Chronicles of A.I. Pospelov Moscow Society of Dermatovenerologists and Cosmetologists (MSDС was founded on October 4, 1891) Bulletin of the MSDС № 1156

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Editorial note

On February 20, 2024, the 1156^th regular meeting of the A.I. Pospelov Moscow Society of Dermatovenereologists and Cosmetologists (MSDC) was held.

A total of 105 participants were present. Three applications were made to join the MSDС.

The Presidium of the Conference included Professor O.Y. Olisova, Corresponding Member of the Russian Academy of Sciences; Professor E.S. Snarskaya; and Associate Professor of the Department of Dermatovenereology and Cosmetology of the Central State Medical Academy of the Administration of Affairs of the President of the Russian Federation A.B. Yakovlev, Cand. Sci. (Medicine).

In the clinical part of the meeting, two reports were presented: a case report on failure of cytostatic therapy in a patient with pustular psoriasis, presented by a research team from the State Research Center of Dermatovenereology and Cosmetology, and characteristics of adverse dermatological reactions in patients receiving pembrolizumab and nivolumab in genetically engineered biological cancer therapy programs (Sechenov First Moscow State Medical University).

In the research part, two reports — on clinical features of perianal dermatoses (Russian Medical Academy of Continuous Postgraduate Education) and diagnosis of erythroderma (Sechenov First Moscow State Medical University) — were presented.

The clinical part of the meeting agenda began with description of a case report on failure of cytostatic therapy in a patient with generalized pustular psoriasis. Psoriasis is a chronic multifactorial disease associated with accelerated proliferation of keratinocytes and impaired differentiation, imbalance between pro-inflammatory and anti-inflammatory cytokines. At the beginning of the presentation, authors mentioned some clinical forms and variants of psoriasis (vulgaris, exudative, seborrheic, guttate, generalized pustular psoriasis von Zumbusch, Barber’s palmoplantar pustulosis, acrodermatitis continua of Hallopeau, erythrodermic, arthropathic) and presented a case report of pustular psoriasis in a 62-year-old female patient with a tendency to generalization. Initially, Diprospan was effective, and then the patient was switched to methotrexate, first injected and then taken as tablets. Three courses (corticosteroid switched to methotrexate) were given, but no improvement was observed. Rash was regressed only after cyclosporine A was added to therapy.

The second case report characterized adverse dermatologic reactions in patients receiving pembrolizumab and nivolumab in programs of genetically engineered biological cancer therapy. This report was presented by a research team from the V.A. Rakhmanov Skin Clinic of the Sechenov First Moscow State Medical University. Two case reports were presented. The first report described a 62-year-old patient who was treated with pembrolizumab and nivolumab for hepatocellular carcinoma. During this treatment, an extensive pustular rash developed on the skin of the trunk and extremities, with itching and burning. Treatment with methylprednisolone at 16 mg daily and a combined topical corticosteroid cream (Tetraderm) resolved toxic skin manifestations. Most importantly, it allowed the patient to continue with antitumor immunotherapy. In another reported case, a 53-year-old patient with peripheral lung cancer received carboplatin and paclitaxel, resulting in a severe papular rash on the trunk and extremities, dry mucous membranes, and arthralgia of hands and feet. A multidisciplinary team diagnosed extensive psoriasis and prescribed methotrexate at 15 mg once weekly with folic acid between methotrexate doses and topical ointment of betamethasone and salicylic acid. Psoriatic lesions regressed.

 

MSDС meeting № 1156 takes place in the conference hall of the V.A. Rakhmanov Clinic of Skin and Venereal Diseases Sechenov University.

 

While immunotherapy certainly expands the range of cancer treatment options, skin toxicity significantly reduces the quality of life of patients, leading to decision to reduce the dose or discontinue immunotherapy. But this is a wrong decision! In case of cancer, dermatological treatment usually allows life-saving therapy to continue.

In the research part, the first report described the clinical features of perianal dermatoses. It was presented by a research team of the Russian Medical Academy of Postgraduate Education, headed by the Head of the Department of Dermatovenereology, Professor A.A. Martynov. In fact, the authors performed clinical and morphological analyses of diagnostic characteristics of the most common anogenital dermatoses.

Anogenital warts are a viral disease that manifests as non-inflammatory exophytic or endophytic papillomatous growths, sometimes cauliflower-like lesions or, in extreme cases, in the form of a giant condyloma acuminatum (Buschke-Lowenstein tumor).

Primary syphilis is called “The Great Pretender” or “The Monkey Among Diseases” (because a chancre can be found widely, not only on the anogenital skin, but also in the rectum, on the cervix, and even extragenitally). In 5% of cases, a primary lesion or its remnants cannot be detected.

Anogenital herpes infections usually have a chronic, recurrent (often monthly) course, which greatly affects the patient’s quality of life.

Both anogenital herpes infection and herpes zoster, along with grouped vesicular eruptions, are often accompanied by serious neurological disorders in the form of very severe pain (herpetic and postherpetic neuralgia). The rash with herpes zoster occurs intermittently, sometimes only a few times during the entire period of the disease, which can lead to presence of vesicles at different stages.

Molluscum contagiosum is characterized by peculiar non-inflammatory papules with a central umbilicus-like depression filled with keratinous masses composed of degenerated keratinocytes. Children are more likely to get infected. In immunocompetent individuals, the disease is usually self-limiting and the rash resolves spontaneously after 5–7 months.

 

Discussion of the report by A.A. Apsheva, dermatovenerologist, Department of the Clinical Dermatology, State Scientific Centre of Dermatovenerology and Cosmetology.

 

Lichen planus, most commonly anogenital, presents with lichenoid, shiny, inflammatory, polygonal papules with central umbilicated depression and erythematous-cyanotic surface. In many cases, lichen planus of the vulva is characterized by a progression without subjective symptoms until an erosive and ulcerative lesion develops. Immersion dermatoscopy reveals Wickham striae caused by uneven granulosis. Wickham striae can be observed on the vaginal mucosa even without using immersion oil.

Ichthyosis is characterized by pigmented scales and severely dry skin. Ichthyosis vulgaris is caused by impaired desquamation of scales that remain attached for a long time and present clinically as orthohyperkeratosis. In X-linked ichthyosis, the scales are saucer-shaped and larger than in ichthyosis vulgaris.

Psoriasis vulgaris also acquires some special characteristics when located in the anogenital area. The inflammatory process was aggravated by high humidity, which led to skin maceration and the Koebner phenomenon. The typical dermatoscopic picture is also observed; punctate, glomerular or globular vessels and thin silvery scales are visible on a light red background.

Anogenital scabies is characterized by rash on the inner thighs, in the intergluteal cleft (Rhombus of Michaelis) and is often accompanied by impetiginization, especially in children. However, rash is rare in hairy areas. The scabies route looks like a whitish line with a mite female at the blind end (Bazin’s mite elevation). When filled with eggs, the scabies route looks dermatoscopically like a “string of pearls.”

Anogenital atopic dermatitis is often characterized by very intense itching, vesicular rash during periods of exacerbation, impetiginization (especially in children), and almost always significant lichenification. Histology is completely nonspecific; inflammatory acanthosis/papillomatosis, vacuolar dystrophy of keratinocytes in the stratum corneum, exocytosis of lymphocytes and neutrophils; dermal lymphohistiocytic infiltrates.

Sclerotic atrophic lichen is a dermatosis of unknown origin, most likely autoimmune, with manifestations similar to those of scleroderma. In women, an anogenital figure-of-eight lesion is formed involving the vulva and anus. Porcelain-white macules and atrophic plaques with erosions, petechiae, and telangiectasias appear. The process is associated with severe itching. In later stages, the natural orifices may become narrow.

Vitiligo is typical of the anogenital area, accompanied by non-atrophic white patches with clear borders. This condition should be distinguished from lichen sclerosus.

The variety of anogenital forms requires differential diagnosis, often with combination of multiple disease entities. Some special considerations should be made when treating anogenital conditions.

The second report in the research part of the MSDС-1156 meeting described diagnostic modalities for erythroderma. The report was presented by a research group from the V.A. Rakhmanov Skin Clinic of Sechenov First Moscow State Medical University.

Erythroderma is a life-threatening condition characterized by diffuse erythema and scaling of more than 80%–90% of the skin surface. The mortality rates range from 18% to 64%.

In addition to erythroderma, which complicates some dermatoses (psoriasis, Devergie’s disease, lymphomas (Wilson-Brocq type of erythroderma, lichen ruber of Hebra), there is also senile erythroderma, which is often drug-induced. Hill’s atopic erythroderma is one of the most life-threatening forms of erythroderma.

 

Discussion of the report: comment from Professor A.A. Martynov, Head of the Department of Dermatovenerology and Cosmetology, Russian Medical Academy of Continuous Professional Education.

 

Report by E.V. Grekova, Associate Professor V.A. Rakhmanov Department of Skin and Venereal Diseases (Sechenov University).

 

Medical history plays a key role in the diagnosis of erythroderma, as it helps to identify a trigger such as co-morbidities, family history, occupational hazards, vaccinations, stress, use of some agents.

Approximately 105 medications can induce erythroderma.

There are some common mechanisms for erythroderma, both in a pre-existing dermatosis and after previous infections (for example, post-COVID erythroderma has been reported) or after a trigger enters the body.

Pathogenetically, erythroderma is caused by increased expression of adhesion molecules in epithelial cells (VCAM-1, ICAM-1, E-selectin, P-selectin), mutations in the caspase recruitment domain, the gene of family member 14 (CARD14), mutations in connexin 26 (Cx26) gene.

Clinically, common sign and symptoms include frequent fever, hepatosplenomegaly, generalized lymphadenopathy, and chills. The latter is particularly typical of drug-induced erythroderma.

Paraneoplastic erythroderma is characterized by chronic itching, unexplained weight loss, night sweats, diarrhea, lack of treatment response, hyperpigmentation of individual areas or the entire skin surface (melanoerythroderma), fine lamellar peeling, cachexia.

Despite the common clinical signs and symptoms of various erythrodermas, when it is difficult to establish a clinical diagnosis, dermatoscopic, histologic, and immunohistochemical findings are quite informative for any erythroderma, especially when erythroderma complicates the severe course of a pre-existing dermatosis.

About the authors

Alexey B. Yakovlev

Central State Medical Academy of Department of Presidential Affairs

Email: ale64080530@yandex.ru
ORCID iD: 0000-0001-7073-9511
SPIN-code: 6404-7701
Russian Federation, Moscow

Ivan S. Maximov

Sechenov First Moscow State Medical University (Sechenov University)

Email: maximov.is@mail.ru
ORCID iD: 0000-0003-2850-2910
SPIN-code: 1540-1485
Russian Federation, Moscow

Eugenia V. Petukhova

Sechenov First Moscow State Medical University (Sechenov University)

Author for correspondence.
Email: petuxova0304@gmail.com
ORCID iD: 0000-0002-9396-4874
Russian Federation, Moscow

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