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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Three examples of seborrhucas showing typical features commonly shared by warts and SK &#40;H&#38;E x20&#41;&#46; Many whorls can be seen in B&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Scientific medical literature&#44; sometimes&#44; describes seborrheic keratosis &#40;SK&#41; as a seborrheic wart due to its clinical similarity to warts&#46; However&#44; microscopic examination is a significant tool to distinguish between these 2 entities&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">There are several morphological types of SK recognized in the literature&#44; being the acanthotic and reticulated types the most common of all&#46; In addition to these&#44; we would like to highlight a pattern we frequently encounter in our routine dermatopathology practice that&#44; still&#44; has not been described in the classic texts on SK&#58; the coexistence within the same lesion of overlapping features of SK and a common wart&#46; We have coined the term &#8220;seborrhuca&#8221; to describe this pattern&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Seborrhucas exhibit characteristics of common warts&#58; a papillomatous silhouette &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>A&#41;&#44; hyperkeratosis&#44; columns of parakeratosis at the tips of the papillae &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>B&#41; with agranulosis underneath the parakeratotic column and a prominent granular layer in some other regions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>C&#41;&#46; In the papillary dermis of the papillae&#44; tortuous and often dilated capillaries become evident &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>D&#41;&#46; Focal koilocytic changes can sometimes be seen &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>E&#41;&#46; Many different characteristics of SK overlapping these wart-typical features are&#44; also&#44; evident&#46; Excessive growth of monomorphic round cells&#44; for example&#44; is prominent &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>F&#41;&#46; Additionally&#44; corneal pseudocysts or infundibular tunnels can sometimes be an accompanying feature&#44; as well as the typical whorls of SK &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Whether this type of SK is related to human papillomavirus &#40;HPV&#41; infection is still a matter of discussion&#46; Studies on HPV associated with SK have included all types of SK without morphological selection of the seborrhuca type&#46; Therefore&#44; most of the cases included probably fall into the category of acanthotic SK&#46; For example&#44; Lee et al&#46; studied a total of 40 non-genital SKs by polymerase chain reaction &#40;PCR&#41; and found no HPV of the types tested&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> However&#44; their <a class="elsevierStyleCrossRef" href="#fig0005">figure 1</a>A&#8212;selected by them as representative of their series&#8212;clearly shows an acanthotic type of SK&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Conversely&#44; other studies have managed to find HPV in SK&#58; HPV-like particles in ultrastructural studies of non-genital SK&#59;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> HPV DNA detected in 20&#37; of non-genital SKs by in situ hybridization&#59;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> and 15&#37; up to 30&#37; of SK cases positive for HPV on the PCR&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In the cases found in the genital area&#44; the association with HPV infection seems even stronger&#44; with the virus demonstrated in up to 72&#37; of genital cases by PCR or immunohistochemistry<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> to the point that some authors claim that genital SKs containing HPV are actually condylomas acuminata<span class="elsevierStyleSup">&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In this regard&#44; Zhu et al&#46; presented a very interesting study of DNA amplification by PCR in lesions they called &#8220;benign verrucous acanthomas&#44;&#8221; describing them with characteristic features of common warts but lacking koilocytes in the granular layer&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> They could not find any HPV DNA sequences in amplified samples of these benign verrucous acanthomas<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> but found HPV in verrucous lesions with koilocytes&#46; Consequently&#44; they considered koilocytes as the critical histopathological sign distinguishing common warts from benign verrucous acanthoma&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Admitting this&#44; however&#44; would grant koilocytes a specificity and sensitivity as high as HPV-PCR&#44; which contrasts with what has been described in the scientific medical literature on this regard&#46; For example&#44; in a very comprehensive study on histopathological features and HPV types&#44; Jablonska et al&#46; confirmed the presence of koilocytes only in warts induced by certain viral types &#40;such as HPV-4 or HPV-10&#41; but not in others&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> As we know&#44; HPV-4 and HPV-10 are related to flat warts&#44; while common warts are usually caused by HPV-2<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> and condylomas by HPV-6 and HPV-11<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> &#40;types 6 and 11 can also be found in common warts in adults<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a>&#41;&#46; Other HPV types sometimes found in common warts are HPV-16&#44; 42&#44; 43&#44; or 44&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a> shows additional examples of seborrhucas at low magnification&#46; But how significant is seborrhuca then&#63; Is it a viral verrucous change &#40;related to HPV&#41; overlapping a SK&#44; that is&#44; a common wart-like SK&#63; Or is it a seborrheic change occurring in a common wart&#44; that is&#44; a common wart-like SK&#63; Or is it the collision of a SK and a common wart&#63; Or is it merely a morphological change mimicking a wart but without the HPV infection&#63; We&#8217;d rather stick to option &#35;1 for 3 reasons&#58; in the first place&#44; common wart changes sometimes collide with SK areas &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>A&#41;&#59; also&#44; when HPV is studied in collision cases&#44; it is only seen in verrucous&#8212;not in SK&#8212;regions&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Therefore&#44; we conducted several immunohistochemical studies with Ki67 and p16 in seborrhuca cases&#44; and results are similar to those seen in a viral warts&#44; i&#46;e&#46;&#44; patchy groups of more than 10 cells positive for p16 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>B and C&#41;&#44; with a high proliferation index in the basal layers of the lesion &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>D&#41;&#46; This contrasts with what has been reported in SK cases &#40;negative for p16&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>E&#41;&#46; Furthermore&#44; these findings contrast with what has been confirmed through evidence in obvious collision cases between common warts and seborrheic keratosis&#44; in which only the common wart areas test positive for p16&#44; while the seborrheic keratosis test negative for p16 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>F and G&#41;&#46; All these findings support the idea that seborrhuca is a lesion with morphological characteristics of seborrheic keratosis that has sustained an HPV infection&#44; eventually leading to the acquisition of additional wart-like features&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The term seborrhuca is intended for cases in which histopathological features overlap so much that a simple diagnosis of wart or SK would be arbitrary&#46; It is not intended to replace either of those diagnoses when the morphological features are clear enough to the point of being able to achieve a specific diagnosis of one of these entities&#46;</p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Histopathological features observed in seborrhuca&#58; A&#41; papillomatous silhouette &#40;H&#38;E x20&#41;&#46; B&#41; parakeratotic columns at the tips of the papillae with agranulosis &#40;H&#38;E x100&#41;&#46; C&#41; thick keratohyalin granules &#40;H&#38;E x200&#41;&#46; D&#41; tortuous capillary vessels in the papillae &#40;H&#38;E x100&#41;&#46; E&#41; koilocytes &#40;H&#38;E x400&#41;&#46; F&#41; overgrowth of monomorphic basaloid cells &#40;H&#38;E x100&#41;&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#41; Changes of common wart in collision with peripheral areas of SK &#40;H&#38;E x20&#41;&#46; B&#44; C&#44; and D&#41; Typical features of seborrhuca in the immunohistochemical study&#46; Seborrhuca shows patches of positive staining with p16 &#40;B&#58; p16&#44; x20&#41;&#46; The patches consist of more than 10 cells positive for p16&#44; with both cytoplasmic and nuclear staining &#40;C&#58; p16&#44; x400&#41;&#46; Ki-67 shows positivity in the basal layer of the lesion only &#40;D&#58; Ki67&#44; x20&#41;&#46; In contrast&#44; SK is p16 negative &#40;E&#58; p16&#44; x20&#41;&#46; When collision lesions between wart and SK are seen&#44; the wart areas are p16-positive while the SK ones are p16-negative &#40;F&#58; p16&#44; x20&#59; G&#58; p16 x40&#41;&#46;</p>"
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Case and Research Letter
Seborrhuca: Vindication of a Pattern?
Seborruca: ¿reivindicación de un patrón?
J. Aróstegui Aguilara,b, N. Martínez Campayob,c, D. Cassarinod, A. Fernandez-Floresb,e,f,
Autor para correspondencia
dermatopathonline@gmail.com

Corresponding author.
a Departamento de Dermatología, Hospital Universitario de Navarra, Pamplona, España
b Departamento de Histopatología, Hospital Universitario del Bierzo. Ponferrada, España
c Departamento de Dermatología, Hospital Universitario de A Coruña, A Coruña, España
d Los Angeles Medical Center (LAMC), Southern California Kaiser Permanente, Departamento de Dermatopatología, Los Angeles, California, EE. UU.
e Departamento de Patología Celular, Hospital de la Reina, Ponferrada, España
f Departamento de Investigación, Instituto de Investigación Biomédica de A Coruña (INIBIC): Universidad de A Coruña (UDC), A Coruña, España
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Three examples of seborrhucas showing typical features commonly shared by warts and SK &#40;H&#38;E x20&#41;&#46; Many whorls can be seen in B&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Scientific medical literature&#44; sometimes&#44; describes seborrheic keratosis &#40;SK&#41; as a seborrheic wart due to its clinical similarity to warts&#46; However&#44; microscopic examination is a significant tool to distinguish between these 2 entities&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">There are several morphological types of SK recognized in the literature&#44; being the acanthotic and reticulated types the most common of all&#46; In addition to these&#44; we would like to highlight a pattern we frequently encounter in our routine dermatopathology practice that&#44; still&#44; has not been described in the classic texts on SK&#58; the coexistence within the same lesion of overlapping features of SK and a common wart&#46; We have coined the term &#8220;seborrhuca&#8221; to describe this pattern&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Seborrhucas exhibit characteristics of common warts&#58; a papillomatous silhouette &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>A&#41;&#44; hyperkeratosis&#44; columns of parakeratosis at the tips of the papillae &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>B&#41; with agranulosis underneath the parakeratotic column and a prominent granular layer in some other regions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>C&#41;&#46; In the papillary dermis of the papillae&#44; tortuous and often dilated capillaries become evident &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>D&#41;&#46; Focal koilocytic changes can sometimes be seen &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>E&#41;&#46; Many different characteristics of SK overlapping these wart-typical features are&#44; also&#44; evident&#46; Excessive growth of monomorphic round cells&#44; for example&#44; is prominent &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>F&#41;&#46; Additionally&#44; corneal pseudocysts or infundibular tunnels can sometimes be an accompanying feature&#44; as well as the typical whorls of SK &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Whether this type of SK is related to human papillomavirus &#40;HPV&#41; infection is still a matter of discussion&#46; Studies on HPV associated with SK have included all types of SK without morphological selection of the seborrhuca type&#46; Therefore&#44; most of the cases included probably fall into the category of acanthotic SK&#46; For example&#44; Lee et al&#46; studied a total of 40 non-genital SKs by polymerase chain reaction &#40;PCR&#41; and found no HPV of the types tested&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> However&#44; their <a class="elsevierStyleCrossRef" href="#fig0005">figure 1</a>A&#8212;selected by them as representative of their series&#8212;clearly shows an acanthotic type of SK&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Conversely&#44; other studies have managed to find HPV in SK&#58; HPV-like particles in ultrastructural studies of non-genital SK&#59;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> HPV DNA detected in 20&#37; of non-genital SKs by in situ hybridization&#59;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> and 15&#37; up to 30&#37; of SK cases positive for HPV on the PCR&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In the cases found in the genital area&#44; the association with HPV infection seems even stronger&#44; with the virus demonstrated in up to 72&#37; of genital cases by PCR or immunohistochemistry<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> to the point that some authors claim that genital SKs containing HPV are actually condylomas acuminata<span class="elsevierStyleSup">&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In this regard&#44; Zhu et al&#46; presented a very interesting study of DNA amplification by PCR in lesions they called &#8220;benign verrucous acanthomas&#44;&#8221; describing them with characteristic features of common warts but lacking koilocytes in the granular layer&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> They could not find any HPV DNA sequences in amplified samples of these benign verrucous acanthomas<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> but found HPV in verrucous lesions with koilocytes&#46; Consequently&#44; they considered koilocytes as the critical histopathological sign distinguishing common warts from benign verrucous acanthoma&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Admitting this&#44; however&#44; would grant koilocytes a specificity and sensitivity as high as HPV-PCR&#44; which contrasts with what has been described in the scientific medical literature on this regard&#46; For example&#44; in a very comprehensive study on histopathological features and HPV types&#44; Jablonska et al&#46; confirmed the presence of koilocytes only in warts induced by certain viral types &#40;such as HPV-4 or HPV-10&#41; but not in others&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> As we know&#44; HPV-4 and HPV-10 are related to flat warts&#44; while common warts are usually caused by HPV-2<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> and condylomas by HPV-6 and HPV-11<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> &#40;types 6 and 11 can also be found in common warts in adults<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a>&#41;&#46; Other HPV types sometimes found in common warts are HPV-16&#44; 42&#44; 43&#44; or 44&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a> shows additional examples of seborrhucas at low magnification&#46; But how significant is seborrhuca then&#63; Is it a viral verrucous change &#40;related to HPV&#41; overlapping a SK&#44; that is&#44; a common wart-like SK&#63; Or is it a seborrheic change occurring in a common wart&#44; that is&#44; a common wart-like SK&#63; Or is it the collision of a SK and a common wart&#63; Or is it merely a morphological change mimicking a wart but without the HPV infection&#63; We&#8217;d rather stick to option &#35;1 for 3 reasons&#58; in the first place&#44; common wart changes sometimes collide with SK areas &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>A&#41;&#59; also&#44; when HPV is studied in collision cases&#44; it is only seen in verrucous&#8212;not in SK&#8212;regions&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Therefore&#44; we conducted several immunohistochemical studies with Ki67 and p16 in seborrhuca cases&#44; and results are similar to those seen in a viral warts&#44; i&#46;e&#46;&#44; patchy groups of more than 10 cells positive for p16 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>B and C&#41;&#44; with a high proliferation index in the basal layers of the lesion &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>D&#41;&#46; This contrasts with what has been reported in SK cases &#40;negative for p16&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>E&#41;&#46; Furthermore&#44; these findings contrast with what has been confirmed through evidence in obvious collision cases between common warts and seborrheic keratosis&#44; in which only the common wart areas test positive for p16&#44; while the seborrheic keratosis test negative for p16 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>F and G&#41;&#46; All these findings support the idea that seborrhuca is a lesion with morphological characteristics of seborrheic keratosis that has sustained an HPV infection&#44; eventually leading to the acquisition of additional wart-like features&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The term seborrhuca is intended for cases in which histopathological features overlap so much that a simple diagnosis of wart or SK would be arbitrary&#46; It is not intended to replace either of those diagnoses when the morphological features are clear enough to the point of being able to achieve a specific diagnosis of one of these entities&#46;</p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Histopathological features observed in seborrhuca&#58; A&#41; papillomatous silhouette &#40;H&#38;E x20&#41;&#46; B&#41; parakeratotic columns at the tips of the papillae with agranulosis &#40;H&#38;E x100&#41;&#46; C&#41; thick keratohyalin granules &#40;H&#38;E x200&#41;&#46; D&#41; tortuous capillary vessels in the papillae &#40;H&#38;E x100&#41;&#46; E&#41; koilocytes &#40;H&#38;E x400&#41;&#46; F&#41; overgrowth of monomorphic basaloid cells &#40;H&#38;E x100&#41;&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Three examples of seborrhucas showing typical features commonly shared by warts and SK &#40;H&#38;E x20&#41;&#46; Many whorls can be seen in B&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#41; Changes of common wart in collision with peripheral areas of SK &#40;H&#38;E x20&#41;&#46; B&#44; C&#44; and D&#41; Typical features of seborrhuca in the immunohistochemical study&#46; Seborrhuca shows patches of positive staining with p16 &#40;B&#58; p16&#44; x20&#41;&#46; The patches consist of more than 10 cells positive for p16&#44; with both cytoplasmic and nuclear staining &#40;C&#58; p16&#44; x400&#41;&#46; Ki-67 shows positivity in the basal layer of the lesion only &#40;D&#58; Ki67&#44; x20&#41;&#46; In contrast&#44; SK is p16 negative &#40;E&#58; p16&#44; x20&#41;&#46; When collision lesions between wart and SK are seen&#44; the wart areas are p16-positive while the SK ones are p16-negative &#40;F&#58; p16&#44; x20&#59; G&#58; p16 x40&#41;&#46;</p>"
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