LETTERS TO THE EDITOR
© 2008 The Authors
JEADV 2009, 23, 441–496Journal compilation © 2008 European Academy of Dermatology and Venereology
Our experience supports that CO2 laser is an effective and safe
therapy for superficial microcyst vascular LM. It should be
considered when surgery or sclerosis is contraindicated. CO2
laser can be used in combination with Diode laser, Nd:YAG laser
and PDL laser when a haematological component is present.
Nevertheless, laser therapy is not curative since it cannot
eliminate the deep areas of the LM, and the lesion might recur.10
Therefore, a close follow-up is important in order to detect the
relapses of the disease.
S Beà-Ardébol,* P Boixeda, L Bagazgoitia, JL Santiago
Sánchez-Mateos, L Pérez-Carmona, P Jaén
Dermatology Department, Ramon y Cajal Hospital, University of Alcala de
Henares, Madrid, Spain
*Correspondence: S Beà-Ardébol. E-mail:
1 Lavie A, Desouches C, Casanova D, Bardot J, Magalon G. Surgical treatment
of lymphatic malformations. Ann Chir Plast Esthet 2006; 51: 433–439.
2 Hsu T-S, Weiss RA. Foam sclerotherapy. A new era. Arch Dermatol 2003;
3 Huilgol SC, Neill S, Barlow JR. CO2 laser therapy of vulval lymphangiectasia
and lymphangioma circumscriptum. Dermatol Surg 2002; 28: 575–577.
4 Loche F, Schwarze HP, Bazex J. Treatment of acquired cutaneous
lymphangiectasias of the thigh and vulva with a carbon dioxide laser. Acta
Derm Venereol 1999; 79: 335.
5 Novak C, Spelman L. Low energy fluence CO2 laser treatment of
lymphangiectasia. Australs J Dermatol 1998; 39: 277–278.
6 Landthaler M, Hohenleutner U, Braun-Falco O. Acquired lymphangioma of
the vulva: palliative treatment by means of laser vaporization carbon dioxide.
Arch Dermatol 1990; 126: 967–968.
7 Redondo P. Vascular malformations (II) Diagnosis, pathology and
treatment. Actas Dermosifiliogr 2007; 98: 219–235.
8 Lai CH, Hanson SG, Mallory SB. Lymphangioma circumscriptum treated
with pulsed dye laser. Pediatr Dermatol 2001; 18: 509–510.
9 Wang LC, Krunic AL, Medenica MM et al. Treatment of hemorrhagic
lymphatic malformation of the tongue with a pulsed-dye laser. J Am Acad
Dermatol 2005; 52: 1088–1090.
10 Berwald C, Salazard B, Casanova Dm Bardot J, Magalon G. Indications of
lasers treatment for lymphatic malformations. Ann Chir Plast Esthet 2006;
XXX Letters to the EditorLetters to the EditorLetters to the Editor
LETTERS TO THE EDITOR
Neutrophilic dermatosis of the
dorsal hands: an emerging entity
Neutrophilic dermatoses are a collection of diseases of which
Sweet’s syndrome is a protoptype. Clinical features of Sweet’s
syndrome include acute onset of painful erthematous papules,
plaques or nodules accompanied by fever and peripheral neutrophil
leucocytosis. Histologically, a dense neutrophilic infiltrate without
evidence of primary vasculitis is found.1 An acral form of Sweet’s
syndrome is recognized and now termed neutrophilic dermatosis
of the dorsal hands (NDDH).2 We report here two cases of NDDH.
The first patient was an 80-year-old Chinese woman with newly
diagnosed myelodysplastic syndrome. She developed a bulla on
the dorsum of her right hand and a purplish, bruise-like patch
over the dorsum of her left hand. Both areas were previous sites
of intravenous (IV) cannulation. Within a few days, the lesions on
both hands expanded into large haemorrhagic, oedematous plaques
(Fig. 1). Her C-reactive protein and erythrocyte sedimentation
rate were markedly raised. A skin biopsy revealed dermal oedema
and an infiltrate of neutrophils, lymphocytes with extravasated
red blood cells. Tissue cultures were negative. Based on the clin-
ical and histological findings, NDDH was diagnosed. High-dose
prednisolone and cyclosporine failed to control the skin lesions.
She was subsequently given IV immunoglobulin for refractory throm-
bocytopaenia. With this regimen, the plaques finally began to resolve.
Unfortunately, she subsequently died from nosocomial pneumonia.
Figure 1 Eyelid lymphangiectasia before treatment.
Figure 2 Eyelid lymphangiectasia after treatment.
LETTERS TO THE EDITOR
© 2008 The Authors
JEADV 2009, 23, 441–496 Journal compilation © 2008 European Academy of Dermatology and Venereology
The second case was a 78-year-old Chinese woman with peri-
pheral vascular disease who underwent above-knee amputation
for right leg gangrene. Two weeks postoperatively, she developed
a wound infection. Concurrently, she developed indurated viola-
ceous plaques with pustules over the dorsum of both hands. The
plaques were located over IV cannulation sites. Skin biopsy con-
firmed a neutrophilic dermatosis. Systemic steroid was withheld
in view of the concurrent infection, and she was treated with
topical 0.1% betamethasone valerate ointment. Her wound infec-
tion was successfully treated with IV antibiotics and her rashes
NDDH is a localized form of Sweet’s syndrome. It has been
previously called ‘pustular vasculitis’, ‘atypical pyoderma gangre-
nosum’ and ‘bullous pyoderma gangrenosum’.3,4 Sweet’s syndrome
is frequently associated with haematological malignancies, solid
tumours and inflammatory bowel disease.5 A similar pattern is
seen in NDDH. We collated and reviewed 55 cases of NDDH that
has been reported in the literature2,3,6–9 (including our two cases) and
found that haematological diseases (18%) were most commonly
associated with NDDH, followed by ulcerative colitis (11%) and
solid tumours (9%). Pathery was present in both of our cases, and
this has also been previously reported.2,6 The pathogenesis of
Sweet’s syndrome remains unknown. It is thought to be related to
an altered immunological state in reaction to bacterial, viral or tumour
antigens. It has been theorized that cytokine dysregulation plays a key
role in the activation of neutrophils and release of toxic metabolites.10
The management of NDDH is similar to Sweet’s syndrome.
Majority of cases respond well to systemic corticosteroids.2,6,8
Dapsone has been used either alone or in combination with sys-
temic corticosteroids to good effect.2,8 Other medications that have
been used as adjuncts to steroids include cyclosporine, methotrexate,
potassium iodide and salazopyrine. Monotherapy with colchicine,
minocycline, azathioprine, intralesional triamcinolone, topical
steroids, topical tacrolimus have also had anecdotal success.8,9
The prognosis of NDDH is generally good as the disease is
usually readily treatable with corticosteroids or other immune
modulating or anti-inflammatory drugs. In some cases, main-
tenance doses of dapsone, minocycline or colchicine are required to
prevent disease recurrence.
In conclusion, NDDH can be best understood as a localized
variant of Sweet’s syndrome. It is commonly associated with an
underlying systemic illness and most cases are readily treatable
with systemic corticosteroid therapy.
Y-S Wang,*† A Tan‡
†Division of Dermatology, Department of Medicine, Changi General
Hospital, Singapore, ‡National Skin Centre, Singapore
*Correspondence: Y-S Wang. E-mail: firstname.lastname@example.org
1 Sweet RD. An acute febrile neutrophilic dermatois. Br J Dermatol 1964; 76:
2 Galaria N, Junkins-Hopkins J, Kligman D, James WD. Neutrophilic
dermatosis of the dorsal hands: Pustular vasculitis revisited. J Am Acad
Dermatol 2000; 43: 870–874.
3 Strutton G, Weedon D, Robertson I. Pustular vasculitis of the hands. J Am
Acad Dermatol 1995; 32: 192–198.
4 Curco N, Pagerols X, Tarroch X, Vives P. Pustular vasculitis of the hands:
report of two men. Dermatology 1998; 196: 346–347.
5 Kemmett D, Hunter JAA. Sweet’s syndrome: a clinicopathologic review of 29
cases. J Am Acad Dermatol 1990; 23: 503–507.
6 Walling H, Snipes C, Gerami P, Piette WW. The relationship between
neutrophilic dermatosis of the dorsal hands and Sweet syndrome. Arch
Dermatol 2006; 142: 57–63.
7 Duquia R, Almeida H. Vettorato G, Souza PR, Schwartz J. Neutrophilic
dermatosis of the dorsal of the hands: acral Sweet syndrome? Int J Dermatol
2006; 45: 51–52.
8 Weenig R, Bruce A, McEvoy M, Gibson LE, davis MD. Neutrophilic
dermatosis of the hands: four new cases and review of the literature. Int J
Dermatol 2004; 43: 95–102.
9 Dicaudo D, Connolly S. Neutrophilic dermatosis (Pustular vasculitis) of
dorsal hands. Arch Dermatol 2002; 138: 361–365.
10 Cohen Pr, Kurzrock R. The pathogenesis of Sweet’s syndrome. J Am Acad
Dermatol 1991; 25: 734.
XXXLetters to the Editor Letters to the Editor
Letters to the EditorLETTERS TO THE EDITOR
Concurrence of erythema
migrans and herpes simplex: first
description of a highly unusual
dual skin infection
A wide range of colocalizations of two different cutaneous
tumours (collision lesions) has been reported.1 Combinations of
two (localized) cutaneous infections at the same body site are
Figure 1 Haemorrhagic, purpuric and necrotic plaque with an
overlying flaccid bulla and surrounding erythema and oedema over
the dorsum of the right hand.