Self-healing juvenile cutaneous mucinosis

Pediatric Lichen Myxedematosus: A Diagnostic and Management Challenge

Localized lichen myxedematosus (LM) is a rare, idiopathic mucinosis characterized by dermal mucin deposition and variable fibroblast proliferation. Nodular lichen myxedematosus, a clinicopathologic subtype of localized LM, is exceedingly rare in pediatric patients with only three prior cases reported. Understanding of LM in pediatric patients is limited by the rarity of the disease, and diagnosis is complicated by overlapping clinical and histopathologic features. There is no standardized treatment for localized LM and treatment is largely dictated by a patient’s desire to minimize cosmetic disfigurement. This case series reports two additional patients with juvenile nodular lichen myxedematosus, highlights the limitations of existing diagnostic criteria, and describes successful treatment of one patient with intralesional triamcinolone.

Self-healing juvenile cutaneous mucinosis, a sclerodermoid disorder simulating juvenile dermatomyositis: a case-based review

Self-healing juvenile cutaneous mucinosis (SHJCM) is a rare childhood disease with characteristic cutaneous and rheumatic manifestations. Cutaneous manifestations include a combination of nodules affecting peri-articular (especially interphalangeal joints) and head and neck areas; and linearly arranged ivory white papules over an erythematous indurated skin. Despite a benign course, an abrupt onset of symptoms with extensive cutaneous involvement often leads to parental anxiety, overenthusiastic evaluation and sometimes aggressive treatment. A peculiar cutaneous distribution in SHJCM including nodular lesions and periorbital edema, arthritis and arthralgia in a few cases, may simulate juvenile dermatomyositis. It is, therefore, important for dermatologists and pediatricians to be aware of this entity. In this report, we describe two cases of SHJCM and briefly review similarly reported cases in children.

Self-Healing Juvenile Cutaneous Mucinosis: A Case Report in the Middle East

Patient: Male, 12

Final Diagnosis: Self-healing juvenile cutaneous mucinosis

Symptoms: Facial edema • nodular skin lesion

Medication: —

Clinical Procedure: None

Specialty: Pediatrics and Neonatology

Self-healing juvenile cutaneous mucinosis

Girl, aged 4 years old, began the disease with pain of the lower extremities, fever up to 38°C and signs of upper airway infection. Then the patient developed oedema and redness of the whole face, thickened skin, subcutaneous nodular foldings of the frontal, occipital, cervical and axillary regions, extensor areas of the joints; fine, hard whitish nodules in the frontal region and over interphalangeal joints of the hands, pruritus; oedemas of the ankles, knees and joints of the hands, cervical lymphadenopathy and hepatomegaly. Blood tests at the moment of the diagnosis revealed elevation of markers of inflammation as ESR and CRP, leukocytosis, thrombocytosis, hypoalbuminemia, and hyper-alfa-2-globulinemia. Histopathological examination of the skin biopsy specimen and subcutaneous tissue revealed myxoid subcutaneous tissue located under the dermis and a section consisting of myxoid mesenchymal tissue with inflammatory infiltration by histiocytic cells. The presence of acid mucopolysaccharides in fields of the myxoid tissue was also observed. The self-healing juvenile cutaneous mucinosis (SJCM) was diagnosed.

A mimic of self-healing juvenile cutaneous mucinosis?

A 14-year-old boy presented with a chronic history of atypical papular mucinosis consisting of multiple subcutaneous nodules and confluent papular skin lesions. He initially presented at age 2 years with the rapid onset of numerous subcutaneous nodular lesions that completely resolved over a period of years. Clinical and histologic evidence, together with his clinical course, were suggestive of self-healing juvenile cutaneous mucinosis (SHJCM), but a few years later, during childhood, he experienced a recurrence of the subcutaneous nodules involving the limbs, trunk, and face, in addition to new findings of multiple flesh-colored papules coalescing into plaques on his neck and back. Although his early childhood course and histologic picture were suggestive of SHJCM, the progressive nature of his disorder is not like that seen in SHJCM and appears different from other reported disorders involving cutaneous mucinosis.

Nodular lesions of self-healing juvenile cutaneous mucinosis: a pitfall!

Self-healing juvenile cutaneous mucinosis (SHJCM) is a rare disorder of unknown origin, which occurs in children in good health. It is characterized by the multiplication of transient cutaneous papules and nodules, mainly located on the head and periarticular areas that spontaneously resolve. Histological features of SHJCM have been well described; therefore, the diagnosis is usually made easily when papules are biopsied. We report a series of 3 new cases of SHJCM presenting mainly with nodular lesions. Histological examination of these nodules showed either lesions consistent with nodular or proliferative fasciitis or nonspecific panniculitis. Mucinous deposits were present but often inconspicuous, so could be disregarded. We wanted to emphasize this misleading presentation because a biopsy for histological examination is always mandatory in cases of proliferating nodules to rule out malignant tumors. Therefore, the diagnosis always requires discussion between pathologists and clinicians to rapidly reassure the parents and avoid inappropriate therapy.

Multiple lesions of cutaneous focal mucinosis in a teenager

A 19-year-old Hispanic woman presented to our clinic with a chief complaint of multiple pink papules on her face (Figure 1). The lesions were asymptomatic, had appeared several years before her consultation, and had remained stable in size. Similar lesions on her trunk and extremities had spontaneously resolved before presentation. She had no significant medical history and was not on any medications. Cutaneous examination was remarkable for a few scattered, well-demarcated, slightly raised pink papules and plaques with no scale, ranging from 0.5 to 1 cm in diameter. The lesions were distributed on the right cheek, right temple, left lower eyelid, and neck area. The rest of the cutaneous examination was unremarkable. A punch biopsy was performed from a lesion near the left premandibular area. Hematoxylin and eosin staining of the biopsy specimen revealed superficial perivascular dermatitis with a slight increase in the number of fibroblasts (Figure 2). Colloidal iron staining was diffusely positive with replacement of collagen with mucinous material in the dermal layer (Figure 3). Laboratory values for a complete blood cell count, metabolic panel, serum protein electrophoresis, urine protein electrophoresis, thyroid-stimulating hormone, and antinuclear antibody were within normal limits. The patient was diagnosed with cutaneous focal mucinosis. Because of cosmetic concerns, the patient declined surgical excision and intralesional corticosteroid injections. A 4-month trial of topical tacrolimus 0.1% ointment was ineffective.

Self-healing juvenile cutaneous mucinosis: Cases highlighting subcutaneous/fascial involvement

BACKGROUND

Self-healing juvenile cutaneous mucinosis is a rare disease affecting young people characterized by transient cutaneous lesions and sometimes mild inflammatory symptoms. The deep dermal and subcutaneous features of this disorder have not yet been well described.

OBJECTIVE

The purpose of our study was to present 3 cases of self-healing juvenile cutaneous mucinosis in which the histopathologic features caused diagnostic confusion between this disorder and proliferative fasciitis.

METHODS

The study includes clinical and histologic findings of 3 patients, complemented by a literature review.

RESULTS

The histologic descriptions of nodular lesions in self-healing juvenile cutaneous mucinosis reveal features of proliferative fasciitis, including a myxoid stroma and gangliocyte-like giant cells.

LIMITATIONS

Self-healing juvenile cutaneous mucinosis is a rare condition and has not been frequently reported in medical literature. Our findings are based on the pathologic features of 3 patients.

CONCLUSIONS

Our findings further elucidate the histologic features of self-healing juvenile cutaneous mucinosis and expand the differential diagnosis for entities in which gangliocyte-like giant cells are noted.

Adult variant of self-healing papular mucinosis in a patient with rheumatoid arthritis: predominant proliferation of dermal dendritic cells expressing CD34 or factor XIIIa in association with dermal deposition of mucin

According to a recent classification, self-healing papular mucinosis (SHPM) is a subtype of papular mucinosis (also known as lichen myxedematosus), which is in turn a type of idiopathic localized cutaneous mucinosis. SHPM tends to occur in children, but there have been a few reports of an adult type. We report a 70-year-old Japanese woman who presented with reddish, rice-kernel-sized papules of a few days' duration on her right arm. She had a 25-year history of rheumatoid arthritis, which had been well treated with a low dose of corticosteroid as well as some other medications. No paraproteinemia or thyroid dysfunction were observed. The eruptions spontaneously resolved within 2.5 months of onset. Histological findings showed a well-circumscribed mucinous stroma surrounded by dermal mesenchymal cells, such as fibroblast-like cells in the middle of the dermis. Immunohistochemically, these cells were positive only for vimentin on the mucinous lesion. On the circumference of the mucinous lesion, these cells expressed either CD34 or factor XIIIa (FXIIIa). Because vimentin was common to dermal mesenchymal cells, we defined the cells expressing CD34 or FXIIIa, except for vimentin+ cells lacking CD34 or FXIIIa, as dermal dendritic cells (DDC). The findings of the present case suggest that CD34+ or FXIIIa+ DDC and tryptase-positive mast cells on the perilesional area in combination with vimentin+ cells on the mucinous lesion might have given rise to the dermal deposition of mucin in our case. These cells, which are possibly activated in an autoimmune manner associated with rheumatoid arthritis, might play important roles in the development of dermal deposition of mucin in SHPM.

Self-healing juvenile cutaneous mucinosis

Self-healing juvenile cutaneous mucinosis is an extremely uncommon disorder characterized by the acute eruption of multiple papules and subcutaneous nodules. In this report, we describe one of the youngest patients reported to date with self-healing juvenile cutaneous mucinosis and further define several of the histologic and clinical characteristics unique to the disorder. Awareness of this disease is important because, despite an ominous presentation, all reported cases have resolved spontaneously. Therefore, aggressive therapy should be avoided.

Self-healing juvenile cutaneous mucinosis

A healthy 14-month-old black girl presented with a 3-week complaint of "knots" on the face and hands. The lesions were acute in onset and asymptomatic. Multiple, firm, nontender, skin-colored to erythematous nodules were noted on the scalp, forehead, axillae, lower legs, abdomen, and hands. A skin biopsy specimen revealed a well-circumscribed accumulation of mucin in the reticular dermis. Colloidal iron stain was positive. Radiographs showed soft tissue prominence only. Serum protein electrophoresis, thyroid function tests, complete blood count, sedimentation rate, and antinuclear antibody were normal, except for lymphocytosis. Findings were consistent with self-healing juvenile cutaneous mucinosis (SHJCM). SHJCM is a condition of unknown etiology characterized by rapid onset of asymptomatic, indurated papules or nodules. Affected children may have arthralgias, but are otherwise well. Spontaneous resolution is the rule. Most skin lesions in our patient had resolved within 6 months of onset. This patient is unique because of the young age of onset.

Cutaneous focal mucinosis: a case report

Cutaneous or dermal mucinoses are a heterogeneous group of connective tissue disorders in which there is an accumulation of mucin in the skin or within the hair follicle. They have a number of different morphologic presentations and can often be confused with other diseases. We report a 12-year-old Chinese girl with a 1-year history of a well-defined, hypopigmented plaque on her chin, consistent with cutaneous focal mucinosis, a rare condition in children.

Myxoid malignant fibrous histiocytoma mimicking papular mucinosis

Malignant fibrous histiocytoma is the most common type of soft tissue sarcoma in late adulthood. The myxoid variant of malignant fibrous histiocytoma, also known as myxofibrosarcoma, can develop in subcutaneous rather than deep soft tissue, and the true extent of these superficial tumors is often underestimated. Patients with these low-grade myxoid malignant fibrous histiocytomas have an excellent 5-year survival rate, and it is therefore important to recognize them. We present a case with a superficial cutaneous accumulation of mucin that was diagnosed clinically and histologically as papular mucinosis. In retrospect, a subcutaneous presentation of myxofibrosarcoma should have been considered.

Self-healing infantile familial cutaneous mucinosis

Childhood cutaneous mucinoses have been rarely reported and are difficult to classify. We describe two brothers who developed multiple, extensive cutaneous lesions during the first few months of life. Histologically the lesions were composed of mucin deposits in the dermis. In the first patient, the lesions spontaneously disappeared over the years. We believe that familial self-healing cutaneous mucinosis represents a unique entity not previously reported.

Cutaneous focal mucinosis--a histopathological and immunohistochemical analysis of 11 cases

The histogenesis of cutaneous focal mucinosis (CFM) is controversial. Eleven cases of CFM (5F, 6M; mean age 51 years) from our routine files between 1986 and the present time have, therefore, been examined histopathologically and immunohistochemically. Histology revealed an increased number of fibroblast-like cells in early lesions, whereas they were diminished or predominantly at the margin in advanced ones. The myxomatous areas showed slight to absent reticulum formation. Similarly, elastic fibers were almost absent, and collagen fibers were fragmented and replaced by variable amounts of mucin. One specimen revealed an epithelial component within the lesion reminiscent of a poorly induced trichofolliculoma. Immunohistochemically, vimentin was consistently present and correlated with the number of fibroblast-like cells. A few (< 5%) CD34+ dermal dendritic cells (DDs) were focally seen within CFM. In contrast, FXIIIa+ DDs accounted for up to 30%. Fibroblast-like cells were negative for S-100 protein, Leu7, desmin and alpha-SMA. The epithelial component within one of our specimens seems to have been induced by CFM and is a feature also seen in (angio)-myxomas. CFM appears to be a mesenchymally derived lesion composed predominantly of fibroblasts. DDs do not form the major cell component but rather seem passively incorporated.

An unusual case of infantile dermal mucinosis

Dermal mucinosis occurred in a 3-month-old and persisted for six years. The features suggest is represents a novel type of childhood mucinosis.

Linear connective tissue naevus of the proteoglycan type ('naevus mucinosus')

We report a case of naevus mucinosus, a recently described condition. Clinically, the lesions presented as unilateral, multiple, firm, 3-5-mm-diameter, coalescent papules in a linear arrangement on the back of a 23-year-old man. Histologically, large amounts of acid mucopolysaccharides (proteoglycans) were demonstrated in the superficial dermis. As far as we are aware, this is the first report of the onset of naevus mucinosus in an adult. Naevus mucinosus appears to be a distinct type of connective tissue naevus which is characterized by an increase in proteoglycans.

Cutaneous mucinosis of infancy

Cutaneous mucinosis of infancy has been reported only rarely in the literature. We describe a case occurring in a black infant girl. Although no associated abnormalities have been described previously, our patient had a history of developmental delay, congenital cataracts, bilateral inguinal hernias, and an accessory tragus. The significance of these features is unclear.

Self-healing juvenile cutaneous mucinosis in a patient with nephroblastoma

Self-healing juvenile cutaneous mucinosis is characterized by an early age of onset, the presence of plaques and nodules in a characteristic distribution, and rapid onset followed by spontaneous resolution of the lesions within a period of weeks to months. Only four previous cases have been reported. The patient in this study was an 8-year-old child who developed cutaneous lesions characteristic of self-healing juvenile cutaneous mucinosis while undergoing chemotherapy for a nephroblastoma. This is the first case described of self-healing juvenile cutaneous mucinosis associated with a neoplasm.

An unusual case of transient papular mucinosis associated with carpal tunnel syndrome

A 67-year-old man presented with discrete mucinous papules on the scalp and fingers, and bilateral carpal tunnel syndrome. Both features remitted spontaneously within several months. The acral distribution, and histopathological features, were in keeping with the recently described acral persistent papular mucinosis. Involvement of the scalp, however, has not previously been described, and transient mucin deposition is unusual. The history of bilateral carpal tunnel compression raises the possibility of extracutaneous involvement, not previously reported in this group of patients.

Cutaneous mucinosis in a child with systemic lupus erythematosus

Cutaneous mucinosis is rarely associated with systemic lupus erythematosus. A 13-year-old girl had a two-month history of numerous cutaneous mucinous papules and the new onset of systemic lupus erythematosus. The differential diagnosis and pathogenesis of this variant of cutaneous mucinosis are discussed. This is the first report of a child with this unusual entity.

The new cutaneous mucinoses: a review with an up-to-date classification of cutaneous mucinoses

In the past years seven new cutaneous mucinoses have been described. These are briefly reviewed and included in a revised classification of cutaneous mucinoses.

Acral persistent papular mucinosis

Acral persistent papular mucinosis has recently been proposed as a distinct form of cutaneous mucinosis. We describe a patient and review the literature. We conclude that acral persistent papular mucinosis is a distinct clinical entity, clearly separable from most other forms of cutaneous mucinosis except for one variant of lichen myxedematosus, from which it is less easily distinguished.