When a psoriasis patient shows
When a psoriasis patient shows primary or secondary failure or has adverse effects to one biologic agent, shifting to use another biologic agent of either the same or different mode of action should be considered. Psoriasis could impair patients’ quality of life significantly. New biologics not only provide a chance to treat psoriasis better but also may make our patients to live better.
Acknowledgments The trial of ustekinumab was funded by Janssen-Cilag Pharmaceuticals and the trial of secukinumab was funded by Novartis International AG.
Introduction Eruptive melanocytic nevi (EMN) is a rare phenomenon in which hundreds of melanocytic nevi appear suddenly. This condition has been associated with multiple dermatological diseases and suppression of the immune system. Although EMN is associated with a higher risk of malignant transformation, no previous study has reported a concurrent melanocytic malignancy. BRAF and p16 mutations have been implicated in the pathogenesis of EMN, but few studies have examined samples of EMN for these markers. Herein, we report a rare case of EMN associated with multiple concurrent low-grade melanocytic malignancies, for which we performed an immunohistochemistry (IHC) study for p16 natural antibiotics and used real-time polymerase chain reaction (PCR) to identify BRAF mutation in tissue samples of EMN.
Case Report A 32-year-old man presented with multiple asymptomatic purplish and blackish papules (1–4 mm in diameter) over his trunk, axilla, and upper extremities (Figures 1A and 1B). There were more than 100 of these lesions, all of which had abruptly erupted in the 6 months prior to the visit. Other skin findings and symptoms were unremarkable. The patient was previously healthy and denied any history of drug use. A skin biopsy was performed on one of the lesions on his right abdomen. Microscopic examination revealed that it was a Spitz nevus (Figures 1C and 1D). Under the impression of EMN, we arranged a thorough examination. Two additional skin biopsies were performed on lesions on the left abdomen and right wrist, both of which were proven histopathologically to also be Spitz nevi. His serum biochemical and hematologic panels were all within normal limits, as were his levels of prostate-specific antigen, cortisol, and adrenocorticotropic hormone. An anti-HIV antibody test was negative. Chest radiography, panendoscopy, colonoscopy, whole-body computed tomographic scan, and positron emission tomography scan were all normal. However, fibrolaryngoscopy detected a pigmented lesion over the hypopharynx (Figure 2A), which was then removed through laryngomicrosurgery. The tissue was sent for pathology, which revealed a heavily pigmented papule confined to a superficial connective tissue composed of predominantly epithelioid nevus cells with prominent central eosinophilic nucleoli, focal hyperchromatism and mild nuclear atypia (Figure 2B–D). The lesion revealed both benign characteristics, including a well-circumscribed architecture with maturation and no mitotic activity, and troubling characteristics, including a slightly asymmetrical architecture, confluent cell nests, and frequent pagetoid extensions of the nevus cell into the surface epithelium, even in the upper half of the epithelium. These histologic features led to a diagnosis of melanocytic tumor with uncertain malignant potential (MELTUMP). After 1 month, the patient returned for follow-up. The number of skin lesions had increased and some of them had become more raised and enlarged. He received a fibrolaryngoscopy again, and three newly erupted pigmented nevi were detected over the hypopharynx. All of them were excised, sent for pathology, and proven histologically to be MELTUMPs. We detected BRAF V600E mutations by using a real-time melting curve analysis of PCR on four of the excised tissues and using IHC to identify p16 in five of the excised tissues. The PCR result indicated the presence of BRAF V600E mutations in three of the four excised tissues(Supplementary Table 1). The IHC staining for the p16 revealed variable decreased positivity in all the five excised samples, namely two cutaneous Spitz nevi and three hypopharyngeal MELTUMPs (Figure 3). The sites of the excised lesions and corresponding examination results are shown in Table 1.