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What Caused This Refractory Unilateral Pruritic Hyperpigmented Eruption?

What Caused This Refractory Unilateral Pruritic Hyperpigmented Eruption?

DermDx Figure 1

A 29-year-old otherwise healthy Asian woman presented with refractory and debilitating bouts of itching limited to the right lateral knee (Figure 1), right lower leg, and right dorsal foot (Figure 2) for more than 5 years’ duration. She had seen multiple dermatologists for resultant right leg prurigo nodules, hyperpigmentation, lichenification, and more than 40 to 50 raised, rough, wart-like papules. Her left leg was completely clear and the remainder of the physical exam was unremarkable. One dermatopathology report of a biopsy of the right knee dated 3 years prior noted papulosquamous dermatitis, lichenified with no evidence of psoriasis. 

DermDx Figure 2

Examination of the low back confirmed moderate spinal tenderness over the fourth lumbar through first sacral vertebrae that was associated with bilateral muscle spasm, particularly of the left side. Pertinent history included a motor vehicle accident several years prior and periods of extended daily driving for work. Patient denied debility or pain in the neck or back. 

She had failed to improve despite numerous past therapies, including potent topical and intralesional steroids, phototherapy with narrowband UV-B, steroid-impregnated tape, and oral and topical antihistamines.

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