Letters to the Editor

which was approved by our ethics committee.3 We identified S2889X FLG gene heterozygous nonsense mutation in this patient. The patient was treated with topical tacrolimus and corticosteroids. Currently, his pigmentation has slightly improved. We diagnosed the patient’s poikiloderma as AD because of the childhood-onset long history, concomitance of eczema, presence of asthma, high serum levels of IgE and CCL17, and palmar hyperlinearity with FLG mutation. Other poikilodermapresenting diseases, including mycosis fungoides, dermatomyositis and Rothmund–Thomson disease were excluded. To our knowledge, this is the first report of generalized poikiloderma in association with AD. Approximately 2% of adult AD patients exhibit rippled, poikiloderma-like lesions on the neck, called “dirty neck”.4 Histopathologically, dirty neck shows marked pigmentary incontinence as well as eczematous changes. Deposition of amyloid also may occur. In addition to pigmentary incontinence, our case showed increased melanosis in the epidermal rete ridges. The present case may represent extreme extension of such poikiloderma-like lesions. Various skin lesions are associated with FLG mutation, such as xerosis cutis, keratosis pilaris, flexural eczema and dirty neck.5 Our case suggests that generalized poikiloderma may be one of the manifestations of AD with FLG mutation.

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Shinsuke NAKAZAWA, Mutsumi MORIKI, Shigeki IKEYA, Jun-ichi SAKABE, Yoshiki TOKURA Department of Dermatology, Hamamatsu University School of Medicine, Hamamatsu, Japan doi: 10.1111/1346-8138.12339

REFERENCES 1 Palmer CN, Irvine AD, Terron-Kwiatkowski A et al. Common loss-offunction variants of the epidermal barrier protein filaggrin are a major predisposing factor for atopic dermatitis. Nat Genet 2006; 38: 441– 446. 2 Akiyama M. FLG mutations in ichthyosis vulgaris and atopic eczema: spectrum of mutations and population genetics. Br J Dermatol 2010; 162: 472–477. 3 Yamaguchi H, Kabashima-Kubo R, Bito T et al. High frequencies of positive nickel/cobalt patch tests and high sweat nickel concentration in patients with intrinsic atopic dermatitis. J Dermatol Sci 2013; (Epub ahead of print). 4 Humphreys F, Spencer J, Mclaren K, Tidman MJ. An histological and ultrastructural study of the ‘dirty neck’ appearance in atopic eczema. Clin Exp Dermatol 1996; 21: 17–19. 5 Landeck L, Visser M, Kezic S, John SM. Genotype-phenotype associations in filaggrin loss-of-function mutation carriers. Contact Dermatitis 2013; 68: 149–155.

None.

Perifollicular elastolysis with atopic dermatitis Dear Editor, Perifollicular elastolysis, first described by Varadi and Saqueton, is a relatively rare disorder.1 We herein report a case of perifollicular elastolysis in atopic dermatitis (AD). A 45-year-old Japanese woman with AD had been treated in our department for 20 years. She is a junior high school teacher and avoids sun exposure. Her serum levels of total immunoglobulin E were high, ranging 15 000–21 500 U/mL, and the eosinophil count and serum levels of lactate dehydrogenase and thymus and activation regulated chemokine were also high, at 300/lL, 295 U/L and 3200 pg/mL, respectively. Although she had used topical corticosteroid ointments and 0.1% tacrolimus ointment as well as antihistamine agents, her skin symptoms and pruritus had not been well controlled. In January 2012, she noticed yellowish-white papules on her face and neck. Physical examination revealed rice grain-sized yellowish-white papules on the forehead, cheeks and neck (Fig. 1a). A small number of papules were also seen on the upper part of the trunk. Most papules corresponded to hair follicles. She had had no past history of acne vulgaris or varicella.

Histological study of her papule revealed acanthosis, perivascular mononuclear cell infiltrations and dilation of capillary vessels suggesting that the change was due to AD (Fig. 1b). Weigert’s stain demonstrated diminished elastic fibers around hair follicles (Fig. 1c). No calcification or fragmentation of elastic fibers was seen. Based on the above findings, we diagnosed her as having perifollicular elastolysis. Because she refused surgical and liquid nitrogen treatment, she has been under observation. Some papules spontaneously resolved. Perifollicular elastolysis is a disease characterized by small, yellowish-white, hypopigmented, follicular papules on the face and/or upper trunk.1,2 The papule may protrude or herniate. Some authors have suggested the term “papular acne scars” for the disorder due to its strong association with acne vulgaris.3 Histological characteristics of perifollicular elastolysis include a lack of elastic fibers around perifollicular and sebaceous units. The differential diagnosis of perifollicular elastolysis includes post-acne scars, varicella, white fibrous papulosis of the neck (WFPN), pseudoxanthoma elasticum-like papillary dermal elastolysis, milium and atrophoderma vermiculatum. In

Correspondence: Hiroo Amano, M.D., Ph.D., Department of Dermatology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan. Email: [email protected]

Ó 2014 Japanese Dermatological Association

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Letters to the Editor

(a)

(b)

(c)

follicular destruction and perifollicular lymphocytic infiltration histologically. In the present case, long-term application of topical corticosteroid ointments might have induced folliculitis leading to inflammation and perifollicular elastolysis. In most patients, however, folliculitis induced by corticosteroid ointment does not evolve into this condition. Certain factors in host reaction to folliculitis may be responsible for the disease. Because the disease is cosmetically problematic, we should carefully observe patients with AD to diagnose it as early as possible.

CONFLICT OF INTEREST:

Figure 1. (a) Physical examination revealed rice grain-sized yellowish-white papules on the forehead. Most papules corresponded to hair follicles. (b) Acanthosis, perivascular mononuclear cell infiltrations and dilation of capillary vessels suggesting that the change is due to atopic dermatitis (hematoxylin–eosin, original magnification 9100). (c) Absence of elastic fibers around hair follicle (Weigert’s staining, 9100).

None.

Hiroo AMANO, Chikako KISHI, Sei-ichiro MOTEGI, Kumi AOYAMA, Akira SHIMIZU, Osamu ISHIKAWA Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan doi: 10.1111/1346-8138.12388

REFERENCES the present case, the patient’s history excluded post-acne scars and varicella. The most likely disorder to consider was WFPN, which is characterized by discrete and firm papules localized to the neck of elderly people.4 Our patient was in her 40s when the disease started, and the lesions were distributed not only on the neck but also the face. Pseudoxanthoma elasticulum-like papillary dermal elastolysis consists of soft, coalescent, yellowish-white papules mainly on the lateral neck and superclavicular regions.5 Milium is composed of small cysts surrounded by horny epithelium. Atrophoderma vermiculatum is usually preceded by keratotic lesions with

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1 Varadi DP, Saqueton AC. Perifollicular elastolysis. Br J Dermatol 1970; 83: 143–150. 2 Wilson BB, Dent HC, Cooper PH. Papular acne scars. Arch Dermatol 1990; 126: 797–800. 3 Elder D, Elenitsas R, Jaworsky C, Johnson B Jr. Levers Histopathology of the Skin, 8th edn. Philadelphia: Lippincott Williams & Wilkins, 1997; 412. 4 Shimizu H, Kimura S, Harada T, Nishikawa T. White fibrous papulosis of the neck: a new clinicopathologic entity? J Am Acad Dermatol 1989; 20: 1073–1077. ~as PF, Fraga J, Aragu €es M, Garcıa-Dıez A. Pseu5 Vargas-Dıez E, Pen doxanthoma elasticum-like papillary dermal elastolysis. A report of two cases and review of the literature. Acta Derm Venereol 1997; 77: 43–45.

Ó 2014 Japanese Dermatological Association

Perifollicular elastolysis with atopic dermatitis.

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