Case for Diagnosis
Painful Nodules on the Thighs
Nódulos dolorosos en muslos
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"apellidos" => "Ara" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Royo Villanova, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Dermatología del Hospital de Alcañiz, Teruel, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nódulos dolorosos en muslos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 900 "Ancho" => 900 "Tamanyo" => 273933 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histology. A. Hematoxylin-eosin, original magnification, ×10. B and C. Hematoxylin-eosin, original magnification, ×40.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Presentation</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 23-year-old woman consulted for the gradual appearance of painful lesions on the external aspect of the thighs. The lesions had first appeared 5 weeks earlier. The patient reported similar flare-ups over 3 consecutive years; these appeared during the coldest months of the year and resolved without scarring as the seasonal temperature increased. No other manifestations were observed. The patient was a horseback rider and rode and cared for horses on a daily basis.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">The examination revealed erythematous-violaceous lesions that were painful to the touch and tended to coalesce and form plaques on the outer part of the upper thigh (both legs) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Erythematous-violaceous reticulated macules with a vascular appearance were observed on the rest of the thigh. The local temperature was lower in the affected areas.</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">The histopathology workup (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A) revealed a perivascular and periadnexal dermal lymphocytic infiltrate beneath a normal epidermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C), as well as venulitis in the deep reticular dermis and hypodermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). No signs of panniculitis were observed. Alcian-blue staining did not reveal mucin deposits.</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">The results of the laboratory work-up were normal (negative for autoimmunity, cold agglutinins, cryoglobulins, and serology). Capillaroscopy performed on the hands revealed normal findings, as did Doppler ultrasound of the lower limbs.</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">Cold-associated perniosis of the thighs (CAPT).</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Course and Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was recommended to wear looser clothing and prescribed medium-potency topical corticosteroids. The lesions had improved at the 1-month check-up.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">CAPT is the term proposed in 2016 by Ferrara and Cerroni<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> to describe a condition for which no consensus had been reached and that had been reported with various names: equestrian panniculitis, equestrian-type perniosis, or equestrian-type chilblains. Diagnosis is based on previous exposure to cold, cutaneous lesions on the side of the thighs, and a compatible history.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The usual clinical picture of CAPT does not differ significantly from that originally described in 1980 by Beacham et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> under the name of equestrian cold panniculitis. It is characterized by the presence of infiltrated erythematous-violaceous plaques that may be pruritic or painful. The plaques are found mainly on the outer part of the upper thigh and are not accompanied by other abnormalities.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The term <span class="elsevierStyleItalic">equestrian</span> was replaced by <span class="elsevierStyleItalic">cold-associated</span>. Other causes have been identified, for example, riding a bicycle, occupational exposure to humid environments, toboganning,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> wearing jeans with a low waistband,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and application of icepacks.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The term <span class="elsevierStyleItalic">perniosis</span> is now preferred to <span class="elsevierStyleItalic">panniculitis</span> because signs of panniculitis were not observed in many of the cases analyzed. The most common finding is a perivascular and periadnexal lymphocytic infiltrate in the superficial and deep dermis. Other findings include mucin deposits in the dermis and inflammation of small- and medium-caliber venules. Some cases also present lymphocytic lobular panniculitis, which is probably an advanced stage of deep venulitis. Histology makes it possible to differentiate the condition from other conditions in which cold leads to necrosis of hypodermal fat, such as Haxthausen disease or panniculitis caused by sucking ice cream; the term <span class="elsevierStyleItalic">cold-induced panniculitis</span> should be reserved for these conditions.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6</span></a> Furthermore, cases of cold-induced dermatosis have been reported in horseback riders or persons who have applied cold locally in order to treat low back pain. This can take the form of panniculitis and chilblains (perniosis), which, in histologic terms, resemble lupus.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The outer part of the upper thigh is the most common location, for several reasons. The area is more exposed to cold, thus leading to vasoconstriction and increased blood viscosity. In addition, it is exposed to tight clothes that place continuous pressure on the area and reduce blood flow in the subcutaneous fat. Moreover, the area is characterized by abundant adipose tissue, which isolates blood vessels and makes them more susceptible to the effects of cold.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Treatment is based on recommending loose clothing. Topical corticosteroids can also be applied. Vasodilators are not useful.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The condition usually resolves without scarring after a few weeks.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of Interest</span><p id="par0065" 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 Presentation" ] 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" => "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 "fechaRecibido" => "2019-02-22" "fechaAceptado" => "2019-05-23" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Conejero R, Rivera-Rodríguez Á, Ara M. Nódulos dolorosos en muslos. Actas Dermosifiliogr. 2021;112:357–358.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 580 "Ancho" => 600 "Tamanyo" => 37807 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical image.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 900 "Ancho" => 900 "Tamanyo" => 273933 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histology. A. Hematoxylin-eosin, original magnification, ×10. B and C. Hematoxylin-eosin, original magnification, ×40.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cold-Associated Perniosis of the Thighs (“Equestrian-Type” Chilblain): A Reappraisal Based on a Clinicopathologic and Immunohistochemical Study of 6 Cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G. Ferrara" 1 => "L. Cerroni" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/DAD.0000000000000477" "Revista" => array:7 [ "tituloSerie" => "Am J Dermatopathol." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 7 | 20 |
| 2024 October | 122 | 57 | 179 |
| 2024 September | 109 | 39 | 148 |
| 2024 August | 155 | 63 | 218 |
| 2024 July | 149 | 49 | 198 |
| 2024 June | 125 | 44 | 169 |
| 2024 May | 108 | 38 | 146 |
| 2024 April | 123 | 31 | 154 |
| 2024 March | 102 | 29 | 131 |
| 2024 February | 99 | 41 | 140 |
| 2024 January | 95 | 44 | 139 |
| 2023 December | 108 | 19 | 127 |
| 2023 November | 114 | 38 | 152 |
| 2023 October | 81 | 20 | 101 |
| 2023 September | 80 | 27 | 107 |
| 2023 August | 75 | 28 | 103 |
| 2023 July | 116 | 36 | 152 |
| 2023 June | 70 | 27 | 97 |
| 2023 May | 91 | 31 | 122 |
| 2023 April | 69 | 23 | 92 |
| 2023 March | 94 | 36 | 130 |
| 2023 February | 107 | 30 | 137 |
| 2023 January | 70 | 36 | 106 |
| 2022 December | 85 | 59 | 144 |
| 2022 November | 66 | 39 | 105 |
| 2022 October | 40 | 22 | 62 |
| 2022 September | 39 | 29 | 68 |
| 2022 August | 45 | 37 | 82 |
| 2022 July | 36 | 49 | 85 |
| 2022 June | 61 | 29 | 90 |
| 2022 May | 94 | 48 | 142 |
| 2022 April | 110 | 40 | 150 |
| 2022 March | 83 | 65 | 148 |
| 2022 February | 88 | 36 | 124 |
| 2022 January | 92 | 44 | 136 |
| 2021 December | 61 | 48 | 109 |
| 2021 November | 73 | 43 | 116 |
| 2021 October | 55 | 75 | 130 |
| 2021 September | 47 | 60 | 107 |
| 2021 August | 57 | 40 | 97 |
| 2021 July | 59 | 34 | 93 |
| 2021 June | 66 | 53 | 119 |
| 2021 May | 76 | 69 | 145 |
| 2021 April | 197 | 149 | 346 |
| 2021 March | 47 | 26 | 73 |
| 2021 February | 57 | 20 | 77 |
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