A case of radiation-induced bullous morphea/lichen sclerosus overlap in a breast cancer patient

A Rare Case of Bullous Morphea Associated with Autoimmune Hepatitis

(1) Background: Bullous morphea is an extremely rare form of localized scleroderma, a condition that is marked by the presence of sporadic and intermittent blisters on sclerodermatous skin. This condition stands out due to its rarity and the unique manifestation of blistering, which sets it apart from other forms of localized scleroderma. Due to the infrequent presentation of bullous morphea, there is a significant gap in our understanding of its pathogenesis. The exact mechanisms that lead to the development of this condition remain largely unknown, which poses a challenge for medical professionals in terms of both diagnosis and treatment. The limited number of reported cases makes it difficult to establish a standardized approach to managing this condition, and as a result, treatment options are often limited and may vary from one patient to another. (2) Methods: In this case report, we present a rare case of bullous morphea that manifested before the onset of autoimmune hepatitis. When morphea presents unusually or is resistant to traditional immunosuppressive treatment, a comprehensive assessment of possible concurrent autoimmune illnesses provoking the rash must be conducted. (3) Results: We report a successful case of bullous morphea treated with systemic corticosteroids following a diagnosis of autoimmune hepatitis. (4) Conclusions: This case highlights the importance of considering overlapping autoimmune conditions in the management of bullous morphea and the potential efficacy of systemic corticosteroids in such scenarios. Collaborative efforts involving dermatologists, rheumatologists, and hepatologists are essential to enhance understanding and optimize treatment outcomes for patients affected by this rare and complex condition. Thus, further research is necessary to gain a deeper understanding of the pathogenesis of bullous morphea and to develop more effective and targeted treatment options for patients affected by this condition.

A Rare Presentation of Lichen Sclerosus Involving the Vaginal Canal After Radiation Therapy: A Case Report and Review of the Literature

Vaginal lichen sclerosus (LS) is an extremely rare entity. Classically, LS is referred to as a chronic, inflammatory skin disease with a distinct predilection for the anogenital skin that is observed in post-menopausal women and typically manifests clinically as white, atrophic plaques. Here, we report a case of a 61-year-old patient who presented for a follow-up visit three years after vaginal brachytherapy as an adjuvant treatment for endometrial adenocarcinoma. This lesion was biopsied and confirmed to be vaginal LS on histological analysis. While LS has been previously observed to impact mucosal areas outside of the anogenital region, such as the mouth, reported cases of vaginal LS are very rare in the literature. Our case highlights both the underrecognized location of this disease as well as radiation as a potential risk factor.

Dermal Hemorrhage: A Clue to Lichen Sclerosus et Atrophicus

Lichen sclerosus et atrophicus (LSA) may present in a rare bullous and hemorrhagic form that is often difficult to recognize both clinically and histopathologically. Clinically, the lesions may be characterized by atrophic and ivory-white sclerotic plaques in both genital and extragenital regions. Histologically, fully developed lesions of LSA are characterized by a thinned, effaced epidermis with interface change, a wide band of hyalinization in the upper dermis, and a lymphohistiocytic infiltrate below the hyalinized area. Extensive vacuolar degeneration weakens the integrity of the dermoepidermal junction, which contributes to the development of marked edema in the papillary dermis and subepidermal vesiculation. With increased fragility of dermal capillaries, hemorrhage can accumulate within the bullae. Recognizing prominent upper dermal hemorrhage as a secondary change may lead to a prompt diagnosis of LSA. We present a case of extragenital LSA that mimics a dermal hemorrhage clinically and histologically in a 71-year-old Caucasian woman.

Incidence of Morphea following Adjuvant Irradiation of the Breast in 2,268 Patients

Background

Morphea of the breast is an autoimmune reaction of the subcutaneous connective tissue which can be triggered by exposure to ionizing radiation. The literature suggests incidence rates of 1:500 to 1:3,000 which, however, do not seem to match the very small number of cases reported.

Objectives

The aim of the present study was to determine the incidence of morphea following irradiation of the breast in order to generate more evidence about the frequency of this serious and mutilating complication.

Method

Retrospective analysis of patient data who underwent adjuvant radiotherapy in the period 2009-2018 following breast-conserving surgery and who made use of the recommended radiooncology follow-up examinations in 2018. Analysis was done by descriptive statistics.

Results

Of a total of 5,129 patients who had undergone radiotherapy over a 10-year period, follow-up data were available in 2,268 patients. In 2,236 patients (98.6%) the breast had been irradiated using conventional fractionation schemes with a total dose of 50-50.4 Gy; 32 (1.4%) were given a total dose of 40.05 Gy in 15 fractions. During the observation period, 6 patients were diagnosed with morphea (4 unilateral and 2 bilateral) by punch biopsies resulting in a cumulative incidence proportion of 0.26% (95% CI: 0.24-0.28), translating into 1 case for every 378 irradiated patients.

Conclusions

In the case studies reported to date, morphea is described as a very rare complication. In contrast, our data suggest a cumulative incidence of 1:378, which is higher than other authors have estimated. This leads us to suspect that in a large number of patients, morphea is incorrectly diagnosed as an infection (in the early stages) and radiation-induced fibrosis (in later stages).

Radiation-induced morphea-a rare but severe late effect of adjuvant breast irradiation : Case report and review of the literature

Background

Radiation-induced morphea (RIM) is a circumscribed localized scleroderma that occurs most often in the breast. After an asymptomatic period of one month to several years, the symptoms (circumscribed inflammation, edema, sclerosis) often arise suddenly and cannot be clinically distinguished from a local recurrence in the form of inflammatory carcinoma.

Case

We present a case of a 74-year-old woman who developed this rare and serious local side-effect in connective tissue following neoadjuvant CDK 4/6 inhibitor abemaciclib (Verzenio®) and aromatase inhibitor anastrozole (Arimidex®) therapy and subsequent radiation therapy of the breast.

Conclusions

Little is known about risk factors and pathogenesis of RIM. Here we describe the first case of RIM following immunotherapy. The diagnosis is based on clinical appearance and histopathological examination. Treatment should be initiated in the inflammatory stage in order to prevent or delay irreversible fibrosis and atrophy of the breast.