Case Letter
Hidden clear cell acanthoma with uncommon dermoscopic findings
Marcial Álvarez-Salafranca
, Mar García-García, Andrea Montes-Torres, Mariano Ara-Martín
Corresponding author
Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "517" "paginaFinal" => "518" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Marcial Álvarez-Salafranca, Mar García-García, Andrea Montes-Torres, Mariano Ara-Martín" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Marcial" "apellidos" => "Álvarez-Salafranca" "email" => array:1 [ 0 => "malvarezs@salud.aragon.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Mar" "apellidos" => "García-García" ] 2 => array:2 [ "nombre" => "Andrea" "apellidos" => "Montes-Torres" ] 3 => array:2 [ "nombre" => "Mariano" "apellidos" => "Ara-Martín" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1163 "Ancho" => 1674 "Tamanyo" => 153749 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Well delimited erythematous shiny plaque on the left buttock, surrounded by a hypopigmented area.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 73-year-old woman presented with less than a 1-year history of an erythematous, well-delimited and shiny lesion on her left buttock, near the gluteal fold (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Dermoscopic examination showed dotted vessels arranged in a linear pattern involving the entire lesion. These vascular findings are also called metaphorically a ‘string of pearls’ pattern. Another vascular pattern observed on the periphery of the lesion is that of branched vessels with rounded endings. Surprisingly, dermoscopy also revealed multiple rosettes (also known as ‘four-clod dots’) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Differential diagnoses included mainly clear cell acanthoma, irritated seborrheic keratosis, Bowen´s disease and eccrine poroma. The lesion was completely surgically removed and histopathologic examination revealed an epidermic lesion with marked psoriasiform hyperplasia, in which epidermal cells show clear cytoplasms (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). These findings are consistent with the diagnosis of Clear Cell Acanthoma (CCA).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">CCA is an uncommon benign epidermal lesion of unknown etiology, although a recent hypothesis suggests its reactive origin. The typical presentation is a red to brown, dome-shaped papule or plaque on the lower extremities, with a peak of age incidence of 60-years.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However, like in this case, it can appear in unusual locations. Clinical differential diagnosis includes a wide range of cutaneous neoplasms, including malignant lesions such as squamous cell carcinoma or amelanotic melanoma. Indeed, it is frequently mistaken clinically for other skin lesions.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this setting, almost unique dermoscopic findings can be a useful tool to suspect this diagnosis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On dermoscopy CCA is highly characteristic, showing dotted or glomerular vessels arranged in a linear or serpiginous pattern. These linear arrangements usually adopt a reticular distribution, forming what is known as a ‘string of pearls’ pattern, of which this case is very representative.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In this sense, these stereotypical dermoscopic findings can be helpful in the setting of otherwise nonspecific lesions.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Other dermoscopic findings reported in CCA are, in order of frequency, a pale pink background, a collarette of translucent scales, hemorrhagic areas, orange crusts, and crystalline structures.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Otherwise, branched vessels with rounded terminal endings are not typical of CCA. Moreover, these dermoscopic finding is positively associated with the diagnosis of eccrine poroma, which is one of the main differential diagnoses of CCA.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In the studied patient, they were distributed along the entire periphery of the lesion, showing various morphologies such as a chalice-like or leaf-like shape. This peripheral distribution could suggest that, in this case, vessel type depends more on the viewing angle on dermoscopy than on the morphology of these vessels.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Rosettes are dermoscopic structures only observed under polarized light. They are also called ‘four-clod dots’ and, first believed to be specific for actinic keratosis and squamous cell carcinoma, currently, they are not considered lesion-specific and can also be observed in another type of skin lesions. Rosettes are considered to be an optical effect of crossed polarization by concentric fibrosis or horny material.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> To the authors’ knowledge, there are no previous reports showing this structure end CCA.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, the authors report a case of CCA with an unusual location, showing uncommon dermoscopic findings, classically associated with other cutaneous lesions such as actinic keratosis or eccrine poroma. Although the ‘string of pearls’ pattern is highly characteristic, CCA can show other dermoscopic features that should be known in order to make an accurate differential diagnosis.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contributions</span><p id="par0040" class="elsevierStylePara elsevierViewall">Marcial Álvarez-Salafranca: Approval of the final version of the manuscript; composition of the manuscript; collection, analysis, and interpretation of data; participation in the design of the study; critical review of the literature; critical review of the manuscript.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Mar García-García: Approval of the final version of the manuscript; collection, analysis, and interpretation of data; critical review of the manuscript.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Andrea Montes-Torres: Approval of the final version of the manuscript; collection, analysis, and interpretation of data; critical review of the manuscript.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Mariano Ara-Martín: Approval of the final version of the manuscript; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-14" "fechaAceptado" => "2020-06-19" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Álvarez-Salafranca M, García-García M, Montes-Torres A, Ara-Martín M. Hidden clear cell acanthoma with uncommon dermoscopic findings. An Bras Dermatol. 2021;96:517–8.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1163 "Ancho" => 1674 "Tamanyo" => 153749 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Well delimited erythematous shiny plaque on the left buttock, surrounded by a hypopigmented area.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1431 "Ancho" => 1674 "Tamanyo" => 151302 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dermoscopy showed dotted vessels arranged in a linear pattern involving the central part of the lesion (‘String of pearls’ pattern). In addition, branched vessels with rounded endings (white asterisk; bottom inset) and four-clod dots can be observed (white arrows; upper black inset).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 886 "Ancho" => 1674 "Tamanyo" => 342765 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">At low power view there is a very well-demarcated lesion with prominent acanthosis and psoriasiform hyperplasia. Clear, pale-staining keratinocytes are characteristically present in this lesion (Hematoxylin & eosin, ×2).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clear cell acanthoma: a rare clinical diagnosis prior to biopsy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L.K. Morrison" 1 => "M. Duffey" 2 => "M. Janik" 3 => "H.N. 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Nazzaro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/jdv.14729" "Revista" => array:6 [ "tituloSerie" => "J Eur Acad Dermatol Venereol" "fecha" => "2018" "volumen" => "32" "paginaInicial" => "1263" "paginaFinal" => "1271" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29194789" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rosettes and other white shiny structures in polarized dermoscopy: histological correlate and optical explanation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Haspeslagh" 1 => "M. Noë" 2 => "I. De Wispelaere" 3 => "N. Degryse" 4 => "K. Vossaert" 5 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 8 | 23 |
| 2024 October | 107 | 71 | 178 |
| 2024 September | 152 | 90 | 242 |
| 2024 August | 162 | 141 | 303 |
| 2024 July | 126 | 114 | 240 |
| 2024 June | 132 | 84 | 216 |
| 2024 May | 152 | 72 | 224 |
| 2024 April | 113 | 98 | 211 |
| 2024 March | 107 | 78 | 185 |
| 2024 February | 117 | 85 | 202 |
| 2024 January | 97 | 378 | 475 |
| 2023 December | 64 | 74 | 138 |
| 2023 November | 175 | 81 | 256 |
| 2023 October | 113 | 67 | 180 |
| 2023 September | 68 | 71 | 139 |
| 2023 August | 68 | 32 | 100 |
| 2023 July | 63 | 27 | 90 |
| 2023 June | 65 | 41 | 106 |
| 2023 May | 52 | 19 | 71 |
| 2023 April | 48 | 18 | 66 |
| 2023 March | 76 | 38 | 114 |
| 2023 February | 52 | 38 | 90 |
| 2023 January | 46 | 45 | 91 |
| 2022 December | 70 | 28 | 98 |
| 2022 November | 79 | 55 | 134 |
| 2022 October | 82 | 53 | 135 |
| 2022 September | 48 | 69 | 117 |
| 2022 August | 44 | 57 | 101 |
| 2022 July | 54 | 63 | 117 |
| 2022 June | 47 | 52 | 99 |
| 2022 May | 38 | 55 | 93 |
| 2022 April | 58 | 58 | 116 |
| 2022 March | 49 | 73 | 122 |
| 2022 February | 38 | 40 | 78 |
| 2022 January | 69 | 77 | 146 |
| 2021 December | 60 | 74 | 134 |
| 2021 November | 68 | 59 | 127 |
| 2021 October | 85 | 107 | 192 |
| 2021 September | 115 | 82 | 197 |
| 2021 August | 92 | 71 | 163 |
| 2021 July | 113 | 79 | 192 |
| 2021 June | 46 | 51 | 97 |
| 2021 May | 26 | 40 | 66 |
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