Two Cases of Hallopeau Type of Pemphigus Vegetans in Two Women in Burkina Faso

Pemphigus of Hallopeau (PH) is a mild and pustular form of pemphigus vegetans, termed initially as “pyodermite végétante” described by Hallopeau. We report cases in two black women. Two women aged 32 and 36 respectively (case 1 and case 2) were seen for a pustulosis associated with blisters and erosions. Their history and their review have found the mouth ulcerations. The clinical examination showed pustules on the cephalic end, the trunk, the limbs and the large folds. Lesions had a polycyclic aspect and spread in a centrifugal way, developing towards budding, squamous and scabby erosions quickly surrounded by new pustules. Regression left a pigmented macula. Histological examination of the skin lesion showed images similar to vulgaris pemphigus (PV), together with hyperacanthosis and papillomatosis. Aspects observed in immunofluorescence were identical to those of PV (case1). General corticoid therapy led to a rapid disappearance of lesions in Case 1 but in Case 2 the Lever protocol combining corticoid and methotrexate have been used. PH is rarely described in our regions. Clinical diagnosis is not obvious for the uninitiated. Beyond the clinical presentation, PH has the same paraclinical diagnosis and the same treatment as PV.


Introduction
Pemphigus of Hallopeau (PH) is a mild and postular form of pemphigus vegetans.It is also called Hallopeau type by Anglo-Saxons = Acrodermatitis continua suppurativa [1].This affection termed "pyodermite végétante" was first de- scribed by Hallopeau in Paris at the 1st International Congress of Dermatology and syphiligraphy [2].PH is a rare form of pemphigus vegetans and it has a better prognosis with 1% to 2% of spontaneous remission [3].It is also considered as an infectious disease [4] or as a disease associated with inflammatory enterocolitis [5].It is a rare affection that occurs in the form of vegetating and pustular lesions at the level of the main folds, accompanied by mouth ulcerations.Two cases are reported in black women to describe the clinical characteristics and therapeutic similarities of a quite rare affection.

Case 1
Ms MF, 32 years old, a primary school teacher was seen for pustules and blisters, accompanied by skin erosions.Her past medical history revealed mouth and tongue ulcerations five followed by repetitive pustulo-bullous eruptions of the scalp and armpits.Then, the condition worsened with many pustules spreading rapidly on an altered state of health.The examination revealed pustules due to inflammation on the the cephalic end, the trunk, the limbs and the large folds.
Lesions had a polycyclic aspect, spread in a centrifugal way and developed towards budding, squamous and scabby erosions, surrounded quickly by new pustules (Figure 1

Case 2
GH, a 36-year-old trader was seen for erosive lesions evolving for two months.
Past medical history found a similar episode whose regression left a pigmented macula.On the onset, tongue and mouth ulcerations were reported, followed a

Case Discussion
Our two cases involve young negroid women in their thirties with a past medical history of similar episodes; These are cases of first recurrence.Very few cases of PH are described in french literature.Its prevalence is not well established.A  Complications such as deafness, otalgia, otorrhea and facial paralysis are secondarily described [4], though they are absent in our observations.Diagnostic problems on black skin occur with the bullous lichen, the toxicodermatitis, the dermatophytosis, the pemphigus vulgaris, Stevens-Johnson syndrome and eczema.Complementary examinations, especially histology and direct immunofluorescence on surrounding skin through IgG or even C3 make it possible to confirm the strong clinical suspicion [2].The physiopathology is not well clarified and an association with IEC is described.Many circulating antibodies are in question [5].Like in our two cases, the treatment is mainly based on oral corticoid therapy at high dose (prednisone 1.5 mg/kg/day) and on the Lever Protocol, light in case of failure [6] [7].

Conclusion
PH is rarely described in our regions.Clinical diagnosis is not obvious for the uninitiated.Our cases are specific because they occur in black people, without classical paronychia and with various responses to the general corticoid therapy.
Beyond the clinical presentation, PH has the same paraclinical diagnosis and the same treatment as PV.
(a)).Regression left a pigmented macula.The histopathological examination showed a suprabasal intraepidermic cleavage as in pemphigus vulgaris (PV), and specific lesions: hyperacanthosis and papillomatosis (Figure 2), with club-form bulge of interpapillary buds in the upper dermis.Immunofluorescence showed images evoking a PV.The general corticoid treatment (prednisone 60 mg/day + usual care) associated with local care (Bath with KMnO 4 + AQ eosin 2%) led to the disappearance of lesions within 10 days, leaving pigmented macula-type aftereffects (Figure 1(b)).

Figure 1 .
Figure 1.(a) Erosive lesions spreading in a centrifugal way and red coloring due to local treatment with eosin before admission to hospital.(b) Pigmented macular scar of lesions shown in Figure 1 after 15 days of general corticoid therapy.ab

Figure 3 .Figure 4 .
Figure 3. (a) Lesions at the stage of crustous ulcerations near the large folds.we observe on the figure a pigmented macula on the chest, scar of previous episode.(b) After 3 months under corticosteroid and metothrexate we observed cicatrization with pigmented macula.The patient gained weight with corticosteroids.ab