Cases for Diagnosis
Grouped Papules and Plaques on the Lower Limbs
Pápulas y placas agrupadas en extremidades inferiores
J.A. Suárez-Pérez
, N. López-Navarro, E. Herrera-Acosta
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Servicio de Dermatología, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain
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Suárez-Pérez, N. López-Navarro, E. Herrera-Acosta" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J.A." "apellidos" => "Suárez-Pérez" "email" => array:1 [ 0 => "jasuape@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "N." "apellidos" => "López-Navarro" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Herrera-Acosta" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pápulas y placas agrupadas en extremidades inferiores" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1217 "Ancho" => 915 "Tamanyo" => 118596 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 33 year-old man with no relevant medical history who was seen for skin lesions that had been present on both pretibial areas and lateral borders of the feet for 2 years. The lesions were slightly pruritic and followed an intermittent course with periods of improvement but never healed completely. No improvement was seen with the application of topical corticosteroids. The patient reported no extracutaneous symptoms.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed multiple brownish papules and plaques distributed over both pretibial areas (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There were also multiple papules that coalesced to form brownish plaques with irregular borders on the lateral aspects of both feet (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). These lesions extended onto the lateral surface of both ankles, where discrete ulceration was observed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Histology showed fibrinoid necrosis of the small caliber vessels, with a polymorphonuclear infiltrate and karyorrhexis. The early stages of concentric perivascular fibrosis were also present (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Immunofluorescence was negative.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">Blood tests, liver function, kidney function, serum electrolytes, protein analysis and serum protein electrophoresis, antinuclear antibodies, and cryoglobulin were all normal. Urinary sediment was normal. Serology for human immunodeficiency virus (HIV) and hepatitis A, B, and C viruses was negative.</p><p id="par0025" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis?</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Erythema elevatum diutinum (EED).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Blood tests confirmed normal glucose-6-phosphate dehydrogenase levels, and treatment was then initiated with dapsone 100<span class="elsevierStyleHsp" style=""></span>mg/d, achieving a good clinical response. After 6 weeks of treatment with no recurrence of the symptoms, the dose of dapsone was reduced to 50<span class="elsevierStyleHsp" style=""></span>mg/d. At the time of writing, only a residual postinflammatory hyperpigmentation remained.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">EED is a rare form of leukocytoclastic vasculitis characterized by a chronic clinical course.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> It affects adults aged between 30 and 70 years, although cases have been reported in other age ranges. It presents clinically as erythematous-purpuric and yellowish papules that can develop into infiltrated plaques with irregular borders.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> The lesions are initially soft, but later acquire a firm, doughy consistency. Some patients enter a chronic phase of fibrosis in which the initial lesions are replaced by nodules that are hard and can grow to a large size.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Histologically, EED is characterized by leukocytoclastic vasculitis of small-caliber vessels, with fibrinoid necrosis and a neutrophilic infiltrate. The epidermis shows acanthosis and parakeratosis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The most distinctive feature of the disease is the appearance of progressive concentric perivascular fibrosis around the affected vessels. Histological findings are very similar to those of granuloma faciale in an extrafacial location and differentiation of the 2 conditions is difficult for single lesions.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">EED has been described in association with many systemic conditions, including autoimmune and hematological diseases and infections, in particular HIV infection,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> in which EED may be the first manifestation.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Hepatitis B or C virus infection must also be ruled out, and a complete blood count and protein electrophoresis are needed to exclude IgA and IgG gammopathy, IgA multiple myeloma, polycythemia vera, hairy cell leukemia, mixed cryoglobulinemia, and myelodysplasia.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> The group of diseases associated with EED includes inflammatory bowel disease, rheumatoid arthritis, systemic lupus erythematosus, and relapsing polychondritis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The treatment of choice for EED is dapsone, which reduces disease severity but is not curative; recurrence is common when treatment is stopped.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Control of associated diseases, when present, is essential. Other therapeutic options include niacinamide, colchicine, and sulfapyridine.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Treatment with intralesional corticosteroids and surgical excision are only indicated in cases of localized disease.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></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" => "Additional Tests" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Suárez-Pérez JA, et al. Pápulas y placas agrupadas en extremidades inferiores. Actas Dermosifiliogr.2011;102:823-824.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1217 "Ancho" => 915 "Tamanyo" => 118596 ] ] ] 1 => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 995 "Ancho" => 1015 "Tamanyo" => 95200 ] ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 807 "Ancho" => 1073 "Tamanyo" => 244739 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification x100.</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" => "Cutaneous vasculitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Chung" 1 => "B. Kea" 2 => "D.F. Fiorentino" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Dermatology" "paginaInicial" => "355" "paginaFinal" => "357" "serieFecha" => "2008" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eritema elevatum diutinum" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.T. Bordel" 1 => "J. Bassas" 2 => "A.M. Morales" 3 => "J.A. Tejerina" 4 => "M.H. Aragoneses" 5 => "A. 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Garcia-Diez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2010" "volumen" => "101" "paginaInicial" => "814" "paginaFinal" => "815" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21034719" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Erythema elevatum diutinum in a patient with acquired immunodeficiency syndrome. Another clinical simulator of Kaposi's sarcoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "L. Requena" 1 => "E. Sanchez Yus" 2 => "L. Martin" 3 => "A. Barat" 4 => "D. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 15 | 10 | 25 |
| 2024 Octubre | 145 | 41 | 186 |
| 2024 Septiembre | 123 | 27 | 150 |
| 2024 Agosto | 133 | 51 | 184 |
| 2024 Julio | 128 | 41 | 169 |
| 2024 Junio | 145 | 34 | 179 |
| 2024 Mayo | 99 | 33 | 132 |
| 2024 Abril | 99 | 15 | 114 |
| 2024 Marzo | 109 | 33 | 142 |
| 2024 Febrero | 145 | 45 | 190 |
| 2024 Enero | 104 | 35 | 139 |
| 2023 Diciembre | 96 | 20 | 116 |
| 2023 Noviembre | 85 | 25 | 110 |
| 2023 Octubre | 91 | 20 | 111 |
| 2023 Septiembre | 101 | 34 | 135 |
| 2023 Agosto | 66 | 18 | 84 |
| 2023 Julio | 86 | 38 | 124 |
| 2023 Junio | 64 | 25 | 89 |
| 2023 Mayo | 107 | 28 | 135 |
| 2023 Abril | 71 | 18 | 89 |
| 2023 Marzo | 80 | 21 | 101 |
| 2023 Febrero | 48 | 27 | 75 |
| 2023 Enero | 58 | 56 | 114 |
| 2022 Diciembre | 72 | 41 | 113 |
| 2022 Noviembre | 33 | 23 | 56 |
| 2022 Octubre | 30 | 24 | 54 |
| 2022 Septiembre | 29 | 33 | 62 |
| 2022 Agosto | 25 | 29 | 54 |
| 2022 Julio | 26 | 27 | 53 |
| 2022 Junio | 20 | 21 | 41 |
| 2022 Mayo | 70 | 33 | 103 |
| 2022 Abril | 83 | 36 | 119 |
| 2022 Marzo | 89 | 56 | 145 |
| 2022 Febrero | 81 | 34 | 115 |
| 2022 Enero | 90 | 34 | 124 |
| 2021 Diciembre | 70 | 43 | 113 |
| 2021 Noviembre | 71 | 31 | 102 |
| 2021 Octubre | 87 | 54 | 141 |
| 2021 Septiembre | 53 | 36 | 89 |
| 2021 Agosto | 96 | 34 | 130 |
| 2021 Julio | 80 | 26 | 106 |
| 2021 Junio | 52 | 31 | 83 |
| 2021 Mayo | 62 | 51 | 113 |
| 2021 Abril | 142 | 102 | 244 |
| 2021 Marzo | 99 | 40 | 139 |
| 2021 Febrero | 68 | 20 | 88 |
| 2021 Enero | 60 | 26 | 86 |
| 2020 Diciembre | 35 | 19 | 54 |
| 2020 Noviembre | 28 | 16 | 44 |
| 2020 Octubre | 37 | 18 | 55 |
| 2020 Septiembre | 66 | 16 | 82 |
| 2020 Agosto | 19 | 21 | 40 |
| 2020 Julio | 32 | 18 | 50 |
| 2020 Junio | 36 | 26 | 62 |
| 2020 Mayo | 29 | 22 | 51 |
| 2020 Abril | 29 | 18 | 47 |
| 2020 Marzo | 29 | 18 | 47 |
| 2020 Febrero | 3 | 8 | 11 |
| 2020 Enero | 4 | 10 | 14 |
| 2019 Diciembre | 4 | 3 | 7 |
| 2019 Noviembre | 4 | 1 | 5 |
| 2019 Octubre | 0 | 1 | 1 |
| 2019 Septiembre | 1 | 1 | 2 |
| 2019 Agosto | 6 | 6 | 12 |
| 2019 Julio | 4 | 3 | 7 |
| 2019 Junio | 5 | 9 | 14 |
| 2019 Mayo | 4 | 13 | 17 |
| 2019 Abril | 2 | 9 | 11 |
| 2019 Marzo | 2 | 9 | 11 |
| 2019 Febrero | 0 | 4 | 4 |
| 2019 Enero | 2 | 3 | 5 |
| 2018 Diciembre | 3 | 1 | 4 |
| 2018 Noviembre | 1 | 5 | 6 |
| 2018 Octubre | 2 | 0 | 2 |
| 2018 Septiembre | 1 | 0 | 1 |
| 2018 Abril | 0 | 1 | 1 |
| 2018 Marzo | 1 | 1 | 2 |
| 2018 Febrero | 67 | 4 | 71 |
| 2018 Enero | 52 | 6 | 58 |
| 2017 Diciembre | 73 | 5 | 78 |
| 2017 Noviembre | 40 | 6 | 46 |
| 2017 Octubre | 49 | 8 | 57 |
| 2017 Septiembre | 36 | 1 | 37 |
| 2017 Agosto | 66 | 10 | 76 |
| 2017 Julio | 55 | 3 | 58 |
| 2017 Junio | 44 | 16 | 60 |
| 2017 Mayo | 37 | 8 | 45 |
| 2017 Abril | 34 | 7 | 41 |
| 2017 Marzo | 24 | 13 | 37 |
| 2017 Febrero | 32 | 7 | 39 |
| 2017 Enero | 33 | 12 | 45 |
| 2016 Diciembre | 56 | 7 | 63 |
| 2016 Noviembre | 64 | 6 | 70 |
| 2016 Octubre | 79 | 15 | 94 |
| 2016 Septiembre | 82 | 5 | 87 |
| 2016 Agosto | 62 | 13 | 75 |
| 2016 Julio | 52 | 10 | 62 |
| 2016 Junio | 19 | 10 | 29 |
| 2016 Mayo | 10 | 13 | 23 |
| 2016 Abril | 5 | 6 | 11 |
| 2016 Marzo | 6 | 1 | 7 |
| 2016 Febrero | 8 | 10 | 18 |
| 2016 Enero | 12 | 7 | 19 |
| 2015 Diciembre | 11 | 9 | 20 |
| 2015 Noviembre | 18 | 10 | 28 |
| 2015 Octubre | 16 | 8 | 24 |
| 2015 Septiembre | 11 | 6 | 17 |
| 2015 Agosto | 15 | 3 | 18 |
| 2015 Julio | 39 | 9 | 48 |
| 2015 Junio | 36 | 4 | 40 |
| 2015 Mayo | 72 | 16 | 88 |
| 2015 Abril | 37 | 8 | 45 |
| 2015 Marzo | 41 | 9 | 50 |
| 2015 Febrero | 32 | 4 | 36 |
| 2015 Enero | 25 | 11 | 36 |
| 2014 Diciembre | 34 | 6 | 40 |
| 2014 Noviembre | 34 | 8 | 42 |
| 2014 Octubre | 39 | 18 | 57 |
| 2014 Septiembre | 28 | 7 | 35 |
| 2014 Agosto | 45 | 12 | 57 |
| 2014 Julio | 56 | 21 | 77 |
| 2014 Junio | 75 | 12 | 87 |
| 2014 Mayo | 74 | 18 | 92 |
| 2014 Abril | 55 | 12 | 67 |
| 2014 Marzo | 65 | 14 | 79 |
| 2014 Febrero | 51 | 17 | 68 |
| 2014 Enero | 54 | 11 | 65 |
| 2013 Diciembre | 60 | 13 | 73 |
| 2013 Noviembre | 26 | 8 | 34 |
| 2013 Octubre | 17 | 5 | 22 |
| 2013 Septiembre | 13 | 7 | 20 |
| 2013 Agosto | 10 | 5 | 15 |
| 2013 Julio | 9 | 12 | 21 |
| 2013 Junio | 10 | 9 | 19 |
| 2013 Mayo | 16 | 9 | 25 |
| 2013 Abril | 17 | 14 | 31 |
| 2013 Marzo | 13 | 9 | 22 |
| 2013 Febrero | 37 | 4 | 41 |
| 2013 Enero | 18 | 3 | 21 |
| 2012 Diciembre | 19 | 4 | 23 |
| 2012 Octubre | 0 | 1 | 1 |
| 2012 Julio | 1 | 0 | 1 |
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