Multiple Whorled Keloidal Plaques in a Tea Plucker-Repeated Microtraumas Leading to Unique Morphology

Sir A 48-year-old lady presented with a history of multiple raised lesions on the body for the last 33 years. It started as few raised asymptomatic skin-coloured lesions on limbs and trunk and eventually increased in size and number over the following years to involve both upper and lower limbs. She had been working in tea gardens since the age of 15 years and had started developing the lesions after one year of starting work and the lesions kept on increasing in number and size. There was no history of any co-morbid illness, weight loss or systemic symptoms. General and systemic examinations were within normal limits. The dermatological examination revealed multiple skin coloured to hyperpigmented whorled keloidal plaques asymmetrically distributed over trunk, thighs, legs, feet and arms with sparing of face and folds [Figures 1-4]. All the lesions were non-tender with no associated discharge.Figure 1: Multiple keloidal plaques over bilateral lower limbsFigure 2: Multiple whorled keloidal plaques over right lower limbFigure 3: Multiple keloids over right footFigure 4: Multiple keloids over both upper limbsAll haematological and serological investigations including complete hemogram, serum biochemistry were normal and; Viral markers and Mantoux test were negative. Skin biopsies taken from different lesions showed dense collagen bundles with spindle-shaped cells, i.e. fibroblasts in dermal region suggestive of keloid [Figures 5 and 6].Figure 5: (H and E100x)- Hypocellular lesion composed of thickened glassy eosinophilic collagen bundlesFigure 6: (H and E 400x)- Thick ropey collagen bundles seenA keloid scar is a benign hyperproliferative growth of dense fibrous tissue resulting from an abnormal healing response to cutaneous injury that extends beyond the borders of the original wound. A keloid scar is a clinical diagnosis, and one important consideration in reaching a keloid scar diagnosis is identifying a history of injury prior to the occurrence of the scar.[1] Keloid scars usually present as erythematous nodules with shiny surfaces which are frequently pruritic and painful and are mostly non-regressing. The most frequent sites of keloid scars are on the chest, the shoulders, the upper back extending to the neck and the earlobes. In general, individuals with dark skin colour are at greater risk of developing keloids compared with whites.[1] The pathogenesis of keloid formation is inadequately understood, but keloids frequently result from trauma or inflammation of the skin. In histopathology, keloids are characterized by increased collagen with thickened hyalinized collagen bundles referred to as keloidal collagen in the dermis.[2] The aetiology of keloids is possibly linked to both genetic and environmental factors; some individuals are more predisposed to keloid formation than others. Spontaneous keloid formation, a rare entity with elusive cause, has been reported in certain syndromes like Dubowitz syndrome, Rubinstein-Taybi syndrome, Noonan syndrome, Goeminne syndrome and conjunctivo-corneal dystrophy.[3-7] In addition, dermatoses like lobomycosis, cutaneous leishmaniasis, basal cell carcinoma, sarcoidosis, morphea and dermatofibrosarcoma protuberans can present like a localized keloid.[8] Our case had multiple lesions predominantly on limbs with varying morphology like annular keloidal plaques, linear scars with fibrous chord-like structures and whorled patterns in some lesions. However, clinically she was well preserved for having a disseminated infection or malignancy yet the diverse morphology of lesions intrigued us to biopsy and look for the potential underlying cause of these atypical keloidal lesions. Although the clear history of trauma could not be elicited, the occupational history, i.e. patient being a tea garden worker in the past and predominant limb involvement, was strongly suggestive of recurrent subtle trauma and subsequent keloid formation with a unique morphology in a person. We report this case for its unique and uncommon presentation. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.