Although typical naked sarcoid granulomas are the most common features of cutaneous sarcoidosis, the dermatopathologist must be aware of possible atypical findings, which are more common than previously expected, because of the differential diagnosis with other causes of cutaneous granulomas, namely infectious diseases.

Background The H1-antihistamine cetirizine, a piperazine derivative widely used in daily practice, is rarely the cause of cutaneous drug reaction. Nevertheless, four cases of fixed drug eruption (FDE) as a result of this drug have been described recently. We present the case of a 45-year-old woman with a multilocalized FDE following oral intake of cetirizine for allergic rhinitis. Methods Patch testing with hydroxyzine 1% and 10% in petrolatum (Chemotechnique), and with powdered Zyrtec® (cetirizine) and Xyzal® (levocetirizine) pills, prepared at 20% in water and at 20% in petrolatum, was performed in both residual lesions and healthy skin. ResultsPositive results (++) to these drugs (24 h occlusion and readings at days 2 and 3) were obtained in residual lesions only. These results allowed us to confirm the drug responsible for this FDE and to study cross-reactions between antihistamines of the same chemical family. ConclusionsTo the best of our knowledge, this is the first report of FDE to cetirizine with positive patch testing to hydroxyzine, cetirizine, and levocetirizine. This case highlights the importance of patch testing in the study of cutaneous drug reactions, namely FDE.

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due to MTX is reported in a small numbers of patients with psoriasis. 5-7 Cutaneous ulceration by MTX toxicity is an exclusion diagnosis, and its pathogenic mechanism may be multifactorial, including direct toxicity of the drug in addition to local factors. 8 Lawrence and Dahl 5 described two type of skin ulceration in patients with psoriasis being treated with MTX. In type 1 ulceration, psoriatic lesions became painful and eroded shortly after starting MTX. Type 2 ulcers occurred in skin clinically uninvolved with psoriasis but affected by other pathologies, such as stasis dermatitis, scars and had a variable relationship to the duration of MTX treatment. In both types, the pathogenic mechanism was thought to be direct toxicity of MTX.Kazlow et al. 6 reported a 58-year-old man with psoriasis that had been treated with MTX and had ulcers developed within psoriatic plaques (type 1), in an abdominal scar (type 2) and on the lower lip. Our patient's lesions were evaluated as type 1 erosions.Pearce and Wilson 7 found 17 patients who had experienced cutaneous erosion believed to be secondary to MTX toxicity. The most common risk factors in these patients were the use of non-steroidal anti-inflammatory drugs and an alteration in MTX dosage. They also reported a possible association between the patient's age (55 years or older) and toxicity. Our case was associated with these risk factors, too. Her age was older than 55 and she had been using meloxicam.The erosions and ulcerations developed within psoriatic plaques of the patients receiving MTX for psoriasis must be considered as a rare side effect caused by MTX. Folic acid must be absolutely used with MTX to decrease the side-effects. And also the fact that non-steroidal anti-inflammatory drugs should not be used under MTX therapy since they can increase the risk of erosions and ulcerations. Evidence-based (S3) guidelines for the treatment of psoriasis vulgaris. J Dtsch Dermatol Ges 2007; 5(s3): 1-119. 4 Bangert CA, Costner MI. Methotrexate in dermatology. Dermatol Ther 2007; 20: 216-228. 5 Lawrence CM, Dahl GC. Two patterns of skin ulceration induced by methotrexate in patients with psoriasis. J Am Acad Dermatol 1984; 11: 1059-1065. 6 Kazlow DW, Federgrun D, Kurtin S, Lebwohl MG. Cutaneous ulceration caused by methotrexate. J Am Acad Dermatol 2003; 49(2 Suppl Case Reports): S197-S198. 7 Pearce HP, Wilson BB. Erosion of psoriatic plaques: an early sign of methotrexate toxicity. J Am Acad Dermatol 1996; 35: 835-838. 8 Del Pozo J, Martinez V, Garcia-Silva J et al. Cutaneous ulceration as a sign of methotrexate toxicity. Recurrent impetigo herpetiformis successfully treated with methotrexateEditor A 25-year-old primigravida at 36th week of gestation was observed with multiple erythematous annular plaques with crusts and perypheric pustules, located on the scalp, thoracoabdominal wall, upper and lower limbs (Fig. 1), accompanied with fever with no other systemic symptoms. These lesions appeared during the 30th week of gestation. The personal and familiar medical history w...

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