10.5826/dpc.1201a27
text/xml
2160-9381
1853
en
Prashant  Sengupta
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dermoscopy
Bullous Erythema Nodosum Leprosum Through the Dermoscope
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2022-02-02
2021-06-28
2022-02-02
2022-02-09
e2022027
Dermatol Pract Concept
Prashant  Sengupta
2022/02/02
10.5826/dpc.1201a27
e2022027
Department of Pathology, Armed Forces Medical College, Pune, India
2160-9381
dermoscopy
en
e2022027
Chopra A, Mitra D, Agarwal R, Saraswat N, Talukdar K, Solanki A. Correlation of Dermoscopic and Histopathologic Patterns in Leprosy - A Pilot Study. Indian Dermatol Online J. 2019;10(6):663-668. DOI: 10.4103/idoj.IDOJ_297_18. PMID: 31807445. PMCID: PMC6859759.
Bullous Erythema Nodosum Leprosum Through the Dermoscope
https://dpcj.org/index.php/dpc/article/download/1853/1490
      Bullous Erythema Nodosum Leprosum Through
                    the Dermoscope
        Deepak Vashisht1, Shekhar Neema1, Durga Madhab Tripathy1, Prashant Sengupta2


1 Department of Dermatology, Armed Forces Medical College, Pune, India
2 Department of Pathology, Armed Forces Medical College, Pune, India



Key words: bullous ENL, dermoscopy
Citation: Vashsisht D, Neema S, Tripathy DM, Sengupta P. Bullous erythema nodosum leprosum through the dermoscope.
Dermatol Pract Concept. 2022;12(1):e2022027. DOI: https://doi.org/10.5826/dpc.1201a27
Accepted: June 29, 2021; Published: January 2022
Copyright: ©2022 Vashisht D et al. This is an open-access article distributed under the terms of the Creative Commons Attribution
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: Durga Madhab Tripathy, Senior Resident, Department of Dermatology, Armed Forces Medical College, Pune, India.
E-mail: dmt5861@gmail.com




Introduction                                                            We report dermoscopic findings of bullous ENL lesions in
                                                                        a patient, findings that revealed both typical and atypical
Erythema nodosum leprosum (ENL) forms a part of type 2                  features.
leprosy reaction characterized by crops of tender evanescent
erythematous nodules that appear on extensors accompanied
                                                                        Case Presentation
by systemic symptoms like fever and arthritis. Bullous ENL is
a rare variant of the type 2 reaction characterized by multiple         A 37-year-old male, with a known case of Hansen disease
vesicles and flaccid bullae at sites of classic ENL with severe         (borderline lepromatous leprosy) and on multidrug therapy
systemic symptoms. Other atypical variants include necrotic,            consisting of rifampicin 600 mg monthly, dapsone 100 mg
hemorrhagic, purpuric, Sweet syndrome-like and erythema                 and clofazimine 50 mg daily for 1 year, presented with mul-
multiforme-like ENL.                                                    tiple red raised, painful, erythematous nodules distributed
    Nowadays, dermoscopy is routinely employed in the                   symmetrically over the face, back, and upper limbs. Vesicles
diagnosis of leprosy, and it shows features akin to granulo-            and bullae containing clear fluid were superimposed on most
matous dermatoses, explicitly, yellow-orange background                 lesions (Figure 1, A and B). There was associated redness of
reminiscent of underlying granulomas and few specific fea-              the eyes, a high-grade fever, and joint pains. Mucosal surfaces,
tures. Specific features in the tuberculoid pole include loss           palms and soles were not involved, and Nikolsky sign was
of appendages and in the lepromatous pole xerosis, scaling,             negative.
and hypopigmentation. Leprosy reactions are character-                       Tzanck smear showed neutrophils, and acantholytic
ized by vascular changes in the form of arborizing blood                cells were absent. A slit-skin smear test for acid-fast bacilli
vessels in ENL and diffuse erythema in type 1 reaction [1].             (Mycobacterium leprae) from 8 different sites, including




Research Letter | Dermatol Pract Concept. 2022;12(1):e2022027                                                                         1
Figure 1. (A) Two ruptured bullae containing clear fluid located on both the forearms. (B) Solitary larger ruptured bullae over the right pinna.




         Figure 2. Histopathologic examination. (A) An intraepidermal split with spongiosis and neutrophils (×40) (black arrow).
         (B) Multiple ill-formed granulomas comprised of epithelioid cells and lymphocytes, and foamy histiocytes were noted
         surrounding the dermal nerves and appendages.



lesions, showed an average bacteriological index of 4+.                   fabric appearance of white-pink areas and brown-gray dots
Histopathology of the involved skin showed an intraepi-                   and globules at the periphery (Figure 3, A and B).
dermal separation, spongiosis, and neutrophilic infiltrate.                   The patient was managed as a type 2 leprosy reaction
Multiple ill-formed granulomas comprising of epithelioid                  (bullous ENL) with prednisolone 40 mg/day and thalidomide
cells, lymphocytes, and foamy histiocytes were noted sur-                 100 mg 4 times a day. He responded to treatment and is cur-
rounding the dermal nerves and appendages (Figure 2, A and                rently on tapering doses of steroids and thalidomide
B). Dermoscopy was performed using handheld DermLite
DL4 dermatoscope, and images were captured with a Sam-                    Conclusions
sung phone. It showed a homogeneous white-pink area with
an irregular border and surrounding erythema, similar to                  Leprosy has always eluded dermatologists with its varied
findings mentioned in the literature [2]. A closer view showed            presentations, and bullous ENL is an excellent example. With
a few atypical and novel features in the form of a crumpled               the growing popularity of dermoscopy in the diagnosis of



2                                                                             Research Letter | Dermatol Pract Concept. 2022;12(1):e2022027
         Figure 3. Dermoscopy. (A) A homogeneous white-pink area with irregular borders (blue arrow) and surrounding erythe-
         ma (black arrow). (B) A closer view showed a few atypical and novel features in the form of a crumpled fabric appearance
         of white-pink areas (blue arrow) and brown-gray dots and globules at the periphery (black arrow and circles).




leprosy, we tried to analyze dermoscopic findings of bullous               histopathology: a prospective observational study. J Eur Acad
ENL lesions. The novelty of this case lies in intriguing clinical          Dermatol Venereol. 2019;33(10):1947-1951. DOI: 10.1111/
                                                                           jdv.15635. PMID: 31004456.
aspects and newer perspectives through the dermoscope.
                                                                        2. Chopra A, Mitra D, Agarwal R, Saraswat N, Talukdar K,
   Informed consent: Written informed consent for publica-
                                                                           ­Solanki A. Correlation of Dermoscopic and Histopathologic
tion of clinical details and clinical images was obtained from              Patterns in Leprosy - A Pilot Study. Indian Dermatol Online J.
the patient.                                                                2019;10(6):663-668. DOI: 10.4103/idoj.IDOJ_297_18. PMID:
                                                                            31807445. PMCID: PMC6859759.

References
 1. Vinay K, Kamat D, Chatterjee D, Narang T, Dogra S. Dermatos-
    copy in leprosy and its correlation with clinical spectrum and




Research Letter | Dermatol Pract Concept. 2022;12(1):e2022027                                                                           3
