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Scaling Lesions on the Axillary Skin of a 52-Year-Old Man—Diagnosis

Scaling Lesions on the Axillary Skin of a 52-Year-Old Man—Diagnosis Diagnosis: Axillary granular parakeratosis. Microscopic findings and clinical course Histologic examination of the punch biopsy specimen from an affected area showed a clearly thickened and compact stratum corneum above a typically differentiated and stratified epidermis. There was a clear retention of nuclei, with nuclear parakeratosis, in the corneocytes, and a number of intact keratohyaline granules were evident within the cytoplasm. These granules imparted basophilic properties to the compact horny layer. The epidermis was mildly acanthotic, with some hyperplasia of the rete ridges. In general, the keratinocytes appeared normal. A superficial perivascular lymphocytic inflammation was present in the dermis. No evidence of fungal infection was found on periodic acid–Schiff staining. Based on the clinical and microscopic findings, a diagnosis of axillary granular parakeratosis was made. Topical 0.025% tretinoin therapy was initiated, with poor response. Oral isotretinoin therapy (40 mg/d) was then begun, and within 2 months, the skin eruption had completely cleared. The patient refused patch testing. Discussion Granular parakeratosis is an unusual, benign, acquired dermatosis of intertriginous surfaces that represents a distinctive clinicopathologic entity. It typically manifests as brownish red keratotic papules and plaques that can become macerated. The cutaneous eruption can be asymptomatic or more often pruritic and arises over a period of days to months.1-4 Most patients with granular parakeratosis are women in the fifth to sixth decades of life, but it has also been described in children.3 It was initially described in the axillary area,1,2 but other areas of involvement, such as submammary and intermammary4,5 and inguinal and perianal regions, have been reported.3,5 Histologic examination shows parakeratosis with a large number of basophilic keratohyaline granules within a compact hyperkeratotic stratum corneum.1-6 The main differential diagnoses include flexural (inverse) psoriasis, Hailey-Hailey disease, contact dermatitis, Candida intertrigo, and disseminated seborrheic keratoses. The characteristic alterations of the stratum corneum exclude all other relevant diagnoses. The pathogenesis of granular parakeratosis is unclear. It has been proposed that the persistence of keratohyalin granules in the stratum corneum is due to abnormal nondissolution of filaggrin and the nonfusion of keratin lamellae.1,5,6 Therefore, granular parakeratosis may represent an unusual form of retention hyperkeratosis. Further evidence that this unusual axillary eruption is a disorder of keratinization is suggested by the clinical response to treatment with retinoids in the present case and in other reported cases.7,8 However, the primary triggers for this condition remain unknown. Because the first reports described involvement of the axillae, antiperspirants or deodorants have been suggested as causative factors, but the lesions of granular parakeratosis have since been found in other intertriginous sites, where these products are not usually applied.3,4 Microbiologic cultures have not shown a responsible pathogen. Nevertheless, the role of a heretofore unrecovered microorganism cannot be excluded. Because all reported cases have involved skin folds,1-8 it is likely that occlusion and maceration are at least indirectly involved in the development of the disorder. The optimal therapy for granular parakeratosis is unknown. In various reports, patients have shown variable response to topical treatment with corticosteroids, antifungal agents, and antibiotics. Oral or topical retinoids seem to be a good alternative.7,8 Also, cases have been reported in which spontaneous resolution has occurred in a period of weeks to months.5 Article Submissions Clinicians, local and regional societies, and residents and fellows in dermatology are invited to submit quiz cases to this section. Cases should follow the established pattern and be submitted double-spaced. Photomicrographs and illustrations must be clear and submitted as 3 positive color transparencies and as 3 color prints. Material should be accompanied by the required copyright transfer statement, as noted in "Instructions for Authors." Material for this section should be submitted to Michael E. Ming, MD, Department of Dermatology, University of Pennsylvania Health System, 2 Maloney Bldg, 3600 Spruce St, Philadelphia, PA 19104-4283. Reprints are not available from the authors. References 1. Northcutt ADNelson DMTschen JA Axillary granular parakeratosis J Am Acad Dermatol. 1991;24541- 544PubMedGoogle ScholarCrossref 2. Mehregan DAVandersteen PSikorsky LMehregan DR Axillary granular parakeratosis J Am Acad Dermatol. 1995;33373- 375PubMedGoogle ScholarCrossref 3. Patrizi ANeri IMisciali CFanti PA Granular parakeratosis: four paediatric cases Br J Dermatol. 2002;1471003- 1006PubMedGoogle ScholarCrossref 4. Wohlrab JLuftl MWolter MMarsch WC Submammary granular parakeratosis: an acquired punctate hyperkeratosis of exogenic origin J Am Acad Dermatol. 1999;40813- 814PubMedGoogle Scholar 5. Metze DRutten A Granular parakeratosis: a unique acquired disorder of keratinization J Cutan Pathol. 1999;26339- 352PubMedGoogle ScholarCrossref 6. Grosshans E A new histopathologic form of parakeratosis: granular parakeratosis Nouv Dermatol. 1992;11244- 247Google Scholar 7. Brown SKHeilman ER Granular parakeratosis: resolution with topical tretinoin J Am Acad Dermatol. 2002;47(suppl)S279- S280PubMedGoogle ScholarCrossref 8. Webster CGResnik KSWebster GF Axillary granular parakeratosis: response to isotretinoin J Am Acad Dermatol. 1997;37789- 790PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Scaling Lesions on the Axillary Skin of a 52-Year-Old Man—Diagnosis

Archives of Dermatology , Volume 140 (9) – Sep 1, 2004

Scaling Lesions on the Axillary Skin of a 52-Year-Old Man—Diagnosis

Abstract

Diagnosis: Axillary granular parakeratosis. Microscopic findings and clinical course Histologic examination of the punch biopsy specimen from an affected area showed a clearly thickened and compact stratum corneum above a typically differentiated and stratified epidermis. There was a clear retention of nuclei, with nuclear parakeratosis, in the corneocytes, and a number of intact keratohyaline granules were evident within the cytoplasm. These granules imparted basophilic properties to the...
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Publisher
American Medical Association
Copyright
Copyright © 2004 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archderm.140.9.1161-f
Publisher site
See Article on Publisher Site

Abstract

Diagnosis: Axillary granular parakeratosis. Microscopic findings and clinical course Histologic examination of the punch biopsy specimen from an affected area showed a clearly thickened and compact stratum corneum above a typically differentiated and stratified epidermis. There was a clear retention of nuclei, with nuclear parakeratosis, in the corneocytes, and a number of intact keratohyaline granules were evident within the cytoplasm. These granules imparted basophilic properties to the compact horny layer. The epidermis was mildly acanthotic, with some hyperplasia of the rete ridges. In general, the keratinocytes appeared normal. A superficial perivascular lymphocytic inflammation was present in the dermis. No evidence of fungal infection was found on periodic acid–Schiff staining. Based on the clinical and microscopic findings, a diagnosis of axillary granular parakeratosis was made. Topical 0.025% tretinoin therapy was initiated, with poor response. Oral isotretinoin therapy (40 mg/d) was then begun, and within 2 months, the skin eruption had completely cleared. The patient refused patch testing. Discussion Granular parakeratosis is an unusual, benign, acquired dermatosis of intertriginous surfaces that represents a distinctive clinicopathologic entity. It typically manifests as brownish red keratotic papules and plaques that can become macerated. The cutaneous eruption can be asymptomatic or more often pruritic and arises over a period of days to months.1-4 Most patients with granular parakeratosis are women in the fifth to sixth decades of life, but it has also been described in children.3 It was initially described in the axillary area,1,2 but other areas of involvement, such as submammary and intermammary4,5 and inguinal and perianal regions, have been reported.3,5 Histologic examination shows parakeratosis with a large number of basophilic keratohyaline granules within a compact hyperkeratotic stratum corneum.1-6 The main differential diagnoses include flexural (inverse) psoriasis, Hailey-Hailey disease, contact dermatitis, Candida intertrigo, and disseminated seborrheic keratoses. The characteristic alterations of the stratum corneum exclude all other relevant diagnoses. The pathogenesis of granular parakeratosis is unclear. It has been proposed that the persistence of keratohyalin granules in the stratum corneum is due to abnormal nondissolution of filaggrin and the nonfusion of keratin lamellae.1,5,6 Therefore, granular parakeratosis may represent an unusual form of retention hyperkeratosis. Further evidence that this unusual axillary eruption is a disorder of keratinization is suggested by the clinical response to treatment with retinoids in the present case and in other reported cases.7,8 However, the primary triggers for this condition remain unknown. Because the first reports described involvement of the axillae, antiperspirants or deodorants have been suggested as causative factors, but the lesions of granular parakeratosis have since been found in other intertriginous sites, where these products are not usually applied.3,4 Microbiologic cultures have not shown a responsible pathogen. Nevertheless, the role of a heretofore unrecovered microorganism cannot be excluded. Because all reported cases have involved skin folds,1-8 it is likely that occlusion and maceration are at least indirectly involved in the development of the disorder. The optimal therapy for granular parakeratosis is unknown. In various reports, patients have shown variable response to topical treatment with corticosteroids, antifungal agents, and antibiotics. Oral or topical retinoids seem to be a good alternative.7,8 Also, cases have been reported in which spontaneous resolution has occurred in a period of weeks to months.5 Article Submissions Clinicians, local and regional societies, and residents and fellows in dermatology are invited to submit quiz cases to this section. Cases should follow the established pattern and be submitted double-spaced. Photomicrographs and illustrations must be clear and submitted as 3 positive color transparencies and as 3 color prints. Material should be accompanied by the required copyright transfer statement, as noted in "Instructions for Authors." Material for this section should be submitted to Michael E. Ming, MD, Department of Dermatology, University of Pennsylvania Health System, 2 Maloney Bldg, 3600 Spruce St, Philadelphia, PA 19104-4283. Reprints are not available from the authors. References 1. Northcutt ADNelson DMTschen JA Axillary granular parakeratosis J Am Acad Dermatol. 1991;24541- 544PubMedGoogle ScholarCrossref 2. Mehregan DAVandersteen PSikorsky LMehregan DR Axillary granular parakeratosis J Am Acad Dermatol. 1995;33373- 375PubMedGoogle ScholarCrossref 3. Patrizi ANeri IMisciali CFanti PA Granular parakeratosis: four paediatric cases Br J Dermatol. 2002;1471003- 1006PubMedGoogle ScholarCrossref 4. Wohlrab JLuftl MWolter MMarsch WC Submammary granular parakeratosis: an acquired punctate hyperkeratosis of exogenic origin J Am Acad Dermatol. 1999;40813- 814PubMedGoogle Scholar 5. Metze DRutten A Granular parakeratosis: a unique acquired disorder of keratinization J Cutan Pathol. 1999;26339- 352PubMedGoogle ScholarCrossref 6. Grosshans E A new histopathologic form of parakeratosis: granular parakeratosis Nouv Dermatol. 1992;11244- 247Google Scholar 7. Brown SKHeilman ER Granular parakeratosis: resolution with topical tretinoin J Am Acad Dermatol. 2002;47(suppl)S279- S280PubMedGoogle ScholarCrossref 8. Webster CGResnik KSWebster GF Axillary granular parakeratosis: response to isotretinoin J Am Acad Dermatol. 1997;37789- 790PubMedGoogle ScholarCrossref

Journal

Archives of DermatologyAmerican Medical Association

Published: Sep 1, 2004

Keywords: axilla,skin,parakeratosis

References