Dermatology Online Journal

Letter: Pseudoverrucous irritant peristomal dermatitis with an histological pattern of nutritional deficiency dermatitis
Irene Salgüero Fernández, Carmen Moreno, Sergio Vano-Galvan, Pedro Jaén Olasolo
Dermatology Online Journal 16 (9): 16

Hospital Ramón y Cajal, Madrid, Spain

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Abstract

Pseudoverrucous papules and nodules (PPN) is an uncommon complication, mainly reported in the diaper area. It is thought to be a manifestation of chronic irritant contact dermatitis that develops as a result of prolonged exposure to liquid stool and/or urine. We report a case of a peristomal PPN with a histolopathology simulating a nutritional deficiency dermatitis.

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Introduction

Pseudoverrucous papules and nodules (PPN) is an uncommon complication, mainly reported in the diaper area [1]. It is thought to be a manifestation of chronic irritant contact dermatitis that develops as a result of prolonged exposure to liquid stool and/or urine. We report a case of a peristomal PPN with a histolopathology simulating a nutritional deficiency dermatitis.

Case report

A 66-year-old man presented with a 3-month history of an asymptomatic peristomal dermatitis, which was diagnosed as fungal infection and treated with a topical antifungal agent (fluconazole) without improvement. He had no personal history of atopic dermatitis or psoriasis, but he had a urostomy for one year after treatment of bladder carcinoma with radical cystectomy.

Figure 1

Dermatological examination showed several 3-5 mm flat grey-white warty papules and nodules with a peristomal distribution (Figure 1). Microbiological cultures did not identify any infectious agent.

A skin biopsy revealed a marked psoriasiform epidermal hyperplasia with broad hyperparakeratosis and an underlying severe pallor of the upper epidermis. The papillary dermis showed dilated blood vessels and a mild band-like lymphocytic infiltrate (Figures 2 and 3).

Figure 2	Figure 3

The patient was initially treated only with topical betametasone cream twice a day and zinc ointment for one month without improvement. Therefore the stoma attachment was replaced in order to ensure an adequate adjustment and to avoid urine leaks or skin trauma. One week later the patient showed a significant improvement of his lesions that was maintained four months later.

Discussion

Many patients have ostomies after surgery for gastrointestinal or urologic diseases and despite technological breakthroughs in this area, dermatitis remains a significant problem in stoma patients [2]. Mostly this dermatitis results from contact irritation because of chronic contact with urine and stool.

PPN, presenting as pseudoverrucous lesions, is an uncommon complication mainly described in the diaper area and around urostomies. Several mechanisms seem to be involved in the pathogenesis. It has been suggested to be a special form of irritant contact dermatitis that occurs where alkaline urine, particulary that infected with urea-splitting bacteria, is in chronic contact with the skin. The clinical appearance of coalescent warty papules is distinct and is probably unique to urostomies [3]. The differential diagnosis includes viral warts, condyloma lata, condyloma acuminata, neoplastic processes, halogenoderma, bacterial infections, candidiasis, cutaneous Crohn disease, and Langerhans cell histiocytosis [4, 5].

Histologicaly most of the reported cases of stomal dermatosis show features of chronic irritant contact dermatitis or in long-standing cases a more non-specific pattern of lichen simple chronicus. PPN appears as an acanthomatous dermatitis with papillomatosis or pseudoepitheliomatous hyperplasia. Our case presented morphologic features that could be misdiagnosed as a nutritional deficiency dermatitis instead. To our knowlegde, this is the third reported case of severe chronic contact dermatitis that should be distinguished histologically from nutritional deficiency dermatitis, the first reported in association with a urostomy. As it has been previously pointed out, the clinical information is essential to reach a correct diagnosis [6].

In the literature, few reports are published about the nature and optimal management of these peristomal dermatoses. The approach to the assesment of patients with peristomal skin problems may be first to undertake a thorough history and examination, looking for evidence of pre-existing skin diseases, such as psoriasis, contact hypersensitivities and a tendency to irritant contact dermatitis. The peristomal skin should be swabbed in all cases for microbiological examination because treatable primary and secondary infections are relatively common [3]. The treatment of the irritant contact dermatitis first requires thorough inspection of the stoma equipment to ensure a good fit. Adjustments may be needed to avoid leaks or skin trauma. Once this problem is corrected, if the lesions persist, they usually respond well to topical corticosteroids preparations [7].

In summary, we report a case of irritant peristomal dermatitis presenting with pseudoverrucous lesions similar to PPN. Pseudoverrucous lesions may appear in the context of an irritant contact dermatitis and dermatologists should be aware of this entity that may present in peristomal skin. Adequate treatment requires modification of the stoma attachments in order to avoid leaks.

References

1. Rodríguez Cano L, García-Patos Briones V, Pedragosa Jové R, Castells Rodellas A. Perianal pseudoverrucois papules and nodules after surgery for Hirschsprung disease. J Pediatr 1994;125:914-6. [PubMed]

2. Scalf LA, Fowler JF Jr. Peristomal allergic contact dermatitis due to Gantrez in Stomahesive paste. J Am Acad Dermatol 2000;42:355-6. [PubMed]

3. Lyon CC, Smith AJ, Griffiths CE, Beck MH. The spectrum of skin disorders in abdominal stoma patients.Br J Dermatol 2000;143:1248-60. [PubMed]

4. Amiry SA, Pride HB, Tyler WB. Perianal pseudoverrucose papules and nodules mimicking condylomata acuminata and child sexual abuse. Cutis 2001;67:335-8. [PubMed]

5. Coppo P, Salomone R. Pseudoverrucous papules: an aspect of incontinence in children. J Eur Acad Dermatol Venereol 2002;16:409-10. [PubMed]

6. Resnik KS, Kutzner H. Mimicry Illuminating Pitfalls in Histopathologic Diagnosis: Nutritional Deficiency-Like Dermatitis Secondary toTopical Tazarotene and Keratoacanthomatous Pseudocarcinomatous Hyperplasia in CD30+ Lymphoproliferative Disorder As Illustrative. Am J Dermatopathol 2009; 31:22-25. [PubMed]

7. Lyon CC, Smith AJ, Griffiths CE, Beck MH. Peristomal dermatoses: a novel indication for topical steroid lotions. J Am Acad Dermatol 2000;43:679-82. [PubMed]

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