Confluent Brownish Papules and Plaques on the Neck, Upper Chest and Back: A Quiz

Alina Jankowska-Konsur, Joanna Maj, Małgorzata Tupikowska and Jacek C. Szepietowski*

Department of Dermatology, Venereology and Allergology, Medical University, Chalubinskiego 1, 50-368 Wroclaw, Poland. *E-mail: jacek.szepietowski@am.wroc.pl

A 20-year-old woman presented with multiple confluent, brownish lesions, which had developed gradually over the previous year, on the upper trunk and neck. She had been treated for pityriasis versicolor with oral ketokonazole 200 mg daily for one week and topical antifungal (clotrimazole) creams with no improvement, and applied topical 1% hydrocortisone cream for more than one month with no effect.

Dermatological examination revealed brownish, scaling plaques and papules distributed in a confluent and reticulated pattern on the lateral parts of the neck, the nape, upper back, intermammary area and caudal region (Fig. 1). Potassium hydroxide (KOH) examination was negative for Malassezia spp. and examination with a Wood’s lamp showed no fluorescence in the lesional areas. Histopathological examination of a punch biopsy obtained from the lesional skin revealed hyperkeratosis, acanthosis and papillomatosis, with scant perivascular lymphocytic infiltration (Fig. 2). Periodic acid-Schiff (PAS) staining demonstrated no fungal cells. Blood tests excluded diabetes mellitus and thyroid dysfunction. The patient was otherwise healthy.

Fig. 1. Brownish, scaling plaques and papules distributed in a confluent and reticulated pattern on: (a) the chest, and (b) the abdomen.

Fig. 2. Hyperkeratosis, acanthosis and papillomatosis with scant perivascular lymphocytic infiltration was observed in the lesional skin (H&E staining, × 100).

What is your diagnosis? See next page for answer.

doi: 10.2340/00015555-1504

Confluent Brownish Papules and Plaques on the Neck, Upper Chest and Back: Comment

Acta Derm Venereol 2013; 93: XX–XX

Diagnosis: Confluent and reticulated papillomatosis of Gougerot and Carteaud

Confluent and reticulated papillomatosis of Gougerot and Carteaud (CRP) is a rare epidermal proliferation, which affects mainly young patients, with female predominance (1). The disease usually occurs sporadically; however, a familial incidence has been noted (2).

The aetiology of the disorder is unknown. The prevalent hypothesis is that confluent and reticulated papillomatosis represents a disorder of keratinization, since histological and immunohistochemical analysis shows altered maturation and differentiation of the keratinocytes, and some cases respond well to treatment with oral and topical retinoids or topical calcipotriol (3–5). On the other hand, infection with Malassezia spp. or other microorganisms has been proposed as a trigger of the abnormal immunological host response; however, the yeast or bacterial growth may be secondary to the skin lesions (6).

Initially, skin lesions present as small, brownish, flat-topped papules that tend to coalesce to form confluent central plaques and reticular arrangement peripherally.Eruptions develop mostly on the intermammary, interscapular and epigastric area, but they may spread also to the neck, nape, axillary and caudal region. The lesions are asymptomatic, rarely pruritic, and the patients’ major complaint is the cosmetic appearance. Histological examination reveals hyperkeratosis, acanthosis and papillomatosis with scant perivascular lymphocytic infiltration.

Differential diagnosis includes pityriasis versicolor, acanthosis nigricans, Darier’s disease, Dowling-Degos syndrome and ichthyosis.

Numerous therapeutic options for CRP are used with variable and often transitory effect, including topical agents (keratinolytics, tretinoin (7), vitamin D analogues (5) or antifungal preparations (8, 9)) and systemic medications (oral minocycline (1), isotretinoin (3), antifungal agents). A good response to 70% alcohol swabbing has been reported (10).

ACKNOWLEDGEMENTS

The authors thank Dr Zdzisław Woźniak for histopathological assessment and assistance in preparation of the illustrations.

REFERENCES

1. Davis MD, Weenig RH, Camilleri MJ. Confluent and reticulate papillomatosis (Gougerot-Carteaud syndrome): a minocycline-responsive dermatosis without evidence for yeast in pathogenesis. A study of 39 patients and a proposal of diagnostic criteria. Br J Dermatol 2006; 154: 287–293.

2. Kellet JK, Macdonald RH. Confluent and reticulated papillomatosis. Arch Dermatol 1985; 121: 587–588.

3. Lee SH, Choi EH, Lee WS, Kang WH, Bang DS. Confluent and reticulated papillomatosis: a clinical, histological, and electron microscopic study. J Dermatol 1991; 18: 725–730.

4. Erkek E, Ayva S, Atasoy P, Emeksiz MC. Confluent and reticulated papillomatosis: favourable response to low-dose isotretinoin. J Eur Acad Dermatol Venereol 2009; 23: 1342–1343.

5. Carozzo AM, Gatti S, Ferranti G, Primavera G, Vidolin AP, Nini G. Calcipotriol treatment of confluent and reticulated papillomatosis (Gougerot-Carteaud syndrome). J Eur Acad Derm Venereol 2000; 14: 131–133.

6. Gupta AK, Batra R, Bluhm R, Boekhout T, Dawson TL Jr. Skin diseases associated with Malassezia species. J Am Acad Dermatol 2004; 51: 785–798.

7. Schwartzberg JB, Schwartzberg HA. Response of confluent and reticulate papillomatosis of Gougerot and Carteaud to topical tretinoin. Cutis 2000; 66: 291–293.

8. Nordby CA, Mitchell AJ. Confluent and reticulated papillomatosis responsive to selenium sulfide. Int J Dermatol 1986; 25: 194–199.

9. Hamaguchi T, Nagase M, Higuchi R, Takiuchi I. A case of confluent and reticulated papillomatosis responsive to ketoconazole cream. Nihon Ishinkin Gakkai Zasshi 2002; 43: 95–98.

10. Berk DR. Confluent and reticulated papillomatosis response to 70% alcohol swabbing. Arch Dermatol 2011; 147: 247–248.