Case for Diagnosis
Indurated Papules on the Face
Pápulas faciales induradas
C. González-Cruz
, V. Cabezas, V. García-Patos
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Servicio de Dermatología, Hospital Universitari Vall d’Hebron, Barcelona, Spain
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"apellidos" => "García-Patos" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitari Vall d’Hebron, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pápulas faciales induradas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 612 "Ancho" => 850 "Tamanyo" => 95209 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 61-year-old woman with no history of allergy to drugs or addictions consulted us for evaluation of facial lesions present for many years. She reported no relevant family history but her own history included renal angiomyolipomas and severe acne continuing after adolescence. She had also been diagnosed with rosacea some years before and was following treatments with topical metronidazole and brimonidine. She complained of flushing and papular and pustular skin eruptions on the face that had resolved before the visit but had left her with other persistent papules.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">We observed malar erythema, telangiectasia and a dozen hemispherical, indurated, whitish-yellow papules measuring 2–3<span class="elsevierStyleHsp" style=""></span>mm in diameter dispersed across the forehead, chin, and cheeks (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</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 well-defined, dark bluish-violet nodular deposit was observed in the mid-dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Higher magnification revealed mature bony trabeculae with osteocytes inside and Haversian canals containing blood vessels and connective tissue (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B).</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">A blood work-up showed no abnormalities in renal function. Calcium and phosphorous metabolism was normal.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">What Is Your Diagnosis?</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Multiple miliary osteoma cutis (MMOC) secondary to acne.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical Course and Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">The lesions have remained stable. The patient opted not to undergo treatment.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">MMOC is a rare subtype of skin ossification that is characterized by bony tissue formation in the dermis and subcutaneous layers. The pathogenesis is unclear, but an association with chronic inflammatory processes such as acne, as described in our patient, has been suggested.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Chronic inflammation is thought to induce metaplasia in pluripotent dermal mesenchymal cells and lead to the formation of osteoblasts.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Previous authors have described a possible association between MMOC and treatment with bisphosphonates.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">MMOC is characterized clinically by the presence of multiple, firm, asymptomatic, skin-colored papules and nodules mainly on the face in young or postmenopausal women.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–3</span></a>Clinical signs and imaging (dermatologic ultrasound and simple radiographs) can facilitate diagnosis, but histology is required for certainty. Histology demonstrates bony spicules in the dermis and osteocytes and osteoblasts in subcutaneous cellular tissue.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Differential diagnosis must take into consideration cutaneous calcification, which is associated with endocrine and metabolic disorders. In this condition calcium is deposited in the dermis, whereas in MMOC bone is actually formed.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> The absence of other clinical signs, the age at which the disorder presents, and the clinical course can also help distinguish MMOC from primary syndromes associated with cutaneous osteomas, such as Albright hereditary osteodystrophy, progressive ossifying fibrodysplasia, progressive osseous heteroplasia, and platelike osteoma cutis. Finally, differential diagnosis should also consider closed comedones and milium cysts.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">No standard treatment for MMOC has emerged. Any approach undertaken will have aesthetic improvement as its purpose. Topical retinoids, carbon dioxide laser therapy,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> dermabrasion, and the excision of large lesions have been tried, with variable results.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4</span></a> Surgical mini-excision using a needle and curettage was reported to give good results in a series of 11 patients.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">This description of a case of MMOC — an uncommon, benign condition that is probably underdiagnosed — shows that details of a patient's medical history can provide the clues to making this diagnosis. Our patient had experienced severe acne, a disease that other published cases have linked to the development of MMOC.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,6</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case 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:3 [ "identificador" => "sec0025" "titulo" => "What Is Your Diagnosis?" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Diagnosis" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Clinical Course and Treatment" ] ] ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Comment" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of Interest" ] 7 => 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: González-Cruz C, Calderón VC, Briones VG-P. Pápulas faciales induradas. Actas Dermosifiliogr. 2019;110:599–600.</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" => 612 "Ancho" => 850 "Tamanyo" => 95209 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1308 "Ancho" => 850 "Tamanyo" => 316686 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Histologic findings. A, Hematoxylin-eosin, original magnification ×400. B, Hematoxylin-eosin, original magnification, ×2000.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation and management of multiple miliary osteoma cutis: Case series of 11 patients and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I.S. Chabra" 1 => "S. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 17 | 10 | 27 |
| 2024 Octubre | 113 | 29 | 142 |
| 2024 Septiembre | 105 | 25 | 130 |
| 2024 Agosto | 134 | 47 | 181 |
| 2024 Julio | 109 | 29 | 138 |
| 2024 Junio | 120 | 40 | 160 |
| 2024 Mayo | 93 | 44 | 137 |
| 2024 Abril | 92 | 19 | 111 |
| 2024 Marzo | 91 | 33 | 124 |
| 2024 Febrero | 68 | 37 | 105 |
| 2024 Enero | 77 | 36 | 113 |
| 2023 Diciembre | 65 | 15 | 80 |
| 2023 Noviembre | 71 | 32 | 103 |
| 2023 Octubre | 79 | 21 | 100 |
| 2023 Septiembre | 72 | 31 | 103 |
| 2023 Agosto | 55 | 18 | 73 |
| 2023 Julio | 75 | 38 | 113 |
| 2023 Junio | 63 | 22 | 85 |
| 2023 Mayo | 87 | 22 | 109 |
| 2023 Abril | 84 | 19 | 103 |
| 2023 Marzo | 80 | 20 | 100 |
| 2023 Febrero | 67 | 20 | 87 |
| 2023 Enero | 63 | 19 | 82 |
| 2022 Diciembre | 56 | 37 | 93 |
| 2022 Noviembre | 43 | 27 | 70 |
| 2022 Octubre | 36 | 29 | 65 |
| 2022 Septiembre | 37 | 35 | 72 |
| 2022 Agosto | 53 | 33 | 86 |
| 2022 Julio | 64 | 52 | 116 |
| 2022 Junio | 33 | 28 | 61 |
| 2022 Mayo | 54 | 34 | 88 |
| 2022 Abril | 69 | 29 | 98 |
| 2022 Marzo | 75 | 48 | 123 |
| 2022 Febrero | 73 | 27 | 100 |
| 2022 Enero | 86 | 44 | 130 |
| 2021 Diciembre | 75 | 31 | 106 |
| 2021 Noviembre | 85 | 41 | 126 |
| 2021 Octubre | 85 | 54 | 139 |
| 2021 Septiembre | 74 | 34 | 108 |
| 2021 Agosto | 106 | 25 | 131 |
| 2021 Julio | 135 | 21 | 156 |
| 2021 Junio | 80 | 30 | 110 |
| 2021 Mayo | 41 | 35 | 76 |
| 2021 Abril | 156 | 80 | 236 |
| 2021 Marzo | 103 | 28 | 131 |
| 2021 Febrero | 89 | 15 | 104 |
| 2021 Enero | 38 | 9 | 47 |
| 2020 Diciembre | 29 | 17 | 46 |
| 2020 Noviembre | 17 | 20 | 37 |
| 2020 Octubre | 22 | 10 | 32 |
| 2020 Septiembre | 25 | 12 | 37 |
| 2020 Agosto | 18 | 13 | 31 |
| 2020 Julio | 13 | 11 | 24 |
| 2020 Junio | 23 | 18 | 41 |
| 2020 Mayo | 13 | 10 | 23 |
| 2020 Abril | 17 | 9 | 26 |
| 2020 Marzo | 17 | 5 | 22 |
| 2020 Febrero | 4 | 2 | 6 |
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