Poster Presentations

2021 Australasian Journal of Dermatology  
Pityriasis rubra pilaris (PRP) is a rare papulosquamous disorder characterized by erythroderma, orange-red keratoderma and islands of sparing. There are 6 subtypes based on morphology, with the majority being type I adult PRP. Some cases go into spontaneous remission after 2-3 years. As PRP is a rare condition, there are not RCTs assessing treatment efficacy with treatment recommendations based on case reports and small case series. Case: We report a case of treatment refractory PRP
more » ... g initial complete response to ustekinumab. This case adds to the literature supporting biologic therapy in the setting of treatment resistant PRP. A 70-year-old gentleman was referred to a tertiary hospital dermatology clinic for escalation of therapy in the setting of progressive erythroderma secondary to treatment refractory PRP. He was on 20 mg subcutaneous methotrexate at the time of presentation, having previously failed acitretin, ciclosporin and mycophenolate. Investigations for underlying malignancy, including CT-CAP were unremarkable. Screening investigations prior to biologic therapy revealed a positive Quantiferon gold. Accordingly, ustekinumab 45 mg was selected and commenced with concurrent isoniazid, in consultation with respiratory and infectious diseases teams. Tumour necrosis factor inhibitors (TNFi) were avoided due to the risk of reactivation of latent TB. Six months into treatment he has achieved complete clinical remission. Conclusion: While TNF antagonists have the greatest evidence base for treatment resistant PRP, this case adds to the body of literature supporting IL12/23i in the setting of PRP, in instances where TNFi need to be avoided due to risk of infectious complications. An underdiagnosed entity: papulonecrotic tuberculid Introduction: Papulonecrotic tuberculid is a rarely reported cutaneous manifestation of tuberculosis (TB). It is thought to occur due to immune reactions to M. tuberculosis or its antigens within the skin, in individuals with strong anti-tuberculous cell-mediated immunity. Case report: A 58-year-old otherwise well woman of Filipino descent was referred to dermatology with a 4-month history of tender ulcerated papules and nodules. Some lesions had central necrosis and pitted scarring. Her Mantoux test and Quantiferon gold were strongly positive. Vasculitis screening was unremarkable. Skin biopsies were collected for histopathology and microbiology (including mycobacterium culture, bacterial culture, fungal culture and mycobacterium PCR). The histopathology demonstrated ischaemic necrosis and a caseating granuloma suggestive of papulonecrotic tuberculid. A pan-CT scan showed granulomata of the spleen and pancreas, but no abnormality in the lungs was identified. The microbiology investigations were negative. With the clinical presentation and classical histopathology, a diagnosis of papulonecrotic tuberculid was made. The patient has been referred to infectious diseases for antituberculous treatment. Discussion: Only a portion of papulonecrotic tuberculid cases exhibit a confirmatory mycobacterial PCR. However, its classical clinical presentation with necrosis and scarring, histological findings of caseating granuloma, as well as its response to anti-tuberculous treatments reinforces its mycobacterial aetiology. This case represents a classical presentation of papulonecrotic tuberculid and raises awareness regarding the diagnostic pathway for the disease. Psoriasis treatment in a dermatology day unit: a clinical audit
doi:10.1111/ajd.13279 fatcat:5qpyympdlbhnfhvwgbw6vbcoau