Perforating Morphea: A Rare Association with Elastosis Perforans Serpiginosa

Elastosis perforans serpiginosa (EPS) is a rare acquired perforating dermatosis char acterized by trans-epidermal elimination of abnormal elastic fibers. Although EPS has been associated with inherited connective tissue disorders, certain medications and systemic diseases, its coexistence with morphea is exceptionally uncommon. A 62-year-old female with generalized morphea and Hashimoto thyroiditis developed painful, serpiginous hyperkeratotic papules within a gluteal sclerotic plaque. Histology revealed perforation of connective tissue elements and confirmed a distinct connection between the damaged elastic fibers in the perforation and the thickened morphoeic collagen bundles. Combination therapy with topical clobetasol propionate, emollients, and NB-UVB achieved partial clinical resolution, though new lesions emerged in adjacent morphea plaques four months post-treatment. Given the intimate anatomical relation, we conclude that this represents perforating morphea rather than a random overlap (as a secondary form of EPS). We present a rare clinicopathological association of elastosis perforans serpiginosa arising within morphea, accompanied by autoimmune thyroiditis. Hyperkeratotic lesions developing within morphea plaques warrant histological evaluation for EPS and extended follow-up to monitor for recurrence. To our knowledge, this is only the second documented case of co-occurring EPS and morphea.