Use of topical povidone-iodine resulting in a iododerma.

Sir,

Iododerma occurs after oral, topical or intravenous iodine usage. It can be seen very rarely after topical application. Various types of lesions such as ulcerous, pustulonodular, vegetative plaques can be seen. We present a case with iododerma after topical iodine usage.

A 23-year-old man was referred to our outpatient institution, with large verrucous vegetative plaques on the neck which developed in a short time [Figure 1]. Hot tea was accidentally poured on the left cheek at first and then on the neck, 2 weeks ago, and silver sulfadiazine cream, lidocaine pomade, and dexpanthenol cream, proposed by a health care center, were applied on this. However, lesions in the shape of acne, whose inside was purulent, developed on the neck after 10 days of application of the above medication and batticon solution dressing and per oral cefprozil tablet were used for them. Three days after this application, lesions in the shape of bulky vegetative plaques that bled in patches formed on the skin. On dermatological examination, six hemorrhagic, palpable, large (the largest was 4 cm in diameter) black crusted vegetative plaques were found. His laboratory and physical examination were normal. Eosinophilia was determined at hemogram. Epidermis showed pseudo-epitheliomatous hyperplasia and the dermis showed extensive venous edema in skin biopsy that was taken [Figure 2]. It was diagnosed as iododerma by anamnesis and histopathological findings.

Figure 1

Vegetative plaques on face

Figure 2

Histopathological view of the lesion

Iododerma occurs after oral, topical or intravenous iodine usage. It can be seen very rarely after topical application.[1-8] Lesions can be in the shape of ulcerous, pustulonodular, and vegetative plaques. In our literature survey, we came across a case presentation related to iododerma after topical iodine application; it was reported that it occurred after anal fissure. Findings such as skin lesions in the shape of pustule and hemorrhagic bullae were connected with iododerma; fever, tachycardia, hypotension were defined.[1] After the application of 15 minutes of daily bath water during 15 days, skin lesions occurred in our case after topical application for a short period of time. Another instance that we came across in our literature survey was that of a case which developed acute kidney failure and respiratory insufficiency with skin lesions in the shape of vegetative mass and vesicular lesions that developed after cardiac catheter application with iodized contrast substance, in addition to systemic findings.[2] It is reported that disorders such as polyarteritis nodosa, monoclonal gammapathy, multiple myeloma, and kidney failure cause predisposition to iododerma.[35] Vegetative iododerma that developed due to potassium iodide treatment in those with these kinds of disorders is reported.[39]

We did not encounter any underlying disorders in our laboratory investigations that was carried out in our case. A case that developed after irrigation with catheter because of abdomen abscess[4] and another one that developed after cardiac irrigation[2] were some other reported cases. There was no iodine intake history in our case; lesions developed only after topical application. Toxicity is reported in areas rich in sebaceous glands, in which there is more absorption, especially after topical application, in cases where skin integrity is compromised.[1] Our patient reported that he carried out topical application to pustules that occurred after burn. Pathogenesis of iododerma is not known. However, it is thought that there is a delayed type hypersensitivity delayed. However it is thought that it occurs with antigenic warning that repeats in those with individual sensitivity.[5] There was eosinophilia (8%) although there was no other allergic history in our case.

In differential diagnosis, deep mycosis, pemphigus vegetans, mycosis fungoides, sweet syndrome, herpetic infection, and pyoderma vegetans are considered.[5-7] It can be definitively differentiated from these disorders by clinical and histopathological findings. Hyperkeratosis in epidermis, edema, perivascular-interstitial lymphocyte infiltration in papillary dermis, and polymorphonuclear infiltration, eosinophile and lymphocyte infiltration in dermis are seen in histopathology. Intensive neutrophilic inflammatory infiltration, sometimes epidermal hyperplasia, pseudoepitheliomatous hyperplasia including intraepidermal or subepidermal vesiculation, epidermal, epidermali dermal and subcutaneous eosinophilic infiltration can be seen.[57] It is thought that it is compatible with iododerma, supported by anamnesis and clinical findings [Figures 1 and 2]. Discontinuation of iodine usage is the principle of treatment.[168] If there are systemic findings, diuretic treatment, topical or systemic corticosteroid or hemodialysis are proposed for iodine elimination.[18] Because of the fact that there were no systemic findings in our case, intra-lesional corticosteroid and chemical cauterant were applied after stopping iodine usage. The lesions recovered with hyperpigmentation [Figure 3]. İododerma is a rare entity after topical povidone therapy; we decided to present at this case because of this reason.

Figure 3

View of lesion after treatment