Case and Research Letter
Pachydermodactyly Successfully Treated With Triamcinolone Injections
Paquidermodactilia tratada con éxito con infiltraciones de triamcinolona
A. Plana Pla
, J. Bassas Vila, M.A. Toro Montecinos, C. Ferrandiz Foraster
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Departamento de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
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Plana Pla, J. Bassas Vila, M.A. Toro Montecinos, C. Ferrandiz Foraster" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Plana Pla" "email" => array:1 [ 0 => "adriplanapla@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Bassas Vila" ] 2 => array:2 [ "nombre" => "M.A." "apellidos" => "Toro Montecinos" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Ferrandiz Foraster" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Paquidermodactilia tratada con éxito con infiltraciones de triamcinolona" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1375 "Ancho" => 901 "Tamanyo" => 176488 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pretreatment photograph showing the conspicuous, diffuse thickening around the proximal interphalangeal joints of all the fingers with the exception of the thumb and fifth finger.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pachydermodactyly, from the Greek pachy (thick), dermos (skin), and dactylos (digits), is a very rare form of acquired benign digital fibromatosis. It is characterized clinically swelling of the medial and lateral aspects of the proximal interphalangeal joints of practically all the fingers of the hands (with the exception of the thumb). We describe a clinically striking new case that responded satisfactorily to corticosteroid infiltration and we discuss the different therapeutic options available.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 15-year-old patient with no past medical history of interest was referred to dermatology outpatients for evaluation of thickening of the second, third, and fourth fingers of both hands that had started to develop 2 years earlier. An additional finding was that the patient attended a gymnasium 4 days a week to perform weight training.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed very marked, diffuse thickening at the level of the proximal interphalangeal joints of all the fingers of the hands, except the thumbs and fifth fingers. Movement was not limited (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and there were no others skin changes.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Histology of a skin biopsy taken from the lateral aspect of the second finger of the right hand showed thickening of the dermis with an increase both in collagen fibers and, to a lesser extent, in fibroblasts (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, A and B). Few changes were detected in the epidermis, though minimal hyperkeratosis with compact orthokeratosis was observed.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A full laboratory work-up, including renal and liver function and markers of autoimmunity, was completely normal. X-rays of the hands showed no bone or joint abnormalities, and magnetic resonance revealed thickening of the dermis that extended down to the subcutaneous cellular tissue.</p><p id="par0030" class="elsevierStylePara elsevierViewall">It was decided to treat the patient with corticosteroid injections into the affected area. We used a solution of triamcinolone acetonide, 40 mg/mL, mixed with an equal volume of 2% mepivacaine solution, and performed injections (2-3<span class="elsevierStyleHsp" style=""></span>mL of the solution into each thickened area) in 2 sessions, 2 months apart. This achieved a marked decrease in the size and firmness of the lesions after the 2 sessions (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Pachydermodactyly is a rare condition, with only 80 published cases to date.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is included in the group of the fibromatoses and since it was first described by Bazex et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> in 1973 it has been referred to by various names, including knuckle pads, pseudo-knuckle pads, heloderma, and subcutaneous fibroma.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Our patient presented a model case with regard to age and sex, as pachydermodactyly is usually seen in young patients (mean age at presentation, 21.2 years), although the age range of published cases is from 5 to 69 years, and the condition is more common in men, with a male to female ratio of 3 to 2.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This predominance in men has been related to the possible etiology and pathogenesis of the disorder as, although this is not yet fully understood, it has been suggested that pachydermodactyly may be a reactive disorder secondary to repeated minor exogenous trauma.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> This proposal is based on the finding that pachydermodactyly shows a relationship with numerous occupations and activities such as martial arts and climbing,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> work in food-processing factories,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> patients with obsessive compulsive disorders associated with tics affecting the hands,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> or weight lifting, as in the case we present.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Our case is also highly illustrative of the clinical manifestations, as the typical findings are asymptomatic and symmetrical swelling of the sides of the fingers. The second, third, and fourth fingers are most commonly affected, but the fifth finger and even the dorsum of the hand can occasionally be affected.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> There are usually no epidermal changes, though mild erythema, fine desquamation, or lichenification may sometimes be observed.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7</span></a> Hand movements are not affected.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The diagnosis is clinical. The most typical findings on histology are a thickening of the dermis, which may be accompanied by a benign proliferation of fibroblasts, and an increase in collagen fibers that extends down to the subcutaneous cellular tissue. Hyperkeratosis (ortokeratosis or parakeratosis) may also be observed, as well as a decrease in the elastic fibers and mucin.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Plain x-rays are normal and magnetic resonance shows an increase in soft tissue volume around the joints.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The main differential diagnosis is with knuckle pads. These nodules, which can be idiopathic (true) or due to recurrent trauma (pseudo-knuckle pads), are differentiated from pachydermodactyly by the site of the lesions; in pachydermodactyly the lesions typically affect the sides of the fingers whereas knuckle pads are found on the dorsal surface. In addition, they are usually more circumscribed lesions.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Another disease that we must consider is juvenile hyaline fibromatosis. This disease, due to a genetic abnormality that alters the regulation of collagen synthesis, leads to the appearance of multiple subcutaneous nodules on the fingers. However, it also causes other changes, such as bone lesions, ulceration, gingival hypertrophy, and tumors on the scalp and nose.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Certain types of polyarthritis that affect the proximal interphalangeal joints, such as psoriatic arthritis and rheumatoid arthritis, must also be considered in the differential diagnosis. The diagnosis of these dermatoses is facilitated by the clear presence of inflammatory signs.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Published reports on pachydermodactyly focus little on its treatment. Some authors even advocate therapeutic abstention, suggesting only that patients stop performing the activities that gave rise to the exogenous trauma. This approach comes from the fact that pachydermodactyly is a benign dermatosis that interferes little with movement. However, in our opinion, the disease can have a significant impact on the quality of life of some patients, and therapy should not therefore be ignored. At the present time, the 2 treatment options considered are local corticosteroid infiltration and surgical treatment by resection of the fibrous tissue.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Descriptions on how to perform these procedures (the surgical technique or the dose and regimen of corticosteroid infiltration) are scarce.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In our patient we used a solution of triamcinolone acetonide, 40 mg/mL, mixed with an equal volume of 2% mepivacaine solution, and we performed injections in 2 sessions, 2 months apart. At each session we injected a total of 2-3<span class="elsevierStyleHsp" style=""></span>mL of the solution into each thickened area. The cosmetic result was acceptable, and there was mild periarticular hypopigmentation. Thus, with the caution that comes from a report of a single case, we propose this therapeutic regimen as one of the treatment options in similar cases.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Plana Pla A, Bassas Vila J, Toro Montecinos M, Ferrandiz Foraster C. Paquidermodactilia tratada con éxito con infiltraciones de triamcinolona. Actas Dermosifiliogr. 2014 105:319–321.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1375 "Ancho" => 901 "Tamanyo" => 176488 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pretreatment photograph showing the conspicuous, diffuse thickening around the proximal interphalangeal joints of all the fingers with the exception of the thumb and fifth finger.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2001 "Ancho" => 946 "Tamanyo" => 1008226 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Histology image in which thickening of the dermis may be observed, associated with an increase of both collagen fibers and, to a lesser extent, fibroblasts (hematoxylin-eosin, original magnification x10). B, Histology image at higher magnification showing the increase of the collagen fibers and fibroblasts (hematoxylin-eosin, original magnification x20).</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" => 856 "Ancho" => 951 "Tamanyo" => 102115 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Photograph taken 2 months after the second session of injections. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 28 | 6 | 34 |
| 2024 Octubre | 234 | 47 | 281 |
| 2024 Septiembre | 174 | 29 | 203 |
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| 2023 Noviembre | 129 | 30 | 159 |
| 2023 Octubre | 141 | 30 | 171 |
| 2023 Septiembre | 115 | 37 | 152 |
| 2023 Agosto | 104 | 30 | 134 |
| 2023 Julio | 107 | 39 | 146 |
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| 2023 Febrero | 118 | 32 | 150 |
| 2023 Enero | 108 | 34 | 142 |
| 2022 Diciembre | 87 | 51 | 138 |
| 2022 Noviembre | 59 | 39 | 98 |
| 2022 Octubre | 40 | 29 | 69 |
| 2022 Septiembre | 52 | 45 | 97 |
| 2022 Agosto | 55 | 36 | 91 |
| 2022 Julio | 28 | 38 | 66 |
| 2022 Junio | 34 | 29 | 63 |
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| 2022 Abril | 123 | 26 | 149 |
| 2022 Marzo | 90 | 52 | 142 |
| 2022 Febrero | 120 | 48 | 168 |
| 2022 Enero | 139 | 72 | 211 |
| 2021 Diciembre | 124 | 60 | 184 |
| 2021 Noviembre | 115 | 59 | 174 |
| 2021 Octubre | 111 | 62 | 173 |
| 2021 Septiembre | 119 | 40 | 159 |
| 2021 Agosto | 113 | 36 | 149 |
| 2021 Julio | 142 | 40 | 182 |
| 2021 Junio | 162 | 35 | 197 |
| 2021 Mayo | 150 | 31 | 181 |
| 2021 Abril | 274 | 115 | 389 |
| 2021 Marzo | 145 | 42 | 187 |
| 2021 Febrero | 92 | 33 | 125 |
| 2021 Enero | 64 | 18 | 82 |
| 2020 Diciembre | 52 | 20 | 72 |
| 2020 Noviembre | 49 | 18 | 67 |
| 2020 Octubre | 56 | 19 | 75 |
| 2020 Septiembre | 41 | 21 | 62 |
| 2020 Agosto | 26 | 25 | 51 |
| 2020 Julio | 25 | 12 | 37 |
| 2020 Junio | 30 | 36 | 66 |
| 2020 Mayo | 22 | 16 | 38 |
| 2020 Abril | 42 | 20 | 62 |
| 2020 Marzo | 25 | 9 | 34 |
| 2020 Febrero | 5 | 4 | 9 |
| 2020 Enero | 0 | 2 | 2 |
| 2019 Diciembre | 4 | 23 | 27 |
| 2019 Noviembre | 0 | 7 | 7 |
| 2019 Octubre | 0 | 4 | 4 |
| 2019 Septiembre | 4 | 13 | 17 |
| 2019 Agosto | 0 | 4 | 4 |
| 2019 Julio | 0 | 16 | 16 |
| 2019 Junio | 2 | 20 | 22 |
| 2019 Mayo | 1 | 80 | 81 |
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| 2019 Marzo | 2 | 7 | 9 |
| 2019 Febrero | 4 | 9 | 13 |
| 2019 Enero | 1 | 11 | 12 |
| 2018 Diciembre | 0 | 1 | 1 |
| 2018 Noviembre | 1 | 1 | 2 |
| 2018 Octubre | 5 | 0 | 5 |
| 2018 Septiembre | 4 | 2 | 6 |
| 2018 Agosto | 0 | 6 | 6 |
| 2018 Julio | 0 | 18 | 18 |
| 2018 Junio | 0 | 6 | 6 |
| 2018 Abril | 0 | 7 | 7 |
| 2018 Marzo | 11 | 6 | 17 |
| 2018 Febrero | 70 | 12 | 82 |
| 2018 Enero | 62 | 9 | 71 |
| 2017 Diciembre | 67 | 11 | 78 |
| 2017 Noviembre | 64 | 14 | 78 |
| 2017 Octubre | 64 | 11 | 75 |
| 2017 Septiembre | 63 | 25 | 88 |
| 2017 Agosto | 71 | 19 | 90 |
| 2017 Julio | 75 | 20 | 95 |
| 2017 Junio | 78 | 16 | 94 |
| 2017 Mayo | 92 | 21 | 113 |
| 2017 Abril | 70 | 14 | 84 |
| 2017 Marzo | 75 | 16 | 91 |
| 2017 Febrero | 81 | 22 | 103 |
| 2017 Enero | 77 | 14 | 91 |
| 2016 Diciembre | 70 | 16 | 86 |
| 2016 Noviembre | 120 | 17 | 137 |
| 2016 Octubre | 112 | 34 | 146 |
| 2016 Septiembre | 147 | 18 | 165 |
| 2016 Agosto | 90 | 18 | 108 |
| 2016 Julio | 56 | 13 | 69 |
| 2016 Junio | 7 | 8 | 15 |
| 2016 Mayo | 7 | 15 | 22 |
| 2016 Abril | 3 | 18 | 21 |
| 2016 Marzo | 3 | 2 | 5 |
| 2016 Febrero | 2 | 12 | 14 |
| 2016 Enero | 10 | 2 | 12 |
| 2015 Diciembre | 9 | 9 | 18 |
| 2015 Noviembre | 8 | 2 | 10 |
| 2015 Octubre | 9 | 8 | 17 |
| 2015 Septiembre | 9 | 10 | 19 |
| 2015 Agosto | 6 | 3 | 9 |
| 2015 Julio | 128 | 22 | 150 |
| 2015 Junio | 97 | 5 | 102 |
| 2015 Mayo | 94 | 11 | 105 |
| 2015 Abril | 65 | 5 | 70 |
| 2015 Marzo | 74 | 9 | 83 |
| 2015 Febrero | 60 | 6 | 66 |
| 2015 Enero | 74 | 6 | 80 |
| 2014 Diciembre | 84 | 8 | 92 |
| 2014 Noviembre | 51 | 5 | 56 |
| 2014 Octubre | 35 | 2 | 37 |
| 2014 Septiembre | 31 | 3 | 34 |
| 2014 Agosto | 29 | 6 | 35 |
| 2014 Julio | 28 | 8 | 36 |
| 2014 Junio | 35 | 5 | 40 |
| 2014 Mayo | 42 | 13 | 55 |
| 2014 Abril | 22 | 13 | 35 |
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