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Long-term Control of Papular Dermatitis (“Dermal Hypersensitivity Reaction”) With Mycophenolate Mofetil

Long-term Control of Papular Dermatitis (“Dermal Hypersensitivity Reaction”) With Mycophenolate... In dermatology practice, patients frequently present with a recalcitrant eruption distinguished by the presence of edematous, urticarial, intensely pruritic papules. After analysis of patient biopsy specimens, the dermatopathologist will often report a “dermal hypersensitivity reaction” (DHR) characterized by an eosinophil-rich infiltrate. The only clinical differentials that correspond to this pathologic diagnosis are arthropod bite and drug eruption, neither of which is clinically relevant to the present case. This skin biopsy finding of DHR was described by Fung as “a histopathologic pattern for which corresponding clinical phenotypes have not been established.”1(p899) Fung's description of DHR (which he termed urticarial papulosis) is clinically and histologically identical to what was termed papular dermatitis by Clark et al2 in 1998. Both studies comment on the difficulty of long-term control in affected patients.1,2 This skin disease (herein referred to as “papular dermatitis”) is not rare, and it is very challenging to treat. Affected patients rarely respond to topical therapy, and dependence on systemic steroids becomes a significant problem. The following case illustrates my experience with mycophenolate mofetil as a steroid-sparing agent for long-term control of papular dermatitis. Report of a Case A 69-year-old man presented with a progressively intense, pruritic eruption. The rash consisted of edematous, erythematous, urticarial papules and plaques. These lesions were concentrated symmetrically over the scalp, lower back (Figure), buttocks, and the extensor surfaces of the extremities. Initial treatments included tacrolimus ointment, clobetasol cream, acitretin, and oral doxepin, none of which relieved the extreme pruritus. Three courses of prednisone were required for relief, with significant rebound flares occurring after each steroid course. A generalized screening laboratory workup was performed, which showed no hematologic abnormalities. Hepatitis profile findings were negative. Figure 1. View LargeDownload Patient with papular dermatitis. A, At initial presentation, urticarial erythematous papules are evident on the back. B, After multiple treatment modalities, just before beginning therapy with mycophenolate mofetil, some active disease and postinflammatory pigmentation are still evident. C, After completing 6 months of mycophenolate mofetil therapy at a dose of 2 g/d, symptoms are largely cleared. Skin biopsy specimens revealed a superficial and deep perivascular and interstitial dermatitis with numerous eosinophils. These findings were read by the dermatopathologist to represent a DHR. Direct immunofluorescence findings were negative. Owing to the need for a steroid-sparing agent in this case, the patient was started on a treatment regimen of mycophenolate mofetil at a dose of 2 g/d. Within 6 weeks, he had experienced resolution of his symptoms. The patient reported no adverse effects or laboratory abnormalities while being treated with mycophenolate mofetil, and he did not require any further courses of prednisone during the subsequent 9 months of mycophenolate mofetil therapy. Mycophenolate mofetil has been used to treat other patients in a similar manner; details of 2 other cases are summarized in the Table. Table. View LargeDownload Clinical Characteristics of 2 Other Patients With Papular Dermatitis Treated With Mycophenolate Mofetil Comment Mycophenolate mofetil is an immunosuppressive agent that has been shown to have efficacy in the treatment of a wide array of inflammatory skin diseases including psoriasis and bullous disorders.3-5 It is rapidly gaining acceptance as a steroid-sparing agent with a favorable tolerability profile. The use of mycophenolate mofetil in a patient with papular dermatitis represents a novel approach to treat a dermatologic condition that has not been precisely defined as a clinical entity These cases suggest that mycophenolate mofetil may prove to be a viable steroid-sparing option for the management of papular dermatitis. It behaves like other steroid-sparing agents in that it is not effective as monotherapy. The onset of action is gradual, and thus mycophenolate mofetil should be administered while the patient's symptoms are adequately controlled by systemic steroids. This approach to the management of papular dermatitis is similar to the standard management of blistering disorders. Furthermore, it should be noted that mycophenolate mofetil is one of many potential steroid-sparing agents that may be useful in treating this condition. Just as in the treatment of blistering dermatoses, other nonsteroidal immunosuppressive agents such as azathioprine, methotrexate, cyclosporine, and thalidomide may have efficacy in the management of papular dermatitis. Further study of similar patients will aid in defining the proper treatment parameters and clinical course of this enigmatic, but by no means rare, dermatologic condition. Correspondence: Dr Flugman, Department of Dermatology, Huntington Hospital, 177 Main St, Huntington, NY 11743 (scottfmd@optonline.net). Financial Disclosure: None reported. Back to top Article Information Acknowledgment: I thank Paul Chu, MD, for his valuable input regarding the pathologic findings in this case. References 1. Fung MA The clinical and histopathologic spectrum of “dermal hypersensitivity reactions,” a nonspecific histologic diagnosis that is not very useful in clinical practice, and the concept of a “dermal hypersensitivity reaction pattern.” J Am Acad Dermatol 2002;47898- 907PubMedGoogle ScholarCrossref 2. Clark ARJorizzo JLFleischer AB Papular dermatitis (subacute prurigo, “itchy red bump” disease): pilot study of phototherapy. J Am Acad Dermatol 1998;38929- 933PubMedGoogle ScholarCrossref 3. Nousari HCSragovich AKimyai-Asadi AOrlinsky DAnhalt G Mycophenolate mofetil in autoimmune and inflammatory skin disorders. J Am Acad Dermatol 1999;40265- 268PubMedGoogle ScholarCrossref 4. Kazlow Stern DTripp JMHo VCLebwohl M The use of systemic immune moderators in dermatology: an update. Dermatol Clin 2005;23259- 300PubMedGoogle ScholarCrossref 5. Katz KHMarks JGHelm KF Pemphigus foliaceus successfully treated with mycophenolate mofetil as a steroid-sparing agent. J Am Acad Dermatol 2000;42514- 515PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Long-term Control of Papular Dermatitis (“Dermal Hypersensitivity Reaction”) With Mycophenolate Mofetil

Archives of Dermatology , Volume 142 (11) – Nov 1, 2006

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Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archderm.142.11.1512
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Abstract

In dermatology practice, patients frequently present with a recalcitrant eruption distinguished by the presence of edematous, urticarial, intensely pruritic papules. After analysis of patient biopsy specimens, the dermatopathologist will often report a “dermal hypersensitivity reaction” (DHR) characterized by an eosinophil-rich infiltrate. The only clinical differentials that correspond to this pathologic diagnosis are arthropod bite and drug eruption, neither of which is clinically relevant to the present case. This skin biopsy finding of DHR was described by Fung as “a histopathologic pattern for which corresponding clinical phenotypes have not been established.”1(p899) Fung's description of DHR (which he termed urticarial papulosis) is clinically and histologically identical to what was termed papular dermatitis by Clark et al2 in 1998. Both studies comment on the difficulty of long-term control in affected patients.1,2 This skin disease (herein referred to as “papular dermatitis”) is not rare, and it is very challenging to treat. Affected patients rarely respond to topical therapy, and dependence on systemic steroids becomes a significant problem. The following case illustrates my experience with mycophenolate mofetil as a steroid-sparing agent for long-term control of papular dermatitis. Report of a Case A 69-year-old man presented with a progressively intense, pruritic eruption. The rash consisted of edematous, erythematous, urticarial papules and plaques. These lesions were concentrated symmetrically over the scalp, lower back (Figure), buttocks, and the extensor surfaces of the extremities. Initial treatments included tacrolimus ointment, clobetasol cream, acitretin, and oral doxepin, none of which relieved the extreme pruritus. Three courses of prednisone were required for relief, with significant rebound flares occurring after each steroid course. A generalized screening laboratory workup was performed, which showed no hematologic abnormalities. Hepatitis profile findings were negative. Figure 1. View LargeDownload Patient with papular dermatitis. A, At initial presentation, urticarial erythematous papules are evident on the back. B, After multiple treatment modalities, just before beginning therapy with mycophenolate mofetil, some active disease and postinflammatory pigmentation are still evident. C, After completing 6 months of mycophenolate mofetil therapy at a dose of 2 g/d, symptoms are largely cleared. Skin biopsy specimens revealed a superficial and deep perivascular and interstitial dermatitis with numerous eosinophils. These findings were read by the dermatopathologist to represent a DHR. Direct immunofluorescence findings were negative. Owing to the need for a steroid-sparing agent in this case, the patient was started on a treatment regimen of mycophenolate mofetil at a dose of 2 g/d. Within 6 weeks, he had experienced resolution of his symptoms. The patient reported no adverse effects or laboratory abnormalities while being treated with mycophenolate mofetil, and he did not require any further courses of prednisone during the subsequent 9 months of mycophenolate mofetil therapy. Mycophenolate mofetil has been used to treat other patients in a similar manner; details of 2 other cases are summarized in the Table. Table. View LargeDownload Clinical Characteristics of 2 Other Patients With Papular Dermatitis Treated With Mycophenolate Mofetil Comment Mycophenolate mofetil is an immunosuppressive agent that has been shown to have efficacy in the treatment of a wide array of inflammatory skin diseases including psoriasis and bullous disorders.3-5 It is rapidly gaining acceptance as a steroid-sparing agent with a favorable tolerability profile. The use of mycophenolate mofetil in a patient with papular dermatitis represents a novel approach to treat a dermatologic condition that has not been precisely defined as a clinical entity These cases suggest that mycophenolate mofetil may prove to be a viable steroid-sparing option for the management of papular dermatitis. It behaves like other steroid-sparing agents in that it is not effective as monotherapy. The onset of action is gradual, and thus mycophenolate mofetil should be administered while the patient's symptoms are adequately controlled by systemic steroids. This approach to the management of papular dermatitis is similar to the standard management of blistering disorders. Furthermore, it should be noted that mycophenolate mofetil is one of many potential steroid-sparing agents that may be useful in treating this condition. Just as in the treatment of blistering dermatoses, other nonsteroidal immunosuppressive agents such as azathioprine, methotrexate, cyclosporine, and thalidomide may have efficacy in the management of papular dermatitis. Further study of similar patients will aid in defining the proper treatment parameters and clinical course of this enigmatic, but by no means rare, dermatologic condition. Correspondence: Dr Flugman, Department of Dermatology, Huntington Hospital, 177 Main St, Huntington, NY 11743 (scottfmd@optonline.net). Financial Disclosure: None reported. Back to top Article Information Acknowledgment: I thank Paul Chu, MD, for his valuable input regarding the pathologic findings in this case. References 1. Fung MA The clinical and histopathologic spectrum of “dermal hypersensitivity reactions,” a nonspecific histologic diagnosis that is not very useful in clinical practice, and the concept of a “dermal hypersensitivity reaction pattern.” J Am Acad Dermatol 2002;47898- 907PubMedGoogle ScholarCrossref 2. Clark ARJorizzo JLFleischer AB Papular dermatitis (subacute prurigo, “itchy red bump” disease): pilot study of phototherapy. J Am Acad Dermatol 1998;38929- 933PubMedGoogle ScholarCrossref 3. Nousari HCSragovich AKimyai-Asadi AOrlinsky DAnhalt G Mycophenolate mofetil in autoimmune and inflammatory skin disorders. J Am Acad Dermatol 1999;40265- 268PubMedGoogle ScholarCrossref 4. Kazlow Stern DTripp JMHo VCLebwohl M The use of systemic immune moderators in dermatology: an update. Dermatol Clin 2005;23259- 300PubMedGoogle ScholarCrossref 5. Katz KHMarks JGHelm KF Pemphigus foliaceus successfully treated with mycophenolate mofetil as a steroid-sparing agent. J Am Acad Dermatol 2000;42514- 515PubMedGoogle ScholarCrossref

Journal

Archives of DermatologyAmerican Medical Association

Published: Nov 1, 2006

Keywords: mycophenolate mofetil,hypersensitivity,dermatitis,papule

References