Letters to the Editor
2257
acceptable adverse effect profile and can induce sustained remission. G.-Y. Chu,1 S. C.-S. Hu,1 C.-C. E. Lan1,2,* 1
Department of Dermatology, Kaohsiung Medical University Hospital, College of Medicine , 2Department of Dermatology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan *Correspondence: Dr. C.-C. E. Lan. E-mail: [email protected]
References 1 Khachemoune A, Janjua SA, Guldbakke KK. Inflammatory linear verrucous epidermal nevus: a case report and short review of the literature. Cutis 2006; 78: 261–267. 2 Vissers WH, Muys L, Erp PE et al. Immunohistochemical differentiation between inflammatory linear verrucous epidermal nevus (ILVEN) and psoriasis. Eur J Dermatol 2004; 14: 216–220. 3 Jesionek-Kupnicka D, Chomiczewska-Sk ora D, Rotsztejn H. Influence of phototherapy in psoriasis on Ki-67 antigen expression: a preliminary study. Pol J Pathol 2013; 64: 96–103. DOI: 10.1111/jdv.12554
Hair dermatophytosis diagnosed by reflectance confocal microscopy: six cases Editor Reflectance confocal microscopy (RCM) is an emerging imaging technique that has been used to diagnose skin1–3 and nail4 dermatophytosis. Moreover, it has been recently applied to the study of hair5,6 but not of hair dermatophytosis. We report four
cases of tinea capitis and two of tinea barbae diagnosed by in vivo or ex vivo RCM and the first conidia imaged by RCM. Major clinical, RCM, optical microscopy and cultural features are reported in Table 1. RCM examination was performed during the dermatological consultation without the use of any particular staining. In vivo RCM examination (VivaScope3000â, CALIBER, distributed in Europe by MAVIG GmbH) was performed in case of superficial non-suppurated lesions (Fig. 1), whereas ex vivo examination (VivaScope 2500â) was performed when there were suppuration and crusts (Fig. 2). Ex vivo RCM was performed immediately after the hair collection: loose hairs that could be painlessly removed were selected and, whenever not available, hairs were collected by gently plucking the hair root with sterile forceps. In vivo or ex vivo RCM examination took approximately 5 min per patient. RCM examination showed the presence of roundish homogeneous (5–10 lm in size) hyper-reflective structures corresponding to conidia around the proximal part of the hair shaft in all cases (Figs 1, 2). In in vivo conditions conidia had a compact organization, whereas in ex vivo conditions they were more disperse. In two cases sparse elongated hyper-reflective structures outside the hair shafts, corresponding to hyphae, could also be identified. Dermatophytes inside the medulla of the hair shaft could not be identified. Conventional optical microscopic examination with blue lactophenol solution confirmed the presence of conidia outside the hair shaft in all cases, but could find hyphae in only one case. The culture, performed on Sabouraud’s dextrose agar containing chloramphenicol (0.05%) and cycloheximide (0.5%), showed the presence of Microsporum canis or Trichophyton mentagrophytes. In our case series, we could confirm in few minutes the diagnosis of hair dermatophytosis by using RCM during the
Table 1 Clinical features of the six hair dermatophytosis with their respective findings of reflectance confocal microscopy, optical microscopy and cultural examination. Case number
Age/ sex
Site of the lesions
Evolution
Clinical presentation
Wood’s light examination
In vivo RCM
Ex vivo RCM
Optical microscopy examination
Cultural examination
1
5/F
Scalp
2 months
Two scaly patches of alopecia
Green
Ectothrix conidia
NA
Ectothrix conidia
Microsporum canis
2
7/M
Scalp
1 month
One scaly patch of alopecia
Green
Ectothrix conidia
NA
Ectothrix conidia
Microsporum canis
3
6/F
Scalp
15 days
Abscess
Negative
NA
Ectothrix conidia
Ectothrix conidia
Trichophyton Mentagrophytes
4
54/M
Beard
15 days
Abscess
Negative
NA
Ectothrix conidia and hyphae
Ectothrix conidia
Trichophyton Mentagrophytes
5
28/M
Beard
1 month
Abscesses
Green
NA
Ectothrix conidia
Ectothrix conidia
Microsporum canis
6
4/M
Scalp
1 month
One patch of alopecia with pustules
Green
Ectothrix conidia and hyphae
NA
Ectothrix conidia and hyphae
Microsporum canis
JEADV 2015, 29, 2255–2273
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
2258
(a)
(b)
(c)
(d)
Figure 1 Two cases of tinea capitis due to Microsporum canis. (a, c) Clinical aspect with patchy alopecia. (b, c) In vivo reflectance confocal microscopy aspect with conidia (red asterisk) and hyphae (red arrow).
(a)
(b)
(c)
(d)
Figure 2 Tinea barbae due to Trichophyton Mentagrophytes. (a) Clinical aspect with an inflammatory crusted patch. (b) Ex vivo reflectance confocal microscopy aspect with conidia (red asterisk) and hyphae (red arrow).
JEADV 2015, 29, 2255–2273
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
dermatological consultation, and could quickly initiate an appropriate treatment without waiting for the conventional mycological examination. In contrast, conventional fungal cultures require long incubation periods of 1–5 weeks7 and optical microscopy is usually performed with a particular staining such as KOH or blue lactophenol with an incubation of around 10–30 min8,9 to increase its sensitivity. In vivo RCM has the additional advantage, compared to conventional optical microscopy and cultures, of being non-invasive and not limited to the analysis of the extracted hair, being able to explore the entire lesion, thus reducing false negative cases. However, in vivo examination cannot be performed in case of suppuration or crusting that give artefacts. Ex vivo RCM examination avoids the problem of movements in children and is not very invasive because the collection of the hair, in case of hair dermatophytosis due to the parasitic involvement, is usually not painful. In conclusion, this study shows that RCM can identify hair dermatophytes and that conidia are ‘visible’ under RCM due to their high reflectance. Further studies are needed to define the RCM features of different types of dermatophytes and to compare RCM performances with the conventional techniques. Although at present RCM cannot replace the current diagnostic standards for hair dermatophytosis, it may be successfully used as an additional tool to facilitate the diagnosis and indicate the need for further investigation of the patient. E. Cinotti,1,* J.L. Perrot,1 B. Labeille,1 H. Raberin,2 P. Flori,2 F. Cambazard1 1
Department of Dermatology, University Hospital of Saint-Etienne, Saint Etienne, France, 2Department of Parasitology, University Hospital of SaintEtienne, Saint Etienne, France *Correspondence: E. Cinotti. E-mail: [email protected]
References 1 Slutsky JB, Rabinovitz H, Grichnik JM, Marghoob AA. Reflectance confocal microscopic features of dermatophytes, scabies, and demodex. Arch Dermatol 2011; 147: 1008. 2 Hui D, Xue-cheng S, Ai-e Xu. Evaluation of reflectance confocal microscopy in dermatophytosis. Mycoses 2013; 56: 130–133. 3 Liansheng Z, Xin J, Cheng Q et al. Diagnostic applicability of confocal laser scanning microscopy in tinea corporis. Int J Dermatol 2013; 52: 1281–1282. 4 Cinotti E, Fouilloux B, Perrot JL, Labeille B, Douchet C, Cambazard F. Confocal microscopy for healthy and pathological nail. J Eur Acad Dermatol Venereol 2013; doi: 10.1111/jdv.12330. [Epub ahead of print]. 5 Rudnicka L, Olszewska M, Rakowska A. In vivo reflectance confocal microscopy: usefulness for diagnosing hair diseases. J Dermatol Case Reports 2008; 2: 55–59. 6 Scope A, Benvenuto-Andrade C, Agero A-LC et al. In vivo reflectance confocal microscopy imaging of melanocytic skin lesions: consensus terminology glossary and illustrative images. J Am Acad Dermatol 2007; 57: 644–658. 7 Tampieri MP. Update on the diagnosis of dermatomycosis. Parassitologia 2004; 46: 183–186.
JEADV 2015, 29, 2255–2273
2259
8 Rothmund G, Sattler EC, Kaestle R et al. Confocal laser scanning microscopy as a new valuable tool in the diagnosis of onychomycosis - comparison of six diagnostic methods. Mycoses 2013; 56: 47–55. 9 Grillot R. Techniques de diagnostic biologique des mycoses. In Les mycoses humaines: Demarche diagnostique (Grillot R, ed). Elsevier, Paris: Collection Option Bio, 1996;3: 221. DOI: 10.1111/jdv.12557
Widespread erythema ab igne caused by hot bathing Editor Erythema ab igne (EAI) is caused by frequent exposure to heat, usually infrared radiation.1 Although it may be seen anywhere on the body, most cases are localized. It typically affects the thighs and lower legs of individuals who sit in front of heaters or fires. Recently, laptop computer-induced EAI has been frequently reported.2 The cultures of bathing are unique in each culture throughout the world. In Japan, bathtub is more popular than shower. Furthermore, the temperature of bath water in Japan is usually hotter than that in Europe. Nevertheless, there are no English literatures with EAI caused by bathing, from Japan. Lin et al. reported a case due to frequent hot bathing, who was affected in the lower extremities.3 We present here a widespread EAI on the body caused by hot bathing. A 50-year-old man was referred to our hospital with netlike pigmented skin eruptions on his trunk and legs that had been present for a year. There were no subjective symptoms. He had not been receiving topical ointments or other medications. Physical examination revealed reticulated pigmented eruptions on both the lower extremities, the buttocks and the trunk, with a clear border on the chest (Fig. 1). No skin ulcerations, papules, or indurations were detected. He showed no peripheral circulatory disturbance in the palpable dorsalis pedis artery pulse. The complete blood count, serum chemistry profile, liver function test, complement and urinalysis were normal. Anti-nuclear antibody was positive, with a titer of 1 : 40. Anti-double-stranded DNA antibody and cryoglobulin were negative. A skin biopsy was taken from a pigmented lesion on the left leg. The microscopic findings showed mild superficial perivascular lymphocytic infiltration, dermal pigmentation and a dyskeratotic cells in the epidermis, but not vasculitis (Fig. 2). In the dermis, inner lumen of eccrine duct was obstructed or slender (Fig. 2). On further questioning, he reported taking a very hot bath (approximately 45°C for 30 min) every day for the previous 2 years. The distribution of the pigmented lesions corresponded to the areas that were
© 2014 European Academy of Dermatology and Venereology
2257
acceptable adverse effect profile and can induce sustained remission. G.-Y. Chu,1 S. C.-S. Hu,1 C.-C. E. Lan1,2,* 1
Department of Dermatology, Kaohsiung Medical University Hospital, College of Medicine , 2Department of Dermatology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan *Correspondence: Dr. C.-C. E. Lan. E-mail: [email protected]
References 1 Khachemoune A, Janjua SA, Guldbakke KK. Inflammatory linear verrucous epidermal nevus: a case report and short review of the literature. Cutis 2006; 78: 261–267. 2 Vissers WH, Muys L, Erp PE et al. Immunohistochemical differentiation between inflammatory linear verrucous epidermal nevus (ILVEN) and psoriasis. Eur J Dermatol 2004; 14: 216–220. 3 Jesionek-Kupnicka D, Chomiczewska-Sk ora D, Rotsztejn H. Influence of phototherapy in psoriasis on Ki-67 antigen expression: a preliminary study. Pol J Pathol 2013; 64: 96–103. DOI: 10.1111/jdv.12554
Hair dermatophytosis diagnosed by reflectance confocal microscopy: six cases Editor Reflectance confocal microscopy (RCM) is an emerging imaging technique that has been used to diagnose skin1–3 and nail4 dermatophytosis. Moreover, it has been recently applied to the study of hair5,6 but not of hair dermatophytosis. We report four
cases of tinea capitis and two of tinea barbae diagnosed by in vivo or ex vivo RCM and the first conidia imaged by RCM. Major clinical, RCM, optical microscopy and cultural features are reported in Table 1. RCM examination was performed during the dermatological consultation without the use of any particular staining. In vivo RCM examination (VivaScope3000â, CALIBER, distributed in Europe by MAVIG GmbH) was performed in case of superficial non-suppurated lesions (Fig. 1), whereas ex vivo examination (VivaScope 2500â) was performed when there were suppuration and crusts (Fig. 2). Ex vivo RCM was performed immediately after the hair collection: loose hairs that could be painlessly removed were selected and, whenever not available, hairs were collected by gently plucking the hair root with sterile forceps. In vivo or ex vivo RCM examination took approximately 5 min per patient. RCM examination showed the presence of roundish homogeneous (5–10 lm in size) hyper-reflective structures corresponding to conidia around the proximal part of the hair shaft in all cases (Figs 1, 2). In in vivo conditions conidia had a compact organization, whereas in ex vivo conditions they were more disperse. In two cases sparse elongated hyper-reflective structures outside the hair shafts, corresponding to hyphae, could also be identified. Dermatophytes inside the medulla of the hair shaft could not be identified. Conventional optical microscopic examination with blue lactophenol solution confirmed the presence of conidia outside the hair shaft in all cases, but could find hyphae in only one case. The culture, performed on Sabouraud’s dextrose agar containing chloramphenicol (0.05%) and cycloheximide (0.5%), showed the presence of Microsporum canis or Trichophyton mentagrophytes. In our case series, we could confirm in few minutes the diagnosis of hair dermatophytosis by using RCM during the
Table 1 Clinical features of the six hair dermatophytosis with their respective findings of reflectance confocal microscopy, optical microscopy and cultural examination. Case number
Age/ sex
Site of the lesions
Evolution
Clinical presentation
Wood’s light examination
In vivo RCM
Ex vivo RCM
Optical microscopy examination
Cultural examination
1
5/F
Scalp
2 months
Two scaly patches of alopecia
Green
Ectothrix conidia
NA
Ectothrix conidia
Microsporum canis
2
7/M
Scalp
1 month
One scaly patch of alopecia
Green
Ectothrix conidia
NA
Ectothrix conidia
Microsporum canis
3
6/F
Scalp
15 days
Abscess
Negative
NA
Ectothrix conidia
Ectothrix conidia
Trichophyton Mentagrophytes
4
54/M
Beard
15 days
Abscess
Negative
NA
Ectothrix conidia and hyphae
Ectothrix conidia
Trichophyton Mentagrophytes
5
28/M
Beard
1 month
Abscesses
Green
NA
Ectothrix conidia
Ectothrix conidia
Microsporum canis
6
4/M
Scalp
1 month
One patch of alopecia with pustules
Green
Ectothrix conidia and hyphae
NA
Ectothrix conidia and hyphae
Microsporum canis
JEADV 2015, 29, 2255–2273
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
2258
(a)
(b)
(c)
(d)
Figure 1 Two cases of tinea capitis due to Microsporum canis. (a, c) Clinical aspect with patchy alopecia. (b, c) In vivo reflectance confocal microscopy aspect with conidia (red asterisk) and hyphae (red arrow).
(a)
(b)
(c)
(d)
Figure 2 Tinea barbae due to Trichophyton Mentagrophytes. (a) Clinical aspect with an inflammatory crusted patch. (b) Ex vivo reflectance confocal microscopy aspect with conidia (red asterisk) and hyphae (red arrow).
JEADV 2015, 29, 2255–2273
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
dermatological consultation, and could quickly initiate an appropriate treatment without waiting for the conventional mycological examination. In contrast, conventional fungal cultures require long incubation periods of 1–5 weeks7 and optical microscopy is usually performed with a particular staining such as KOH or blue lactophenol with an incubation of around 10–30 min8,9 to increase its sensitivity. In vivo RCM has the additional advantage, compared to conventional optical microscopy and cultures, of being non-invasive and not limited to the analysis of the extracted hair, being able to explore the entire lesion, thus reducing false negative cases. However, in vivo examination cannot be performed in case of suppuration or crusting that give artefacts. Ex vivo RCM examination avoids the problem of movements in children and is not very invasive because the collection of the hair, in case of hair dermatophytosis due to the parasitic involvement, is usually not painful. In conclusion, this study shows that RCM can identify hair dermatophytes and that conidia are ‘visible’ under RCM due to their high reflectance. Further studies are needed to define the RCM features of different types of dermatophytes and to compare RCM performances with the conventional techniques. Although at present RCM cannot replace the current diagnostic standards for hair dermatophytosis, it may be successfully used as an additional tool to facilitate the diagnosis and indicate the need for further investigation of the patient. E. Cinotti,1,* J.L. Perrot,1 B. Labeille,1 H. Raberin,2 P. Flori,2 F. Cambazard1 1
Department of Dermatology, University Hospital of Saint-Etienne, Saint Etienne, France, 2Department of Parasitology, University Hospital of SaintEtienne, Saint Etienne, France *Correspondence: E. Cinotti. E-mail: [email protected]
References 1 Slutsky JB, Rabinovitz H, Grichnik JM, Marghoob AA. Reflectance confocal microscopic features of dermatophytes, scabies, and demodex. Arch Dermatol 2011; 147: 1008. 2 Hui D, Xue-cheng S, Ai-e Xu. Evaluation of reflectance confocal microscopy in dermatophytosis. Mycoses 2013; 56: 130–133. 3 Liansheng Z, Xin J, Cheng Q et al. Diagnostic applicability of confocal laser scanning microscopy in tinea corporis. Int J Dermatol 2013; 52: 1281–1282. 4 Cinotti E, Fouilloux B, Perrot JL, Labeille B, Douchet C, Cambazard F. Confocal microscopy for healthy and pathological nail. J Eur Acad Dermatol Venereol 2013; doi: 10.1111/jdv.12330. [Epub ahead of print]. 5 Rudnicka L, Olszewska M, Rakowska A. In vivo reflectance confocal microscopy: usefulness for diagnosing hair diseases. J Dermatol Case Reports 2008; 2: 55–59. 6 Scope A, Benvenuto-Andrade C, Agero A-LC et al. In vivo reflectance confocal microscopy imaging of melanocytic skin lesions: consensus terminology glossary and illustrative images. J Am Acad Dermatol 2007; 57: 644–658. 7 Tampieri MP. Update on the diagnosis of dermatomycosis. Parassitologia 2004; 46: 183–186.
JEADV 2015, 29, 2255–2273
2259
8 Rothmund G, Sattler EC, Kaestle R et al. Confocal laser scanning microscopy as a new valuable tool in the diagnosis of onychomycosis - comparison of six diagnostic methods. Mycoses 2013; 56: 47–55. 9 Grillot R. Techniques de diagnostic biologique des mycoses. In Les mycoses humaines: Demarche diagnostique (Grillot R, ed). Elsevier, Paris: Collection Option Bio, 1996;3: 221. DOI: 10.1111/jdv.12557
Widespread erythema ab igne caused by hot bathing Editor Erythema ab igne (EAI) is caused by frequent exposure to heat, usually infrared radiation.1 Although it may be seen anywhere on the body, most cases are localized. It typically affects the thighs and lower legs of individuals who sit in front of heaters or fires. Recently, laptop computer-induced EAI has been frequently reported.2 The cultures of bathing are unique in each culture throughout the world. In Japan, bathtub is more popular than shower. Furthermore, the temperature of bath water in Japan is usually hotter than that in Europe. Nevertheless, there are no English literatures with EAI caused by bathing, from Japan. Lin et al. reported a case due to frequent hot bathing, who was affected in the lower extremities.3 We present here a widespread EAI on the body caused by hot bathing. A 50-year-old man was referred to our hospital with netlike pigmented skin eruptions on his trunk and legs that had been present for a year. There were no subjective symptoms. He had not been receiving topical ointments or other medications. Physical examination revealed reticulated pigmented eruptions on both the lower extremities, the buttocks and the trunk, with a clear border on the chest (Fig. 1). No skin ulcerations, papules, or indurations were detected. He showed no peripheral circulatory disturbance in the palpable dorsalis pedis artery pulse. The complete blood count, serum chemistry profile, liver function test, complement and urinalysis were normal. Anti-nuclear antibody was positive, with a titer of 1 : 40. Anti-double-stranded DNA antibody and cryoglobulin were negative. A skin biopsy was taken from a pigmented lesion on the left leg. The microscopic findings showed mild superficial perivascular lymphocytic infiltration, dermal pigmentation and a dyskeratotic cells in the epidermis, but not vasculitis (Fig. 2). In the dermis, inner lumen of eccrine duct was obstructed or slender (Fig. 2). On further questioning, he reported taking a very hot bath (approximately 45°C for 30 min) every day for the previous 2 years. The distribution of the pigmented lesions corresponded to the areas that were
© 2014 European Academy of Dermatology and Venereology
