P6324Fumaric acid esters to treat psoriasis: Experience in a UK teaching hospital

Esther Burden-Teh, MBBS, Dermatology Department, Queen’s Medical Centre,Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; MinhLam, MBBS, Dermatology Department, Queen’s Medical Centre, NottinghamUniversity Hospitals NHS Trust, Nottingham, United Kingdom; Stuart Cohen,MBBS, Dermatology Department, Queen’s Medical Centre, NottinghamUniversity Hospitals NHS Trust, Nottingham, United Kingdom

Fumaric acid esters (FAEs) are widely used in Germany as a first-line systemictherapy for chronic plaque psoriasis. They have been in use for over 40 years butremain unlicensed in the UK and other countries. For this reason, uptake is variableand information regarding their utility in patients in the UK is limited. Commonadverse effects include gastrointestinal disturbance, flushing, and lymphopenia.These tend to be dose-related and do not usually require cessation of the drug. Wepresent data on FAE use in psoriasis within a UK teaching hospital. Thirty-eightpatients were identified frompharmacy records as having received a prescription forthe FAE preparation Fumaderm over an 8-month period. Three records wereunobtainable; the remaining 35 were reviewed. 51% of patients were male and themean age was 54 years (range, 23-75 years). All were refractory to conventionaltherapy and 74% had previously failed on $ 2 systemic therapies. 68% developedgastrointestinal adverse effects and/or flushing, but in the majority of cases thesesettled without intervention. 45% developed an abnormality in the monitoringblood tests or urinalysis; in the majority this was transient and not significant. Nosevere adverse event occurred during the audit period. Response to treatment wasdetermined from the medical records, though in the case of 3 patients it was toosoon after the initiation of treatment to establish this. 54%were documented to havean excellent response, 28% a partial response, and 6% a poor response. 23% stoppedtreatment during the audit period because of gastrointestinal side effects, patientconcerns over long-term treatment, and uncontrolled disease. Of those whostopped, 50% are now on a biologic therapy for their psoriasis, demonstrating theseverity of psoriasis in the cohort. These data give insight into our experience ofFumaderm in a single center over an 8-month period. More than 82% of patients hada partial or excellent response and there were no serious adverse events. However, asignificant minority chose to discontinue treatment because of the largely predict-able adverse effects. These results are in line with other recent prospective andretrospective studies. Although this treatment is not first-line in the UK, it shouldcontinue to be considered as a therapeutic option, potentially before the introduc-tion of biologic therapy, which is around double the cost per annum.

AB52

cial support: None identified.

Commer

P6728Generalized and very itchy skin lesions after starting a treatment withenalapril

Mar�ıa Salazar Nievas, San Cecilio Hospital, Granada, Spain; Carmen DulantoCampos, San Cecilio Hospital, Granada, Spain; Vicente Crespo Lora, San CecilioHospital, Granada, Spain

Background: Toxicodermias are a common and important complication in themedical practice. The dermatologist is who can define the clinical pattern in the bestway in many cases and assist in the identification of the causative agent. They affectthe skin, mucous membranes, and/or the areas around. They are caused by theharmful effect of various substances, usually drugs that enter into the body indifferent ways.

Case report: A 76-year-old man was worried about several erythematous, annularlesions of different sizes. Some of them had central crust and scaling and theyaffected a large part of the body surface. Palms and soles were respected. The lesionshad appeared 5 months ago and he had not improved despite the treatment withemollients and oral corticoids. The patient mentioned he had been suffering severeitching all the time. Therefore he could not sleep at all. It was requested a completelaboratory blood count, biochemistry, coagulation, autoimmunity study, and tumormarkers, whose results were normal. Among the patient’s personal history therecently diagnosed hypertension stood out. Because of that a treatment withenalapril had been established 1 year ago. According to the negative progress of theskin disease, we decided to do a biopsy of the lesions. The study withhematoxylineeosin showed an acanthotic epidermis with impaired dermoepider-mal interface, subcorneal pustule formation with neutrophils and foci of spongiosis,lymphocyte exocytosis and a few necrotic keratinocytes. In superficial dermis therewas an interstitial and perivascular lymphocytic infiltrate with eosinophils. Thedirect immunofluorescence study result was negative. According to these results,we confirmed the diagnosis of toxicodermia. Enalapril was removed and after thetreatment with low doses of oral steroids during two months, the patient improvedspectacularly.

Conclusion: We present a case of toxicodermia with very large skin lesions and witha clinical appearance that led to a wide differential diagnosis, including systemicdiseases. In addition, the skin disease significantly compromised the quality of life ofpatients. The identification of the causal agent was the key to cure it. Therefore, thedermatologist should be trained in the identification and management oftoxicodermias.

cial support: None identified.

Commer

J AM ACAD DERMATOL

P6793Granuloma annulare of the penis

Kara Walton, MD, Henry Ford Hospital System, Department of Dermatology,Detroit, MI, United States; Laurie Kohen, MD, Henry Ford Hospital System,Department of Dermatology, Detroit, MI, United States

Granuloma annulare (GA) is a benign, relatively common granulomatous dermatosisthat classically presents as annular plaques on the extremities in young femalepatients. While several clinical variants exist, granuloma annulare of the penis is anuncommon presentation, with only 13 cases previously reported. We present a caseof a 55-year-old white man who presented to our clinic with a 1-year history ofasymptomatic, firm subcutaneous nodules on the shaft of the penis. A biopsyshowed central necrobiosis with surrounding palisaded histiocytic inflammation,consistent with a diagnosis of GA. GA of the penis is a rare presentation of a commondisease and should be considered in the differential diagnosis of penile dermatoses.Of the reported cases of penile GA, the subcutaneous variant is most frequent.Association with systemic disease has not been demonstrated. Lesions are mostoften asymptomatic and may spontaneously regress. Treatments, including surgicalexcision, have been associated with recurrence; therefore, accurate identificationmay avoid unnecessary procedures.

cial support: None identified.

Commer

P5985Histiocytic inflammation induced by granulocyte-macrophage colonyestimulating factors

Bassel Mahmoud, MD, PhD, Henry Ford Hospital, Detroit, MI, United States;Holly Kerr, MD, Henry Ford Hospital, Detroit, MI, United States

Background: Granulocyte and granulocyte-macrophage colonyestimulating factors(G-CSF, GM-CSF) are growth factors that promote proliferation and maturation ofbone marrow stem cells. G-CSF primarily stimulates neutrophil production, whileGM-CSF stimulates proliferation of neutrophils, monocytes and eosinophils.

Case report: A 62-year-old white woman with a history of refractory acute myeloidleukemia (AML) was admitted for induction of chemotherapy followed by a bonemarrow transplant. The patient developed an asymptomatic eruption of 1 weeks’duration. Examination showed bilateral and symmetrical discrete, partially blanch-able erythematous macules, involving the arms, forearms, and palms. Differentialdiagnosis included leukemia cutis versus drug eruption versus viral exanthem.Histopathologic examination showed collection of histiocytes in the dermis withvesicular nuclei and ample cytoplasm; CD 68was positive andmyeloperoxidase wasnegative. Patient’s medication history showed that she received GM-CSF 3 weeksbefore the eruption started. We diagnosed her with cutaneous histiocytic inflam-mation induced by GM-CSF.

Discussion: GM-CSF stimulates proliferation of monocytes. Histiocytic inflammationwith cutaneous eruption has been described secondary to GM-CSF. Differentialdiagnoses included histiocytoid Sweet syndrome, infection process, and leukemiacutis, which can be excluded with immunohistochemistry work-up. Patient wasstarted on triamcinolone ointment 0.1% twice daily. GM-CSF was already discon-tinued. The eruption started to clear within a few days. Previous reports have shownthat the clinical course is self-limited even though the drug is not stopped; therefore,it was recommended to not discontinue GM-CSF if it is still indicated.

cial support: None identified.

Commer

APRIL 2013