leukocyte functioneassociated antigen type 1epo-sitive cells near the transplanted melanocytes.

This is, to our knowledge, a unique description ofa patient experiencing repigmentation of vitiligoduring treatment with the biological efalizumab.Previously, a pilot study was conducted with eta-nercept undertaken after good results with thetopical tumor necrosis factor-a blocking agenttacrolimus. None of the 4 patients with vitiligoshowed any alteration after 4 months.5 This unex-pected effect is also remarkable because the vitiligoin this patient existed for almost 2 decades, but stillproved to be a dynamic process. Although this is anobservation in a single patient, it may offer new inputinto research on the pathogenesis of vitiligo and thedevelopment of potential new therapies.

Marlies Wakkee, MD, Yvette J. Assen, MD, H. BingThio, MD, PhD, and H. A. Martino Neumann,MD, PhD

Department of Dermatology, Erasmus MedicalCenter Rotterdam (The Netherlands)

Funding sources: None.

Disclosure: Dr Wakkee has conducted clinical trialsfor Centocor, Merck-Serono, and Schering-Plough and has received an unrestricted grantfor research by Merck-Serono, Schering-Plough,and Wyeth. Dr Thio has done clinical trials andacted as paid consultant for Abbott, Centocor,Merck-Serono, Novartis, Schering-Plough, andWyeth. Drs Assen and Neumann have no con-flicts of interest to declare.

Reprint requests: H. Bing Thio, MD, PhD, Depart-ment of Dermatology and Venereology, ErasmusMedical Center Rotterdam, PO Box 2040, 3000CA Rotterdam, The Netherlands

E-mail: h.thio@erasmusmc.nl

REFERENCES

1. Norris DA. Cytokine modulation of adhesion molecules in the

regulation of immunologic cytotoxicity of epidermal targets.

J Invest Dermatol 1990;95(Suppl):111S-20S.

2. van den Wijngaard R, Wankowicz-Kalinska A, Le Poole C,

Tigges B, Westerhof W, Das P. Local immune response in skin

of generalized vitiligo patients: destruction of melanocytes is

associated with the prominent presence of CLA1 T cells at the

perilesional site. Lab Invest 2000;80:1299-309.

3. Werther WA, Gonzalez TN, O’Connor SJ, McCabe S, Chan B,

Hotaling T, et al. Humanization of an anti-lymphocyte function-

associated antigen (LFA)-1 monoclonal antibody and reengin-

eering of the humanized antibody for binding to rhesus LFA-1.

J Immunol 1996;157:4986-95.

4. Abdallah M, Abdel-Naser MB, Moussa MH, Assaf C, Orfanos CE.

Sequential immunohistochemical study of depigmenting

and repigmenting minigrafts in vitiligo. Eur J Dermatol

2003;13:548-52.

5. Rigopoulos D, Gregoriou S, Larios G, Moustou E, Belayeva-

Karatza E, Kalogeromitros D. Etanercept in the treatment of

vitiligo. Dermatology 2007;215:84-5.

doi:10.1016/j.jaad.2008.03.032

Fig 1. Perifollicular repigmentation of vitiligo is noted onface 3 months after initiation of efalizumab.

Fig 2. Psoriasiform plaques persist on extensor surfaces ofelbow with scattered areas of perifollicular repigmentation3 months after initiation of efalizumab.

J AM ACAD DERMATOL

AUGUST 2008

S58 Letters

Dapsone-responsive histiocytoid Sweet’ssyndrome associated with Crohn’s disease

To the Editor: Histologically, Sweet’s syndrome ex-hibits features of a neutrophilic dermatosis withpapillary dermal edema and a dense infiltrate ofneutrophils in the papillary and mid dermis.1 Severalconditions have been associated with the develop-ment of Sweet’s syndrome: infections, hematologicand visceral malignancies, inflammatory boweldisease, pregnancy, and certain medications.2

J AM ACAD DERMATOL

VOLUME 59, NUMBER 2

Letters S59

Requena et al3 described 41 patients with a variantof Sweet’s syndrome that exhibited histiocytoid mon-onuclear cells. Although the clinical features weresimilar to typical Sweet’s syndrome, histologicallythese cases exhibited a dense dermal infiltrate ofmononuclear cells with large, slightly eccentric, elon-gated, kidney-shaped, basophilic nuclei that reactedwith CD15, CD43, CD45, CD68, MAC-386, HAM56,and lysozyme, immunohistochemically. Of these41 patients, several demonstrated associated hemato-logic and visceral malignancies and one was reportedto have ulcerative colitis. Response to treatment wasnot described. We report a patient with histiocytoidSweet’s syndrome associated with Crohn’s diseasethat responded to dapsone.

Case report. A 42-year-old white woman presentedwith a 1-month history of fever, arthralgias, weak-ness, watery diarrhea, abdominal pain, and occa-sional bloody mucus in the stool. Four days beforeadmission, she noted a pruritic skin eruption on herback and extremities.

Physical examination demonstrated a fever(38.08C) and several erythematous papules andplaques on her back (Fig 1), neck, and extensorsurfaces of the arms and legs. Laboratory studiesrevealed normal white blood cell counts with ele-vated monocytes noted on the differential. Colonicbiopsy specimen showed heavy acute and chronicinflammation with focal ulceration and varyingamounts of histiocytes identified in the infiltratemost consistent with Crohn’s disease.

Skin biopsy specimen showed a nodular andinterstitial dermal infiltrate of large mononuclearcells with bean-shaped nuclei admixed with afew neutrophils (Fig 2). These mononuclear cellsstained positive for chloracetate esterase and CD68but negative for S100 and CD1a. Myeloperoxidasewas positive on many of the mononuclear cells.

Bone-marrow biopsy showed reactive hemato-poietic tissues with an erythroid hyperplasia and noevidence of immaturity or dysplasia.

The patient’s skin eruption quickly cleared withoral prednisone at 40 mg/d but relapsed whentapered off corticosteroids despite the use of aza-thioprine (150 mg/d) to control her Crohn’s disease.Dapsone therapy was initiated, her skin cleared,and she was successfully tapered off corticosteroidswhile remaining on dapsone (100 mg/d). Shecontinued taking azathioprine for her Crohn’sdisease.

Discussion. Histiocytoid Sweet’s syndrome is arare variant of the acute febrile neutrophilic derma-tosis characterized by an infiltrate of immature

myeloid cells. Histopathologically, the infiltratemay easily be mistaken for myelogenous leukemia,which is also immunoreactive for myeloperoxidaseand CD68.4 Our patient’s negative bone-marrowbiopsy specimen results and rapid responsivenessto corticosteroids helped to exclude this possibility.Our patient’s skin condition was clearly associatedwith the development of Crohn’s disease and fortu-nately was controlled with dapsone.

The use of dapsone in the treatment of Sweet’ssyndrome is well documented.5 Dapsone inhibitsneutrophils by interfering with the myeloperoxi-dase-peroxidase-halide system and chemotaxis.Dapsone should be considered as an alternative tocorticosteroids in the treatment of histiocytoidSweet’s syndrome.

Fig 1. Erythematous papules and plaques on upperaspect of back.

Fig 2. Nodular and interstitial dermal infiltrate of mon-onuclear histiocytoid cells. (Hematoxylin-eosin stain;original magnification: 3400.)

and photoexacerbation have also been reported.4

Histopathologically, there is epidermal spongiosis,papillary dermal edema, and prominent lymphocyticand eosinophilic infiltrates with a preponderance ofCD41 T cells in the dermis. CD41 T-cell infiltration isthought to occur in response to antigen-presentingcells that display melanocytic antigens in the skin.4

Less frequently described findings include exocyto-sis, perivascular and follicular lymphocytic infil-

Fig 1. A, Edematous and erythematous axillary plaquewith faint follicular papules on chest and upper aspect ofabdomen. B, Close-up view of follicular eruption on chest.

J AM ACAD DERMATOL

AUGUST 2008

S60 Letters

Brent Spencer, MD,a Amit Nanavati, MD,b JohnGreene, MD,c and David F. Butler, MDa

Division of Dermatologya and Department ofPathology,c Scott and White Memorial Hospitaland Clinic, Temple, Texas; and the Departmentof Medicine, Boston University Medical Center,Massachusettsb

Funding sources: None.

Conflicts of interest: None declared.

Reprints not available from the authors

Correspondence to: David F. Butler, MD, Divisionof Dermatology, Scott and White Memorial Hos-pital, 2401 S 31 St, Temple, TX 76508

E-mail: dfbutler@swmail.sw.org

REFERENCES

1. Cohen P, Kurzrock R. Sweet’s syndrome revisited: a review of

disease concepts. Int J Dermatol 2003;42:761-78.

2. Von den Driesch P. Sweet’s syndrome (acute febrile neutro-

philic dermatosis). J Am Acad Dermatol 1994;31:535-56.

3. Requena L, Kutzner H, Palmedo G, Pascual M, Fernandez-

Herrera J, Fraga J, et al. Histiocytoid Sweet syndrome: a dermal

infiltration of immature neutrophilic granulocytes. Arch Derma-

tol 2005;141:834-42.

4. Kaddu S, Zenahlik P, Beham-Schmid C, Kerl H, Cerroni L. Specific

cutaneous infiltrates in patients with myelogenous leukemia: a

clinicopathologic study of 26 patients with assessment of diag-

nostic criteria. J Am Acad Dermatol 1999;40:966-78.

5. El Sherif A, Bharija S, Belhaj M, Singh G. Dapsone in Sweet

syndrome. Int J Dermatol 1990;29:737.

doi:10.1016/j.jaad.2008.03.044

Intertriginous and follicular eruption toanticytotoxic T-lymphocyte antigen 4monoclonal antibody

To the Editor: Cytotoxic T-lymphocyte antigen 4(CTLA4) antibody is a novel immunotherapy usuallyadministered with peptide vaccine for advanced mel-anoma. CTLA4 is a costimulatory molecule expressedby activated T cells. When CTLA4 binds to the B7receptor on antigen-presenting cells, T-cell activationis inhibited, which confers self-recognition. BlockingCTLA4 antigen with a monoclonal antibody inhibitsself-recognition, thereby increasing the immune sys-tem’s ability to target and kill malignant cells.

Cutaneous drug reactions attributed to CTLA4antibody have been highlighted recently. Estimatesof the prevalence of skin toxicity varied widelyfrom 14% to 100% and included rash, vitiligo, andalopecia areata.1-4 The most frequently reportedrash is a macular and papular exanthem affectingtrunk and extremities. A photodistributed pattern

trates, or a preponderance of CD31 or CD81 cells.We report a unique presentation of an eruption to

CTLA4 antibody that was predominantly intertrigi-nous and follicular clinically with follicular-basedinflammation histopathologically. A 46-year-old manwith metastatic melanoma presented with an erup-tion involving the chest and axillae. Three monthsprior, he had been enrolled in a CTLA4 antibody 1/e

glycoprotein 100 peptide vaccine trial for lung andbrain metastases. After his initial dose of CTLA4antibody and glycoprotein 100 vaccine, he devel-oped a burning sensation in the axilla. He receivedtwo additional doses at 3-week intervals, and noted aprogressive papular erythematous eruption in theaxillae that spread to the chest and neck associatedwith a peripheral eosinophilia. While taking dexa-methasone for concurrent cerebral edema, his erup-tion improved. However, as the dexamethasone wastapered, it worsened again.

On examination, edematous and erythematousplaques with peripheral honey-colored crustingwere seen in both axillae (Fig 1). Surrounding these