A 37-year-old woman presented with a 10-year history of an asymptomatic, slowly enlarging atrophic plaque located on the left shoulder. A punch biopsy had been performed 5 years ago but was not diagnostic; annual follow-up had been advised by her previous dermatologist. She was otherwise healthy and had no systemic symptoms. There was no history of trauma to the area. Physical examination showed 1×1.5 cm smooth, depressed yellowish plaque with telangiectases on the left shoulder. On palpation the lesion was atrophic but indurated ( Figure 1a).Dermatoscopic examination revealed arborizing telangiectasias, and yellowish background coloration ( Figure 1b). No pigment network, pores or hair shafts were seen.A 4-mm punch biopsy was performed. Histopathological examination revealed a severely atrophic epidermis and dermis with decreased appendageal structures and a monomorphic dermal spindle cell proliferation infiltrating the subcutaneous fat tissue in a honeycomb pattern. This pattern suggested the atrophic variant of dermatofibrosarcoma protuberans (DFSP). Immunohistochemistry using anti-CD34 antibody revealed that spindle cells were positive, confirming the diagnosis (Figure 2). The previous biopsy performed 5 years earlier was re-examined by a dermatopathologist and similar histopathological features were noticed. The lesion was totally excised with a margin of 5 cm. Histopathology revealed that tumor cells deeply infiltrated subcutaneous tissue and were detected as close as 1.60 mm to the excision margin despite wide excision. As the patient refused additional surgery, adjuvant radiation therapy was performed. The patient remained disease free for 6 months after surgery and is still in close follow-up.DFSP is a locally aggressive, slowly growing mesenchymal neoplasm with a high rate of local recurrence [1]. Atrophic DFSP was first described by Lambert et al. [2] in 1985 as a clinical variant of DFSP. Classical DFSP usually appears as an indurated, exophytic, asymptomatic, flesh-to-red/brown plaque [1]. Atrophic DFSP most commonly presents as an asymptomatic, slowly growing, atrophic, and morphea-like plaque [2]. The clinical diagnosis of atrophic DFSP remains difficult because the lesion often resembles an atrophic plaque rather than having the typical protuberant morphology.
Based on these results, long-pulsed Nd:YAG laser can be used as an effective treatment for onychomycosis, but further studies are needed to draw firmer conclusions.
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