- Email: [email protected]
Multiple minute digitate hyperkeratoses
J AM ACAD DERMATOL VOLUME 69, NUMBER 4
Letters e207
infectious disease physicians will initiate an appropriate combination of antifungal therapy and surgical debridement. Noel Prevost, PA-C, and Joseph C. English III, MD University of Pittsburgh Department of Dermatology, Pennsylvania Funding sources: None. Conflicts of interest: None declared. Correspondence to: Joseph C. English III, MD, University of Pittsburgh Department of Dermatology, 200 Lothrop Street, Suite 3880, Presby South Tower, Pittsburgh PA 15213 E-mail: [email protected] REFERENCES 1. Lew DP, Waldvogel FA. Osteomyelitis. N Eng J Med 1997;366:999-1007. 2. Slenker AK, Keith S, Horn DL. Two hundred and eleven cases of candida osteomyelitis: 17 case reports and a review of the literature. Diagn Microbiol Infect Dis 2012;73:89-93. 3. Gamaletsou MN, Kontoyiannis DP, Sipsas NV, et al. Candida osteomyelitis: analysis of 207 pediatric and adult cases(19702011). Clin Infect Dis 2012;55:1338-51. 4. Malani PN, McNeil SA, Bradley SF, Kauffman CA. Candida albicans sternal wound infections: a chronic and recurrent complication of median sternotomy. Clin Infect Dis 2002;35:1316-20.
Fig 1. Multiple minute digitate hyperkeratosis affecting the right flank.
http://dx.doi.org/10.1016/j.jaad.2013.06.005
Multiple minute digitate hyperkeratoses To the Editor: A 61-year-old woman presented with a 1-year history of dry skin. Examination revealed numerous digitate papules affecting the chest and abdomen (Fig 1). The face, palms, soles, and all other skin sites were normal. The papules were both white and brown colored, nonfollicular, and measured 1 to 2 mm in diameter. Her medical history was unremarkable. There was no history of digitate keratosis or skin rashes in any related family members, and no personal history of malnutrition, malignancy, or relevant topical or systemic drug therapy. Shave biopsy was performed. Histologic examination showed focal columns of hyperorthokeratosis with a compact stratum corneum arising from a tented epidermis. No parakeratotic cells were seen in the long protrusions. The stratum granulosum was preserved (Fig 2). A basic screen for malignancy or inflammatory disease — including a complete blood count, chemistry panel, hepatitis panel, erythrocyte sedimentation rate, C-reactive protein, serum electrophoresis, and free light chains — was unrevealing. Additionally, the patient reported that she had an unremarkable chest x-ray study, mammogram, and
Fig 2. Multiple minute digitate hyperkeratosis, light microscopy. High-power image of multiple minute digitate hyperkeratosis exhibiting a digitate projection of compact orthokeratin arising from a tented, slightly acanthotic epidermis. (Hematoxylin-eosin stain; original magnification: 3100.)
colonoscopy performed within the last 2 years. A diagnosis of multiple minute digitate keratoses (MMDH) was made. The patient was treated with urea cream 40%. Follow-up at 2 weeks showed some improvement although her lesions persisted. MMDH is a rare nonfollicular skin disease of unknown etiology, characterized by multiple asymptomatic spiny keratotic lesions preferentially affecting the trunk and limbs. The face and palmoplantar surfaces are normally spared. The lesions may be white, yellow, brown, or skin-colored, and vary in length and diameter.1 Histopathology reveals fingerlike projections of orthokeratosis arising from a tented acanthotic epidermis and, less commonly, parakeratosis. The stratum granulosum may vary in thickness but is often prominent. Treatment of
J AM ACAD DERMATOL
e208 Letters
MMDH is often unsuccessful; however, various topical keratolytics and topical and oral retinoids have been reported to show some improvement. Initially described by Goldstein2 in 1967, difficulties in the diagnosis of MMDH include its rarity and resemblance to other digitate keratoses. To limit confusion from synonymous terms and previously suggested classifications, in 2010 Caccetta et al1 proposed an algorithm for diagnosing digitate keratoses. This diagnostic algorithm designates MMDH as the generalized, nonfollicular form of digitate keratosis. According to clinical presentation, cases of MMDH are classified into early and late-onset forms.3 The early onset form usually manifests in the second to third decades, and may be hereditary (autosomal dominant) or acquired. The late-onset form often presents after the fourth decade, with no family history. Although most late-onset forms are idiopathic, there have been reports of concomitant cancer or inflammatory disease. With the new criteria proposed by Caccetta et al,1 it is now recognized that many of these cases involved forms of digitate keratoses currently recognized as separate from MMDH.3,4 Currently, the pathogenesis of MMDH is unknown. An improved understanding may be gained from electron microscopy and immunohistochemical cytokeratin analysis, as was done for spiny keratoderma.5 The case reported here can be classified as lateonset MMDH, with no associated disorder. Adoption of the diagnostic algorithm proposed by Caccetta et al facilitated distinction of MMDH from other forms of digitate keratoses. Our reason for reporting this case, besides the rarity of MMDH, is to support
OCTOBER 2013
previous reports that the association between lateonset MMDH and concomitant cancer or inflammatory disease may be coincidental. Courtney J. Ensslin, BS,a Jason Cohen, MD,b,c Damian DiCostanzo,d and David Silverstein, MDb Stony Brook University School of Medicinea; Department of Dermatologyb and Department of Pathology,c SUNY Stony Brook; Dermpath Diagnostics,d Port Chester, New York Funding sources: None. Conflicts of interest: None declared. Correspondence to: David Silverstein, MD, 181 N Belle Mead Avenue, Suite 5, East Setauket, NY 11733-3497 E-mail: [email protected]
REFERENCES 1. Caccetta TP, Dessauvagie B, McCallum D, Kumarasinghe SP. Multiple minute digitate hyperkeratosis: a proposed algorithm for the digitate keratoses. J Am Acad Dermatol 2012;67:e49-55. 2. Goldstein N. Multiple minute digitate hyperkeratoses. Arch Dermatol 1967;96:692-3. 3. Ramselaar C, Toonstra J. Multiple minute digitate hyperkeratoses report of two cases with an updated review and proposal for a new classification. Eur J Dermatol 1999;9:460-5. 4. Miller A, Aires D, Fraga G. Multiple minute digitate hyperkeratoses: a case report. Dermatology Online J 2011;17:1. 5. Hashimoto K, Toi Y, Horton S, Sun TT. Spiny keratoderma—a demonstration of hair keratin and hair type keratinization. J Cutan Pathol 1999;26:25-30. http://dx.doi.org/10.1016/j.jaad.2013.05.031
Letters e207
infectious disease physicians will initiate an appropriate combination of antifungal therapy and surgical debridement. Noel Prevost, PA-C, and Joseph C. English III, MD University of Pittsburgh Department of Dermatology, Pennsylvania Funding sources: None. Conflicts of interest: None declared. Correspondence to: Joseph C. English III, MD, University of Pittsburgh Department of Dermatology, 200 Lothrop Street, Suite 3880, Presby South Tower, Pittsburgh PA 15213 E-mail: [email protected] REFERENCES 1. Lew DP, Waldvogel FA. Osteomyelitis. N Eng J Med 1997;366:999-1007. 2. Slenker AK, Keith S, Horn DL. Two hundred and eleven cases of candida osteomyelitis: 17 case reports and a review of the literature. Diagn Microbiol Infect Dis 2012;73:89-93. 3. Gamaletsou MN, Kontoyiannis DP, Sipsas NV, et al. Candida osteomyelitis: analysis of 207 pediatric and adult cases(19702011). Clin Infect Dis 2012;55:1338-51. 4. Malani PN, McNeil SA, Bradley SF, Kauffman CA. Candida albicans sternal wound infections: a chronic and recurrent complication of median sternotomy. Clin Infect Dis 2002;35:1316-20.
Fig 1. Multiple minute digitate hyperkeratosis affecting the right flank.
http://dx.doi.org/10.1016/j.jaad.2013.06.005
Multiple minute digitate hyperkeratoses To the Editor: A 61-year-old woman presented with a 1-year history of dry skin. Examination revealed numerous digitate papules affecting the chest and abdomen (Fig 1). The face, palms, soles, and all other skin sites were normal. The papules were both white and brown colored, nonfollicular, and measured 1 to 2 mm in diameter. Her medical history was unremarkable. There was no history of digitate keratosis or skin rashes in any related family members, and no personal history of malnutrition, malignancy, or relevant topical or systemic drug therapy. Shave biopsy was performed. Histologic examination showed focal columns of hyperorthokeratosis with a compact stratum corneum arising from a tented epidermis. No parakeratotic cells were seen in the long protrusions. The stratum granulosum was preserved (Fig 2). A basic screen for malignancy or inflammatory disease — including a complete blood count, chemistry panel, hepatitis panel, erythrocyte sedimentation rate, C-reactive protein, serum electrophoresis, and free light chains — was unrevealing. Additionally, the patient reported that she had an unremarkable chest x-ray study, mammogram, and
Fig 2. Multiple minute digitate hyperkeratosis, light microscopy. High-power image of multiple minute digitate hyperkeratosis exhibiting a digitate projection of compact orthokeratin arising from a tented, slightly acanthotic epidermis. (Hematoxylin-eosin stain; original magnification: 3100.)
colonoscopy performed within the last 2 years. A diagnosis of multiple minute digitate keratoses (MMDH) was made. The patient was treated with urea cream 40%. Follow-up at 2 weeks showed some improvement although her lesions persisted. MMDH is a rare nonfollicular skin disease of unknown etiology, characterized by multiple asymptomatic spiny keratotic lesions preferentially affecting the trunk and limbs. The face and palmoplantar surfaces are normally spared. The lesions may be white, yellow, brown, or skin-colored, and vary in length and diameter.1 Histopathology reveals fingerlike projections of orthokeratosis arising from a tented acanthotic epidermis and, less commonly, parakeratosis. The stratum granulosum may vary in thickness but is often prominent. Treatment of
J AM ACAD DERMATOL
e208 Letters
MMDH is often unsuccessful; however, various topical keratolytics and topical and oral retinoids have been reported to show some improvement. Initially described by Goldstein2 in 1967, difficulties in the diagnosis of MMDH include its rarity and resemblance to other digitate keratoses. To limit confusion from synonymous terms and previously suggested classifications, in 2010 Caccetta et al1 proposed an algorithm for diagnosing digitate keratoses. This diagnostic algorithm designates MMDH as the generalized, nonfollicular form of digitate keratosis. According to clinical presentation, cases of MMDH are classified into early and late-onset forms.3 The early onset form usually manifests in the second to third decades, and may be hereditary (autosomal dominant) or acquired. The late-onset form often presents after the fourth decade, with no family history. Although most late-onset forms are idiopathic, there have been reports of concomitant cancer or inflammatory disease. With the new criteria proposed by Caccetta et al,1 it is now recognized that many of these cases involved forms of digitate keratoses currently recognized as separate from MMDH.3,4 Currently, the pathogenesis of MMDH is unknown. An improved understanding may be gained from electron microscopy and immunohistochemical cytokeratin analysis, as was done for spiny keratoderma.5 The case reported here can be classified as lateonset MMDH, with no associated disorder. Adoption of the diagnostic algorithm proposed by Caccetta et al facilitated distinction of MMDH from other forms of digitate keratoses. Our reason for reporting this case, besides the rarity of MMDH, is to support
OCTOBER 2013
previous reports that the association between lateonset MMDH and concomitant cancer or inflammatory disease may be coincidental. Courtney J. Ensslin, BS,a Jason Cohen, MD,b,c Damian DiCostanzo,d and David Silverstein, MDb Stony Brook University School of Medicinea; Department of Dermatologyb and Department of Pathology,c SUNY Stony Brook; Dermpath Diagnostics,d Port Chester, New York Funding sources: None. Conflicts of interest: None declared. Correspondence to: David Silverstein, MD, 181 N Belle Mead Avenue, Suite 5, East Setauket, NY 11733-3497 E-mail: [email protected]
REFERENCES 1. Caccetta TP, Dessauvagie B, McCallum D, Kumarasinghe SP. Multiple minute digitate hyperkeratosis: a proposed algorithm for the digitate keratoses. J Am Acad Dermatol 2012;67:e49-55. 2. Goldstein N. Multiple minute digitate hyperkeratoses. Arch Dermatol 1967;96:692-3. 3. Ramselaar C, Toonstra J. Multiple minute digitate hyperkeratoses report of two cases with an updated review and proposal for a new classification. Eur J Dermatol 1999;9:460-5. 4. Miller A, Aires D, Fraga G. Multiple minute digitate hyperkeratoses: a case report. Dermatology Online J 2011;17:1. 5. Hashimoto K, Toi Y, Horton S, Sun TT. Spiny keratoderma—a demonstration of hair keratin and hair type keratinization. J Cutan Pathol 1999;26:25-30. http://dx.doi.org/10.1016/j.jaad.2013.05.031