Case for Diagnosis
Indurated Papules on the Face
Pápulas faciales induradas
C. González-Cruz
, V. Cabezas, V. García-Patos
Corresponding author
Servicio de Dermatología, Hospital Universitari Vall d’Hebron, Barcelona, Spain
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She reported no relevant family history but her own history included renal angiomyolipomas and severe acne continuing after adolescence. She had also been diagnosed with rosacea some years before and was following treatments with topical metronidazole and brimonidine. She complained of flushing and papular and pustular skin eruptions on the face that had resolved before the visit but had left her with other persistent papules.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">We observed malar erythema, telangiectasia and a dozen hemispherical, indurated, whitish-yellow papules measuring 2–3<span class="elsevierStyleHsp" style=""></span>mm in diameter dispersed across the forehead, chin, and cheeks (<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">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">A well-defined, dark bluish-violet nodular deposit was observed in the mid-dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Higher magnification revealed mature bony trabeculae with osteocytes inside and Haversian canals containing blood vessels and connective tissue (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B).</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">A blood work-up showed no abnormalities in renal function. Calcium and phosphorous metabolism was normal.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">What Is Your Diagnosis?</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Multiple miliary osteoma cutis (MMOC) secondary to acne.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical Course and Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">The lesions have remained stable. The patient opted not to undergo treatment.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">MMOC is a rare subtype of skin ossification that is characterized by bony tissue formation in the dermis and subcutaneous layers. The pathogenesis is unclear, but an association with chronic inflammatory processes such as acne, as described in our patient, has been suggested.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Chronic inflammation is thought to induce metaplasia in pluripotent dermal mesenchymal cells and lead to the formation of osteoblasts.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Previous authors have described a possible association between MMOC and treatment with bisphosphonates.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">MMOC is characterized clinically by the presence of multiple, firm, asymptomatic, skin-colored papules and nodules mainly on the face in young or postmenopausal women.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–3</span></a>Clinical signs and imaging (dermatologic ultrasound and simple radiographs) can facilitate diagnosis, but histology is required for certainty. Histology demonstrates bony spicules in the dermis and osteocytes and osteoblasts in subcutaneous cellular tissue.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Differential diagnosis must take into consideration cutaneous calcification, which is associated with endocrine and metabolic disorders. In this condition calcium is deposited in the dermis, whereas in MMOC bone is actually formed.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> The absence of other clinical signs, the age at which the disorder presents, and the clinical course can also help distinguish MMOC from primary syndromes associated with cutaneous osteomas, such as Albright hereditary osteodystrophy, progressive ossifying fibrodysplasia, progressive osseous heteroplasia, and platelike osteoma cutis. Finally, differential diagnosis should also consider closed comedones and milium cysts.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">No standard treatment for MMOC has emerged. Any approach undertaken will have aesthetic improvement as its purpose. Topical retinoids, carbon dioxide laser therapy,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> dermabrasion, and the excision of large lesions have been tried, with variable results.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4</span></a> Surgical mini-excision using a needle and curettage was reported to give good results in a series of 11 patients.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">This description of a case of MMOC — an uncommon, benign condition that is probably underdiagnosed — shows that details of a patient's medical history can provide the clues to making this diagnosis. Our patient had experienced severe acne, a disease that other published cases have linked to the development of MMOC.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,6</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">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:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case 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:3 [ "identificador" => "sec0025" "titulo" => "What Is Your Diagnosis?" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Diagnosis" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Clinical Course and Treatment" ] ] ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Comment" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts 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: González-Cruz C, Calderón VC, Briones VG-P. Pápulas faciales induradas. Actas Dermosifiliogr. 2019;110:599–600.</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" => 612 "Ancho" => 850 "Tamanyo" => 95209 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1308 "Ancho" => 850 "Tamanyo" => 316686 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Histologic findings. A, Hematoxylin-eosin, original magnification ×400. B, Hematoxylin-eosin, original magnification, ×2000.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation and management of multiple miliary osteoma cutis: Case series of 11 patients and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I.S. Chabra" 1 => "S. 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Harms" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1468-3083.2006.01425.x" "Revista" => array:6 [ "tituloSerie" => "J Eur Acad Dermatol Venereol" "fecha" => "2006" "volumen" => "20" "paginaInicial" => "321" "paginaFinal" => "326" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16503897" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000011000000007/v1_201909021030/S1578219019301271/v1_201909021030/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000011000000007/v1_201909021030/S1578219019301271/v1_201909021030/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219019301271?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 17 | 10 | 27 |
| 2024 October | 113 | 29 | 142 |
| 2024 September | 105 | 25 | 130 |
| 2024 August | 134 | 47 | 181 |
| 2024 July | 109 | 29 | 138 |
| 2024 June | 120 | 40 | 160 |
| 2024 May | 93 | 44 | 137 |
| 2024 April | 92 | 19 | 111 |
| 2024 March | 91 | 33 | 124 |
| 2024 February | 68 | 37 | 105 |
| 2024 January | 77 | 36 | 113 |
| 2023 December | 65 | 15 | 80 |
| 2023 November | 71 | 32 | 103 |
| 2023 October | 79 | 21 | 100 |
| 2023 September | 72 | 31 | 103 |
| 2023 August | 55 | 18 | 73 |
| 2023 July | 75 | 38 | 113 |
| 2023 June | 63 | 22 | 85 |
| 2023 May | 87 | 22 | 109 |
| 2023 April | 84 | 19 | 103 |
| 2023 March | 80 | 20 | 100 |
| 2023 February | 67 | 20 | 87 |
| 2023 January | 63 | 19 | 82 |
| 2022 December | 56 | 37 | 93 |
| 2022 November | 43 | 27 | 70 |
| 2022 October | 36 | 29 | 65 |
| 2022 September | 37 | 35 | 72 |
| 2022 August | 53 | 33 | 86 |
| 2022 July | 64 | 52 | 116 |
| 2022 June | 33 | 28 | 61 |
| 2022 May | 54 | 34 | 88 |
| 2022 April | 69 | 29 | 98 |
| 2022 March | 75 | 48 | 123 |
| 2022 February | 73 | 27 | 100 |
| 2022 January | 86 | 44 | 130 |
| 2021 December | 75 | 31 | 106 |
| 2021 November | 85 | 41 | 126 |
| 2021 October | 85 | 54 | 139 |
| 2021 September | 74 | 34 | 108 |
| 2021 August | 106 | 25 | 131 |
| 2021 July | 135 | 21 | 156 |
| 2021 June | 80 | 30 | 110 |
| 2021 May | 41 | 35 | 76 |
| 2021 April | 156 | 80 | 236 |
| 2021 March | 103 | 28 | 131 |
| 2021 February | 89 | 15 | 104 |
| 2021 January | 38 | 9 | 47 |
| 2020 December | 29 | 17 | 46 |
| 2020 November | 17 | 20 | 37 |
| 2020 October | 22 | 10 | 32 |
| 2020 September | 25 | 12 | 37 |
| 2020 August | 18 | 13 | 31 |
| 2020 July | 13 | 11 | 24 |
| 2020 June | 23 | 18 | 41 |
| 2020 May | 13 | 10 | 23 |
| 2020 April | 17 | 9 | 26 |
| 2020 March | 17 | 5 | 22 |
| 2020 February | 4 | 2 | 6 |
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