Introduction Pseudolymphoma is a rare complication of tattooing, presenting with infiltrated areas often at the site of a red tattoo and postulated to be an allergic reaction to mercury salt. When present, it may be mistaken for the more commonly occurring tattoo-associated granuloma. Case summary We describe a 47-year old female who developed nodular areas on her tattoo four months after placement by a professional tattoo artist. The nodules were restricted to the red regions and spared the blue-black areas of tattoed skin. Initial differentials included a foreign body or sarcoidal granuloma and contact dermatitis to the red dye. Histology revealed a top-heavy lymphocytic infiltrate spanning most of the dermis, with numerous eosinophils. Dark red, non-polarisable exogenous pigment was scattered throughout the dermis, in association with the inflammatory infiltrate. The epidermis showed intense spongiosis and eosinophilic exocytosis. A final diagnosis of tattoo-induced pseudolymphoma was made. Pseudolymphoma, foreign body and sarcoidal granulomatous reaction patterns from tattoos occur more commonly in red tattoos. Biopsy with histology is required to differentiate these three disorders with divergent management. We review the literature on tattoo-induced pseudolymphoma and highlight the pitfalls associated with the diagnosis.

Hidradenitis suppurativa is a chronic inflammatory skin condition associated with an increased prevalence of individual metabolic conditions such as insulin resistance, obesity, hyperlipidemia, hypertension, and with the metabolic syndrome, as a constellation of these risk factors. This places affected patients at an increased risk of early cardiovascular morbidity and mortality. Moreover, many of the therapeutic options, including the newer biologics, used in the treatment of hidradenitis suppurativa have both beneficial and adverse metabolic effects. Therefore, it is critical for physicians to consider the complex interactions between the disease process and the treatment options in the holistic management of these patients with an intrinsically higher risk of metabolic consequences. Other chronic systemic inflammatory diseases such as psoriasis and rheumatoid arthritis have been studied more extensively with regard to their associations and share an underlying link with the metabolic syndrome; we can draw upon the existing knowledge in our understanding and management of hidradenitis suppurativa.
Arthritis, Rheumatoid ; Biological Products ; Comorbidity* ; Diabetes Mellitus ; Hidradenitis Suppurativa* ; Hidradenitis* ; Humans ; Hyperlipidemias ; Hypertension ; Insulin Resistance ; Metabolic Syndrome X ; Mortality ; Obesity ; Prevalence ; Psoriasis ; Risk Factors ; Skin

Objective The T-Spot.TB is an interferon-gamma release assay (IGRA) which is increasingly used in dermatology as a screen for latent TB before initiation of biologics and for confirming diagnosis of tuberculids. This study aims to explore its concordance with tuberculin skin tests (TST) and eventual diagnosis of latent TB. Study design This is a retrospective review of all patients in NSC who had a TB T-spot test done between 2008 and 2010. We looked at the dermatological diagnosis, results of T-Spot.TB and TST, chest radiograph findings, tuberculosis status and treatment of TB. Result 51 TB T spot tests were ordered in National Skin Centre between 1 January 2008 and 9 June 2010. 31 tests were for patients with psoriasis with the intention of initiating biologics; 5 were for patients with suspected tuberculids and tuberculosis verrucosa cutis; 3 were done as part of work-up for possible erythema nodosum; 3 tests were part of screening for latent TB in hospital staff and 9 tests were performed for other reasons. There were a total of 13 patients eventually diagnosed with latent or active TB infection. All of whom had a positive T-Spot.TB result except for 1 patient with an indeterminate result. On the other hand, out of these 13 patients, only 5 showed a positive TST, 2 had negative TST and 4 patients did not have a TST done. There were a total of 14 positive T-Spot.TB results for which 12 eventually received antituberculous therapy. All patients with erythema induratum had a positive test result. Six patients’ T-Spot.TB tests were borderline, indeterminate or could not be interpreted due to insufficient lymphocyte yield. Conclusion Our study shows the utility of T-Spot. TB test in various conditions seen in dermatology clinics in a local setting. We suggest that the T-spot test can supplant the tuberculin skin test in screening latent TB for psoriasis patients for whom biologics are intended and in erythema induratum. The high incidence of borderline and indeterminate results should not be ignored. This should be taken into account when interpreting the IGRA especially if patients are on immunosuppressive therapy.

Introduction: Lichen planus pemphigoides (LPP) is a rare acquired autoimmune disease characterised by the evolution of subepidermal blisters on normal and lichen planus affected skin. Case summary: We describe a case of lichen planus pemphigoides in a 54-year-old Chinese woman. The patient presented initially with scaly psoriasiform plaques and was diagnosed to have guttate psoriasis. She was treated with narrowband ultraviolet (NBUVB) therapy twice weekly. Within a month of starting phototherapy, she experienced a flare up of her skin lesions with a generalised eruption of violaceous papules, tense bullae over the lower limbs as well as Wickham’s striae over the buccal mucosa. Histology of the violaceous papule over abdomen revealed interface dermatitis, while the specimen from a blister showed subepidermal bulla with linear deposition of IgG and C3 along the basement membrane zone. A diagnosis of LPP was made on clinicopathological grounds. The patient subsequently responded well to oral prednisolone at a dose of 0.5 mg/kg/day. Conclusion: This is the first case report of NBUVB alone unmasking LPP. In the presentation, we will describe the pathological mechanism of NBUVB in the development of LPP and the key features distinguishing LPP from bullous lichen planus (BLP), psoriasis and bullous pemphigoid (BP).

Hidradenitis suppurativa (HS) is a chronic inflammatory follicular occlusive disease that involves the intertriginous areas. Treatment methods include conventional topical and systemic medication, radiotherapy, biologic agents, and surgical excision. Of late, there has been an increased focus on the use of biologic agents in patients with moderate to severe HS. Here, we present the case of a 46-year-old man with Hurley stage III HS for whom wide excision was ultimately curative, after aggressive medical therapy with the use of infliximab and adalimumab had succeeded in limiting the body surface area affected by the disease. This case demonstrates the effective treatment of severe HS with a combination of biologic therapy and surgery.
Adalimumab ; Antibodies, Monoclonal ; Biological Factors ; Biological Therapy ; Body Surface Area ; Hidradenitis Suppurativa ; Hidradenitis ; Humans ; Infliximab ; Middle Aged ; Radiotherapy ; Tumor Necrosis Factor-alpha

INTRODUCTION: Psoriasis is a chronic inflammatory disease with a global prevalence of approximately 2% and significant psychiatric comorbidity. There is a great deal of existing literature assessing different aspects of psychology in psoriasis. We aimed to conduct an in-depth review of current evidence linking psoriasis to personality traits and psychiatric comorbidities, as well as factors that put these patients at risk of psychopathology. MATERIALS AND METHODS: A search of the PubMed database identified 1632 articles. We included articles studying psychological comorbidity in patients with psoriasis, looking especially at personality characteristics, and data linking psoriasis with increased risks of psychological distress, depression, anxiety and suicidality. In particular, we also evaluated subgroups in psoriasis found to be at risk. RESULTS: Patients with psoriasis are more likely to be alexithymic, lack body awareness and possess a Type D personality. Alcohol, but not illicit drug use, disorders are also more common in patients with psoriasis. Patient groups who are especially at risk of psychological distress include women, younger patients, patients with a younger age of disease onset, those who self-assess their psoriasis to be severe, and those with lesions on visible or sensitive areas. Adopting motivational interviewing skills and incorporating the use of learning materials during consultations have been found to be useful. CONCLUSION The knowledge of personality characteristics, "at-risk" groups, and early recognition of psychological distress among patients with psoriasis can help clinicians provide better holistic care and encourage a change in patients' behaviour.
Affective Symptoms ; epidemiology ; psychology ; Age Factors ; Age of Onset ; Alcoholism ; epidemiology ; psychology ; Anxiety ; epidemiology ; psychology ; Comorbidity ; Depression ; epidemiology ; psychology ; Humans ; Mental Disorders ; epidemiology ; psychology ; Motivational Interviewing ; Personality ; Psoriasis ; epidemiology ; psychology ; Sex Factors ; Stress, Psychological ; epidemiology ; psychology ; Substance-Related Disorders ; epidemiology ; psychology ; Suicidal Ideation ; Type D Personality

Administration, Oral ; Anti-Bacterial Agents ; administration & dosage ; Brimonidine Tartrate ; administration & dosage ; Diagnosis, Differential ; Doxycycline ; administration & dosage ; Face ; physiopathology ; Female ; Humans ; Inflammation ; Middle Aged ; Rosacea ; diagnosis ; drug therapy ; Singapore ; Steroids ; administration & dosage ; Treatment Outcome