Chloracne with acantholytic dyskeratosis associated with herbicides: a new histological variant?
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Chloracne with acantholytic dyskeratosis associated with herbicides: A new histological variant? To the Editor: Chloracne was first identified by Herx- heimer 1 in 1889. It is characterized by noninflamma- tory keratinization of pilosebaceous units with come- dones and dilated infundibulum after exposure to aromatic chlorinated hydrocarbons of various struc- tures. 2 However, no report has been issued on chlor- acne showing Darier-like changes. We report an un- usual case of chloracne associated with herbicides in the Vietnam War, which showed typical noninflammatory comedones and Darier-like changes, ie, acantholytic dys- keratosis and corps ronds. A 56-year-old Korean man was referred to the Department of Dermatology, Yonsei University Col- lege of Medicine, complaining of multiple black- head comedones on the scalp, preauricular and ret- roauricular areas, chest, and back over a 10-year period. He had been exposed to herbicides during the Vietnam War and has not been exposed to other comedogenic agents such as oil, tars, waxes, and halogenated phenols. His familial and occupational histories were not contributory. A physical examina- tion revealed multiple, 3-5 mm comedones filled with keratotic plugs (Fig 1). His hair, nails, and mucous membranes were normal. The histology of 5 biopsy specimens from papules on the scalp, preau- ricular and retroauricular areas, chest, and back showed the similar feature of a cup-shaped, dilated hair follicle with a central keratotic plug (Fig 2, A). In the lower part of the follicular wall, split at a supra- basal level with upward projection of the dermal papilla, so-called villi and acantholytic cells, and a large number of corps ronds were observed. In the lower dermis, there were sparse inflammatory cells (Fig 2, B). Many treatment methods had been tried in other clinics, including acne extraction and various kinds of topical and systemic acne medications (in- cluding antibiotics and retinoids). However, no im- provement had occurred and he refused further treatment. Chloracne caused by herbicides can be diag- nosed after considering the following points 3 : 1. A history of exposure to herbicides 2. Typical acneiform eruption and predilection sites: preauricular and retroauricular areas, scrotum, and involvement of the meibomian glands 3. Histological features: noninflammatory come- done and dilated infundibulum of the pilose- baceous unit 4. No response to conventional acne treatment Acantholytic dyskeratosis is a typical finding in Darier’s disease, but it is also found in a variety of clinical conditions such as warty dyskeratoma, tran- sient acantholytic dermatosis, and familial dyskeratotic comedones. Hayakawa and Nagashima 4 reported a 72-year-old patient who developed comedonal pap- ules on the scalp, which showed acantholytic dysker- atosis, and Nakagawa et al 5 also reported comedo-like acantholytic dyskeratosis of the face and scalp. There- fore, we consider that chloracne related to herbicide exposure may show acantholytic dyskeratosis, but the mechanism of acantholytic dyskeratosis is unclear. Sanghoon Lee, MD a Sang Gun Park, MD b Min-Geol Lee, MD, PhD b Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, a and Department of Dermatology and Cutaneous Biology Research Institute, b Yonsei University College of Medicine, BK21 Project for Medical Science, Yonsei University, Seoul, Korea Reprint requests: Min-Geol Lee, MD, PhD, Department of Dermatology, Yonsei University College of Medicine, 134 Shinchon-Dong, Seodaemoon-Gu, Seoul 120-752, Korea E-mail: mglee@yumc. yonsei.ac.kr REFERENCES 1. Herxheimer K. Uber Chlorakne. Munch Med Wochenschr 1899; 46:278. 2. Coenraads PJ, Brouwer A, Olie K, Tang N. Chloracne. Some recent issues. Dermatol Clin 1994;12:569-76. 3. Tindall JP. Chloracne and chloracnegens. J Am Acad Dermatol 1985;13:539-58. 4. Hayakawa K, Nagashima M. A rare presentation of acantholytic dyskeratosis. Br J Dermatol 1995;133:487-9. 5. Nakagawa T, Masada M, Moriue T, Takaiwa T. Comedo-like dys- keratosis of the face and scalp: a new entity? Br J Dermatol 2000; 142:1047-8. Published online J Am Acad Dermatol 2004;50:e8 0190-9622/$30.00 © 2004 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2003.09.029 JAM ACAD DERMATOL APRIL 2004 1
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Transcript of Chloracne with acantholytic dyskeratosis associated with herbicides: a new histological variant?
Chloracne with acantholytic dyskeratosisassociated with herbicides: A new histologicalvariant?
To the Editor: Chloracne was first identified by Herx-heimer1 in 1889. It is characterized by noninflamma-tory keratinization of pilosebaceous units with come-dones and dilated infundibulum after exposure toaromatic chlorinated hydrocarbons of various struc-tures.2 However, no report has been issued on chlor-acne showing Darier-like changes. We report an un-usual case of chloracne associated with herbicides in theVietnam War, which showed typical noninflammatorycomedones and Darier-like changes, ie, acantholytic dys-keratosis and corps ronds.
A 56-year-old Korean man was referred to theDepartment of Dermatology, Yonsei University Col-lege of Medicine, complaining of multiple black-head comedones on the scalp, preauricular and ret-roauricular areas, chest, and back over a 10-yearperiod. He had been exposed to herbicides duringthe Vietnam War and has not been exposed to othercomedogenic agents such as oil, tars, waxes, andhalogenated phenols. His familial and occupationalhistories were not contributory. A physical examina-tion revealed multiple, 3-5 mm comedones filledwith keratotic plugs (Fig 1). His hair, nails, andmucous membranes were normal. The histology of 5biopsy specimens from papules on the scalp, preau-ricular and retroauricular areas, chest, and backshowed the similar feature of a cup-shaped, dilatedhair follicle with a central keratotic plug (Fig 2, A). Inthe lower part of the follicular wall, split at a supra-basal level with upward projection of the dermalpapilla, so-called villi and acantholytic cells, and alarge number of corps ronds were observed. In thelower dermis, there were sparse inflammatory cells(Fig 2, B). Many treatment methods had been tried inother clinics, including acne extraction and variouskinds of topical and systemic acne medications (in-cluding antibiotics and retinoids). However, no im-provement had occurred and he refused furthertreatment.
Chloracne caused by herbicides can be diag-nosed after considering the following points3:
1. A history of exposure to herbicides2. Typical acneiform eruption and predilection
sites: preauricular and retroauricular areas,scrotum, and involvement of the meibomianglands
J AM ACAD DERMATOL
3. Histological features: noninflammatory come-done and dilated infundibulum of the pilose-baceous unit
4. No response to conventional acne treatmentAcantholytic dyskeratosis is a typical finding in
Darier’s disease, but it is also found in a variety ofclinical conditions such as warty dyskeratoma, tran-sient acantholytic dermatosis, and familial dyskeratoticcomedones. Hayakawa and Nagashima4 reported a72-year-old patient who developed comedonal pap-ules on the scalp, which showed acantholytic dysker-atosis, and Nakagawa et al5 also reported comedo-likeacantholytic dyskeratosis of the face and scalp. There-fore, we consider that chloracne related to herbicideexposure may show acantholytic dyskeratosis, but themechanism of acantholytic dyskeratosis is unclear.
Sanghoon Lee, MDa
Sang Gun Park, MDb
Min-Geol Lee, MD, PhDb
Department of Dermatology, Yonsei UniversityWonju College of Medicine, Wonju,a and
Department of Dermatology andCutaneous Biology Research Institute,b
Yonsei University College of Medicine,BK21 Project for Medical Science,
Yonsei University, Seoul,Korea
Reprint requests: Min-Geol Lee, MD, PhD,Department of Dermatology, Yonsei University
College of Medicine, 134 Shinchon-Dong,Seodaemoon-Gu, Seoul 120-752, Korea
E-mail: mglee@yumc. yonsei.ac.kr
REFERENCES1. Herxheimer K. Uber Chlorakne. Munch Med Wochenschr 1899;
46:278.2. Coenraads PJ, Brouwer A, Olie K, Tang N. Chloracne. Some recent
issues. Dermatol Clin 1994;12:569-76.3. Tindall JP. Chloracne and chloracnegens. J Am Acad Dermatol
1985;13:539-58.4. Hayakawa K, Nagashima M. A rare presentation of acantholytic
dyskeratosis. Br J Dermatol 1995;133:487-9.5. Nakagawa T, Masada M, Moriue T, Takaiwa T. Comedo-like dys-
keratosis of the face and scalp: a new entity? Br J Dermatol 2000;142:1047-8.
Published online
J Am Acad Dermatol 2004;50:e80190-9622/$30.00
© 2004 by the American Academy of Dermatology, Inc.doi:10.1016/j.jaad.2003.09.029
APRIL 2004 1
2 J AM ACAD DERMATOL
APRIL 2004
Fig 1. Scattered skin-colored, keratotic papules on the malar crescent, scalp (A) and postau-ricular area (B).
Fig 2. A, Biopsy specimens from the comedonal papules of the scalp, face, and back havesimilar features, showing deep epidermal invagination with a large central keratotic plug andrare inflammatory cell infiltrate in the dermis. B, Acantholytic epidermal cell separation isshown with upward projection of dermal papillae at a suprabasal level, and a large number ofcorps ronds are present above the split. (A and B, Hematoxylin-eosin stain; original magnifi-cations: A, �40; B, �100.)
