Elastosis perforans serpiginosa.

A 22-year-old male patient, African descent, in august 2011, complained of “dots in his arms,” for one year duration, associated with slight pruritus. The patient had obesity level II and high blood pressure, on regular hydrochlorothiazide and losartan.

On clinical examination, erythematous papules with central crusts, coalescing to form serpiginous lesions were seen over arms, [Figures 1 and 2]. It was suggestive of elastosis perforans serpiginosa (EPS) and a biopsy was carried out in the right arm lesions.

Figure 1

Erythematous papules with central crusts, coalescing to form serpiginous lesions over right arm

Figure 2

Close up view of the right arm

Histopathological examination of the material, subjected to special Weigert staining, showed fragmented elastic fibers in the base of the perforation, with less intense staining of epidermal depression [Figures 3 and 4]. Therefore, the diagnosis was confirmed.

Figure 3

fragmented elastic fibers in the base of the perforation

Figure 4

less intense staining of epidermal depression

EPS is a rare skin condition included among the primary perforating dermatoses of dermal origin characterized by the transepidermal extrusion of elastic fibers. The etiopathogenesis may be considered idiopathic or associated with Down's syndrome, hereditary diseases of the connective tissue, and the use of D-penicillamine.[1] EPS should be suspected in a patient presenting with keratotic papules, asymptomatic or pruriginous plaques grouped in an arciform or serpiginous pattern. The diagnosis is confirmed by histopathology (gold standard). Clinically, the differential diagnoses are granuloma annulare, tinea corporis, annular sarcoidosis, cutaneous calcinosis, and porokeratosis of Mibelli. The treatment options explored in published articles were cryotherapy, topical tretinoin, 0.1% tazarotene gel, oral isotretinoin, imiquimod, carbon dioxide laser (CO2 laser) and pulsed dye laser, all these results with some constant, varying greatly between authors.[234]

In this case, patient was given the option of treatment with CO2 laser and cryotherapy. The patient opted for cryotherapy and after the first session, the lesions showed partial improvement, with mild hypochromia in some larger lesions.