Letters to the Editor
1025
10 Wallach D, Vignon-Pennamen MD. From acute febrile neutrophilic dermatosis to neutrophilic disease: Forty years of clinical research. J Am Acad Dermatol 2006; 55: 1066–1071. DOI: 10.1111/jdv.12446
Approach to hypohidrosis Editor It is interesting to read the article by Chia K.Y & Tey H.L1. However, I would like to add on a few more entities here, which are pertinent to the subject. Leprosy remains one of the important causes of hypohidrosis in the third world. The hypohidrosis in leprosy results from the atrophy of the sweat glands subsequent to loss of nerve supply. The hypohidrosis in leprosy may either be lesional or diffuse due to autonomic dysfunction.2 Hypohidrosis often appears in early tuberculoid lesions where inflammatory damage is more. Indeed, pilocarpine sweat stimulation test has been used to diagnose early tuberculoid form of leprosy.2 In lepromatous leprosy on the other hand, hypohidrosis appears in the later stages. Syringotropic sarcoidosis may exhibit a reduced sweating response to thermal stimuli.3 Immunohistochemical analyses of the sweat glands surrounded by syringotropic granulomas depicts profoundly decreased expression of dermcidin and aquaporin 5, markers of sweat glands, suggesting functional defects. In addition, granulomatous mycosis fungoides may present with hypohidrosis and masquerade as leprosy.4 P. Verma* Department of Dermatology & STD, North DMC Medical College, Hindu Rao Hospital, I.P University, Delhi, India *Correspondence: P. Verma. E-mail: [email protected]
References 1 Chia KY, Tey HL. Approach to hypohidrosis. J Eur Acad Dermatol Venereol 2013; 27: 799–804. 2 Markendeya N, Srinivas CR. Ninhydrin sweat test in leprosy. Indian J Lepr 2004; 76: 299–304. 3 Hayakawa J, Mizukawa Y, Kurata M, Shiohara T. A syringotropic variant of cutaneous sarcoidosis: presentation of 3 cases exhibiting defective sweating responses. J Am Acad Dermatol 2013; 68: 1016–1021. 4 Gutte R, Kharkar V, Mahajan S et al. Granulomatous mycosis fungoides with hypohidrosis mimicking lepromatous leprosy. Indian J Dermatol Venereol Leprol 2010; 76: 686–690. DOI: 10.1111/jdv.12447
JEADV 2015, 29, 1019–1036
Microbiology of folliculitis decalvans: a histological study of 37 patients Editor Folliculitis decalvans (FD) is a chronic primary disease characterized by neutrophilic cicatricial alopecia. The aetiology is largely unknown but bacterial involvement has been suggested as Staphylococcus aureus (S. aureus) can be isolated from primary lesions in a majority of untreated FD patients.1,2 Recently, Matard et al.3 studied bacterial colonization of hair samples of FD patients and speculated that Propionibacterium acnes (P. acnes) rather than S. aureus might be involved in the pathogenesis of FD. Archival biopsy materials from 37 patients (median age 40 years, range 17–75; 27 males/10 females) diagnosed with FD were retrieved from hospital-affiliated biobanks in Sweden and contained a median of two hair follicles (range 1–5). A dense perifollicular infiltrate consisting of lymphocytes and neutrophils was seen in all samples. Immunofluorescence microscopy (IFM) and fluorescence in situ hybridization (FISH) were employed to visualize fungi, P. acnes and Staphylococcus spp. as described.4,5 All samples were further labelled with DAPI (40 ,60 -diamidino-2-phenylindole). Overall, 13 (35%) patients tested positive for bacterial colonization. Of these, 10 patients (27%) showed colonization in hair follicles while three (8%) displayed bacteria in the stratum corneum. The latter contained single cells or small cell aggregations consisting of 15–20 Gram-positives (n = 2) or DAPI-labelled cocci (n = 1). Two patients showed singular fungal bodies in the stratum corneum. Hair follicles were either colonized by P. acnes (n = 3) or by Gram-positives/cocci (n = 7). P. acnes could be identified as biofilms in two samples (Fig. 1). Biofilms were defined as surface-associated matrix-encased bacterial cell clusters of >1000 bacterial cells.5 Samples scored positive for Gram-positives or DAPI-labelled cocci were further tested with a PNA-FISH kit (AdvanDx A/S, Vedbæk, Denmark). This kit is designed to distinguish S. aureus from coagulase-negative staphylococci (CNS). Three of the seven samples were tested positive; S. aureus could be identified in two samples and CNS in one. S. aureus as well as CNS were observed as singular cells. Using a combination of IFM and FISH makes it possible to relate microbiology and histology and unequivocally shows if bacteria in question reside in primary tissue lesions. Previous results implicating S. aureus in FD were, however, mainly based on culture technique.1,6 Swab sampling is limited to superficial organisms and cannot access bacteria located in deeper parts of the hair follicle and/or organized in biofilms.7 Our study has revealed a greater variety of hair follicle bacteria – P. acnes, S. aureus, CNS and other coccoids than previously thought. Recently, a possible involvement of other bacterial species in FD
© 2014 European Academy of Dermatology and Venereology
1026
Letters to the Editor
(a)
natural phenotype of bacteria in both environmental and clinical settings.8,9 Superficial colonization represented by single bacterial cells or fungal bodies in the stratum corneum is most likely a part of the normal skin flora and not correlated with the inflammatory process. But this observation should be taken into account while interpreting positive culture results. Limitations of FISH/IFM when applied to skin samples are well recognized.4,7 Further limitations relate to the small cohort size and the lack of appropriate control samples/group. Even though FD is associated with bacterial colonization of primary lesions in a third of patients studied, further research will be necessary to establish causality. This will hopefully lead to a better treatment of this debilitating disease.
Funding Sources Financial support to OA was provided through regional agreement between Ume a University and V€asterbotten County Council on cooperation in the field of Medicine, Odontology and Health (ALF) and Kempe Foundation. A. C. Jahns,1 B. Lundskog,1 D. Nosek,2 H. Killasli,3 L. Emtestam,3 O. A. Alexeyev1,*
(b)
Department of Medical Biosciences/Pathology, Ume a University, Ume a, a University, Ume a, Sweden, Sweden, 2Department of Dermatology, Ume 3 Section of Infectious Diseases and Dermatology, Department of Medicine, Karolinska Institute, Huddinge, Stockholm, Sweden *Correspondence: O. A. Alexeyev. E-mail: [email protected] 1
References
Figure 1 Confocal laser scanning microscopic images of a hair follicle in a FD sample showing P. acnes biofilm-like structures labelled with polyclonal anti-P. acnes antibody (green); arrow heads point towards the outer root sheath. (a) Overview, scale bar 10 lm; (b) Close-up of the area marked in (a), scale bar 2 lm.
has emerged3 although the findings were limited by the lack of species identification. Our results have provided unequivocal evidence for P. acnes colonization in 30% of the samples positive for microbial colonization in hair follicles. Moreover, in two of these samples P. acnes occurred in biofilm-like structures. Biofilms have now been recognized as the predominant
JEADV 2015, 29, 1019–1036
1 Powell JJ, Dawber RP, Gatter K. Folliculitis decalvans including tufted folliculitis: clinical, histological and therapeutic findings. Br J Dermatol 1999; 140: 328–333. 2 Brooke RC, Griffiths CE. Folliculitis decalvans. Clin Exp Dermatol 2001; 26: 120–122. 3 Matard B, Meylheuc T, Briandet R et al. First evidence of bacterial biofilms in the anaerobic part of scalp hair follicles: a pilot comparative study in folliculitis decalvans. J Eur Acad Dermatol Venereol 2013; 27: 853–860. 4 Jahns AC, Oprica C, Vassilaki I, Golovleva I, Palmer RH, Alexeyev OA. Simultaneous visualization of Propionibacterium acnes and Propionibacterium granulosum with immunofluorescence and in situ hybridization. Anaerobe 2013; 23: 48–54. 5 Jahns AC, Lundskog B, Ganceviciene R et al. An increased incidence of Propionibacterium acnes biofilms in acne vulgaris: a case-control study. Br J Dermatol 2012; 167: 50–58. 6 Chiarini C, Torchia D, Bianchi B, Volpi W, Caproni M, Fabbri P. Immunopathogenesis of folliculitis decalvans: clues in early lesions. Am J Clin Pathol 2008; 130: 526–534. 7 Alexeyev OA, Jahns AC. Sampling and detection of skin Propionibacterium acnes: Current status. Anaerobe 2012; 18: 479–483. 8 Vlassova N, Han A, Zenilman JM, James G, Lazarus GS. New horizons for cutaneous microbiology: the role of biofilms in dermatological disease. Br J Dermatol 2011; 165: 751–759. 9 Wolcott RD, Ehrlich GD. Biofilms and chronic infections. JAMA 2008; 299: 2682–2684. DOI: 10.1111/jdv.12448
© 2014 European Academy of Dermatology and Venereology
1025
10 Wallach D, Vignon-Pennamen MD. From acute febrile neutrophilic dermatosis to neutrophilic disease: Forty years of clinical research. J Am Acad Dermatol 2006; 55: 1066–1071. DOI: 10.1111/jdv.12446
Approach to hypohidrosis Editor It is interesting to read the article by Chia K.Y & Tey H.L1. However, I would like to add on a few more entities here, which are pertinent to the subject. Leprosy remains one of the important causes of hypohidrosis in the third world. The hypohidrosis in leprosy results from the atrophy of the sweat glands subsequent to loss of nerve supply. The hypohidrosis in leprosy may either be lesional or diffuse due to autonomic dysfunction.2 Hypohidrosis often appears in early tuberculoid lesions where inflammatory damage is more. Indeed, pilocarpine sweat stimulation test has been used to diagnose early tuberculoid form of leprosy.2 In lepromatous leprosy on the other hand, hypohidrosis appears in the later stages. Syringotropic sarcoidosis may exhibit a reduced sweating response to thermal stimuli.3 Immunohistochemical analyses of the sweat glands surrounded by syringotropic granulomas depicts profoundly decreased expression of dermcidin and aquaporin 5, markers of sweat glands, suggesting functional defects. In addition, granulomatous mycosis fungoides may present with hypohidrosis and masquerade as leprosy.4 P. Verma* Department of Dermatology & STD, North DMC Medical College, Hindu Rao Hospital, I.P University, Delhi, India *Correspondence: P. Verma. E-mail: [email protected]
References 1 Chia KY, Tey HL. Approach to hypohidrosis. J Eur Acad Dermatol Venereol 2013; 27: 799–804. 2 Markendeya N, Srinivas CR. Ninhydrin sweat test in leprosy. Indian J Lepr 2004; 76: 299–304. 3 Hayakawa J, Mizukawa Y, Kurata M, Shiohara T. A syringotropic variant of cutaneous sarcoidosis: presentation of 3 cases exhibiting defective sweating responses. J Am Acad Dermatol 2013; 68: 1016–1021. 4 Gutte R, Kharkar V, Mahajan S et al. Granulomatous mycosis fungoides with hypohidrosis mimicking lepromatous leprosy. Indian J Dermatol Venereol Leprol 2010; 76: 686–690. DOI: 10.1111/jdv.12447
JEADV 2015, 29, 1019–1036
Microbiology of folliculitis decalvans: a histological study of 37 patients Editor Folliculitis decalvans (FD) is a chronic primary disease characterized by neutrophilic cicatricial alopecia. The aetiology is largely unknown but bacterial involvement has been suggested as Staphylococcus aureus (S. aureus) can be isolated from primary lesions in a majority of untreated FD patients.1,2 Recently, Matard et al.3 studied bacterial colonization of hair samples of FD patients and speculated that Propionibacterium acnes (P. acnes) rather than S. aureus might be involved in the pathogenesis of FD. Archival biopsy materials from 37 patients (median age 40 years, range 17–75; 27 males/10 females) diagnosed with FD were retrieved from hospital-affiliated biobanks in Sweden and contained a median of two hair follicles (range 1–5). A dense perifollicular infiltrate consisting of lymphocytes and neutrophils was seen in all samples. Immunofluorescence microscopy (IFM) and fluorescence in situ hybridization (FISH) were employed to visualize fungi, P. acnes and Staphylococcus spp. as described.4,5 All samples were further labelled with DAPI (40 ,60 -diamidino-2-phenylindole). Overall, 13 (35%) patients tested positive for bacterial colonization. Of these, 10 patients (27%) showed colonization in hair follicles while three (8%) displayed bacteria in the stratum corneum. The latter contained single cells or small cell aggregations consisting of 15–20 Gram-positives (n = 2) or DAPI-labelled cocci (n = 1). Two patients showed singular fungal bodies in the stratum corneum. Hair follicles were either colonized by P. acnes (n = 3) or by Gram-positives/cocci (n = 7). P. acnes could be identified as biofilms in two samples (Fig. 1). Biofilms were defined as surface-associated matrix-encased bacterial cell clusters of >1000 bacterial cells.5 Samples scored positive for Gram-positives or DAPI-labelled cocci were further tested with a PNA-FISH kit (AdvanDx A/S, Vedbæk, Denmark). This kit is designed to distinguish S. aureus from coagulase-negative staphylococci (CNS). Three of the seven samples were tested positive; S. aureus could be identified in two samples and CNS in one. S. aureus as well as CNS were observed as singular cells. Using a combination of IFM and FISH makes it possible to relate microbiology and histology and unequivocally shows if bacteria in question reside in primary tissue lesions. Previous results implicating S. aureus in FD were, however, mainly based on culture technique.1,6 Swab sampling is limited to superficial organisms and cannot access bacteria located in deeper parts of the hair follicle and/or organized in biofilms.7 Our study has revealed a greater variety of hair follicle bacteria – P. acnes, S. aureus, CNS and other coccoids than previously thought. Recently, a possible involvement of other bacterial species in FD
© 2014 European Academy of Dermatology and Venereology
1026
Letters to the Editor
(a)
natural phenotype of bacteria in both environmental and clinical settings.8,9 Superficial colonization represented by single bacterial cells or fungal bodies in the stratum corneum is most likely a part of the normal skin flora and not correlated with the inflammatory process. But this observation should be taken into account while interpreting positive culture results. Limitations of FISH/IFM when applied to skin samples are well recognized.4,7 Further limitations relate to the small cohort size and the lack of appropriate control samples/group. Even though FD is associated with bacterial colonization of primary lesions in a third of patients studied, further research will be necessary to establish causality. This will hopefully lead to a better treatment of this debilitating disease.
Funding Sources Financial support to OA was provided through regional agreement between Ume a University and V€asterbotten County Council on cooperation in the field of Medicine, Odontology and Health (ALF) and Kempe Foundation. A. C. Jahns,1 B. Lundskog,1 D. Nosek,2 H. Killasli,3 L. Emtestam,3 O. A. Alexeyev1,*
(b)
Department of Medical Biosciences/Pathology, Ume a University, Ume a, a University, Ume a, Sweden, Sweden, 2Department of Dermatology, Ume 3 Section of Infectious Diseases and Dermatology, Department of Medicine, Karolinska Institute, Huddinge, Stockholm, Sweden *Correspondence: O. A. Alexeyev. E-mail: [email protected] 1
References
Figure 1 Confocal laser scanning microscopic images of a hair follicle in a FD sample showing P. acnes biofilm-like structures labelled with polyclonal anti-P. acnes antibody (green); arrow heads point towards the outer root sheath. (a) Overview, scale bar 10 lm; (b) Close-up of the area marked in (a), scale bar 2 lm.
has emerged3 although the findings were limited by the lack of species identification. Our results have provided unequivocal evidence for P. acnes colonization in 30% of the samples positive for microbial colonization in hair follicles. Moreover, in two of these samples P. acnes occurred in biofilm-like structures. Biofilms have now been recognized as the predominant
JEADV 2015, 29, 1019–1036
1 Powell JJ, Dawber RP, Gatter K. Folliculitis decalvans including tufted folliculitis: clinical, histological and therapeutic findings. Br J Dermatol 1999; 140: 328–333. 2 Brooke RC, Griffiths CE. Folliculitis decalvans. Clin Exp Dermatol 2001; 26: 120–122. 3 Matard B, Meylheuc T, Briandet R et al. First evidence of bacterial biofilms in the anaerobic part of scalp hair follicles: a pilot comparative study in folliculitis decalvans. J Eur Acad Dermatol Venereol 2013; 27: 853–860. 4 Jahns AC, Oprica C, Vassilaki I, Golovleva I, Palmer RH, Alexeyev OA. Simultaneous visualization of Propionibacterium acnes and Propionibacterium granulosum with immunofluorescence and in situ hybridization. Anaerobe 2013; 23: 48–54. 5 Jahns AC, Lundskog B, Ganceviciene R et al. An increased incidence of Propionibacterium acnes biofilms in acne vulgaris: a case-control study. Br J Dermatol 2012; 167: 50–58. 6 Chiarini C, Torchia D, Bianchi B, Volpi W, Caproni M, Fabbri P. Immunopathogenesis of folliculitis decalvans: clues in early lesions. Am J Clin Pathol 2008; 130: 526–534. 7 Alexeyev OA, Jahns AC. Sampling and detection of skin Propionibacterium acnes: Current status. Anaerobe 2012; 18: 479–483. 8 Vlassova N, Han A, Zenilman JM, James G, Lazarus GS. New horizons for cutaneous microbiology: the role of biofilms in dermatological disease. Br J Dermatol 2011; 165: 751–759. 9 Wolcott RD, Ehrlich GD. Biofilms and chronic infections. JAMA 2008; 299: 2682–2684. DOI: 10.1111/jdv.12448
© 2014 European Academy of Dermatology and Venereology
