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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a 66-year-old man with a history of dyslipidemia and inguinal hernioplasty&#44; no known drug allergies&#44; and no relevant past history of skin disease&#46; He was referred to the dermatology department for assessment of asymptomatic papules on the scrotum&#44; which had first appeared 20 years earlier and developed gradually&#46; No relation to any specific causative agent was found &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; The patient had a stable partner&#44; no past history of sexually transmitted infection&#44; and no family history of similar lesions&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed more than 25 papules the color of normal skin&#44; approximately 4<span class="elsevierStyleHsp" style=""></span>mm in diameter&#44; on the scrotum&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Histologic examination revealed prominent hyperkeratosis and an adjacent lymphocytic inflammatory infiltrate&#44; foci of dyskeratosis and acantholysis&#44; and the appearance of keratinocytes with pyknotic nuclei and clear cytoplasm &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#44; A and B&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis&#63;</span></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Given the absence of pruritus and similar lesions at other sites&#44; the diagnosis consistent with the histopathologic findings was papular acantholytic dyskeratosis of the anogenital area&#46; Other potentially communicable entities were ruled out&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course and Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment was initiated with pimecrolimus cream&#44; twice daily for 8 weeks&#46; The lesions improved slightly and remained stable after withdrawal of the drug&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Papular acantholytic dyskeratosis of the anogenital area is a benign&#44; chronic&#44; noncommunicable entity that is rare in men&#44; although the reason for the difference between the sexes is unknown&#46; Clinically&#44; this entity is characterized by multiple small papular lesions that are whitish or skin-colored and either appear in isolation or form plaques&#46; The lesions can be asymptomatic or cause pruritus&#46; They are located on the anogenital area and do not affect any other part of the body&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">As for etiology and pathogenesis&#44; mosaicism of the <span class="elsevierStyleItalic">ATP2A2</span> gene has been detected&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> specifically p&#46;706D<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>N mutations&#44; which are also present in Darier disease&#46; <span class="elsevierStyleItalic">ATP2A2</span> encodes the type 2 sarcoplasmic reticulum calcium pump&#44; and the domain where p&#46;706D<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>N occurs is responsible for regulating the enzymatic phosphorylation that conditions calcium conductance&#46; This mutation causes aberrant calcium flux that leads to the loss of epidermal integrity&#46; Knopp et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> did not find the mutated allele in a sample of normal skin taken from an area adjacent to the lesions&#44; although they did find it in samples of the affected skin&#46; It has been suggested that there may be an etiologic and pathogenic relationship to Hailey-Hailey disease&#44; given that the same mutation in the <span class="elsevierStyleItalic">ATP2C1</span> gene has been found in affected tissue in some patients&#44; although the exclusive involvement of the anogenital area and the absence of family history contradicts this theory&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Definitive diagnosis is made by biopsy&#44; which characteristically reveals a pattern of focal acantholytic dyskeratosis that is also typical of entities such as Darier disease&#44; Hailey-Hailey disease&#44; and Grover disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#8211;4</span></a> The clinical differential diagnosis should include sexually transmitted infections such as genital warts&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> molluscum contagiosum&#44; and the histologic differential diagnosis should include the other entities mentioned above&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#44;3</span></a> Darier disease is clinically characterized by multiple crusted&#44; pruritic papules in seborrheic areas&#44; and there have been no reports of the disease exclusively affecting the genital area&#46; There have been reports of Hailey-Hailey disease affecting only the genital area&#44; but the patients had a family history of the disease&#46; In Grover disease&#44; similar lesions appear on the trunk&#44; the neck&#44; and the proximal region of the limbs&#44; but there is no genital involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">As for therapeutic management&#44; no treatment is needed if the lesions are asymptomatic&#59; in symptomatic cases&#44; various treatments can be used&#46; Treatments include corticosteroids&#44; retinoids&#44; and topical immunomodulators&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> although it is also possible to use physical treatments&#8212;which tend to be more effective&#8212;such as cryotherapy&#44; electrocoagulation&#44; excision&#44; and carbon dioxide laser therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3&#44;5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion&#44; papular acantholytic dyskeratosis of the anogenital area is a benign entity located exclusively in the genital area&#46; Therefore&#44; it is important to differentiate this entity adequately from genital warts in order to avoid subjecting patients to expensive and unnecessary treatments&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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