Cases for Diagnosis
Grouped Papules and Plaques on the Lower Limbs
Pápulas y placas agrupadas en extremidades inferiores
J.A. Suárez-Pérez
, N. López-Navarro, E. Herrera-Acosta
Corresponding author
Servicio de Dermatología, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain
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Suárez-Pérez, N. López-Navarro, E. Herrera-Acosta" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J.A." "apellidos" => "Suárez-Pérez" "email" => array:1 [ 0 => "jasuape@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "N." "apellidos" => "López-Navarro" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Herrera-Acosta" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pápulas y placas agrupadas en extremidades inferiores" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1217 "Ancho" => 915 "Tamanyo" => 118596 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 33 year-old man with no relevant medical history who was seen for skin lesions that had been present on both pretibial areas and lateral borders of the feet for 2 years. The lesions were slightly pruritic and followed an intermittent course with periods of improvement but never healed completely. No improvement was seen with the application of topical corticosteroids. The patient reported no extracutaneous symptoms.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed multiple brownish papules and plaques distributed over both pretibial areas (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There were also multiple papules that coalesced to form brownish plaques with irregular borders on the lateral aspects of both feet (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). These lesions extended onto the lateral surface of both ankles, where discrete ulceration was observed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Histology showed fibrinoid necrosis of the small caliber vessels, with a polymorphonuclear infiltrate and karyorrhexis. The early stages of concentric perivascular fibrosis were also present (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Immunofluorescence was negative.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">Blood tests, liver function, kidney function, serum electrolytes, protein analysis and serum protein electrophoresis, antinuclear antibodies, and cryoglobulin were all normal. Urinary sediment was normal. Serology for human immunodeficiency virus (HIV) and hepatitis A, B, and C viruses was negative.</p><p id="par0025" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis?</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Erythema elevatum diutinum (EED).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Blood tests confirmed normal glucose-6-phosphate dehydrogenase levels, and treatment was then initiated with dapsone 100<span class="elsevierStyleHsp" style=""></span>mg/d, achieving a good clinical response. After 6 weeks of treatment with no recurrence of the symptoms, the dose of dapsone was reduced to 50<span class="elsevierStyleHsp" style=""></span>mg/d. At the time of writing, only a residual postinflammatory hyperpigmentation remained.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">EED is a rare form of leukocytoclastic vasculitis characterized by a chronic clinical course.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> It affects adults aged between 30 and 70 years, although cases have been reported in other age ranges. It presents clinically as erythematous-purpuric and yellowish papules that can develop into infiltrated plaques with irregular borders.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> The lesions are initially soft, but later acquire a firm, doughy consistency. Some patients enter a chronic phase of fibrosis in which the initial lesions are replaced by nodules that are hard and can grow to a large size.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Histologically, EED is characterized by leukocytoclastic vasculitis of small-caliber vessels, with fibrinoid necrosis and a neutrophilic infiltrate. The epidermis shows acanthosis and parakeratosis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The most distinctive feature of the disease is the appearance of progressive concentric perivascular fibrosis around the affected vessels. Histological findings are very similar to those of granuloma faciale in an extrafacial location and differentiation of the 2 conditions is difficult for single lesions.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">EED has been described in association with many systemic conditions, including autoimmune and hematological diseases and infections, in particular HIV infection,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> in which EED may be the first manifestation.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Hepatitis B or C virus infection must also be ruled out, and a complete blood count and protein electrophoresis are needed to exclude IgA and IgG gammopathy, IgA multiple myeloma, polycythemia vera, hairy cell leukemia, mixed cryoglobulinemia, and myelodysplasia.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> The group of diseases associated with EED includes inflammatory bowel disease, rheumatoid arthritis, systemic lupus erythematosus, and relapsing polychondritis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The treatment of choice for EED is dapsone, which reduces disease severity but is not curative; recurrence is common when treatment is stopped.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Control of associated diseases, when present, is essential. Other therapeutic options include niacinamide, colchicine, and sulfapyridine.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Treatment with intralesional corticosteroids and surgical excision are only indicated in cases of localized disease.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Additional Tests" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Suárez-Pérez JA, et al. Pápulas y placas agrupadas en extremidades inferiores. Actas Dermosifiliogr.2011;102:823-824.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1217 "Ancho" => 915 "Tamanyo" => 118596 ] ] ] 1 => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 995 "Ancho" => 1015 "Tamanyo" => 95200 ] ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 807 "Ancho" => 1073 "Tamanyo" => 244739 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification x100.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous vasculitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Chung" 1 => "B. Kea" 2 => "D.F. Fiorentino" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Dermatology" "paginaInicial" => "355" "paginaFinal" => "357" "serieFecha" => "2008" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eritema elevatum diutinum" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.T. Bordel" 1 => "J. Bassas" 2 => "A.M. Morales" 3 => "J.A. Tejerina" 4 => "M.H. Aragoneses" 5 => "A. 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Suárez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2002" "volumen" => "93" "paginaInicial" => "501" "paginaFinal" => "506" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Erythema elevatum diutinum: clinical, histopathologic, and immunohistochemical characteristics of six patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.E. Wahl" 1 => "M.B. Bouldin" 2 => "L.E. Gibson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Dermatopathol" "fecha" => "2005" "volumen" => "27" "paginaInicial" => "397" "paginaFinal" => "400" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16148408" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "¿Eritema elevatum et diutinum o granuloma facial extrafacial?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Navarro" 1 => "D. de Argila" 2 => "J. Fraga" 3 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 10 | 25 |
| 2024 October | 145 | 41 | 186 |
| 2024 September | 123 | 27 | 150 |
| 2024 August | 133 | 51 | 184 |
| 2024 July | 128 | 41 | 169 |
| 2024 June | 145 | 34 | 179 |
| 2024 May | 99 | 33 | 132 |
| 2024 April | 99 | 15 | 114 |
| 2024 March | 109 | 33 | 142 |
| 2024 February | 145 | 45 | 190 |
| 2024 January | 104 | 35 | 139 |
| 2023 December | 96 | 20 | 116 |
| 2023 November | 85 | 25 | 110 |
| 2023 October | 91 | 20 | 111 |
| 2023 September | 101 | 34 | 135 |
| 2023 August | 66 | 18 | 84 |
| 2023 July | 86 | 38 | 124 |
| 2023 June | 64 | 25 | 89 |
| 2023 May | 107 | 28 | 135 |
| 2023 April | 71 | 18 | 89 |
| 2023 March | 80 | 21 | 101 |
| 2023 February | 48 | 27 | 75 |
| 2023 January | 58 | 56 | 114 |
| 2022 December | 72 | 41 | 113 |
| 2022 November | 33 | 23 | 56 |
| 2022 October | 30 | 24 | 54 |
| 2022 September | 29 | 33 | 62 |
| 2022 August | 25 | 29 | 54 |
| 2022 July | 26 | 27 | 53 |
| 2022 June | 20 | 21 | 41 |
| 2022 May | 70 | 33 | 103 |
| 2022 April | 83 | 36 | 119 |
| 2022 March | 89 | 56 | 145 |
| 2022 February | 81 | 34 | 115 |
| 2022 January | 90 | 34 | 124 |
| 2021 December | 70 | 43 | 113 |
| 2021 November | 71 | 31 | 102 |
| 2021 October | 87 | 54 | 141 |
| 2021 September | 53 | 36 | 89 |
| 2021 August | 96 | 34 | 130 |
| 2021 July | 80 | 26 | 106 |
| 2021 June | 52 | 31 | 83 |
| 2021 May | 62 | 51 | 113 |
| 2021 April | 142 | 102 | 244 |
| 2021 March | 99 | 40 | 139 |
| 2021 February | 68 | 20 | 88 |
| 2021 January | 60 | 26 | 86 |
| 2020 December | 35 | 19 | 54 |
| 2020 November | 28 | 16 | 44 |
| 2020 October | 37 | 18 | 55 |
| 2020 September | 66 | 16 | 82 |
| 2020 August | 19 | 21 | 40 |
| 2020 July | 32 | 18 | 50 |
| 2020 June | 36 | 26 | 62 |
| 2020 May | 29 | 22 | 51 |
| 2020 April | 29 | 18 | 47 |
| 2020 March | 29 | 18 | 47 |
| 2020 February | 3 | 8 | 11 |
| 2020 January | 4 | 10 | 14 |
| 2019 December | 4 | 3 | 7 |
| 2019 November | 4 | 1 | 5 |
| 2019 October | 0 | 1 | 1 |
| 2019 September | 1 | 1 | 2 |
| 2019 August | 6 | 6 | 12 |
| 2019 July | 4 | 3 | 7 |
| 2019 June | 5 | 9 | 14 |
| 2019 May | 4 | 13 | 17 |
| 2019 April | 2 | 9 | 11 |
| 2019 March | 2 | 9 | 11 |
| 2019 February | 0 | 4 | 4 |
| 2019 January | 2 | 3 | 5 |
| 2018 December | 3 | 1 | 4 |
| 2018 November | 1 | 5 | 6 |
| 2018 October | 2 | 0 | 2 |
| 2018 September | 1 | 0 | 1 |
| 2018 April | 0 | 1 | 1 |
| 2018 March | 1 | 1 | 2 |
| 2018 February | 67 | 4 | 71 |
| 2018 January | 52 | 6 | 58 |
| 2017 December | 73 | 5 | 78 |
| 2017 November | 40 | 6 | 46 |
| 2017 October | 49 | 8 | 57 |
| 2017 September | 36 | 1 | 37 |
| 2017 August | 66 | 10 | 76 |
| 2017 July | 55 | 3 | 58 |
| 2017 June | 44 | 16 | 60 |
| 2017 May | 37 | 8 | 45 |
| 2017 April | 34 | 7 | 41 |
| 2017 March | 24 | 13 | 37 |
| 2017 February | 32 | 7 | 39 |
| 2017 January | 33 | 12 | 45 |
| 2016 December | 56 | 7 | 63 |
| 2016 November | 64 | 6 | 70 |
| 2016 October | 79 | 15 | 94 |
| 2016 September | 82 | 5 | 87 |
| 2016 August | 62 | 13 | 75 |
| 2016 July | 52 | 10 | 62 |
| 2016 June | 19 | 10 | 29 |
| 2016 May | 10 | 13 | 23 |
| 2016 April | 5 | 6 | 11 |
| 2016 March | 6 | 1 | 7 |
| 2016 February | 8 | 10 | 18 |
| 2016 January | 12 | 7 | 19 |
| 2015 December | 11 | 9 | 20 |
| 2015 November | 18 | 10 | 28 |
| 2015 October | 16 | 8 | 24 |
| 2015 September | 11 | 6 | 17 |
| 2015 August | 15 | 3 | 18 |
| 2015 July | 39 | 9 | 48 |
| 2015 June | 36 | 4 | 40 |
| 2015 May | 72 | 16 | 88 |
| 2015 April | 37 | 8 | 45 |
| 2015 March | 41 | 9 | 50 |
| 2015 February | 32 | 4 | 36 |
| 2015 January | 25 | 11 | 36 |
| 2014 December | 34 | 6 | 40 |
| 2014 November | 34 | 8 | 42 |
| 2014 October | 39 | 18 | 57 |
| 2014 September | 28 | 7 | 35 |
| 2014 August | 45 | 12 | 57 |
| 2014 July | 56 | 21 | 77 |
| 2014 June | 75 | 12 | 87 |
| 2014 May | 74 | 18 | 92 |
| 2014 April | 55 | 12 | 67 |
| 2014 March | 65 | 14 | 79 |
| 2014 February | 51 | 17 | 68 |
| 2014 January | 54 | 11 | 65 |
| 2013 December | 60 | 13 | 73 |
| 2013 November | 26 | 8 | 34 |
| 2013 October | 17 | 5 | 22 |
| 2013 September | 13 | 7 | 20 |
| 2013 August | 10 | 5 | 15 |
| 2013 July | 9 | 12 | 21 |
| 2013 June | 10 | 9 | 19 |
| 2013 May | 16 | 9 | 25 |
| 2013 April | 17 | 14 | 31 |
| 2013 March | 13 | 9 | 22 |
| 2013 February | 37 | 4 | 41 |
| 2013 January | 18 | 3 | 21 |
| 2012 December | 19 | 4 | 23 |
| 2012 October | 0 | 1 | 1 |
| 2012 July | 1 | 0 | 1 |
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