Dermatology: Practical and Conceptual


Image Letter | Dermatol Pract Concept. 2023;13(4):e2023218 1

Wide-spread Pruriginous Lesions 
with Flagellate Scarring

He Fu1, Cheng Tan1

1 Department of Dermatology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China

Citation: Fu H, Tan C. Wide-spread Pruriginous Lesions with Flagellate Scarring. Dermatol Pract Concept. 2023;13(4):e2023218. 
DOI: https://doi.org/10.5826/dpc.1304a218

Accepted: April 13, 2023; Published: October 2023

Copyright: ©2023 Fu 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: All authors have contributed significantly to this publication.

Corresponding Author: Cheng Tan, MD, Department of Dermatology, Affiliated Hospital of Nanjing University of Chinese Medicine, 
155 Hanzhong Road, Nanjing, China, 210029. Phone No: +862586617141 E-mail: tancheng@yeah.net

Case Presentation

A 47-year-old man had pruriginous nodules evolving into 

flagellate scarring for 5 years. Family history was negative. 

On examination, pruriginous papules and nodules were 

present on the trunk and extremities associated with hyper-

trophic scars in a flagellate or linear configuration (Figure 1). 

A biopsy of a pruritic papule showed a subepidermal blis-

ter with a dermal proliferation of fibroblasts. The mutation 

was identified in the COL7A1 gene: c.6846G>C, compatible 

with epidermolysis bullosa pruriginosa (EBP). Thalidomide 

100 mg/day was used for three months with some relief from 

itching.

Teaching Point

EBP is a hereditary disease that commonly arises in infancy 

or early childhood. Occasionally, it occurs in the third decade 

or the fifties. EBP starts as pruriginous papules or plaques 

associated with intense itch. Due to scratching, makes in-

tact blister are rarely observed. Recurrent excoriations may 

stimulate skin to develop hypertrophic scars in a linear or 

figurate configuration [1]. Histology shows cell-poor sub-

epidermal splits or blisters. Direct and indirect immunoflu-

orescence studies are negative. EBP can be confirmed by a 

mutation analysis of COL7A1, which disrupts the normal 

functions of anchoring fibrils and leads to sublamina densa 

blistering.

The late-onset and widespread lesion in EBP differs 

from the pretibial form of dystrophic epidermolysis bullosa. 

The intense pruritus in EBP may similarly appear in lichen 

 simplex, nodular prurigo, pemphigoid nodularis, and li-

chen planus. The subepidermal blistering made all these 

skin  disorders unlikely in our patients. Treatment strat-

egies for this  condition include topical and intralesional 

 corticosteroids,  thalidomide, cyclosporine, phototherapy, 

and dupilumab. However, most patients are refractory to 

them [2].



2 Image Letter | Dermatol Pract Concept. 2023;13(4):e2023218

Figure 1. (A) Numerous violaceous papules and nodules are seen on the trunk and extremities with excoriations. (B) Hypertrophic scars are 

scattered among them or arranged in flagellate or linear configurations.

References

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PMID: 23616197.2. Clawson RC, Duran SF, Pariser RJ. Epi-

dermolysis bullosa pruriginosa responding to dupilumab. JAAD 

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