Cases for Diagnosis
A Pseudovesicular Plaque on the Shoulder
Una placa pseudovesicular en el hombro
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"apellidos" => "Calzada González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de Cabueñes, Gijón, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario de Cabueñes, Gijón, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Una placa pseudovesicular en el hombro" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 377 "Ancho" => 1005 "Tamanyo" => 166757 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Hematoxylin–eosin staining. (B) Alcian blue staining.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a 79-year-old woman with a history of rheumatoid arthritis, osteoporosis, and advanced chronic kidney disease managed with renal replacement therapy (hemodialysis). She was referred to the dermatology department of our hospital for assessment of a lesion on her left shoulder that had first appeared several months earlier. The lesion had grown and was occasionally pruritic.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination and Histopathology</span><p id="par0010" class="elsevierStylePara elsevierViewall">At her first visit, we observed a single red-violaceous plaque (8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm) with a clustered pseudovesicular surface on the posterior aspect of her left shoulder (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Histopathology revealed a preserved epidermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). A diffuse mucin deposit was observed in the upper reticular and papillary dermis (positive for Alcian blue staining), together with a slight increase in irregularly distributed fibroblasts and a modest perivascular lymphoplasmocytic infiltrate (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). The elastic fibers were diminished and fragmented. Thin-walled arborizing vessels were visible in the deep dermis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical Course</span><p id="par0015" class="elsevierStylePara elsevierViewall">The lesions began to improve 1 month after the biopsy, with only a pseudovesicular plaque (7<span class="elsevierStyleHsp" style=""></span>mm in diameter) on a residual erythematous-violaceous base remaining (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The lesion had resolved completely at 6 months. Subsequent analysis revealed anemia of chronic disease and increased urea and plasma creatinine (these findings were previously known), with normal thyroid function and absence of paraproteinemia.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">What is your diagnosis?</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Adult self-healing papular mucinosis.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion and Commentary</span><p id="par0030" class="elsevierStylePara elsevierViewall">Cutaneous mucinosis comprises a very diverse and heterogeneous group of diseases, all of which are characterized by abnormal accumulation of mucin in the skin. Mucins are high-molecular-weight proteins composed of glycosaminoglycans. They are synthetized by dermal fibroblasts and act as a key factor in maintaining the hydrosaline balance in the skin.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">According to the most widely accepted classification, which was proposed by Rongioletti and Rebora in 2001, cutaneous mucinosis can be divided into the localized form (papular mucinosis, also known as lichen myxedematosus) and the generalized form (scleromyxedema).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Mucinosis can also be idiopathic (primary) or secondary to other conditions.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Self-healing papular mucinosis (SHPM) is an uncommon entity belonging to the group of localized cutaneous mucinoses (lichen myxedematosus). Since it is more common in children, it was initially reported as a pediatric condition (1–15 years) that manifests with multiple lesions and, occasionally, systemic symptoms. However, there have been reports of cases appearing in adulthood and involving localized lesions.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Unlike generalized cutaneous mucinosis (scleromyxedema), the variants of lichen myxedematosus are not usually associated with systemic diseases, thyroid problems, or paraproteinemia. There have been reports of cases of SHPM in adults with type 2 diabetes mellitus, bacterial pneumonia, and autoimmune diseases such as rheumatoid arthritis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> However, the etiology-pathogenesis of SHPM is unknown.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Adult SHPM is traditionally characterized by multiple pseudovesicular papules arranged symmetrically and mainly affecting the upper half of the skin (head, neck, shoulders, abdomen). The papules may coalesce to form plaques and/or nodules and may be associated with systemic symptoms (fever, asthenia, joint and muscle pain). Very few cases of adult SHPM with unilateral and asymmetrical involvement have been reported.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The skin lesions tend to resolve spontaneously over a period of weeks or months. Histology frequently reveals abundant mucinous material in the middle and upper dermis, with a slight increase in the fibroblast count. These findings usually appear alongside a nonspecific inflammatory pattern.</p><p id="par0055" class="elsevierStylePara elsevierViewall">We present a case of adult SHPM that presented asymmetrically and involuted spontaneously. Given the considerable heterogeneity of cutaneous mucinosis, the correlation between disease and symptoms could be key to reaching a correct diagnosis, especially in atypical cases. Lastly, it is important to distinguish between SHPM and self-healing juvenile cutaneous mucinosis, since these are different entities.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination and Histopathology" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Clinical Course" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion and Commentary" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of Interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 576 "Ancho" => 752 "Tamanyo" => 46124 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">First visit. Left shoulder: red-violaceous plaque measuring 8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm with a pseudovesicular and clustered surface.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 377 "Ancho" => 1005 "Tamanyo" => 166757 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Hematoxylin–eosin staining. (B) Alcian blue staining.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 537 "Ancho" => 805 "Tamanyo" => 59339 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Follow-up visit. Left shoulder: residual erythematous-violaceous macule, with a single vesicle in the center.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary paediatric cutaneous mucinoses" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F. Rongioletti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/bjd.18004" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2020" "volumen" => "182" "paginaInicial" => "29" "paginaFinal" => "38" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30977896" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Updated classification of papular mucinosis, lichen myxedematosus, and scleromyxedema" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F. Rongioletti" 1 => "A. Rebora" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1067/mjd.2001.111630" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2001" "volumen" => "44" "paginaInicial" => "273" "paginaFinal" => "281" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11174386" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Self-healing papular mucinosis in an adult" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B.R. Sperber" 1 => "J. Allee" 2 => "W.D. James" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0190-9622(03)00790-4" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2004" "volumen" => "50" "paginaInicial" => "121" "paginaFinal" => "123" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14699380" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adult variant of self-healing papular mucinosis in a patient with rheumatoid arthritis: predominant proliferation of dermal dendritic cells expressing CD34 or factor XIIIa in association with dermal deposition of mucin" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. Yokoyama" 1 => "M. Muto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1346-8138.2006.00005.x" "Revista" => array:6 [ "tituloSerie" => "J Dermatol" "fecha" => "2006" "volumen" => "33" "paginaInicial" => "30" "paginaFinal" => "35" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16469081" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adult self-healing papular mucinosis on genital skin" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Feliciani" 1 => "I. Pennacchia" 2 => "G. Massi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2230.2009.03483.x" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "2009" "volumen" => "34" "paginaInicial" => "e760" "paginaFinal" => "e762" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19817766" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00017310/0000011400000004/v1_202304111712/S000173102300162X/v1_202304111712/en/main.assets" "Apartado" => array:4 [ "identificador" => "6149" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Casos para el diagnóstico" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/00017310/0000011400000004/v1_202304111712/S000173102300162X/v1_202304111712/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S000173102300162X?idApp=UINPBA000044" ]
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| 2023 March | 120 | 81 | 201 |
| 2023 February | 2 | 4 | 6 |
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