Koebner phenomenon in a patient with hypertrophic chronic cu
A 53-year-old female patient was admitted to the Department of Dermatology due to multiple hyperkeratotic, erythematous lesions located on the scalp, face, upper part of the trunk and upper extremities. The patient was diagnosed with discoid lupus erythematosus (DLE) in 2010. Past treatment involved moderate and high potency topical steroids and 250 mg of chloroquine orally for several years. Recently she received oral methylprednisolone, but despite increasing the daily dose from 4 mg up to 16 mg, the disease was progressing continuously.

Physical examination on the day of admission revealed linear atrophic scars with peripheral inflammation within the skin of the trunk. Arrangement of the lesions suggested repetitive excoriations. Moreover numerous erythematous and hyperkeratotic, nodular lesions were found on the trunk and upper extremities. The most severe and painful skin lesions with the verrucous surface, fissures, recurrent bleeding and features of superinfection were located on the hands. Scarring alopecia on the scalp was present. Mucous membranes were not affected. The patient complained about pruritus and admitted to scratching. She also reported paraesthesia of the fingers.

Complete blood count was normal, except thrombocytosis. Laboratory testing showed an increased erythrocyte sedimentation rate and C reactive protein. C3 complement was decreased. Autoantibody screening revealed positive antinuclear antibodies (ANA) with a titre of 1 : 640, with no particular subtype found. The following tests were negative: lupus anticoagulant, anticardiolipin antibodies IgM, IgG, anti-2-glycoprotein IgM, IgG, rapid plasma reagin. 24-urine collection was done but no significant proteinuria was found.

Radiological imaging: chest X-ray and abdominal ultrasound showed no significant abnormalities.

Punch biopsy was taken for microbiological examination to exclude tuberculosis cutis. Direct preparation and culture revealed no mycobacteria. Additionally the real-time PCR test showed no DNA of Mycobacterium tuberculosis. QuantiFERON TB Gold test also was negative.

Another punch biopsy was taken for the histopathological examination, which confirmed the diagnosis of hypertrophic CCLE. The characteristic features were: epidermal thickening with the pseudoepitheliomatous hyperplasia, vacuolation and necrosis of basal keratinocytes, with the presence of subepidermal fissures and quite abundant, diffused lymphocytic and histiocytic infiltrates beneath the epidermis.

The treatment with chloroquine in the dose of 250 mg and acitretin of 25 mg was introduced, along with topical steroids. The previous methylprednisolone treatment has been maintained, but with a gradually reduced dose down to 4 mg daily. The follow-up examination was performed after 6 weeks of treatment. Marked improvement of the clinical condition was visible with the flattening and partial regression of skin lesions as a result. According to the patient also the itching sensation has been reduced. As the tolerability and no adverse effects appeared, the treatment has been continued.

CLE. It is characterized by irregular epidermal hyperplasia and hyperkeratosis. In this case the differential diagnosis included tuberculosis cutis, keratosis lichenoides chronica and hypertrophic actinic keratosis. Some of the lesions resembled disseminated warts. Also excluding the squamous cell carcinomas and multiple keratoacanthoma seems to be significant.