Confluent and Reticulated Papillomatosis

Authors:

Brian Ng, BS; Blessing Oyeniyi, BS; and Lynnette Mazur MD, MPH
John P. and Kathrine G. McGovern Medical School, Houston, Texas

Citation:

Ng B, Oyeniyi B, Mazur L. Confluent and reticulated papillomatosis [published online January 22, 2018]. Consultant for Pediatricians.

A 14-year-old boy presented to our clinic with a rash on his chest.

History. His history was significant for morbid obesity, prediabetes with hemoglobin A_1c of 6.3% (reference range, 4.0%-5.6%; prediabetes range, 5.7%-6.4%), and a facial rash that had been treated on 2 previous occasions with topical ketoconazole and minocycline and that had completely resolved.

Physical examination. Physical examination findings included a height of 1.74 m, weight of 111.3 kg, body mass index (BMI) of 36.8 kg/m². Acanthosis nigricans (AN) was present on the neck, and scaly, reticulated, hyperpigmented papules had coalesced on his anterior chest and neck (Figures 1 and 2). The rest of the examination findings were unremarkable. He was referred to a dermatologist and received a diagnosis of confluent and reticulated papillomatosis (CRP).

Figure 1. CRP on the anterior chest.

Figure 2. CRP around the neck and AN in the neck creases.

Discussion. Gougerot-Carteaud syndrome, also known as CRP, is an uncommon cutaneous hyperpigmentation disorder that affects individuals of all ages.^1,2 In a case series of 39 patients, the mean age of onset was 15 years; 33 patients presented with cosmetic concerns, and 8 presented with mild pruritus.³

Although the pathogenesis is thought to be altered keratinocyte differentiation and increased melanosomes in the hyperkeratotic stratum corneum, the etiology is uncertain.⁴ The condition initially had been thought to be the result of an abnormal host response to Malassezia furfur. However, inconsistencies in detecting fungal elements and the lack of response to antifungal therapies made this etiology less likely.³ Given the clinical and histologic similarities between CRP and AN, insulin resistance in patients with a history of obesity and endocrinopathies also has been proposed as a possible etiology.⁵ However, only a minority of patients have both CRP and AN.³ The current theory is that CRP is bacterial in origin, because it responds well to antibiotics. One study suggests that the actinomycete Dietzia papillomatosis may be the causative agent.⁶

The rash of CRP usually presents as hyperpigmented macules and papules that peripherally form a reticulated pattern and centrally coalesce to form a plaque. The plaques demonstrate epidermal changes such as hyperkeratosis or scaling.⁷ Typically asymptomatic, CRP can present with varying degrees of pruritus. It usually involves the upper trunk and axillae, and the diagnosis is made on a clinical basis.

CRP can resemble tinea versicolor, AN, asteatosis, epidermodysplasia verruciformis, epidermal nevus, Darier disease, verruca plana, dermatitis, cutaneous amyloidosis, and parapsoriasis.³ Five criteria are suggested for the diagnosis³:

1. Scaling brown macules and patches, at least part of which appear reticulated and papillomatous
2. Involvement of the upper trunk and neck
3. Negative fungal staining of scales
4. No response to antifungal treatment
5. Excellent response to minocycline

Suggestions for first-line treatment are tetracyclines (doxycycline or minocycline) or macrolide antibiotics, which have a better adverse-effect profile. Both antibiotic classes result in more than 50% improvement, although recurrence is possible.^3,8

Outcome of the Case. Our patient continues to experience recurrent episodes of CRP, which have mostly resolved with minocycline therapy.

References:

1. Kumar AS, Pandhi RK. Syndrome of Carteaud and Gougerot—case report: confluent and reticulate papillomatosis. Mykosen. 1984;27(6):313-315.
2. Schwartz RA. Confluent and reticulated papillomatosis. Medscape. https://emedicine.medscape.com/article/1106748-overview. Updated May 4, 2017. Accessed January 18, 2018.
3. Davis MDP, Weenig RH, Camilleri MJ. Confluent and reticulate papillomatosis (Gougerot-Carteaud syndrome): a minocycline-responsive dermatosis without evidence for yeast in pathogenesis. A study of 39 patients and a proposal of diagnostic criteria. Br J Dermatol. 2006;154(2):287-293.
4. Jimbow M, Talpash O, Jimbow K. Confluent and reticulated papillomatosis: clinical, light and electron microscopic studies. Int J Dermatol. 1992;31(7):480-483.
5. Hirokawa M, Matsumoto M, Iizuka H. Confluent and reticulated papillomatosis: a case with concurrent acanthosis nigricans associated with obesity and insulin resistance. Dermatology. 1994;188(2):148-151.
6. Jones AL, Koerner RJ, Natarajan S, Perry JD, Goodfellow M. Dietzia papillomatosis sp. nov., a novel actinomycete isolated from the skin of an immunocompetent patient with confluent and reticulated papillomatosis. Int J Syst Evol Microbiol. 2008;58(pt 1):68-72.
7. Lim JH-L, Tey HL, Chong W-S. Confluent and reticulated papillomatosis: diagnostic and treatment challenges. Clin Cosmet Investig Dermatol. 2016;9:217-223.
8. Huang W, Ong G, Chong W-S. Clinicopathological and diagnostic characterization of confluent and reticulate papillomatosis of Gougerot and Carteaud: a retrospective study in a South-East Asian population. Am J Clin Dermatol. 2015;16(2):131-136.