Female patient, 55 years old, dental assistant, evolved with asymptomatic lesions on the\nback and upper limbs for three years. At the dermatological examination, whitish plaques\nof hardened consistency, with well-defined borders and horny spikes were observed on the\nback and upper limbs. There were also plaques with hemorrhagic aspect, with superficial\nhorny spikes and blisters, located on the back (). During this time of evolution, she underwent two cutaneous biopsies at\nprevious evaluations carried out at other outpatient clinics, with histological\ndiagnosis suggesting circumscribed lymphangioma and scleroderma plaque, respectively.\nShe was referred to a REFERENCES center, undergoing a new biopsy; the histopathological\nexamination revealed atrophic epidermis, with hyperkeratosis and follicular plugs.\nVacuolar degeneration of the basal layer was observed in the dermis, with subepidermal\nblisters and extravasation of red blood cells. Edema and collagen homogenization in\npapillary dermis were also observed, with a perivascular lymphohistiocytic inflammatory\ninfiltrate, confirming the diagnosis of bullous and hemorrhagic lichen sclerosus (). Routine laboratory tests did not show\nother changes. The patient was treated with high-potency topical corticoid, evolving to\nremission of the hemorrhagic bullous lesions after 2 months of treatment. She remains\nunder clinical follow-up, with hyperkeratotic lesions on the back ().
We report a 63-year-old woman with a few months' history of cutaneous lesions on her\ntrunk and extremities. Histopathological analysis of the lesions revealed lichen\nsclerosus et atrophicus (LSA), which were treated with topical corticosteroids.\nPersonal and family history was unremarkable. Our first examination revealed\nmultiple, disseminated, hypopigmented and hyperpigmented atrophic and sclerotic\nplaques on her trunk and extremities. The patient presented a 6x8cm fragile,\nhemorrhagic bulla within an atrophic plaque on her lower back (). We performed an incisional biopsy of the bulla that\nrevealed epidermal atrophy, a subepidermal blister with marked edema of the\npapillary dermis and homogenization of collagen (). Blood count, biochemical parameters and coagulation studies\nwere within the normal range. Immunological analyses revealed positive (1:160)\nantinuclear antibodies (ANAs) by indirect immunofluorescence (Hep-2-cells)\n(homogenous pattern), and negative anti-ssDNA, anti-dsNA, anti SSA/Ro,Scl-70 and\nanti-SSB/ La. IgG and IgM (EIA) antibodies were negative for Lyme's disease. Chest\nX-ray, abdomen ultrasound and gynecological examination showed no pathological\nfindings. The patient was initially treated with doxycycline 100 mg/ day and locally\napplied 0, 5% clobetasol. The bulla resolved within three weeks, but new hemorrhagic\nbulla appeared in the same place together with painful, non-hemorrhagic bullae on\nboth gluteal regions (). Chloroquine\nwas administered in daily doses of 250 mg. After a month, we observed some\nimprovement of the skin lesion and resolution of the bulla on the back, but soon\nafter, new multiple hemorrhagic bullae appeared on the trunk ( and ). We\nobserved no erosion healing on the sites of previous bullae in the gluteal regions,\nwhere shallow, painful ulcers were formed. The patient refused the advised\nhospitalization and further follow-up appointments.