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1</a>&#41;&#46; Dermoscopy revealed hyperkeratosis and dilation of hair follicles &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; On palpation&#44; the skin had a rough&#44; sandpaper-like texture&#46; The skin examination was otherwise unremarkable&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Additional Tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 2-mm punch biopsy was taken from the left preauricular region&#46; Histologic examination revealed the presence of 2 dilated follicular infundibula&#44; with foci of compact hyperkeratosis&#44; associated in both cases with the presence of a mite &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; A mild perivascular lymphocytic inflammatory infiltrate was observed in the underlying dermis&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The complete blood count and biochemistry profile showed no abnormalities&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis&#63;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Spinulosis of the face&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course</span><p id="par0035" class="elsevierStylePara elsevierViewall">Following histologic confirmation of spinulosis of the face associated with <span class="elsevierStyleItalic">Demodex folliculorum</span>&#44; treatment was initiated with 0&#46;5&#37; ivermectin in carbohydrate-based cream once daily for 2 months&#46; Clinical improvement was evident after 1 month of treatment and all signs had resolved by the end of treatment&#46; No similar lesions have appeared during 6 months of follow-up&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Spinulosis of the face is characterized by the presence of asymptomatic&#44; hyperkeratotic&#44; filiform spicules with a follicular distribution&#44; located predominantly on the facial skin &#40;cheeks&#44; forehead&#44; and chin&#41;&#46; Although the association of this entity with <span class="elsevierStyleItalic">D folliculorum</span> was initially controversial&#44; today the causal relationship is accepted&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">D folliculorum</span> is a mite that is occasionally found in human skin in association with the pilosebaceous unit&#46; This colonization is generally asymptomatic&#44; but in predisposed individuals the presence of <span class="elsevierStyleItalic">D folliculorum</span> has been associated with various dermatoses&#44; including rosacea&#44; perioral dermatitis&#44; and madarosis&#46; The presence of 5 or more mites per square centimeter of skin or the presence of the mite in the dermis has been proposed as a pathogenic criterion&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In the case of spinulosis of the face associated with <span class="elsevierStyleItalic">D folliculorum</span>&#44; case series in patients with other diseases&#8212;particularly multiple myeloma and polycythemia vera&#8212;have been reported&#46; Other associations with spinulosis of the face caused by <span class="elsevierStyleItalic">D folliculorum</span> include chronic renal failure&#44; inflammatory bowel disease&#44; and monoclonal gammopathy&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;4</span></a> Differential diagnosis should include eczema&#44; seborrheic dermatitis&#44; pityriasis folliculorum &#40;which is also caused by <span class="elsevierStyleItalic">D folliculorum</span> but is associated with diffuse scaling&#44; pruritus&#44; and erythema&#44; and in many cases with poor facial hygiene&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> and trichodysplasia spinulosa&#44; a polyomavirus infection that occurs in immunocompromised patients and is characterized by hyperkeratotic spicules&#44; especially on the face &#40;nose&#44; eyebrows&#44; etc&#46;&#41;&#44; and causes the facial deformity leonine facies&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Diagnosis is based on clinical suspicion&#46; Thin spicules confined to the dilated follicular orifices of the face&#44; making the skin of the affected areas rough to the touch&#44; are highly characteristic&#46; Histologic examination confirms the presence of the mite and hyperkeratotic material forming spicules in the follicular orifices&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Like other skin diseases caused by <span class="elsevierStyleItalic">Demodex</span> mites&#44; spinulosis of the face is treated with various specific antiparasitic agents&#46; Topical treatment is sufficient in most cases&#46; Drugs used include 0&#46;75&#37; metronidazole&#44; 5&#37; permethrin&#44; and 0&#46;5&#37; ivermectin&#44; with the latter achieving good response&#44; as in our patient&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> In resistant cases&#44; oral therapy with ivermectin or retinoids&#44; among other drugs&#44; can be used&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;3</span></a></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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Vol. 108. Núm. 8.
Páginas 773-774 (octubre 2017)
Visitas
11251
Vol. 108. Núm. 8.
Páginas 773-774 (octubre 2017)
Case and Research Letter
Acceso a texto completo
Filiform Follicular Hyperkeratosis on the Face
Hiperqueratosis folicular filiforme en la cara
Visitas
11251
J. Ruiz-Riveroa,
Autor para correspondencia
juncalrr@gmail.com

Corresponding author.
, M. Campos Domíngeza, V. Parra Blancob, R. Suárez-Fernándeza
a Servicio de Dermatología Médico-Quirúrgica y Venereología, Madrid, Spain
b Servicio de Anatomía Patológica, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Medical History

The patient was a 16-year-old girl with a past history of cholangitis, reactive arthritis, and stable plaque morphea who had been receiving follow-up rheumatologic and dermatologic care. During a routine follow-up visit, the patient reported the appearance of asymptomatic plaques on both cheeks that were mildly erythematous and rough to the touch.

Physical Examination

Physical examination revealed facial skin with a xerotic appearance on both cheeks and along the mandibular rami and erythematous plaques with a distinct border (Fig. 1). Dermoscopy revealed hyperkeratosis and dilation of hair follicles (Fig. 2). On palpation, the skin had a rough, sandpaper-like texture. The skin examination was otherwise unremarkable.

Figure 1
(0.26MB).
Figure 2
(0.13MB).
Additional Tests

A 2-mm punch biopsy was taken from the left preauricular region. Histologic examination revealed the presence of 2 dilated follicular infundibula, with foci of compact hyperkeratosis, associated in both cases with the presence of a mite (Fig. 3). A mild perivascular lymphocytic inflammatory infiltrate was observed in the underlying dermis.

Figure 3.

Hematoxylin-eosin, original magnification ×40.

(0.39MB).

The complete blood count and biochemistry profile showed no abnormalities.

What Is Your Diagnosis?

Diagnosis

Spinulosis of the face.

Clinical Course

Following histologic confirmation of spinulosis of the face associated with Demodex folliculorum, treatment was initiated with 0.5% ivermectin in carbohydrate-based cream once daily for 2 months. Clinical improvement was evident after 1 month of treatment and all signs had resolved by the end of treatment. No similar lesions have appeared during 6 months of follow-up.

Comment

Spinulosis of the face is characterized by the presence of asymptomatic, hyperkeratotic, filiform spicules with a follicular distribution, located predominantly on the facial skin (cheeks, forehead, and chin). Although the association of this entity with D folliculorum was initially controversial, today the causal relationship is accepted.1,2

D folliculorum is a mite that is occasionally found in human skin in association with the pilosebaceous unit. This colonization is generally asymptomatic, but in predisposed individuals the presence of D folliculorum has been associated with various dermatoses, including rosacea, perioral dermatitis, and madarosis. The presence of 5 or more mites per square centimeter of skin or the presence of the mite in the dermis has been proposed as a pathogenic criterion.1,3

In the case of spinulosis of the face associated with D folliculorum, case series in patients with other diseases—particularly multiple myeloma and polycythemia vera—have been reported. Other associations with spinulosis of the face caused by D folliculorum include chronic renal failure, inflammatory bowel disease, and monoclonal gammopathy.1,4 Differential diagnosis should include eczema, seborrheic dermatitis, pityriasis folliculorum (which is also caused by D folliculorum but is associated with diffuse scaling, pruritus, and erythema, and in many cases with poor facial hygiene),4 and trichodysplasia spinulosa, a polyomavirus infection that occurs in immunocompromised patients and is characterized by hyperkeratotic spicules, especially on the face (nose, eyebrows, etc.), and causes the facial deformity leonine facies.5

Diagnosis is based on clinical suspicion. Thin spicules confined to the dilated follicular orifices of the face, making the skin of the affected areas rough to the touch, are highly characteristic. Histologic examination confirms the presence of the mite and hyperkeratotic material forming spicules in the follicular orifices.2 Like other skin diseases caused by Demodex mites, spinulosis of the face is treated with various specific antiparasitic agents. Topical treatment is sufficient in most cases. Drugs used include 0.75% metronidazole, 5% permethrin, and 0.5% ivermectin, with the latter achieving good response, as in our patient.6 In resistant cases, oral therapy with ivermectin or retinoids, among other drugs, can be used.1,3

Conflicts of Interest

The authors declare that they have no conflicts of interest.

References
[1]
B. Monteagudo, M. Cabanillas, J.A. García Rego, C. de las Heras.
Espinulosis como manifestación de demodicidosis.
Actas Dermosifilliogr, 100 (2009), pp. 512-514
[2]
M.C. Fariña, L. Requena, J.L. Sarasa, L. Martin, P. Escalonilla, M.L. Soriano.
Spinulosis of the face as a manifestation of demodicidosis.
Br J Dermatol, 138 (1998), pp. 901-903
[3]
C.A. Elston, D.M. Elston.
Demodex mites.
Clin Dermatol, 32 (2014), pp. 739-743
[4]
W. Chen, G. Plewig.
Human demodicosis: Revisit and a proposed classification.
Br J Dermatol, 170 (2014), pp. 1219-1225
[5]
M.G. Kirchhof, K. Shojania, M.W. Hull, R.L. Crawford, S. Au.
Trichodysplasia spinulosa: Rare presentation of polyomavirus infection in immunocompromised patients.
J Cutan Med Surg, 18 (2014), pp. 430-435
[6]
M. Abokwidir, A.B. Fleischer.
An emerging treatment: Topical ivermectin for papulopustular rosacea.
J Dermatolog Treat, 26 (2015), pp. 379-380

Please cite this article as: Ruiz-Rivero J, Domíngez MC, Blanco VP, Suárez-Fernández R. Hiperqueratosis folicular filiforme en la cara. Actas Dermosifiliogr. 2017;108:773–774.

Copyright © 2016. Elsevier España, S.L.U. and AEDV
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