Subcorneal pustulosis: causes, symptoms, diagnosis, treatment

Subcorneal pustulosis Sneddona-Wilkinson - a chronic relapsing disease that occurs more often in women over 40 years of age.

Synonym: Sneddon-Wilkinson's disease

The disease was first described in 1956 by English dermatologists Sneddon and Wilkinson. Until recently, in the literature, the question was discussed whether the disease is an independent nosological form of dermatosis or under its mask there are pustular psoriasis, herpetiform impetigo of Gebra, pustular form of Dühring's dermatitis and a number of other skin diseases.

The causes and pathogenesis of subcorneal pustules are unknown. In the emergence of the disease an important role is played by concomitant infections, immunological and endocrine disorders.

Symptoms of subcorneal pustules. The onset of the disease is sometimes associated with hormonal disorders that accompany thyrotoxicosis, pregnancy and childbirth, in some patients with mental trauma. The skin of the trunk and proximal parts of the extremities is affected mainly. The rashes are represented by pustules surrounded by a narrow rim of hyperemia, sometimes grouped. Pustules are quickly opened, and as a result, polycyclic erosions, covered with crusts with scraps of tire caps around the periphery, prevail in the clinical picture. After healing of the sores, hyperpigmentation often remains. The disease has a benign course compared with other forms of generalized pustules, the condition of patients is insignificant. A combination with gangrenous pyoderma is described.

Subcorneal pustulosis is characterized by the formation of superficially located pustules - fliken, which arise on the erythematous base, tend to group and herpetiform arrangement. Favorite location of the rashes - the skin of the trunk, extremities, inguinal and axillary folds. Tires of pustules burst quickly, and their contents are poured into yellowish crusts, on the periphery of which there are scraps of the stratum corneum of the epidermis. After resolving the elements, pinkish and then slightly pigmented spots remain. In the content of flicten there are found acantholytic cells. The symptom of Nikolsky can be positive. The appearance of rashes and its subsequent development is usually not accompanied by subjective sensations. Sometimes there is a fickle and insignificant itching of the skin. Pustules are sterile in typical cases. Mucous membranes are extremely rare. The disease flows for a long time, with remissions. The general condition of the patients is satisfactory. Exacerbations occur more often in the summer.

Histopathology of subcorneal pustules. Pustules are located directly under the stratum corneum, which is most typical for this dermatosis. In the upper part of the skin itself, only the most insignificant phenomena of nonspecific inflammation are noted.

Pathomorphology of subcorneal pustules. In the epidermis a small acanthosis, parakeratosis. Pustules are formed directly under the stratum corneum, contain neutrophilic granulocytes, fibrin, epithelial cells, single eosinophilic granulocytes and lymphocytes. They are usually single-chambered. The cover of the pustule forms the parakeratotic cornea, the bottom is a granular layer. Under the pustules spongios and exocytosis are noted. In the papillate layer of the dermis under pustules - edema and perivascular infiltrates, consisting of lymphocytes, histiocytes, neutrophilic fanuloschgtes and single eosinophilic granulocytes. In some cases, pustules, increasing in size, can capture the entire thickness of the epidermis, sometimes penetrating the dermis. Such pustules contain neutrophilic granulocytes and a large number of eosinophilic granulocytes. In bacteriological studies, microorganisms are not detected in them. In old foci of lesions, the epidermis is somewhat thickened, and clearly defined pustules filled with neutrophilic granulocytes and their enzymes are found under the well-preserved stratum corneum. Pustules capture only the surface layers of the epidermis. Deeper - massive intercellular edema and penetration of individual neutrophilic granulocytes from the dermis; in the upper part of the latter the capillaries are sharply enlarged, there is a strong edema and a slight infiltration. Elastic and collagen fibers without much change.

According to the histological picture, subcorneal pustulosis differs from other generalized pustules by the location of pustules, the absence of spongioform pustules of Kogoy and the limited nature of the inflammatory reaction of the dermis.

The histogenesis of the disease has been studied little. Attention is given to the immune complexes found in the serum of patients. The disease can provoke drugs, infections and other factors, including tumors. Electron microscopic examination showed that cytolysis of cells of the upper layers of the epidermis, especially granular cells, develops around the pustule, with the formation of subcorneal cracks. Along with the recognition of the independence of the subcorneal pustules, there are opinions that it is one of the variants of pustular psoriasis, the herpetiform dermatitis of Dühring.

Differential diagnosis. The disease should be distinguished from the pustular variety of herpetiform dermatitis, the herpetiform impetigo of Hebra, pustular psoriasis, pemphigus.

Treatment of subcorneal pustules. There are no effective therapeutic methods of treatment. Use antibiotics, sulfones, glucocorticoids, retinoids, phototherapy or a combination of phototherapy with retinoids. Oily prescribe aniline dyes and ointments containing corticosteroids and antibiotics.

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