Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Observation Letter
ARTICLE IN PRESS
doi:
10.25259/IJDVL_940_2024

A challenging case of Kyrle’s disease successfully treated with apremilast

Department of Dermatology, Venereology and Leprosy, ESIC Medical College & Hospital, Faridabad, India.

Corresponding author: Dr. Apaopa Jemima Thekho, Department of Dermatology, Venereology and Leprosy, ESIC Medical College & Hospital, NIT-3, Faridabad, Haryana, India. thekho9@gmail.com

Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Uikey D, Thekho AJ, Godara A. A challenging case of Kyrle’s disease successfully treated with apremilast. Indian J Dermatol Venereol Leprol. doi:10.25259/IJDVL_940_2024

Dear Editor,

A 29-year-old woman, with multiple chronic conditions including type 1 diabetes mellitus, hypertension, pancreatitis, gastric ulcer, hypothyroidism, and depression, visited the dermatology department with generalised hyperkeratotic papules associated with intense itching for the past four years. Examination revealed multiple discrete papules and nodules with central keratotic plugs accompanied by excoriations and post-inflammatory hyperpigmentation. Her upper and lower extremities had most of the lesions, with a few on her lower back and face body surface area (BSA>20%); the Koebner phenomenon was also observed [Figure 1a].

Multiple discrete papules and nodules with central keratotic plugs on both lower legs.
Figure 1a:
Multiple discrete papules and nodules with central keratotic plugs on both lower legs.
Dermoscopy revealed four zones: a central keratotic plug with a structureless white area (black star), a structureless pink area with dotted vessels (black arrow), and a structureless brown area in concentric rings (black triangle); (Dermlite DL5, 10 X, polarised mode).
Figure 1b:
Dermoscopy revealed four zones: a central keratotic plug with a structureless white area (black star), a structureless pink area with dotted vessels (black arrow), and a structureless brown area in concentric rings (black triangle); (Dermlite DL5, 10 X, polarised mode).

Dermoscopy (Dermlite DL5 in polarised mode) revealed four zones: a central keratotic plug with a structureless white area, a structureless pink area with dotted vessels, and a structureless brown area in concentric rings [Figure 1b]. Clinical differentials of perforating dermatosis (PD) and excoriated prurigo nodularis were considered. The haematological investigations revealed a significant elevation in blood glucose levels, with HbA1c reading of 11.5%. Complete haemogram, liver, and kidney function tests were normal, and anti-thyroid peroxidase or anti-islet cell antibodies were not detected. Other findings were atrophic pancreas with areas of calcification on computed tomography (CT), pangastritis, and duodenitis on upper gastrointestinal (GI) endoscopy. A punch biopsy from a keratotic papule was sent for histopathology, which depicted a cornified plug with basophilic debris embedded in an epidermal invagination with perifollicular inflammatory infiltrate [Figure 2a and 2b]. Special stains for collagen and elastin were negative. A final diagnosis of Kyrle’s disease (KD) with multisystem pathologies was made.

Cornified plug with basophilic debris in an epidermal invagination. (Haematoxylin and eosin, 40x).
Figure 2a:
Cornified plug with basophilic debris in an epidermal invagination. (Haematoxylin and eosin, 40x).
Basophilic debris with no collagen or elastic fibres (Haematoxylin and eosin, 100x).
Figure 2b:
Basophilic debris with no collagen or elastic fibres (Haematoxylin and eosin, 100x).

Based on the perforating dermatosis (PD) severity score suggested by Kawakami et al., the patient had an Eczema Area and Severity Index (EASI) of 12.2/36 and a pruritus score of 8/10, attaining a total score of 13 which comes under moderate (7–15) involvement.1

Considering the severity and its detrimental effect on the patient’s quality of life, systemic treatment was deemed appropriate. Systemic steroids and oral retinoids were not considered due to underlying comorbidities. Apremilast, a phosphodiesterase inhibitor was considered for treating this patient along with topical keratolytics. After three months of starting apremilast 30mg twice a day, the patient’s itch severity score improved significantly from 9 to 3. There has been a notable decrease in both new and existing lesions [Figure 3]. PD severity score also decreased from 13 to 4. Our patient has been maintaining the clinical response for the past eight months, without experiencing any adverse events.

Significant clinical improvement of skin lesions after four months therapy with apremilast.
Figure 3:
Significant clinical improvement of skin lesions after four months therapy with apremilast.

KD is a type of acquired perforating dermatosis (APD), commonly observed in adults (30–50 years), predominantly among females. The condition manifests as discrete hyperkeratotic papules and nodules, predominantly affecting the extensor surface of the limbs, accompanied by pruritus and koebnerisation. Excoriated prurigo nodularis, insect bite hypersensitivity, chronic folliculitis, and other APDs are among the diagnostic considerations.

The exact pathogenesis of KD remains unclear. Due to its frequent associations, underlying systemic disorders are considered as the main etiology. Some factors that contribute to this are uremia (renal diseases), hyperphosphatemia, elevated fibronectin levels, advanced glycated end products (diabetes), abnormal low-density lipoprotein (LDL) levels (diabetes and lipid disorders), and occasionally infections. The proposed final pathway involves a disruption in the epidermal keratinisation process, leading to the accumulation of abnormal keratin. This triggers inflammation, resulting in the expulsion of material via the epidermis followed by re-epithelisation.2,3 Histologically, the epidermis is hyperplastic with cup-shaped invagination and a degenerative basophilic material with plug formation and no collagen or elastic fibres.4

The treatment of KD poses challenges and often yields unsatisfactory outcomes. Treatment options include topical corticosteroids, keratolytics, retinoids, oral corticosteroids, immunosuppressants, and phototherapy, but with limited effectiveness. Oral upadacitinib (oral selective Janus kinase [JAK] 1 inhibitor) has emerged as a novel treatment approach because of its action on JAK/signal transducers and activators of the transcription (STAT) pathway.3

Apremilast (phosphodiesterase-4 inhibitor) prevents the degradation of cyclic adenosine monophosphate (cAMP), which results in an antagonistic effect on the production of proinflammatory cytokines (TNF-α, IL-23, interferon (IFN)-γ and an increase in anti-inflammatory mediators (e.g. IL-10).5 This broad-spectrum anti-inflammatory action leads to a reduction in inflammatory cell infiltration in the epidermis, the inflammatory response against keratin, normalisation of epidermal keratinisation preventing hyperkeratosis, and reduction in itch severity.6

We encountered only a single case report describing a patient with Down syndrome who had psoriasis, hidradenitis suppurativa (HS), and PD. The patient’s PD showed a remarkable response to apremilast, which was initially prescribed for the treatment of psoriasis and HS.7

Herein, we report the satisfactory response with apremilast in a patient of KD associated with various comorbidities. Given its wide range of immunomodulatory effects and favourable safety profile, it could be a therapeutic option for chronic disorders as in our case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of AI-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

References

  1. , , , , , , et al. Clinical practice guide for the treatment of perforating dermatosis. J Dermatol. 2020;47:1374-82.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , , , , . Dupilumab improve acquired reactive perforating collagenosis characterized by type 2 inflammation. Front Immunol. 2023;14:1240262.
    [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
  3. , , , . A potential new treatment with upadacitinib for acquired reactive perforating collagenosis. JAAD Case Rep. 2024;48:112-4.
    [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
  4. , , . Degenerative diseases and perforating disorders. Lever’s Histopathology of the Skin (11th edition). Philadelphia: Wolters Kluwer; . p. :1006-36.
  5. , , , . Apremilast: A novel PDE4 inhibitor in the treatment of autoimmune and inflammatory diseases. Ther Adv Musculoskelet Dis. 2010;2:271-8.
    [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
  6. , . Apremilast (Otezla): A New Oral Treatment for Adults With Psoriasis and Psoriatic Arthritis. P T. 2015;40:495-500.
    [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
  7. , . Treatment of a perforating dermatosis with apremilast. JAAD Case Rep. 2021;16:155-7.
    [CrossRef] [PubMed] [PubMed Central] [Google Scholar]

Fulltext Views
2,203

PDF downloads
60
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections