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who reported clusters of milium cysts on the posterior aspect of the auricles of the ear&#46; In 1978&#44; Hubler et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> called the condition milia en plaque&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This form of milia usually affects middle-aged adults and there is a slight female predominance &#40;3 to 1&#41;&#46; Milia en plaque presents clinically as clusters of yellowish-white papules on an erythematous base&#59; the lesions are usually asymptomatic but pruritus may occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> Typical sites include the earlobes&#44; preauricular and periocular<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> regions&#44; the nose&#44; and the limbs&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Cysts can arise spontaneously &#40;primary milia&#41;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> or after different triggers &#40;secondary milia&#41;&#44; such as recurrent trauma&#44; topical treatment with corticosteroids or 5-fluoruracil&#44; cryotherapy&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> chemotherapy &#40;6-mercaptopurine&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> or radiotherapy &#40;as observed in our patient&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Two cases of postradiotherapy milia en plaque have been reported in the literature&#59; in both cases the lesions arose on normal skin within the radiation fields&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Follicular changes induced by chemotherapeutic agents have been described in the literature&#44; especially with drugs that target the epidermal growth factor receptor&#46; But the most common chemotherapy-induced changes described in the literature occur in the eccrine gland or duct&#44; in the form of squamous syringometaplasia&#46; We believe that chemotherapeutic agents were not relevant to the pathogenesis in our patient as no lesions were observed outside the fields of radiation&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Histology reveals small cysts containing orthokeratotic keratin&#44; located in the dermis&#46; The cysts are lined by a squamous epithelium with a granular layer&#44; and are accompanied by a mild mixed or lymphocytic perivascular infiltrate&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The pathogenesis of milia en plaque is unknown&#44; although damage to the follicular infundibulum may be assumed in our case due to a direct effect of radiotherapy on the follicular epithelium&#46; In other cases&#44; numerous other factors that could in some way affect the follicular epithelium may be involved&#44; including dermabrasion&#44; 5-fluorouracil&#44; acitretin&#44; or solar damage&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The differential diagnoses that should be considered include comedonal nevus&#44; trichoadenoma of Nikolowski&#44; steatocystoma multiplex&#44; Favre-Racouchot disease&#44; follicular mucinosis&#44; and folliculotropic mycosis fungoides&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Song JC et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> published a case in which skin metastases from a parotid gland carcinoma had a milia-like appearance&#46; Skin metastases must be considered&#44; though the absence of atypia in the histopathology of the lesions in our patient excluded this diagnosis&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Treatment can be provided to patients with symptomatic lesions or for cosmetic reasons&#46; Numerous treatments with satisfactory results have been described in the literature&#44; including topical retinoids&#44; cryotherapy&#44; electrocoagulation&#44; radiofrequency&#44; carbon dioxide laser&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> surgical excision&#44; oral tetracyclines&#44; and photodynamic therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;9</span></a> Given the benign nature of the disease and the absence of any cosmetic issue&#44; our patient was not a candidate for treatment&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion&#44; milia en plaque is a rare but easily diagnosed disease&#46; No cause is detected in the majority of cases&#46; In our case&#44; the recent history of exposure to radiotherapy&#44; with a plausible temporal relationship&#44; would suggest a causal relationship&#46;</p></span>"
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Case and Research Letters
Milia en plaque on the posterior surface of both auricules following radiation therapy
Milia en Placa en la Cara Posterior de Ambos Pabellones Auriculares Secundaria a Radioterapia
A.M. Pisauria,c,
Autor para correspondencia
anapisauri@gmail.com

Corresponding author.
, A. Alvarez-Graciab, C. Ferrandiz-Forastera, J. Bassas-Vilaa
a Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
b Servicio de Oncología Radioterápica, ICO, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
c Servicio de Dermatología, Hospital Argerich, Buenos Aires, Argentina
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Milia are benign epidermal cysts that can present as an isolated finding or associated with other clinical alterations&#46; When found in groups on an erythematous base&#44; the lesions are called milia en plaque&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 48-year-old man with history of adenocarcinoma of the lung with cerebral metastases for which he received palliative treatment with holocranial radiotherapy at a dose of 30<span class="elsevierStyleHsp" style=""></span>Gy in 10 fractions&#46; The radiation fields included the auricles of the ear &#40;2 opposing lateral photon beams to the central nervous system&#41;&#59; the total dose received by the auricles of the ear was calculated as between 20 and 25<span class="elsevierStyleHsp" style=""></span>Gy&#46; The patient came to our outpatient clinic for asymptomatic lesions that had arisen on the posterior aspect of the auricles of both ears 3 months earlier&#46; Since his youth he had occasionally presented isolated lesions of a similar appearance&#44; but the multiple lesions had developed a month after the radiotherapy&#46; On examination&#44; multiple millimetric whitish papules with a shiny surface on an erythematous base were found in groups bilaterally on the auricles of the ears &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Punch biopsy revealed an infundibular follicular cyst full of orthokeratotic keratin &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Postradiotherapy milia en plaque was diagnosed based on the patient&#39;s past medical history and the clinical and histologic findings&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Milia en plaque is rare&#46; It was first described in 1903 by Balzer and Fouquet&#44; who reported clusters of milium cysts on the posterior aspect of the auricles of the ear&#46; In 1978&#44; Hubler et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> called the condition milia en plaque&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This form of milia usually affects middle-aged adults and there is a slight female predominance &#40;3 to 1&#41;&#46; Milia en plaque presents clinically as clusters of yellowish-white papules on an erythematous base&#59; the lesions are usually asymptomatic but pruritus may occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> Typical sites include the earlobes&#44; preauricular and periocular<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> regions&#44; the nose&#44; and the limbs&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Cysts can arise spontaneously &#40;primary milia&#41;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> or after different triggers &#40;secondary milia&#41;&#44; such as recurrent trauma&#44; topical treatment with corticosteroids or 5-fluoruracil&#44; cryotherapy&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> chemotherapy &#40;6-mercaptopurine&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> or radiotherapy &#40;as observed in our patient&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Two cases of postradiotherapy milia en plaque have been reported in the literature&#59; in both cases the lesions arose on normal skin within the radiation fields&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Follicular changes induced by chemotherapeutic agents have been described in the literature&#44; especially with drugs that target the epidermal growth factor receptor&#46; But the most common chemotherapy-induced changes described in the literature occur in the eccrine gland or duct&#44; in the form of squamous syringometaplasia&#46; We believe that chemotherapeutic agents were not relevant to the pathogenesis in our patient as no lesions were observed outside the fields of radiation&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Histology reveals small cysts containing orthokeratotic keratin&#44; located in the dermis&#46; The cysts are lined by a squamous epithelium with a granular layer&#44; and are accompanied by a mild mixed or lymphocytic perivascular infiltrate&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The pathogenesis of milia en plaque is unknown&#44; although damage to the follicular infundibulum may be assumed in our case due to a direct effect of radiotherapy on the follicular epithelium&#46; In other cases&#44; numerous other factors that could in some way affect the follicular epithelium may be involved&#44; including dermabrasion&#44; 5-fluorouracil&#44; acitretin&#44; or solar damage&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The differential diagnoses that should be considered include comedonal nevus&#44; trichoadenoma of Nikolowski&#44; steatocystoma multiplex&#44; Favre-Racouchot disease&#44; follicular mucinosis&#44; and folliculotropic mycosis fungoides&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Song JC et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> published a case in which skin metastases from a parotid gland carcinoma had a milia-like appearance&#46; Skin metastases must be considered&#44; though the absence of atypia in the histopathology of the lesions in our patient excluded this diagnosis&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Treatment can be provided to patients with symptomatic lesions or for cosmetic reasons&#46; Numerous treatments with satisfactory results have been described in the literature&#44; including topical retinoids&#44; cryotherapy&#44; electrocoagulation&#44; radiofrequency&#44; carbon dioxide laser&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> surgical excision&#44; oral tetracyclines&#44; and photodynamic therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;9</span></a> Given the benign nature of the disease and the absence of any cosmetic issue&#44; our patient was not a candidate for treatment&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion&#44; milia en plaque is a rare but easily diagnosed disease&#46; No cause is detected in the majority of cases&#46; In our case&#44; the recent history of exposure to radiotherapy&#44; with a plausible temporal relationship&#44; would suggest a causal relationship&#46;</p></span>"
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