CASE PRESENTATION:
A 43-year-old woman with unremarkable medical history presented to a
university-affiliated dermatology clinic with an 8-year history of an
asymptomatic plaque on her left elbow. upon physical examination the
plaque was found to be round-shaped, well-demarcated, waxy, yellow-brown
with atrophic center and indurated, raised border (FIGURE 1).
Dermoscopically, the elbow lesion was characterized by a diffuse
structureless yellowish-pink background and well-defined linear vessels.
structureless areas and follicular plugging (FIGURE 3A).
Histopathological examination of the elbow plaque revealed near normal
epidermis. The mid to deep dermis featured foci of layered degenerated
collagen alternating with palisaded granulomatous inflammation mainly
composed of histiocytes, lymphocytes, plasma cells and multinucleated
giant cells. Marked lymphocytic and eosinophilic perivascular infiltrate
was noted as well (FIGURE 4). Iron colloidal staining revealed no
evidence of mucin deposition in the affected dermis. These clinical,
dermoscopic and dermatopathological features confirmed the diagnosis of
NL.
In the last 4 months, she noticed the onset of a new hyperpigmented
plaque with well-defined borders and noticeable firmness upon palpation
on the right upper abdomen (FIGURE 2).
On dermoscopy, the truncal lesion showed ill-defined white clouds (also
known as fibrotic beams), scattered pinkish areas, and pigmentary
structures, including structureless brownish and reticular brownish
areas (FIGURE 3B).
Punch biopsy from her truncal plaque was performed and revealed
hyperkeratosis. the dermis featured marked dermal fibrosis with
thickened collagen bundles and perivascular lymphoplasma cell infiltrate
consistent with morphea (FIGURE 5).
During her initial visit, laboratory tests revealed a fasting blood
glucose level of 89 mg/dL (normal range of 70-100 mg/dL), a hemoglobin
level of 10.8 g/dL (normal range of 12.3-15.3 g/dL), and an erythrocyte
sedimentation rate of 38 mm/h (up to 20 mm/h). Other biochemical tests
were normal.
The patient began treatment with topical mometasone furoate 0.1% and
tacrolimus 0.01% along with monthly intralesional injections of
triamcinolone acetonide. However, after 3 months of follow-up no
significant improvement was noted, and she subsequently missed her
follow-up appointments.