Case for Diagnosis
Multiple Keloid Nodules in a Middle-Aged Woman
Múltiples nódulos queloideos en paciente mujer de mediana edad
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Hernández San Martín, V. Kaplan Zapata, C. Morales Huber" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M.J." "apellidos" => "Hernández San Martín" "email" => array:1 [ 0 => "majesus.hsm@gmail.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" => "V." "apellidos" => "Kaplan Zapata" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Morales Huber" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Facultad de Medicina Universidad de Chile, Santiago, Chile" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital del Salvador, Santiago, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Patología, Hospital Clínico Universidad de Chile, Santiago, Chile" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Múltiples nódulos queloideos en paciente mujer de mediana edad" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2042 "Ancho" => 1257 "Tamanyo" => 109381 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin–eosin staining, original magnification ×40.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 61-year-old woman presented with a 6-year history of spontaneous, progressive skin nodules on her neck and trunk. Her medical history was remarkable for hypothyroidism, type 2 diabetes, depression, Raynaud phenomenon, and fundoplication surgery for gastroesophageal reflux. Physical examination showed microstomia and multiple, well-circumscribed, flesh-colored nodules on the neck, anterior thorax, back, shoulders, and arms (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The nodules were not painful, measured 5 to 10 mm in diameter, and were not fixed to the deep layers. The patient also had a plaque measuring 30 × 30 mm on each forearm and bilateral Raynaud phenomenon with an associated ulcer on the right index finger. Examination of three 4-mm biopsy specimens from nodules on the right upper limb showed a preserved epidermis and pronounced dermal fibrosis, decreased skin appendages, and a mild superficial and deep periadnexal and perivascular inflammatory infiltrate (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>). Mucin deposition observed with Alcian blue staining was insignificant. Of note in the blood workup were antinuclear antibodies (+) 1/1280 and anti-RNA polymerase III (+) (RP155+++ and RP11++ subunits). Color Doppler ultrasound of the skin nodules showed moderately solid, vascularized focal areas in the dermis. Capillaroscopy showed nonspecific microcirculation alterations.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis</span><p id="par0015" class="elsevierStylePara elsevierViewall">Based on the physical examination and the results of the histologic examination and other tests, the patient was diagnosed with nodular morphea associated with systemic sclerosis. The patient was treated with systemic mycophenolate mofetil and intralesional corticosteroid injections for the more severe lesions. She was also evaluated by a rheumatologist, who agreed with the diagnosis.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Comment</span><p id="par0020" class="elsevierStylePara elsevierViewall">Morphea, or localized scleroderma, is a rare autoimmune skin disorder characterized by skin and soft tissue inflammation and sclerosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Nodular (keloid) morphea is a rare form of cutaneous sclerosis secondary to an excessive fibrotic reaction that leads to the formation of multiple skin nodules, similar to keloids.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It has been described in association with localized scleroderma or systemic sclerosis with or without active systemic involvement.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Clinically, it is characterized by multiple, firm, raised lesions that vary in size from 2 mm to 4 or 5 mm, do not cause pain, generally appear spontaneously, and tend to affect the trunk and upper extremities. Nodules occur in the absence of previous trauma or lesions, although there have been reports of external triggers, including infections, drugs, and environmental exposures.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Histologic findings vary and can show <span class="elsevierStyleItalic">a</span>) characteristic hypertrophic or keloid scars, <span class="elsevierStyleItalic">b</span>) characteristic scleroderma features, <span class="elsevierStyleItalic">c</span>) a combination of morphea and keloid-like features in the same biopsy specimen, and <span class="elsevierStyleItalic">d</span>) morphea-like features in early-stage lesions and keloid-like features in later-stage lesions.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Correlation of clinical and histopathologic findings and additional evidence of systemic involvement help confirm a suspected diagnosis of nodular morphea. The differential diagnosis should include localized cutaneous mucinosis, which occurs in association with systemic sclerosis or morphea. Several treatment modalities have been described in the literature and include topical and intralesional corticosteroids, systemic corticosteroids, topical calcipotriol, psoralen photochemotherapy, cyclosporine, <span class="elsevierStyleSmallCaps">d</span>-penicillamine, methotrexate, extracorporeal photochemotherapy, and surgical excision. The results, however, have been variable and unsatisfactory.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Nodular morphea is a rare condition, with approximately 40 cases described in the literature.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It should be suspected in patients with extensive nodular or keloidal lesions.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Diagnosis" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Comment" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-19" "fechaAceptado" => "2020-11-15" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hernández San Martín MJ, Kaplan Zapata V, Morales Huber C. Múltiples nódulos queloideos en paciente mujer de mediana edad. Actas Dermosifiliogr. 2021;112:917–918.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1257 "Ancho" => 1674 "Tamanyo" => 142822 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multiple keloid-like skin nodules on the chest.</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" => 965 "Ancho" => 1257 "Tamanyo" => 54401 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin–eosin staining, original magnification ×100.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2042 "Ancho" => 1257 "Tamanyo" => 109381 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin–eosin staining, 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" => "Morphea: current concepts" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 4 | 9 |
| 2024 October | 95 | 39 | 134 |
| 2024 September | 86 | 26 | 112 |
| 2024 August | 116 | 54 | 170 |
| 2024 July | 139 | 36 | 175 |
| 2024 June | 118 | 53 | 171 |
| 2024 May | 134 | 34 | 168 |
| 2024 April | 113 | 26 | 139 |
| 2024 March | 88 | 32 | 120 |
| 2024 February | 105 | 41 | 146 |
| 2024 January | 95 | 36 | 131 |
| 2023 December | 86 | 23 | 109 |
| 2023 November | 113 | 40 | 153 |
| 2023 October | 80 | 25 | 105 |
| 2023 September | 80 | 26 | 106 |
| 2023 August | 77 | 15 | 92 |
| 2023 July | 86 | 26 | 112 |
| 2023 June | 75 | 24 | 99 |
| 2023 May | 71 | 30 | 101 |
| 2023 April | 45 | 20 | 65 |
| 2023 March | 94 | 30 | 124 |
| 2023 February | 55 | 18 | 73 |
| 2023 January | 42 | 28 | 70 |
| 2022 December | 68 | 41 | 109 |
| 2022 November | 28 | 28 | 56 |
| 2022 October | 31 | 21 | 52 |
| 2022 September | 18 | 39 | 57 |
| 2022 August | 26 | 40 | 66 |
| 2022 July | 24 | 27 | 51 |
| 2022 June | 24 | 28 | 52 |
| 2022 May | 54 | 44 | 98 |
| 2022 April | 65 | 48 | 113 |
| 2022 March | 53 | 64 | 117 |
| 2022 February | 54 | 43 | 97 |
| 2022 January | 68 | 47 | 115 |
| 2021 December | 76 | 62 | 138 |
| 2021 November | 78 | 57 | 135 |
| 2021 October | 60 | 49 | 109 |
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