Ulcerated striae with breast fat herniation due to topical and oral steroid overuse

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A 28-year-old woman, diagnosed with pemphigus vulgaris since many years, presented with ulceration over right breast of one-year duration, which was preceded by striae at the same site, for which the patient was self-medicating with clobetasol cream for the last 6 months. The striae began ulcerating following prolonged clobetasol application; however, the patient kept applying clobetasol, which worsened the ulceration. It got further aggravated after the breast fat started herniating due to gravity. The patient was diagnosed with pemphigus vulgaris at ten years of age, and her treatment relied solely on oral and topical steroids without any history of use of rituximab or adjuvants. At the time of presentation, no active cutaneous or mucosal lesions suggestive of pemphigus were present in the patient, and the patient was on 10 mg prednisolone as monotherapy. On general examination, the patient’s weight was 90 kg and body mass index was 34;she had florid cushingoid features comprising of facial plethora, centripetal obesity with large purplish striae, pendulous breasts with areas of bruising, and telangiectasia. Multiple ulcers ranging in size from 8 cm x 7 cm to 1 cm x 1 cm on the right breast, inframammary and perimammary region, extending up to the depth of subcutis and with overhanging margins, were noted,with herniation of the pendulous mammary adipose tissue from the larger ulcer [Figure 1]. Similar ulcers ranging in size from 3 cm x 3 cm to 1 cm x 1 cm were noted in the left inframammary region. Extensive striae in the surrounding skin were also noted. Histopathological examination of the tissue from the edge of the ulcer showed healthy granulation tissue with no features suggestive of pemphigus. Tissue cultures were negative for bacteria, fungi, tubercular or non-tubercular mycobacteria. Based on the above findings, a diagnosis of corticosteroid-induced ulcerated striae was made. The patient was advised to stop topical clobetasol, and her oral prednisolone was tapered gradually in view of clinical remission of her pemphigus vulgaris. The patient was managed with negative pressure wound therapy and platelet-rich fibrin applied over the ulcer, along with general wound care to hasten the wound healing. After a month, there was considerable healing of all ulcers [Figure 2].

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Figure 1: Generalised striae distensae, telangiectasia, and herniation of mammary adipose tissue through the ulcer on right breast.

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Figure 2: Partially healed ulcer with granulation tissue on right breast after one month of therapy.

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Striae, commonly referred to as stretch marks, are a form of dermal scarring resulting from overstretching of the dermis. They can result from either physiological states such as pubertal growth spurt or pregnancy (striae gravidarum), or pathological states like endogenous corticosteroid excess or exogenous corticosteroid use.¹ They can also be associated with other conditions like Marfan syndrome, anorexia nervosa and chemotherapy.^1,2 Ulceration is an uncommon complication of striae, which can be seen in the setting of corticosteroid use and chemotherapy like bevacizumab. Various reports of ulcerated striae have been summarised in Table 1.^2-10 The index case was unique owing to the large size of the ulceration and breast fat herniation due to the presence of a large defect and gravity. Prolonged use of systemic and topical steroids is one of the major cause of ulcerations over striae.³ Other drugs that have been implicated in ulcerated striae include bevacizumab, hydroxyurea, and etretinate; attributed to ischaemia, reduced neoangiogenesis, and increased collagen and elastin turnover.^2,4 The treatment of ulcerated striae distensae can be challenging and usually involves stopping the implicated drug along with wound care. Diltiazem has been used in certain cases where relative ischaemia was present; however was deferred in the present case as the wounds were relatively large.⁵ The diagnosis of ulcerated striae is primarily clinical, based on meticulous history and examination, but investigations like histopathology and cultures may be required to rule out differentials like pyoderma gangrenosum, vasculitis and infectious causes. Awareness among clinicians about this uncommon entity is vital, as misdiagnosis may often lead to inadvertent treatment with steroids, leading to worsening.