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although the majority of cases appear to arise in children and young adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> There are located and generalized forms of lichen nitidus&#44; sometimes described under clinical variants&#58; familiar&#44; actinic&#44; confluent&#44; vesicular&#44; hemorrhagic&#44; palmo-plantaris&#44; mucous&#44; spinulosus and follicularis&#44; keratodermic&#44; perforating or linear&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a> The lesions are located preferentially on the flexor surface of the arms&#44; wrists&#44; on the abdomen and genitalia&#44; though they can become disseminated&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> We are adding to the indexed literature the second case of lichen nitidus exclusively located on both axillae&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient is a 26-year-old Caucasian man who was seen for evaluation of asymptomatic lesions on the both axillae&#59; the lesions had been present more than 4-years and showed insidious emergence&#46; He denied previous treatment on the lesions or any medication intake preceding the crop of the lesions&#46; On his dermatological exam&#44; discrete or grouped skin-colored&#44; shiny&#44; firm&#44; monomorphic round&#44; and dome-topped papules of 1-to 3-mm in diameter were observed on both axillae &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A skin biopsy was performed from these lesions&#44; and that displayed a lymphohistiocytic infiltrate in a broadened dermal papilla&#44; with a descending growth of the rete ridges surrounding the dermal inflammatory infiltrate in a &#8220;ball-and-claw&#8221; manner &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46; The overlying epidermis was noted to be unremarkable&#44; and there was no evidence of spongiosis or exocytosis&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was treated with the combination of dexchlorpheniramine 2&#8239;mg and betamethasone 0&#46;25&#8239;mg t&#46;i&#46;d per os for 10-days&#44; and after thatt he was virtually clear of lesions&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is only one report of lichen nitidus on axillae&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Our patient displayed lesions only in this area&#44; emphasizing the peculiar aspect of our report&#46; Once considered as a tuberculoid reaction&#44; lichen nitidus is currently regarded as a disorder of unknown origin&#46; The differential diagnosis includes lichen planus&#44; psoriasis&#44; verruca plana and keratosis pilaris&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> Rare cases of lichen nitidus associated with atopic dermatitis&#44; Crohn disease&#44; Down&#180;s syndrome and juvenile chronic arthritis have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> The first clinical hypothesis in this case was Fox-Fordyce disease due the presence of popular lesions on the axillae&#46; The final diagnosis was established on histopathological basis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Due to the rare clinical presentation of lichen nitidus exclusively located on the both axillae&#44; the clinicians must alert to the necessity of performing cutaneous biopsy to confirm this diagnosis&#46; The histological study of the biopsy showed characteristic findings of lichen nitidus&#44; including lymphohistiocytic infiltrate in an expanded dermal papilla with thinning of overlying epidermis and downward extension of the rete ridges at the lateral margin of the infiltrate&#44; producing a typical &#34;claw clutching a ball&#34; picture&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In two-thirds of patients the lesions resolve spontaneously after months to 1&#8239;year&#46; Topical glucocorticoids can be useful in localized forms&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In this case&#44; the patient was successfully treated with the combination of dexchlorpheniramine 2&#8239;mg and betamethasone 0&#46;25&#8239;mg t&#46;i&#46;d per os for 10-days&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The authors would like to highlight the rarity of the presentation of this case and the importance of considering the lichen nitidus as a differential diagnosis of papular lesions in the axillae&#44; itchy or not&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall">Walter Belda Junior&#58; Statistical analysis&#59; approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Paulo Ricardo Criado&#58; Statistical analysis&#59; approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Nilton Gioia Di Chiacchio&#58; Statistical analysis&#59; approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Case Letter
Axillary papules: an uncommon location of lichen nitidus
Walter Belda Juniora, Paulo Ricardo Criadob, Nilton Gioia Di Chiacchiob,c,
Corresponding author
dichiacchiong@gmail.com

Corresponding author.
a Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
b Faculdade de Medicina do ABC, São Paulo, SP, Brazil
c Hospital do Servidor Público Municipal de São Paulo, São Paulo, SP, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Lichen nitidus is a relatively rare&#44; chronic&#44; papulosquamous cutaneous disease that is characterized by multiple flesh-coloured shiny&#44; dome-shaped papules&#44; with sizes from 1 to 2&#8239;mm&#44; often referred as pinhead-like papules&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The crop of the lesions often is asymptomatic&#59; moreover&#44; it sometimes may associate with pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This uncommon condition was described for the first time by Pinkus in 1901&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The skin is the primary site involved but the mucous membranes and nails also might be affected&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">No racial or sex predilection is reported&#44; although the majority of cases appear to arise in children and young adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> There are located and generalized forms of lichen nitidus&#44; sometimes described under clinical variants&#58; familiar&#44; actinic&#44; confluent&#44; vesicular&#44; hemorrhagic&#44; palmo-plantaris&#44; mucous&#44; spinulosus and follicularis&#44; keratodermic&#44; perforating or linear&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a> The lesions are located preferentially on the flexor surface of the arms&#44; wrists&#44; on the abdomen and genitalia&#44; though they can become disseminated&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> We are adding to the indexed literature the second case of lichen nitidus exclusively located on both axillae&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient is a 26-year-old Caucasian man who was seen for evaluation of asymptomatic lesions on the both axillae&#59; the lesions had been present more than 4-years and showed insidious emergence&#46; He denied previous treatment on the lesions or any medication intake preceding the crop of the lesions&#46; On his dermatological exam&#44; discrete or grouped skin-colored&#44; shiny&#44; firm&#44; monomorphic round&#44; and dome-topped papules of 1-to 3-mm in diameter were observed on both axillae &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A skin biopsy was performed from these lesions&#44; and that displayed a lymphohistiocytic infiltrate in a broadened dermal papilla&#44; with a descending growth of the rete ridges surrounding the dermal inflammatory infiltrate in a &#8220;ball-and-claw&#8221; manner &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46; The overlying epidermis was noted to be unremarkable&#44; and there was no evidence of spongiosis or exocytosis&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was treated with the combination of dexchlorpheniramine 2&#8239;mg and betamethasone 0&#46;25&#8239;mg t&#46;i&#46;d per os for 10-days&#44; and after thatt he was virtually clear of lesions&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is only one report of lichen nitidus on axillae&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Our patient displayed lesions only in this area&#44; emphasizing the peculiar aspect of our report&#46; Once considered as a tuberculoid reaction&#44; lichen nitidus is currently regarded as a disorder of unknown origin&#46; The differential diagnosis includes lichen planus&#44; psoriasis&#44; verruca plana and keratosis pilaris&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> Rare cases of lichen nitidus associated with atopic dermatitis&#44; Crohn disease&#44; Down&#180;s syndrome and juvenile chronic arthritis have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> The first clinical hypothesis in this case was Fox-Fordyce disease due the presence of popular lesions on the axillae&#46; The final diagnosis was established on histopathological basis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Due to the rare clinical presentation of lichen nitidus exclusively located on the both axillae&#44; the clinicians must alert to the necessity of performing cutaneous biopsy to confirm this diagnosis&#46; The histological study of the biopsy showed characteristic findings of lichen nitidus&#44; including lymphohistiocytic infiltrate in an expanded dermal papilla with thinning of overlying epidermis and downward extension of the rete ridges at the lateral margin of the infiltrate&#44; producing a typical &#34;claw clutching a ball&#34; picture&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In two-thirds of patients the lesions resolve spontaneously after months to 1&#8239;year&#46; Topical glucocorticoids can be useful in localized forms&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In this case&#44; the patient was successfully treated with the combination of dexchlorpheniramine 2&#8239;mg and betamethasone 0&#46;25&#8239;mg t&#46;i&#46;d per os for 10-days&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The authors would like to highlight the rarity of the presentation of this case and the importance of considering the lichen nitidus as a differential diagnosis of papular lesions in the axillae&#44; itchy or not&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall">Walter Belda Junior&#58; Statistical analysis&#59; approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Paulo Ricardo Criado&#58; Statistical analysis&#59; approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Nilton Gioia Di Chiacchio&#58; Statistical analysis&#59; approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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