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Case Reports

Abstract

Mid-dermal elastolysis (MDE) is a rare condition characterized by selective loss of elastic tissue in the mid-dermis. While some cases of MDE are idiopathic, a subset of cases are associated with preceding inflammatory dermatoses. We report a case of a 73-year-old female who presented with multiple asymptomatic, skin-colored lesions on her trunk. The lesions first appeared on her upper back five years prior to presentation, and gradually progressed in a waxing and waning pattern. Her medical history was notable for immune thrombocytopenic purpura (ITP), previously treated with methylprednisolone, intravenous immunoglobulin, and rituximab. Physical examination revealed numerous sub-centimeter, skin-colored papules and macules—some with fine wrinkling—on the upper back and shoulders. The clinical differential diagnosis included MDE, anetoderma, pseudoxanthoma elasticum, and deposition disorders such as amyloidosis. A punch biopsy showed a well-demarcated area of perivascular and interstitial granulomatous inflammation and adjacent relatively normal appearing dermis with rare multinucleated giant cells. Verhoeff–Van Gieson (VVG) stain demonstrated marked loss of elastic fibers in the mid-dermis, adjacent to the inflammatory infiltrate. Gomori methenamine silver (GMS) and Fite stains were negative for microorganisms. In summary, the histopathologic findings were consistent with MDE. We hypothesize that this finding may be secondary to granulomatous inflammation. MDE has been reported in association with autoimmune conditions, particularly Hashimoto’s thyroiditis and lupus erythematosus. MDE associated with ITP or medications such as rituximab has not been previously reported.