Case for Diagnosis
Whitish Papules on the Hands
Pápulas Blanquecinas en las Manos
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Bernat García, E. Barberá Montesinos, P. Soriano Sarrio" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Bernat García" "email" => array:1 [ 0 => "josefabernat@hotmail.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" => "E." "apellidos" => "Barberá Montesinos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "Soriano Sarrio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Doctor Peset, Valencia, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Doctor Peset, Valencia, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "*" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pápulas Blanquecinas en las Manos" ] ] "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" => 833 "Ancho" => 1026 "Tamanyo" => 54998 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 56-year-old man presented with multiple small asymptomatic whitish papules that had appeared 3 months earlier on both hands. The patient's past history included systemic hypertension on treatment with valsartan, untreated hyperuricemia, dyslipidemia, and moderate alcohol consumption with findings on magnetic resonance imaging suggestive of chronic pancreatitis.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination showed numerous small (2-3<span class="elsevierStyleHsp" style=""></span>mm) whitish papules on the palms and fingertips of both hands. The papules were hard and smooth and some of them were ulcerated (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Additional Tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">A biopsy was performed of 1 of the lesions. Microscopy revealed a large nodular deposit of amorphous material containing acicular clefts in the dermis, surrounded by pseudopalisading histiocytes and a marked foreign body giant cell reaction. In close proximity to the main lesion we observed multiple, small, coalescing nodular deposits comprised of similar material with a marked associated giant cell reaction. The epidermis showed no significant changes (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis?</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Milia-like cutaneous tophi</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course and Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was referred to the rheumatology department and treated with allopurinol (100<span class="elsevierStyleHsp" style=""></span>mg/d), resulting in a gradual improvement in the lesions.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">The clinical features of gout are caused by deposits of monosodium urate crystals in the tissues. The main clinical manifestations of gout are gouty arthritis, the accumulation of crystals in the connective tissues (tophi), uric acid nephrolithiasis, and renal failure.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Tophi appear after a long period of hyperuricemia. The prevalence of this condition has been reduced by effective therapies and is now limited to patients who fail to comply with treatment and those in whom the diagnosis of gout is delayed.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Rarely, tophi may be the first sign of hyperuricemia.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Tophi appear as whitish-yellowish dermal papules or subcutaneous nodules that are firm to the touch. The borders may be smooth or lobulated. They appear most frequently on the skin covering the joints and on the helix of the ear. Presentation as numerous small papules appearing rapidly on the hands is very rare. Historically, this condition has been referred to as intradermal tophi or pustular gouty tophi. The term milia-like tophi has recently been proposed for this entity based on the similarity between these lesions and millet seeds as well as the wider distribution of the lesions involving not only the fingertips, which has been previously described, but also the palms.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The main histologic feature of gouty tophi is the presence deposits of an amorphous material within the dermis and subcutaneous cellular tissue. These deposits contain acicular clefts, caused by the dissolution of urate crystals, and are surrounded by an infiltrate comprised of histiocytes, in the form of multinucleated giant cells, and lymphocytes, sometimes with the presence of a fibrous capsule. The epidermis may be intact or ulcerated. During standard processing and fixing techniques most of the urate crystals are dissolved and fixation in ethanol or freezing of the tissue is therefore necessary to identify the crystals.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">When observed under a polarized light filter, the acicular crystals exhibit negative birefringence. The clinical differential diagnosis of gouty tophi should include xanthomas, rheumatoid nodules, and calcinosis cutis. The prolonged use of medications that reduce uric acid levels such as allopurinol can successfully treat newer, smaller lesions,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> while larger lesions may be removed surgically.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflict of Interest</span><p id="par0045" 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" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Additional Tests" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course and Treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Comment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of Interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bernat García J, et al. Pápulas blanquecinas en las manos. Actas Dermosifiliogr. 2013;104:349–50.</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" => 833 "Ancho" => 1026 "Tamanyo" => 54998 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1750 "Ancho" => 1428 "Tamanyo" => 455388 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×10.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 917 "Ancho" => 1223 "Tamanyo" => 170690 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, 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" => "Metabolic diseases: gout" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G.F. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 18 | 12 | 30 |
| 2024 Octubre | 143 | 54 | 197 |
| 2024 Septiembre | 145 | 22 | 167 |
| 2024 Agosto | 178 | 68 | 246 |
| 2024 Julio | 131 | 38 | 169 |
| 2024 Junio | 102 | 27 | 129 |
| 2024 Mayo | 82 | 37 | 119 |
| 2024 Abril | 81 | 21 | 102 |
| 2024 Marzo | 121 | 38 | 159 |
| 2024 Febrero | 140 | 29 | 169 |
| 2024 Enero | 114 | 34 | 148 |
| 2023 Diciembre | 186 | 18 | 204 |
| 2023 Noviembre | 265 | 31 | 296 |
| 2023 Octubre | 305 | 29 | 334 |
| 2023 Septiembre | 456 | 48 | 504 |
| 2023 Agosto | 402 | 26 | 428 |
| 2023 Julio | 623 | 42 | 665 |
| 2023 Junio | 526 | 32 | 558 |
| 2023 Mayo | 319 | 25 | 344 |
| 2023 Abril | 172 | 21 | 193 |
| 2023 Marzo | 172 | 32 | 204 |
| 2023 Febrero | 166 | 29 | 195 |
| 2023 Enero | 125 | 33 | 158 |
| 2022 Diciembre | 145 | 35 | 180 |
| 2022 Noviembre | 70 | 24 | 94 |
| 2022 Octubre | 113 | 25 | 138 |
| 2022 Septiembre | 140 | 61 | 201 |
| 2022 Agosto | 100 | 64 | 164 |
| 2022 Julio | 70 | 62 | 132 |
| 2022 Junio | 62 | 48 | 110 |
| 2022 Mayo | 125 | 57 | 182 |
| 2022 Abril | 148 | 45 | 193 |
| 2022 Marzo | 128 | 66 | 194 |
| 2022 Febrero | 87 | 35 | 122 |
| 2022 Enero | 77 | 52 | 129 |
| 2021 Diciembre | 69 | 60 | 129 |
| 2021 Noviembre | 71 | 50 | 121 |
| 2021 Octubre | 75 | 78 | 153 |
| 2021 Septiembre | 82 | 38 | 120 |
| 2021 Agosto | 49 | 35 | 84 |
| 2021 Julio | 53 | 31 | 84 |
| 2021 Junio | 38 | 28 | 66 |
| 2021 Mayo | 52 | 40 | 92 |
| 2021 Abril | 104 | 52 | 156 |
| 2021 Marzo | 57 | 24 | 81 |
| 2021 Febrero | 57 | 31 | 88 |
| 2021 Enero | 39 | 12 | 51 |
| 2020 Diciembre | 26 | 24 | 50 |
| 2020 Noviembre | 27 | 7 | 34 |
| 2020 Octubre | 23 | 15 | 38 |
| 2020 Septiembre | 23 | 10 | 33 |
| 2020 Agosto | 29 | 25 | 54 |
| 2020 Julio | 15 | 21 | 36 |
| 2020 Junio | 30 | 21 | 51 |
| 2020 Mayo | 24 | 19 | 43 |
| 2020 Abril | 36 | 16 | 52 |
| 2020 Marzo | 32 | 18 | 50 |
| 2020 Febrero | 3 | 0 | 3 |
| 2020 Enero | 0 | 2 | 2 |
| 2019 Diciembre | 4 | 4 | 8 |
| 2019 Noviembre | 0 | 1 | 1 |
| 2019 Octubre | 0 | 4 | 4 |
| 2019 Septiembre | 4 | 1 | 5 |
| 2019 Agosto | 0 | 4 | 4 |
| 2019 Julio | 0 | 2 | 2 |
| 2019 Junio | 2 | 11 | 13 |
| 2019 Mayo | 1 | 11 | 12 |
| 2019 Abril | 1 | 11 | 12 |
| 2019 Marzo | 3 | 7 | 10 |
| 2019 Febrero | 0 | 3 | 3 |
| 2019 Enero | 4 | 0 | 4 |
| 2018 Diciembre | 5 | 0 | 5 |
| 2018 Noviembre | 4 | 0 | 4 |
| 2018 Octubre | 5 | 0 | 5 |
| 2018 Septiembre | 6 | 0 | 6 |
| 2018 Agosto | 0 | 4 | 4 |
| 2018 Junio | 0 | 6 | 6 |
| 2018 Mayo | 0 | 9 | 9 |
| 2018 Marzo | 23 | 6 | 29 |
| 2018 Febrero | 99 | 5 | 104 |
| 2018 Enero | 72 | 6 | 78 |
| 2017 Diciembre | 106 | 13 | 119 |
| 2017 Noviembre | 81 | 10 | 91 |
| 2017 Octubre | 82 | 10 | 92 |
| 2017 Septiembre | 89 | 11 | 100 |
| 2017 Agosto | 111 | 13 | 124 |
| 2017 Julio | 106 | 5 | 111 |
| 2017 Junio | 138 | 22 | 160 |
| 2017 Mayo | 110 | 14 | 124 |
| 2017 Abril | 91 | 8 | 99 |
| 2017 Marzo | 91 | 23 | 114 |
| 2017 Febrero | 76 | 14 | 90 |
| 2017 Enero | 92 | 12 | 104 |
| 2016 Diciembre | 82 | 14 | 96 |
| 2016 Noviembre | 81 | 18 | 99 |
| 2016 Octubre | 102 | 19 | 121 |
| 2016 Septiembre | 109 | 15 | 124 |
| 2016 Agosto | 127 | 17 | 144 |
| 2016 Julio | 69 | 10 | 79 |
| 2016 Junio | 8 | 4 | 12 |
| 2016 Mayo | 4 | 19 | 23 |
| 2016 Abril | 8 | 9 | 17 |
| 2016 Marzo | 4 | 4 | 8 |
| 2016 Febrero | 5 | 4 | 9 |
| 2016 Enero | 6 | 1 | 7 |
| 2015 Diciembre | 8 | 3 | 11 |
| 2015 Noviembre | 7 | 2 | 9 |
| 2015 Octubre | 6 | 3 | 9 |
| 2015 Septiembre | 14 | 4 | 18 |
| 2015 Agosto | 19 | 4 | 23 |
| 2015 Julio | 93 | 8 | 101 |
| 2015 Junio | 85 | 13 | 98 |
| 2015 Mayo | 116 | 28 | 144 |
| 2015 Abril | 42 | 9 | 51 |
| 2015 Marzo | 42 | 1 | 43 |
| 2015 Febrero | 42 | 6 | 48 |
| 2015 Enero | 43 | 6 | 49 |
| 2014 Diciembre | 65 | 7 | 72 |
| 2014 Noviembre | 22 | 3 | 25 |
| 2014 Octubre | 52 | 2 | 54 |
| 2014 Septiembre | 46 | 2 | 48 |
| 2014 Agosto | 40 | 6 | 46 |
| 2014 Julio | 50 | 7 | 57 |
| 2014 Junio | 54 | 7 | 61 |
| 2014 Mayo | 52 | 8 | 60 |
| 2014 Abril | 45 | 5 | 50 |
| 2014 Marzo | 48 | 9 | 57 |
| 2014 Febrero | 23 | 9 | 32 |
| 2014 Enero | 44 | 5 | 49 |
| 2013 Diciembre | 39 | 9 | 48 |
| 2013 Noviembre | 18 | 4 | 22 |
| 2013 Octubre | 20 | 5 | 25 |
| 2013 Septiembre | 17 | 6 | 23 |
| 2013 Agosto | 27 | 4 | 31 |
| 2013 Julio | 26 | 4 | 30 |
| 2013 Junio | 7 | 3 | 10 |
| 2013 Mayo | 4 | 4 | 8 |
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