Viewpoints in dermatology • Correspondence
Correspondence
Unilateral laterothoracic or asymmetric periflexural exanthem: is time to change the name of the disease? doi: 10.1111/ced.12486 We read with interest the article by Niedermeier et al.1 about ‘superimposed lateralized exanthem of childhood related to adenovirus infection’, and we would like to make a few comments on it. This exanthem is also known as ‘unilateral laterothoracic exanthema’ (ULE) or ‘asymmetrical periflexural exanthema of childhood’ (APEC). Both denominations, however, are inaccurate, as they do not match the clinical features of the exanthem fully. First, although the exanthem is prevalent in childhood, it is not exclusive to it, as several cases have been reported in adults.2,3 Second, the eruption does not always remain unilateral, and may involve, even primarily, the groin and the legs. Accordingly, we endorse the title suggested by Happle et al.4 that is ‘superimposed lateralized exanthem’ (SLEx). We also agree with their hypothesis explaining the unilateral preponderance of this exanthem as increased responsiveness of a polygenic predisposed side of the body to various infectious agents. Doctors are accustomed to the idea that an infectious disease is caused by a single infectious agent. However, the same infectious agent may cause different types of exanthems, and the same exanthem may be caused by different infectious agents. In addition, different infectious agents may cooperate with each other simultaneously or in temporal succession to produce the clinical manifestations. It seems probable that this also occurs in some cases of drug reactions. In fact, an association with adenovirus, parainfluenza virus, parvovirus B19, human herpes virus (HHV)6 and HHV-7, and Epstein–Barr virus has been reported in SLEx.5 Some of these viruses provide particular features to the exanthem while keeping it mainly lateralized. For example, as we reported years ago,3 Parvovirus B19 may be responsible for an evident purpuric component of the exanthem. An asymmetrical presentation may also be observed in pityriasis rosea (PR). In our updated series of 578 PR cases, an atypical presentation starting from the axilla or presenting a strictly asymmetrical involvement was observed in nine patients (1.5%; seven adults and two children), and in seven of them, an endogenous HHV-6 or
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Clinical and Experimental Dermatology (2015) 40, pp570–579
HHV-7 systemic reactivation was detected, giving a virological confirmation of the diagnosis of PR.6 In fact, we believe the clinical differential diagnosis of SLEx should also include atypical PR, and probably certain cases of SLEx might be atypical presentations of PR. Consequently, we consider that it is time to adopt ‘superimposed lateralized exanthem’ as the most suitable term for this condition. F. Drago, G. Ciccarese and A. Rebora Department of Dermatology, DISSAL, IRCCS AOU San Martino-IST, Genoa, Italy E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 5 May 2014
References 1 Niedermeier A, Pfutzner W, Ruzicka T et al. Superimposed lateralized exanthem of childhood: report of a case related to adenovirus infection. Clin Exp Dermatol 2014; 39: 351–3. 2 Bauza A, Redondo P, Fernandez J. Asymmetric periflexural exanthem in adults. Br J Dermatol 2000; 143: 198–233. 3 Drago F, Semino M, Rampini P et al. Parvovirus B19 infection associated with acute hepatitis and a purpuric exanthem. Br J Dermatol 1999; 141: 154–79. 4 Happle R. Superimposed segmental manifestations of polygenic skin disorders. J Am Acad Dermatol 2007; 57: 690–9. 5 Duarte AF, Cruz MJ, Baudrier T et al. Unilateral laterothoracic exanthem and primary Epstein-Barr virus infection: case report. Pediatr Infect Dis J 2009; 28: 549–50. 6 Broccolo F, Drago F, Careddu AM et al. Additional evidence that pityriasis rosea is associated with reactivation of human herpesvirus-6 and -7. J Invest Dermatol 2005; 124: 1234–40.
Site of botulinum toxin type A administration in craniofacial hyperhidrosis doi: 10.1111/ced.12558 Over recent years, botulinum toxin type A (BoNTA) has been used in an increasing number of clinical
ª 2014 British Association of Dermatologists
Correspondence
Unilateral laterothoracic or asymmetric periflexural exanthem: is time to change the name of the disease? doi: 10.1111/ced.12486 We read with interest the article by Niedermeier et al.1 about ‘superimposed lateralized exanthem of childhood related to adenovirus infection’, and we would like to make a few comments on it. This exanthem is also known as ‘unilateral laterothoracic exanthema’ (ULE) or ‘asymmetrical periflexural exanthema of childhood’ (APEC). Both denominations, however, are inaccurate, as they do not match the clinical features of the exanthem fully. First, although the exanthem is prevalent in childhood, it is not exclusive to it, as several cases have been reported in adults.2,3 Second, the eruption does not always remain unilateral, and may involve, even primarily, the groin and the legs. Accordingly, we endorse the title suggested by Happle et al.4 that is ‘superimposed lateralized exanthem’ (SLEx). We also agree with their hypothesis explaining the unilateral preponderance of this exanthem as increased responsiveness of a polygenic predisposed side of the body to various infectious agents. Doctors are accustomed to the idea that an infectious disease is caused by a single infectious agent. However, the same infectious agent may cause different types of exanthems, and the same exanthem may be caused by different infectious agents. In addition, different infectious agents may cooperate with each other simultaneously or in temporal succession to produce the clinical manifestations. It seems probable that this also occurs in some cases of drug reactions. In fact, an association with adenovirus, parainfluenza virus, parvovirus B19, human herpes virus (HHV)6 and HHV-7, and Epstein–Barr virus has been reported in SLEx.5 Some of these viruses provide particular features to the exanthem while keeping it mainly lateralized. For example, as we reported years ago,3 Parvovirus B19 may be responsible for an evident purpuric component of the exanthem. An asymmetrical presentation may also be observed in pityriasis rosea (PR). In our updated series of 578 PR cases, an atypical presentation starting from the axilla or presenting a strictly asymmetrical involvement was observed in nine patients (1.5%; seven adults and two children), and in seven of them, an endogenous HHV-6 or
570
Clinical and Experimental Dermatology (2015) 40, pp570–579
HHV-7 systemic reactivation was detected, giving a virological confirmation of the diagnosis of PR.6 In fact, we believe the clinical differential diagnosis of SLEx should also include atypical PR, and probably certain cases of SLEx might be atypical presentations of PR. Consequently, we consider that it is time to adopt ‘superimposed lateralized exanthem’ as the most suitable term for this condition. F. Drago, G. Ciccarese and A. Rebora Department of Dermatology, DISSAL, IRCCS AOU San Martino-IST, Genoa, Italy E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 5 May 2014
References 1 Niedermeier A, Pfutzner W, Ruzicka T et al. Superimposed lateralized exanthem of childhood: report of a case related to adenovirus infection. Clin Exp Dermatol 2014; 39: 351–3. 2 Bauza A, Redondo P, Fernandez J. Asymmetric periflexural exanthem in adults. Br J Dermatol 2000; 143: 198–233. 3 Drago F, Semino M, Rampini P et al. Parvovirus B19 infection associated with acute hepatitis and a purpuric exanthem. Br J Dermatol 1999; 141: 154–79. 4 Happle R. Superimposed segmental manifestations of polygenic skin disorders. J Am Acad Dermatol 2007; 57: 690–9. 5 Duarte AF, Cruz MJ, Baudrier T et al. Unilateral laterothoracic exanthem and primary Epstein-Barr virus infection: case report. Pediatr Infect Dis J 2009; 28: 549–50. 6 Broccolo F, Drago F, Careddu AM et al. Additional evidence that pityriasis rosea is associated with reactivation of human herpesvirus-6 and -7. J Invest Dermatol 2005; 124: 1234–40.
Site of botulinum toxin type A administration in craniofacial hyperhidrosis doi: 10.1111/ced.12558 Over recent years, botulinum toxin type A (BoNTA) has been used in an increasing number of clinical
ª 2014 British Association of Dermatologists
