Pictorial case study

The case: This patient attended surgery because a family member noticed a red area on their lower back. Examination revealed a 6cm red smooth plaque overlying the lower lumbar spine.

The cause of morphoea or localised scleroderma is unknown and there are no definitive treatments available

On palpation the skin felt thickened, but there was no tenderness, scale, ulceration, telangiectasia or excoriations. The immediately adjacent skin looked normal and rest of the body had only a few scattered seborrhoeic keratoses. The nails, buccal mucosa and scalp were also normal on examination.

The patient reported no previous treatment of the affected areas except for emollients which he applied daily to all of his skin.

Diagnosis and management
When the skin was examined a well demarcated plaque was noted overlying the lower lumbar spine. As the differential diagnoses included malignancy an urgent biopsy was taken the following day via a deep 4mm punch.

The report said: 'There is marked fibrosis of the dermis associated with mild chronic inflammatory changes extending deeply. No evidence of granulomatous reaction, vasculitis or epidermal involvement. Fibrosis and loss of adnexae suggests a diagnosis of morphoea.'

The cause of morphoea or localised scleroderma is unknown and there are no definitive treatments available. This is the plaque type which will often undergo spontaneous resolution over a three to five year period, but can last for up to 25 years. Potent topical or intralesional steroids may help.

The patient was seen and the histological findings discussed. The use of steroid creams was mentioned but the patient felt that it would be difficult for him to apply this to a small area and so it was felt that this was not appropriate in these circumstances.

With time the area is likely to become less red. It will eventually become an ivory colour with a decreased amount of sensation over the areas.

Possible differential diagnoses

  • Lichen sclerosus
  • Lymphoma
  • Granuloma annulare
  • Amyloidosis
  • Keloid or hypertrophic scarring
  • Secondary from internal malignancy

Differential diagnosis

Lichen sclerosus

  • This is six times more common in females than men.
  • Affects both genital and extra genital areas.
  • 15 per cent of cases occur in children.
  • Itch maybe present but the majority of cases are asymptomatic.
  • Asymptomatic extra genital lesions require no treatment.
Contributed by Dr Nigel Stollery, a GP and clinical assistant in dermatology, Leicester.

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