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LETTER TO THE EDITOR
Year : 2019  |  Volume : 10  |  Issue : 3  |  Page : 337-340  

Guttate leukoderma in darier disease: A rare presentation


1 Department of Dermatology, Venereology and Leprosy, Pandit Bhagwat DayalSharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
2 Department of Pathology, Venereology and Leprosy, Pandit Bhagwat DayalSharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India

Date of Web Publication17-May-2019

Correspondence Address:
Isha Gupta
708-A/18, Near Adarsh School, Arya Nagar, Rohtak, Haryana - 124 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/idoj.IDOJ_314_18

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How to cite this article:
Gupta I, Dayal S, Kumar S. Guttate leukoderma in darier disease: A rare presentation. Indian Dermatol Online J 2019;10:337-40

How to cite this URL:
Gupta I, Dayal S, Kumar S. Guttate leukoderma in darier disease: A rare presentation. Indian Dermatol Online J [serial online] 2019 [cited 2019 Aug 21];10:337-40. Available from: http://www.idoj.in/text.asp?2019/10/3/337/258601



Sir,

A 50-year-old female presented with chief complaints of asymptomatic multiple red-brown raised keratotic lesions along with hypopigmented lesions all over body since 20 years. Keratotic lesions started from face and gradually involved bilateral arms, hands, abdomen, back, and feet in symmetrical fashion. She gave history of photosensitivity and heat intolerance. There wass no history of seizures, mental retardation, or developmental delay. There was family history of similar lesions in mother since birth. Reportedly mother had leukodermic macules in addition to classic keratotic papules. Systemic examination was unremarkable. On dermatological examination, multiple red-brown rough keratotic papules were present on face involving forehead, malar areas and chin, chest, abdomen, back, extensor aspect of bilateral upper limbs, dorsal aspect of bilateral hands, and feet. Multiple hypopigmented to depigmented perifollicular macules of size varying from 2 to 5 mm were present on chest, abdomen, back, and anterior aspect of bilateral thighs [Figure 1] and [Figure 2]. Focal palmar keratoderma involving hypothenar eminence was present along with multiple pits on thenar eminence of both palms [Figure 3]. On nail examination, longitudinal ridging and v-nick were present [Figure 4]. Oral mucosa was spared.
Figure 1: Multiple hypopigmented macules along with keratotic lesions on the trunk

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Figure 2: Close-up view showing hypopigmented lesions along with keratotic lesions on trunk

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Figure 3: Yellowish thickening (hypothenar eminence) and multiple pits on right hand

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Figure 4: Multiple nails showing longitudinal ridging and v.nick present on little finger nail

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On histopathology of hyperkeratotic papules, epidermis showed hyperkeratosis with follicular plugging. Few corps ronds are seen in the granular layer and basal layer showed clefting and presence of mixed inflammatory infiltrate, which is reaching in upper dermis [Figure 5]. Histopathology from hypopigmented lesion showed thinned out epidermis with mild spongiosis. Dermis reveals dense collagen bundles and sparse lymphomononuclear infiltrate [Figure 6]. Based on the clinical and histopathological findings, the diagnosis of Darier disease (DD) with guttate leukoderma was made. Patient was started on Acitretin 25 mg twice daily along with topical sunscreen and topical retinoids and asked to follow up after 3 weeks.
Figure 5: Hyperkeratosis with follicular plugging. Few corps ronds are seen in granular layer and basal layer showed clefting and presence of mixed inflammatory infiltrate which is reaching in upper dermis (hematoxylin and eosin ×100). Blue arrow showing corps ronds in granular layer; green arrow showing follicular hyperkeratosis; and black arrow showing basal layer cleft (hematoxylin and eosin ×400)

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Figure 6: Thinned out epidermis with mild spongiosis. Dermis reveals dense collagen bundles and sparse lymphomononuclear infiltrate.(hematoxylin and eosin ×100)

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DD [keratosis follicularis] is an autosomal dominant disorder of keratinization with characteristic dermatological findings, such as keratotic papules on the seborrheic regions, brittle nails, and longitudinal erythronychia, palmoplantar pitting, and cobblestoning in oral mucosa.[1]

Several variants of DD have been reported, including the guttate hypopigmented, vesiculobullous, acral hemorrhagic, acneiform comedonal, cornifying, and segmental or linear variants.[2] Small leukodermic macules were first described by Goodall and Richmond in a patient of DD in 1965.[3] Hypopigmented macules in DD is rare. Terrom et al. in a recent review on this association identified only 21 cases of DD with guttate leukoderma in the English- and French-language literature reported till now.[4]

Etiopathogenesis is currently unknown. Some authors considered guttate leukoderma as postinflammatory or subclinical form of DD; however, the increasing number of reported cases devoid of papular lesions or macules evolving into hyperkeratotic papules refute the above hypothesis.[2] Another proposed hypothesis is dysregulated melanin transfer due to lack of keratinocyte adhesion caused by the ATP2A2 gene mutation leading to guttate leukoderma.[5]

According to Tolat et al., familial hypopigmented Darier's differ from usual Darier by involvement of gluteal region and back.[6] In our patient also, back was involved along with palmar and nail involvement.

Histological examinations of hypopigmented DD variant vary from barely seeing any typical disease features to classic dyskeratosis with the presence of corps ronds and grains and acantholysis.[2]

Guttate leukoderma in DD may be misdiagnosed as tinea versicolor, lichen sclerosus, idiopathic guttate hypomelanosis, or follicular vitiligo.[3] Extragenital lichen sclerosus atrophicans (LSA) presents with pruritic, porcelain-white, shiny slightly elevated interfollicular papules; however, in our patient, lesions were non shiny, non atrophic perifollicular macules with absence of pruritus, wrinkling, and telangiectasia. Moreover, lesions are generally grouped in LSA and often coalesce into larger plaques; however, in our patient, lesions were present since a long time with no coalescing; so, diagnosis of LSA was unlikely. Moreover, classical histopathological features of marked hyperkeratosis, follicular plugging, and band-like infiltrate were absent, which ruled out possibility of extragenital LSA. Lesions were nonscaly; coup d'ongle sign and KOH microscopy were negative, so Pityriasis versicolor was ruled out. Follicular vitiligo was ruled out since lesions were not milky white and due to absence of convex hyperpigmented border. Idiopathic guttate hypomelanosis was excluded based on age of onset and distribution of lesions. Lesions were present since childhood and mainly involve non-sun exposed areas. Treatment modalities include emollients, topical steroids and calcineurin inhibitors, topical 5-fluorouracil, oral retinoids, laser treatments, and surgery.[2] Increasing awareness regarding guttate leukodermic variant of DD is important to prevent misdiagnosis and for appropriate management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kansal NK, Hazarika N, Rao S. Familial case of darier disease with guttate leukoderma: A case series from India. Indian Dermatol Online J 2018;9:62-3.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Morin CB, Netchiporouk E, Billick RC, Srolovitz HD, Roshdy O. Hypopigmented segmental Darier disease. J Cutan Med Surg 2015;19:69-72.  Back to cited text no. 2
    
3.
Sornakumar L, Srinivas CR. Darier'S disease with perifollicular hypopigmentation. Indian J Dermatol 2010;55:299-300.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Terrom M, Dhaille F, Baltazard T, Dadban A, Sevestre H, Lok C, et al. Guttate leukoderma in Darier disease: Case report and review. J Eur Acad Dermatol Venereol 2016;30:e205-9.  Back to cited text no. 4
    
5.
Sharma N, Aggarwal Y, Malhotra SK, Chahal KS. Inheritance pattern of hypopigmented macules associated with familial Darier's disease. Pigment Int 2016;3:46-8.  Back to cited text no. 5
  [Full text]  
6.
Tolat SN, Agarwal S, Borkar MA, Ghosh SN. Darier's disease and depigmented macules. Ind J DermatolVenerolLeprol. 1994;6:173-5.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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