A 57 Year Old Woman with Widespread Scales and Scattered Erosions

Abstract

In November 2010, a 59-year-old female of Indonesian background presented with a 3 year history of a deteriorating and widespread scaly rash. She has no other medical history and had been on no medications. She reported her rash had been diagnosed as “eczema” and could not recall how her rash initially developed. On examination, she had an exfoliative erythroderma with thick scales over her face, trunk, hands and feet (Figs. 12.1, 12.2, and 12.3). Amongst the scales there were several shallow erosions. Her palms and feet were hyperkeratotic. However her mucosal membranes were spared. On further questioning, it was found that she had had skin biopsies taken from her arms and cheek for the same problem at another dermatology institution in 2008. Retrieval of the biopsy report revealed focal superficial acantholysis in the subcorneal zone with parakeratosis and hyperkeratosis. Direct immunofluorescence was negative but indirect immunofluorescence showed intercellular IgG in the epidermis, including at the surface. A diagnosis was made with the combination of clinical presentation, histopathology and immunofluorescence in 2008. However as the patient had been lost to follow-up, she was not informed of her diagnosis nor had been on any treatments for it. A repeat biopsy for direct immunofluorescence was positive between the keratinocytes for IgG.