Confluent and reticulated papillomatosis with eruptions on the trunk and extremities

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Confluent and reticulated papillomatosis with
eruptions on the trunk and extremities

Fukumoto, Takeshi
Oka, Masahiro
(Citation)
Dermatology Reports,15(2):9600

(Issue Date)
2023

(Resource Type)
journal article

(Version)
Version of Record

(Rights)
©Copyright: the Author(s), 2023
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0
International License (CC BY-NC 4.0).

(URL)
https://hdl.handle.net/20.500.14094/0100482716

Dermatology Reports 2023; volume 15:9600

Confluent and reticulated papillomatosis with eruptions on the trunk
and extremities
Takeshi Fukumoto,1 Masahiro Oka2

Division of Dermatology, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe; 2Department of
Dermatology, Kita-Harima Medical Center, Ono City, Japan

1

To the Editor:
Confluent and reticulated papillomatosis (CRP) is a rare skin
disorder in young individuals. It is clinically characterized by
slightly hyperkeratotic or verrucous grayish-brown papules coalescing to form a reticulated pattern peripherally with confluent
plaques centrally.1 Sites of predilection are the neck, interscapular,
intermammary regions, and abdomen. CRP commonly arises dur-

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Correspondence: Masahiro Oka, Department of Dermatology, KitaHarima Medical Center, 926-250 Ichiba-cho, Ono City, Hyogo 6751392, Japan.
Tel.: +81.794.888800 - Fax: +81.794.629931.
E-mail: masahiro_oka@kitahari-mc.jp

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Key words: reticulated, papillomatosis, extremities, trunk, bacterial
infection.

Contributions: TF and MO designed the study and drafted the manuscript. TF and MO contributed to data collection and interpretation
of the results. All authors have read and approved the final manuscript.

ing puberty or in early adulthood. Herein, we describe an atypical
case of CRP in which the skin lesions developed not only on the
abdomen, as a site of predilection, but also on broad areas of the
extremities.
The patient had noticed asymptomatic, brownish macular skin
eruptions on the inner aspects of the thighs seven months earlier.
These skin eruptions expanded to the lower legs within a few
months. One month before first presentation, similar lesions had
developed on the inner aspects of the upper extremities. Physical
examination of these lesions revealed symmetric, hyperpigmented, slightly hyperkeratotic brownish macules having very fine
reticular pattern (Figure 1 A-D). On the lower extremities, multiple petechiae were scattered in similar reticular macules (Figure 1
C,D). Additionally, skin lesions resembling those on the upper
extremities were symmetrically distributed on the lower abdomen
(Figure 1E). The patient had not noticed these abdominal lesions
until discovered during the physical examination. Direct mycological examination of scales from the lesions on the extremities and
the lower abdomen using potassium hydroxide yielded negative
results. Two skin biopsies from lesions on the right thigh and left
lower abdomen showed similar histopathological findings.
Findings included orthokeratotic epidermis with hyperkeratosis,
papillomatosis, focal acanthosis and hyperpigmentation in the
basal layer, and perivascular discrete lymphocytic infiltrate in the
superficial dermis (Figure 1F).
Based on the clinical and histopathological findings, CRP was
diagnosed. After the biopsy, cefcapene pivoxil hydrochloride
hydrate (100 mg thrice daily for 3 days) was prescribed routinely
for infection prevention. At the second presentation, three weeks
later, skin lesions on the extremities unexpectedly showed complete resolution, within a week after the first presentation.
However, skin lesions were still present on the lower abdomen,
with minor improvement. Hence, these lesions were treated with
minocycline (100 mg twice daily for 28 days) but no improvement
was noted. Treatment was then changed to cefcapene pivoxil
hydrochloride hydrate (100 mg thrice daily for 14 days). After 14
days of cefcapene pivoxil hydrochloride hydrate treatment, all
lower abdominal skin lesions resolved completely. No recurrence
of CRP lesions was seen during six months of follow-up.
The striking feature in the present case was the unusual localization of skin lesions on the extremities. To the best of our knowledge, a total of four case studies of CRP with skin lesions restricted to small areas somewhere on extremities have been reported.25 Locations of CRP lesions in these cases included the antecubital
fossae,2,5 popliteal fossae,2,3 elbows and knees,4 and upper arms.5
However, no case of CRP with skin lesions on broad areas on the
extremities has previously been reported.
Although unclear, several underlying causes regarding the
CRP pathogenesis include keratinization disorder, reaction to
Pityrosporum, eruption related to endocrinopathy, reaction to bacterial infections such as Dietzia papillomatosis or to ultraviolet
light, processes involving amyloidosis, or genetic factors.1

Conflict of interest: the authors declare no potential conflict of interest.

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Funding: none

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Informed consent: the patient provided written informed consent
for the publication.

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Availability of data and materials: All data are available in the main
text and materials.

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Acknowledgements: this work was supported by KOSÉ
Cosmetology Research Foundation (T.F.) and Kinoshita memorial
enterprise subsidy (T.F.).

Received for publication: 20 September 2022.
Accepted for publication: 11 November 2022.
Early view: 23 December 2022.

This work is licensed under a Creative Commons AttributionNonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: the Author(s), 2023
Licensee PAGEPress, Italy
Dermatology Reports 2023; 15:9600
doi:10.4081/dr.2023.9600

Publisher's note: all claims expressed in this article are solely those
of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article or claim
that may be made by its manufacturer is not guaranteed or endorsed
by the publisher.

[Dermatology Reports 2023; 15:9600]

[page 89]

Letter
The idea that CRP is related to bacterial infection is evident
by the responsiveness of CRP to a variety of antibacterial agents,
including minocycline,7,8 cefdinir,9 fusidic acid,10 clarithromycin,10
and erythromycin.10 In particular, the effectiveness of oral minocycline therapy against CRP has been well recognized. However, in
the present case, cefcapene pivoxil hydrochloride hydrate (but not

minocycline) was effective against CRP lesions. Cefcapene pivoxil
hydrochloride hydrate is a cephem antibiotic developed in Japan
that inhibits the synthesis of bacterial cell walls and is used for
treating bacterial infections.11 A case of CRP that responded to
amoxicillin, but not minocycline was reported.12 Additionally, the
present case suggests that a variety of bacteria cause CRP.

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,6

Figure 1. Clinical appearance of the skin lesions. Hyperpigmented, slightly hyperkeratotic macules with a very fine reticular pattern are
evident on the inner aspect of the left upper arm (A). Magnified image of A (B). Hyperpigmented, slightly hyperkeratotic brownish macules with multiple scattered petechiae on the inner aspect of the right thigh (C). Magnified image of C (D). Hyperpigmented, slightly
hyperkeratotic symmetric reticular macules on the lower abdomen (E). F) Histopathological findings for the lesion on the right thigh (F).
The epidermis shows orthokeratotic hyperkeratosis, papillomatosis, focal acanthosis, and hyperpigmentation in the basal layer.
Perivascular lymphocytic infiltration is present in the superficial dermis. (hematoxylin and eosin, original magnification ×200).
[page 90]

[Dermatology Reports 2023; 15:9600]

Letter

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