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    • NSC74859 manufacturer Intertriginous areas and mucous membra

    2018-11-12

    Intertriginous areas and mucous membranes are the most frequently involved sites for pemphigus vegetans. The involvement of nonintertriginous areas is extremely rare. Only a few cases with solitary lesions limited to the scalp, face, and soles have been reported. A case with involvement of nonintertriginous areas including the trunk and right upper arm has also been reported. Our case occurred on the upper arm exclusively. The pathogenesis of pemphigus vegetans remains unknown. The frequent involvement of intertriginous areas may be attributed to relative occlusion and maceration with subsequent bacterial infection, suggesting a response to superinfection. However, this could not explain the skin lesions of nonintertriginous areas. It is clear that patients with pemphigus vulgaris have an increased risk of incidence of internal malignancy. Pemphigus may precede or follow malignant tumor. Coexistence of pemphigus vegetans and neoplasms are rarely reported. Pemphigus vegetans associated with lymphoproliferative disorders (non-Hodgkin-lymphoma and chronic lymphocytic leukemia) and internal malignancy (lung and gastric cancer) have been described. Koga et al reported a case of pemphigus vegetans with coexisting gastric cancer. In contrast to our case, their patient typically presented with vegetating and exudative lesions on the scrotum and bilateral inguinal areas. The patient was diagnosed with gastric cancer 4 months after starting the corticosteroid treatment and died of multiple organ failure 4 months after operation. Our case and that of Koga et al seem to suggest that gastric cancer was related to pemphigus vegetans. Systemic corticosteroid is the mainstay of therapy. The addition of immunosuppressive agents (azathioprine, cyclosporine, cyclophosphamide, mycophenolate mofetil, and methotrexate) is often considered whereas systemic corticosteroid alone does not induce disease remission. Immunosuppressive agents may improve remission rates and allow the steroid-sparing effect to occur.
    Poly--lactic NSC74859 manufacturer (PLA; Sculptra; Dermik Laboratories, Berwyn, PA, USA) was introduced in 2004 for the treatment of facial lipoatrophy associated with human immunodeficiency virus. Later, it gained popularity as a cosmetic volumizer for soft-tissue enhancement in the general population. Overall, PLA injections are associated with low complication rates. Self-limited, short-term complications include bruising and edema. Long-term complications such as clinically visible papules and subcutaneous nodules at the injection site have also been reported. Herein, we present a case of multiple subcutaneous granulomas formation, which was confirmed by histopathological analysis, in an immunocompetent patient who received PLA injections for soft-tissue cosmetic enhancement. A 62-year-old healthy woman presented to our clinic with a complaint of multiple firm skin-colored papules and subcutaneous nodules on the bilateral cheeks, chin, and temporal areas for 3–4 months (). She mentioned a history of PLA (Sculptra) injection (three doses of unknown volume and dilution) during the past year. Results of a skin biopsy revealed granulomatous dermatitis consisting of epithelioid histiocytes, numerous multinucleated and osteoclast-like giant cells. Many of these giant cells also had fusiform clefts in the cytoplasm or stellate-shaped inclusion bodies (). The intracytoplasmic fusiform clefts were filled with whitish birefringence crystalloid structures. The patient was treated with intralesional triamcinolone acetonide (3 mg/mL; 0.06–0.08 mL for each lesion, three treatment sessions; treatment duration: 2 weeks apart). After treatment, the subcutaneous nodules softened and gradually shrank. Delayed granulomatous reactions have been related to collagen, silicon, and hyaluronic acid. However, the rates of PLA-induced granulomas in the literature vary from 0.1% (reported by Vleggaar) to 44% (reported in the VEGA study). The discrepancy in the quoted rates of foreign-body granuloma formation after PLA injection may be attributed to differences in the injection techniques and the PLA concentrations used. Higher dilution volumes (5:1–7:1) are associated with lower rates.