Monthly Archives: December 2012

Although bacterial pyoderma is among the most commonly encountered dermatologic conditions in dogs, some cases present diagnostic challenges even to experienced clinicians. This article presents several unusual manifestations of pyoderma, including bullous impetigo, superficial spreading pyoderma, mucocutaneous pyoderma, and post-grooming furunculosis. Conditions mimicking pyoderma, including juvenile cellulitis, immunomodulatory-responsive lymphocytic-plasmacytic pododermatitis, and pemphigus foliaceus are also described. Diagnostic techniques used for diagnosing and characterizing pyoderma are also discussed.

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Pemphigus vulgaris (PV) is an autoimmune mucocutaneous disease presenting clinically with blisters or erosions of the skin and mucous membrane. The main histopathologic characteristic of this disease is suprabasal vesicles due to loss of cell–cell adhesion between keratinocytes named acantholysis. Studies have shown that apoptosis is increased in PV. The purpose of this study is to investigate the role of apoptosis in blister formation in PV.


This cross-sectional study was conducted on 25 specimens of oral PV. The presence of apoptosis was evaluated using the TUNEL technique in the normal perilesional region, vesicle area, and acantholytic cells. Also, the expression of Bax pro-apoptotic marker was assessed by the biotin–streptavidin immunohistochemical method. SPSS software was used for Wilcoxon test analysis. P values <0.05 were considered significant.


The percentage and intensity staining of TUNEL-positive cells were noteworthy. There were statistically significant differences between basal and parabasal) = 0.05 (, tombstone with vesicle roof (= 0.038) and basal with tombstone (= 0.038). However, the expression and staining intensity of pro-apoptotic marker Bax were weak, and no statistically significant differences were observed between the various areas.


The results obtained in the present study suggest that the process of apoptosis occurs early in PV because it was observed in the perilesional normal appearing tissue. Also, the process of apoptosis may cause exacerbation or speeding of the bulla formation. In other words, inhibition of apoptosis in the patients could reduce the severity of the lesions.

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 A small, but perfectly formed group of PEM Friends braved the floods  in the UK on Monday 26th November 2012 to have a sociable lunch together and share their experiences of Pemphigus and Pemphigoid. Even though it was a low turnout of  just seven patients, there was a wide diversity of the diseases represented and a great deal of empathy and common interest.

People came from as far away as Leicestershire and Suffolk.   We met in the self-service restaurant of Peter Jones in Sloane Square, London.

We were joined by Dr. Jane Setterfield, a Consultant Dermatologist with a great wealth of knowledge in the field of blistering diseases, particularly when there is oral involvement. Dr. Setterfield was able to answer our many questions and suggest possible actions for those attending.

Some of the particularly helpful sources of further information that Dr. Setterfield guided the group to were:-

It was a very enjoyable and useful event.

 Pemphigus can be a tough disease to live with but many patients now in remission have found inspiration, this is Sally’s story:

I have been in remission now for over 1 year (YES!!!). That is complete remission with no symptoms and no meds. I was diagnosed in 2004 and rode the roller coaster of varying doses of prednisone coupled with Cellcept at first and then Imuran. After many ups and downs, 4 years of meds, and a very slow taper of prednisone, I was able to go off of all meds and have been doing great for the past year. My treatment was with Dr. Anhalt, who I am extremely grateful to for his knowledge and compassion.

I have never done IVIG or Rituxan although these therapies were discussed as options had I not finally started doing well on the meds I was on. I do have to say, however, that I have never taken zinc or niacinamide, so I cannot owe my remission to that.

I think that it is wonderful that we have alternative therapies such as Rituxan and IVIG. My understanding is that most of the time, these treatments are used for those patients who do not respond well to traditional therapies. I know there are people in {the discussion)} group who have had tough battles and have not responded well to prednisone and immunosuppressive therapies. I think that is when these other treatments come into play.

I think using supplements can be very wonderful and if it works for some, then that is great. I don’t think, however, it’s always enough for everyone. And, I think with this disease, the treatment and journey is different for us all.

Story found at:


We report on a patient with longstanding multicentric Castleman’s disease, hyaline-vascular type, who developed a follicular dendritic cell sarcoma, and finally presented a fatal paraneoplastic pemphigus. We review all four cases of such a triple association described in the literature so far.

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Experience in the Texas Department of Criminal Justice Dermatology Clinic

In this article, the authors review the skin conditions seen in a dermatology referral clinic for inmates in the Texas Department of Criminal Justice system at the University of Texas Medical Branch. A database search of dermatology visits over a 34-month period yielded 3,326 adult outpatient encounters for analysis. Psoriasis, actinic keratoses, and hair diseases were the most commonly encountered diagnoses. Dermatophytes were the most common infection, keloids the most common benign tumor, and pemphigus the most common autoimmune disease.

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Pyodermatitis-pyostomatitis vegetans (PD-PSV) is a rare disorder characterized by mucocutaneous involvement and associated with inflammatory bowel disease. A 42-year-old woman with ulcerative colitis who manifested verrucous and pyogenic lesions on her scalp, neck, axillae, inguinal areas, umbilicus, trunk and oral cavity for about 11 months is described. She also experienced general fatigue and swelling in her lower extremities. Histology revealed eosinophilic inflammation with microabscesses and pseudoepitheliomatous hyperplasia, but she was negative on direct immunofluorescence for IgA, IgG and C3. She was diagnosed with PD-PSV and treated with infusions of 20% human albumin (100 mL) for 5 days, followed by methylprednisolone (40 mg/d), with remission of lesions observed after 1 month. The differential diagnosis of PD-PSV and pemphigus vegetans is discussed.

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Introduction: Though oral aphthosis is common, it has a significant impact on the quality of life in the patients. It is the most common oral ulcerative condition encountered in clinical practice. This study describes the characteristics and patterns of oral aphthosis seen at a tertiary dermatological centre in Singapore, with emphasis in evaluating the management gaps and in identifying underlying systemic diseases and nutritional deficiencies. Materials and Methods: This is a retrospective review of medical records over a 10-year period between June 2000 and June 2010. Two hundred and thirteen patients were identified using the search terms ‘oral ulcers’, ‘aphthous ulcers’, ‘oral aphthosis’, and ‘Behcet’s disease’. Patients with Behcet’s disease without oral ulcers and other diagnoses such as pemphigus vulgaris, lichen planus and herpes simplex were

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excluded. The remaining patients were evaluated with regard to demographic characteristics, characteristics of oral ulcers, associated connective tissue disorders and nutritional deficiencies, diagnostic tests results, treatment response as well as follow-up duration. Results: One hundred and seventy-five patients were included in this study. One hundred and one patients had recurrent oral aphthosis, with 77 having simple aphthosis and 24 having complex aphthosis. Fourteen patients (8%) fulfilled the International Study Criteria (ISG) for Behcet’s disease, of which, 85.71% had complex aphthosis. The therapeutic ladder for such patients ranged from topical steroids and colchicine through to oral corticosteroids and/or dapsone therapy. Conclusion: Recurrent oral aphthosis is a niche condition in which dermatologists are well-poised to manage. This study demonstrates that a more definitive management and therapeutic algorithm for oral aphthosis are needed for better management patients in the future. In particular, complex aphthosis needs to be monitored for progression onto Behcet’s disease.


Pemphigus is a rare vesiculobullous autoimmune disease that exhibits blistering of the skin and oral cavity. It is caused by autoantibodies directed against antigens on the surface of keratinocytes. All forms of pemphigus are associated with the presence of circulating and skin-fixed autoantibodies. Pemphigus vegetans is a rare clinical variant of pemphigus vulgaris and comprises up to 5 percent of all pemphigus cases. In the following we present the oral presentation of pemphigus vegetans. We describe a 33-year-old man who was referred to our clinic complaining about mouth sores, tooth pain, and multiple pustules. During clinical exam we were able to recognize multiple pustules, ulcerated areas on the gingiva, and whitish mucosal plaques. Clinical, histopathological, and direct immunofluorescence findings were compatible with pemphigus vegetans.

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Context.-Pemphigus is a group of autoimmune vesiculobullous diseases characterized by immunoglobulin G (IgG) antibodies directed against desmosomal adhesion proteins, with IgG4 being the predominant subclass in active diseases. Direct immunofluorescence for IgG performed on fresh-frozen tissue plays a crucial role in diagnosing pemphigus. However, the diagnosis might be hindered when frozen tissue is not available. Objective.-To evaluate the usefulness of immunohistochemistry for IgG4 performed on paraffin sections as a diagnostic test for pemphigus. Design.-Eighteen immunofluorescence-proven pemphigus cases (12 pemphigus vulgaris, 6 pemphigus foliaceus) were studied. Four normal skin specimens and 32 nonpemphigus vesiculobullous disease specimens served as controls. Paraffin sections of all cases were examined immunohistochemically for IgG4 expression. Positivity was defined as distinct, condensed, continuous immunoreactivity localized to the intercellular junctions of keratinocytes. Results.-The immunostains were independently evaluated in a masked manner by 3 pathologists, with a 100% interobserver agreement. Nine of 12 pemphigus vulgaris cases (sensitivity 75.0%), and 4 of 6 pemphigus foliaceus cases (sensitivity 66.7%), were positive for IgG4 immunostain. The overall sensitivity was 72.2%. One control specimen (bullous pemphigoid) showed IgG4 positivity (specificity 97.2%). In specimens demonstrating acantholysis, 8 of 10 pemphigus vulgaris cases (sensitivity 80.0%) and 4 of 4 pemphigus foliaceus cases (sensitivity 100.0%) were positive for IgG4. The overall sensitivity for specimens with acantholytic lesions was 85.7%. Conclusion.-Immunohistochemistry for IgG4 provides a reasonably sensitive and highly specific test for diagnosing pemphigus, especially when frozen tissue is not available, and active acantholytic lesions are examined.

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