Dermoscopic Aspects of Bullous Haemorrhagic Lichen Sclerosus Atrophicus of Breast: Before and During Treatment Observations

Sir, Lichen sclerosus atrophicus (LSA), a chronic disorder, typically presents with atrophic ivory-white sclerotic plaques affecting the genitalia. Extragenital lesions constitute 15-20% cases of LSA.[1] Its variant, bullous haemorrhagic LSA (BHLSA) of breast is an uncommon presentation.[1] In this article, dermoscopic aspects of BHLSA of breast have been elucidated drawing attention to the value of dermoscopy before and during treatment in solving this diagnostic enigma. A 55-year-old woman presented with asymptomatic lesion on the left breast with history of recurrent haemorrhagic blisters for one year. The patient was concerned believing it to be cancerous. History of trauma or radiotherapy was absent. Clinically, a well-defined erythematous sclerotic plaque of size 6 × 3 cm2 with shiny wrinkled overlying skin and haemorrhagic crusts was present on inferolateral quadrant of the left breast with an adjacent slightly hyperpigmented atrophic skin [Figure 1]. Lymphadenopathy was absent. Rest of the examination was normal.Figure 1: Haemorrhagic sclerotic plaque with shiny wrinkled overlying skin at upper border and haemorrhagic crusts with adjacent hyperpigmented atrophic plaque on breastDermoscopy with DermLite DL4 (using International Dermoscopy Society criteria for non-neoplastic dermatoses for skin of colour)[2] under polarised view revealed varying shades of structureless diffuse red areas with intervening white radial lines in the periphery; white structureless areas and white scales and reddish brown structureless areas in patchy distribution [Figure 2a and b]. Lesional biopsy revealed orthokeratosis, spongiosis, vacuolisation of basal keratinocytes and markedly dilated vascular channels with extravasated RBCs at dermo-epidermal junction. Upper dermis showed dermal edema and homogenisation of collagen. Mid-dermis showed perivascular and periadnexal mononuclear inflammatory infiltrate consistent with diagnosis of BHLSA [Figure 3].Figure 2: Polarised dermoscopy with DermLite DL4 showing (a) diverse shades of diffuse structureless red areas with intervening radial white lines at periphery (blue arrow), white structureless areas (yellow arrow); (b) patchy white scales (black asterisk), white (yellow arrow) and reddish brown (yellow asterisk) structureless areas in patchy distributionFigure 3: Orthokeratosis, spongiosis, extensive basal layer vacuolisation, with blister near dermoepidermal junction and markedly dilated vascular channels with extravasated erythrocytes. Upper dermis shows marked dermal edema and homogenisation of collagen. Mid-dermis showed perivascular and periadnexal mononuclear infiltrate (H and E, ×200)Significant improvement occurred with topical clobetasol 0.05% cream once daily [Figure 4a]. Bright white structures, white structureless areas, red globules and peripheral linear vessels with branches became evident on polarised dermoscopy after treatment [Figure 4b].Figure 4: (a) Improvement noticed after topical therapy; (b) polarised dermoscopy showing remarkably visible linear vessels with branches at the periphery (red arrow), 'bright' white structures (green arrow), white structureless areas (yellow arrow) and red globules (white asterisk) with reduction of multi-coloured red areas and reddish brown structureless areasNoticeably, BHLSA of breast has a distinctive clinical appearance than classical LSA, making it a diagnostic challenge. Because of its location on breast, it may pose a worrisome clinical scenario for both patient and clinician; hence, crucial entity for clinicians to recognize. So far, only nine cases of BHLSA of breast are reported; however, none was reported from the Indian literature [Table 1].[1,3-8]Table 1: Illustrating the reported cases of BHLSA of breastExtensive vacuolar basal layer degeneration compromises the strength of dermo-epidermal junction, causing bulla formation. However, homogenisation of collagen and extensive dermal edema reduces the collagen support of dermal vessels, predisposing them to rupture on friction causing haemorrhagic lesions.[1] Dermoscopically, in LSA, white structureless areas represent hyperkeratosis and epidermal atrophy, whereas 'bright' white structures (observed in later stages) correspond to homogenisation of collagen bundles and excessive collagen density in the superficial dermis, which gives rise to shiny white shade.[2,10] Follicular plugs (usually absent in advanced lesions) represent follicular hyperkeratosis. Peripheral linear vessels with branches (seen in both early and late stages) represent telangiectasias or dilated blood vessels.[10] Dermoscopy in BHLSA in a male patient showed similar multi-coloured red areas; reddish brown structureless areas and follicular plugs.[11] The absence of the latter in our case could possibly be due to follicular destruction as observed in late lesions. In our case, red areas and globules may correspond histopathologically to haemorrhages seen as extravasated erythrocytes around dilated vascular channels. On dermoscopic follow-up, bright white structures and linear vessels became apparent with diminution in multi-coloured red areas and structureless areas, thereby, revealing the classical dermoscopic features of LSA that were obscured by diffuse structureless red areas of BHLSA at initial presentation, thus, demystifying the diagnostic perplexity. Conclusively, dermoscopic and histopathological features form a good correlation and aid in confirming the diagnosis of BHLSA of breast. Follow-up dermoscopy can help in corroborating this uncommon diagnosis and monitoring response to therapy. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.