Case for Diagnosis
Whitish Papules on the Hands
Pápulas Blanquecinas en las Manos
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Bernat García, E. Barberá Montesinos, P. Soriano Sarrio" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Bernat García" "email" => array:1 [ 0 => "josefabernat@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "Barberá Montesinos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "Soriano Sarrio" "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 Doctor Peset, Valencia, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Doctor Peset, Valencia, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "*" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pápulas Blanquecinas en las Manos" ] ] "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" => 833 "Ancho" => 1026 "Tamanyo" => 54998 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 56-year-old man presented with multiple small asymptomatic whitish papules that had appeared 3 months earlier on both hands. The patient's past history included systemic hypertension on treatment with valsartan, untreated hyperuricemia, dyslipidemia, and moderate alcohol consumption with findings on magnetic resonance imaging suggestive of chronic pancreatitis.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination showed numerous small (2-3<span class="elsevierStyleHsp" style=""></span>mm) whitish papules on the palms and fingertips of both hands. The papules were hard and smooth and some of them were ulcerated (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Additional Tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">A biopsy was performed of 1 of the lesions. Microscopy revealed a large nodular deposit of amorphous material containing acicular clefts in the dermis, surrounded by pseudopalisading histiocytes and a marked foreign body giant cell reaction. In close proximity to the main lesion we observed multiple, small, coalescing nodular deposits comprised of similar material with a marked associated giant cell reaction. The epidermis showed no significant changes (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><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">Milia-like cutaneous tophi</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course and Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was referred to the rheumatology department and treated with allopurinol (100<span class="elsevierStyleHsp" style=""></span>mg/d), resulting in a gradual improvement in the lesions.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">The clinical features of gout are caused by deposits of monosodium urate crystals in the tissues. The main clinical manifestations of gout are gouty arthritis, the accumulation of crystals in the connective tissues (tophi), uric acid nephrolithiasis, and renal failure.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Tophi appear after a long period of hyperuricemia. The prevalence of this condition has been reduced by effective therapies and is now limited to patients who fail to comply with treatment and those in whom the diagnosis of gout is delayed.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Rarely, tophi may be the first sign of hyperuricemia.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Tophi appear as whitish-yellowish dermal papules or subcutaneous nodules that are firm to the touch. The borders may be smooth or lobulated. They appear most frequently on the skin covering the joints and on the helix of the ear. Presentation as numerous small papules appearing rapidly on the hands is very rare. Historically, this condition has been referred to as intradermal tophi or pustular gouty tophi. The term milia-like tophi has recently been proposed for this entity based on the similarity between these lesions and millet seeds as well as the wider distribution of the lesions involving not only the fingertips, which has been previously described, but also the palms.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The main histologic feature of gouty tophi is the presence deposits of an amorphous material within the dermis and subcutaneous cellular tissue. These deposits contain acicular clefts, caused by the dissolution of urate crystals, and are surrounded by an infiltrate comprised of histiocytes, in the form of multinucleated giant cells, and lymphocytes, sometimes with the presence of a fibrous capsule. The epidermis may be intact or ulcerated. During standard processing and fixing techniques most of the urate crystals are dissolved and fixation in ethanol or freezing of the tissue is therefore necessary to identify the crystals.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">When observed under a polarized light filter, the acicular crystals exhibit negative birefringence. The clinical differential diagnosis of gouty tophi should include xanthomas, rheumatoid nodules, and calcinosis cutis. The prolonged use of medications that reduce uric acid levels such as allopurinol can successfully treat newer, smaller lesions,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> while larger lesions may be removed surgically.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflict of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</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" => "Additional Tests" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course and Treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Comment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of Interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bernat García J, et al. Pápulas blanquecinas en las manos. Actas Dermosifiliogr. 2013;104:349–50.</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" => 833 "Ancho" => 1026 "Tamanyo" => 54998 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1750 "Ancho" => 1428 "Tamanyo" => 455388 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×10.</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" => 917 "Ancho" => 1223 "Tamanyo" => 170690 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×40.</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" => "Metabolic diseases: gout" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G.F. 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Borbujo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2230.2011.04163.x" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "2012" "volumen" => "37" "paginaInicial" => "450" "paginaFinal" => "452" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22582916" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ulcerated nodules on the posterior aspect of the legs" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Ramírez-Santos" 1 => "R. Martín-Polo" 2 => "P. Sánchez-Sambucety" 3 => "M.A. Rodríguez-Prieto" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2010" "volumen" => "101" "paginaInicial" => "263" "paginaFinal" => "265" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20398603" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of urate-lowering therapy on the velocity of size reduction of tophi in chronic gout" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "F. Perez-Ruiz" 1 => "M. Calabozo" 2 => "J.I. Pijoan" 3 => "A.M. Herrero-Beites" 4 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 17 | 12 | 29 |
| 2024 October | 143 | 54 | 197 |
| 2024 September | 145 | 22 | 167 |
| 2024 August | 178 | 68 | 246 |
| 2024 July | 131 | 38 | 169 |
| 2024 June | 102 | 27 | 129 |
| 2024 May | 82 | 37 | 119 |
| 2024 April | 81 | 21 | 102 |
| 2024 March | 121 | 38 | 159 |
| 2024 February | 140 | 29 | 169 |
| 2024 January | 114 | 34 | 148 |
| 2023 December | 186 | 18 | 204 |
| 2023 November | 265 | 31 | 296 |
| 2023 October | 305 | 29 | 334 |
| 2023 September | 456 | 48 | 504 |
| 2023 August | 402 | 26 | 428 |
| 2023 July | 623 | 42 | 665 |
| 2023 June | 526 | 32 | 558 |
| 2023 May | 319 | 25 | 344 |
| 2023 April | 172 | 21 | 193 |
| 2023 March | 172 | 32 | 204 |
| 2023 February | 166 | 29 | 195 |
| 2023 January | 125 | 33 | 158 |
| 2022 December | 145 | 35 | 180 |
| 2022 November | 70 | 24 | 94 |
| 2022 October | 113 | 25 | 138 |
| 2022 September | 140 | 61 | 201 |
| 2022 August | 100 | 64 | 164 |
| 2022 July | 70 | 62 | 132 |
| 2022 June | 62 | 48 | 110 |
| 2022 May | 125 | 57 | 182 |
| 2022 April | 148 | 45 | 193 |
| 2022 March | 128 | 66 | 194 |
| 2022 February | 87 | 35 | 122 |
| 2022 January | 77 | 52 | 129 |
| 2021 December | 69 | 60 | 129 |
| 2021 November | 71 | 50 | 121 |
| 2021 October | 75 | 78 | 153 |
| 2021 September | 82 | 38 | 120 |
| 2021 August | 49 | 35 | 84 |
| 2021 July | 53 | 31 | 84 |
| 2021 June | 38 | 28 | 66 |
| 2021 May | 52 | 40 | 92 |
| 2021 April | 104 | 52 | 156 |
| 2021 March | 57 | 24 | 81 |
| 2021 February | 57 | 31 | 88 |
| 2021 January | 39 | 12 | 51 |
| 2020 December | 26 | 24 | 50 |
| 2020 November | 27 | 7 | 34 |
| 2020 October | 23 | 15 | 38 |
| 2020 September | 23 | 10 | 33 |
| 2020 August | 29 | 25 | 54 |
| 2020 July | 15 | 21 | 36 |
| 2020 June | 30 | 21 | 51 |
| 2020 May | 24 | 19 | 43 |
| 2020 April | 36 | 16 | 52 |
| 2020 March | 32 | 18 | 50 |
| 2020 February | 3 | 0 | 3 |
| 2020 January | 0 | 2 | 2 |
| 2019 December | 4 | 4 | 8 |
| 2019 November | 0 | 1 | 1 |
| 2019 October | 0 | 4 | 4 |
| 2019 September | 4 | 1 | 5 |
| 2019 August | 0 | 4 | 4 |
| 2019 July | 0 | 2 | 2 |
| 2019 June | 2 | 11 | 13 |
| 2019 May | 1 | 11 | 12 |
| 2019 April | 1 | 11 | 12 |
| 2019 March | 3 | 7 | 10 |
| 2019 February | 0 | 3 | 3 |
| 2019 January | 4 | 0 | 4 |
| 2018 December | 5 | 0 | 5 |
| 2018 November | 4 | 0 | 4 |
| 2018 October | 5 | 0 | 5 |
| 2018 September | 6 | 0 | 6 |
| 2018 August | 0 | 4 | 4 |
| 2018 June | 0 | 6 | 6 |
| 2018 May | 0 | 9 | 9 |
| 2018 March | 23 | 6 | 29 |
| 2018 February | 99 | 5 | 104 |
| 2018 January | 72 | 6 | 78 |
| 2017 December | 106 | 13 | 119 |
| 2017 November | 81 | 10 | 91 |
| 2017 October | 82 | 10 | 92 |
| 2017 September | 89 | 11 | 100 |
| 2017 August | 111 | 13 | 124 |
| 2017 July | 106 | 5 | 111 |
| 2017 June | 138 | 22 | 160 |
| 2017 May | 110 | 14 | 124 |
| 2017 April | 91 | 8 | 99 |
| 2017 March | 91 | 23 | 114 |
| 2017 February | 76 | 14 | 90 |
| 2017 January | 92 | 12 | 104 |
| 2016 December | 82 | 14 | 96 |
| 2016 November | 81 | 18 | 99 |
| 2016 October | 102 | 19 | 121 |
| 2016 September | 109 | 15 | 124 |
| 2016 August | 127 | 17 | 144 |
| 2016 July | 69 | 10 | 79 |
| 2016 June | 8 | 4 | 12 |
| 2016 May | 4 | 19 | 23 |
| 2016 April | 8 | 9 | 17 |
| 2016 March | 4 | 4 | 8 |
| 2016 February | 5 | 4 | 9 |
| 2016 January | 6 | 1 | 7 |
| 2015 December | 8 | 3 | 11 |
| 2015 November | 7 | 2 | 9 |
| 2015 October | 6 | 3 | 9 |
| 2015 September | 14 | 4 | 18 |
| 2015 August | 19 | 4 | 23 |
| 2015 July | 93 | 8 | 101 |
| 2015 June | 85 | 13 | 98 |
| 2015 May | 116 | 28 | 144 |
| 2015 April | 42 | 9 | 51 |
| 2015 March | 42 | 1 | 43 |
| 2015 February | 42 | 6 | 48 |
| 2015 January | 43 | 6 | 49 |
| 2014 December | 65 | 7 | 72 |
| 2014 November | 22 | 3 | 25 |
| 2014 October | 52 | 2 | 54 |
| 2014 September | 46 | 2 | 48 |
| 2014 August | 40 | 6 | 46 |
| 2014 July | 50 | 7 | 57 |
| 2014 June | 54 | 7 | 61 |
| 2014 May | 52 | 8 | 60 |
| 2014 April | 45 | 5 | 50 |
| 2014 March | 48 | 9 | 57 |
| 2014 February | 23 | 9 | 32 |
| 2014 January | 44 | 5 | 49 |
| 2013 December | 39 | 9 | 48 |
| 2013 November | 18 | 4 | 22 |
| 2013 October | 20 | 5 | 25 |
| 2013 September | 17 | 6 | 23 |
| 2013 August | 27 | 4 | 31 |
| 2013 July | 26 | 4 | 30 |
| 2013 June | 7 | 3 | 10 |
| 2013 May | 4 | 4 | 8 |
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