Lichen myxedematosus in a patient with hepatocellular carcinoma.

Abstract

S ir, Lichen myxedematosus (LM), or papular mucinosis, is a rare disorder characterized by a cutaneous eruption consisting of waxy papules with extensive thickening and hardening of the skin involving the arms, face and, to a lesser extent, the trunk and lower extremities. The skin changes are due to the deposition of mucin and proliferation of fibroblasts in the dermis. The cause of LM is unknown but monoclonal paraproteinaemia of the IgG‐lambda type is commonly found. LM shows a fluctuating but progressive course and does not remit spontaneously. Treatment remains unsatisfactory and may be required for considerable cosmetic disturbance and morbidity. Here we report a case of LM with concurrent development of hepatocellular carcinoma (HCC), which subsided following tumour resection. A 50‐year‐old male, who was a hepatitis C virus (HCV) carrier and an alcoholic, suffered from asymptomatic firm nodules of the lateral part of the eyebrows with diminished hair growth for 3 months, then multiple, grouped confluent skin‐coloured to erythematous papules and plaques appeared over the scalp, nape of the neck, upper back and anterior chest ( Fig. 1a). Similar lesions over the hands, with numbness, were also found. Biopsies from the scalp, eyebrow and left hand showed fragmentation and separation of collagen bundles with mucin deposition throughout the upper dermis confirmed by alcian blue at pH 2·5 (Fig. 1c). Large stellate elongated fibroblasts were present within the mucinous stroma. A series of examinations revealed elevated serum α‐fetoprotein level at 43·03 ng mL−1 (normal range < 10), abnormal liver function test (AST 69 U L−1 ALT 86 U L−1), polyclonal gammopathy, carpal tunnel syndrome, and hypertension. Abdominal computed tomography demonstrated a 1·5‐cm contrast‐enhanced tumour in segment 8 of the liver. Segmentectomy of the liver was performed and pathology revealed grade III HCC of trabecular type. Therefore LM associated with HCC was diagnosed. The numbness of his hands was relieved shortly after the surgical intervention. The polyclonal gammopathy did not significantly alter (IgG 2800 mg dL−1 before surgery and 2250 mg dL−1 six months later; normal range 735–1770 mg dL−1). The patient was observed for 7 months. Progressive improvement of the skin lesions with regrowth of the eyebrows was noted without further treatment (Fig. 1b).