Resident Dermatologist: Polina Rzepka, MD

Attending Dermatologist: Susan Massick, MD

Dermatopathologist: Catherine Chung, MD

HISTORY:

70 year old female with past medical history of breast cancer, lung cancer, hyperlipidemia, and hypertension presenting with about a one year history of a rash on her abdomen, right wrist, bilateral axillae, right thumb, left eyebrow, and right chest. Lesions are pruritic and continuing to spread. She has had some improvement with topical Hydrocortisone. No previous history of skin cancer.

On exam she has numerous irregular, white and atrophic appearing macules and patches.

Wrist

Axilla

Abdomen

At scanning magnification, the epidermis is thinned and there is increased stratum corneum (hyperkeratosis). The superficial dermis appears pale and smudgy compared to the deeper dermis, where well-defined collagen bundles are seen.

Hyperkeratosis is more prominent in hair follicles (yellow arrow). At this power, there are three zones from top to bottom: hyperkeratosis (red arrow), pale-staining hyalinized collagen (white arrow), and a perivascular lymphocytic infiltrate (blue arrow).

Collagen in the papillary dermis (yellow arrow) is pale and smudgy (i.e. hyalinized) compared to normal collagen in the reticular dermis (red arrow).

What is the most likely diagnosis?

  1. Lichen sclerosus
  2. Morpheus
  3. Lichen planus
  4. Vitiligo
Lichen sclerosus, extragenital