Diffuse Dermal Angiomatosis Of The Breast In A 35-Year-Old Woman With Large Pendulous Breasts

Diffuse dermal angiomatosis of the breast in a 35year-old woman with large pendulous breasts A. Gan, J. Teoh, I. Narang, R. Hawari and M. Abid University Hospitals of Derby and Burton NHS Trust, Derby, UK A 35-year-old white woman with a background of smoking, myotonic dystrophy and atrial flutter on warfarin was initially seen by the breast surgeons with tender ulcerated plaques on both breasts. As the pathology was limited superficially, the breast team referred her to our dermatology service, and examination revealed erythematous-to-violaceous plaques with central ulceration on a background of large pendulous breasts. Several years earlier, she experienced similar lesions to her breasts to a milder extent, which spontaneously resolved. She had an unremarkable family history, and there were no recent changes to her medications, or any trauma to her breasts. Treatment with topical corticosteroid, oral doxycycline and high-dose oral prednisolone was ineffective. Differential diagnoses at this point included pyoderma gangrenosum and infective causes, although bilateral distribution would be unusual in such cases. An incisional biopsy subsequently revealed florid ectatic thin-walled blood vessel proliferation within the dermis, lined by reactive endothelial cells, with no cellular atypia or mitosis, surrounded by mild perivascular inflammation and fibrosis. There was no evidence of vasculitis and immunohistochemical staining for CD34 was positive, while human herpes virus 8 was negative. Putting the histological findings and clinical presentation together, a diagnosis of diffuse dermal angiomatosis (DDA) of the breast was made. She was advised to stop smoking and was referred to the vascular team to exclude any underlying vascular pathology. Furthermore, treatment with oral isotretinoin is being considered. DDA is a rare variant of reactive angioendotheliomatosis that tends to occur on the extremities or the breasts. Histologically, it exhibits the characteristic findings seen in our patient, with the addition of positive CD31 and ERG immunostaining, if available (Tollefson M, McEvoy MT, Torgerson RR, Bridges AG. Diffuse dermal angiomatosis of the breast: clinicopathologic study of 5 patients. J Am Acad Dermatol 2014; 71: 1212– 17). Angiogenesis is thought to be driven by tissue hypoxia and ischaemia, usually due to atherosclerotic processes, but other associations include hypercoagulable states, trauma, smoking and large, pendulous breasts. It may resolve spontaneously, as in our patient’s case initially, but if not, it can be treated definitively by means of revascularization procedures, reduction mammoplasty or surgical excision. Conservative management with oral corticosteroids, pentoxifylline/aspirin or isotretinoin may also be considered, although their efficacy is undetermined (Nguyen N, Silfvast-Kaiser AS, Frieder J et al. Diffuse dermal angiomatosis of the breast. Proc (Bayl Univ Med Cent) 2020; 33: 273–5). Although rare, dermatologists should recognize DDA as a potential diagnosis in patients with purpuric ulcerating plaques on the breasts. DP16 Severe, ulcerative cold panniculitis following COVID-19 infection S. Cameron, S. McCarthy, P. Mitra and S. Wakelin St Mary’s Hospital and Cellular Pathology Services, London, UK A previously healthy 19-year-old riding instructor developed clusters of painful swellings on her anterolateral and medial thighs in November, a month after polymerase chain reactionconfirmed SARS-CoV-2 (COVID-19) infection. She had no ongoing systemic symptoms excepting fatigue. Lesions began as inflamed urticated plaques, evolving into dusky indurated macules with some central ulceration and crusting. Lesions were noticeably colder than the unaffected skin on palpation. She was advised to stop riding, dress warmly and was treated with topical clobetasol propionate and a short course of oral antibiotics. A microbial skin swab was negative and routine bloods, including full blood count, erythrocyte sedimentation rate, C-reactive protein, antinuclear antibodies and complement C3 and C4, were normal. Skin biopsy of a lesion, present for approximately 2 months, showed a mild superficial and deep perivascular, perifollicular and perieccrine chronic lymphocytic inflammatory infiltrate with occasional plasma cells. Inflammation extended into fat lobules and was more prominent at the dermal–subcutaneous interface. No evidence of vasculitis was seen. The histological features were consistent with perniosis, and, in this context, cold panniculitis. Her lesions have persisted for over 3 months, despite avoiding cold temperatures. Cold panniculitis of the thighs has been described in young female equestrians during the winter months and is thought to arise as a result of cold exposure, as well as the constricting effect of tightly fitting jodhpurs. Histology typically shows inflammation of the veins most prominent at the dermal–subcutaneous fat junction. Various cutaneous and vascular manifestations have been reported in association with COVID-19 infection, including perniosis (‘COVID toes’), which typically occur as a late sequelae in fit young adults (Freeman EE, McMahon DE, Lipoff JB et al. The spectrum of COVID-19-associated dermatologic manifestations: an international registry of 716 patients from 31 countries. J Am Acad Dermatol 2020; 83: 1118–29). Eosinophilic panniculitis in association with COVID-19, manifesting with erythema nodosum-like lesions, has also been reported (Suter P, Mooser B, Thien HP. Erythema nodosum as a cutaneous manifestation of COVID-19 infection. BMJ Case Rep 2020; 13: e236613). Owing to the severe and recalcitrant nature of our patient’s panniculitis, and its onset shortly after SARS-CoV-2 infection, it may represent a further unreported cutaneous manifestation of COVID-19.