ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Confluent and reticulated papillomatosis

Confluent and reticulated papillomatosis
Literature review current through: Jan 2024.
This topic last updated: Oct 12, 2022.

INTRODUCTION — Confluent and reticulated papillomatosis (CARP) is an uncommon dermatosis characterized by hyperpigmented scaly macules or papillomatous papules coalescing into confluent patches or plaques centrally with a reticular pattern peripherally (picture 1A-D). It most commonly occurs on the trunk. Oral antibiotic therapy is the mainstay of treatment.

The clinical features, diagnosis, and management of CARP will be reviewed here. Other causes of cutaneous hyperpigmentation are reviewed separately. (See "Acquired hyperpigmentation disorders".)

EPIDEMIOLOGY — First described by two French dermatologists, Gougerot and Carteaud, CARP has been reported worldwide and occurs in all racial groups and ethnicities [1]. It is estimated that the incidence of CARP in the Lebanese population is around 0.02 percent [2]. No epidemiologic study has been conducted in the United States. However, only 39 patients were identified in a retrospective review collected from 1972 to 2003 at the Mayo Clinic [3].

CARP typically affects young adults; the Mayo Clinic retrospective study found a mean age of onset of 15 years and a range of 8 to 32 years. CARP occurs in both males and females [3].

ETIOLOGY — Decades after its initial description, the pathogenesis and etiology of CARP remain elusive and controversial. Several theories have been proposed, although none have been definitively proven.

Among all of the proposed etiologic factors, the strongest evidence exists to support CARP as a disorder of keratinization resulting in a hyperproliferative state. Electron microscopy (EM) of the affected skin shows alteration of cornified cell structures, an increased number of lamellar granules in the granular layer, and increased melanosomes in the horny layers [4]. In another EM study, an increased number of transitional cells between stratum corneum and stratum granulosum were noted [5]. Furthermore, in one study with siblings with CARP, increased expression of keratin 16 was demonstrated in focal areas of stratum granulosum [6]. Other genetic factors may also, at least in some part, contribute to the development of CARP, as several other familial cases have been reported [7-10].

Many reports have linked Malassezia, formally known as Pityrosporum, to CARP due to its clinical resemblance to tinea versicolor. Although CARP and tinea versicolor may coexist, and it is postulated that CARP may represent an inappropriate inflammatory response to Malassezia resulting in abnormal keratinization [6,11-13], available evidence does not support the involvement of Malassezia in the pathogenesis of CARP [3]. Similarly, no bacterial species have been consistently isolated from CARP patients [1]. Other proposed causes of CARP include a reaction to ultraviolet light, a cutaneous response to underlying endocrinopathy, a process involving amyloid, and immune dysregulation [1,14]. (See "Tinea versicolor (pityriasis versicolor)".)

CLINICAL PRESENTATION — CARP is most often characterized by hyperpigmented scaly macules or papillomatous papules coalescing into confluent patches or plaques centrally and exhibiting a reticular pattern peripherally (picture 1A-D). Rarely, CARP can also appear as atrophic macules with a cigarette paper-like surface [1].

CARP typically starts on the upper trunk, especially in the intermammary and interscapular areas, with subsequent development of lesions on the neck and axilla, where skin markings are sometimes exaggerated [1,3]. Concurrent or isolated involvement of the face, shoulders, upper arms, antecubital fossa, popliteal fossa, and pubic areas has been reported (picture 2A-C) [3,15-20]. CARP does not involve the mucosa or nails. In a retrospective study of 39 CARP patients, 80 percent did not report any symptoms while 20 percent reported mild pruritus [3].

CARP typically persists if not treated, although spontaneous resolution has been reported [3,21]. In a retrospective study of 39 patients with CARP evaluated at an academic medical center, the mean duration of disease up to the time of clinical presentation was 3 years (range 3 months to 20 years) [3].

HISTOPATHOLOGY — CARP shares histologic features with acanthosis nigricans, including hyperkeratosis, papillomatosis, and a mild superficial perivascular lymphocytic infiltrate (see "Acanthosis nigricans") [1,2]. Follicular plugging, present in 9 of 10 patients in one study, can help to distinguish between the two conditions [2]. Fungal stains should be negative.

DIAGNOSIS — A diagnosis of CARP should be strongly suspected in young adults with hyperpigmented reticulated and papillomatous patches or plaques on the trunk, neck, or flexural areas. In clinical practice, the diagnosis is usually made based upon the recognition of these classic physical findings and the absence of fungal elements on a potassium hydroxide (KOH) preparation performed to rule out tinea versicolor. If the diagnosis remains uncertain because of atypical physical findings, a skin biopsy can be performed to identify histologic features consistent with CARP or other disorders; however, CARP has no pathognomonic histologic findings.

DIFFERENTIAL DIAGNOSIS — Several other cutaneous diseases may be confused with CARP [3,22,23]:

Tinea versicolor – Clinically, CARP is most often confused with tinea versicolor, a superficial fungal infection that may present with hyperpigmented macules or patches on the trunk or proximal upper extremities (picture 3A-B). A potassium hydroxide (KOH) preparation of the scale will reveal hyphae and yeast cells. (See "Tinea versicolor (pityriasis versicolor)" and "Office-based dermatologic diagnostic procedures", section on 'Potassium hydroxide preparation'.)

Acanthosis nigricans – CARP and acanthosis nigricans share many clinical and histologic features. Acanthosis nigricans is characterized by velvety, hyperpigmented plaques with predilection for flexural areas and histologic findings of hyperkeratosis and epidermal papillomatosis (picture 4A-B). Patients with acanthosis nigricans often have associated obesity, diabetes, and/or polycystic ovarian syndrome (PCOS). (See "Acanthosis nigricans".)

Epidermal nevus – Epidermal nevi most commonly present at birth or during the first year of life and are often linear. They start out as subtle linear patches or very thin plaques composed of light brown to skin-colored papules. Around puberty, epidermal nevi may become thicker and darker (picture 5). (See "Epidermal nevus and epidermal nevus syndrome".)

Erythema ab igne – Erythema ab igne is an acquired dermatosis that presents as a reticulated pattern of skin hyperpigmentation. The condition develops secondary to repeated exposure of skin to heat or infrared radiation. (See "Acquired hyperpigmentation disorders", section on 'Erythema ab igne'.)

Verruca plana – Verruca plana (flat warts) are skin-colored or hyperpigmented, flat-topped papules caused by cutaneous human papillomavirus (HPV) infection (picture 6). Verruca plana will not have the typical reticular appearance seen at the periphery of CARP. (See "Cutaneous warts (common, plantar, and flat warts)".)

Epidermodysplasia verruciformis – Patients with epidermodysplasia verruciformis, an autosomal recessive disorder characterized by high susceptibility to HPV infection, present with multiple skin lesions during early infancy or childhood. The cutaneous findings vary widely from verruca-like papillomatous lesions, to skin-colored flat-topped papules, to red to reddish brown papules or plaques on the face, neck, and trunk (picture 7). (See "Epidermodysplasia verruciformis".)

Darier disease – Darier disease is an uncommon autosomal dominantly inherited disease with skin, nail, and mucous membrane findings. Skin involvement usually appears as yellowish brown, skin-colored, or hyperpigmented waxy papules on the chest and back that can coalesce into crusted plaques (picture 8). Groin, axilla, and inframammary skin involvement is also present in most patients. Punctate keratosis and pits are sometimes noted in the palms. Longitudinal white and red bands on the nails, as well as V-shaped nicks at the free nail margin, are characteristic and pathognomonic findings. White papules can be noted in the oral mucosa of some patients. Skin biopsy of cutaneous lesions shows characteristic focal suprabasal acantholysis and dyskeratosis with characteristic pink "corps ronds" and "grains." (See "Darier disease".)

Lichen or macular amyloidosis – Lichen amyloidosis presents as pruritic skin-colored and pink to light brown scaly lichenoid papules that most commonly occur on the bilateral shins (picture 9), while macular amyloidosis typically appears as pruritic brown rippled macules on the mid-upper back (picture 10). Skin biopsy with amyloid staining will help to differentiate lichen or macular amyloidosis from CARP.

TREATMENT

Overview — CARP is a benign and often asymptomatic skin condition; therefore, treatment is not mandatory. However, patients often desire treatment because of cosmetic concerns or associated pruritus.

No randomized trials have evaluated the treatment of CARP. Treatment recommendations are based on data from retrospective analyses, case series, and case reports. Oral antibiotic therapy with minocycline is a well-accepted first-line treatment. Macrolide antibiotics are reasonable second-line interventions for patients who cannot tolerate minocycline or fail to improve with minocycline therapy. Less commonly used treatments that may improve CARP include topical retinoids, topical vitamin D analogs, topical tacrolimus, and alternative oral antibiotics. Oral isotretinoin is an additional treatment that is primarily reserved for patients with refractory disease.

If immediate relief from associated pruritus is necessary, medium-potency topical corticosteroids can be applied to affected areas on the trunk and extremities twice daily for two to four weeks. For facial or intertriginous involvement, a low-potency topical corticosteroid should be used once or twice daily for two to four weeks (table 1). Long-term use of topical corticosteroids may cause skin atrophy or dyspigmentation and must be carefully monitored. Alternatively, topical tacrolimus or pimecrolimus can be used for pruritus if long-term maintenance therapy is needed. These agents do not cause skin atrophy or dyspigmentation. (See "Topical corticosteroids: Use and adverse effects", section on 'Adverse effects'.)

First-line therapy — Oral antibiotic therapy is typically used in the initial treatment of CARP. The antiinflammatory properties of antibiotics, such as inhibition of neutrophil migration and reactive oxygen release, may be responsible for clinical efficacy, as no bacteria are consistently isolated from CARP patients [3,24-26]. Minocycline is the most commonly used antibiotic for CARP.

Minocycline — Treatment with minocycline is supported by multiple case reports and case series [3,16,18,27-37]. As an example, in an uncontrolled study of nine CARP patients treated with minocycline (50 mg twice per day for six weeks), seven patients had a 90 to 100 percent response to therapy and the remainder had lesser degrees of improvement [35]. No adverse reaction was reported, and the patients were followed for an average of 11 months. Recurrence was noted in three of nine patients; all responded to retreatment with minocycline.

Benefit of minocycline therapy is also suggested in a retrospective analysis of 39 CARP patients. Minocycline (most commonly at the dose of 100 mg twice daily for one to three months) was prescribed for 22 patients. One hundred percent of treated patients improved: 78 percent had complete clearance and 22 percent had a partial response. Minocycline was well tolerated [3].

When treating CARP in adults, we typically prescribe minocycline at a dose of 50 or 100 mg twice daily for a minimum of six weeks. Improvement is usually evident within the first several weeks of treatment. If there is no response after three months, we discontinue minocycline treatment.

Potential side effects of minocycline include gastrointestinal distress, skin discoloration, dizziness, tinnitus, a lupus-like syndrome, and drug reaction with eosinophilia and systemic symptoms (DRESS). Minocycline may cause discoloration of developing permanent teeth and is contraindicated in children under the age of nine and pregnant women. See Lexicomp monograph: Minocycline: Drug information, section on Adverse reactions.

Second-line therapy — Patients who cannot tolerate minocycline or who fail to respond to minocycline may be treated with alternative antibiotics.

Macrolide antibiotics — Case reports describe successful treatment with clarithromycin (500 mg daily for five weeks) [27], erythromycin (1000 mg daily for six weeks) [27], and azithromycin (500 mg daily for three to four weeks) [27,38,39]. Roxithromycin, a macrolide not available in the United States, has also successfully treated CARP at a dose of 300 mg per day in a patient who failed to respond to minocycline [40].

Potential side effects of macrolides include gastrointestinal distress (particularly with erythromycin), drug interactions, and QT interval prolongation. The side effects of these drugs are reviewed in greater detail separately. (See "Azithromycin and clarithromycin", section on 'Adverse reactions' and "Azithromycin and clarithromycin", section on 'Drug interactions'.)

Alternative oral antibiotics — In addition to minocycline and macrolide antibiotics, case reports suggest other antibiotics may be effective. Doxycycline has yielded good responses at a dose of 200 mg per day for three months [19,41]. Other antibiotics associated with successful treatment include amoxicillin (250 mg three times per day for three months) [3,17] and cefdinir (300 mg for two weeks) [28]. Fusidic acid, a bacteriostatic antibiotic not available in the United States, given as 1000 mg daily for four weeks has also been associated with disease clearance [27].

Other therapies — A variety of other treatments may be effective for refractory CARP based upon reports of small numbers of patients, including topical therapies and systemic therapies.

Topical agents — Topical agents that may be beneficial for CARP include topical retinoids, topical vitamin D analogs, and topical tacrolimus. The efficacy of topical retinoid and topical vitamin D analog therapy is postulated to relate to effects on disordered keratinization in CARP (see 'Etiology' above):

Topical retinoids Topical tretinoin and tazarotene have appeared effective for CARP in case reports [7,13,42]. Three patients with CARP treated with once-daily applications of tretinoin 0.01% or 0.025% gel improved markedly within six to eight weeks [7] and application of tretinoin 0.1% cream cleared treated areas in another patient [42]. Treatment of an 11-year-old girl with twice-daily application of tazarotene 0.1% gel led to noticeable improvement within one week and clearance of CARP within two months [13]. Subsequently, tazarotene was resumed as needed for recurrences.

Topical vitamin D analogs Case reports document successful treatment of CARP with twice-daily application of topical calcipotriol ointment or topical tacalcitol [11,12,43,44]. Marked improvement has occurred within several weeks.

Topical tacrolimus – Treatment with tacrolimus 0.1% ointment twice daily for three months led to marked clinical improvement in a patient with CARP [45]. A recurrence of CARP two months after discontinuation of tacrolimus responded to retreatment.

Oral retinoids — Because of concern for side effects, oral retinoid therapy is usually reserved for patients with refractory CARP.

Case reports describe successful treatment of CARP with oral isotretinoin given in doses ranging from 0.25 mg/kg per day to 2 mg/kg per day for two to five months [42,46-48]. In one report, two patients who failed to respond to minocycline had resolution of CARP after treatment with oral isotretinoin (1 mg/kg per day for 14 to 18 weeks) and topical 10% lactic acid. Both patients remained lesion-free at 1.5 years follow-up [48].

Treatment with oral etretinate (0.25 to 0.35 mg/kg per day or 50 mg per day) has been associated with clearance of CARP in case reports; however, disease recurred after stopping therapy [49,50]. Etretinate is no longer available in the United States.

Oral retinoids are teratogenic and may lead to a variety of adverse effects, such as cheilitis, visual changes, lipid abnormalities, and pseudotumor cerebri. The risks and benefits of oral retinoids must be carefully considered prior to treatment. (See "Oral isotretinoin therapy for acne vulgaris", section on 'Adverse effects'.)

SUMMARY AND RECOMMENDATIONS

Epidemiology Confluent and reticulated papillomatosis (CARP) is a rare cutaneous disorder that most often occurs in young adults. (See 'Epidemiology' above.)

Etiology The pathogenesis of CARP is unclear. The disorder is postulated to represent a disorder of keratinization resulting in cutaneous hyperproliferation. (See 'Etiology' above.)

Clinical presentation The classic clinical findings of CARP are hyperpigmented, scaly macules or papules that coalesce into confluent patches or plaques that exhibit a reticular pattern peripherally (picture 1A-D). The upper trunk (particularly the intermammary and interscapular skin), neck, and axilla are common sites of involvement. CARP is usually asymptomatic, but may be associated with pruritus. (See 'Clinical presentation' above.)

Diagnosis The diagnosis of CARP can usually be made based upon recognition of the classic clinical features and performance of a potassium hydroxide (KOH) preparation to rule out tinea versicolor, a cutaneous fungal infection that may be mistaken for CARP. If the diagnosis is uncertain, a skin biopsy can be helpful. (See 'Diagnosis' above and 'Histopathology' above.)

Treatment Data are limited on treatments for CARP. For adults with CARP, we suggest oral minocycline as first-line therapy (Grade 2C). Oral macrolide antibiotics are an alternative initial treatment for patients who cannot tolerate minocycline therapy. (See 'Treatment' above.)

  1. Scheinfeld N. Confluent and reticulated papillomatosis : a review of the literature. Am J Clin Dermatol 2006; 7:305.
  2. Tamraz H, Raffoul M, Kurban M, et al. Confluent and reticulated papillomatosis: clinical and histopathological study of 10 cases from Lebanon. J Eur Acad Dermatol Venereol 2013; 27:e119.
  3. Davis MD, 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; 154:287.
  4. Jimbow M, Talpash O, Jimbow K. Confluent and reticulated papillomatosis: clinical, light and electron microscopic studies. Int J Dermatol 1992; 31:480.
  5. Griffiths CE. Gougerot-Carteaud still an enigma after all these years. J Dermatolog Treat 2002; 13:1.
  6. Inalöz HS, Patel GK, Knight AG. Familial confluent and reticulated papillomatosis. Arch Dermatol 2002; 138:276.
  7. Schwartzberg JB, Schwartzberg HA. Response of confluent and reticulate papillomatosis of Gougerot and Carteaud to topical tretinoin. Cutis 2000; 66:291.
  8. Henning JP, de Wit RF. Familial occurrence of confluent and reticulated papillomatosis. Arch Dermatol 1981; 117:809.
  9. Baden HP. Familial cutaneous papillomatosis. Arch Dermatol 1965; 92:394.
  10. Stein JA, Shin HT, Chang MW. Confluent and reticulated papillomatosis associated with tinea versicolor in three siblings. Pediatr Dermatol 2005; 22:331.
  11. Gülec AT, Seçkin D. Confluent and reticulated papillomatosis: treatment with topical calcipotriol. Br J Dermatol 1999; 141:1150.
  12. Ginarte M, Fabeiro JM, Toribio J. Confluent and reticulated papillomatosis (Gougerot-Carteaud) successfully treated with tacalcitol. J Dermatolog Treat 2002; 13:27.
  13. Bowman PH, Davis LS. Confluent and reticulated papillomatosis: response to tazarotene. J Am Acad Dermatol 2003; 48:S80.
  14. Ballout RA, Helou G, Maatouk I. Antiretroviral-responsive confluent and reticulated papillomatosis: a case report of an unusual association. Oxf Med Case Reports 2019; 2019:omz099.
  15. Lee D, Cho KJ, Hong SK, et al. Two cases of confluent and reticulated papillomatosis with an unusual location. Acta Derm Venereol 2009; 89:84.
  16. Kim BS, Lim HJ, Kim HY, et al. Case of minocycline-effective confluent and reticulated papillomatosis with unusual location on forehead. J Dermatol 2009; 36:251.
  17. Davis RF, Harman KE. Confluent and reticulated papillomatosis successfully treated with amoxicillin. Br J Dermatol 2007; 156:583.
  18. Kim MR, Kim SC. Confluent and reticulated papillomatosis on the arm successfully treated with minocycline. J Dermatol 2010; 37:749.
  19. Jo S, Park HS, Cho S, Yoon HS. Updated diagnosis criteria for confluent and reticulated papillomatosis: a case report. Ann Dermatol 2014; 26:409.
  20. Hallel-Halevy D, Grunwald MH, Halevy S. Confluent and reticulated papillomatosis (Gougerot-Carteaud) of the pubic region. Acta Derm Venereol 1993; 73:155.
  21. Sakiyama T, Amagai M, Ohyama M. Chronology of confluent and reticulated papillomatosis: spontaneous regression in a case after long-term follow-up may imply transient nature of the condition. J Dermatol 2015; 42:335.
  22. Groh V, Schnyder UW, Sigg C. 'Papillomatose papuleuse confluente et réticulée Gougerot-Carteaud'--a further form of skin amyloidosis? Dermatologica 1981; 162:118.
  23. Groh V, Sigg C, Schnyder UW. New histochemical and ultrastructural findings in three cases of 'papillomatose papuleuse confluente et réticulée (Gougerot-carteaud)'. Dermatologica 1982; 165:145.
  24. Zalewska-Kaszubska J, Górska D. Anti-inflammatory capabilities of macrolides. Pharmacol Res 2001; 44:451.
  25. Sapadin AN, Fleischmajer R. Tetracyclines: nonantibiotic properties and their clinical implications. J Am Acad Dermatol 2006; 54:258.
  26. Monk E, Shalita A, Siegel DM. Clinical applications of non-antimicrobial tetracyclines in dermatology. Pharmacol Res 2011; 63:130.
  27. Jang HS, Oh CK, Cha JH, et al. Six cases of confluent and reticulated papillomatosis alleviated by various antibiotics. J Am Acad Dermatol 2001; 44:652.
  28. Yamamoto A, Okubo Y, Oshima H, et al. Two cases of confluent and reticulate papillomatosis: successful treatments of one case with cefdinir and another with minocycline. J Dermatol 2000; 27:598.
  29. Sassolas B, Plantin P, Guillet G. Confluent and reticulated papillomatosis: treatment with minocycline. J Am Acad Dermatol 1992; 26:501.
  30. Poskitt L, Wilkinson JD. Clearance of confluent and reticulate papillomatosis of Gougerot and Carteaud with minocycline. Br J Dermatol 1993; 129:351.
  31. Katayama I, Yokozeki H, Nishioka K. Oral minocycline improved keratosis follicularis squamosa (Dohi) and related disorder: bacterial factors are possibly involved in abberant keratinization. J Dermatol 1994; 21:604.
  32. Shimizu S, Han-Yaku H. Confluent and reticulated papillomatosis responsive to minocycline. Dermatology 1997; 194:59.
  33. Puig L, de Moragas JM. Confluent and reticulated papillomatosis of Gougerot and Carteaud: minocycline deserves trial before etretinate. Arch Dermatol 1995; 131:109.
  34. Chang SN, Kim SC, Lee SH, Lee WS. Minocycline treatment for confluent and reticulated papillomatosis. Cutis 1996; 57:454.
  35. Montemarano AD, Hengge M, Sau P, Welch M. Confluent and reticulated papillomatosis: response to minocycline. J Am Acad Dermatol 1996; 34:253.
  36. Fung MA, Frieden IJ, LeBoit PE, et al. Confluent and reticulate papillomatosis: successful treatment with minocycline. Arch Dermatol 1996; 132:1400.
  37. Fuller LC, Hay RJ. Confluent and reticulate papillomatosis of Gougerot and Carteaud clearing with minocycline. Clin Exp Dermatol 1994; 19:343.
  38. Atasoy M, Ozdemir S, Aktaş A, et al. Treatment of confluent and reticulated papillomatosis with azithromycin. J Dermatol 2004; 31:682.
  39. Gruber F, Zamolo G, Saftić M, et al. Treatment of confluent and reticulated papillomatosis with azithromycin. Clin Exp Dermatol 1998; 23:191.
  40. Ito S, Hatamochi A, Yamazaki S. A case of confluent and reticulated papillomatosis that successfully responded to roxithromycin. J Dermatol 2006; 33:71.
  41. Angeli-Besson C, Koeppel MC, Jacquet P, et al. Confluent and reticulated papillomatosis (Gougerot-Carteaud) treated with tetracyclines. Int J Dermatol 1995; 34:567.
  42. Lee MP, Stiller MJ, McClain SA, et al. Confluent and reticulated papillomatosis: response to high-dose oral isotretinoin therapy and reassessment of epidemiologic data. J Am Acad Dermatol 1994; 31:327.
  43. Carrozzo AM, Gatti S, Ferranti G, et al. Calcipotriol treatment of confluent and reticulated papillomatosis (Gougerot-Carteaud syndrome). J Eur Acad Dermatol Venereol 2000; 14:131.
  44. Lang EW, Czosnyka M, Mehdorn HM. Tissue oxygen reactivity and cerebral autoregulation after severe traumatic brain injury. Crit Care Med 2003; 31:267.
  45. Tirado-Sánchez A, Ponce-Olivera RM. Tacrolimus in confluent and reticulated papillomatosis of Gougerot Carteaud. Int J Dermatol 2013; 52:513.
  46. Erkek E, Ayva S, Atasoy P, Emeksiz MC. Confluent and reticulated papillomatosis: favourable response to low-dose isotretinoin. J Eur Acad Dermatol Venereol 2009; 23:1342.
  47. Hodge JA, Ray MC. Confluent and reticulated papillomatosis: response to isotretinoin. J Am Acad Dermatol 1991; 24:654.
  48. Solomon BA, Laude TA. Two patients with confluent and reticulated papillomatosis: response to oral isotretinoin and 10% lactic acid lotion. J Am Acad Dermatol 1996; 35:645.
  49. Bruynzeel-Koomen CA, de Wit RF. Confluent and reticulated papillomatosis successfully treated with the aromatic etretinate. Arch Dermatol 1984; 120:1236.
  50. Baalbaki SA, Malak JA, al-Khars MA. Confluent and reticulated papillomatosis. Treatment with etretinate. Arch Dermatol 1993; 129:961.
Topic 101429 Version 7.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟