Lichen myxedematosus associated with chronic hepatitis C

A 55-year-old woman presented with a 4-month history of sclerotic and thickened lichen myxedematosus (LM) cutaneous lesions on her face and trunk. She suffered from chronic hepatitis and had been seen by a physician for 8 months. Examination revealed an asymptomatic hard nodular lesion on her nose, multiple flesh-colored papules grouped on her nape, upper back, and chest, and painful swollen lesions on both of her hands (Fig. 1). Laboratory data indicated no abnormalities in peripheral blood count, serum gamma-globulin level, serum electrophoresis, immunoelectrophoresis, cryoglobulin, and rheumatoid factor. Triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) levels were normal; the anti-TSH receptor antibody test was negative with a slightly positive anti-TSH antibody. An antinuclear antibody was detected (x160; homogeneous). Serum immunoglobulin G (IgG) and IgM were elevated (2600 and 281 mg/dL, respectively), but IgA was within the normal range. Serum glutamate oxalacetate transaminase (GOT) and glutamate pyruvate transaminase (GPT) levels were elevated (231 and 219 IU/L, respectively). Both anti-hepatitis C virus (anti-HCV) antibodies [fluoro enzyme immunoassay (FEIA); 90.0 cut-off index (COI)] and HCV RNA (reverse transcriptase polymerase chain reaction) tests were positive (genotype IV2b), while the anti-hepatitis B antibody and hepatitis B antigen tests were negative. Serum hyaluronic acid was elevated (150 ng/mL). A biopsy of the cutaneous lesion revealed prominent edema between collagen fibers in the dermis, with accumulation of abundant mucinous material, ascertained by specific alcian blue and toluidine blue stains (Fig. 2). Chronic active hepatitis was identified by liver biopsy. Urinalysis revealed no abnormalities and Bence-Jones protein was not detected. A chest X-ray and electrocardiogram were normal. The cutaneous lesions started to resolve after 8 months of therapy with oral corticosteroid (betamethasone 1.5 mg/day).