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Treatment of multiple miliary osteoma cutis with tretinoin gel
LETTERS ii ii
Follicular m u c i n o s i s in exaggerated arthropod-bite reactions o f patients with chronic l y m p h o c y t i c l e u k e m i a To the Editor.. The clinical, histopathologic, and immunopathologic features of a papulovesicular eruption developing in patients with chronic lymphocytic leukemia (CLL) have been recently characterized by Davis et al (J Am Acad Dermatol 1998;39:27-35) and regarded as an exaggerated response to arthropod bites. We report an additional case whose histopathologic features support such interpretation. A 63-year-old patient with long-standing CLL had a pruritic papulonodulovesicular eruption on the trunk and extremities of 8 months' duration. He denied any recent a r t h r o p o d bites. The lesions cleared with oral prednisone but relapsed after its discontinuation. Histopathologic examination showed intraepidermal blister, a diffuse dermatitis composed of lymphocytes and abundant eosinophils with flame figures, and typical features of follicular mucinosis. Mucin accumulates in the follicular epithelium in two distinctive clinical conditions, namely alopecia mucinosa of Pinkus and urticaria-like follicular mucinosis, but also, as a secondary phenomenon, in many different disorders including pseudolymphomas and arthropod bite reactions. 1,2 In our patient the follicular mucinosis accompanied the eosinophilic cellulitis with flame figures, which is another tissue reaction associated with arthropod bites.3 These histopathologic findings support the etiologic interpretation of Davis et al that the unusual papulonodulovesicular eruption seen in patients with CLL is an exaggerated and persistent response to arthropod bites. Franco Rongioletti, MD Alfredo Rebora, MD Department of Dermatology University of Genoa viale Benedetto XV 16132 Genoa, Italy REFERENCES 1. Rongioletti F, Rebora A.The cutaneous mucinoses. In: Arndt KA, LeBoit PE, Robinson JQ, Wintroub BU, editors. Cutaneous medicine and surgery: an integrated program in dermatology. Philadelphia:WB Saunders; 1996. p. 1832-40. 2. Hempstead RW, Ackerman AB. Follicular mucinosis: a reaction pattern in follicular epithelium. Am J Dermatopathol 1985;7: 245-57. 3. Schorr WF, Tauscheck AL, Dickson KB, Melski JW. Eosinophilic cellulitis (Well's syndrome): histologic and clinical features in arthropod bite reactions. J Am Acad Dermatol 1984;11:1043-9.
500
SEPTEMBER, PART 1, 1999
Treatment of multiple miliary o s t e o m a cutis with tretinoin gel To the Editor: In the May 1991 issue of the Journal, Moritz and Elewski 1 described successful use of topical tretinoin for a case of multiple miliary osteoma curls. The proposed mechanism of action was transepidermal elimination. Multiple miliary osteoma cutis is a rare process, usually occurring after longstanding acne vulgaris, characterized by firm, skin-colored to bluish papules of the face. 1,2 We recently evaluated 2 middle-aged women with this characteristic presentation. Histologic evaluation confirmed the presence of osteomas. Treatment options for multiple miliary osteoma cutis have been limited and are usually invasive, such as dermabrasion and/or punch excision.3-5 Our patients opted for a conservative approach in the manner of Moritz and Elewski. Each woman applied topical 0.025% tretinoin gel to half of the face for 9 months, with the other cheek serving as an internal control. Papule counts were performed at baseline, 6 months, and 9 months. Papule counts decreased in both treated and untreated cheeks, but there was a much greater decrease in counts in the treated cheeeks. Both patients noticed improvement to the treated cheek within a few weeks, raising the possibility that they then began treating both cheeks. One of the patients, similar to the patient of Moritz and Elewski, reported elimination of"rice-like grains." Histologic evaluation of a "grain" confirmed osteoma. Both our patients were pleased with the improvement they achieved with tretinoin. Tretinoin appears to offer a safe, noninvasive treatment option to patients with multiple miliary osteoma cutis and deserves further study. Corinne G. Smith, MD Dee Anna Glaser, MD Department of Dermatology Saint Louis University Health Sciences Center I402 Grand Blvd St Louis, MO 6.3104 REFERENCES 1. Moritz D, Elewski B. Pigmented postacne osteoma cutis in a patient treated with minocycline: report and review of the literatu re. J Am Acad Dermatol 1991 ;24:851-3. 2. Levell N, Lawrence C. Multiple papules on the face. Arch Dermatol 1994;130:370-4. 3. Fulton J. Dermabrasion-loo-punch technique for the treatment of acne-induced osteoma cutis.J Dermatol Surg Onco11987;13: 655-9. 4. Goldminz D, Greenberg R. Multiple miliary osteoma cutis.J Am Acad Dermatol 1991 ;24:878-81. 5. Wilhelmsen H, Bereston E. Treatment of osteoma cutis. Cutis 1984;33:481-3.
J AM ACAD DERMATOL
Follicular m u c i n o s i s in exaggerated arthropod-bite reactions o f patients with chronic l y m p h o c y t i c l e u k e m i a To the Editor.. The clinical, histopathologic, and immunopathologic features of a papulovesicular eruption developing in patients with chronic lymphocytic leukemia (CLL) have been recently characterized by Davis et al (J Am Acad Dermatol 1998;39:27-35) and regarded as an exaggerated response to arthropod bites. We report an additional case whose histopathologic features support such interpretation. A 63-year-old patient with long-standing CLL had a pruritic papulonodulovesicular eruption on the trunk and extremities of 8 months' duration. He denied any recent a r t h r o p o d bites. The lesions cleared with oral prednisone but relapsed after its discontinuation. Histopathologic examination showed intraepidermal blister, a diffuse dermatitis composed of lymphocytes and abundant eosinophils with flame figures, and typical features of follicular mucinosis. Mucin accumulates in the follicular epithelium in two distinctive clinical conditions, namely alopecia mucinosa of Pinkus and urticaria-like follicular mucinosis, but also, as a secondary phenomenon, in many different disorders including pseudolymphomas and arthropod bite reactions. 1,2 In our patient the follicular mucinosis accompanied the eosinophilic cellulitis with flame figures, which is another tissue reaction associated with arthropod bites.3 These histopathologic findings support the etiologic interpretation of Davis et al that the unusual papulonodulovesicular eruption seen in patients with CLL is an exaggerated and persistent response to arthropod bites. Franco Rongioletti, MD Alfredo Rebora, MD Department of Dermatology University of Genoa viale Benedetto XV 16132 Genoa, Italy REFERENCES 1. Rongioletti F, Rebora A.The cutaneous mucinoses. In: Arndt KA, LeBoit PE, Robinson JQ, Wintroub BU, editors. Cutaneous medicine and surgery: an integrated program in dermatology. Philadelphia:WB Saunders; 1996. p. 1832-40. 2. Hempstead RW, Ackerman AB. Follicular mucinosis: a reaction pattern in follicular epithelium. Am J Dermatopathol 1985;7: 245-57. 3. Schorr WF, Tauscheck AL, Dickson KB, Melski JW. Eosinophilic cellulitis (Well's syndrome): histologic and clinical features in arthropod bite reactions. J Am Acad Dermatol 1984;11:1043-9.
500
SEPTEMBER, PART 1, 1999
Treatment of multiple miliary o s t e o m a cutis with tretinoin gel To the Editor: In the May 1991 issue of the Journal, Moritz and Elewski 1 described successful use of topical tretinoin for a case of multiple miliary osteoma curls. The proposed mechanism of action was transepidermal elimination. Multiple miliary osteoma cutis is a rare process, usually occurring after longstanding acne vulgaris, characterized by firm, skin-colored to bluish papules of the face. 1,2 We recently evaluated 2 middle-aged women with this characteristic presentation. Histologic evaluation confirmed the presence of osteomas. Treatment options for multiple miliary osteoma cutis have been limited and are usually invasive, such as dermabrasion and/or punch excision.3-5 Our patients opted for a conservative approach in the manner of Moritz and Elewski. Each woman applied topical 0.025% tretinoin gel to half of the face for 9 months, with the other cheek serving as an internal control. Papule counts were performed at baseline, 6 months, and 9 months. Papule counts decreased in both treated and untreated cheeks, but there was a much greater decrease in counts in the treated cheeeks. Both patients noticed improvement to the treated cheek within a few weeks, raising the possibility that they then began treating both cheeks. One of the patients, similar to the patient of Moritz and Elewski, reported elimination of"rice-like grains." Histologic evaluation of a "grain" confirmed osteoma. Both our patients were pleased with the improvement they achieved with tretinoin. Tretinoin appears to offer a safe, noninvasive treatment option to patients with multiple miliary osteoma cutis and deserves further study. Corinne G. Smith, MD Dee Anna Glaser, MD Department of Dermatology Saint Louis University Health Sciences Center I402 Grand Blvd St Louis, MO 6.3104 REFERENCES 1. Moritz D, Elewski B. Pigmented postacne osteoma cutis in a patient treated with minocycline: report and review of the literatu re. J Am Acad Dermatol 1991 ;24:851-3. 2. Levell N, Lawrence C. Multiple papules on the face. Arch Dermatol 1994;130:370-4. 3. Fulton J. Dermabrasion-loo-punch technique for the treatment of acne-induced osteoma cutis.J Dermatol Surg Onco11987;13: 655-9. 4. Goldminz D, Greenberg R. Multiple miliary osteoma cutis.J Am Acad Dermatol 1991 ;24:878-81. 5. Wilhelmsen H, Bereston E. Treatment of osteoma cutis. Cutis 1984;33:481-3.
J AM ACAD DERMATOL