LAUSR

To the Editor, Papuloerythroderma of Ofuji (PEO) is an uncommon chronic skin disease described for first time by Ofuji, Furokawa, Miyachi, and Ohno (1984). Since then more than 100 papers have been published (Torchia, Miteva, Hu, Cohen, & Romanelli, 2010) contributing both to the knowledge of the entity and to add confusión about if it is an independent entity or a peculiar pattern in which other dermatoses could be expressed (Saurat, 1993). However, Torchia et al. (2010) established diagnostic criteria that allow us recognize PEO as an independent disease and subsequently define other secondary causes of papuloerythroderma. We treated a patient which fulfilled all 10 diagnostic criteria for PEO successfully with methotrexate. A 78-year-old man with a history of hyperlipidemia, achalasia, and normal pressure hydrocephalus following treatment with atorvastatin, distraneurin, alprazolam, omeprazole, paracetamol, and calcium carbonate/vitamin D3, was referred for a 1-year severe pruritic rash. He had been treated with topical and oral steroids, several antihistamines, and antibiotics. Physical examination showed multiple, nonscaly, pink to brown confluent papules on the trunk, with flattened surface, that grouped giving a cobblestone-like appearance, and sparing the skin folds (Figure 1). No accessible lymphadenopathy was evident. A skin biopsy showed elongation of epidermal rete ridges and, in the dermis, edema, and perivascular inflammatory infiltrate with lymphocytes and few eosinophils that sometimes extended between the collagen bundles in the papillary and upper reticular dermis (Figure 2). An extensive workup to rule out internal malignancy, infections and autoimmune diseases was negative, however, we found an elevated total IgE (1,507 KU/L, NV < 25), a relative lymphocytopenia (14.9% NV: 20.0–44.0) and eosinophilia (12.3%, NV, 1.0–7.0). Since the patient did not have the facility to go to phototherapy, oral methotrexate in a 15 mg weekly dose plus 5 mg folic acid supplementation was started. Two months later the rash (Figure 3), itching and eosinophilia had been disappeared. No recurrences were seen at 3-month follow-up. Our patient had primary PEO because all 10 diagnostic criteria proposed by Torchia et al. (2010) were fulfilled: the five necessary ones (eruption of coalescing flat-topped papules, sparing of the skin folds— the well-known, although not pathognomonic, deck-chair sign—itch, histopathological exclusion of other diseases, mainly cutaneous T-cel lymphoma, and extensive work up to exclude any possible cause or association) and the five additional minor criteria (age over 55 years, male gender, peripheral, and/or tissue eosinophilia, increased serum IgE, and perypheral lymphopenia). In primary PEO, having no causal factors or associations to adress, treatment has been based primarily on topical or systemic corticosteroids, and/or phototherapy, with variable results. Antihistamines, interferon, etretinate, cyclosporine, and azathioprine have been other alternatives used (Torchia et al., 2010). Our patient had been treated with emollients, antihistamines, antibiotics, and corticosteroids without response, however, treatment with methotrexate was followed by a rapid and complete disappearance of skin lesions, pruritus, and eosinophilia. PEO is a T-cell mediated skin disease and it has been suggested that Th2 and Th22 cells could be important in its pathogenesis (Teraki & Inoue, 2014). Low doses of methotrexate could act in this dermatosis through an immunosuppressive mechanism on activated