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and showed a slightly decreased C3 fraction &#40;83&#160;mg&#47;dL&#41; without clinical relevance&#46; Despite the absence of a definitive diagnosis&#44; it was decided to retreat the patient with oral hydroxychloroquine and high-potency topical corticosteroids in view of the possibility of cutaneous lupus erythematosus&#44; but there was no response&#46; The presence of abundant <span class="elsevierStyleItalic">Demodex</span> species in the biopsy specimen&#44; combined with the other manifestations&#44; was also suggestive of a rosacea component&#44; and the patient was started on a full course of oral metronidazole and ivermectin&#46; Again&#44; she showed no clinical response&#46; Considering the clinical and histologic findings and the lack of response to both topical and systemic treatments&#44; we established a diagnosis of facial discoid dermatosis&#46; On reviewing the literature&#44; we decided to treat the patient with topical calcipotriol and betamethasone based on the experience described in a case report&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We are currently waiting to see how she responds&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Facial discoid dermatosis was first described in 2010 in a series of 3 cases in which the authors described pink-orange&#44; frequently annular&#44; lesions with a scale that were located exclusively on the face&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The lesions remained stable for years and were resistant to multiple treatments&#46; Histopathologically&#44; they showed epidermal acanthosis&#44; parakeratosis&#44; and follicular plugging&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Ten other cases have been described since&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a> Based on the few reports in the literature&#44; facial discoid dermatosis appears to be more common in women &#40;male to female ratio&#44; 1&#58;5&#46;5&#41;&#44; tends to develop in the third decade&#44; and has a clear predilection for Asians&#46; Lesions are limited to the facial region and mainly affect the cheeks &#40;93&#37;&#41;&#44; the chin &#40;69&#37;&#41;&#44; and the forehead &#40;38&#37;&#41;&#46; They typically remain stable for years and respond poorly to treatment&#46; Partial response to certain treatments&#44; such as tacrolimus and topical corticosteroids<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and topical calcipotriol&#47;betamethasone combined with low doses of oral acitretin&#44; has been described in 53&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Of note&#44; 1 patient developed type II pityriasis rubra pilaris &#40;PRP&#41; during follow-up&#46; The most common histologic findings reported are psoriasiform epidermal hyperplasia &#40;92&#46;3&#37;&#41;&#44; hyperkeratosis with parakeratosis &#40;84&#37;&#41;&#44; a superficial perivascular lymphocytic infiltrate &#40;76&#46;9&#37;&#41;&#44; and follicular plugs &#40;61&#46;5&#37;&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The origin of facial discoid dermatosis is unknown&#46; The report of a case that progressed to PRP&#44; combined with the similar histologic findings to those observed in PRP and the poor responses to treatment&#44; has led some authors to postulate that facial discoid dermatosis might actually be a subtype of PRP&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> There are&#44; however&#44; clear clinical differences between the 2 entities and much remains to be elucidated&#46; We believe that the case presented in this report is a clear example of facial discoid dermatosis&#44; a little-known and probably underdiagnosed dermatosis&#46; Of note is its persistent clinical course&#44; with lesions that can remain stable for many years&#44; and its lack of response to currently available treatments&#46;</p></span>"
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Case and Research Letters
Facial Discoid Dermatosis: An Enigmatic Disease
Dermatosis discoide facial, una entidad enigmática
L. Condala, A. Querb, C. Ferrándiza, I. Bielsaa,
Corresponding author
ibielsa.germanstrias@gencat.cat

Corresponding author.
a Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, Universitat Autònoma de Barcelona, Barcelona, Spain
b Servicio de Anatomia Patológica, Hospital Universitari Germans Trias i Pujol, Badalona, Universitat Autònoma de Barcelona, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Facial discoid dermatosis is a recently described entity that presents with erythematous&#44; frequently annular&#44; scaling papules and plaques located exclusively on the face&#46; The main characteristic of this condition is the presence of persistent lesions that do not respond to topical or systemic treatments&#46; The clinical differential diagnosis includes other entities involving papulosquamous lesions on the face&#44; such as seborrheic dermatitis&#44; tinea faciei&#44; cutaneous lupus erythematosus&#44; and psoriasis&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 45-year-old woman with familial hypercholesterolemia presented with persistent facial lesions present since adolescence&#46; The lesions had shown a complete lack of response to numerous treatments&#44; including topical corticosteroids and calcineurin inhibitors and systemic methotrexate and hydroxychloroquine&#46; Physical examination showed erythematous&#44; scaling papules and plaques with a slightly orange&#44; seborrheic appearance on the cheeks and forehead &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; There were no lesions on any other parts of the body&#44; including the mucous membranes&#44; palms&#44; soles&#44; and scalp&#46; Biopsy of a lesion showed mild epidermal acanthosis&#44; hyperkeratosis with foci of parakeratosis&#44; follicular corneal plugs&#44; a moderate interstitial and perifollicular inflammatory infiltrate in the superficial dermis&#44; and <span class="elsevierStyleItalic">Demodex</span> species in the hair follicles &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; There was no evidence of basal vacuolar changes&#44; basement membrane thickening&#44; or mucin deposition&#46; Direct immunofluorescence was negative&#46; Blood tests were negative for antinuclear antibodies&#44; including anti-Ro&#47;SSA and anti-La&#47;SSB antibodies&#44; and showed a slightly decreased C3 fraction &#40;83&#160;mg&#47;dL&#41; without clinical relevance&#46; Despite the absence of a definitive diagnosis&#44; it was decided to retreat the patient with oral hydroxychloroquine and high-potency topical corticosteroids in view of the possibility of cutaneous lupus erythematosus&#44; but there was no response&#46; The presence of abundant <span class="elsevierStyleItalic">Demodex</span> species in the biopsy specimen&#44; combined with the other manifestations&#44; was also suggestive of a rosacea component&#44; and the patient was started on a full course of oral metronidazole and ivermectin&#46; Again&#44; she showed no clinical response&#46; Considering the clinical and histologic findings and the lack of response to both topical and systemic treatments&#44; we established a diagnosis of facial discoid dermatosis&#46; On reviewing the literature&#44; we decided to treat the patient with topical calcipotriol and betamethasone based on the experience described in a case report&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We are currently waiting to see how she responds&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Facial discoid dermatosis was first described in 2010 in a series of 3 cases in which the authors described pink-orange&#44; frequently annular&#44; lesions with a scale that were located exclusively on the face&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The lesions remained stable for years and were resistant to multiple treatments&#46; Histopathologically&#44; they showed epidermal acanthosis&#44; parakeratosis&#44; and follicular plugging&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Ten other cases have been described since&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a> Based on the few reports in the literature&#44; facial discoid dermatosis appears to be more common in women &#40;male to female ratio&#44; 1&#58;5&#46;5&#41;&#44; tends to develop in the third decade&#44; and has a clear predilection for Asians&#46; Lesions are limited to the facial region and mainly affect the cheeks &#40;93&#37;&#41;&#44; the chin &#40;69&#37;&#41;&#44; and the forehead &#40;38&#37;&#41;&#46; They typically remain stable for years and respond poorly to treatment&#46; Partial response to certain treatments&#44; such as tacrolimus and topical corticosteroids<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and topical calcipotriol&#47;betamethasone combined with low doses of oral acitretin&#44; has been described in 53&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Of note&#44; 1 patient developed type II pityriasis rubra pilaris &#40;PRP&#41; during follow-up&#46; The most common histologic findings reported are psoriasiform epidermal hyperplasia &#40;92&#46;3&#37;&#41;&#44; hyperkeratosis with parakeratosis &#40;84&#37;&#41;&#44; a superficial perivascular lymphocytic infiltrate &#40;76&#46;9&#37;&#41;&#44; and follicular plugs &#40;61&#46;5&#37;&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The origin of facial discoid dermatosis is unknown&#46; The report of a case that progressed to PRP&#44; combined with the similar histologic findings to those observed in PRP and the poor responses to treatment&#44; has led some authors to postulate that facial discoid dermatosis might actually be a subtype of PRP&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> There are&#44; however&#44; clear clinical differences between the 2 entities and much remains to be elucidated&#46; We believe that the case presented in this report is a clear example of facial discoid dermatosis&#44; a little-known and probably underdiagnosed dermatosis&#46; Of note is its persistent clinical course&#44; with lesions that can remain stable for many years&#44; and its lack of response to currently available treatments&#46;</p></span>"
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