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Kristina Kostić, Tomislav Mladenović and Radoš Zečević

Abstract

Squamous cell carcinoma (SCC) is a malignant tumor of epidermal keratinocytes which may arise de novo, or at already affected skin areas of different etiology, including chronic vascular ulcers (CVUs). We present a 74-year-old female patient, hospitalized in the Department of Dermatology, with venous ulceration of the lower right leg, 10x5 cm in size, with well-demarcated edges, and the base covered with fibrin and granulation tissue. The ulceration appeared 7 years ago, while 3 years ago it spread rapidly with pain in the right lower leg. In the beginning, the patient was treated with local and systemic antibiotic therapy. Later, hydrocoloid dressings and compressive bandages were applied, and after that hyperoxygenation was performed in the hyperbaric chamber. Although the above-mentioned therapy was applied correctly, it was not efficient. Since malignant alteration was suspected, two biopsies were taken and in both, histopathologic analysis showed granulation tissue without dysplasia. The third biopsy, however, performed a month after the second one, revealed a squamous cell carcinoma. After further investigations, amputation of the right lower leg was suggested. Therefore, in cases with extended CVUs without no adequate therapeutical response during a long period of time, malignant transformation should be considered, and multiple biopsies at various sites should be performed.

Open access

Ljubica Jevremović, Ivana Ilijin, Kristina Kostić, Željko Mijušković, Ivana Tufegdžić and Lidija Kandolf Sekulović

Abstract

Pyoderma vegetans (PV) or blastomycosis-like pyoderma (BLP) is a chronic inflammatory disease, by some authors considered a rare variety of pyoderma gangrenosum (PG), and others describe it as a distinct entity. It commonly presents with verrucous plaques with multiple pustules. The etiology of this disease is unknown, but it has been connected with staphylococcal and streptococcal infections, inflammatory bowel disease, hematological diseases, primary immunodeficiency, alcoholism, and nutritional deficit. Here we present a 66-year-old, otherwise healthy female, with a 2-year-long history of well-defined, vegetative livid plaques with multiple pustules on the dorsal side of both hands. Histopathological analysis of the skin biopsy of the hand showed chronic inflammation and micro-abscesses, ruptured follicular cysts and follicular pseudoepitheliomatous hyperplasia. Treatment with anti-tuberculosis drugs and antibiotics showed to be ineffective, as well as the treatment with systemic corticosteroids, dapsone and cyclosporine. Itraconazole was given for its immunomodulatory effects and findings of Penicillium species in one of the swabs, which led to partial regression of lesions. Since the treatment did not lead to complete resolution, acitretin was indicated 3 months later, but the patient was lost to follow-up.

Open access

Kristina Kostić, Miroslav Dinić, Željko Mijušković, Lidija Zolotarevski, Lidija Kandolf-Sekulović and Radoš Zečević

Abstract

Neurofibromatosis type I (NF1) is an autosomal dominant, multisystemic disease that usually affects the skin, nervous system and bones. Diagnosis is made by matching at least two of the following 7 diagnostic criteria: six or more caféau- lait macules over 15 mm in diameter, two or more neurofibromas, axillary and/or inguinal freckles, optic glioma, two or more Lisch’s nodules (iris hamartoma), changes in the bones in the form of sphenoid dysplasia, thinning of the cortex of long bones and existence of neurofibromatosis in the first degree relatives. We report three patients, two men and a woman aged 18 to 33 years, in whom the first changes occurred at puberty, and there was no positive family history in any of them. All three patients had café-au-lait spots over 15 mm in diameter and numerous localized neurofibromas on the skin of the trunk and extremities that were histologically verified. In two patients, ophthalmic examinations recorded Lisch’s nodules in the iris. In one of the patients, MRI of the head, revealed presence of oval lesions with diameters of 10-15 mm, which may correspond to neurofibromas, and in the other patient fibrous dysplasia of the femur and tibia were observed. Psychological testing in one patient revealed IQ at the lower limits of average (IQ 68). After the diagnosis of neurofibromatosis type I, the patients were given advice about the disease and a plan for the monitoring and control of possible symptoms, and also the possibility of genetic testing during pregnancy. A multidisciplinary approach is required for diagnosing and monitoring of patients with neurofibromatosis type 1.

Open access

Kristina Kostić, Lidija Kandolf Sekulović and Radoš D. Zečević

Abstract

Bullous pemphigoid is an autoimmune blistering disease that predominantly affects elderly persons and rarely children. We present a 12-year-old girl with sudden appearance of tense blisters on an erythematous base on the trunk, neck, hands and legs with intense pruritus. Standard laboratory test results were within the normal range except for blood eosinophilia of 12% of the total white cell count. Skin biopsy specimens showed evolving subepidermal blisters with perivascular lymphohistiocytic, eosinophil and neutrophil infiltrations in the papillary dermis. Direct immunofluorescence of perilesional skin showed linear, continuous deposits of IgG and C3 along the dermoepidermal junction. Indirect immunofluorescence showed circulating anti-basement membrane zone IgG autoantibodies at a titer of 1:80. We started treatment with systemic corticosteroids, methylprednisolone 0,5 mg/kg per day and 500 mg erythromycin 4 times a day during 10 days. After 3 days 50 mg dapsone (DDS, 4,4-diaminodiphenylsulphone) per day was added. After a few days, there were no new changes on the skin and pruritus disappeared completely.

Open access

Tanja Tirnanić, Kristina Kostić, Lidija Kandolf Sekulović and Radoš Zečević

Abstract

Chronic urticaria is defined as daily or intermittent appearance of hives for more than 6 weeks. Patients with more severe forms of the disease have increased needs for immune modifying agents for disease control, and among these cyclosporine is the mainstay of treatment. Material and Methods: This retrospective study included patients treated for chronic urticaria from 2009 - 2016 at the Department of Dermatology of the Military Medical Academy. Results: There were 145 treated patients, of whom 20 (13.8%) were resistant to at least two lines of treatment (maximum dose of antihistamine monotherapy, combination of antihistamines, addition of dapsone and short courses of corticosteroids). The patients were treated with cyclosporine (6 males and 14 females; average age 40.05 years). Median duration of treatment was 6 months (range: 2 - 17). In 9 (45%) patients, cyclosporine treatment led to a complete response, in 3 (15%) occasional urticarial plaques developed in spite of treatment, while in 2 (10%) urticaria was resistant to cyclosporine treatment, with continuous disease activity. During the follow-up period, 20% of patients experienced adverse effects. Conclusion: In conclusion, 13.8% of patients were resistant to first-line standard treatment. In these patients, cyclosporine can be regarded as a safe and effective treatment modality, with relatively short course of treatment, but 10% of patients can be regarded as treatment resistant and around 20% experience adverse effects, pointing to the need for further treatment options, including omalizumab.

Open access

Lidija Kandolf Sekulović, Kristina Kostić, Željko Mijušković, Miroslav Dinić, Lidija Cvetković Jordanov and Radoš Zečević

Abstract

Atopic dermatitis is most frequently well controlled with topical therapeutic agents, but based on several studies, 10-20% of patients need systemic therapy. The most common systemic treatment for atopic dermatitis in everyday practice includes systemic corticosteroids, although there are insufficient valid data to support this. Cyclosporine is the treatment of choice for severe atopic dermatitis resistant to other commonly used treatment options, since its favorable therapeutic risk/benefit ratio is well documented in randomized placebo controlled trials, and also in uncontrolled trials. However, approximately 10% of patients with atopic dermatitis with indication for cyclosporine treatment are actually treated with this modality in Serbia, and there are no published case series on its use in this region so far. In this article, we evaluated the treatment efficacy and safety of cyclosporine microemulsion in patients with severe atopic dermatitis hospitalized at the Military Medical Academy in Belgrade from 2009 to 2012. This restrospective analysis included patients with severe forms of atopic dermatitis treated at the Department of Dermatology of the Military Medical Academy from 2009 - 2012. The hospital database was used to retrieve patients’ medical records. Approximately 200 patients were treated for atopic dermatitis and 20 patients were admitted to the hospital, 17 due to severe forms of disease. In total, 8 of 17 (47.05%) hospitalized patients with severe forms or erythroderma due to atopic dermatitis were treated with cyclosporine microemulsion with an initial dose of 4-5 mg/kg. Laboratory tests were done before treatment, 7 days later, and/or at the end of hospitalization. Therapeutic efficacy was evaluated based on the percentage of reduction of skin lesions from baseline to the end of hospital treatment (early efficacy), and at the end of follow-up (late efficacy). Duration of therapy, adverse events, treatment efficacy and reasons for treatment cessation were recorded during the follow-up period. There were five male and 3 female patients, with an average age of 36.8 years (15 - 60 years). Previous treatment modalities in all patients included emollients, topical and systemic corticosteroids and PUVA therapy. The average dose of cyclosporine was 4.5±0,5 mg/kg. Median reduction of skin lesions at discharge was 60%. There was no need for further hospitalization after an average of 10±3.2 days. Mean duration of treatment was 16 months (3 - 24), with an average reduction of skin lesions of 75% during follow-up. Arterial blood pressure increased in 3/8 (37.5%) patients, regardless of their age, with and average increase of systolic blood pressure of 11.9±11.6 mm Hg (median 7.5, 0-30 mm Hg) and diastolic blood pressure of 5.6±12.9 mm Hg (median 0, -10-20). Mean increase in urea concentration was 0.3 mmol/L (11.8%) and creatinine increased only in three patients by 4.2% (median increase 4 mmol/L). Hypertension was found in three patients during follow-up, and there were no other adverse events. In conclusion, based on previous studies and this small case series of hospitalized patients with severe forms of atopic dermatitis including erythroderma, cyclosporine can be regarded as a safe and effective treatment modality and it can be recommended as first line therapy in severe forms of atopic dermatitis refractory to topical therapy and phototherapy. Long term therapy, however, should be avoided and a maximum 1-2 year therapy is recommended.

Open access

Snežana Radoš, Milena Milovanović, Milica Rajović, Kristina Kostić, Ivana Tufegdžić and Lidija Kandolf Sekulović

Abstract

Porokeratosis belongs to a group of disorders of keratinization that are characterized by the histopathological feature of the cornoid lamella, a column of tightly fitted parakeratotic cells. The etiology of porokeratosis is still unclear. Different variants of porokeratosis (PK) have been subsequently recognized, each with its own specific properties in terms of morphology, distribution and clinical course. Linear porokeratosis is one of the variants of porokeratosis, a rare disorder of keratinization that may develop into several epidermal malignancies, squamous cell carcinoma being the most frequent among all of them. Thus, a clinical surveillance for malignancy is an imperative. We present a case of a 54-year-old man with non-healing ulcer of the lower leg caused by squamous cell carcinoma arising on long-standing linear porokeratosis. The treatment included wide excision of tumor with the reconstruction of the area. Acitretin was prescribed for linear porokeratosis treatment. The follow-up of our patient so far has shown that he does not have new malignant lesions after surgical excision.