Letters to the Editor
Table 1. Quality indicators for cutaneous vasculitis Process 1 Serum ANCA testing ratio on patients with suspected cutaneous vasculitis who underwent skin biopsy Process 2 DIF testing of skin biopsy ratio for patients with suspected IgA vasculitis Outcome 1 IgA deposit detected using DIF testing of skin biopsy ratio for patients with suspected IgA vasculitis Outcome 2 Histopathological necrotizing vasculitis detection ratio using skin biopsy for patients with suspected cutaneous arteritis ANCA, antineutrophil cytoplasmic antibody; DIF, direct immunofluorescence; Ig, immunoglobulin.
sized arteries within the skin, without the involvement of internal organs.4,5 Diagnosis is typically based on the presence of histopathological necrotizing vasculitis in the lower dermis and the subcutaneous fat. Histopathological analysis of a skin biopsy is the gold standard diagnostic tool for cutaneous arteritis. Based on these findings, we established two quality indicators for “process” and two quality indicators for “outcome” (Table 1). Retrospective data at our hospital between 2010 and 2012 were evaluated. Process 1 was 100% in 2010 (42/42 cases), 2011 (46/46 cases) and 2012 (67/67 cases). We performed ANCA testing such as myeloperoxidase- and proteinase 3-ANCA using the ELISA method in the sera of all patients who had suspected cutaneous vasculitis and underwent skin biopsy between 2010 and 2012. Process 2 was 100% in 2010 (13/13 cases), 2011 (15/15 cases) and 2012 (23/23 cases). We performed DIF testing on palpable purpura in all patients who had suspected IgA vasculitis between 2010 and 2012. Outcome 1 was 77% (10/13 cases) in 2010. The ratio increased to 80% (12/15 cases) in 2011, and further to 87% (20/23 cases) in 2012. The number of patients who had suspected IgA vasculitis and were positive for IgA deposits based on DIF testing of the skin biopsy increased gradually, reaching approximately 90% by 2012. Outcome 2 was 79% (11/14 cases) in 2010. The ratio increased to 80% (16/20 cases) in 2011, and further to 82% (14/17 cases) in 2012. The percentage of patients suspected of cutaneous arteritis and in whom necrotizing vasculi-
tis was detected based on histopathological analysis of a skin biopsy increased gradually to approximately 80%, although it was not statistically significant. Early diagnosis and treatment of vasculitis is important in order to limit the amount of irreversible damage, which can often commence early in the disease. The detection of vasculitisrelated cutaneous symptoms is important for earlier diagnosis of vasculitides. However, the detection remains a problem because many patients at an early stage are seen by non-specialists who may not sufficiently recognize cutaneous symptoms or fail to diagnose and initiate therapy promptly. We expect that the proposed quality indicators on cutaneous vasculitis could help improve the quality of clinical examination on vasculitis. We plan multicentric analysis which will be necessary to convincingly demonstrate the usefulness of the quality indicator proposed.
ACKNOWLEDGMENTS: This work was supported by grants from the Scientific Research Fund of the Ministry of Health, Labor and Welfare, Japan (Grant-in-Aid for Scientific Research). CONFLICT OF INTEREST:
None declared.
Tamihiro KAWAKAMI, Sora TAKEUCHI, Satoko KIMURA, Yoshinao SOMA Department of Dermatology, St Marianna University School of Medicine, Kawasaki, Japan doi: 10.1111/1346-8138.12545
REFERENCES 1 Mukhtyar C, Luqmani R. Disease-specific quality indicators, guidelines, and outcome measures in vasculitis. Clin Exp Rheumatol 2007; 25: 120–129. 2 Bombardier C, Mian S. Quality indicators in rheumatoid arthritis care: using measurement to promote quality improvement. Ann Rheum Dis 2013; 72 (Suppl 2): ii128–ii131. 3 Kawakami T. New algorithm (KAWAKAMI algorithm) to diagnose primary cutaneous vasculitis. J Dermatol 2010; 37: 113–124. 4 Moreland LW, Ball GV. Cutaneous polyarteritis nodosa. Am J Med 1991; 88: 426–430. 5 Nakamura T, Kanazawa N, Ikeda T et al. Cutaneous polyarteritis nodosa: revisiting its definition and diagnostic criteria. Arch Dermatol Res 2009; 301: 117–121.
Dermoscopy of discoid lupus erythematosus: Report of two cases Dear Editor, In case 1, a 29-year-old Japanese man presented with erythematous plaques with partial scales, crust and pigmentation
of 3 months’ duration on the lip (Fig. 1a), earlobe, cheek (Fig. 1b) and back (Fig. 1c). The tests for antinuclear antibody (ANA), anti-SSA/Ro and anti-SSB/La were negative. There were
Correspondence: Shigeki Inui, M.D., Ph.D., Department of Regenerative Dermatology, Graduate School of Medicine, Osaka University, 2-2 G2 Yamada-oka, Suita-shi, Osaka 565-0871, Japan. Email: [email protected]
756
© 2014 Japanese Dermatological Association
Letters to the Editor
(d)
(a) (b)
(e)
(c)
Figure 1. In case 1, erythematous and scaly plaques had developed on the lip (a), earlobe, cheek (b) and back (c). Dermoscopy of the eruption on the back showed a follicular keratotic plug (black triangle), polymorphous telangiectatic vessels, white scales, peripheral radial pigment streaks and structureless whitish area (d). In contrast, the dermoscopy of the eruption showed follicular keratotic plugs, perifollicular pigmentation and polymorphous telangiectatic vessels in case 2 (e). (Scale bars, 1 mm.)
no systemic symptoms possibly caused by systemic lupus erythematosus (SLE). Dermoscopy of the eruption on the back showed a follicular keratotic plug (black triangle), polymorphous telangiectatic vessels, white scales, peripheral radial pigment streaks and structureless whitish area using a DermLite II pro (3Gen, San Juan Capistrano, CA, USA) (Fig. 1d). Recently, it has been reported that dermoscopic criteria for discoid lupus erythematosus (DLE) are perifollicular whitish halo, follicular keratotic plug, telangiectatic vessel, white scales, pigment network, structureless whitish area and follicular red dot, whose relevant histological feature is perifollicular fibrosis, follicular hyperkeratosis, telangiectasia, hyperkeratosis, pigmentary incontinence, dermal fibrosis and perifollicular red blood cell extravasation, respectively.1 He showed the five among these seven criteria and the clinical distribution and appearance of the plaques indicated diagnosis of DLE although we could not obtain skin biopsy because of the patient’s refusal. In case 2, a 39-year-old Japanese woman presented with a slightly erythematous plaque of 1 weeks’ duration on the cheek. ANA, anti-SSA/Ro and anti-SSB/La were all negative and there were no systemic symptoms possibly related to SLE. Dermoscopy on the eruption showed follicular keratotic plugs, perifollicular pigmentation and polymorphous telangiectatic vessels (Fig. 1e). Two months later, she developed a dimple around this eruption and then received oral prednisolone 20 mg/day. Immediately, both the erythema and dimple began to gradually disappear. Although we could not perform skin biopsy due to the patient’s refusal, she was diagnosed as
© 2014 Japanese Dermatological Association
having DLE and lupus profundus form the dermoscopic findings and clinical course. In DLE, Lallas et al.1 demonstrated that perifollicular whitish halo and follicular keratotic plug are apt to be seen in the acute phase but telangiectatic vessels, white scales, pigment network and structureless whitish area occur in the late phase. Because the duration of the skin lesions were 3 months in case 1, the patient was in the chronic stage and therefore he showed only one follicular keratotic plug and prominently the latter four findings. On the other hand, case 2 was in the acute phase because the duration was only 1 week and therefore follicular keratotic plugs were conspicuous. In addition, the dermoscopy of case 2 showed perifollicular pigmentation, which was not recognized in the report by Lallas et al.1 The possible reasons for this discrepancy are: (i) our case 2 was at a very early stage compared with their case series (several months);1 and (ii) follicular red dots were not found in our case 2, which may mask perifollicular pigmentation. So far, perifollicular pigmentation has never been reported in DLE, suggesting that the present report is the first to describe it. Perifollicular pigmentation has been observed dermoscopically or confocal-microscopically in repigmentation of vitiligo,2 melanoma3 and androgenetic alopecia,4 and these may be differential diagnoses of DLE. However, discrimination between them is seemingly easy from clinical appearance.
CONFLICT OF INTEREST:
The authors have no conflict of
interest.
Shigeki INUI,1,2 Satoshi ITAMI,1 Miho MURAKAMI,2,3 Norihiro NISHIMOTO2,3 1
Department of Regenerative Dermatology, Graduate School of Medicine, Osaka University, Suita, 2Osaka Rheumatology Clinic, and 3Department of Molecular Regulation for Intractable Diseases, Institute of Medical Science, Tokyo Medical University, Osaka, Japan doi: 10.1111/1346-8138.12547
REFERENCES 1 Lallas A, Apalla Z, Lefaki I et al. Dermoscopy of discoid lupus erythematosus. Br J Dermatol 2013; 168: 284–288. 2 Lai LG, Xu AE. In vivo reflectance confocal microscopy imaging of vitiligo, nevus depigmentosus and nevus anemicus. Skin Res Technol 2011; 17: 404–410. 3 Carrera C, Palou J, Malvehy J et al. Early stages of melanoma on the limbs of high-risk patients: clinical, dermoscopic, reflectance confocal microscopy and histopathological characterization for improved recognition. Acta Derm Venereol 2011; 91: 137–146. 4 Inui S, Nakajima T, Itami S. Scalp dermoscopy of androgenetic alopecia in Asian people. J Dermatol 2009; 36: 82–85.
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Table 1. Quality indicators for cutaneous vasculitis Process 1 Serum ANCA testing ratio on patients with suspected cutaneous vasculitis who underwent skin biopsy Process 2 DIF testing of skin biopsy ratio for patients with suspected IgA vasculitis Outcome 1 IgA deposit detected using DIF testing of skin biopsy ratio for patients with suspected IgA vasculitis Outcome 2 Histopathological necrotizing vasculitis detection ratio using skin biopsy for patients with suspected cutaneous arteritis ANCA, antineutrophil cytoplasmic antibody; DIF, direct immunofluorescence; Ig, immunoglobulin.
sized arteries within the skin, without the involvement of internal organs.4,5 Diagnosis is typically based on the presence of histopathological necrotizing vasculitis in the lower dermis and the subcutaneous fat. Histopathological analysis of a skin biopsy is the gold standard diagnostic tool for cutaneous arteritis. Based on these findings, we established two quality indicators for “process” and two quality indicators for “outcome” (Table 1). Retrospective data at our hospital between 2010 and 2012 were evaluated. Process 1 was 100% in 2010 (42/42 cases), 2011 (46/46 cases) and 2012 (67/67 cases). We performed ANCA testing such as myeloperoxidase- and proteinase 3-ANCA using the ELISA method in the sera of all patients who had suspected cutaneous vasculitis and underwent skin biopsy between 2010 and 2012. Process 2 was 100% in 2010 (13/13 cases), 2011 (15/15 cases) and 2012 (23/23 cases). We performed DIF testing on palpable purpura in all patients who had suspected IgA vasculitis between 2010 and 2012. Outcome 1 was 77% (10/13 cases) in 2010. The ratio increased to 80% (12/15 cases) in 2011, and further to 87% (20/23 cases) in 2012. The number of patients who had suspected IgA vasculitis and were positive for IgA deposits based on DIF testing of the skin biopsy increased gradually, reaching approximately 90% by 2012. Outcome 2 was 79% (11/14 cases) in 2010. The ratio increased to 80% (16/20 cases) in 2011, and further to 82% (14/17 cases) in 2012. The percentage of patients suspected of cutaneous arteritis and in whom necrotizing vasculi-
tis was detected based on histopathological analysis of a skin biopsy increased gradually to approximately 80%, although it was not statistically significant. Early diagnosis and treatment of vasculitis is important in order to limit the amount of irreversible damage, which can often commence early in the disease. The detection of vasculitisrelated cutaneous symptoms is important for earlier diagnosis of vasculitides. However, the detection remains a problem because many patients at an early stage are seen by non-specialists who may not sufficiently recognize cutaneous symptoms or fail to diagnose and initiate therapy promptly. We expect that the proposed quality indicators on cutaneous vasculitis could help improve the quality of clinical examination on vasculitis. We plan multicentric analysis which will be necessary to convincingly demonstrate the usefulness of the quality indicator proposed.
ACKNOWLEDGMENTS: This work was supported by grants from the Scientific Research Fund of the Ministry of Health, Labor and Welfare, Japan (Grant-in-Aid for Scientific Research). CONFLICT OF INTEREST:
None declared.
Tamihiro KAWAKAMI, Sora TAKEUCHI, Satoko KIMURA, Yoshinao SOMA Department of Dermatology, St Marianna University School of Medicine, Kawasaki, Japan doi: 10.1111/1346-8138.12545
REFERENCES 1 Mukhtyar C, Luqmani R. Disease-specific quality indicators, guidelines, and outcome measures in vasculitis. Clin Exp Rheumatol 2007; 25: 120–129. 2 Bombardier C, Mian S. Quality indicators in rheumatoid arthritis care: using measurement to promote quality improvement. Ann Rheum Dis 2013; 72 (Suppl 2): ii128–ii131. 3 Kawakami T. New algorithm (KAWAKAMI algorithm) to diagnose primary cutaneous vasculitis. J Dermatol 2010; 37: 113–124. 4 Moreland LW, Ball GV. Cutaneous polyarteritis nodosa. Am J Med 1991; 88: 426–430. 5 Nakamura T, Kanazawa N, Ikeda T et al. Cutaneous polyarteritis nodosa: revisiting its definition and diagnostic criteria. Arch Dermatol Res 2009; 301: 117–121.
Dermoscopy of discoid lupus erythematosus: Report of two cases Dear Editor, In case 1, a 29-year-old Japanese man presented with erythematous plaques with partial scales, crust and pigmentation
of 3 months’ duration on the lip (Fig. 1a), earlobe, cheek (Fig. 1b) and back (Fig. 1c). The tests for antinuclear antibody (ANA), anti-SSA/Ro and anti-SSB/La were negative. There were
Correspondence: Shigeki Inui, M.D., Ph.D., Department of Regenerative Dermatology, Graduate School of Medicine, Osaka University, 2-2 G2 Yamada-oka, Suita-shi, Osaka 565-0871, Japan. Email: [email protected]
756
© 2014 Japanese Dermatological Association
Letters to the Editor
(d)
(a) (b)
(e)
(c)
Figure 1. In case 1, erythematous and scaly plaques had developed on the lip (a), earlobe, cheek (b) and back (c). Dermoscopy of the eruption on the back showed a follicular keratotic plug (black triangle), polymorphous telangiectatic vessels, white scales, peripheral radial pigment streaks and structureless whitish area (d). In contrast, the dermoscopy of the eruption showed follicular keratotic plugs, perifollicular pigmentation and polymorphous telangiectatic vessels in case 2 (e). (Scale bars, 1 mm.)
no systemic symptoms possibly caused by systemic lupus erythematosus (SLE). Dermoscopy of the eruption on the back showed a follicular keratotic plug (black triangle), polymorphous telangiectatic vessels, white scales, peripheral radial pigment streaks and structureless whitish area using a DermLite II pro (3Gen, San Juan Capistrano, CA, USA) (Fig. 1d). Recently, it has been reported that dermoscopic criteria for discoid lupus erythematosus (DLE) are perifollicular whitish halo, follicular keratotic plug, telangiectatic vessel, white scales, pigment network, structureless whitish area and follicular red dot, whose relevant histological feature is perifollicular fibrosis, follicular hyperkeratosis, telangiectasia, hyperkeratosis, pigmentary incontinence, dermal fibrosis and perifollicular red blood cell extravasation, respectively.1 He showed the five among these seven criteria and the clinical distribution and appearance of the plaques indicated diagnosis of DLE although we could not obtain skin biopsy because of the patient’s refusal. In case 2, a 39-year-old Japanese woman presented with a slightly erythematous plaque of 1 weeks’ duration on the cheek. ANA, anti-SSA/Ro and anti-SSB/La were all negative and there were no systemic symptoms possibly related to SLE. Dermoscopy on the eruption showed follicular keratotic plugs, perifollicular pigmentation and polymorphous telangiectatic vessels (Fig. 1e). Two months later, she developed a dimple around this eruption and then received oral prednisolone 20 mg/day. Immediately, both the erythema and dimple began to gradually disappear. Although we could not perform skin biopsy due to the patient’s refusal, she was diagnosed as
© 2014 Japanese Dermatological Association
having DLE and lupus profundus form the dermoscopic findings and clinical course. In DLE, Lallas et al.1 demonstrated that perifollicular whitish halo and follicular keratotic plug are apt to be seen in the acute phase but telangiectatic vessels, white scales, pigment network and structureless whitish area occur in the late phase. Because the duration of the skin lesions were 3 months in case 1, the patient was in the chronic stage and therefore he showed only one follicular keratotic plug and prominently the latter four findings. On the other hand, case 2 was in the acute phase because the duration was only 1 week and therefore follicular keratotic plugs were conspicuous. In addition, the dermoscopy of case 2 showed perifollicular pigmentation, which was not recognized in the report by Lallas et al.1 The possible reasons for this discrepancy are: (i) our case 2 was at a very early stage compared with their case series (several months);1 and (ii) follicular red dots were not found in our case 2, which may mask perifollicular pigmentation. So far, perifollicular pigmentation has never been reported in DLE, suggesting that the present report is the first to describe it. Perifollicular pigmentation has been observed dermoscopically or confocal-microscopically in repigmentation of vitiligo,2 melanoma3 and androgenetic alopecia,4 and these may be differential diagnoses of DLE. However, discrimination between them is seemingly easy from clinical appearance.
CONFLICT OF INTEREST:
The authors have no conflict of
interest.
Shigeki INUI,1,2 Satoshi ITAMI,1 Miho MURAKAMI,2,3 Norihiro NISHIMOTO2,3 1
Department of Regenerative Dermatology, Graduate School of Medicine, Osaka University, Suita, 2Osaka Rheumatology Clinic, and 3Department of Molecular Regulation for Intractable Diseases, Institute of Medical Science, Tokyo Medical University, Osaka, Japan doi: 10.1111/1346-8138.12547
REFERENCES 1 Lallas A, Apalla Z, Lefaki I et al. Dermoscopy of discoid lupus erythematosus. Br J Dermatol 2013; 168: 284–288. 2 Lai LG, Xu AE. In vivo reflectance confocal microscopy imaging of vitiligo, nevus depigmentosus and nevus anemicus. Skin Res Technol 2011; 17: 404–410. 3 Carrera C, Palou J, Malvehy J et al. Early stages of melanoma on the limbs of high-risk patients: clinical, dermoscopic, reflectance confocal microscopy and histopathological characterization for improved recognition. Acta Derm Venereol 2011; 91: 137–146. 4 Inui S, Nakajima T, Itami S. Scalp dermoscopy of androgenetic alopecia in Asian people. J Dermatol 2009; 36: 82–85.
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