Vol 50, No 7 (2022)

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Ultrasonographic characteristics of Bowen's disease

Khlebnikova A.N., Selezneva E.V.


Background: Bowen's disease (BD), or squamous cell carcinoma in situ, is an epithelium-derived tumor with high oncogenicity. Nowadays, high frequency ultrasonography is widely used for non-invasive diagnosis of skin tumors. The results of investigations into the echo signs of BD are contradictory, while they based on the use of 20 and 45 MHz converters. To make intra-epidermal lesions visible, it is necessary to use sonographic converters with at least 50 MHz resolution.

Aim: To determine ultrasonographic signs of BD with the use of a high frequency 75 MHz sensor.

Materials and methods: We examined 8 patients (2 women and 6 men) aged 38 to 86 years with histologically confirmed BD diagnosis. With a high resolution ultrasonographic system (75 MHz sensor) we scanned 8 solid BD lesions and 8 visually unchanged contralateral skin areas as controls, measuring the epidermal and dermal thickness, depth of hypodense areas in derma in the chosen regions of interest.

Results: The ultrasonographic picture of the BD lesions was characterized by hyperdense epidermis of two types: the first one (n = 6) was of uneven thickness and wave form, with budlike sprouts into the dermal depth, while the second one (n = 2) was of similar width all through, with even external and internal contours. Mean epidermal thickness in the BD lesions was significantly different from that of the contralateral visually unchanged skin areas (192.37 ± 75.48 vs 69.88 ± 12.48 mcm, p = 0.011719). In BD lesion, there were intradermal hypodense areas located just under the epidermis; they included diffuse and heterogeneous band-like structures in the type 1 lesions and round structures in the type 2 lesions. The mean thickness of the hypodense BD zones in the tumor located in the open skin areas was bigger than that in those located in the closed skin areas (1288.25 ± 450.25 vs 585.75 ± 150.62 mcm, p = 0.025348).

Conclusion: With ultrasonographic scanning with a 75 MHz sensor, we have identified the following BD characteristics: thickened epidermis with an even internal contour and hypodense intradermal areas of diffuse heterogeneous structures, which had the biggest depth in the lesions located in the open skin areas. The ultrasonographic picture of BD can be of two types depending on the combination of the main signs with different shape.

Almanac of Clinical Medicine. 2022;50(7):415-419
pages 415-419 views

The role of the traumatic factor and isomorphic reaction in the early diagnosis of psoriatic arthritis

Koreshkova K.M., Khismatullina Z.R.


Rationale: Evaluation of the role of the deep Koebner's phenomenon and traumatization seems to be a promising direction in the search of the solution for the delayed diagnosis of psoriatic arthritis (PsA) in patients with psoriasis. We have put forward the question if joint and ligament abnormalities induced by a trauma or persistent physical activity could be an analogue of the skin isomorphic reaction in psoriasis.

Aim: To identify joint and ligament abnormalities in patients with psoriasis caused by mechanical stress and their association with the deep Koebner's phenomenon and PsA.

Materials and methods: This was an open-label, non-randomized, comparative study in parallel groups in 80 in-patients with psoriasis (recruited in the Dermatovenereological clinic № 1, Ufa); the control group included 80 in-patients with PsA. All patients were assessed by a dermatovenereologist, including past history, severity of psoriasis, degree of PsA activity, special questionnaires and the presence of an isomorphic reaction in the skin and periarticular tissues. The joints with maximal physical activity were assessed by X-ray. PsA was diagnosed by a rheumatologist.

Results: The patients from both groups were matched in terms of age, gender, and duration of psoriasis. Pain, joint stiffness and limitation of mobility were present not only in the PsA group, but also in the patients with psoriasis (35%, 27.5% and 26.2% of the patients, respectively). Despite most of the patients in the psoriasis group had no active complaints (65.0% vs. 0% in the control group, p < 0.001), clinical signs of inflammation of the tendons and entheses and relevant history were found in 47.5% (68.7% in the control group, p = 0.007). Hand tendinitis was most prevalent symptom in both groups: 40.0% (32/80) in the psoriasis group and 63.7% (51/80) in the PsA group (p = 0.003). Achilles tendon lesions were found in 17.5% (14/80) and 52.5% (42/80) (p < 0.001) and periarticular edema in 27.5% (22/80) and 63.7% (51/80), respectively (p < 0.001). The combination of these signs with psoriatic plaques in this area was observed in 32.5% (26/80) and 92.5% (74/80) of the patients, respectively (p < 0.001). The comparison of the clinical and X-ray data showed that 38 patients with psoriasis and newly diagnosed PsA had had an increased physical load on the affected joints, as well as signs of a deep isomorphic reaction (tendinitis, periarticular edema, or enthesitis near the involved joints). In both groups, the most common form of PsA was distal one (63.2% [24/38] of the patients with newly diagnosed PsA and 58.7% [47/80] of the patients with previously diagnosed PsA, p = 0.648).

Conclusion: Involvement of the periarticular tissues, as well as early, including preclinical, X-ray abnormalities in the joints of patients with psoriasis can be associated with increased physical activity and the deep Koebner's phenomenon. Therefore, even if patients with psoriasis do not have any clinical manifestations of PsA and no complaints when seen by a dermatovenereologist, it is recommended to perform a detailed collection of past history data with clarification of the type of physical activity and past trauma, as well as to examine both by inspection and palpation the periarticular tissues (tendons and entheses), for the timely use of X-ray examination, consultation of a rheumatologist aimed at diagnosis of psoriatic arthritis.

Almanac of Clinical Medicine. 2022;50(7):420-427
pages 420-427 views


Langerhans cell histiocytosis as a clonal disease of mononuclear phagocyte system

Khynku E.F., Monaenkova M.K., Tamrazova O.B., Taganov A.V., Gureeva М.А., Bagramova G.E., Molochkov A.V.


Langerhans cell histiocytosis (LCH) belongs to histiocytic proliferative diseases, which are rare in clinical practice; however they pose significant challenges both for their diagnosis and choice of therapeutic strategies. Histiocytic proliferative diseases are the scope of oncology; nevertheless, at the diagnostic stage the patients are referred to pediatricians or dermatologists. That is why the interdisciplinary interaction of various specialties and common approaches to their classification, diagnosis and treatment are important for the management of patients with histiocytic proliferative disorders.

Accumulation of the studies on the LCH pathophysiology has promoted the development of new diagnostic algorithms and treatment methods. After the fact of MAPK signal pathway activation had been established, the potential target for therapy was identified. Neoplastic nature of LCH has been hypothesized. If confirmed, we can expect actual diagnostic algorithms being elaborated, in particular, the potential to predict the disease depending on the tumor clone mutation type. The unique characteristics of LCH including proliferate clonality (presumable of neoplastic nature), the disease course with spontaneous regression and frequent relapses and tropism to certain tissues (target organs) make up the grounds for further in-depth studies of the disease.

Almanac of Clinical Medicine. 2022;50(7):428-438
pages 428-438 views


B-cell depletion in the treatment of pemphigus: two clinical cases and literature review

Karzanov O.V., Chernyaeva E.V., Kupriyanova A.G., Molochkova Y.V., Zenkevich E.V., Molochkov A.V.


Pemphigus presents a group of chronic autoimmune bullous skin disorders with well-known clinical signs, which pathophysiology is mediated by antibodies to various epidermal self-antigens. For a long time, the only therapeutic option for this disease was the lifelong use of non-selective immunosuppressive agents limited by high rate of severe adverse reactions. The article presents two clinical cases of rituximab use (a targeted agent leading to B-cell depletion) in patients with pemphigus (vulgaris and foliaceous) who were previously resistant to high-dose steroid therapy. Treatment with rituximab lead to response and allowed to decrease the prednisone dose in both cases. These results confirm that rituximab can be successfully used in pemphigus as adjuvant therapy if conventional agents for this dermatosis are ineffective.

Almanac of Clinical Medicine. 2022;50(7):439-446
pages 439-446 views

Inverse psoriasis: the diagnostic value of dermatoscopic assessment and the experience of treatment with a combination topical agent (a clinical series)

Khlebnikova A.N.


Background: Inverse psoriasis that is characterized by skinfold rash is seen in 12 to 36% of European patients with psoriasis. Isolated involvement of skinfolds can mimic a number of dermatoses with similar location. The differential diagnosis is increasingly frequently based on non-invasive methods, including dermatoscopy. Taking into account the warm and wet milieu of skinfolds, facilitating secondary infection, topical antibacterials and antiseptics are recommended for treatment, along with topical glucocorticosteroids and vitamin D3 analogues.

Materials and methods: We have analyzed the results of assessment and treatment of 15 patients with psoriasis of major skinfolds that were admitted to the in-patient department of dermatology. All patients underwent dermatoscopy at × 20 magnification. The patients were treated with desensitizing agents, hepatic protectors, and group B vitamins. Topical treatments applied in the rash areas included a combination topical agent containing mometasone furoate (0.5 mg), gentamicin sulfate (1 mg), econazole nitrate (10 mg), and dexpanthenol (50 mg). The treatment was considered effective if the M-PASI decreased at least by 75%; the results were assessed after 7 and 14 days of treatment.

Results: In all cases, dermatoscopy of the vulgar psoriasis lesions showed vermilion or red to rosy background with evenly distributed dotted vessels and white scales diffusely located all over the visualized surface. The skinfold lesions were characterized by rosy or red background with evenly distributed dotted vessels, white scales located either as isolated groups, or at the periphery of the visualized areas; some plaques had local erosions, and in one case, hemorrhages. Morphological assessment of the biopsy samples in all patients with isolated skinfold lesions (n = 5) confirmed the diagnosis of psoriasis. Treatment-induced improvement was seen at day 2 to 3, and at day 14, there was a decrease of M-PASI by 90% in 6 (40%) patients and resolution of the lesions in 9 (60%). There were no treatment-associated adverse events or reactions.

Conclusion: Dermatoscopy has proved to be a useful tool for non-invasive diagnostics of inverse psoriasis. At low magnification (× 20), its main sign was an even distribution of dotted vessels throughout the visualized area. In a number of cases, the dermatoscopic symptoms additionally included white scales grouped as isolated foci. The addition of the combination topical agent (mometasone furoate, gentamicin sulfate, econazole nitrate, and dexpanthenol) to the standard systemic therapy facilitated almost full resolution of skinfold psoriatic lesions.

Almanac of Clinical Medicine. 2022;50(7):447-454
pages 447-454 views

Actinic keratosis as a predictor of primary multiple synchronous squamous cell skin cancer: a clinical case

Sedova T.G.


We present a clinical case of a primary multiple synchronous highly differentiated keratinizing squamous cell skin cancer in an 84-year old patient with multiple actinic keratosis and actinic cheilitis. The clinical case is unique for the simultaneous development of primary multiple squamous cell carcinoma of the tip of the nose and the vermilion zone of the lower lip in a patient with a past occupational and solar burden, a light phenotype, and signs of chronic photo injury the skin. Clinical, dermatoscopic and sonographic signs of keratotic actinic keratosis were identified in the patient and confirmed by pathomorphological examination. The risk factors for malignant transformation of actinic keratosis were found, such as multiple efflorescences and a long disease history. The malignant transformation of the actinic areas manifested as rapidly progressive ulceration zones more than 1 cm in diameter, pronounced hyperkeratosis, inflammation and infiltration of the underlying tissues, increased bleeding and pain. It is to be underlined that definitive and differential diagnosis requires pathomorphological assessment of the skin biopsy sample. This clinical case indicates that patients with multiple foci of actinic keratosis should be under a lifelong follow-up by dermatovenereologists, with mandatory treatment and prevention measure.

Almanac of Clinical Medicine. 2022;50(7):455-461
pages 455-461 views

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