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JAMA Pediatrics Clinical Challenge

Spiny Follicular Hyperkeratotic Papules on the Face

Image of figure 1


Samer Ghosn, MD
Miguel Abboud, MD
Mazen Kurban, MD
Ossama Abbas, MD

A 5-year-old boy, known to have acute lymphoblastic leukemia since the age of 3 years, presented with a 3-week history of asymptomatic skin lesions primarily affecting the face and to a lesser extent the trunk and extremities (Figure, A and B). He had been undergoing a maintenance chemotherapy regimen consisting of vincristine sulfate, 6-mercaptopurine, methotrexate, and high-dose prednisone. He did not undergo bone marrow or stem cell transplant as part of his treatment. Multiple topical medications including keratolytics were applied to the affected areas without effect.

Skin examination revealed multiple 1- to 3-mm, spiny, follicular, flesh-colored to erythematous hyperkeratotic papules predominantly on the face and to a lesser extent on the trunk, and extremities, with fine hairlike spicules emanating from most of them (Figure, A and B). Alopecia was also noted involving the eyebrows and the eyelashes, but the scalp was spared. A punch biopsy specimen was taken (Figure, C and D).

See the full article for an explanation and discussion.

Author Affiliations: Ghosn, Abboud, Kurban, and Abbas (ossamaabbas2003@yahoo.com) are affiliated with the American University of Beirut Medical Center, Beirut, Lebanon.