Case for Diagnosis
Erythematous Lesion on the Nose
Lesión eritematosa nasal
D. González Fernández
, S. Requena López, F. Valdés Pineda
Corresponding author
Servicio de Dermatología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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Valdés" "apellidos" => "Pineda" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesión eritematosa nasal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1333 "Ancho" => 1000 "Tamanyo" => 550233 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×20.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 68-year-old man presented with scaly lesions on an erythematous base on the cheeks, nose, and forehead.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed lesions consistent with actinic keratoses in the aforementioned areas, notably an erythematous plaque with atrophic areas and superficial telangiectasias on the right side of the nose (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient stated that several years earlier he had been treated in that area with topical imiquimod for a lesion whose diagnosis we were unable to ascertain because the treatment had been administered at a different healthcare facility. The patient reported itching and a burning sensation in the area, which worsened with sun exposure.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Biopsy revealed a flattened epidermis that had an atrophic appearance in some areas, with vacuolar degeneration of the basal layer, which contained necrotic keratinocytes. The dermis was edematous, with a proliferation of capillaries and activated fibroblasts. A perivascular and periadnexal lymphohistiocytic infiltrate was observed in both the superficial and deep layers (<a class="elsevierStyleCrossRef" href="#fig0010">Figs. 2</a><span class="elsevierStyleHsp" style=""></span>A and 2<span class="elsevierStyleHsp" style=""></span>B). Colloidal iron staining showed no mucin deposits and periodic acid–Schiff staining revealed a moderate thickening of the basement membrane (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The results of the complete blood count, coagulation study, blood biochemistry including glucose, kidney function, liver function, acute phase reactants, and antinuclear antibodies were within the normal range.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis?</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Lupus-like reaction in imiquimod-treated skin.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course and Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">Sun protection measures were recommended and treatment was started with topical mometasone, applied once daily for 3 weeks, after which maintenance therapy with 0.1% topical tacrolimus was started, with clinical and symptomatic improvement.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Imiquimod is a topical immunomodulator approved for the treatment of condylomata acuminata, actinic keratoses, and superficial basal cell carcinomas. It is also used off-label in Bowen disease and lentigo maligna. Various clinical and histologic skin reactions such as lichenoid reactions, psoriasiform reactions, vitiligo, alopecia, and urticaria have been described.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> To date, there have been 3 reports of histologic lupus-like reaction in imiquimod-treated skin, but clinically the lesions did not resemble lupus lesions at all.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> After the imiquimod penetrates the epidermis, it binds to macrophages and dermal dendritic cells via toll-like receptor 7 and releases interferon alfa, tumor necrosis factor, and interleukins 2, 6, and 8, among other proinflammatory cytokines. It has been postulated that interface dermatitis could be caused by an interferon alfa–mediated cytotoxic attack on the basal keratinocytes,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> and there have been numerous reports of lupus-like lesions at the injection sites of subcutaneous interferon alfa treatment.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a> The term <span class="elsevierStyleItalic">interface dermatitis</span> refers to a process in which an inflammatory infiltrate composed mainly of lymphocytes develops at the dermoepidermal junction. Other typical findings are vacuolar changes along the dermoepidermal junction, the presence of necrotic keratinocytes, and spongiosis (usually mild). Interface dermatitis can be classified according to the density of the infiltrate: in vacuolar interface dermatitis the inflammation is mild, whereas in lichenoid interface dermatitis a dense band-like infiltrate is present. Erythema multiforme is considered the prototype of vacuolar interface dermatitis, but the differential diagnosis should also include autoimmune connective tissue diseases such as systemic lupus erythematosus, dermatomyositis, and mixed connective tissue disease, as well as graft-versus-host disease, certain viral rashes, and some drug-induced reactions. One clue to distinguishing a lupus-like reaction in imiquimod-treated skin from true systemic lupus erythematosus is that no mucin deposits are present in the former.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> Each case of lupus-like reaction in imiquimod-treated skin reported to date has had a different set of clinical characteristics, but our case is the only one that clinically resembles cutaneous lupus erythematosus (in fact, lupus pernio and lupus vulgaris were considered in the differential diagnosis).</p><p id="par0040" class="elsevierStylePara elsevierViewall">We present a case of a clinically and histologically lupus-like reaction in imiquimod-treated skin. This reaction is a rare side effect of topical imiquimod that must be taken into account in order to avoid the misdiagnosis of cutaneous lupus erythematosus.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course and Treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández DG, López SR, Pineda FV. Lesión eritematosa nasal. Actas Dermosifiliogr. 2018;109:173–174.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 824 "Ancho" => 1000 "Tamanyo" => 98054 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1333 "Ancho" => 1000 "Tamanyo" => 550233 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×20.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 753 "Ancho" => 1000 "Tamanyo" => 255396 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Periodic acid–Schiff, original magnification ×40.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lupus erythematosus-like reaction in imiquimod-treated skin: A report of 2 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.P. 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Tuting" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/jid.2008.96" "Revista" => array:6 [ "tituloSerie" => "J Invest Dermatol" "fecha" => "2008" "volumen" => "128" "paginaInicial" => "2392" "paginaFinal" => "2402" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18418411" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lupus-like reaction to interferon at the injection site: Report of five cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "I. Arrue" 1 => "A. Saiz" 2 => "P.L. Ortiz-Romero" 3 => "J.L. 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Gershenwald" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Drugs Dermatol" "fecha" => "2012" "volumen" => "11" "paginaInicial" => "393" "paginaFinal" => "398" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22395592" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010900000002/v1_201803020443/S1578219017304262/v1_201803020443/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010900000002/v1_201803020443/S1578219017304262/v1_201803020443/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219017304262?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 20 | 11 | 31 |
| 2024 October | 199 | 65 | 264 |
| 2024 September | 182 | 49 | 231 |
| 2024 August | 189 | 91 | 280 |
| 2024 July | 189 | 62 | 251 |
| 2024 June | 170 | 71 | 241 |
| 2024 May | 138 | 63 | 201 |
| 2024 April | 145 | 44 | 189 |
| 2024 March | 151 | 38 | 189 |
| 2024 February | 159 | 35 | 194 |
| 2024 January | 161 | 35 | 196 |
| 2023 December | 131 | 21 | 152 |
| 2023 November | 145 | 25 | 170 |
| 2023 October | 153 | 33 | 186 |
| 2023 September | 128 | 35 | 163 |
| 2023 August | 92 | 18 | 110 |
| 2023 July | 101 | 36 | 137 |
| 2023 June | 131 | 26 | 157 |
| 2023 May | 169 | 26 | 195 |
| 2023 April | 127 | 15 | 142 |
| 2023 March | 171 | 35 | 206 |
| 2023 February | 136 | 38 | 174 |
| 2023 January | 149 | 30 | 179 |
| 2022 December | 142 | 46 | 188 |
| 2022 November | 95 | 31 | 126 |
| 2022 October | 81 | 31 | 112 |
| 2022 September | 68 | 35 | 103 |
| 2022 August | 64 | 39 | 103 |
| 2022 July | 37 | 48 | 85 |
| 2022 June | 48 | 22 | 70 |
| 2022 May | 159 | 41 | 200 |
| 2022 April | 165 | 45 | 210 |
| 2022 March | 154 | 45 | 199 |
| 2022 February | 135 | 29 | 164 |
| 2022 January | 156 | 44 | 200 |
| 2021 December | 127 | 44 | 171 |
| 2021 November | 148 | 51 | 199 |
| 2021 October | 184 | 74 | 258 |
| 2021 September | 167 | 46 | 213 |
| 2021 August | 118 | 44 | 162 |
| 2021 July | 124 | 38 | 162 |
| 2021 June | 109 | 45 | 154 |
| 2021 May | 122 | 49 | 171 |
| 2021 April | 248 | 98 | 346 |
| 2021 March | 179 | 40 | 219 |
| 2021 February | 141 | 45 | 186 |
| 2021 January | 84 | 40 | 124 |
| 2020 December | 90 | 46 | 136 |
| 2020 November | 79 | 48 | 127 |
| 2020 October | 66 | 27 | 93 |
| 2020 September | 65 | 19 | 84 |
| 2020 August | 76 | 30 | 106 |
| 2020 July | 60 | 26 | 86 |
| 2020 June | 67 | 32 | 99 |
| 2020 May | 71 | 11 | 82 |
| 2020 April | 69 | 13 | 82 |
| 2020 March | 33 | 11 | 44 |
| 2020 February | 1 | 0 | 1 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 6 | 0 | 6 |
| 2019 September | 9 | 0 | 9 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 5 | 0 | 5 |
| 2019 April | 2 | 0 | 2 |
| 2019 March | 2 | 0 | 2 |
| 2019 February | 2 | 0 | 2 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 2 | 0 | 2 |
| 2018 September | 1 | 0 | 1 |
| 2018 April | 1 | 0 | 1 |
| 2018 March | 1 | 0 | 1 |
| 2018 February | 6 | 8 | 14 |
| 2018 January | 2 | 4 | 6 |
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