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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Mammillary fistula&#44; or Zuska disease&#44; was first described in 1951<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> as the appearance of small&#44; painful inflammatory nodules in the area of the areola that generally progress to recurrent abscesses&#44; sinuses&#44; and fistulas&#46; Atkins<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> subsequently coined the term mammillary fistula to refer to this entity&#44; which accounts for 1&#37;-2&#37; of all symptomatic mammary conditions&#46; Mammillary fistula is difficult to treat&#44; is associated with long-term morbidity&#44; and has a considerable impact on patient quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 23-year-old woman &#40;smoker&#41; was being followed at the Breast Pathology Unit &#40;BPU&#41; of our hospital for recurrent flares of mastitis affecting the left breast that had first appeared 9 months previously&#46; The clinical response to several cycles of oral antibiotics was favorable&#44; although the inflammatory symptoms reappeared&#44; with disabling pain&#44; inflammatory changes&#44; and suppuration a few weeks after each cycle&#46; Consequently&#44; she had consulted on at least 10 occasions at the BPU and the emergency department&#44; as well as with her primary care physician&#46; Before a wedge resection of the milk ducts was performed&#44; the BPU referred the patient for a dermatologic assessment&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The physical examination revealed an elongated and erythematous indurated area in the area of the areola of the left breast that was painful to touch &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Ultrasound revealed a longitudinal hypoechoic band-like image &#40;15&#8239;&#215;&#8239;2&#46;4&#8239;&#215;&#8239;6&#8239;mm&#41; in the superficial dermis &#40;Doppler negative&#41; compatible with a fistulous tract &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Based on these findings&#44; the patient was diagnosed with mammillary fistula and prescribed treatment with intralesional triamcinolone&#44; which led to clinical and ultrasound resolution of the lesion&#46; No recurrences were observed during the following 6 months &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">For many years&#44; mammillary fistula was thought to result from obstruction of a distal milk duct by squamous metaplasia&#44; with keratinization and&#47;or epidermalization of the duct&#46; However&#44; it was recently proposed that mammillary fistula originates in a hair follicle&#44; where the initial event is occlusion of the follicle because of hyperkeratinization&#46; This leads to dilatation and rupture of the duct&#44; with release of secretions into the subcutaneous cell tissue and&#44; therefore&#44; an inflammatory reaction&#44; secondary bacterial infection&#44; and&#44; finally&#44; formation of abscesses with drainage of sinus tracts and fistulas in the area of the areola&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In this case&#44; the squamous metaplasia identified in the biopsy specimens would represent the response of the tissue to a chronic inflammatory process&#44; thus indicating that it is a result of inflammation and not the cause thereof&#46; Based on this theory&#44; the cause of mammillary fistula would be similar to that of the various components of follicular occlusion syndrome&#44; such as hidradenitis suppurativa&#44; pilonidal cysts&#44; dissecting cellulitis of the scalp&#44; and acne conglobata&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Mammillary fistula behaves in much the same way as hidradenitis suppurativa&#44; with a chronic&#44; recurrent course characterized by flares of inflammatory activity and the formation of fistulas&#46; Both conditions affect women aged 20 to 50 years&#44; are closely related to smoking&#44; and have a considerable impact on quality of life&#46; Diagnosis in each of these conditions is based on clinical findings&#59; ultrasound provides more accurate information for diagnosis&#46; Hidradenitis suppurativa may appear at various sites&#44; whereas mammillary fistula always affects the areola and nipple&#46; Management is similar in both cases and includes antibiotics&#44; anti-inflammatory agents&#44; and surgery&#46; The presence of both mammillary fistula and hidradenitis suppurativa in the same patient supports the notion that mammillary fistula may be yet another manifestation of hidradenitis suppurativa&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In summary&#44; mammillary fistula is probably underdiagnosed and relatively unknown by dermatologists and gynecologists&#46; It should be suspected in the presence of recurrent abscesses of the areola&#46; This entity shares clinical and&#8212;probably&#8212;etiological-pathogenic characteristics with hidradenitis suppurativa&#46; Intralesional corticosteroids should be taken into consideration for treatment&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letters
Mammillary Fistula as a Possible Manifestation of Hidradenitis Suppurativa
Fístula mamilar como una posible manifestación de una hidradenitis supurativa
M.J. Sánchez-Pujol
Autor para correspondencia
mjsanchezpujol@gmail.com

Corresponding author.
, P. Álvarez-Chinchilla, A. Docampo-Simón, J.C. Pascual Ramírez
Servicio de Dermatología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL). Alicante, Spain
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was being followed at the Breast Pathology Unit &#40;BPU&#41; of our hospital for recurrent flares of mastitis affecting the left breast that had first appeared 9 months previously&#46; The clinical response to several cycles of oral antibiotics was favorable&#44; although the inflammatory symptoms reappeared&#44; with disabling pain&#44; inflammatory changes&#44; and suppuration a few weeks after each cycle&#46; Consequently&#44; she had consulted on at least 10 occasions at the BPU and the emergency department&#44; as well as with her primary care physician&#46; Before a wedge resection of the milk ducts was performed&#44; the BPU referred the patient for a dermatologic assessment&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The physical examination revealed an elongated and erythematous indurated area in the area of the areola of the left breast that was painful to touch &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Ultrasound revealed a longitudinal hypoechoic band-like image &#40;15&#8239;&#215;&#8239;2&#46;4&#8239;&#215;&#8239;6&#8239;mm&#41; in the superficial dermis &#40;Doppler negative&#41; compatible with a fistulous tract &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Based on these findings&#44; the patient was diagnosed with mammillary fistula and prescribed treatment with intralesional triamcinolone&#44; which led to clinical and ultrasound resolution of the lesion&#46; No recurrences were observed during the following 6 months &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">For many years&#44; mammillary fistula was thought to result from obstruction of a distal milk duct by squamous metaplasia&#44; with keratinization and&#47;or epidermalization of the duct&#46; However&#44; it was recently proposed that mammillary fistula originates in a hair follicle&#44; where the initial event is occlusion of the follicle because of hyperkeratinization&#46; This leads to dilatation and rupture of the duct&#44; with release of secretions into the subcutaneous cell tissue and&#44; therefore&#44; an inflammatory reaction&#44; secondary bacterial infection&#44; and&#44; finally&#44; formation of abscesses with drainage of sinus tracts and fistulas in the area of the areola&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In this case&#44; the squamous metaplasia identified in the biopsy specimens would represent the response of the tissue to a chronic inflammatory process&#44; thus indicating that it is a result of inflammation and not the cause thereof&#46; Based on this theory&#44; the cause of mammillary fistula would be similar to that of the various components of follicular occlusion syndrome&#44; such as hidradenitis suppurativa&#44; pilonidal cysts&#44; dissecting cellulitis of the scalp&#44; and acne conglobata&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Mammillary fistula behaves in much the same way as hidradenitis suppurativa&#44; with a chronic&#44; recurrent course characterized by flares of inflammatory activity and the formation of fistulas&#46; Both conditions affect women aged 20 to 50 years&#44; are closely related to smoking&#44; and have a considerable impact on quality of life&#46; Diagnosis in each of these conditions is based on clinical findings&#59; ultrasound provides more accurate information for diagnosis&#46; Hidradenitis suppurativa may appear at various sites&#44; whereas mammillary fistula always affects the areola and nipple&#46; Management is similar in both cases and includes antibiotics&#44; anti-inflammatory agents&#44; and surgery&#46; The presence of both mammillary fistula and hidradenitis suppurativa in the same patient supports the notion that mammillary fistula may be yet another manifestation of hidradenitis suppurativa&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In summary&#44; mammillary fistula is probably underdiagnosed and relatively unknown by dermatologists and gynecologists&#46; It should be suspected in the presence of recurrent abscesses of the areola&#46; This entity shares clinical and&#8212;probably&#8212;etiological-pathogenic characteristics with hidradenitis suppurativa&#46; Intralesional corticosteroids should be taken into consideration for treatment&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; S&#225;nchez-Pujol MJ&#44; &#193;lvarez-Chinchilla P&#44; Docampo-Sim&#243;n A&#44; Pascual Ram&#237;rez JC&#46; F&#237;stula mamilar como una posible manifestaci&#243;n de una hidradenitis supurativa&#46; Actas Dermosifiliogr&#46; 2020&#59;111&#58;278&#8211;280&#46;</p>"
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