Case for Diagnosis
Erythematous Lesion on the Nose
Lesión eritematosa nasal
D. González Fernández
, S. Requena López, F. Valdés Pineda
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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" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 22 | 11 | 33 |
| 2024 Octubre | 199 | 65 | 264 |
| 2024 Septiembre | 182 | 49 | 231 |
| 2024 Agosto | 189 | 91 | 280 |
| 2024 Julio | 189 | 62 | 251 |
| 2024 Junio | 170 | 71 | 241 |
| 2024 Mayo | 138 | 63 | 201 |
| 2024 Abril | 145 | 44 | 189 |
| 2024 Marzo | 151 | 38 | 189 |
| 2024 Febrero | 159 | 35 | 194 |
| 2024 Enero | 161 | 35 | 196 |
| 2023 Diciembre | 131 | 21 | 152 |
| 2023 Noviembre | 145 | 25 | 170 |
| 2023 Octubre | 153 | 33 | 186 |
| 2023 Septiembre | 128 | 35 | 163 |
| 2023 Agosto | 92 | 18 | 110 |
| 2023 Julio | 101 | 36 | 137 |
| 2023 Junio | 131 | 26 | 157 |
| 2023 Mayo | 169 | 26 | 195 |
| 2023 Abril | 127 | 15 | 142 |
| 2023 Marzo | 171 | 35 | 206 |
| 2023 Febrero | 136 | 38 | 174 |
| 2023 Enero | 149 | 30 | 179 |
| 2022 Diciembre | 142 | 46 | 188 |
| 2022 Noviembre | 95 | 31 | 126 |
| 2022 Octubre | 81 | 31 | 112 |
| 2022 Septiembre | 68 | 35 | 103 |
| 2022 Agosto | 64 | 39 | 103 |
| 2022 Julio | 37 | 48 | 85 |
| 2022 Junio | 48 | 22 | 70 |
| 2022 Mayo | 159 | 41 | 200 |
| 2022 Abril | 165 | 45 | 210 |
| 2022 Marzo | 154 | 45 | 199 |
| 2022 Febrero | 135 | 29 | 164 |
| 2022 Enero | 156 | 44 | 200 |
| 2021 Diciembre | 127 | 44 | 171 |
| 2021 Noviembre | 148 | 51 | 199 |
| 2021 Octubre | 184 | 74 | 258 |
| 2021 Septiembre | 167 | 46 | 213 |
| 2021 Agosto | 118 | 44 | 162 |
| 2021 Julio | 124 | 38 | 162 |
| 2021 Junio | 109 | 45 | 154 |
| 2021 Mayo | 122 | 49 | 171 |
| 2021 Abril | 248 | 98 | 346 |
| 2021 Marzo | 179 | 40 | 219 |
| 2021 Febrero | 141 | 45 | 186 |
| 2021 Enero | 84 | 40 | 124 |
| 2020 Diciembre | 90 | 46 | 136 |
| 2020 Noviembre | 79 | 48 | 127 |
| 2020 Octubre | 66 | 27 | 93 |
| 2020 Septiembre | 65 | 19 | 84 |
| 2020 Agosto | 76 | 30 | 106 |
| 2020 Julio | 60 | 26 | 86 |
| 2020 Junio | 67 | 32 | 99 |
| 2020 Mayo | 71 | 11 | 82 |
| 2020 Abril | 69 | 13 | 82 |
| 2020 Marzo | 33 | 11 | 44 |
| 2020 Febrero | 1 | 0 | 1 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 8 | 0 | 8 |
| 2019 Noviembre | 6 | 0 | 6 |
| 2019 Septiembre | 9 | 0 | 9 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 5 | 0 | 5 |
| 2019 Abril | 2 | 0 | 2 |
| 2019 Marzo | 2 | 0 | 2 |
| 2019 Febrero | 2 | 0 | 2 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Noviembre | 2 | 0 | 2 |
| 2018 Septiembre | 1 | 0 | 1 |
| 2018 Abril | 1 | 0 | 1 |
| 2018 Marzo | 1 | 0 | 1 |
| 2018 Febrero | 6 | 8 | 14 |
| 2018 Enero | 2 | 4 | 6 |
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