10.5826/dpc.1202a48
text/xml
2160-9381
1852
en
Cheng Tan
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dermatology
Dermoscopic and Reflectance Confocal Microscopic Presentations of Superficial Morphea on Preexisting Atrophoderma of Pasini and Pierini
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2022-05-02
2021-06-27
2022-05-02
2022-05-24
e2022048
Dermatol Pract Concept
Cheng Tan
2022/05/02
10.5826/dpc.1202a48
e2022048
Department of Dermatology, Affiliated Hospital of Nanjing University of Chinese Medicine，Nanjing, China
2160-9381
dermatology
en
e2022048
Dermoscopic and Reflectance Confocal Microscopic Presentations of Superficial Morphea on Preexisting Atrophoderma of Pasini and Pierini
https://dpcj.org/index.php/dpc/article/download/1852/1569
 Dermoscopic and Reflectance Confocal Microscopy
  Features of Superficial Morphea on Preexisting
        Atrophoderma of Pasini and Pierini
                                  Chun-Xiao Song1, Yu-Ting Zhang1, Cheng Tan1


1 Department of Dermatology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China



Key words: morphea, atrophoderma, hyperpigmentation, hypopigmentation, dermatology
Citation: Song CX, Zhang YT, Tan C. Dermoscopic and reflectance confocal microscopy features of superficial morphea on preexisting
atrophoderma of Pasini and Pierini. Dermatol Pract Concept. 2022;12(2):e2022048. DOI: https://doi.org/10.5826/dpc.1202a48
Accepted: July 28, 2021; Published: April, 2022
Copyright: ©2022 Song et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License
BY-NC-4.0, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors
and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Cheng Tan, MD, Department of Dermatology, Affiliated Hospital of Nanjing University of Chinese Medicine,
155 Hanzhong Road, Nanjing, China, 210029. E-mail: tancheng@yeah.net




Introduction
Superficial morphea (SM) is a distinct new variant of local-
ized scleroderma with the collagen proliferated and deposited
in the papillary and upper reticular dermis [1]. We present a
case of SM developed on a primary lesion of atrophoderma
of Pasini and Pierini (APP), and describe related dermoscopic
and reflectance confocal microscopy (RCM) features.


Case Presentation
A    26-year-old     Chinese     woman       presented     with    a
­seven-year-history of large hyperpigmented patches on the
right leg. On examination, larger hyperpigmented patches
were distributed in a zosteriform pattern. It spread from the
right groin area, down the medial portions of the thigh, and
                                                                         Figure 1. Large hyperpigmented patches were distributed in a zos-
finally to the popliteal fossa region. Furthermore, multiple
                                                                         teriform pattern on the right groin area, and the thigh. Lesions were
2 to 3 mm depigmented macules were disseminated within                   atrophic and slightly depressed without induration. Multiple 2 to
these hyperpigmented patches (Figure 1). Dermoscopic ex-                 3 mm depigmented macules speckled within the hyperpigmented
amination of the white spots showed whitish fibrotic beams               patch are shown.



Research Letter | Dermatol Pract Concept. 2022;12(2):e2022048                                                                               1
and linear arborizing vessels. The pigment network was                 the deeper dermis’s invariable sparing. Perivascular lympho-
irregularly distributed with a storiform pattern in some               cytic infiltration is present in the superficial dermis with oc-
speckled hypopigmented macules. Histological examination               casional plasma cells [2]. Dermoscopic examination of the
of a hypopigmented macule displayed decreased epidermal                white spots in our patient showed whitish fibrotic beams and
thickness with flattened rete pegs. There were mild superfi-           linear arborizing vessels. The pigment network is irregularly
cial perivascular lymphocytic infiltrate and pronounce dense           distributed with a storiform pattern in some speckled hy-
clumping and homogenization of collagen bundles, com-                  popigmented macules. RCM mosaic shows marked hyperre-
pared to the neighboring area’s unaltered collagen. Discrete,          flective areas with decreased appendageal structures.
highly-reflective clouds were in the “coffee-bean” pattern                 Divergent opinions about the relationship between SM
under RCM, which might be corresponding to the clumps                  and APP are present in literature. Some authors believe
of collagen in histopathology (Figure 2). These findings               that SM is not identical to APP considering the clinical de-
were consistent with the diagnosis of SM (over APP), and               pression of “cliff sign” and older age of onset in APP. SM
the application of 1% pimecrolimus ointment for 4 months               differs itself from APP with thickened collagen in upper
showed no improvement.                                                 reticular dermis. Others believe SM and APP belong to the
                                                                       same entity mainly considering both share a chronic be-
                                                                       nign course and a favorable prognosis that usually needs
Discussion
                                                                       no treatment [3,4]. Besides, APP and SM may coexist as
SM is typically presented with symmetric hypopigmented to              separate entities in the same patient or association with
hyperpigmented patches at intertriginous sites. H
                                                ­ istologically,       classical morphea or systemic scleroderma, and therefore
there are flattened rete ridges. The collagen fibers in the up-        APP can be considered an abortive type of scleroderma
per reticular dermis become thickened or homogenized, with             without sclerosis [4].




Figure 2. Dermoscopic examination of the white spots showed ­whitish fibrotic beams and linear arborizing vessels (green arrows). (A,B)
The pigment network is irregularly distributed with a storiform pattern (red oval circles) in some speckled hypopigmented macule (blue
oval circles). (C) RCM mosaic shows marked hyperreflective areas with decreased appendageal structures. Histological examination of this
hypopigmented macule displayed decreased epidermal thickness with flattened rete pegs. (D) mild superficial perivascular lymphocytic infil-
trate and pronounce dense clumping and homogenization of collagen bundles, compared to the neighboring area’s unaltered collagen. (E,F)
Discrete, highly reflective clouds in the “coffee-bean” pattern under RCM, which might be corresponding to the clumps of collagen under
the microscope.



2                                                                           Research Letter | Dermatol Pract Concept. 2022;12(2):e2022048
Conclusions                                                                 phenomenon. Am J Dermatopathol. 1999;21(4):315–3199.
                                                                            DOI: 10.1097/00000372-199908000-00001. PMID: 10446770.
The presence of discrete hypopigmented macules of SM                     2. Mosbeh AS, Aboeldahab S, El-Khalawany M. Superficial
                                                                            Morphea: Clinicopathological Characteristics and a Novel
                                                                            ­
within the primary lesion of APP adds another evidence that
                                                                            Therapeutic Outcome to Excimer Light Therapy. Dermatol
                                                                            ­
SM and APP are part of the same spectrum of disease. The                    Res Pract. 2019;2019:1967674. DOI: 10.1155/2019/1967674.
marked hyperreflective areas with discrete, highly reflective               PMID: 31641348. PMCID: PMC6770326.
clumped as white coffee beans. Dermoscopy and RCM can                    3. Ling X, Shi X. Idiopathic atrophoderma of Pasini-Pierini associ-
be applied as an ancillary diagnostic technique in SM.                      ated with morphea: the same disease spectrum? G Ital Dermatol
                                                                            Venereol. 2016;151(1):127–128. PMID: 26373865.
                                                                         4. Amano H, Nagai Y, Ishikawa O. Multiple morphea coexistent
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Research Letter | Dermatol Pract Concept. 2022;12(2):e2022048                                                                             3
