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228 SHORT COMMUNICATION Two Cases of Acute Febrile Neutrophilic Dermatosis Thought to be Caused by Topical Clindamycin Kiriko NITTA, Yoko KANO, Yukiko USHIGOME, Jun HAYAKAWA and Tetsuo SHIOHARA Department of Dermatology, Kyorin University School of Medicine, 6-20-2 Shinkawa Mitaka, Tokyo 181-8611, Japan. E-mail: yukta@ ks.kyorin-u.ac.jp Accepted Aug 29, 2018; E-published Sep 3, 2018 Acute febrile neutrophilic dermatosis (AFND), or Sweet’s syndrome, is characterized by the sudden onset of pyrexia, peripheral neutrophilia, and erythematous skin lesions, comprising massive neutrophilic infiltration in the dermis. Onset can be linked to various factors, including infection, inflammatory bowel disease (IBD), malignancy and medication. Drug-induced AFND (Di- AFND) is commonly associated with systemic admi- nistration of drugs. Clindamycin (CLD)-induced AFND has been documented in only a small number of cases (1, 2). Although topical CLD for acne has been used for many years, the frequencies of contact dermatitis and phototoxic reactions are low (3–7). We report here 2 cases with unusual AFND, thought to be induced by CLD, with positive lymphocyte trans- formation test (LTT) or patch testing. Chemical peeling and light exposure might have led to the development of AFND in these patients. CASE REPORTS Case 1. A 23-year-old woman presented to our clinic with ery­ thema, pustules and abscesses on the face and legs, together with high fever. Thirty-eight days prior to this first visit, she had started Clindamycin ® Gel 1% (Kracie Pharmaceutical Ltd., Tokyo, Japan) just after a first chemical peeling procedure with 30% salicylic acid dissolved in macrogol for acne in an aesthetic dermatology clinic. Thirty-three days prior to her visit, chemical peeling was repeated. After the first treatment, intense pulsed light (IPL) (wavelengths 560–1,200 nm) was attempted instead of chemical peeling. She had been applying CLD until the day before her first visit despite the exacerbation. On examination, numerous pustules and absces- ses with painful erythematous lesions were identified on her face (Fig. 1A), trunk and limbs where CLD had never been applied. No arthralgia or muscle pain was detected. Laboratory testing revealed elevations of both the white blood cell (WBC) count (15.2×10 3 /mm 3 ; 80.5% neutrophils) and the concentration of C- reactive protein (CRP) (7.3 mg/dl; normal, < 0.03 mg/dl). Results of bacteriological cultures from an abscess on the neck and blood yielded negative results. Computed tomography showed no solid tumour or lymphoproliferative disorder. Skin biopsies from the neck and leg revealed neutrophilic pustules in the epidermis and a dense inflammatory infiltrate, mainly comprising neutrophils, throughout the entire dermis (Fig. 1B and Fig. S1 1 ). Leukocyto- clastic vasculitis was absent. Based on these findings, a diagnosis of AFND or acne fulminans (AF) was suspected. Positive results were obtained from the LTT for CLD (stimulation index (SI) 10.28; positive ≥ 1.81) on her first visit, although patch testing for 10% petrolatum-based CLD had shown negative results. A diagnosis of CLD-induced AFND or AF was made. Oral predni- https://www.medicaljournals.se/acta/content/abstract/10.2340/00015555-3019 1 doi: 10.2340/00015555-3019 Acta Derm Venereol 2019; 99: 228–229 Fig. 1. Case 1. (A) Subcutaneous abscesses and pustules on the face with peri-orbital and nasal sparing. (B) Epidermal and dermal infiltration of inflammatory cells (haematoxylin-eosin (HE) stain; original magnification ×40). solone (PSL) was then started at 30 mg/day, and her symptoms promptly resolved. Case 2. A 42-year-old woman presented with severe pustular eruptions and high fever. Four weeks prior to presentation, she had started oral PSL, 30 mg/day, for exacerbation of alopecia and facial erythema due to pre-existing systemic lupus erythematosus (SLE). Because she developed steroid-induced acne on the face, she had resumed using Dalacin ® T Gel 1% (Sato Pharmaceutical Ltd, Tokyo, Japan). She had experienced no adverse effects with Fig. 2. Case 2. Erythema has coalesced into plaques studded with monomorphic pustules. This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Journal Compilation © 2019 Acta Dermato-Venereologica.