Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
Therapy Letters
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letter to the Editor
doi: 10.4103/0378-6323.82394
PMID: 21727707

Co-existent acquired perforating collagenosis and lepromatous leprosy with erythema nodosum leprosum: Response to treatment

Lipy Gupta1 , Archana Singal1 , Deepika Pandhi1 , Sonal Sharma2
1 Department of Dermatology, University College of Medical Sciences and GTB Hospital, University of Delhi, Delhi-110 092, India
2 Department of Pathology, University College of Medical Sciences and GTB Hospital, University of Delhi, Delhi-110 092, India

Correspondence Address:
Archana Singal
B-14, Law Apartments, Karkardooma, Delhi-110092
How to cite this article:
Gupta L, Singal A, Pandhi D, Sharma S. Co-existent acquired perforating collagenosis and lepromatous leprosy with erythema nodosum leprosum: Response to treatment. Indian J Dermatol Venereol Leprol 2011;77:520-522
Copyright: (C)2011 Indian Journal of Dermatology, Venereology, and Leprology


Acquired perforating collagenosis (PC) is an uncommon, benign perforating dermatosis of multifactorial etiology in which the collagen is extruded through the epidermis. It presents as skin colored or erythematous papules with central plugging. Inherited and acquired forms exist. The latter presents in adulthood, and is associated with systemic disorders [1] such as diabetes and renal disease in majority of the cases. We report a the case of lepromatous leprosy with erythema nodosum leprosum (ENL) along with PC lesions that resolved following antileprosy treatment and treatment of reaction.

A 60-year-old man presented with multiple erythematous papules and plaques on the face, trunk, and on proximal limbs of 6 months duration. Four months later he developed recurrent crops of multiple erythematous, painful papulo-nodular lesions that resolved spontaneously within 3-5 days with cyanotic discoloration. In addition, the patient reported multiple, pruritic, persistent, umbilicated lesions interspersed with the papulo-nodular lesions [Figure - 1]. He had paresthesia of hands and feet, unnoticed burns and slippage of footwear. There was no history of trauma. Similar complaints were not present in the family members.

Figure 1: Perforating collagenosis lesions interspersed with ENL lesions on the background of diffuse infiltration over the buttock before treatment

Dermatological examination revealed diffuse infiltration of the face, ear lobules and buttocks and multiple, erythematous ill-defined minimally anesthetic plaques over face, trunk, and proximal limbs. Bilateral greater auricular, ulnar, radial cutaneous, common peroneal, and posterior tibial nerves were enlarged and nontender. Sensory examination revealed glove and stocking anesthesia up to knees and elbows. Clawing of toes was present.

Hematological investigations including complete hemogram, liver and kidney function tests including creatinine clearance, and X-ray chest were within normal limits. Slit skin smear was positive for acid-fast bacilli with a bacteriological index (BI) of 4+. Skin biopsy from the tender nodule demonstrated sheets of foamy macrophages and neutrophils in the dermis along with necrotizing vasculitis affecting the venules and capillaries and foci of collagen necrosis in the dermis, consistent with the diagnosis of lepromatous leprosy with the erythema nodosum leprosum. Biopsy from the umbilicated papule demonstrated epidermal hyperkeratosis, acanthosis and, follicular and extrafollicular plugging. The plugs extended up to the upper dermis forming vertical channels filled with parakeratotic keratin, collagen, and pyknotic nuclei [Figure - 2]. The collagen in the dermis demonstrated basophilia which stained red with van Gieson′s stain corroborating the clinical diagnosis of PC. Thus the patient was labeled to have lepromatous leprosy (LL) with ENL with coexistent PC lesions and was started on multibacillary multidrug therapy. Clofazimine 100 mg thrice daily and oral paracetamol 500 mg thrice daily were administered for the management of reaction along with liquid paraffin topically. Two month following treatment, the ENL lesions resolved completely. New PC lesions ceased to appear, while majority of the older ones healed with atrophic scarring [Figure - 3].

Figure 2: Skin biopsy from perforating collagenosis lesion showing epidermal hyperkeratosis, acanthosis, and transepidermal elimination of collagen fibres from the defect in the epidermis as shown by the arrow (H and E, ×100)
Figure 3: Post-treatment, most perforating skin lesions healing with atrophic scars with a closer view of the same in the inset

Transepidermal elimination disorder is characterized by elimination of foreign material from the corium by upward movement of regenerating epithelial cells. PC is a perforating disorder characterized by extrusion of collagen. Acquired PC is most commonly associated with diabetes and renal disease. [1] Dermatological pruritic disorders such as scabies, atopic dermatitis, insect bites, and lichen amyloidosis have been anecdotally reported with PC.

In genetically predisposed individuals, trauma in the form of intense pruritus and subsequent scratching is a common inciting factor for cutaneous and histopathological changes. [2] Trauma leads to release of matrix metalloproteinases (MMP) and serine proteases which transgress the epithelium and digest the extra cellular matrix components contributing to the formation of perforating lesions. [3] This may also lead to a damage in the basement membrane structures by cleaving the anchoring fibrils and collagen IV. [4] The infiltrating leucocytes release various cytokines in the surrounding tissue, such as IL-1 and TGF-beta, which are important modifiers of MMP activation.

Coexistent PC and leprosy has been reported on very few occasions. Patki et al.[5] reported two cases of coexistent leprosy with reactive PC. [5] In the present case, PC lesions were widespread, involving the proximal extremities and trunk interspersed among the lepromatous nodules and ENL lesions where trauma could not be incriminated as an inciting factor. These lesions were present simultaneously at the time of the patient′s first visit.

ENL is an immune complex phenomenon in which fibrinoid degeneration of the collagen and elastic fibers occurs. [6] Probably, in genetically predisposed individuals inflammatory insult occurring in type II lepra reaction results in the release of cytokines and other inflammatory mediators that damage the dermal collagen including collagen at the basement membrane zone, initiating the development of perforating skin lesions. This hypothesis is further supported in the study by Herzinger et al.[7] who observed extrusion of type IV collagen by special staining techniques. [7] Improvement and subsidence of these lesions following treatment of leprosy and of reaction corroborate the aforesaid hypothesis.

Mehregan AH, Schwartz OD, Livingood CS. Reactive perforating collagenosis. Arch Dermatol 1967;96:277-82.
[Google Scholar]
Poliak SC, Lebwohl MG, Parris A, Prioleau PG. Reactive perforating collagenosis associated with diabetes mellitus. N Engl J Med 1982;306:81-4.
[Google Scholar]
Patterson JW, Brown PC. Ultrastuctural changes in acquired perforating dermatosis. Int J Dermatol 1992;31:201-5.
[Google Scholar]
Briggaman RA, Schechter NM, Fraki J, Lazarus GS. Degradation of the epidermal-dermal junction by proteolytic enzymes from human skin and human polymorphonuclear leukocytes. J Exp Med 1984;160:1027-42.
[Google Scholar]
Patki AH, Mehta JM. Coexistent lepromatous leprosy and reactive perforating collagenosis. Cutis 1991;48:137-40.
[Google Scholar]
Ridley MJ, Ridley DS. The immunopathology of erythema nodosum leprosum: The role of extravascular complexes. Lepr Rev 1983;54:95-107.
[Google Scholar]
Herzinger T, Schirren CG, Sander CA, Jansen T, Kind P. Reactive perforating collagenosis-transepidermal elimination of type IV collagen. Clin Exp Dermatol 1996;21:279-82.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections