Koebnerization of lichen sclerosus et atrophicus at insulin
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Lichen sclerosus et atrophicus (LSEA) or lichen sclerosus (LS) is a benign chronic inflammatory dermatosis of unknown etiopathogenesis. It mostly affects prepubertal, perimenopausal, and postmenopausal women. Extragenital LS occurs in 15–20% cases; involves the neck, shoulder, and upper trunk in the form of porcelain white atrophic macules and plaques; and is generally asymptomatic. LS exhibits occasional koebnerization due to stimuli like radiotherapy and physical trauma and rarely occurs at injection sites.

A 65-year-old women, under treatment for diabetes mellitus with subcutaneous human insulin since the past 2 years, presented with gradual onset tightening of skin of abdominal injection sites with difficulty in injecting insulin since 4–5 months followed by gradual onset white discoloration of those sites since 3 months. These were small to begin with otherwise asymptomatic. These lesions gradually extended to the present size. There were no other skin or genital complaints.

Examination revealed indurated well-defined depigmented patches on all four abdominal quadrants. A slightly atrophic surface was noted on closer examination. Dermoscopy (Dinolite video dermoscope, polarized mode) revealed follicular plugging in the form of yellowish plugs, telangiectasias, and whitish patches. Based on the above findings, we kept our provisional diagnosis as LS.

Histopathologic examination of a 4-mm punch biopsy revealed predominantly atrophic epidermis with hyalinization of upper dermis. Lymphoplasmacytic infiltrate was noted around the dermal vessels. A few dilated lymphatics were noted in the upper dermis. A definitive diagnosis of LS was arrived via clinicopathologic correlation and dermoscopy.

The patient was asked to stop injecting insulin in the affected areas. We have prescribed 0.1% Mometasone Furoate cream to be applied twice daily and the patient will be followed up monthly.

Source: https://www.e-ijd.org/article.asp?issn=0019-5154;year=2021;volume=66;issue=2;spage=224;epage=224;aulast=Vishwanath