DermaDiagnosis
Is It Ringworm, Herpes— Or Something Else Entirely?
A 16-year-old girl is referred to dermatology by her pediatrician for evaluation of a rash on her face. She is currently taking acyclovir (dose...
ANSWER
The correct answer is poikiloderma of Civatte (choice “c”), details of which are discussed below.
Poikiloderma vasculare atrophicans (choice “a”) can be an early indication of T-cell lymphoma but would probably not be chronic or confined to sun-exposed skin.
Several forms of lupus (choice “b”) can present with poikilodermatous skin changes, but these would probably not be chronic.
Dermatoheliosis (choice “d”) is the term for the collective effects of overexposure to the sun, of which poikiloderma of Civatte is but one example.
DISCUSSION
The French dermatologist Achille Civatte (1877-1956) first described this particular pattern of sun damage in 1923—about the same time that sunbathing became fashionable among the well-off in the post-WWI era. He noted the distinct combination of telangiectasias, hyperpigmentation, and epidermal atrophy affecting the bilateral neck and lower face, combined with sharply defined sparing of the portion of the anterior neck shaded by the chin. Poikiloderma of Civatte (PC) is extremely common, especially in middle-aged women and, as one might expect, in those with a history of excessive sun exposure over a period of many years.
Though sun-caused, PC is a purely cosmetic issue and does not lead to skin cancer. While it typically causes no symptoms, it does become more obvious with time. The changes are so gradual that others typically notice them before the patient becomes aware.
Transposing these types of skin changes to other locations would make them considerably more worrisome, specifically in the context of possible incipient T-cell lymphoma—one of the very few types of skin cancer that can take years to evolve into frank cancer. But the atrophy, telangiectasias, and discoloration signaling early cutaneous T-cell lymphoma are usually seen in non–sun-exposed skin, particularly in the waistline and groin.
Poikiloderma vasculare atrophicans is only one of several manifestations termed premycotic. This refers to mycosis fungoides, one of the two most common forms of T-cell lymphoma. Serial biopsy, sometimes over the span of several years, is often used to track such changes.
Pulsed light devices and certain types of lasers have been used successfully to treat PC. Our patient, however, declined treatment, declaring her firm intention to maintain “a healthy tan” year-round.
