Correspondence e209

(a) (c)

(b) (d)

Figure 1 (a, b) Baseline and follow-up dermatoscopic images of Case 2. (a) Dermatoscopic examination showed triangular-
shaped light brown spiral LM that had dark brown color proximally. (b) Follow-up, 12 months later, the color had darkened,
LM enlarged the spiral shape now being limited to the edges, with disappearance of the triangular shape. (c, d) Baseline and
follow-up dermatoscopic images of Case 4. (c) Dermatoscopic examination revealed two thick black bands of LM on a brown
background and spiral melanonychia on the ulnar side and distal half of the LM. Also, gray color is visible on the proximal
margin of the nail. (d) Follow-up, 12 months later, the spiral shape moved on to the proximal half of the LM, overall color had
slightly faded, but gray color is still visible on the proximal margin of the nail

the increase in melanocytes in the region of the nevus, moving
back and forth laterally in the nail matrix; or dendritic processes on
melanocytes, which are advancing and retreating periodically.
In our series, all cases were followed up for 1 year. It was
observed that the color of the LM faded especially in patients
whose spiral LM has resolved (Cases 1 and 3). It is quite com-
mon to observe a gradual fading of the band with age. This is
generally unique in children with nail matrix nevus, which may
indicate decreased melanocytic activity from nevus cells. LM
enlarged slightly and darkened only in Case 2, whose spiral LM
has not resolved.
In conclusion, spiral LM, which has not been described
previously in the literature, does not appear to represent a
warning sign of a nail matrix melanoma and in our series was
much more common during childhood. This, combined with the
observation that it appears to resolve over time, makes nail
matrix nevus the likely diagnosis.
Acknowledgment
None.
This report was awarded the first poster presentation prize at
28th Turkish National Dermatology Congress in 2019.
Conflict of interest: None.
Funding source: None.
doi: 10.1111/ijd.14801
References
1 Starace M, Alessandrini A, Brandi N, et al. Use of nail
dermoscopy in the management of melanonychia: review.
Dermatol Pract Concept 2019; 9: 38–43.
2 Lencastre A, Lamas A, Sa  D, et al. Onychoscopy. Clin Dermatol
2013; 31: 587–593.
3 Goettmann-Bonvallott S, Andre
J, Belaich S. Longitudinal
melanonychia in children: a clinical and histopathologic study of
40 cases. J Am Acad Dermatol 1999; 41: 17–22.
4 Tosti A, Piraccini BM, Cagalli A, et al. In situ melanoma of the
nail unit in children: report of two cases in fair-skinned Caucasian
children. Pediatr Dermatol 2012; 29: 79–83.
5 Darmawan CC, Jo G, Montenegro SE, et al. Early detection of
acral melanoma: a review of clinical, dermoscopic,
histopathologic, and molecular characteristics. J Am Acad
Dermatol 2019; 81: 805–812.

1 Zika, chikungunya, and dengue infections as

Bengu Nisa Akay *, MD
exacerbating factors of psoriasis in patients receiving
Canan Ari 1, MD
2,3 biological therapy
Simon P. Clark , MB, ChB, FRCPA
Dear Editor,
1
Department of Dermatology, Faculty of Medicine, Ankara Psoriasis, a chronic, immune-mediated, inflammatory skin
University, Ankara, Turkey disease, presents a wide clinical spectrum. Among potential
2
DHM Pathology, Macquarie Park, NSW, Australia triggers of psoriasis, infections have been receiving growing
3
Tehran University of Medical Sciences, Tehran, Iran attention.1–3 Owing to the increase in international travel,
*E-mail: nisaakay15@yahoo.com immigration, and ongoing climate changes, some previously

ª 2020 the International Society of Dermatology International Journal of Dermatology 2020, 59, e195–e224

e210 Correspondence
uncommon infections are now spreading worldwide.4 Zika,
chikungunya, and dengue are arboviruses that have been
shown to exacerbate psoriasis.1–3 Numerous biological drugs
have been found to be beneficial for the management of pso-
riasis; however, some concerns about the risk of infections
and potential interference with trigger factors have raised
debate.5 In particular, the relationship between arbovirus
infections and worsening of psoriasis in patients receiving bio-
logical therapy has not yet been elucidated. In this study, we
investigated whether arbovirus infections might affect the clini-
cal presentation of psoriasis in patients receiving biological
therapy.
We performed a retrospective cohort study, including con-
secutive patients with psoriasis receiving biological therapy,
who were regularly followed by a single senior dermatologist
(LA-A), between 2016 and 2018. All included patients were
actively screened for arbovirus infections during the study per-
iod. Demographic, therapeutic, and clinical outcome (no interfer-
ence with or exacerbation of psoriasis and need for biological
suspension) data were collected from medical records and inter-
views with all the included patients. Patients with incomplete
medical records or follow-up (<12 months) were excluded. The
independent t-test, v2 test, and Spearman correlation test were
used for statistical analyses. A value of P < 0.05 was consid-
ered statistically significant.
Fifty-six patients with psoriasis (vulgar type, 67.9%;
52.2  13.8 years; females, 51%; and body mass index [BMI],
29.5  5 kg/m2) receiving biological therapy (adalimumab,
36.5%) met the inclusion criteria. The time since the diagnosis
of psoriasis to receiving biological therapy was 231  108 and
77  44 months, respectively.
Figure 1 Clinical presentation of a 74-year-old male receiving biological therapy (infliximab) with worsening of psoriasis due
to Zika infection. (a) Patient’s chest, abdomen, and (b) back, with generalized erythematous scaly plaques
International Journal of Dermatology 2020, 59, e195–e224
13654632, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/ijd.14785 by UNIVERSIDAD NACIONAL DEL COMAHUE UNCOMA, Wiley Online Library on [11/04/2024]. 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
Most patients (all P < 0.001) had no family history of psori-
asis (96.4%) and no history of smoking (94.6%), alcoholism
(92.9%), or arbovirus infections (89.3%). Six patients (10.7%)
presented with confirmed arbovirus infection. There were no
significant (all P > 0.05) differences in the gender, combined
use of biological drugs and immunosuppressants, and the pres-
ence of comorbidities.
Most patients (92.9%, P < 0.001) showed no exacerbation
of psoriasis during follow-up, with four patients experiencing
worsening of psoriasis symptoms during the study period. The
presence of arbovirus infections significantly correlated with the
exacerbation of psoriasis (P < 0.01; Spearman’s rank correlation
coefficient = 0.21; Fig. 1; Table 1). All the other tested parame-
ters (age, gender, race, BMI, type of psoriasis, type of biological
drug, time of diagnosis of psoriasis, time of starting the biological
therapy, family history, alcoholism, smoking, comorbidities, and
concomitant use of immunosuppressants) did not significantly
affect psoriasis exacerbation (all P > 0.05, Table 1; Spearman’s
rank correlation coefficients = 0.35 to 0.59). Three patients
(75%) with arbovirus infection and psoriasis exacerbation were
managed conservatively without discontinuing biological therapy.
The results of this study suggested that arbovirus infec-
tions were significantly associated with psoriasis exacerbation.
Understanding whether dengue, Zika, or chikungunya infections
can worsen psoriasis in patients receiving biological therapy is
of great importance to help implement suitable preventive mea-
sures. Moreover, these patients require regular and standard-
ized follow-up to allow prompt diagnosis and intervention if
psoriasis exacerbation occurs during arbovirus infections. This
study does not answer all the questions on this topic. However,
it provides a data-driven hypothesis generation to be adopted
ª 2020 the International Society of Dermatology
 13654632, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/ijd.14785 by UNIVERSIDAD NACIONAL DEL COMAHUE UNCOMA, Wiley Online Library on [11/04/2024]. 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
Correspondence e211

Table 1 Bivariate analysis for worsening of psoriasis

Psoriasis worsening

No Yes Total
Parameters n (%) n (%) n (%) P-value

Arboviruses No 50 (96.2) 0 (0) 50 (89.3) <0.001

Yesa 2 (3.8) 4b (100) 6 (10.7)
Concomitant use of immunosuppressants No 23 (44.2) 1 (25) 24 (42.9) 0.454
Yes 29 (55.8) 3 (75) 32 (57.1)
Presence of comorbidity No 21 (40.4) 3 (75) 24 (42.9) 0.178
Yes 31 (59.6) 1 (25) 32 (57.1)
Diagnosis Psoriatic arthritis 34 (65.4) 4 (100) 38 (67.9) 0.153
Psoriasis vulgaris 18 (34.6) 0 (0) 18 (32.1)
Alcoholism No 48 (92.3) 4 (100) 52 (92.9) 0.565
Yes 4 (7.7) 0 (0) 4 (7.1)
Family history No 50 (96.2) 4 (100) 54 (96.4) 0.69
Yes 2 (3.8) 0 (0) 2 (3.6)
Smoking No 50 (96.2) 3 (75) 53 (94.6) 0.07
Yes 2 (3.8) 1 (25) 3 (5.4)
Biological therapy Adalimumab 19 (36.5) 2 (50) 21 (37.5) 0.908
Etanercept 15 (28.8) 1 (25) 16 (28.6)
Infliximab 9 (17.3) 1 (25) 10 (17.9)
Ustekinumab 8 (15.4) 0 (0) 8 (14.3)
Secukinumab 1 (1.9) 0 (0) 1 (1.8)

a
Chikungunya (n = 3), dengue (n = 2), and Zika (n = 1) infections.
b
Chikungunya (n = 2), dengue (n = 1), and Zika (n = 1) infections.

as a benchmark for further investigations. Future studies are
needed to verify and expand our current findings with a larger
sample size. Additionally, a multivariate analysis is necessary to
identify predictors of psoriasis exacerbation. Clinicians, policy-
makers, payers, and other stakeholders may also apply the
current findings in strategic, science-driven, and health system-
related decision-making processes, and to guide investment
decisions for the management of patients with psoriasis receiv-
ing biological therapy.
Author Contribution
All the authors included in this article have contributed to the
writing of this article.
Ethics
The procedures followed were in accordance with the ethical
standards of the Helsinki Declaration. IRB-approved research
protocol = 2.531.437.
Conflict of interest: LAA and ALB have received grant/
research and served as consultants for Abbvie, Lilly,
Novartis, and Janssen.
Funding source: None.
doi: 10.1111/ijd.14785
References
1 Andersen LK, Azulay-Abulafia L, Davis MD. Zika virus: skin is
commonly involved. Int J Dermatol 2017; 56: e84–e86.
2 Paniz Mondolfi AE, Hernandez Perez M, Blohm G, et al.
Generalized pustular psoriasis triggered by Zika virus infection.
Clin Exp Dermatol 2018; 43: 171–174.
3 Seetharam KA, Sridevi K. Chikungunya infection: a new trigger
for psoriasis. J Dermatol 2011; 38: 1033–1034.
4 Weaver SC, Charlier C, Vasilakis N, et al. Zika, chikungunya,
and other emerging vector-borne viral diseases. Annu Rev Med
2018; 69: 395–408.
5 Plachouri KM, Georgiou S. Challenges in the treatment of
psoriasis with biologics: vaccination, history of malignancy,
human immunodeficiency virus (HIV) infection, and pediatric
psoriasis. Int J Dermatol 2019; 58: 1008–1013.

Karin M. Araujo, MD
Aline L. Bressan, MD, MSc
Luna Azulay-Abulafia*, MD, PhD
Department of Dermatology, State University of Rio de
Janeiro, Rio de Janeiro, Brazil
*E-mail: lunaazulay@gmail.com
Custom dental trays with topical corticosteroids for
management of gingival lesions of mucous membrane
pemphigoid
Dear Editor,
Mucous membrane pemphigoid (MMP) is an immune-me-
diated, vesiculobullous disease characterized by autoantibodies

ª 2020 the International Society of Dermatology International Journal of Dermatology 2020, 59, e195–e224