Case for Diagnosis
Confluent, Retiform, Violaceous Hyperkeratotic Papules
Pápulas violáceas hiperqueratósicas confluentes retiformes
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Garzón Aldás" "autores" => array:1 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Garzón Aldás" "email" => array:1 [ 0 => "Eduderma@Hotmail.Com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Clínica Dermatológica Garzón, Quito. Ecuador" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento De Dermatología, Universidad Central Del Ecuador, Quito, Ecuador" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pápulas violáceas hiperqueratósicas confluentes retiformes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 390 "Ancho" => 1000 "Tamanyo" => 90219 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Hematoxylin–eosin ×4. B, Hematoxylin–eosin ×10.</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">A 76-year old woman with no relevant past medical history visited our department with highly pruritic skin lesions that had appeared 6 years earlier. The patient did not associate the appearance of these lesions with any trigger factor. Additional tests requested, blood count, general biochemistry, hepatitis virus serology (HBV and HBC), HIV, syphilis, thyroid and autoimmune profile, chest x-ray, and tuberculin test (PPD) showed only abnormal levels of the following: glucose, 171 mg/dL; glycosylated hemoglobin, 8.33%; triglycerides, 386 mg/dL; and total cholesterol, 221 mg/dL.</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 a symmetric bilateral rash consisting of violaceous papules, some of which were even purplish, with a hyperkeratotic center, which coalesced in a retiform pattern, mainly on the flexor surface of the upper limbs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), the axillary folds, the root of the lower member and the groin, and on the torso (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The rest of the skin, nails and mucosa were not involved.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">The histologic study of a skin biopsy revealed irregular epidermal acanthosis with hyperkeratosis and follicular keratotic plugs, and a lymphocytic lichenoid inflammatory infiltrate in bands in the dermis, with foci of vacuolar damage in the basement layer of the epidermis, dilated blood vessels in the superficial plexus without vasculitis, and some extravasated red blood cells (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">[[?]]What is your Diagnosis?</p></span></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Chronic lichenoid keratosis.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course and Treatment</span><p id="par0025" class="elsevierStylePara elsevierViewall">Topical treatment was prescribed with a calcipotriol/betamethasone cream and oral prednisone at a dose of 1 mg/kg of weight; this achieved a considerable reduction in the pruritus and resolution of the papular lesions, leaving hyperpigmented postinflammatory patches, after 4 weeks of treatment.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comments</span><p id="par0030" class="elsevierStylePara elsevierViewall">Chronic lichenoid keratosis or Nekam disease<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> is a rarely reported and underdiagnosed entity.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> It was first described by Kaposi in 1895 as a variant of lichen, and dubbed <span class="elsevierStyleItalic">lichen ruber acuminatus verrucosus et reticularis</span>.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In 1938, Nekam postulated that it was a variant of porokeratosis and therefore called it <span class="elsevierStyleItalic">porokeratosis striata lichenoides</span>. The current name of lichenoid keratosis was proposed by Margolis en 1972.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">It is a disease of unknown etiology, characterized by the presence of violaceous papules reminiscent of lichen planus, distributed over the torso and extremities in a linear and/or reticular symmetric, bilateral pattern, with a tendency to become generalized.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">4</span></a> Onset is usually in adulthood with no predominance of sex or race. It follows a chronic course, in which pruritus may vary from minimal or absent to very intense.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">It has been reported to coexist with facial lesions that simulate seborrheic eczema or perioral dermatosis, palmoplantar keratoderma, and dystrophic ungual lesions. In exceptional cases, the presence of oral or genital sores has been reported, and ocular lesions such as blepharitis, keratoconjunctivitis, or iridocyclitis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Histopathology is nonspecific. Focal parakeratotic hyperkeratosis is found with some follicular plugs. Vacuolization of the basement layer is present. A lymphocytic infiltrate in bands with a clearly defined lower limit can be seen in the upper dermis.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a> A purplish variety has been described, characterized by hematic extravasation and occasional vasculitis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">4</span></a> The differential diagnosis must include lichen planus, drug-induced lichenoid eruptions, pityriasis rubra pilaris, pityriasis lichenoides, mycosis fungoides, and other processes.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The definitive diagnosis is established by means of a clinical-disease correlation where the main clinical sign is the retiform appearance of the dermatosis and the characteristic erythematous-violaceous coloring of the papules, in patients with no temporal association with medication. The histologic findings that support the diagnosis are lymphocytic lichenoid dermatitis with varying degrees of acanthosis, hyperkeratosis, and foci of parakeratosis. All these findings were present in the patient described. Treatment with daily application of calcipotriol/betamethasone cream was justified by the current understanding of the disease as a keratinization disorder,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> and the oral prednisone was justified by the intense pruritus, the considerable lymphocytic inflammatory infiltrate, and the extent of the lesions on the body. The patient’s diabetes was controlled with combination oral hypoglycemic agents, with no complications.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The author declares that he has 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" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course and Treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Comments" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-11-08" "fechaAceptado" => "2019-01-11" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Garzón Aldás E. Pápulas violáceas hiperqueratósicas confluentes retiformes. Actas Dermosifiliogr. 2020;111:601–602.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 628 "Ancho" => 1000 "Tamanyo" => 96462 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 607 "Ancho" => 1000 "Tamanyo" => 75167 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 390 "Ancho" => 1000 "Tamanyo" => 90219 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Hematoxylin–eosin ×4. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 18 | 12 | 30 |
| 2024 October | 107 | 46 | 153 |
| 2024 September | 98 | 34 | 132 |
| 2024 August | 111 | 63 | 174 |
| 2024 July | 109 | 38 | 147 |
| 2024 June | 109 | 31 | 140 |
| 2024 May | 79 | 34 | 113 |
| 2024 April | 77 | 27 | 104 |
| 2024 March | 91 | 25 | 116 |
| 2024 February | 73 | 34 | 107 |
| 2024 January | 94 | 37 | 131 |
| 2023 December | 62 | 23 | 85 |
| 2023 November | 90 | 31 | 121 |
| 2023 October | 81 | 24 | 105 |
| 2023 September | 67 | 39 | 106 |
| 2023 August | 58 | 21 | 79 |
| 2023 July | 71 | 40 | 111 |
| 2023 June | 60 | 37 | 97 |
| 2023 May | 111 | 43 | 154 |
| 2023 April | 80 | 34 | 114 |
| 2023 March | 81 | 42 | 123 |
| 2023 February | 61 | 33 | 94 |
| 2023 January | 37 | 39 | 76 |
| 2022 December | 64 | 39 | 103 |
| 2022 November | 43 | 36 | 79 |
| 2022 October | 33 | 37 | 70 |
| 2022 September | 41 | 41 | 82 |
| 2022 August | 39 | 51 | 90 |
| 2022 July | 26 | 39 | 65 |
| 2022 June | 22 | 33 | 55 |
| 2022 May | 65 | 38 | 103 |
| 2022 April | 65 | 37 | 102 |
| 2022 March | 69 | 62 | 131 |
| 2022 February | 54 | 33 | 87 |
| 2022 January | 68 | 45 | 113 |
| 2021 December | 51 | 32 | 83 |
| 2021 November | 55 | 38 | 93 |
| 2021 October | 74 | 61 | 135 |
| 2021 September | 52 | 37 | 89 |
| 2021 August | 115 | 37 | 152 |
| 2021 July | 49 | 18 | 67 |
| 2021 June | 36 | 19 | 55 |
| 2021 May | 37 | 34 | 71 |
| 2021 April | 112 | 50 | 162 |
| 2021 March | 52 | 24 | 76 |
| 2021 February | 70 | 27 | 97 |
| 2021 January | 56 | 20 | 76 |
| 2020 December | 47 | 11 | 58 |
| 2020 November | 31 | 17 | 48 |
| 2020 October | 65 | 30 | 95 |
| 2020 September | 59 | 32 | 91 |
| 2020 August | 14 | 10 | 24 |
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