Case for Diagnosis
Nodular Peristomal Lesions
Lesiones nodulares periestomales
I. Latour-Álvarez
, E. García-Peris, M.M. Pestana-Eliche, M. García-Bustínduy
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Departamento de Dermatología, Complejo Hospitalario Universitario de Canarias, Santa Cruz de Tenerife, Spain
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"apellidos" => "García-Bustínduy" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Dermatología, Complejo Hospitalario Universitario de Canarias, Santa Cruz de Tenerife, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesiones nodulares periestomales" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1227 "Ancho" => 1650 "Tamanyo" => 802660 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>10.</p>" ] ] ] "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 47-year-old man with a history of prostate cancer diagnosed 5 years earlier with bone metastases in the right acetabulum (stage pT4N1M1). The patient had undergone a radical cystoprostatectomy with a Bricker-type ureteroileostomy. He received hormone therapy with luteinizing hormone-releasing hormone (LHRH) agonists and antiandrogens in addition to external beam radiation therapy. The patient reported the gradual development of pruritic lesions in the area around the stoma over the previous 6 months.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed multiple hard grayish-white domed papules 2 to 10<span class="elsevierStyleHsp" style=""></span>mm in diameter that coalesced to form a peristomal pseudoverrucous mass (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The lesions were pruritic but not painful. The patient had no palpable lymph nodes in the groin area or any other site.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">A skin biopsy was performed and histologic examination revealed pseudoepitheliomatous epithelial hyperplasia and chronic inflammatory infiltrate with no koilocytes, atypia, or mitotic figures (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Proteus vulgaris</span> was isolated from urine culture.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Pseudoverrucous papules and nodules (PPN) or chronic papillomatous dermatitis.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment was started with amoxicillin–clavulanic acid (875 and 125<span class="elsevierStyleHsp" style=""></span>mg, respectively, every 8<span class="elsevierStyleHsp" style=""></span>hours for 10 days); by the end of the treatment the lesions had improved slightly. The patient was also advised to adjust the drainage device and change the collection pouch and topical olive oil frequently. After 3 months, the lesions had virtually disappeared.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">PPN, or chronic papillomatous dermatitis, is a rare complication found mainly on the skin around stomas and the perianal area.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Peristomal PPN is considered to be a special form of irritant contact dermatitis caused by the chronic local action of alkaline urine. Urine can accumulate on the skin surface if the ostomy pouch is not properly adjusted, favoring bacterial overgrowth. The bacteria degrade urea, causing an increase in urinary pH.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> PPN is clinically characterized by multiple erythematous-brownish or grayish-white papules and nodules generally located on the lower side of the stoma. The lesions can appear on peristomal skin and also in the perianal area as a result of severe intractable diarrhea of any cause.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–4</span></a> PPN has also been reported in patients with Hirschsprung disease who have undergone colonic re-anastomosis and in children and adults with urinary incontinence.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a> Diagnosis is established clinically and histologically. Differential diagnosis includes the main dermatoses located around stoma sites (secondary neoplasms, metastases, incrustations, exuberant granulation tissue, human papillomavirus infection, gangrenous pyoderma, pressure ulcers, mucosal transplant).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> To prevent PPN, it is important to adjust the drainage device properly and change the collection pouch frequently. PPN is easy to treat, but without treatment complications such as bleeding, stenosis, and stoma occlusion may develop. The recommended treatment for urostomy-related PPN is urine acidification (cranberry juice and a vitamin C–rich diet or vitamin C supplements) and early treatment of infections.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4</span></a> Few cases have been reported recently.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,4</span></a> We describe a new case that responded well to treatment, with the aim of reminding dermatologists of the existence of this probably underdiagnosed condition.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts 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:9 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Additional Tests" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 8 => 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: Latour-Álvarez I, García-Peris E, Pestana-Eliche MM, García-Bustínduy M. Lesiones nodulares periestomales. Actas Dermosifiliogr. 2017;108:363–364.</p>" ] ] "multimedia" => array:2 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 787 "Ancho" => 1059 "Tamanyo" => 122872 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1227 "Ancho" => 1650 "Tamanyo" => 802660 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>10.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dermatosis alrededor de ostomías" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 15 | 12 | 27 |
| 2024 Octubre | 90 | 42 | 132 |
| 2024 Septiembre | 108 | 23 | 131 |
| 2024 Agosto | 114 | 66 | 180 |
| 2024 Julio | 107 | 46 | 153 |
| 2024 Junio | 101 | 61 | 162 |
| 2024 Mayo | 63 | 37 | 100 |
| 2024 Abril | 96 | 43 | 139 |
| 2024 Marzo | 106 | 38 | 144 |
| 2024 Febrero | 99 | 31 | 130 |
| 2024 Enero | 83 | 48 | 131 |
| 2023 Diciembre | 66 | 25 | 91 |
| 2023 Noviembre | 115 | 25 | 140 |
| 2023 Octubre | 112 | 21 | 133 |
| 2023 Septiembre | 91 | 36 | 127 |
| 2023 Agosto | 78 | 19 | 97 |
| 2023 Julio | 77 | 34 | 111 |
| 2023 Junio | 92 | 25 | 117 |
| 2023 Mayo | 86 | 41 | 127 |
| 2023 Abril | 64 | 27 | 91 |
| 2023 Marzo | 52 | 46 | 98 |
| 2023 Febrero | 48 | 38 | 86 |
| 2023 Enero | 48 | 27 | 75 |
| 2022 Diciembre | 53 | 41 | 94 |
| 2022 Noviembre | 27 | 40 | 67 |
| 2022 Octubre | 33 | 27 | 60 |
| 2022 Septiembre | 34 | 53 | 87 |
| 2022 Agosto | 24 | 36 | 60 |
| 2022 Julio | 25 | 48 | 73 |
| 2022 Junio | 25 | 35 | 60 |
| 2022 Mayo | 47 | 45 | 92 |
| 2022 Abril | 72 | 39 | 111 |
| 2022 Marzo | 54 | 53 | 107 |
| 2022 Febrero | 41 | 32 | 73 |
| 2022 Enero | 62 | 43 | 105 |
| 2021 Diciembre | 41 | 45 | 86 |
| 2021 Noviembre | 42 | 36 | 78 |
| 2021 Octubre | 55 | 60 | 115 |
| 2021 Septiembre | 28 | 35 | 63 |
| 2021 Agosto | 46 | 30 | 76 |
| 2021 Julio | 38 | 27 | 65 |
| 2021 Junio | 30 | 24 | 54 |
| 2021 Mayo | 42 | 35 | 77 |
| 2021 Abril | 106 | 45 | 151 |
| 2021 Marzo | 86 | 17 | 103 |
| 2021 Febrero | 65 | 28 | 93 |
| 2021 Enero | 36 | 14 | 50 |
| 2020 Diciembre | 43 | 15 | 58 |
| 2020 Noviembre | 44 | 17 | 61 |
| 2020 Octubre | 31 | 18 | 49 |
| 2020 Septiembre | 42 | 9 | 51 |
| 2020 Agosto | 33 | 14 | 47 |
| 2020 Julio | 20 | 14 | 34 |
| 2020 Junio | 40 | 21 | 61 |
| 2020 Mayo | 21 | 12 | 33 |
| 2020 Abril | 21 | 15 | 36 |
| 2020 Marzo | 30 | 7 | 37 |
| 2020 Febrero | 5 | 0 | 5 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 6 | 0 | 6 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 5 | 0 | 5 |
| 2019 Abril | 2 | 3 | 5 |
| 2019 Marzo | 1 | 0 | 1 |
| 2019 Febrero | 5 | 0 | 5 |
| 2019 Enero | 1 | 0 | 1 |
| 2018 Diciembre | 7 | 0 | 7 |
| 2018 Noviembre | 6 | 0 | 6 |
| 2018 Octubre | 13 | 0 | 13 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Febrero | 50 | 3 | 53 |
| 2018 Enero | 48 | 3 | 51 |
| 2017 Diciembre | 63 | 6 | 69 |
| 2017 Noviembre | 27 | 4 | 31 |
| 2017 Octubre | 24 | 7 | 31 |
| 2017 Septiembre | 25 | 7 | 32 |
| 2017 Agosto | 27 | 11 | 38 |
| 2017 Julio | 21 | 9 | 30 |
| 2017 Junio | 39 | 10 | 49 |
| 2017 Mayo | 63 | 24 | 87 |
| 2017 Abril | 15 | 12 | 27 |
| 2017 Marzo | 2 | 5 | 7 |
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