Atrophoderma of Pasini and Pierini Address for Correspondence: Dr

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Letters to the Editor

number of seborrheic keratoses, sometimes well over 100, and he had not taken any treatment for them. These patches present a particular challenge, if the patient wishes to have were depressed below the level of skin surface with well- them removed given the limitations on performing multiple defined border giving an impression of “cliff drop” appearance surgeries.[1] [Figure 1]. There was no induration, tenderness but slight atrophy was perceived. The lesions were nonprogressive. Treatment option of surgical excision in multiple sittings was There was no history of any trauma, infection, or ulceration declined by the patient. Involvement of palms and soles and at the sites. Laboratory examination including total and extensive verrucous seborrheic keratosis mimicking deep differential lymphocytic count, erythrocyte sedimentation mycoses hitherto unreported were interesting observations in rate, renal function tests, liver function test, and antinuclear this therapeutically challenging case. antibody test were within normal limits. Chest X-ray was normal. Histopathological examination revealed normal Gurcharan Singh, Prathima Koratagere Murudaraju epidermis, hyalinization of collagen in dermis with minimal Department of Dermatology and Pathology, Raji’s Skin Care scattered inflammatory infiltrate. Dermis was slightly reduced Centre and Cauvery Medical Centre, Bangalore, India in thickness [Figures 2 and 3] as compared with normal adjacent skin. A diagnosis of atrophoderma of Pasini and Pierini Address for correspondence: Dr. Gurcharan Singh, (APP) was made on the basis of clinical and histopathological 108-A, Jal Vayu Vihar, Kammanahalli, Bangalore-560 043, India. E-mail: [email protected] examination.

[1] Access this article online In 1923, Pasini described the entity under the name progressive idiopathic atrophoderma. In 1936, in Argentina, Quick Response Code: Pierini and Vivoli[2] extensively studied and defined the Website: www.idoj.in condition and its possible link to morphea. In 1958, Canizares et al.[3] reviewed Pierini’s findings and renamed it idiopathic DOI: APP. Canizares et al. believed that idiopathic APP differed 10.4103/2229-5178.86011 sufficiently from morphea to classify it as a distinct entity. In 2000, Yokoyama et al.[4] reported that skin glycosaminoglycans extracted from idiopathic APP lesions are different from those in REFERENCES typical morphea lesions. The cause of APP is not known. The pathophysiologic events that cause the discrete lesions seen 1. Hafner C., Vogt T. Seborrheic keratosis. J Dtsch Dermatol Ges clinically, as well as the timing of their appearance, are also 2008;6:664-77. 2. Dsousa M, Garg RB, Reddy BS, Ratnakar C. Lepromatous leprosy with unknown. Some authors have suggested a role for infection with extensive truncal seborrheic keratosis with acral verruca vulgaris. Int J Borrelia burgdorferi. APP is a benign, asymptomatic disease Dermatol 1994;33:498-500. and is not associated with any significant complications or 3. Stefanaki C, Rozakou A, Stefanaki K, Christofidou E, Antoniou C. Giant mortality. It usually begins insidiously in individuals during the perianal seborrhoeic keratosis mimicking Condylomata acuminata. Int second or third decade of life. However, it has been described J STD AIDS 2009;20:213-4. 4. de Giorgi V, Massi D, Salvini C, Mannone F, Carli P. Pigmented in individuals as young as 7 years old and as old as 66 years, [5] seborrheic keratoses of the vulva clinically mimicking a malignant with one report of congenital atrophoderma. melanoma: A clinical, dermoscopic-pathologic case study. Clin Exp Dermatol 2005;30:17-9. The precise classification and exact nosology of APP have 5. MabuchiT, Akasaka E, Kondoh A, Umezawa Y, Matsuyama T, Ozawa always been a matter of debate. Some authors believe it to be A. Seborrheic keratosis that follows Blaschko’s lines. J Dermatol 2008;35:301-03. a variant of localized scleroderma or morphea on the basis of 6. Ghosh SK, Bandyopadhyay D, Sarkar S. Myiasis in a large perigenital certain clinical or histopathological grounds. These are sclerosis seborrheic keratosis. Indian J Dermatol 2010;55:305-6. and induration in some lesions of APP. Morphea and APP were observed in the same patient; in its late atrophic stage, lesions of morphea resemble APP and homogenization of collagen and a perivascular lymphocytic infiltrate are common Atrophoderma of Pasini and histological features seen in morphea and APP.[6] However, there are certain features which suggest that APP and morphea Pierini are different entities. Morphea characteristically begins as a discrete circumscribed, erythematous-to-sclerotic plaque, Sir, often with a white center and characteristic peripheral lilac A 38-year-old man was under treatment for cutaneous rim. APP lack sclerosis, and lesions commonly coalesce over leishmaniasis (single lesion) in our department. The skin time, producing a moth-eaten appearance that is not consistent examination revealed multiple asymptomatic, hyperpigmented with morphea.[7] patches of various sizes (2 to 6 cm) over back and thighs, which according to the patient were present since childhood APP is a form of dermal atrophy that manifests as single or

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Figure 1: Multiple well-defined depressed plaque over back

Figure 2: Normal epidermis, dense collagen bundles in dermis, and minimal inflammatory infiltrate (H and E, ×10)

thickness is reduced. The sweat glands and the pilosebaceous units are not affected. The appendages are preserved. Elastic fibers appear normal after elastic tissue staining and with electron microscopic studies.[6] No effective treatment is available for APP. Topical and systemic steroids, antimalarials, D-penicillamine, antibiotics, and phototherapy have been used with variable efficacy. Q-switched alexandrite laser (755 nm) was found to be effective in diminishing the hyperpigmentation by 50% after three treatments in one case.[8]

APP should always we differentiated from morphea so as to Hyalinization of collagen with minimal inflammatory infiltrate Figure 3: avoid unnecessary treatment to the patient. in dermis (H and E, ×100)

Anubhav Garg, Pramod Kumar1 multiple sharply demarcated, round to oval, hyperpigmented, Department of Dermatology, Venereology and Leprosy, RNT nonindurated patches of varying sizes ranging from few Medical College, Udaipur, Rajasthan, and 1Department of millimeters to several centimeters. The lesions may be discrete Dermatology, Venereology and Leprosy, Kasturba Medical College, or confluent and are usually asymptomatic and do not show any Mangalore, Karnataka, India signs of inflammation. These patches are marked by a slight Address for correspondence: Dr. Anubhav Garg, depression of the skin with an abrupt edge often exhibiting a 71-A, Madhuban, Hospital Road, Udaipur – 313001, Rajasthan, India. “cliff-drop border,” usually on the backs of adolescents or young E-mail: [email protected] adults. Another description commonly used is “footprints in the Access this article online snow,” characterizing the common oval shape of the depressed Quick Response Code: lesions. Histopathologic changes are often minimal and are notdiagnostic. The epidermis is usually normal or slightly Website: www.idoj.in atrophic. Interstitial edema and a mild perivascular infiltrate consisting of lymphocytes and histiocytes may be present. DOI: 10.4103/2229-5178.86012 Collagen bundles show varying degrees of homogenization and clumping. When compared with adjacent normal skin, dermal

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Letters to the Editor REFERENCES 5. Kim SK, Rhee SH, Kim YC, Lee ES, Kang HY. Congenital atrophoderma of Pasini and Pierini. J Korean Med Sci 2006;21:169-71. 1. Pasini A. Atrofodermiaidiopaticaprogressiva. G Ital Dermatol 6. Saleh Z, Abbas O, Dahdah MJ, Kibbi AG, Zaynoun S, Ghosn 1923;58:785. S. Atrophoderma of Pasini and Pierini: A clinical and histopathological 2. Pierini L, Vivoli D. Atrofodermiaprogressiva (Pasini). G Ital study. J Cutan Pathol 2008;35:1108-14. Dermatol 1936;77:403-9. 7. Jain A, De D, Dogra S, Saikia UN. Depressed plaques over back in a 3. Canizares O, Sachs PM, Jaimovich L, Torres VM. Idiopathic 35-year-old male. Indian J Dermatol Venereol Leprol 2010;76:305-6. atrophoderma of Pasini and Pierini. AMA Arch Derm 1958;77:42-58; 8. Arpey CJ, Patel DS, Stone MS, Qiang-Shao J, Moore KC. Treatment of discussion 58-60. atrophoderma of Pasini and Pierini-associated hyperpigmentation with 4. Yokoyama Y, Akimoto S, Ishikawa O. Disaccharide analysis of skin glycosaminoglycans in atrophoderma of Pasini and Pierini. Clin Exp the Q-switched alexandrite laser: A clinical, histologic, and ultrastructural Dermatol 2000;25:436-40. appraisal. Lasers Surg Med 2000;27:206-12.

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