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April 2014, Volume 64, Issue 4

Letter to the Editor

Multiple flesh coloured nodules with unilateral segmental distribution

Enver Turan  ( Department of Dermatology, Faculty of Medicine, Harran University, Sanliurfa, Turkey. )
Yavuz Yesilova  ( Department of Dermatology, Faculty of Medicine, Harran University, Sanliurfa, Turkey. )
Hacer Altin Surucu  ( Department of Dermatology, Faculty of Medicine, Harran University, Sanliurfa, Turkey. )
Naime Eroglu  ( Department of Dermatology, Faculty of Medicine, Harran University, Sanliurfa, Turkey. )
Osman Tanrikulu  ( Department of Dermatology, Faculty of Medicine, Harran University, Sanliurfa, Turkey. )
Sezen Ko├žarslan  ( Department of Pathology, Faculty of Medicine, Harran University, Sanliurfa, Turkey. )

Madam, Piloleiomyomas are benign smooth muscle tumours arising from the arrectores pilorum muscles in the skin, and they are rare dermal tumours.1 They usually present as small, reddish-brown or skin-coloured, firm, often painful papules or as nodules on the trunk and the extremities. Lesions on the trunk are typically multiple, also known as leiomyomatosis, and can be arranged in a diffuse (disseminated), blaschkoid or segmental distribution.2 Although segmental leiomyomas are called zosteriform leiomyoma by some writers, these do not show a dermatomal distribution.3 Lesions on the extremities tend to be solitary.
A 41-year-old male was referred to our dermatological clinic for swelling, which had started 8 years earlier and increased with time. There was no history of similar illness among family members, and the patient was otherwise healthy. Dermatological examination revealed numerous additional erythematous, nodular lesions, which were smooth surfaced, oval-round and ranged from 3 to 10 mm in diameter. They were on the right lumbar side and on the gluteal and outer side of the thigh and were painful on palpation (Figure-a). The histopathological examination, showed smooth muscle cells composed of small bundles. These were disorganised, and there was eosinophilic cytoplasm in the stroma of the lesions (Figure-b). The immunohistochemical study showed smooth muscle cells with smooth muscle actin (SMA) (Figure-c).


Piloleiomyoma was diagnosed according to the clinical, histopathological and immunohistochemical features.4 No specific treatment was prescribed. The patient was called for follow-up studies at regular intervals.
Multiple leiomyomas can be common and show a segmental distribution. Although segmental leiomyomas are referred to as zosteriform leiomyoma by some writers, do not show a dermatomal distribution.3 Painful skin lesions, such as granular cell tumours, eccrine spiradenomas, dermatofibromas, neuromas, neurilemmomas, glomus tumours, angiolipomas and endometriomas, should be considered in the differential diagnosis of cutaneous leiomyomas.5
There is no effective treatment for leiomyomas. Surgical excision is the first choice of treatment for solitary painful lesions. Excision of multiple lesions results in a high incidence of local recurrence, and therefore it is not practical.1 Destructive methods such as CO2 laser ablation, cryotherapy and electrosurgery have been used in the treatment.6 In multiple painful lesions, the use of alpha blockers, diuretics, calcium channel blockers, nitrates, ethaverine, analgesics, antidepressants and gabapentin have been reported.7 The use of liquid nitrogen, topical nitroglycerin, lidocaine, xylocaine and phentolamine can reduce pain.

References

1. Lun KR, Spelman LJ. Multiple piloleiomyomas. Australas J Dermatol 2000; 41: 185-6.
2. Mialot M, Prata D, Girard-Luc A, Rakotovao F, Cuveillier JF, Bernex F. Multiple progressive piloleiomyomas in a ferret (Mustela putorius furo): a case report. Vet Dermatol 2011; 22: 100-3.
3. Kitoh A, Akiyama H, Yoshida Y, Tanaka T. Multiple piloleiomyomas: do they follow dermatomes or blaschko lines? J Dermatol 2003; 30: 851-2.
4. Thissen MR, Koedam MI. [Clustered and disseminated cutaneous piloleiomyomas]. Ned Tijdschr Geneeskd 1998; 142: 2707-8.
5. Haugen RN, Tharp MD. The use of gabapentin for recurrent painful attacks with multiple piloleiomyomas. J Drugs Dermatol 2008; 7: 401-2.
6. Christenson LJ, Smith K, Arpey CJ. Treatment of multiple cutaneous leiomyomas with CO2 laser ablation. Dermatol Surg 2000; 26: 319-22.
7. Archer CB, Greaves MW. Assessment of treatment for painful cutaneous leiomyomas. J Am Acad Dermatol 1987; 17: 141-2.

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