Letters to the Editor e247

asthenia (n = 3), headache (n = 1) and tinnitus (n = 1) in the
methotrexate group. Cheilitis (n = 2), dyslipidaemia (n = 2),
gastric intolerance (n = 2), xerophthalmia (n = 1) and itch
(n = 1) were observed in patients receiving acitretin. One
patient receiving acitretin and 2 patients treated with methotrex-
ate discontinued the treatment because of adverse events. The
major finding of the study is that low dose acitretin and
methotrexate have similar efficacy in the treatment of PP at
6 months and is associated with a high retention rate and a lim-
ited number of adverse events. Limitations of our study include
its retrospective, unblinded design and the limited sample size.
P. Gisondi,* A. Mattiucci, B. Tonin, G. Girolomoni
Department of Medicine, Section of Dermatology, University of Verona,
Verona, Italy
*Correspondence: P. Gisondi. E-mail: paolo.gisondi@univr.it
admission, the central part of the skin of the face, forehead, nose
and cheeks, was affected by fleshy erythema with numerous fresh
pustules with thin lid and single scabs arising after the evacua-
tion of purulent content. No blackheads were found (Fig. 1).
Since June, infiltrated erythematous lesions have occurred
within the skin of the scalp. In July, the eruptions spread to the
forehead, nose and cheeks. Moreover, very painful and easily
bursting inflammatory pustules erupted on the whole face. At
that time, the patient received adapalene and clindamycin with
benzoyl peroxide topical treatment. Due to lack of clinical
improvement, 300 mg of limecycline daily was added. Complete
resolution of skin lesions was observed; however, treatment was
discontinued due to the occurrence of bowel comorbidity.
Patient was treated with 2000 mg of mesalazine per day,

References
1 Adisen E, Tekin O, G€ ulekon A, G€urer MA. A retrospective analysis of treat-
ment responses of palmoplantar psoriasis in 114 patients. J Eur Acad Der-
matol Venereol 2009; 23: 814–819.
2 Kumar B, Saraswat A, Kaur I. Palmoplantar lesions in psoriasis: a study of
3065 patients. Acta Derm Venereol 2002; 82: 192–195.
3 Engin B, Askın O,€ T€uz€
un Y. Palmoplantar psoriasis. Clin Dermatol 2017;
35: 19–27.
4 Splus PI, Hadi S, Rivera L, Lebwohl M. Retrospective analysis of the treat-
ment of psoriasis of the palms and soles. J Dermatolog Treat 2003; 14: 21–
25.
5 Janagond AB, Kanwar AJ, Handa S. Efficacy and safety of systemic
methotrexate vs. acitretin in psoriasis patients with significant palmoplan-
tar involvement: a prospective, randomized study. J Eur Acad Dermatol
Venereol 2013; 27: e384–e389.
6 Bissonnette R, Pariser DM, Wasel NR et al. Apremilast, an oral phosphodi-
esterase-4 inhibitor, in the treatment of palmoplantar psoriasis: Results of
a pooled analysis from phase II PSOR-005 and phase III Efficacy and Safety
Trial Evaluating the Effects of apremilast in psoriasis (ESTEEM) clinical Figure 1 Skin lesions (erythema, pustules) of our patient which
trials in patients with moderate to severe psoriasis. J Am Acad Dermatol
are present at the beginning of therapy in Clinic (December 2017).
2016; 75: 99–105.

DOI: 10.1111/jdv.15518

Rosacea fulminans –
coincidence of the disease with
inflammatory bowel disease
Editor
Rosacea fulminans is characterized by indurated erythematous
plaques, papules, pustules, nodules, typically occurring on the
face.1 Forehead, nasal bridge, cheeks and chin are most severely
affected. Scarring is unfortunately very common and expected
often in poorly managed patients.2
We present a case of 48-year-old male patient was admitted to
Figure 2 Skin condition at the follow-up in Clinic in April 2017.
our Clinic with erythematous skin lesions within the face. At the

JEADV 2019, 33, e230–e251 © 2019 European Academy of Dermatology and Venereology

e248
budesonide 9 mg every three days due to colitis ulcerosa diag-
nosed in October 2017.
Laboratory tests performed during hospitalization revealed
increased parameters of inflammation: OB 61, CRP 62.87, WBC
13.55, basophils 10.74, however negative procalcitonin.
Gastroenterological consultation confirmed remission of the
underlying disease; however, increasing doses of medication to
3000 mg mesalazine and budesonide to 9 mg per day was rec-
ommended. It was indicated that the treatment with doxycycline
or isotretinoin should not affect the condition of the intestinal
disease.
The patient was diagnosed with rosacea fulminans, based on
the typical course of the disease and characteristic clinical pic-
ture, as well as described in literature co-occurrence of AF with
inflammatory diseases of the intestines.3–7
CRP decreased to 54.93 mg/L in control tests. Patient in good
general condition was discharged home. He was prescribed
doxycycline oral treatment in dose 100 mg twice a day.
As a topical treatment, ivermectin cream was prescribed to be
used locally on the face and on the eyelid in the morning and
0.3% adapalene with 2.5% benzoyl peroxide gel only on the face
for the night. Initially, the gel was advised to be used every other
day interchangeably with ichthyol paste and after about one
week to be used every day.
At follow-up in April, complete recovery was observed
(Fig. 2), and after a month-long break, further treatment with
isotretinoin in dose 40 mg once a day was implemented.
RF is the only indication for use of corticosteroids in the man-
agement of rosacea. Treatment usually begins with short course
oral and topical corticosteroids followed by oral isotretinoin as
the corticosteroid is withdrawn gradually. The highest aim is to
reduce inflammation at first place. Once the disease is handled,
it does not reoccur.8
RF should be suspected in patients presenting with an abrupt
onset of erythematous facial lesions of unknown etiology that
spare the trunk and lack comedones, especially common in
female patients aged 20–30 years old. We highly advise to
exclude RF, when diagnosing patients with inflammatory bowel
disease as a comorbidity, as there are reports stating simultane-
ous co-existence of those two diseases.
In those cases, antimicrobial agents combined with oral pred-
nisone are an effective treatment for stabilizing the patient and
preventing debilitating scarring.9
The majority of the patients are negatively affected by poor
cosmetic treatment outcome, such as keloids. Therefore, the dis-
ease should be properly diagnosed and adequate measures
should be undertaken to treat it.

ska-Rybak, D. Mehrholz, J. Nowicki
M. Nowak,* W. Baran
Clinic of Dermatology, Venereology and Allergology, Medical University of
Gdansk, ul.Kaczencowa 31, Gdynia 81-575, Poland
*Correspondence: M. Nowak. E-mail: mcela94@gmail.com
JEADV 2019, 33, e230–e251
14683083, 2019, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jdv.15520 by UNISINOS - UNIVERSIDADE DO VALE DO RIO DOS SINOS, Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Letters to the Editor
References
1 Plewig G, Jansen T, Kligman AM. Pyoderma faciale a review and report of
20 additional cases: is it rosacea? Arch Dermatol 1992; 128: 1611–1617.
2 Firooz A, Firoozabadi MR, Dowlati Y. Rosacea fulminans (pyoderma
faciale): successful treatment of a 3-year-old girl with oral isotretinoin. Int
J Dermatol 2001; 40: 203–205.
3 Wakabayashi M, Fujimoto N, Uenishi T, Danno K, Tanaka T. A case
of acne fulminans in a patient with ulcerative colitis successfully treated
with prednisolone and diaminodiphenylsulfone: a literature review of
acne fulminans, rosacea fulminans and neutrophilic dermatoses occur-
ring in the setting of inflammatory bowel disease. Dermatology 2011;
222: 231–235.
4 McAuley D, Miller RA. Acne fulminans associated with inflammatory
bowel disease: report of a case. Arch Dermatol 1985; 121: 91–93.
5 Jansen T, Plewig G. Fulminating rosacea conglobata (rosacea fulminans)
and ulcerative colitis [6]. Br J Dermatol 1997; 137: 830–831.
6 Gatzka M, Simon M, Schuler G, L€ uftl M. Rosacea fulminans, pyostom-
atitis und pyovulvitis bei morbus Crohn: Dapson als entscheidender
wirkstoff einer erfolgreichen kombinationstherapie? Hautarzt 2006; 57:
898–902.
7 Simental-Lara F, Ponce-Olivera RM. Rosacea fulminans in a patient with
ulcerative colitis. Dermatologia Revista Mexicana 2014; 58: 471–475.
8 Jansen T, Plewig G, Kligman AM. Diagnosis and treatment of rosacea ful-
minans. Dermatology 1994; 188: 251–254.
9 Lages RB, Bona SH, Silva FV, Gomes AKL, Campelo V. Acne fulminans
successfully treated with prednisone and dapsone. An Bras Dermatol 2012;
87: 612–614.
DOI: 10.1111/jdv.15520
Virulent Staphylococcus
lugdunensis with limited genetic
diversity in hidradenitis
suppurativa lesions
To the Editor,
Hidradenitis suppurativa (HS) is an inflammatory skin dis-
ease characterized by recurring painful, deep-seated inflamma-
tory nodules, abscesses, sinus tracts and scarring in the
intertriginous areas.1 Bacteria may be involved in the pathogene-
sis of HS via follicular dysbiosis in the initial stages and via bio-
film in chronic sinus tracts.2 Staphylococcus lugdunensis, a
coagulase-negative staphylococcus (CNS), has been cultured
from hidradenitis suppurativa nodules and abscesses. This
points towards a role of S. lugdunensis in the aggravation and
secondary colonization of HS lesions.3,4 Staphylococcus
lugdunensis has also been associated with biofilm-driven infec-
tions in different tissues.5 Therefore, we compared the in vitro
growth, antibiotic susceptibility and biofilm-forming capabilities
of S. lugdunensis strains from HS lesions with those of healthy
controls and a reference strain.
This study has been approved by the ethical board and the
data protection agency of Denmark. Informed consent was
© 2019 European Academy of Dermatology and Venereology