A case of radiation-induced bullous morphea/lichen sclerosus overlap in a breast cancer patient

Abstract

Radiation induced morphea (RIM) is an increasingly common complication of radiation treatment for malignancy as early detection has made more patients eligible for non-surgical treatment options. In many cases, the radiation oncologist is the first person to learn of the initial skin changes, often months before a dermatologist sees them. In this paper we present a breast cancer patient who developed a rare bullous variant of RIM, which delayed her diagnosis and subsequent treatment. It is imperative to diagnose RIM early as it carries significant morbidity and permanent deformity if left untreated. The lesions typically present within 1 year of radiation therapy and extend beyond the radiated field. RIM is often mistaken for radiation dermatitis or cellulitis. Bullae, when present, are often hemorrhagic in appearance, which can serve as another clinical clue. It is important to refer these patients for a full gynecologic exam as there can be concurrent anogenital lichen sclerosus et atrophicus which is both debilitating and carries a long term risk for squamous cell carcinoma. Treatment with systemic agents is often necessary, and can be managed by a dermatologist. The most proven regimen in the literature appears to be methotrexate, with our without concurrent narrow band UVB phototherapy.

Dermal Hemorrhage: A Clue to Lichen Sclerosus et Atrophicus

“…Patients with extragenital hemorrhagic and/or bullous LSA can either present with localized isolated plaques or more extensive lesions with the latter being more difficult to treat. Bullous and non-bullous extragenital LSA have also been reported in association with idiopathic morphea as well as radiation-induced morphea [8,9]. However, overlap between morphea and LSA is unlikely in our patient due to different histopathological features.…”

An unusual presentation of localized bullous morphea

“…Morphea and LS are both considered autoimmune phenomena [7]. In their typical form, the two diseases are often distinguishable clinically and histologically.…”

Bullous hemorrhagic lichen sclerosus of the breast: a report of two cases and review of the literature

“…Bullous hemorrhagic LS of the breast is exceedingly rare with very few reports in the literature (Table 1), [7][8][9][10][11][12]. Several of these cases were associated with previous radiation treatment for breast cancer and two of these cases arose within [9] and concurrently [12] with post-irradiation morphea. A separate series examining cases of post-irradiation morphea found histological evidence of concurrent LS and morphea in two of the five cases examined [13].…”