Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2022;12(2):e2022063 1 Dermoscopic Keys in Extragenital Bullous Hemorrhagic Lichen Sclerosus Siddharth Mani, Bhavni Oberoi Department of Dermatology, INHS Asvini, Near RC Church, Colaba, Mumbai, India Key words: lichen sclerosus, hemorrhagic, dermoscopy, follicular plugs Citation: Mani S, Oberoi B. Dermoscopic keys in extragenital bullous hemorrhagic lichen sclerosus. Dermatol Pract Concept. 2022;12(2):e2022063. DOI: https://doi.org/10.5826/dpc.1202a63 Accepted: September 22, 2021; Published: April 2022 Copyright: ©2022 Mani et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: Both authors have contributed significantly to this publication Corresponding author: Bhavni Oberoi, Department of Dermatology, INHS Asvini, Near RC Church, Colaba, Mumbai- 400005 India. E-mail: bhavni.oberoi@gmail.com Introduction Lichen sclerosus (LS) is a chronic inflammatory dermatosis characterized by leukoderma and scarring, predominantly affecting the genital skin. It may sometimes involveextragen- ital areas. The suffix atrophicans is no longer used as a few cases are associated with hypertrophy rather than atrophy. Few atypical variants include bullous, hemorrhagic, pig- mented, verrucous, and keratotic forms. Herein, we report a case of extragenital bullous hemorrhagic lichen sclerosus with its dermoscopic features. Case Presentation A 40-year-old male presented with a nine-month history of a slow-growing asymptomatic raised lesion on his back asso- ciated with occasional bleeding episodes after casual trauma. There was no history of similar lesions in the past or else- where on the body. Physical examination revealed a solitary, well-defined, 2.5 cm × 2.0 cm, non-tender, hemorrhagic bulla with crusting in the center and atrophy in the surrounding area (Figure 1 A). Dermoscopy revealed superficial yellowish white and hemorrhagic crusts, follicular plugs, and multi- colored diffuse hemorrhagic area with varying shades rang- ing from black to red, with black color representing old hemorrhage and red color representing recent hemorrhage (Figure 1B). Surrounding skin revealed atrophy with follicu- lar plugs (Figure 1C). Based on the clinical and dermoscopic examination, we considered hemorrhagic lichen sclerosus, ir- ritated seborrheic keratosis, Bowen disease, and discoid lupus erythematosus as our differential diagnoses. Histopathology revealed follicular plugs, epidermal atrophy, subepidermal blister, and hyalinized compact collagen, which confirmed the case to be LS (Figure 1D). Discussion The extragenital form of LS is less common, and the bullous hemorrhagic form is very rare, with only a handful of cases in the literature. This form is generally associated with less pruritus and the absence of any malignancy, as seen in our patient as well. In our case, the lesion was present on the back, a site that has not been reported for this particular variant. The formation of bullous lesions has been described 2 Research Letter | Dermatol Pract Concept. 2022;12(2):e2022063 in LS. A possible explanation for the formation of bulla and hemorrhage could be the pronounced edema within the skin that disrupts the capillaries collagen support, predisposing them to rupture with minimal trauma or damage [1]. Conclusions Dermoscopy of extragenital LS has been described as white structureless areas, follicular plugs, white chrysalis-like structures, and variable vascular patterns being the essential components [2]. Our case had superficial yellowish white and hemorrhagic crusts, a multicolored (black to red) hem- orrhagic area, and a peripheral atrophic area with follicular plugs. There was no vascular pattern which commensurates with the chronicity of the lesion. The patient was managed with topical corticosteroids with a good response. This case report helps establish the fact that follicular plugs which have been reported in LS are seen in this rare variant also. In addition, the dermoscopic features of the hemorrhagic area of LS, which have not been previously described, have been Figure 1. A. A solitary, well defined, 2.5 cm × 2.0 cm, non-tender, hemorrhagic bulla with crusting in the centre and atrophy in the surrounding area. B. Dermoscopic examination of lesion shows superficial yellowish white and hemorrhagic crusts, follic- ular plugs and multicolored diffuse hemorrhagic area with varying shades ranging from black to red (black color representing old hemorrhage and red color indicating recent hemorrhage). Blue color indicates marking for biopsy site. C. Dermoscopic examination of surrounding skin shows atrophy with follicular plugs. D. Skin biopsy showing presence of follicular plugs, epidermal atrophy, subepidermal blister and hyalinized compact collagen (H&E x 40). Research Letter | Dermatol Pract Concept. 2022;12(2):e2022063 3 brought out. This report will enhance the existing repertoire of knowledge of dermoscopic features of LS which may aid diagnosis in future and avoid invasive procedures. References 1. Gómez-Calcerrada, del Cerro Heredero M, Sanchez MH, Fernan- dez RS, de Eusebio Murillo E, Yus ES. Bullous and hemorrhagic lesions. Arch Dermatol. 1999;135(1):81-86. DOI: 10.1001/arch- derm.135.1.81. PMID: 9935386. 2. Ankad BS, Beergouder SL. Dermoscopic patterns in lichen sclerosus: A report of three cases. Ind Dermatol Online J. 2015;6(3):237-240. DOI:10.4103/2229-5178.156450. PMID: 26009734. PMCID: PMC4439768.