare and requires exclusion of other common dermatosis, which includes tinea capitis, pemphigus and its variants, discoid lupus erythematosus, and folliculitis decalvans. An inflammatory annular lesion of the scalp with presence of pustules suggested a diagnosis of tinea capitis.
ª 2013 The International Society of Dermatology
Absence of broken or loose hairs and negative KOH examination on skin scrapings ruled out this possibility. Pemphigus can present with erosions and crusting localized to the scalp.4 Histopathological examination and negative immunofluorescence study helped in excluding these disorders. Discoid lupus erythematosus and folliculitis decalvans were also excluded because of the short history and absence of scarring alopecia. Although matting of hair developing into palisades was seen in our case, tufts of hair emerging from a single orifice characteristic of folliculitis decalvans was not noted. Pityriasis amiantacea, a clinically distinct entity with thick adherent asbestos-like scales, can also present with matted hairs, but annular pattern is not its feature. Other rare causes of annular pustular eruptions include drug-induced annular pustular eruption secondary to erlotinib5 and eosinophilic pustular folliculitis.6 These were excluded by relevant history and clinical examination. Because of characteristic histological features and response to topical steroids, a diagnosis of APP confined to the scalp was made. Though localized pustular psoriasis can be triggered in patients with pre-existing chronic plaque psoriasis by use of topical irritants, no such factor could be identified. Moreover, circinate pustular psoriasis is more likely to occur de novo. The treatment of APP depends on the extent of the disease. Mild and localized disease can be treated with topical corticosteroids, but widespread APP occurring as a subacute or chronic form requires systemic therapy with methotrexate, acitretin, or biologics.1 Acknowledgments We acknowledge the contribution of Dr. Tarun Narang and Dr. Jane George in clinical management of the patient.
International Journal of Dermatology 2014, 53, 70–72
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Morphology
Annular pustular psoriasis
References 1 Liao PB, Rubinson R, Howard R, et al. Annular pustular psoriasis-most common form of pustular psoriasis in children: report of three cases and review of the literature. Pediatr Dermatol 2002; 19: 19–25. 2 Zala L, Hunziker T. Localized form of psoriasis of the erythema annulare centrifugum type with pustulation. Hautarzt 1984; 35: 53–55. 3 Park YM, Kang H, Cho BK. Annular pustular psoriasis localized to the dorsa of the feet. Acta Derm Venereol 1999; 79: 161–162.
International Journal of Dermatology 2014, 53, 70–72
Vinay et al.
4 Zaraa I, El Euch D, Kort R, et al. Localized pemphigus: a report of three cases. Int J Dermatol 2010; 49: 715–716. 5 Lin TC, Wu PY. Painful annular pustular drug eruption induced by erlotinib in a patient with non-small cell lung cancer. Cutis 2011; 88: 281–283. 6 Dinehart SM, Noppakun N, Solomon AR, et al. Eosinophilic pustular folliculitis. J Am Acad Dermatol 1986; 14: 475–479.
ª 2013 The International Society of Dermatology
Crusted erythematous plaques over scalp with hair palisades Keshavamurthy Vinay1, MBBS, Dipankar De1, MD, Savita Yadav1, MD, Uma N. Saikia2, 1 MD, and Amrinder J. Kanwar , MD, FRCP
Departments of 1 Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India, and 2 Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India Correspondence Prof. Amrinder J. Kanwar Department of Dermatology, Venereology and Leprology Postgraduate Institute of Medical Education and Research Sector 12, Chandigarh 160012, India E-mail: [email protected] Funding source: None.
Annular pustular psoriasis (APP) is an uncommon form of pustular psoriasis characterized by annular and polycyclic lesions with erythematous scaly pustular margins. Herein we describe an unusual presentation of APP presenting as crusted erythematous plaques on the scalp with hair palisades. Case report A 24-year-old male farmer presented with multiple, erythematous, mildly itchy lesions over the scalp with pus discharge for 15 days. There was no history of drug intake, photosensitivity, joint pain, fever, any systemic symptoms, or similar lesions at other body sites. He denied use of any topical medications. On examination, annular and polycyclic erythematous plaques covered with yellowish crust in the center and matting of hairs in the periphery with apparent arrangement in palisades were noted (Fig. 1a). A few discrete pustules were seen at the edge of the lesion. The remaining cutaneous examination and examination of the mucosae and nails was unremarkable. Gram stain of pus showed neutrophils without any organisms. KOH mount and Tzanck smear showed negative results. A punch biopsy was taken from the edge of a lesion and submitted for histopathological examination. Skin biopsy showed parakeratosis, inconspicuous granular layer, acanthosis, and elongation of rete ridges.
There was focal accumulation of neutrophils in stratum malpighii with infiltration of neutrophils and lymphomononuclear cells in the upper dermis. Increased vascularity was also noted in the papillary dermis (Fig. 1b). Direct immunofluorescence of perilesional skin did not reveal any immune deposits. Other hematological and biochemical investigations were normal, and antinuclear antibody was negative. Based on the clinical features and histological examination, a diagnosis of APP localized to the scalp was made, and the patient was treated with topical clobetasol lotion twice daily. On the 10th day follow-up visit, the pustules and matting of hair follicles had decreased to reveal annular erythematous scaly plaques of psoriasis (Fig. 2). On continuing the treatment for another four weeks, there was complete remission of the scalp lesions. During his final visit, after a further four weeks, the patient had no active lesions and continued to be in clinical remission. Discussion Annular pustular psoriasis (APP), also known as erythema circine recidivants, Lapiere-type psoriasis, and erythema annulare centrifugum-type psoriasis, is an uncommon form of pustular psoriasis characterized by annular and polycyclic lesions with erythematous scaly pustular margins.1 It is considered to be a variant of generalized pus-
70 International Journal of Dermatology 2014, 53, 70–72
ª 2013 The International Society of Dermatology
Vinay et al.
Annular pustular psoriasis
Morphology
(a)
(b) Figure 2 Post-treatment clinical photography showing erythematous scaly plaque of psoriasis. Hair palisades can still be appreciated at the periphery
Figure 1 (a) Multiple, crusted, erythematous, annular plaques over the scalp showing matting of hairs in the periphery with apparent arrangement in palisades. (b) Photomicrography of the skin biopsy showing parakeratosis, inconspicuous granular layer and acanthosis with elongation of rete ridges. Focal accumulation of neutrophils in the epidermis and increased vascularity in the papillary dermis is also seen. (Hematoxylin and eosin 9 200)
tular psoriasis occurring commonly in children with a slight male predominance.1 Occasional case reports of localized APP confined to thighs, forehead extending to scalp, and dorsum of foot have been described.2,3 Our case is unique in that APP localized only to the scalp has not been described previously. Such a presentation is rare and requires exclusion of other common dermatosis, which includes tinea capitis, pemphigus and its variants, discoid lupus erythematosus, and folliculitis decalvans. An inflammatory annular lesion of the scalp with presence of pustules suggested a diagnosis of tinea capitis.
ª 2013 The International Society of Dermatology
Absence of broken or loose hairs and negative KOH examination on skin scrapings ruled out this possibility. Pemphigus can present with erosions and crusting localized to the scalp.4 Histopathological examination and negative immunofluorescence study helped in excluding these disorders. Discoid lupus erythematosus and folliculitis decalvans were also excluded because of the short history and absence of scarring alopecia. Although matting of hair developing into palisades was seen in our case, tufts of hair emerging from a single orifice characteristic of folliculitis decalvans was not noted. Pityriasis amiantacea, a clinically distinct entity with thick adherent asbestos-like scales, can also present with matted hairs, but annular pattern is not its feature. Other rare causes of annular pustular eruptions include drug-induced annular pustular eruption secondary to erlotinib5 and eosinophilic pustular folliculitis.6 These were excluded by relevant history and clinical examination. Because of characteristic histological features and response to topical steroids, a diagnosis of APP confined to the scalp was made. Though localized pustular psoriasis can be triggered in patients with pre-existing chronic plaque psoriasis by use of topical irritants, no such factor could be identified. Moreover, circinate pustular psoriasis is more likely to occur de novo. The treatment of APP depends on the extent of the disease. Mild and localized disease can be treated with topical corticosteroids, but widespread APP occurring as a subacute or chronic form requires systemic therapy with methotrexate, acitretin, or biologics.1 Acknowledgments We acknowledge the contribution of Dr. Tarun Narang and Dr. Jane George in clinical management of the patient.
International Journal of Dermatology 2014, 53, 70–72
71
72
Morphology
Annular pustular psoriasis
References 1 Liao PB, Rubinson R, Howard R, et al. Annular pustular psoriasis-most common form of pustular psoriasis in children: report of three cases and review of the literature. Pediatr Dermatol 2002; 19: 19–25. 2 Zala L, Hunziker T. Localized form of psoriasis of the erythema annulare centrifugum type with pustulation. Hautarzt 1984; 35: 53–55. 3 Park YM, Kang H, Cho BK. Annular pustular psoriasis localized to the dorsa of the feet. Acta Derm Venereol 1999; 79: 161–162.
International Journal of Dermatology 2014, 53, 70–72
Vinay et al.
4 Zaraa I, El Euch D, Kort R, et al. Localized pemphigus: a report of three cases. Int J Dermatol 2010; 49: 715–716. 5 Lin TC, Wu PY. Painful annular pustular drug eruption induced by erlotinib in a patient with non-small cell lung cancer. Cutis 2011; 88: 281–283. 6 Dinehart SM, Noppakun N, Solomon AR, et al. Eosinophilic pustular folliculitis. J Am Acad Dermatol 1986; 14: 475–479.
ª 2013 The International Society of Dermatology
