Received: 9 December 2016

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Revised: 7 February 2017

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Accepted: 13 February 2017

DOI 10.1111/dth.12486

THERAPEUTIC HOTLINE: LETTERS

Successful treatment to a tretinoin/clindamycin gel in a late onset of nevus comedonicus Correspondence n 62, 28006 Madrid, Spain, Tania Marusia Capusan, Hospital Universitario de La Princesa, Servicio de Dermatología, Calle Diego de Leo Email: [email protected] Funding information No funding sources supported the work.

Dear Editor, Nevus comedonicus (NC) is a rare abnormality of the pilosebaceous unit development of unknown cause (Kirtak, Inaloz, Karakok, Erguven, & Ozgoztasi, 2004). The prevalence has been estimated to be from 1 in 45,000 to 1 in 100,000, with no gender or race predilection (Happle, 2010). It can occur at birth in 50% of the cases, and in the other 50% it appears later in life, usually before the age of 10. Single cases of late development of NC or NC syndrome have been described (Tchernev et al., 2013). Recently, somatic NEK9 mutations have been identified, suggesting that these are a potential regulator of follicular homeostasis (Dereure, 2017; Levinsohn, Sugarman, McNiff, Antaya, & Choate, 2016). Generally, most treatments have been unsuccessful. An 80-year-old man with a history of osteoarthritis and hyperten-

F I G U R E 1 Bilateral grouped blackish follicular plugs comedo like on the forehead

sion, presented with asymptomatic frontal lesion that appeared 30 years before. Physical examination revealed numerous blackish follicu-

cases of limited response to tretinoin (Kaliyadan, Nambiar, Al Ameer, &

lar plugs in an area of 14 cm 3 5 cm occupying the entire forehead. At

Amri, 2014; Manola, Ljubojević, Lipozencić, & Pustisek, 2003; Polat,

the top right edge there was also a congenital vascular malformation

Altunay Tuman, Sahin, Dogan, & Boran, 2016). Our patient showed a

(Figure 1). He did not show any skeletal, dental, or ocular abnormalities.

great improvement with this combination. It is well known that treti-

Histopathological study showed dilated infundibula occupied by kera-

noin inhibits microcomedo formation and decreases cohesiveness of

totic material, some of them constituting small superficial cysts (Figure 2). Topical treatment with once daily tretinoin/clindamycin gel 0.025%/1% (Treclinac Gel, Meda Pharma, Spain) was prescribed. Lesions disappeared within four months (Figure 3 ) with a good tolerance and compliance. Maintenance therapy at patient’s demand was undertaken with 3–4 applications monthly with satisfactory aesthetic results. Aggressive treatment of NC generally is not required. Only in complicated cases (cyst formation, with secondary infection and development of scarring) or for aesthetic reasons can be tried keratolytics such as salicylic acid and 0.1% retinoic acid, vitamin D derivatives as topical calcipotriol, and keratoregulators such as 12% ammonium lactate. Laser (CO2, Erbium Yag, diode laser) or complete surgical removal has also been used. In severe cases, oral retinoids have proven to be partially effective (Tchernev et al., 2013). We have not found reported cases of the combination tretinoin/clindamycin, although there are isolated *All authors participated in the paper and gave their consent for publication.

Dermatologic Therapy. 2017;e12486. https://doi.org/10.1111/dth.12486

F I G U R E 2 (H&E 203) Dilated infundibula occupied by keratotic material, some of them constituting small superficial cysts

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CAPUSAN

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Department of Pathology, Hospital Universitario de La Princesa, Madrid, Spain

RE FE RE NCE S Dereure, O. (2017). Nevus comedonicus: somatic mutations in NEK9. Annales de Dermatologie et de Venereologie, 144, 84–85. Happle, R. (2010). The group of epidermal nevus syndromes Part I. Well defined phenotypes. Journal of the American Academy of Dermatology, 63, 1–22. Kaliyadan, F., Nambiar, A., Al Ameer, A., & Amri, M. (2014). Nevus comedonicus of the scalp. Skinmed, 12, 59–60. F I G U R E 3 Great improvement after 4 months of daily treatment with topical tretinoin/clindamycin

keratinocytes in sebaceous follicles. As for clindamycin, its effect could be similar to that of antibiotics in acne vulgaris, by preventing comedo formation and inflammation, promoting differentiation of cells within the hair follicle unit, reducing sebum secretion and sebocyte proliferation, and killing P. acnes (Levinsohn et al., 2016). The involvement of P. acnes contributes to the production of inflammatory cytokines, antimicrobial peptides, and metalloproteinases from part of the activated cells  pez-Estebaranz, and participates in the development of comedones (Lo no, in press). We consider both of these medicaHerranz-Pinto, & Dre tions had influenced in clearing comedones. We present a new case of bilateral NC, with late onset and great improvement after topical treatment with once daily tretinoin/clindamycin gel (0.025%/1%), with good tolerance and a very satisfactory

Kirtak, N., Inaloz, H., Karakok, M., Erguven, H., & Ozgoztasi, O. (2004). Extensive inflammatory nevus comedonicus involving half of the body. International Journal of Dermatology, 43, 434–436. Levinsohn, J., Sugarman, J., McNiff, J., Antaya, R., & Choate, K. (2016). Somatic mutations in NEK9 cause nevus comedonicus. American Journal of Human Genetics, 98, 1030–1037.  pez-Estebaranz, J., Herranz-Pinto, P., & Dre no, B. (in press). ConsenLo sus-Based Acne Classification System and Treatment Algorithm for Spain. Actas Dermo Sifiliograficas. doi: 10.1016/j.ad.2016.10.001. [Epub ahead of print] Manola, I., Ljubojević, S., Lipozencić, J., & Pustisek, N. (2003). Nevus comedonicus case report and review of therapeutical approach. Acta Dermatovenerologica Croatica: ADC, 11, 221–224. Polat, M., Altunay Tuman, B., Sahin, A., Dogan, U., & Boran, C. (2016). Bilateral nevus comedonicus of the eyelids associated with bladder cancer and successful treatment with topical tretinoin. Dermatologic Therapy, 29, 479–481. € nlebe, J., & Tchernev, G., Ananiev, J., Semkova, K., Dourmishev, L., Scho Wollina, U. (2013). Nevus comedonicus: an updated review. Dermatology and Therapy, 3, 33–40.

aesthetic result.

CONFLICT OF I NTERES T DIS CLOSURE None declared How to cite this article: Capusan TM, Chicharro P, RodriguezT. M. Capusan1, P. Chicharro1, P. Rodriguez-Jimenez1,

Jimenez P, et al. Successful treatment to a tretinoin/clindamycin

s1, D. de Argila1 €e C. Martinez-Mera1, A. Urquía2, M. Aragu

gel in a late onset of nevus comedonicus. Dermatologic Therapy.

1

Department of Dermatology, Hospital Universitario de La Princesa, Madrid, Spain

2017;00:e12486. https://doi.org/10.1111/dth.12486

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