10.5826/dpc.1303a141
text/xml
2160-9381
2898
en
Pandharinath Khade
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
inflammoscopy
Extragenital Lichen Sclerosus et Atrophicus-Morphea Overlap Masquerading as Lupus Vulgaris: Histopathology to the Rescue 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2023-07-31
2022-10-08
2023-07-31
2023-08-24
e2023141
Dermatol Pract Concept
Pandharinath Khade
2023/07/31
10.5826/dpc.1303a141
e2023141
Department of Dermatology, Leprosy and Venereology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India
2160-9381
inflammoscopy
en
e2023141
Careta MF, Romiti R. Localized scleroderma: clinical spectrum and therapeutic update. An Bras Dermatol. 2015;90(1):62-73. DOI: 10.1590/abd1806-4841.20152890. PMID: 25672301. PMCID: PMC4323700.
Extragenital Lichen Sclerosus et Atrophicus-Morphea Overlap Masquerading as Lupus Vulgaris: Histopathology to the Rescue 
https://dpcj.org/index.php/dpc/article/download/2898/2215
   Extragenital Lichen Sclerosus et Atrophicus-
 Morphea Overlap Masquerading as Lupus Vulgaris:
          Histopathology to the Rescue
         Swati Prasanna1, Nishigandha S Haridas1, Vidya Kharkar1, Pandharinath Khade1


1 Department of Dermatology, Leprosy and Venereology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India



Key words: Lichen sclerosus, Cutaneous tuberculosis, Lupus vulgaris, Inflammoscopy
Citation: Prasanna S, Haridas NS, Kharkar V, Khade P. Extragenital Lichen Sclerosus et Atrophicus-Morphea Overlap Masquerading as
Lupus Vulgaris: Histopathology to the Rescue. Dermatol Pract Concept. 2023;13(3):e2023141.
DOI: https://doi.org/10.5826/dpc.1303a141
Accepted: December 19, 2022; Published: July 2023
Copyright: ©2023 Prasanna et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/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: Dr Nishigandha S Haridas, Department of Dermatology, Seth G.S. Medical College and K.E.M. Hospital, Parel,
Mumbai, 400012, Maharashtra, India Email: drnishigandhaharidas@gmail.com




Introduction                                                             revealed an erythematous plaque with central atrophy and
                                                                         purpuric borders, approximately 4 x 3 cm in size, with an ad-
Lichen sclerosus et atrophicus (LSA) presents as atrophic                vancing elevated edge and an atrophic regressing edge (Figure
plaques in genital region usually but can present at extragenital        1A) with no regional lymphadenopathy. Mantoux skin test was
locations such as neck, shoulder, trunk and proximal extrem-             positive (15 mm). However, interferon gamma release assay
ities [1,2]. Morphea is characterized by skin thickening and             (IGRA) and chest X-ray were normal. Dermoscopy revealed
increased collagen within the indurated lesion [3]. Although             follicular plugging, white structureless areas, yellowish to or-
both these pathologies have been described as distinct clinical          ange globules, network of linear vessels within white streaks
and histopathological entities, there are cases and retrospec-           along with few unfocussed violaceus vessels (Figure 1, B and
tive studies which suggest that both the diseases could be a             C)]. A provisional diagnosis of plaque type lupus vulgaris (LV)
part of the spectrum of localized sclerosing disorders [1,2].            was given and a skin biopsy was done for histopathology and
                                                                         CBNAAT (Cartridge based Nucleic Acid Amplification Test).

Case Presentation                                                        Histopathology from the advancing edge of the plaque revealed
                                                                         follicular plugging, pan dermal sclerosis with thickening and
A 56-year-old male presented with an asymptomatic reddish                homogenization of dermal collagen with replacement of sub-
plaque over neck, gradually increasing in size for 8 months. He          cutaneous fat below eccrine apparatus by thickened collagen.
gave history of taking anti-tuberculous drugs for inguinal tuber-        There was sparse interstitial lymphocytic infiltrate between
culous lymphadenitis twenty years ago. Physical examination              the collagen fibres (Figure 1, D-F). Ziehl Neelson staining of




Research Letter | Dermatol Pract Concept. 2023;13(3):e2023141                                                                          1
Figure 1. Cutaneous examination and dermoscopic and histopathological findings (H&E stain). (A) Erythematous plaque with central
orange yellow hue, advancing edge at one border and regressing atrophic edge at the other end. (B) Dermoscopy showing follicular plugs
(black arrow) with yellowish brown crust, 100x without polarization. (C) Yellowish orange globules (black star) with few unfocused vessels
(black arrow) at 100x magnification with polarization. (D) Pandermal sclerosis with thickened collagen (black star) and scarce appendages
pulled up in the mid dermis (arrow), 2x magnification, H&E stain. (E) Subcutaneous fat below eccrine apparatus replaced by thickened
collagen (black star) with lymphocytic interstitial infiltrate (black arrow) 40x magnification, H&E stain. (F) Pulled-up eccrine ducts, 100x
magnification, H&E stain.




Figure 2. Results after topical calcitriol 0.0003% ointment application. (A) Pretreatment. (B) After 2 weeks of treatment. (C) After 4 weeks
of treatment.




histopathological section was negative for acid fast bacilli. Skin      given and the patient was started on calcitriol 0.0003% oint-
biopsy CBNAAT was negative for mycobacterium tuberculo-                 ment. There was decrease in the size of plaque within 4 weeks
sis. A final diagnosis extragenital LSA-morphea overlap was             of commencing treatment (Figure 2, A-C).



2                                                                           Research Letter | Dermatol Pract Concept. 2023;13(3):e2023141
Conclusions                                                       follicles, orange red background with white streaks and
                                                                  structureless areas
LSA presents with white atrophic plaques and papules, most           However, the presence of pan dermal sclerosis, dimin-
commonly on the vulvar and perianal area but may be seen          ished appendages, replacement of subcutaneous fat beneath
anywhere, with trunk and extremities being the most com-          eccrine glands by thickened dermal collagen were against LV.
mon extragenital sites.                                              This case posed a diagnostic challenge due to its disguise
   Dermoscopy of LSA shows porcelain white structureless          as cutaneous tuberculosis which emphasizes on the impor-
areas, comedo like openings and a network of dotted blood         tance of clinico-dermoscopic-histopathological correlation.
vessels [1] .On histopathology, LSA presents with follicular
plugging, lichenoid papillary dermal infiltrate and homoge-
                                                                  Acknowledgement: We would like to thank Dr Rajiv Joshi
nization of papillary dermis whereas morphea presents with
                                                                  for his valuable inputs in histopathology.
increased basal layer melanization, reticular dermal sclerosis,
thickened collagen bundles, interstitial lymphocytic infiltrate
and decreased appendages [1].                                     References
   LV on dermoscopy presents with follicular plugging,
                                                                   1. Rose AE, Boyd KP, Meehan SA, Latkowski JA. Lichen sclerosus
hemorrhagic crusts, yellowish orange background sugges-               et atrophicus. Dermatol Online J. 2013;19(12):20714. PMID:
tive of granuloma, linear vessels arranged along the white            24365005.
streaks, and white structureless areas. On histopathology,         2. Almuqati RR, Hariri J, Abduljabbar M. Histopathological
tuberculoid granulomas in reticular dermis with absent or             Coexistence of Extragenital Lichen Sclerosus and Morphea in
scanty caseation are seen along with hyperkeratosis, atrophy          a Single Lesion. Cureus. 2020;12(12):e12215. DOI: 10.7759
                                                                      /cureus.12215. PMID: 33489622. PMCID: PMC7815259.
and fibrosis.
                                                                   3. Careta MF, Romiti R. Localized scleroderma: clinical spectrum
   Findings in support of LV included past history of TB              and therapeutic update. An Bras Dermatol. 2015;90(1):62-73.
lymphadenitis with positive Mantoux test, classical mor-              DOI: 10.1590/abd1806-4841.20152890. PMID: 25672301.
phology of the lesion with an advancing edge, patulous                PMCID: PMC4323700.




Research Letter | Dermatol Pract Concept. 2023;13(3):e2023141                                                                    3
