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.

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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

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Figure 1 Reticular hyperpigmentation on the buttocks, trunk, upper thighs, lower legs, and feet. The eruptions on the trunk are clearly demarcated (arrow).

Figure 2 Histologically, mild superficial perivascular lymphocytic infiltration, dermal pigmentation and a dyskeratotic cells were in the epidermis. In the dermis, inner lumen of eccrine duct was narrow (H&E staining).

immersed in the bath. Based on the clinical manifestations, microscopic findings and habitual history, he was diagnosed with EAI from prolonged hot bathing. The patient was instructed to avoid taking hot baths. The clinical manifestations of EAI initially present as transient, reticulated, macular erythemas are blanchable.4,5 Over time and with repeated exposure, the lesions become hyperpigmented and fixed, with overlying atrophy and occasional telangiectases or hyperkeratosis. The histological manifestations are vasodilation, dermal edema, extravasation of erythrocytes, infiltrates of lymphocytes or histiocytes, and deposition of hemosiderin or melanin in the dermis.4,5 The epidermis may show atrophy and vacuolar degeneration. In the present case, inner lumen of eccrine duct was narrow.

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While previous reports have not described about eccrine duct in detail, this finding may be specific for EAI. The pathomechanisms of EAI remain unknown. It is, however, hypothesized that the distribution of affected blood vessels may result in the net-like pattern.4 Exposure to heat is postulated to induce epidermal damage to superficial blood vessels. Subsequently, it may lead to a vascular dilation, extravasation of erythrocytes and hemosiderin deposition in the reticular dermis. The extravasation of erythrocytes and deposition of hemosiderin that follow clinically appear as hyperpigmentation. Treatment involves eliminating contact with the heat source.4,5 Removal of the heat sources results in the spontaneous resolution of erythema for most patients in the early stage. Chronic exposure often leads to long-lasting hyperpigmentation, however, it

© 2014 European Academy of Dermatology and Venereology

Letters to the Editor

may spontaneously fade gradually. Similar to other conditions that result in hyperpigmentation, laser therapy may be potentially useful to diminish or eliminate the pigmentary sequelae of EAI.6 S. Takashima, H. Iwata,* M. Sakata, R. Osawa, W. Nishie, H. Shimizu Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan *Correspondence: H. Iwata. E-mail: [email protected]

References 1 Page EH, Shear NH. Temperature-dependent skin disorders. J Am Acad Dermatol 1988; 18: 1003–1019. 2 Riahi RR, Cohen PR. Laptop-induced erythema ab igne: report and review of literature. Dermatol Online J 2012; 18: 5. 3 Lin S-J, Hsu C-J, Chiu H-C. Erythema ab igne caused by frequent hot bathing. Acta Derm Venereol 2002; 82: 478–479. 4 Huynh N, Sarma D, Huerter C. Erythema ab igne: a case report and review of the literature. Cutis 2011; 88: 290–292. 5 Riahi RR, Cohen PR, Robinson FW, Gray JM. Erythema ab igne mimicking livedo reticularis. Int J Dermatol 2010; 49: 1314–1317. 6 Cho S, Jung JY, Lee JH. Erythema ab igne successfully treated using 1,064-nm Q-switched neodymium-doped yttrium aluminum garnet laser with low fluence. Dermatol Surg 2011; 37: 551–553. DOI: 10.1111/jdv.12558

Delusional infestation carries an increased mortality risk: a report of two cases Editor Delusional infestation (DI) is the persistent belief of pathogenic infestation of the skin or body, without objective medical evidence.1 It is also known as Ekbom’s syndrome. The literature includes one report of suicide in a 40-year-old man with delusions of parasitosis and a further case series including five patients who committed suicide.2,3 There is otherwise very limited body of evidence in the literature about fatal outcomes in DI. Although DI is considered as a rare disorder, recent studies have shown that its diagnosis is increasing.4 We report two cases, the first of a 65-year-old lady who had a fixed belief that she had an infestation of mites in her nose, throat and skin. On examination she had a low body mass index with multiple excoriations on her arms and chest. Mini-mental state examination score was 19 out of 30. Because of an identified risk of self-neglect and the diagnosis of DI the patient was referred to Old Age Mental Health Services. The patient did not wish to receive treatment and she was not detainable under sections 2 or 3 of the Mental Health

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Act 1983. A few weeks later the patient was found dead at home. Our second patient is a 52-year-old woman with a diagnosis of DI who presented with excoriations scattered across her body. Mental state examination suggested a concomitant depressive illness. She refused an offer of risperidone, but accepted treatment of her depression with citalopram. At this point she denied any suicidal ideation. A few days later, she was found at home having taken an overdose of her antiepileptic medication. She was sent to the hospital and was admitted to the local psychiatric unit where she was treated with olanzapine. Later she was discharged home with appropriate psycho-social support. Delusional infestation has an estimated prevalence rate ranging from 2.37–83.33 per million population and estimated annual incidence rates of 2.37 and 17 per 1 million inhabitants per year.5,6 About 90% of patients with DI seek help firstly from dermatologists, while many psychiatrists do not see a single patient in their career.6 In a review of twenty-three cases by Bloggid et al. patients saw an average of six doctors of different specialities before presenting to a specialist centre.7 The condition causes a loss in quality of life and significant morbidity to the patient and their family members. In all cases of DI, a psychiatric assessment is important, especially in view of patients’ own risk to themselves. In certain situations it is important to decide whether the patient has decision-making capacity. If the patient lacks capacity, the second step involves determining what interventions are in the patient’s best interests.8 Despite the reported suicidal ideation, there is a very limited body of evidence in the literature about fatal outcomes in DI. It is reasonable to suggest that death is a more frequent outcome of DI than reported, whether that is a result of suicide or selfneglect. We need to be aware of the suicide risk of our patients with DI. The availability of a specialized psychodermatology clinic, with a dermatologist and an attending psychiatrist, may help to identify patients at risk of self-harm more accurately, which may improve the overall outcome. If a joint clinic is not possible, then a close cooperation between the two specialities is required to identify and manage the risk some of the DI patients show. Good cooperation will also allow better identification of those patients who may need to be treated under Mental Health Act (1983) provisions. Further research is needed to evaluate whether this approach yields improved outcomes. S. Nasir,1 S. Ziaj,2,* L.E. Holloway,1 R.H. Meyrick-Thomas,3 A. Bewley1 1

Department of Dermatology, Royal London Hospital, Whitechapel, London, UK, 2Department of Dermatology, St Marys Hospital, London, UK, 3Department of Dermatology, Salisbury District Hospital, Salisbury, UK *Correspondence: S. Ziaj. E-mail: [email protected]

© 2014 European Academy of Dermatology and Venereology

Widespread erythema ab igne caused by hot bathing.

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