Transcript Flagellate Dermatoses - Abdel Hamid Derm Atlas

Flagellate dermatoses
Flagellation of Christ by Rubens
The Flagellation of Our Lord Jesus Christ, William-Adolphe
Bouguereau
Shi'ites in Pakistan flagellate themselves during the Moharram
procession
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flagellate dermatoses as religious punishment
Causes of flagellate dermatoses
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Flagellate dermatoses
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Flagellate dermatoses are uncommon figurate dermatoses characterized by parallel linear or
curvilinear arrangement simulating the marks of whiplashes.
True flagellation/mechanical
Flagellation has been used in various religions for penance or punishment. Whipping has also
been used to "discipline" children, but in the modern context flagellate marks on children should
arouse a suspicion of child abuse. . Sadomasochistic behavior involves voluntary whipping of
oneself or the partner for sexual gratification. Artefactual whiplash marks may be produced for
tangible or intangible gains in malingering and other psychiatric illnesses.
Chemotherapy induced flagellate dermatitis and pigmentation
Bleomycin is a polypeptide chemotherapeutic agent with predominant adverse reactions in the
cutaneous and respiratory systems presumably due to the lack of inactivating enzyme, hydrolase
in these tissues. The common mucocutaneous lesions described are pigmentation (~50%),
alopecia (~50%) and flagellate dermatitis (8-66%). . The rash heals with persistent flagellate
hyperpigmentation . Pigmentation has also been described without pruritus or rash. Although it
usually appears after a cumulative dose >100 U; it has also been reported after doses as small as
14 U used for intralesional injections of verrucae. Peplomycin is a bleomycin derivative with
reduced pulmonary toxicity that is used for lymphomas and prostatic carcinoma. It has also been
implicated in flagellate erythema by mechanisms similar to bleomycin.
Docetaxel is a taxane with a high rate of cutaneous reactions including flagellate dermatitis.
Rheumatological diseases
Dermatomyositis is known to produce linear lesions variously described as centripetal flagellate
erythema, zebra-like striped erythema, and linear streaks . In contrast to bleomycin-induced
flagellate dermatitis, erythema is more pronounced than pigmentation. The trauma of scratching
appears to play an important role, as in the bleomycin induced rash.
Adult-onset Still's disease is an autoimmune disease occasionally associated with flagellate
erythema.
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Flagellate dermatoses ( Continue)
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Toxin-induced
Shiitake mushrooms (Lentinus edodes) are commonly used in Asian cuisines and are known to produce flagellate dermatitis
(toxicoderma). The rash is very pruritic, predominantly truncal and does not generally heal with pigmentation. Toxicoderma is probably
caused by a lentinan-like polysaccharide, which is denatured by cooking and thus occurs only on eating raw or under-cooked
mushrooms.
Cnidarians (Portuguese man-of-war and jellyfish) contain nematocysts in their tentacles which discharge by an osmotic process when
injected in the prey. Most human envenomations are caused by Anthozoa (anemones and corals), Hydrozoa (Portuguese man-of-war and
hydroids), Scyphozoa (the true jellyfish) or Cubozoa (the box jellyfish). Initially, the victim experiences a severe burning pain in skin that
comes in contact with the tentacles followed within minutes by a zigzag, whip-like pattern of raised red wheals 2-3 mm wide. Though
about 80% of cases are limited to skin manifestations, some have systemic effects including malaise, vomiting, dyspnea and tachycardia.
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Rove beetles of family Staphylinidae and genus Paederus contain a vesicant, pederin and produce lesions only when they are crushed on
the skin. A wheal forms at the sites followed by a blister within 12-24 h, which may be a linear "whiplash dermatitis."
Other pruritic dermatoses
Many other itchy dermatoses may present with linear marks simulating flagellate dermatitis . Dermatographism may produce a flagellate
pattern . Phytophotodermatitis and poison ivy dermatitis may cause flagellate lesions where the leaves have brushed the cutaneous
surface. Neurotic excoriations mimicking a flagellate pattern
Hypereosinophilic syndrome
Two men with HIV infection who had unusual cutaneous manifestations of hypereosinophilic syndrome, exfoliative erythroderma and
linear flagellate plaques.
Chikungunya fever induced flagellate pigmentation
Chikungunya fever commonly causes hyperpigmentation such as accentuation of melasma, pigmentation of nose, periorbital melanosis
and irregular and flagellate patterns on the trunk and extremities. It is primarily considered a post-inflammatory response with the
chikungunya virus probably triggering intraepidermal melanin dispersion or retention.
Idiopathic flagellate pigmentation
Pise et al., have reported a case with flagellate pigmentation without any systemic illness, pruritus or drug intake. The flagellate marks did
not follow the lines of Blaschko. It appears that rarely, flagellate pigmentation may be idiopathic; though the diagnosis should be one of
exclusion.
Public flogging of a slave in Rio de Janeiro, Brazil - work of French painter
Jean-Baptiste Debret (1768–1848).
Self-flagelation is ritually performed in the Philippines during Holy Week
(on Good Friday, before Easter).
Pain and the erotic
Postcard from the Krafft Ebing Collection. The Wellcome Library, London
'Lots of Noise from Such a
Little Box'
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A group of people engaged in a modern secular ritual called pulling
The Martyrdom of St. Barbara by Wilhelm Kalteysen von Aachen, a medieval
spectacle of ritual execution, reflecting sadomasochism's "polymorphis
fantasies" of pain,
Child abuse
Factitious dermatitis
Dermatitis artefacta is defined as the deliberate and conscious production of
self-inflicted skin lesions to satisfy an unconscious psychological or emotional
need. Patients with this condition require both dermatologic assessment and
psychosocial support.
Chemotherapy induced flagellate dermatitis
Bleomycin
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Bleomycin is a glycopeptide antitumor antibiotic and antiviral drug produced by
the bacterium Streptomyces verticillus. Bleomycin refers to a family of structurally
related compounds. When used as an anticancer agent, the chemotherapeutical
forms are primarily bleomycin A2 and B2. The drug is used in the treatment
of Hodgkin's lymphoma ,squamous cell carcinomas, and testicular cancer, as well as
in the treatment of plantar warts and as a means of effecting pleurodesis. The
mechanism of action involves breaking DNA strands.
Bleomycin is on the World Health Organization's List of Essential Medicines that are
needed for a basic health system
Peplomycin,
Peplomycin, a bleomycin-related cytostatic agent
Chemotherapy induced flagellate dermatitis
Docetaxel
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Docetaxel is a clinically well-established anti-mitotic chemotherapy medication that
works by interfering with cell division. Docetaxel is approved by the FDA for treatment
of locally advanced or metastatic breast cancer, head and neck cancer, gastric
cancer, hormone-refractory prostate cancer and non small-cell lung
cancer. Docetaxel can be used as a single agent or in combination with other
chemotherapeutic drugs as indicated depending on specific cancer type and stage.
Chemotherapy induced flagellate dermatitis
Bendamustine
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Bendamustine is a nitrogen mustard used in the treatment of chronic
lymphocytic leukemia and lymphomas. It belongs to the family of drugs
called alkylating agents.
Bleomycin induced flagellate dermatitis
Skin lesions due to bleomycin
Skin biopsy revealing an inflammatory dermal infiltration (arrow) suggesting
drug eruption.
Bleomycin induced flagellate dermatitis with linear erythematous streaks
involving the (a) upper back, (b) buttocks, (c) left arm, (d) right arm and (e) multiple
erythematous papules involving the interdigital clefts and dorsum of both
hands JCrT,2013 : 9 : 3 : 500
Acquired hyperpigmentations. Flagellate Dermatitis– Linear urticariform lesions, some
with a slight superficial blistering, located on the lateral side of the chest, which appeared
15 days after the initiation of treatment with bleomycin An. Bras. Dermatol.89 Rio de
Janeiro 2014
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Lesser known evil of a commonly used devilbleomycin induced flagellate dermatitis
• Bleomycin is a glycopeptide used in oncology as a
chemotherapeutic agent for Hodgkins disease, germ cell tumors,
and pleurodesis of malignant pleural effusions. Though the
pulmonary toxicity of bleomycin is well known, its cutaneous side
effects are uncommon. The cutaneous effects of bleomcyin range
from generalized hyperpigmentation, sclerodermoid changes,
erythema multiforme, gangrene, to flagellate dermatosis. First
reported in 1970, the incidence of bleomycin induced flagellate
dermatosis varies from 8 to 20%. The exact mechanism of
bleomycin induced flagellate dermatosis is unclear and is
hypothesized to be due to raised local levels of the drug in the
skin. This in turn is due to low levels of bleomycin hydrolase in the
skin. There is no specific treatment for bleomycin induced flagellate
dermatosis and the skin lesions are usually self-limiting.
Neurotic excoriations mimicking a flagellate pattern
Dermatographism in a flagellate pattern
Flagellate erythema
Flagellate erythema
Flagellate erythema
Dermatomyositis
Telangiectatic macules and papules on the breast in a patient with
longstanding disease
Acquired hyperpigmentations. Poikiloderma of Civatte. Note the grid-like
hyperpigmentation, affecting the lateral areas and base of the neck in a 51 years-old
phototype 3 woman. Observe photodamage lesions and a lighter area correspondings to
the region shaded by the chin An. Bras. Dermatol.89 Rio de Janeiro 2014
Adult-Onset Still’s Disease
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Adult-onset Still’s disease (often called AOSD) is a relatively rare condition. It begins with fever
and may lead to arthritis and a distinctive salmon-colored bumpy rash. Classified as an
inflammatory illness, the disease often causes fatigue and swelling in joints, tissues, organs, and
lymph nodes. the condition persists or recurs. In children, a similar condition exists called
juvenile idiopathic arthritis.
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Shiitake mushroom
Dermatol Alergol :Published online 2014 Jun 13.
Flagellate dermatitis after consumption of Shiitake mushrooms
Shiitake mushroom
An. Bras. Dermatol.
87 no.3 Rio de Janeiro , 2012
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Shiitake mushrooms (Lentinus edodes) (Figure 1), a woodland type of
mushrooms used in Japanese/Chinese cuisine, are the second-most
common edible mushrooms in the world. The precise number of tons
consumed per year is not known but is estimated in the 10,000-ton range
worldwide [1]. In addition to its culinary properties (Umami), an
antihypertensive effect, reduction of elevated cholesterol levels and an
anticarcinogenic property are known. For this reason, the Shiitake
mushroom plays a large role in traditional Asian medicine.
A severely-itching dermatitis (toxicoderma) following consumption of the
mushroom was first reported by Nakamura in 1977 [2]. Typically, 24–48 h
after eating raw or half-cooked Shiitake mushrooms, the patient developed
severely-itching, isolated or grouped papules or papulovesicles with striped,
infiltrated erythemas, which arose in a Köbner phenomenon due to stripelike scratching [3].
The preferred localizations of the dermatosis are the trunk, extremities and
the nape area, less often the face or hair-covered scalp [2]. No lifethreatening systemic reactions have been documented thus far. The usually
spontaneous regression of skin symptoms lasts from a few days to several
weeks
Parallel, striped whiplash-like infiltrated erythemas with severe itching on the trunk
Flagellate dermatitis after consumption of Shiitake mushrooms
Papulovesicles on urticarial erythemas on the right shoulder
Flagellate dermatitis after consumption of Shiitake mushrooms
Close-up view of parallel, striped whiplash-like infiltrated erythemas on the
trunk
Flagellate dermatitis after consumption of Shiitake mushrooms
Histopathology :severe edema of the Stratum papillare, mild focal (not
spreading) acute lymphocytic eczema reaction, superficial, cuff-shaped
perivascular lymphocytic infiltrate
Flagellate dermatitis after consumption of Shiitake mushrooms
Shiitake dermatitis
Shiitake dermatitis
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Shiitake dermatitis is due to lentinan which is found in shiitake mushrooms. This
substance is broken down by heat so the dermatitis only occurs following ingestion of
raw or lightly cooked shiitake mushrooms.Lentinan is well known for its health
benefits (eg, lowering blood pressure and serum cholesterol). In Japan, lentinan is
used therapeutically in cancer treatment and a flagellate dermatitis following such
treatment has been well documented.
Cnidaria
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Cnidaria is a phylum containing over 10,000 species of animals found exclusively in
aquatic and mostly marine environments. Their distinguishing feature is cnidocytes,
specialized cells that they use mainly for capturing prey. Their bodies consist
of mesoglea, a non-living jelly-like substance, sandwiched between two layers
of epithelium that are mostly one cell thick. They have two basic body forms:
swimming medusae and sessile polyps, both of which are radially symmetrical with
mouths surrounded by tentacles that bear cnidocytes. Both forms have a
single orifice and body cavity that are used for digestion and respiration, and some
have simple eyes. Not all cnidarians reproduce sexually. Many have complex
lifecycles with asexual polyp stages and sexual medusae, but some omit either the
polyp or the medusa stage.
Paederus
Aesthet Dermatol. 2011; 4(11): 44
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Paederus Dermatitis
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Paederus:
• it has given its name to paederus dermatitis, a
characteristic skin irritation that occurs if one of the
insects is crushed against skin.
Aesthet Dermatol. 2011; 4(11): 44
Paederus Dermatitis
Phytophotodermatitis
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Phytophotodermatitis (PPD) is a cutaneous phototoxic inflammatory eruption resulting
from contact with light-sensitizing botanical substances and long-wave ultraviolet (UVA 320-380 nm) radiation. The eruption usually begins approximately 24 hours after
exposure and peaks at 48-72 hours. The phototoxic result may be intensified by wet
skin, sweating, and heat
A 26-year-old female airline flight attendant exposed to lime
while serving drinks en route to the Caribbean. During the
Caribbean layover, she had significant sun exposure. The
combination of lime juice and sun exposure led to a drippattern blister formation on the dorsal forearm consistent with
phytophotodermatitis.
Phytophotodermatitis
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Phytophotodermatitis, also known as "Lime Disease" (not to be confused with Lyme
Disease), "Berloque dermatitis", or "Margarita photodermatitis" is a chemical reaction
which makes skin hypersensitive to ultraviolet light. It is frequently mistaken for
hereditary conditions such as atopic dermatitis or chemical burns, but it is caused by
contact with the photosensitizing compounds found naturally in some plants and
vegetables like parsnips, citrus fruits, and more. Symptoms can be burning, itching,
stinging, and large blisters that slowly accumulate over time
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Phytophotodermatitis
Plants that cause phytophotodermatitis
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Parasnip
Lime
•Wild carrot
Parsley
Poison Ivy Dermatitis
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"Leaves of three - let it be!" aptly describes this woody vine with 2-4" leaflets in groups of three.
The center leaf has a longer stem than the other two. Poison ivy clings to tree trunks and other
vertical surfaces with hair-like aerial rootlets that grow out of the stem. If a climbing surface isn't
available, poison ivy will grow as a free standing shrub. The leaves of poison ivy turn shades of
red and purple in fall.
Poison ivy is caused by an allergic reaction (allergic contact dermatitis) to the oily coating that
covers of these plants. The resinous coating is called "urushiol". These are called Rhus plants
after the old scientific name (it was changed to toxidendron). A person doesn't have to come in
direct contact with the leaves, roots, or branches of Rhus plants to get the rash. One can get it
from contaminated clothing. Even in winter the leafless stems and vines can cause the familiar
skin rash.
Dogs and other animals are not affected by poison ivy, but people can get the rash by petting a
dog that's been exposed.
The rash itself is not contagious, and the fluid in the blisters does not spread the rash. Poison ivy
dermatitis appears as soon as four hours or as long as 10 days after the exposure, depending on
individual sensitivity and the amount exposure. As the rash appears, any sensitivity a person had
begins to increase. One starts to react to the slightest traces of a few molecules on the skin. This
causes the rash to appear to be spreading, even after treatment has begun.
Poison ivy dermatitis rashes are self-limited; sooner or later they clear up without treatment.
Letting nature take its course with mild poison ivy dermatitis is reasonable, but severe rashes
need treatment to ease the misery and disability they cause. The very first time this rash is gotten,
it lasts longer than a repeat attack, often 3 or 4 weeks.
Poison Ivy Dermatitis
Hypereosinophilic syndrome
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The hypereosinophilic syndrome (HES) is a disease characterized by a
persistently elevated eosinophil count (≥ 1500 eosinophils/mm³) in the blood for at
least six months without any recognizable cause, with involvement of either
the heart, nervous system, or bone marrow.
HES is a diagnosis of exclusion, after clonal eosinophilia (such as leukemia) and
reactive eosinophilia (in response to infection, autoimmune disease,
atopy, hypoadrenalism, tropical eosinophilia, or cancer) have been ruled out.
If left untreated, HES is progressively fatal. It is treated with glucocorticoids such as
prednisone. The addition of the monoclonal antibody mepolizumab may reduce the
dose of glucocorticoids
Chikungunya fever
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Chikungunya virus is transmitted to people by mosquitoes. The most common symptoms of
chikungunya virus infection are fever and joint pain. Other symptoms may include headache,
muscle pain, joint swelling, or rash There is no vaccine to prevent or medicine to treat
chikungunya virus infection. Travelers can protect themselves by preventing mosquito bites. When
traveling to countries with chikungunya virus, use insect repellent, wear long sleeves and pants,
and stay in places with air conditioning or that use window and door screens
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Rash from chikungunya on the right foot
Chikungunya fever
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An A. aegypti mosquito biting a person
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Transmission electron micrograph of Chikungunya virus particles
Gordon, a whipped slave, photo taken at Baton Rouge, 1863. The
scars are clearly visible because of keloid formation
Whip
riding crop
A leather cat o'
nine tails
stockwhip
bullwhip
Whip
Longeing whip
signal whip
metal
whip