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.