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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 17-year-old boy without medical antecedents presented to the dermatology clinic with a six-month history of papular lesions on his lower extremities&#46; Dermatologic examination revealed three asymptomatic&#44; firm&#44; yellow-brown papules&#44; scattered on the lower extremities &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#8211;C&#41;&#46; On dermoscopy&#44; a yellow homogenous area with the central white network&#44; surrounded by a pinkish halo&#44; was seen &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#8211;C&#41;&#46; Routine blood tests showed normal full blood count&#44; renal and liver biochemistry&#46; A punch biopsy of a papule was performed for light microscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#8211;C&#41;&#46; Low power view revealed a hypercellular lesion with increased collagen fibers&#44; extending from the superficial dermis to the deep dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; Abundant foamy histiocytes were seen among dense collagen fibers &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#8211;C&#41;&#46; Immunohistochemically&#44; these cells with vacuolar cytoplasm were CD68 positive &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>D&#41;&#46; Given the clinicopathologic findings&#44; lipidized dermatofibroma was diagnosed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0010" class="elsevierStylePara elsevierViewall">Dermatofibromas are common fibrohistiocytic tumors that are mostly diagnosed clinically&#46; However&#44; variants of dermatofibroma sometimes present significant clinical and dermoscopic challenges&#44; and they are best diagnosed by histologic examination&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Dermatofibroma is a very common fibrosing cutaneous soft-tissue tumor&#44; typically diagnosed in young to middle-aged adults&#46; Most patients present with a firm&#44; solitary 0&#46;5&#8211;1&#160;cm papule&#44; nodule&#44; or plaque&#44; usually brown in color&#44; on the lower extremities&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Lipidized dermatofibroma is a poorly recognized variant of dermatofibroma&#46; It was first reported as lipidized or &#8220;ankle-type&#8221; fibrous histiocytoma by Calonje and Fletcher in 1994&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Later&#44; two case series investigated the clinical features of lipidized dermatofibroma&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Lipidized dermatofibroma represents 2&#37; of dermatofibromas&#46; It usually manifests as a solitary exophytic yellowish papule or nodule&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Compared to ordinary dermatofibromas&#44; lipidized dermatofibroma tends to present with larger solitary lesions and at an older age&#44; mostly in the fifth or sixth decades of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> To our knowledge&#44; there is only one patient presenting with two lesions and one patient under the age of thirty&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Unlike atypical&#44; cellular&#44; and aneurysmal subtypes&#59; this variant of dermatofibroma seems to have a very good prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A recent study evaluating 13 cases revealed three dermoscopic patterns of lipidized dermatofibroma&#46; In the total yellowish homogenous area pattern&#44; the yellowish area involves the whole lesion&#46; The atypical pattern is associated with irregular or centrally located yellowish homogenous areas&#46; The third pattern contains the combination of a central white network and a peripheral delicate pigment network&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In our case&#44; total yellowish homogenous area along with other characteristic features of dermatofibromas such as a central white network and peripheral reddish halo point to the diagnosis of lipidized dermatofibroma&#46; Yellow homogenous area and white network correspond to histiocytes with foamy cytoplasm and to collagenized stroma respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The main differential diagnosis of our patient was Juvenile Xanthogranuloma &#40;JXG&#41;&#46; JXG is the most common non-Langerhans cell histiocytosis and typically presents as a solitary well-demarcated&#44; dome-shaped yellowish papule or nodule&#44; mostly on the head and neck of young children&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Lesions in children show spontaneous regression within 2-years of diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> JXG may rarely occur in adults as persistent lesions&#44; mostly in the second to fourth decades&#46; However&#44; similar to lipidized dermatofibroma&#44; JXG may affect older patients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In contrast to lipidized dermatofibroma which has a predilection for lower extremities&#44; adult JXG tends to involve the head and neck region&#46; While the yellowish papulonodules of JXG typically measure several millimeters in diameter&#44; typical lesions of lipidized dermatofibroma are larger&#44; with a median diameter of 2&#46;5&#160;cm&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> &#8220;Setting sun&#8221; appearance is a typical dermoscopic aspect of JXG with central yellow core and peripheral erythema&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Histopathologically&#44; JXG is characterized by the presence of histiocytes&#44; foam cells&#44; and Touton giant cells&#46; Although typical for JXG&#44; the latter can also be seen in lipidized dermatofibroma&#46; Histiocytes in JXG have more eosinophilic and less lipidized cytoplasm as compared to lipidized dermatofibroma&#46; Observation of an epidermal collarette and a more prominent inflammatory infiltrate that frequently includes eosinophils help distinguish JXG from lipidized dermatofibroma&#46; Furthermore&#44; lipidized dermatofibroma displays a prominent spindle cell component arranged in a storiform pattern and these cells entrap the dermal collagen fibers at the periphery of the lesion&#46; Stromal &#8220;wiry&#8221; hyalinization&#44; which can sometimes be very extensive&#44; is also a frequent histopathologic feature of lipidized dermatofibroma&#44; differentiating it from JXG&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;10</span></a> Lastly&#44; several immunohistochemical differences may have a role in the differential diagnosis&#44; such as the presence of CD4 expression in JXG that is not seen in lipidized dermatofibroma&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The disease generally follows a benign course&#46; However&#44; patients with JXG should undergo a complete physical examination regularly&#46; In case of multiple lesions&#44; an ophthalmologic examination should also be performed&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Lipidized dermatofibroma rarely presents in young adults as small papular lesions&#46; This uncommon clinical presentation of lipidized dermatofibromas could be easily mistaken for juvenile xanthogranuloma&#44; cutaneous mastocytoma&#44; or eruptive xanthomata&#46; However&#44; typical dermoscopic and histopathological findings point to the diagnosis of lipidized dermatofibroma&#44; and no further investigations are performed&#46; Lipidized dermatofibromas should be kept in mind in the differential diagnosis of lesions representing yellow areas in dermoscopy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors&#8217; contributions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Tugba KevserUzuncakmak - Participated in data collection&#59; analysis and interpretation and critical literature review&#59; preparation and writing of the manuscript&#46; Muazzez CigdemOba - Participated in data collection&#59; analysis and interpretation and critical literature review&#59; preparation and writing of the manuscript&#46; MehmetSar - Preparation and writing of the manuscript&#46; ZekayiKutlubay - Participated in data collection&#59; analysis and interpretation and critical literature review&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Letter - Clinical
Dermoscopy of lipidized dermatofibromas
Tugba Kevser Uzuncakmaka, Muazzez Cigdem Obaa,
Autor para correspondência
muazzez.oba@istanbul.edu.tr

Corresponding author.
, Mehmet Sarb, Zekayi Kutlubaya
a Department of Dermatology and Venereology, Istanbul University-Cerrahpasa, Cerrahpaşa Medical Faculty, Istanbul, Turkey
b Department of Pathology, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 17-year-old boy without medical antecedents presented to the dermatology clinic with a six-month history of papular lesions on his lower extremities&#46; Dermatologic examination revealed three asymptomatic&#44; firm&#44; yellow-brown papules&#44; scattered on the lower extremities &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#8211;C&#41;&#46; On dermoscopy&#44; a yellow homogenous area with the central white network&#44; surrounded by a pinkish halo&#44; was seen &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#8211;C&#41;&#46; Routine blood tests showed normal full blood count&#44; renal and liver biochemistry&#46; A punch biopsy of a papule was performed for light microscopy &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#8211;C&#41;&#46; Low power view revealed a hypercellular lesion with increased collagen fibers&#44; extending from the superficial dermis to the deep dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; Abundant foamy histiocytes were seen among dense collagen fibers &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#8211;C&#41;&#46; Immunohistochemically&#44; these cells with vacuolar cytoplasm were CD68 positive &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>D&#41;&#46; Given the clinicopathologic findings&#44; lipidized dermatofibroma was diagnosed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0010" class="elsevierStylePara elsevierViewall">Dermatofibromas are common fibrohistiocytic tumors that are mostly diagnosed clinically&#46; However&#44; variants of dermatofibroma sometimes present significant clinical and dermoscopic challenges&#44; and they are best diagnosed by histologic examination&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Dermatofibroma is a very common fibrosing cutaneous soft-tissue tumor&#44; typically diagnosed in young to middle-aged adults&#46; Most patients present with a firm&#44; solitary 0&#46;5&#8211;1&#160;cm papule&#44; nodule&#44; or plaque&#44; usually brown in color&#44; on the lower extremities&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Lipidized dermatofibroma is a poorly recognized variant of dermatofibroma&#46; It was first reported as lipidized or &#8220;ankle-type&#8221; fibrous histiocytoma by Calonje and Fletcher in 1994&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Later&#44; two case series investigated the clinical features of lipidized dermatofibroma&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Lipidized dermatofibroma represents 2&#37; of dermatofibromas&#46; It usually manifests as a solitary exophytic yellowish papule or nodule&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Compared to ordinary dermatofibromas&#44; lipidized dermatofibroma tends to present with larger solitary lesions and at an older age&#44; mostly in the fifth or sixth decades of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> To our knowledge&#44; there is only one patient presenting with two lesions and one patient under the age of thirty&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Unlike atypical&#44; cellular&#44; and aneurysmal subtypes&#59; this variant of dermatofibroma seems to have a very good prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A recent study evaluating 13 cases revealed three dermoscopic patterns of lipidized dermatofibroma&#46; In the total yellowish homogenous area pattern&#44; the yellowish area involves the whole lesion&#46; The atypical pattern is associated with irregular or centrally located yellowish homogenous areas&#46; The third pattern contains the combination of a central white network and a peripheral delicate pigment network&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In our case&#44; total yellowish homogenous area along with other characteristic features of dermatofibromas such as a central white network and peripheral reddish halo point to the diagnosis of lipidized dermatofibroma&#46; Yellow homogenous area and white network correspond to histiocytes with foamy cytoplasm and to collagenized stroma respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The main differential diagnosis of our patient was Juvenile Xanthogranuloma &#40;JXG&#41;&#46; JXG is the most common non-Langerhans cell histiocytosis and typically presents as a solitary well-demarcated&#44; dome-shaped yellowish papule or nodule&#44; mostly on the head and neck of young children&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Lesions in children show spontaneous regression within 2-years of diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> JXG may rarely occur in adults as persistent lesions&#44; mostly in the second to fourth decades&#46; However&#44; similar to lipidized dermatofibroma&#44; JXG may affect older patients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In contrast to lipidized dermatofibroma which has a predilection for lower extremities&#44; adult JXG tends to involve the head and neck region&#46; While the yellowish papulonodules of JXG typically measure several millimeters in diameter&#44; typical lesions of lipidized dermatofibroma are larger&#44; with a median diameter of 2&#46;5&#160;cm&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> &#8220;Setting sun&#8221; appearance is a typical dermoscopic aspect of JXG with central yellow core and peripheral erythema&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Histopathologically&#44; JXG is characterized by the presence of histiocytes&#44; foam cells&#44; and Touton giant cells&#46; Although typical for JXG&#44; the latter can also be seen in lipidized dermatofibroma&#46; Histiocytes in JXG have more eosinophilic and less lipidized cytoplasm as compared to lipidized dermatofibroma&#46; Observation of an epidermal collarette and a more prominent inflammatory infiltrate that frequently includes eosinophils help distinguish JXG from lipidized dermatofibroma&#46; Furthermore&#44; lipidized dermatofibroma displays a prominent spindle cell component arranged in a storiform pattern and these cells entrap the dermal collagen fibers at the periphery of the lesion&#46; Stromal &#8220;wiry&#8221; hyalinization&#44; which can sometimes be very extensive&#44; is also a frequent histopathologic feature of lipidized dermatofibroma&#44; differentiating it from JXG&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;10</span></a> Lastly&#44; several immunohistochemical differences may have a role in the differential diagnosis&#44; such as the presence of CD4 expression in JXG that is not seen in lipidized dermatofibroma&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The disease generally follows a benign course&#46; However&#44; patients with JXG should undergo a complete physical examination regularly&#46; In case of multiple lesions&#44; an ophthalmologic examination should also be performed&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Lipidized dermatofibroma rarely presents in young adults as small papular lesions&#46; This uncommon clinical presentation of lipidized dermatofibromas could be easily mistaken for juvenile xanthogranuloma&#44; cutaneous mastocytoma&#44; or eruptive xanthomata&#46; However&#44; typical dermoscopic and histopathological findings point to the diagnosis of lipidized dermatofibroma&#44; and no further investigations are performed&#46; Lipidized dermatofibromas should be kept in mind in the differential diagnosis of lesions representing yellow areas in dermoscopy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors&#8217; contributions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Tugba KevserUzuncakmak - Participated in data collection&#59; analysis and interpretation and critical literature review&#59; preparation and writing of the manuscript&#46; Muazzez CigdemOba - Participated in data collection&#59; analysis and interpretation and critical literature review&#59; preparation and writing of the manuscript&#46; MehmetSar - Preparation and writing of the manuscript&#46; ZekayiKutlubay - Participated in data collection&#59; analysis and interpretation and critical literature review&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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