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Print version ISSN 0365-0596
On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.86 no.4 supl.1 Rio de Janeiro July/Aug. 2011
Facial miliary osteoma in HIV patient*
Osteoma miliar da face em paciente portadora do HIV
Camila CamozzatoI; Franciani de Oliveira BassoI; Rodrigo Pereira DuquiaII; Ana Letícia BoffIII; Hiram Larangeira de Almeida JrIV
IMedical doctor - Dermatology Resident- Santa Casa de Misericórdia Hospital from Porto Alegre - Porto Alegre (RS), Brazil
IIMaster's degree in Epidemiology - Preceptor at the Dermatology Service of the Santa Casa Hospital from Porto Alegre - Dermatology Assistant Professor, The Federal University of Pelotas (UFPel) - Pelotas (RS), Brazil
IIISpecialist in Pathology - Dermatology Service, Santa Casa Hospital from Porto Alegre - Porto Alegre (RS), Brazil
IVAssociate professor - Assistant professor - The Federal University of Pelotas (UFPel) - Dermatology Adjunct Professor, The Catholic University of Pelotas (UCPEL) - Pelotas (RS), Brazil
Facial miliary osteoma is characterized by the presence of multiple normochromic papules, affecting mainly middle-aged women, with a previous history of acne. A 39-year-old HIV positive female patient presented hardened papules which had appeared 3 years before, located on the malar region, glabella and mentum. Optical microscopy showed spherical bone formations in the dermis. Computerized tomography of the face revealed small calcifications on the surface consistent with bone formation. Multiple facial osteomas are rare as well as its association with HIV virus infection.
Keywords: HIV; Osteoma; Skin neoplasms
Os osteomas miliares da face são caracterizados por múltiplas pápulas normocrômicas na face, afetando, geralmente, mulheres de meia idade, com história pregressa de acne. Uma paciente de 39 anos, portadora do HIV, apresentou pápulas endurecidas, com 3 anos de evolução, localizadas na região malar, glabela e mento. A microscopia óptica demonstrou formações ósseas esféricas na derme. A tomografia computadorizada da face observou pequenas calcificações na superfície, compatíveis com formação óssea. Os osteomas múltiplos da face são raros assim como sua associação com a infecção pelo HIV.
Palavras-chave: HIV; Neoplasias cutâneas; Osteoma
Osteoma cutis is a rare disease, characterized by bone formation in the cutaneous and subcutaneous tissues. It is divided into primary and secondary forms, according to the absence or presence of previous skin injury.1,2 The facial miliary osteoma (FMO) is characterized by the presence of multiple osteomas, affecting mainly young middle-aged women, with a previous background of acne.1,3-5 We report the case of a patient with the human immunodeficiency virus (HIV) with FMO.
A 39-years-old female patient, phototype III, presented multiple skin-colored papules on her face, which appeared 3 years ago. The lesions measured 1 to 3mm, had a hard consistency, located in the malar region, glabella and mentum (Figure 1). Clinical laboratory examinations (hemogram, calcium, phosphor, sodium, potassium, urea and creatinine) were normal, HIV sorology was positive. A computer tomography of her face observed small calcifications on the skin surface suggesting bone formation (Figure 2). Light microscopy of a lesion of the glabella revealed a spherical bone formation on the dermis, comprised of osteocytes in oval gaps, laid-out in a laminar manner (Figure 2). Topical treatment with 0.05% retinoic acid in cream was suspended due to intolerance and lack of response, incision and curettage of the bone material, followed by closure by second intention was performed in some lesions with good results.
The FMO was initially described by Hopkins in 1928. 1 It is a rare, benign condition, characterized by the presence of ossification on the dermal and subcutaneous tissue.4
The primary ossification is believed to occur when there is no previous tissue injury, it may be associated with syndromes such as: Albright's hereditary osteodystrophy, progressive osseous fibrodysplasia and progressive osseous heteroplasia.4,5 Secondary ossification, the most common form, occurs on skin areas which were previously affected by inflammatory or infectious processes, such as acne vulgaris, scars and tumors (pilomatrixoma, basal cell carcinoma, desmoplastic malignant melanoma, chondroid syringoma, among others), it may be more rarely associated to chronic inflammatory processes such as dermatomyositis, systemic sclerosis and ossifying myositis.3,4 Despite the division into primary and secondary osteomas, the causal relationship between the presence of previous inflammation on skin and the onset of miliary osteoma on the face is not fully understood.1
The FMO has been reported mainly in fair-skinned middle-aged women, in most cases with a previous background of acne, one previous case was described in the Brazilian literature.1,3,4,6
The diagnosis is based on the histopathologic findings and image exams. Light microscoy reveals the presence of bone spicules of various sizes that can be found on the dermis or on the subcutaneous tissue.7 The bone contains fairly numerous osteocytes (as well as cement lines that may be accentuated in polarized light.). In addition, there are osteoblasts along the surface of the spicules and often osteoclasts in Howships lacunae.The pathogenesis of this condition remains unknown.2, 4
Surgical treatment has been described as the most effective therapeutic modality. 8 The use of topical tretinoin presents favorable results in small and superficial lesions.9 The use of Carbon Dioxide or Erbium: YAG laser with posterior curettage was also described, but it has a higher cost and few cases described in literature. 10,11
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2. Altman JF, Nehal KS, Busam KJ, Halpern AC. Treatment of primary miliary osteoma cutis with incision, curettage, and primary closure. J Am Acad Dermatol. 2001;44:96-9. [ Links ]
3. Goldminz D, Greenberg RD. Multiple military osteoma cutis. J Am Acad Dermatol 1991;24:878-81. [ Links ]
4. Thielen AM, Stucki L, Braun RP, Masouyé I, Germanier L, Harms M, et al . Multiple cutaneous osteomas of the face associated with chronic inflammatory acne. J Eur Acad Dermatol Venereol. 2006;20:321-6. [ Links ]
5. Lo Scocco G, Di Lernia V, Bisighini G. Multiple miliary osteoma of the face. Clin Exp Dermatol. 1997;22:152-3. [ Links ]
6. Habermann Neto T, Nogueira Neto JCP, Prada AA, Cintra ML, Lima RB, Vincenti BHR. Osteoma cutâneo. An Bras Dermatol. 1995;70:39-41. [ Links ]
7. Elder DE. Atlas and Synopsis of Lever's histopathology of the Skin. 2nd ed. Philadelphia: Lippincott-Raven; 2007. p.396 [ Links ]
8. Baskan EB, Turan H, Tunali S, Toker SC, Adim SB, Bolca N. Miliary osteoma cutis of the face: treatment with the needle microincision-extirpation method. J Dermatolog Treat. 2007;18:252-4. [ Links ]
9. Smith CG, Glaser DA. Treatment of multiple military osteoma cutis with tretinoin gel. J Am Acad Dermatol. 1999;41:500. [ Links ]
10. Ochsendorf FR, Kalfmann R. Erbium: YAG laser-assited treatment of military osteoma cutis. Br J Dermatol. 1998;138:371-2. [ Links ]
11. Baginski DJ, Arpey CJ. Management of multiple miliary osteoma cutis. Dermatol Surg. 1999;25:233-5 [ Links ]
Hiram Larangeira de Almeida Jr
Rua Barroso 1202 - UCPEL
Zip Code 96010-280 Pelotas RS
Received on 03.08.2010.
Approved by the Advisory Board and accepted for publication on 14.10.2010.
Conflict of interest: None
Financial funding: None
* Work carried out at the Dermatology Service of the Santa Casa de Misericórdia Hospital from Porto Alegre - Porto Alegre (RS), Brazil.