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\begin{document}

\title{Alternative Therapeutic Approach in the Treatment of Warner and
Wilson-Jones Syndrome of the Scalp in Pediatric Patient}



\author[1]{Marwa THABOUTI}%
\author[2]{Nadia Ghariani Fetoui}%
\author[3]{Wafa Jouini}%
\author[1]{Baderedine Sriha}%
\author[4]{Mohamed Denguezli}%
\affil[1]{Farhat Hached University Hospital of Sousse}%
\affil[2]{Centre Hospitalier Universitaire Farhat Hached de Sousse}%
\affil[3]{Charles Nicolle Hospital}%
\affil[4]{Farhat Hached hospital, Sousse, Tunisia}%


\vspace{-1em}



  
  \date{March 14, 2025}


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\selectlanguage{english}
\begin{abstract}
Warner and Wilson-Jones syndrome (WWS), is a rare entity. We report a
pediatric case of 6-year-old patient, referred to our department for
recurrent nodules of the scalp following removal of capillary
hemangioma. Intralesional corticosteroids infiltration was decided
without recurrence until today.%
\end{abstract}%



\sloppy


\section*{Alternative Therapeutic Approach in the Treatment
of}

{\label{alternative-therapeutic-approach-in-the-treatment-of}}

\textbf{Warner and Wilson-Jones Syndrome of the Scalp in Pediatric
Patient}

\textbf{M. Thabouti(1), N. Ghariani Fetoui (1), W. Jouini (1), B. Sriha
(2), M. Denguezli (1)}

\textbf{(1)- Dermatology Departement, Farhat Hached Hospital, Sousse,
Tunisia}

\textbf{(2)- Anatomopathology Department, Farhat Hached Hospital,
Sousse, Tunisia}

\textbf{Abstract:}

Warner and Wilson-Jones syndrome (WWS), is a rare entity. We report a
pediatric case of 6-year-old patient, referred to our department for
recurrent nodules of the scalp following removal of capillary
hemangioma. Intralesional corticosteroids infiltration was decided
without recurrence until today.

\textbf{Sir,}

Warner and Wilson-Jones syndrome (WWS), is a rare entity, described
since 1968 (1). Usually involves patients aged 13 to 20 years mostly on
the back or in the scapular area. This report describes an unusual case
of WWS in pediatric patient successfully treated with a series of
intralesional corticosteroid injections.

A 6-year-old lady, was referred to our department for multiple
recurrent, violaceous nodules of the scalp. The first lesion appeared at
the age of 6 months, as a reddish lesion. The diagnosis of capillary
hemangioma was made. Six months later, the excised nodule recurred with
multiple satellite violaceous papules. Brain magnetic resonance imaging
was performed to rule out a vascular malformation. The patient was
treated by systemic beta-blockers without efficacy. On examination,
there were multiple angiomatous, dome shaped and firm papules
(\textbf{Figure1a).} No history of trauma was reported. Dermoscopic
examination showed a red homogeneous background, white areas and white
rail lines that intersected the lesion, with white peripheral
collarette\textbf{(Figure1b)} . Histopathological examination showed a
nodular mass of fibrous connective tissue with dilated capillaries,
chronic inflammatory cells and fibroblasts dispersed within the reactive
granulation tissue, revealing a pyogenic granuloma
(PG)\textbf{(Figure2)} . Combining clinical, dermoscopic and microscopic
features, WWS was made. Treatment with CO2 laser ablation and surgical
excision were associated with rapid recurrence. As an alternative,
intralesional steroid injection was performed. We diluted 0.1 ml of
triamcinolone acetonide at the concentration of 40mg/ml with 0.5 ml of
0.5\% Xylocaine. A total of 0.1 ml of the mixture was injected per
lesion. The first and second injections were given 1 week apart, and the
remaining four injections were given bi-weekly over a period of 9 weeks.
During a follow up visit at 3 months, the lesions were 90\%
resolved\textbf{(Figure 3a),} with residual fibrosis \textbf{(Figure
3b)} , without recurrence until today.

PG is a common, benign vascular proliferation \textbf{(1)} . It can
occur spontaneously or triggered by several factors. It appears as a
rapidly growing, erythematous nodule with tendency for bleeding
\textbf{(2)} . The lesion is often solitary with high rate of local
recurrence after excision \textbf{(3)} . The occurrence of multiple
satellite lesions of PGs after complete removal is an extremely rare
entity \textbf{(2,4)} , known as WWS. It mostly affects patients under
the age of 25 and is located on the back, scapular area, upper limb and
oral cavity\textbf{(2,4)} . Scalp location, like our patient, is
uncommon, described in only one adult patient \textbf{(3)} . The
pathogenesis of this syndrome is still unclear. It may be explained by
an aggressive immune response. Different therapeutic modalities can be
used, including surgical excision, cauterization, cryotherapy and CO2
laser therapy\textbf{(2)} , but their therapeutic effects are limited.
Intralesional corticosteroid injection, has been reported in only one
case\textbf{(5)} . Because its' anti-inflammatory and vasoconstrictive
actions, corticosteroid infiltration can be an alternative to
conventional methods, especially in pediatric population. To our
knowledge, this is the first case of WWS located on the scalp in a
pediatric patient, treated by intralesional corticosteroid injections,
with successful results.

\textbf{REFERENCES}

1- Warner J, Jones EW. Pyogenic granuloma recurring with multiple
satellites. a report of 11 cases. Br J Dermatol. 1968; 80:218-227.

2- Richard D. Blickenstaff. Recurrent pyogenic granuloma with
satellitosis. JAM ACAD DERMATOL 1989; 21:1241-4

3- James W. Taira, Tamara L. Hill, Mark A. Everett, M. Lobular capillary
hemangioma (pyogenic granuloma) with satellitosis. J AM ACAD DERMATOL
1992; 27:297-300

4- Uppada R,Pullela RV.Warner and Wilson-Jones syndrome.CHRISMED J
Health Res 2015; 2:91-2

5- E Parisi, PH Glick, M Glick. Recurrent intraoral pyogenic granuloma
with satellitosis treated with corticosteroids. Oral Diseases (2006) 12,
70--72

\textbf{Figure 1a:} multiple angiomatous, well demarcated, dome shaped
and firm papules measuring 5 to 7 mm in diameter.

\textbf{Figure 1b:} Dermoscopic abnormalities: red homogeneous
background with white areas and white rail lines that intersected the
lesion, with white peripheral collarette.

\textbf{Figure 2:} Fibrous connective tissue with dilated capillaries,
chronic inflammatory cells and fibroblasts dispersed within the reactive
granulation tissue. (HE X 40)

\textbf{Figure 3a:} Clinic appearance after 3 months of follow up (The
lesions were 90\% resolved).

\textbf{Figure 3b:} Dermoscopic appearance after 3 months of follow up
(Residual fibrosis).\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure1/Figure1}

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\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

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\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

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