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Multiple Pruriginous Reticular Plaques With Spontaneous Resolution in a Young Woman: Answer.

COMMENT Prurigo pigmentosa is a rare and distinctive inflammatory skin disease characterized by recurrent episodes of pruriginous inflammatory cutaneous lesions that resolve leaving a characteristic reticulated mottled hyperpigmentation. The disease seems to have a predilection for Asian patients, particularly Japanese, being not well recognized in western countries.1–3 Clinically, it presents with very pruriginous erythematous papules, papulovesicles, and vesicles that coalesce into reticulated plaques most commonly located on the neck, chest, and interscapular and lumbosacral region. Concurrent involvement of the face, upper arms, axillae, buttocks, and palms has also been reported.3,4 Lesions typically spontaneously heal within days to few weeks, leaving a netlike or mottled hyperpigmentation. Different types of lesions can coexist in the same location at the same time, and excoriations are common. It usually affects young women between 10 and 30 years of age and tends to occur more frequently in spring and summer. The histopathological features vary with the age of the lesion. Early stages are characterized by slight neutrophilic spongiosis, papillary dermal edema, and a mild superficial perivascular inflammatory infiltrate of neutrophils, with sometimes scattered eosinophils. In some very early cases, myeloperoxidase-positive cells with histiocytoid appearance, corresponding to immature myelomonocytic cells, may be the leading cells.5 As lesions evolve, spongiosis and epidermal exocytosis of neutrophils increases, sometimes leading to vesiculation and formation of microabscesses. In addition, a variable number of necrotic keratinocytes and vacuolar degeneration of the base membrane are also seen. Finally, in later stages, lymphocytes predominate and melanophages are found in the papillary dermis. The epidermis becomes hyperplastic and hyperpigmented. The clinicopathological differential diagnosis is broad and include urticaria, psoriasis, spongiotic dermatitis such as atopic dermatitis and irritant and allergic contact dermatitis, interface or lichenoid dermatitis such as erythema multiforme and lupus erythematous, and immunobullous diseases such as linear IgA dermatosis and dermatitis herpetiformis. In chronic stages, differential diagnosis may include macular amyloidosis, postinflammatory hyperpigmentation, and confluent and reticulated papillomatosis of Gougerot and Carteaud among others. Correct diagnosis can be easily made by paying attention to the characteristic evolving clinicopathological features of the disease. The pathogenesis and etiology of prurigo pigmentosa remain elusive and controversial. Many reports have linked nutrition, diabetes, and ketoacidosis related to fasting restriction diets, to prurigo pigmentosa.6 However, most patients do not associate the disease with these conditions. Other proposed causes include a reaction to ultraviolet light, sweating, contact allergens, hormonal changes, and infections caused by Borrelia and Helicobacter pylori.7,8 No randomized trials have evaluated the treatment of prurigo pigmentosa, and recommendations are mainly based on case series. Oral antibiotic therapy with minocycline is considered as first-line treatment by most of the authors.9 Our patient was treated with oral minocycline 100 mg/d for 2 weeks with complete resolution of the lesions. Other antibiotics with anti-inflammatory and immunomodulatory effects such as doxycycline, dapsone, clarithromycin, and azithromycin can also be effective. Successful treatment with From the *Department of Dermatology, Hospital San Pablo, Coquimbo, Chile; †Dermatology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain; ‡Department of Dermatology, Clínica Dermatológica Multidisciplinar Dermik, Barcelona; §Department of Dermatology, Hospital Sant Pau, Barcelona, Spain; and ¶Department of Dermatology, Hospital Son Llàtzer, Palma de Mallorca, Spain. E. Rozas Muñoz, D. Game, J. Piquero-Casals, S. Planas, and J. F. Mir-Bonafé had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: E. Rozas Muñoz, D. Game, J. Piquero-Casals, S. Planas, and J. F. Mir-Bonafé. Acquisition of data: E. Rozas Muñoz, D. Game, J. Piquero-Casals, S. Planas, and J. F. Mir-Bonafé. Analysis and interpretation of data: E. Rozas Muñoz, D. Game, J. Piquero-Casals, S. Planas, and J. F. Mir-Bonafé. Drafting of the manuscript: E. Rozas Muñoz, D. Game, J. Piquero-Casals, S. Planas, and J. F. Mir-Bonafé. Critical revision of the manuscript for important intellectual content: E. Rozas Muñoz, D. Game, J. Piquero-Casals, S. Planas, and J. F. Mir-Bonafé. Statistical analysis: Nonapplicable. Obtained funding: None. Administrative, technical, or material support: None. Study supervision: Nonapplicable. The authors declare no conflicts of interest. Correspondence: Eduardo Rozas-Muñoz, MD, Department of Dermatology, Hospital San Pablo, Avenida Videla S/N, 1780000-Coquimbo, Chile (e-mail: docrozas@yahoo.com). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.