Case Report - (2022) Volume 8, Issue 6
Received: 24-Mar-2022, Manuscript No. IPCPDR-22-12768; Editor assigned: 26-Mar-2022, Pre QC No. IPCPDR-22-12768(PQ); Reviewed: 11-Apr-2022, QC No. IPCPDR-22-12768; Revised: 10-Oct-2022, Manuscript No. IPCPDR-22-12768(R); Published: 17-Oct-2022, DOI: 10.36648/2472-0143.8.6.27
Hyperhidrosis piercings of the body and ears is a popular practice amongst the US adolescent population. Localized infections and reactions are common, including allergic contact dermatitis, bleeding, scarring, and keloid formation. Piercing the skin serve as a site of trauma, thus predisposing patients to these complications. Enhancement of systemic reactions to localized regions is an uncommon phenomenon but has been reported in several cases such as chemotherapy-induced radiation dermatitis. We present a case of lamotrigine induced erythema multiform major in a 17 years old female, whose diagnosis was delayed due to initial presentation mimicking disseminated herpes simplex virus, Bechet’s, and an autoimmune condition due to unknown steroid use. In addition, the patient had enhancement of erythema and pain around multiple facial piercings. Although the cause of enhancement at the piercing sites is unclear, the bodily piercings may serve as an example of an enhanced immunologic reaction at Immuno Compromised Districts (ICD). ICDs are areas of skin that have experienced prior trauma resulting in chronic skin changes resulting in enhanced or weakened immunologic reactions. This case highlights a unique localized complication of body piercings as well as several important learning points including the complications of piercings, importance of medication reconciliations, atypical presentations of diseases secondary to patients concealing relevant medical information, the benefit of broad differentials, and overlapping disease presentations resulting in delay of correct diagnoses.
Hyperhidrosis piercings; Erythema Multiform (EM); Leukocytosis neutrophil; Predominance; Immuno compromised districts
Piercings of the body and ears is a popular practice amongst the US population localized infections and reactions are common, including allergic contact dermatitis, bleeding, scarring, and keloid formation. Piercing the skin serve as a site of trauma, thus predisposing patients to these complications. Depending on the piercing site and the reaction, treatments vary [1,2]. Enhancement of systemic reactions to localized regions is an uncommon phenomenon but has been reported in several cases such as chemotherapy induced radiation dermatitis [3]. In this article, we report a patient with Erythema Multiform (EM) major with enhancement of erythema and pain around multiple bodily piercing sites.
A 17 years old female was admitted to the gynecological service for what was assumed to be an initial presentation of oral and genital manifestations of Herpes Simplex Virus (HSV).
At the time of initial presentation, the patient had 6 small (1-3 mm) oral ulcerations and a single ulcer on the labia majora (3 mm). Medical history was significant for obsessive compulsive disorder and bipolar disorder and patient started lamotrigine 16 days prior. Over the next three days, ulcerations increased in number and size. The patient also began to develop conjunctivitis with watery discharge. Initial labs were most notable for: leukocytosis with a neutrophil predominance, elevated ESR and CRP, and ANA positivity with a titer of 1:640 in a homogenous pattern. Given this constellation of symptoms, physical exam findings, and laboratory data, the initial differential diagnosis included disseminated HSV vs. Behcet’s vs. autoimmune disease vs. drug reaction. Follow up studies were ordered, and lamotrigine was discontinued. Unbeknownst to the team, the patient had been taking oral prednisone for the past 5 days. Prednisone was tapered and discontinued for concerns for infectious etiology.
The following day the patient developed an acute worsening of cutaneous symptoms. The patient's oral and genital ulcerations became confluent. The oral mucosa now appeared raw with cheilitis and dried blood. The patient also developed new painful cutaneous manifestations on their face with focal areas of erythema around sites of bodily piercings as shown in Figure 1 including the umbilicus (not pictured). Follow up laboratory results demonstrated an acute eosinophilia, worsening leukocytosis, HSV PCR returned negative, along with negative rheumatologic makers and normal complement levels. Patient was started on high dose IV steroids and the differential was narrowed to autoimmune disease vs. drug reaction. Skin biopsy demonstrated interface dermatitis with necrotic keratinocytes and melanin pigment incontinence in the superficial dermis.
No eosinophils were noted in the biopsy. The final diagnosis of lamotrigine induced erythema multiform major was made. The piercings were removed, and the patient was treated with IV steroids, moxifloxacin eye drops to prevent ocular infection, mupirocin ointment to apply on the oral/ vaginal mucosa to prevent infection, and an intravaginal steroid ointment to prevent the development of adhesions as the labial/vaginal ulcerations healed. The patient had a complete recovery including piercing sites, and was discharged within a week.
Figure 1: Erythema multiforme major with periocular erythema, circular erythematous patches on the cheek and nose, targetoid lesions on the lower check and forehead. enhanced erythema surrounding nose piercings.
The patient’s initial presentation resulted in mimicry of HSV and Behest’s delaying the diagnosis of EM major. However, the unique observation in this case is the enhancement of erythema at sites of bodily piercings. Although the cause is unclear, the bodily piercings may serve as an example of an enhanced immunologic reaction at Immuno Compromised Districts (ICD). ICDs are areas of skin that have experienced prior trauma resulting in chronic skin changes resulting in enhanced or weakened immunologic reactions [4,5]. Erythema multiform is an immune mediated disorder, therefore it is possible an immunological reaction was exaggerated at the sites of bodily piercings [6].
Therefore, rococo’s theory of ICD can provide an explanation as to why enhancement of was observed around the patients’ sites of bodily piercings. This case highlights a unique localized complication of body piercings in a pediatric patient with several important learning points including the importance of piercings, medication reconciliations, and atypical presentations of diseases secondary to patients concealing relevant medical information, the benefit of broad differentials, and overlapping disease presentations resulting in delay of correct diagnosis.
Authors declare no conflicts of interest.
Citation: Kaszycki M, Bub A (2022) Unique Piercing Site Drug Reaction. Clin Pediatr Dermatol. 8:27
Copyright: © 2022 Kaszycki M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
