Case and Research Letter
Multiple Secondary Cutaneous Osteomas in a Patient With Folliculitis Decalvans
Osteoma cutáneo múltiple secundario en paciente con foliculitis decalvante
a Servicio de Dermatología, Complejo Hospitalario Universitario de Ferrol, Área Sanitaria de Ferrol, SERGAS, Ferrol, A Coruña, Spain
b Servicio de Anatomía Patológica, Complejo Hospitalario Universitario de Ferrol, Área Sanitaria de Ferrol, SERGAS, Ferrol, A Coruña, Spain
c Servicio de Radiología, Complejo Hospitalario Universitario de Ferrol, Área Sanitaria de Ferrol, SERGAS, Ferrol, A Coruña, Spain
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Monteagudo, A. Varela-Veiga, J.Á. Vázquez-Bueno, A.M. Porta" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Monteagudo" "email" => array:1 [ 0 => "benigno.monteagudo.sanchez@sergas.es" ] "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" => "A." "apellidos" => "Varela-Veiga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J.Á." "apellidos" => "Vázquez-Bueno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "A.M." "apellidos" => "Porta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Complejo Hospitalario Universitario de Ferrol, Área Sanitaria de Ferrol, SERGAS, Ferrol, A Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Complejo Hospitalario Universitario de Ferrol, Área Sanitaria de Ferrol, SERGAS, Ferrol, A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiología, Complejo Hospitalario Universitario de Ferrol, Área Sanitaria de Ferrol, SERGAS, Ferrol, A Coruña, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Osteoma cutáneo múltiple secundario en paciente con foliculitis decalvante" ] ] "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" => 634 "Ancho" => 951 "Tamanyo" => 100461 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Plaque of scarring alopecia in the parietal area with numerous white papular lesions inside (<elsevierMultimedia ident="201704010123491781"></elsevierMultimedia>, and papules and follicular pustules, and tufted hair folliculitis at the margins (▴).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Diagnosis of head and scalp diseases is based, in most cases, on recognizing of the clinical manifestations. Sometimes, these manifestations are not characteristic and we need to resort to more invasive techniques such as a trichogram or biopsy.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Histological study of the scalp is often difficult to interpret and sometimes inconclusive. Dermoscopy, in contrast, is a noninvasive diagnostic technique that facilitates diagnosis of many hair disorders.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this article, we present a case of folliculitis decalvans that led to secondary osteoma cutis (OC) in areas of scarring alopecia.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 45-year-old man with an unremarkable personal history who was in follow-up in the dermatology department for scarring alopecia of the scalp of 9 years duration. Treatment with corticosteroids, topical antibiotics, and oral hydroxychloroquine had been administered without success.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The physical examination revealed a plaque of scarring alopecia affecting the vertex and frontal and parietal areas. At the edges, follicular papules and pustules were present as well as tufted hair folliculitis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Dermoscopy revealed polytrichia, follicular pustules, and milky-red areas with loss of follicular orifices (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). The histopathological study showed chronic granulomatous-histiocytic inflammatory infiltrate in perifollicular regions. In the reticular dermis, this infiltrate occupied the site of the hair stems (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In the area of scarring alopecia, numerous white papular lesions measuring less than 2<span class="elsevierStyleHsp" style=""></span>mm across were observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In the corresponding dermoscopic image, only whitish areas could be seen (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C). The histopathological study showed mature bone tissue with bone marrow immersed in dermal collagen and subcutaneous cell tissue (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>D). Head computed tomography showed punctiform cutaneous lesions with a high attenuation compared to calcium (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). The finer the cut the more lesions were observed. The 3-dimensional image showed frontal and parietal lesions (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B). In another image, the location of these lesions in the skin could be observed (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>C). Laboratory analyses, including Ca (24<span class="elsevierStyleHsp" style=""></span>h urine calcium, P, parathyroid hormone, and 25-hydroxy-vitamin D), were normal.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">With diagnosis of folliculitis decalvans, a combination of oral rifampicin and clindamycin was prescribed. Given that the OC lesions were asymptomatic, the patient decided not to receive treatment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Folliculitis decalvans is a neutrophilic scarring alopecia, which is more frequent in young and middle-aged men. The pathogenesis is related to <span class="elsevierStyleItalic">Staphylococcus aureus</span> infection, immune abnormalities, and genetic predisposition. It presents at the vertex and occipital area in the form of 1 or several irregular, atrophic, slow-growing plaques of scarring alopecia with evidence of activity at the edges. Tufted hair folliculitis is typically present, giving a doll hair appearance.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Characteristic dermoscopy findings of this entity include multiple hairs originating from a single, dilated orifice (polytrichia), erythema, scabs and perifollicular eczemas, and milky-red areas without follicular orifices.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> In the histopathological analysis, in the early phases, infundibular dilation is observed, along with intrafollicular and perifollicular neutrophilic infiltrate in the upper and middle parts of the follicle. In advanced phases, the entire follicle is affected and in addition to neutrophils, lymphocytes, histiocytes, plasma cells, and multinucleated giant cells can be seen. Finally, the fibrous tracts replace the hair follicles.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In cutaneous ossification, deposits of Ca and P are arranged in an organized pattern as if they were in normal bone. Clinically, the lesions are hard, and the histopathological study shows a proliferation of bone tissue with osteoblasts and sometimes osteoclasts. They are classified as primary or secondary forms according to whether prior cutaneous lesions were present. The secondary form is more frequent and has been linked to scarring and inflammatory processes among others, processes which can include folliculitis decalvans. Unlike ossification, the mineral phase in cutaneous calcification is deposited in disorganized fashion and the material is soft and pasty.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In this case, differential diagnosis should be established with other types of OC, such as plaque OC, a primary and idiopathic form that usually presents with plaque lesions on the scalp. Initially, this was thought to be a congenital process, but acquired cases have been reported.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Another condition to include in the differential diagnosis is multiple miliary OC in its a primary form or associated with acne. That entity is characterized by multiple hard papules distributed mainly on the face, but also the scalp.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The optimum treatment for OC is not well established, and given that the lesions are often asymptomatic and are not usually associated with complications, management is usually from an aesthetic perspective. In miliary OC lesions, surgical removal, incision with needle or scalpel, punch biopsy, curettage, laser therapy (erbium:YAG laser and CO<span class="elsevierStyleInf">2</span> laser), dermabrasion, systemic and topical retinoids (tretinoin), biphosphonates, and oral antibiotics have all been used, at times in combinations.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, the case concerned a man with folliculitis decalvans and multiple secondary OC (we have not found this association reported in the literature). The clinical presentation resembled plaque OC or multiple miliary OC on the scalp.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => 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: Monteagudo B. Osteoma cutáneo múltiple secundario en paciente con foliculitis decalvante. Actas Dermosifiliogr. 2016;107:250–253.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 634 "Ancho" => 951 "Tamanyo" => 100461 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Plaque of scarring alopecia in the parietal area with numerous white papular lesions inside (<elsevierMultimedia ident="201704010123491781"></elsevierMultimedia>, and papules and follicular pustules, and tufted hair folliculitis at the margins (▴).</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" => 1858 "Ancho" => 1651 "Tamanyo" => 878296 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Dermoscopic image. Polytrichia, follicular pustules, and milky-red areas with loss of follicular orifices. B, In the dermis, chronic granulomatous-histiocytic inflammatory infiltrate in perifollicular regions (hematoxylin-eosin<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>100). C, Dermoscopic image. Whitish areas. D, Mature bone tissue with bone marrow immersed in dermal collagen and subcutaneous cell tissue (hematoxylin-eosin<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>100).</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" => 1309 "Ancho" => 1651 "Tamanyo" => 150406 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Head computed tomography. A, Punctiform cutaneous lesions with high attenuation. B, Three-dimensional image of frontal and parietal lesions. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 10 | 6 | 16 |
| 2024 Octubre | 82 | 39 | 121 |
| 2024 Septiembre | 91 | 21 | 112 |
| 2024 Agosto | 102 | 63 | 165 |
| 2024 Julio | 96 | 27 | 123 |
| 2024 Junio | 105 | 30 | 135 |
| 2024 Mayo | 71 | 30 | 101 |
| 2024 Abril | 69 | 20 | 89 |
| 2024 Marzo | 66 | 28 | 94 |
| 2024 Febrero | 68 | 36 | 104 |
| 2024 Enero | 54 | 32 | 86 |
| 2023 Diciembre | 64 | 15 | 79 |
| 2023 Noviembre | 75 | 37 | 112 |
| 2023 Octubre | 75 | 27 | 102 |
| 2023 Septiembre | 88 | 32 | 120 |
| 2023 Agosto | 55 | 18 | 73 |
| 2023 Julio | 62 | 28 | 90 |
| 2023 Junio | 81 | 23 | 104 |
| 2023 Mayo | 65 | 26 | 91 |
| 2023 Abril | 66 | 26 | 92 |
| 2023 Marzo | 78 | 21 | 99 |
| 2023 Febrero | 60 | 23 | 83 |
| 2023 Enero | 54 | 34 | 88 |
| 2022 Diciembre | 58 | 39 | 97 |
| 2022 Noviembre | 49 | 24 | 73 |
| 2022 Octubre | 43 | 24 | 67 |
| 2022 Septiembre | 53 | 39 | 92 |
| 2022 Agosto | 28 | 36 | 64 |
| 2022 Julio | 24 | 35 | 59 |
| 2022 Junio | 25 | 23 | 48 |
| 2022 Mayo | 47 | 41 | 88 |
| 2022 Abril | 56 | 19 | 75 |
| 2022 Marzo | 52 | 39 | 91 |
| 2022 Febrero | 45 | 27 | 72 |
| 2022 Enero | 34 | 30 | 64 |
| 2021 Diciembre | 30 | 36 | 66 |
| 2021 Noviembre | 38 | 31 | 69 |
| 2021 Octubre | 30 | 46 | 76 |
| 2021 Septiembre | 31 | 43 | 74 |
| 2021 Agosto | 21 | 26 | 47 |
| 2021 Julio | 29 | 34 | 63 |
| 2021 Junio | 25 | 47 | 72 |
| 2021 Mayo | 28 | 37 | 65 |
| 2021 Abril | 60 | 71 | 131 |
| 2021 Marzo | 52 | 45 | 97 |
| 2021 Febrero | 60 | 46 | 106 |
| 2021 Enero | 24 | 24 | 48 |
| 2020 Diciembre | 25 | 21 | 46 |
| 2020 Noviembre | 30 | 26 | 56 |
| 2020 Octubre | 19 | 28 | 47 |
| 2020 Septiembre | 32 | 23 | 55 |
| 2020 Agosto | 22 | 21 | 43 |
| 2020 Julio | 21 | 17 | 38 |
| 2020 Junio | 35 | 35 | 70 |
| 2020 Mayo | 24 | 29 | 53 |
| 2020 Abril | 37 | 19 | 56 |
| 2020 Marzo | 27 | 21 | 48 |
| 2020 Febrero | 2 | 5 | 7 |
| 2020 Enero | 4 | 2 | 6 |
| 2019 Diciembre | 4 | 6 | 10 |
| 2019 Noviembre | 4 | 5 | 9 |
| 2019 Octubre | 0 | 2 | 2 |
| 2019 Septiembre | 0 | 16 | 16 |
| 2019 Agosto | 4 | 3 | 7 |
| 2019 Julio | 4 | 22 | 26 |
| 2019 Junio | 4 | 6 | 10 |
| 2019 Mayo | 7 | 29 | 36 |
| 2019 Abril | 2 | 4 | 6 |
| 2019 Marzo | 2 | 3 | 5 |
| 2019 Febrero | 1 | 0 | 1 |
| 2019 Enero | 3 | 0 | 3 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 3 | 0 | 3 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Febrero | 26 | 4 | 30 |
| 2018 Enero | 53 | 5 | 58 |
| 2017 Diciembre | 48 | 16 | 64 |
| 2017 Noviembre | 32 | 7 | 39 |
| 2017 Octubre | 32 | 11 | 43 |
| 2017 Septiembre | 23 | 14 | 37 |
| 2017 Agosto | 31 | 5 | 36 |
| 2017 Julio | 18 | 8 | 26 |
| 2017 Junio | 26 | 9 | 35 |
| 2017 Mayo | 24 | 6 | 30 |
| 2017 Abril | 28 | 3 | 31 |
| 2017 Marzo | 16 | 15 | 31 |
| 2017 Febrero | 11 | 9 | 20 |
| 2017 Enero | 14 | 7 | 21 |
| 2016 Diciembre | 14 | 15 | 29 |
| 2016 Noviembre | 22 | 15 | 37 |
| 2016 Octubre | 20 | 15 | 35 |
| 2016 Agosto | 1 | 1 | 2 |
| 2016 Junio | 0 | 2 | 2 |
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