We report two cases of acrodermatitis continua of Hallopeau with generalized arthritis. Oral cyclosporin together with topical steroid were effective for the skin disorders, but not for the arthritis, whereas infliximab and salazosulfapyridine improved the general arthritis. Although arthritis is usually more refractory to conventional therapies, the arthritis in acrodermatitis continua of Hallopeau is likely to be improved by intravenous infliximab together with methotrexate as well as by oral salazosulfapyridine, similar to psoriatic arthritis

Eiji Itoi

Hiroshi Okuno

Ken Ogura

Ryuhei Okuyama

English

Hrčak - Portal of scientific journals of Croatia

265ACTA DERMATOVENEROLOGICA CROATICATwo Cases of Acrodermatitis Continua of Hallopeau Associated with Generalized ArthritisActa Dermatovenerol Croat   2013;21(4):265-267                               LETTER TO THE EDITORINTRODUCTIONAcrodermatitis continua of Hallopeau (ACH), a variant of pustular psoriasis, chiefly affects distal parts of the hands and feet (1,2). Arthritis occasionally oc-curs in psoriasis, including pustular psoriasis, as pso-riatic arthritis (3), but it is uncommon in ACH. Here, we report on two cases of ACH with arthritis that was improved by infliximab together with methotrexate as well as salazosulfapyridine. As arthritis is refractory to conventional therapies, our cases could provide a clue to clarifying therapies for ACH.CASE REPORTSCase 1A 29-year-old man visited our hospital with polyar-thralgia chiefly at the fingers and big toes. Four years previously, he found cloudy alterations in the nail of the left middle finger. Two years later, distal interpha-langeal joints of the bilateral hands became swollen, reddish and painful, together with pustular forma-tion under the nail plate. The nails became deformed and discolored gradually. Reddish eruptions had not appeared over the trunk and extremities except for acral regions. On the first visit, distal interphalangeal joints of the hands and metatarsophalangeal joints of the big toes were swollen left to right asymmetrically, together with onycholysis and subungual hyperkera-tosis (Fig. 1a). Erythematous changes were diffusely distributed on peripheral regions of the fingers and toes. Routine hematologic and immunologic exami-nations were normal. Bone x-rays showed small ero-sions at the base of the distal phalanx (Fig. 1b). Mag-netic resonance imaging for evaluation of their activi-ties revealed enhancement at the base of the distal phalanx (Fig. 1c). Based on a diagnosis of ACH, the pa-tient was treated with topical clobetasol propionate 0.05% ointment and oral cyclosporin (5 mg/body weight kg/day) for several months, which improved the cutaneous manifestation, but not arthralgia. In addition, arthritis developed in his right elbow. Then, instead of corticosteroid and cyclosporin, we admin-istered intravenous infliximab at a dose of 5 mg/kg on weeks 0, 2, and 6, and every 8 weeks, together with oral methotrexate 6 mg weekly. His arthralgia disap-peared immediately, and the joint swelling and nail deformity gradually improved (Fig. 1d).Case 2A 55-year-old woman visited our hospital with polyarthralgia chiefly at the fingers, big toes, knees and ankles. Three months before the first visit, she had bilateral knee pain together with swelling. In a short time, painful swelling had also developed in the fingers and ankles, which was followed immediately by nail deformity of the bilateral big toes with swell-ing and purulent discharge around the nails. Previ-Figure 1. (a) Clinical features included edematous erythema on the acral parts of the fingers, pustules within the nail bed, and partial shedding of the nail plate; (b) bone x-ray image: arrows show bone ero-sion; (c) magnetic resonance imaging: arrows show the enhancement; (d) clinical feature: improvement of skin manifestation after the administration of inf-liximab and methotrexate.266 ACTA DERMATOVENEROLOGICA CROATICAously, reddish eruptions had not appeared except for acral regions. Examination showed yellowish-white discolored nails with atrophy in the bilateral big toes and erythema in the paronychial regions (Fig. 2a). Pu-rulent discharge was seen from the subungual space and the surrounding erythema. Routine hematologic and immunologic examinations were normal except for an increase in antinuclear antibody, ×160. Fungal and bacterial cultures from the pustules and nails were negative. While bone x-rays showed no abnor-malities, magnetic resonance imaging revealed sy-novitis in the metatarsophalangeal joints of the left index and ring fingers (Fig. 2b). In addition, bone scintigraphy indicated increased uptakes in multiple joints (Fig. 2c). A biopsy from the toe skin showed elongation of rete ridges as well as dermal infiltra-tion of neutrophils and lymphocytes, extending to the epidermis (Fig. 2d). The patient was treated with oral salazosulfapyridine 1000 mg daily as well as an occlusive dressing of tacrolimus ointment, which al-leviated the cutaneous and joint symptoms (Fig. 2e). DISCUSSIONAcrodermatitis continua of Hallopeau usually devel-ops on the distal portion of the digits with pustulation of the nail bed/matrix, which leads to onychodystrophy (1). We diagnosed these two cases as ACH, based on dystrophic nails surrounded by erythema with the his-tory of relapsing periungual and subungual pustules as well as no eruptions except for acral regions.Whereas arthritis is uncommon in ACH, these two cases showed polyarthritis chiefly distributed to the acral joints. However, its occurrence is not surprising because ACH is usually considered a variant of pustu-lar psoriasis (2). Inflammation may extend from the nail folds and beds to the joints underneath. In addi-tion, articular inflammation does not always localize to acral joints, as our two cases. The image findings in our case 1 were consistent with those of enthesitis. Enthesitis is a hallmark finding for psoriatic arthritis. The detection of enthesitis is facilitated by the use of magnetic resonance imaging and bone scintigraphy. They can evaluate not only the presence of enthesi-tis, but also its activities, which are entheseal-related bone formations and erosions (4).Therapeutic guidelines for ACH with arthritis do not seem to be established. ACH is frequently recalci-trant to topical therapies using steroid, vitamin D3 or tacrolimus (5,6). In case 1, oral cyclosporin with topical Figure 2. (a) Clinical features: nail destruction with paronychial erythema on the bilateral big toes; (b) magnetic resonance imaging: arrows show synovitis in metatarsophalangeal joints; (c) bone scintigraphy showing mul-tiple uptakes; asymmetric involvement of the distal and proximal interphalangeal joints; (d) histopathologic findings of erythema on the big toes: elongation of rete ridges with exocytosis of neutrophils and lymphocytes HE; x200; (e) clinical feature: improvement of skin manifestation after the administration of salazosulfapyridine with topical tacrolimus.Letter to the editor	  Acta Dermatovenerol Croat  	 	 	  2013;21(4):265-267267ACTA DERMATOVENEROLOGICA CROATICAsteroid was effective for the skin lesions, but not for arthritis. Cyclosporin is usually not potently effective for arthralgia in psoriatic arthritis, and arthritis seems to be more refractory to conventional therapies than cutaneous manifestations (7). Based on the concept that ACH is a variant of pustular psoriasis, arthritis ac-companied by ACH should be improved by therapies for psoriatic arthritis, including salazosulfapyridine, methotrexate and tumor necrosis factor- α (TNF-α) inhibitors (8). TNF-α inhibitors have been reported to provide satisfactory control of ACH (9). On the other hand, the clinical condition of ACH is occasionally re-fractory to TNF- α inhibitors (10,11). In our case, intra-venous infliximab combined with methotrexate was effective for arthritis and nail lesions in ACH. Based on the clinical manifestations including therapeutic responses, ACH with generalized arthritis would have similar pathological condition to psoriatic arthritis.References1. Sehgal VN, Verma P, Sharma S, Srivastava G, Ag-garwal AK, Rasool F et	al. Acrodermatitis continua of Hallopeau: evolution of treatment options. Int J Dermatol 2011;50:1195-211.2. Gluckman SJ, Heyman W. Diagnosis: acroder-matitis continua of Hallopeau. Clin Infect Dis 2001;32:431, 505.3. Gladman DD. Psoriatic arthritis from Wright’s era until today. J Rheumatol Suppl 2009;83:4-8.4. Anandarajah A. Imaging in psoriatic arthritis. Clin Rev Allergy Immunol 2013;44:157-65.5. Emtestam L, Weden U. Successful treatment for acrodermatitis continua of Hallopeau using topi-cal calcipotriol. Br J Dermatol 1996;135:644-6.6. Wilsmann-Theis D, Hagemann T, Dederer H, Wen-zel J, Bieber T, Novak N. Successful treatment of acrodermatitis continua suppurativa with to-pical tacrolimus 0.1% ointment. Br J Dermatol 2004;150:1194-7.7. Gul U, Gonul M, Kilic A, Erdem R, Cakmak SK, Gun-duz H. Treatment of psoriatic arthritis with etaner-cept, methotrexate, and cyclosporin A. Clin Ther 2006;28:251-4.8. Menter A, Gottlieb A, Feldman SR, Van Voorhees AS, Leonardi CL, Gordon KB et	 al. Guidelines of care for the management of psoriasis and psoria-tic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol 2008;58:826-50.9. Puig L, Dauden E, Carrascosa JM. Commentary on European and British guidelines for the treatment of psoriasis. Actas Dermosifiliogr	 2010;101:285-90.10. Thielen AM, Barde C, Marazza G, Saurat JH. Long-term control with etanercept of a severe acroder-matitis continua of Hallopeau refractory to inflixi-mab. Dermatology 2008;217:137-9.11. Adişen E, Oztaş M, Gürer MA. Lack of efficacy of etanercept in acrodermatitis continua of Hallo-peau. Int J Dermatol 2007;46:1205-7.Hiroshi Okuno1, Ken Ogura1, Ryuhei Okuyama2, Eiji Itoi11Department	of	Orthopedic	Surgery,	Tohoku	Uni-versity	Graduate	School	of	Medicine,	2Department	of	Dermatology,	Shinshu	University	School	of	Medicine,	Sendai,	Japan	Corresponding author:Hiroshi OkunoDepartment of Orthopedic SurgeryTohoku University Graduate School of Medicine1-1 Seiryo-machi, Aoba-kuSendai, 980-8574Japanokuno@med.tohoku.ac.jp	Received: December 10, 2012Accepted: November 15, 2013Letter to the editor	  Acta Dermatovenerol Croat  	 	 	  2013;21(4):265-267

Two Cases of Acrodermatitis Continua of Hallopeau Associated with Generalized Arthritis

Abstract

Similar works

Full text

Available Versions

Hrčak - Portal of scientific journals of Croatia

HRČAK - Portal of Croatian Scientific and Professional Journals