Treatment of this condition is not generally successful.Various topical preparations have been used with variablesuccess, including topical steroids, calcineurin inhibitors,retinoids, and clindamycin. Oral contraceptives and oralisotretinoin3 have also been used, but none producedlong-lasing results, and lesions tend to recur once treat-ment is stopped. Physical therapies including electrocau-tery, liposuction-assisted curettage, and surgical excisioncan be done as a last option.

Fractional photothermolysis is a recently introducedtechnology in the field of ablative lasers. Fractional lasersproduce microscopic treatment zones (MTZ).4 The depthand width of MTZ increases with using higher energylevels. The percentage of area covered by fractional lasersis also variable, but leaving microscopic untreated areaswill speed healing and reduce down time and risk of com-plications.5

The use of fractional lasers in the treatment of Fox–Fordyce disease has not been described before, and to thebest of our knowledge, this is the first case report usingfractional CO2 laser treatment of this difficult-to-treatcondition.

In conclusion, we think that fractional CO2 lasermay be a treatment option for Fox–Fordyce diseasebased on the results we have seen in our patient, espe-cially for patients that have tried conventional treat-ments without good response. Of course this has to besubstantiated by further studies including a larger numberof patients.

Dr Firas Ahmed Al-Qarqaz, MSc, MD

Dr Rasha Al-Shannag, MD

Division of DermatologyDepartment of Internal MedicineKing Abdullah University HospitalJordan University of Science and Technology

IrbidJordan

Dr Firas Ahmed Al-Qarqaz, MSc, MD

Division of DermatologyDepartment of Internal MedicineKing Abdullah University Hospital22110 IrbidJordanE-mail: fqarqaz@just.edu.jo

Conflict of interest: none.Funding sources: none.

References

1 Kamada A, Saga K, Jimbow K. Apoeccrine sweat ductobstruction as a cause for Fox-Fordyce disease. J Am Acad

Dermatol 2003; 48: 453–455.2 Bormate AB Jr, Leboit PE, McCalmont TH. Perifollicular

xanthomatosis as the hallmark of axillary Fox-Fordycedisease: an evaluation of histopathologic features of 7cases. Arch Dermatol 2008; 144: 1020–1024.

3 Effendy I, Ossowski B, Happle R. Fox-Fordyce disease ina male patient – response to oral retinoid treatment. Clin

Exp Dermatol 1994; 19: 67–69.4 Manstein D, Herron GS, Sink RK, et al. Fractional

photothermolysis: a new concept for cutaneous remodelingusing microscopic patterns of thermal injury. Lasers Surg

Med 2004; 34: 426–438.5 Manuskiatti W, Triwongwaranat D, Varothai S, et al.

Efficacy and safety of a carbon-dioxide ablativefractional resurfacing device for treatment of atrophicacne scars in Asians. J Am Acad Dermatol 2010; 63:274–283.

A very rare side effect of mitomycin-C: psoriasiform drug

eruption

Psoriasiform eruption associated with drugs is extremelyrare and creates a clinical and histopathological manifes-tation resembling that of idiopathic psoriasis. It has beencommonly described as erythematous, thick, dry, silver-colored squamous and demarcated plaques.1–3 Manydrugs, including sorafenib, anti-tumor necrosis factoralpha, carbamazepine, and sodium valproate, have beenreported to induce psoriasiform drug eruption.4–8

Drugs may either aggravate the present psoriasis lesionsor may induce them de novo. For instance, lithium andbeta-blockers cause de novo lesions, while antimalarialslead to the aggravation of present lesions. Some drugsmay both induce and aggravate lesions.4 The duration of

time that lapses between the intake of drug and onset oferuption was reported to be longer than one month insome cases and more than three months in others.3

A 62-year-old female patient who was being followedin the oncology clinic for metastatic breast carcinomapresented at our clinic due to red, itchy, and scaly lesionsstarting from the left hand and extending to the elbow.Anamnesis of the patient showed that she had been diag-nosed with metastatic breast carcinoma two years previ-ously, undergone radical mastectomy, and received sixcures of mitomycin-C and navelbine treatment. The treat-ment of navelbine of 25 mg/m2/d was applied to thepatient at the first and eighth days of the treatment,which was once in 21 days. Mitomycin 12 mg/m2/d wasapplied only the first day of treatment. Dermatological

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1572 Correspondence

complaints of the patient had started about 10 days afterreceiving the fifth cure of therapy.

Dermatological examination of the patient showedplaques containing white scales on an erythematous base,starting from the left hand and extending towards theleft elbow. A week later, lesions scattered throughout thepatient’s body, involving the entire trunk and extremities(Fig. 1). According to laboratory examinations including

whole blood count and blood biochemical values, leuko-cyte was 11.200/mm2 (4.6–10.2/mm2); hemoglobin,10.5 g/dl (12.2–18.1 g/dl); total protein, 5.7 g/dl (6.6–8.7 g/dl); albumin, 2.3 g/dl (3.5–5.3 g/dl); and AST,78 U/l (5–40 U/l). Other laboratory analysis results ofthe patient were normal. Histopathological examinationof the lesion biopsy from the left leg of the patientrevealed hyperkeratosis, parakeratosis, loss of granular

(a) (b)

Figure 1 (a) Plaques containing white silver-colored scales on an erythematous base on the front of the trunk. (b) Plaquescontaining white silver-colored scales on an erythematous base on bilateral lower extremities

(b)(a)

Figure 2 (a) Hyperkeratosis, parakeratosis, absence of granular layer, spongiosis and psoriasiform hyperplasia on the epidermis(HE ·100). (b) Occasional lymphocytic and eosinophilic infiltration on the superficial dermis (HE · 400)

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1573Correspondence

layer, spongiosis, psoriasiform hyperplasia on the epider-mis, and occasional lymphocytic infiltration on thesuperficial dermis, which were found consistent withpsoriasiform drug eruption (Fig. 2). On the basis ofthese clinical and histopathological signs, the patient wasdiagnosed with psoriasiform drug eruption induced bymitomycin-C. The patient, who was put on corticoster-oids and moisturizer, showed marked clinical improve-ment after one month.

Our case did not have psoriasis history. Lesions devel-oped de novo due to mitomycin-C. Lesions appeared asplaque-type psoriasis, which contained white scales onan erythematous base. However, the initially acrallocalization of the lesions and the patient’s history ofmalignity suggested Bazex syndrome (acrokeratosisparaneoplastica). Bazex syndrome involves the ears,nails, nose, and palmoplantar area in particular.9 In ourcase, although the lesions started on the hands, otheracral areas like the ears and nose were not involved,and the lesions scattered all through the patient’sbody and covered the trunk and the extremities one -week later.

The histopathology of psoriasiform drug eruptionclosely resembles that of idiopathic psoriasis as well. Pso-riasiform hyperplasia and loss of granular layer on theepidermis and neutrophils in parakeratosis may beobserved in the psoriasiform eruption just as in the idio-pathic psoriasis. However, the former can be distin-guished from the latter by suprapapillary thinning,absence of corrugated capillaries among dermal capillar-ies, and the accompaniment of perivascular eosinophils.2

The histopathological examination of our case was con-sistent with psoriasiform eruption.

We could not find any data about psoriasiform drugeruption associated with navelbine in the literature.A case of massive psoriasiform dermatitis secondary tointravesical mitomycin-C application was reported inSpanish literature.10 So we have agreed that ourcases might be associated more strongly with mito-mycin.

In conclusion, drugs that are used for long periods oftime like mitomycin-C may also cause, though rarely,psoriasiform drug eruption, which closely resembles idio-pathic psoriasis both clinically and histopathologically.

Demet Cicek1, MD

Bengu Cobanoglu2, MD

Rahime I_nci1, MD

Selma Bakar Dertlioglu3, MD

Ibrahim Kokcam1, MD

Tamer Elkiran4, MD

1Firat University Faculty of Medicine Department ofDermatology Elazig, Turkey, 2Firat University Facultyof Medicine Department of Pathology Elazig, Turkey,3Harran University Faculty of Medicine Department ofDermatology Sanliurfa, Turkey, and 4Firat UniversityFaculty of Medicine Department of Oncology Elazig,Turkey

Dr D. Cicek, MD

Firat University Faculty of MedicineDepartment of DermatologyTR23119Elazig-TurkeyE-mail: dr.demetcicek@hotmail.com

References

1 Tsankov N, Angelova I, Kazandjieva J. Drug-inducedpsoriasis. Recognition and management. Am J Clin

Dermatol 2000; 3: 159–165.2 Justiniano H, Berlingeri-Ramos AC, Sánchez JL. Pattern

analysis of drug-induced skin diseases. Am J

Dermatopathol 2008; 30: 352–369.3 Crowson AN, Brown TJ, Magro CM. Progress in the

understanding of the pathology and pathogenesis ofcutaneous drug eruptions. Am J Clin Dermatol 2003; 4:407–428.

4 Wolfe JT, Singh A, Lessin SR, et al. De novo developmentof psoriatic plaques in patients receiving interferon alfafor treatment of erythrodermic cutaneous T-celllymphoma. J Am Acad Dermatol 1995; 32: 887–893.

5 Diamantis ML, Chon SY. Sorafenib-induced psoriasiformeruption in a patient with metastatic thyroid carcinoma.J Drugs Dermatol 2010; 9: 169–171.

6 Pirard D, Arco D, Debrouckere V, et al. Anti-tumornecrosis factor alpha induced psoriasiform eruptions:three further cases and current overview. Dermatology

2006; 213: 182–186.7 Sfikakis PP, Iliopoulos A, Elezoglou A, et al. Psoriasis

induced by antitumor necrosis factor therapy: aparadoxical adverse reaction. Arthritis Rheum 2005; 52:2513–2518.

8 Brenner S, Golan H, Lerman Y. Psoriasiform eruptionand anticonvulsant drugs. Acta Derm Venereol 2000; 80:382.

9 Valdivielso M, Longo I, Suárez R, et al. Acrokeratosisparaneoplastica (Bazex syndrome). J Eur Acad Dermatol

Venereol 2005; 19: 340–344.10 Arrizabalaga M, Casanueva T, Benítez J, et al. Massive

secondary psoriasiform dermatitis secondary tointravesical administration of mitomycin C. Arch Esp

Urol 1989; 42: 670–672.

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