Case for Diagnosis
Nodular Peristomal Lesions
Lesiones nodulares periestomales
I. Latour-Álvarez
, E. García-Peris, M.M. Pestana-Eliche, M. García-Bustínduy
Corresponding author
Departamento de Dermatología, Complejo Hospitalario Universitario de Canarias, Santa Cruz de Tenerife, Spain
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The patient had undergone a radical cystoprostatectomy with a Bricker-type ureteroileostomy. He received hormone therapy with luteinizing hormone-releasing hormone (LHRH) agonists and antiandrogens in addition to external beam radiation therapy. The patient reported the gradual development of pruritic lesions in the area around the stoma over the previous 6 months.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed multiple hard grayish-white domed papules 2 to 10<span class="elsevierStyleHsp" style=""></span>mm in diameter that coalesced to form a peristomal pseudoverrucous mass (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The lesions were pruritic but not painful. The patient had no palpable lymph nodes in the groin area or any other site.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">A skin biopsy was performed and histologic examination revealed pseudoepitheliomatous epithelial hyperplasia and chronic inflammatory infiltrate with no koilocytes, atypia, or mitotic figures (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Proteus vulgaris</span> was isolated from urine culture.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Pseudoverrucous papules and nodules (PPN) or chronic papillomatous dermatitis.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment was started with amoxicillin–clavulanic acid (875 and 125<span class="elsevierStyleHsp" style=""></span>mg, respectively, every 8<span class="elsevierStyleHsp" style=""></span>hours for 10 days); by the end of the treatment the lesions had improved slightly. The patient was also advised to adjust the drainage device and change the collection pouch and topical olive oil frequently. After 3 months, the lesions had virtually disappeared.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">PPN, or chronic papillomatous dermatitis, is a rare complication found mainly on the skin around stomas and the perianal area.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Peristomal PPN is considered to be a special form of irritant contact dermatitis caused by the chronic local action of alkaline urine. Urine can accumulate on the skin surface if the ostomy pouch is not properly adjusted, favoring bacterial overgrowth. The bacteria degrade urea, causing an increase in urinary pH.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> PPN is clinically characterized by multiple erythematous-brownish or grayish-white papules and nodules generally located on the lower side of the stoma. The lesions can appear on peristomal skin and also in the perianal area as a result of severe intractable diarrhea of any cause.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–4</span></a> PPN has also been reported in patients with Hirschsprung disease who have undergone colonic re-anastomosis and in children and adults with urinary incontinence.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a> Diagnosis is established clinically and histologically. Differential diagnosis includes the main dermatoses located around stoma sites (secondary neoplasms, metastases, incrustations, exuberant granulation tissue, human papillomavirus infection, gangrenous pyoderma, pressure ulcers, mucosal transplant).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> To prevent PPN, it is important to adjust the drainage device properly and change the collection pouch frequently. PPN is easy to treat, but without treatment complications such as bleeding, stenosis, and stoma occlusion may develop. The recommended treatment for urostomy-related PPN is urine acidification (cranberry juice and a vitamin C–rich diet or vitamin C supplements) and early treatment of infections.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4</span></a> Few cases have been reported recently.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,4</span></a> We describe a new case that responded well to treatment, with the aim of reminding dermatologists of the existence of this probably underdiagnosed condition.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts 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:9 [ 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:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 8 => 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: Latour-Álvarez I, García-Peris E, Pestana-Eliche MM, García-Bustínduy M. Lesiones nodulares periestomales. Actas Dermosifiliogr. 2017;108:363–364.</p>" ] ] "multimedia" => array:2 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 787 "Ancho" => 1059 "Tamanyo" => 122872 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1227 "Ancho" => 1650 "Tamanyo" => 802660 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>10.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dermatosis alrededor de ostomías" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 10 | 24 |
| 2024 October | 90 | 42 | 132 |
| 2024 September | 108 | 23 | 131 |
| 2024 August | 114 | 66 | 180 |
| 2024 July | 107 | 46 | 153 |
| 2024 June | 101 | 61 | 162 |
| 2024 May | 63 | 37 | 100 |
| 2024 April | 96 | 43 | 139 |
| 2024 March | 106 | 38 | 144 |
| 2024 February | 99 | 31 | 130 |
| 2024 January | 83 | 48 | 131 |
| 2023 December | 66 | 25 | 91 |
| 2023 November | 115 | 25 | 140 |
| 2023 October | 112 | 21 | 133 |
| 2023 September | 91 | 36 | 127 |
| 2023 August | 78 | 19 | 97 |
| 2023 July | 77 | 34 | 111 |
| 2023 June | 92 | 25 | 117 |
| 2023 May | 86 | 41 | 127 |
| 2023 April | 64 | 27 | 91 |
| 2023 March | 52 | 46 | 98 |
| 2023 February | 48 | 38 | 86 |
| 2023 January | 48 | 27 | 75 |
| 2022 December | 53 | 41 | 94 |
| 2022 November | 27 | 40 | 67 |
| 2022 October | 33 | 27 | 60 |
| 2022 September | 34 | 53 | 87 |
| 2022 August | 24 | 36 | 60 |
| 2022 July | 25 | 48 | 73 |
| 2022 June | 25 | 35 | 60 |
| 2022 May | 47 | 45 | 92 |
| 2022 April | 72 | 39 | 111 |
| 2022 March | 54 | 53 | 107 |
| 2022 February | 41 | 32 | 73 |
| 2022 January | 62 | 43 | 105 |
| 2021 December | 41 | 45 | 86 |
| 2021 November | 42 | 36 | 78 |
| 2021 October | 55 | 60 | 115 |
| 2021 September | 28 | 35 | 63 |
| 2021 August | 46 | 30 | 76 |
| 2021 July | 38 | 27 | 65 |
| 2021 June | 30 | 24 | 54 |
| 2021 May | 42 | 35 | 77 |
| 2021 April | 106 | 45 | 151 |
| 2021 March | 86 | 17 | 103 |
| 2021 February | 65 | 28 | 93 |
| 2021 January | 36 | 14 | 50 |
| 2020 December | 43 | 15 | 58 |
| 2020 November | 44 | 17 | 61 |
| 2020 October | 31 | 18 | 49 |
| 2020 September | 42 | 9 | 51 |
| 2020 August | 33 | 14 | 47 |
| 2020 July | 20 | 14 | 34 |
| 2020 June | 40 | 21 | 61 |
| 2020 May | 21 | 12 | 33 |
| 2020 April | 21 | 15 | 36 |
| 2020 March | 30 | 7 | 37 |
| 2020 February | 5 | 0 | 5 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 4 | 0 | 4 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 6 | 0 | 6 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 5 | 0 | 5 |
| 2019 April | 2 | 3 | 5 |
| 2019 March | 1 | 0 | 1 |
| 2019 February | 5 | 0 | 5 |
| 2019 January | 1 | 0 | 1 |
| 2018 December | 7 | 0 | 7 |
| 2018 November | 6 | 0 | 6 |
| 2018 October | 13 | 0 | 13 |
| 2018 September | 4 | 0 | 4 |
| 2018 February | 50 | 3 | 53 |
| 2018 January | 48 | 3 | 51 |
| 2017 December | 63 | 6 | 69 |
| 2017 November | 27 | 4 | 31 |
| 2017 October | 24 | 7 | 31 |
| 2017 September | 25 | 7 | 32 |
| 2017 August | 27 | 11 | 38 |
| 2017 July | 21 | 9 | 30 |
| 2017 June | 39 | 10 | 49 |
| 2017 May | 63 | 24 | 87 |
| 2017 April | 15 | 12 | 27 |
| 2017 March | 2 | 5 | 7 |
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