Cutaneous Amyloidosis, Dermatology, Lichen Amyloid, Pruritus, Teledermatology



  1. Zumwalt, Michael
  2. Jacob, Sharon E.


ABSTRACT: Teledermatology is a term to describe the provision of dermatologic medical services through telecommunication technology. This is a case of itchy cobblestoned papules on the shins.


Article Content

In the store-and-forward teledermatology modality, there is a transfer of patient medical information electronically (including history and visual data) obtained in one location to a provider who is in another location (Roman & Jacob, 2015). The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.



Teledermatology viewpoint: itchy cobblestoned papules on the shins.



Chief complaint: presenting for diagnosis of lesions on the shins.


History of present illness: A 32-year-old woman presents with an itchy rash on her shins. She has stopped shaving because of irritation. Prior treatment: none. Her primary symptoms: pruritus. Prior biopsy: none. She has no personal history of skin cancer. Other significant laboratory/study findings: none.



Fully satisfactory.



One image was provided of a patient's left lower anterior leg. The image shows hyperpigmented dome-shaped papules (appearing as cobblestones) with dusky erythema coalescing into plaques. There is evidence of excoriation (see Figure 1).

Figure 1 - Click to enlarge in new windowFIGURE 1. Hyperpigmented, dome-shaped, cobblestoned papules coalescing into plaques.


The morphology and distribution of the lesions are most consistent with the diagnosis of lichen amyloidosis.



Skin Care and Treatment Recommendations

Recommend prescribing clobetasol 0.05% ointment applied to the raised inflamed skin twice a day for 2 weeks, then once a day for 2 weeks, and then every other day. The patient should be reevaluated at 6 weeks and transitioned to a midpotency steroid, such as triamcinolone ointment 0.1%. The patient should be referred to dermatology for further management if no improvement is noted in 2-3 months.



Type of Visit

The patient should return to the primary care provider to initiate therapy.


Clinical Pearl

Lichen amyloid (LA) is caused by the deposition of amyloid proteins locally into otherwise normal skin, without internal organ involvement. The etiology and pathogenesis of LA remain unclear. Proposed precipitating factors include chronic skin irritation, viral infection, and genetic predisposition (Lin et al., 2005). LA is more common among Asian and South American populations. Men are affected more often than women, and the highest incidence is the fifth and sixth decades of life (Sezer, Erkek, & Sahin, 2014). The most common sites of LA include the pretibial area and other extremity extensor surfaces. The dermatosis typically presents as lichenified hyperpigmented cobblestoned papules coalescing into plaques with patients describing the main symptom being pruritus (Bolognia, Jorizzo, & Schaffer, 2012).


Unfortunately, LA is often difficult to treat, and no treatment regimen has been shown consistently to be curative. The mainstay of treatment is to stop the itch-scratch-itch cycle. The first-line therapy consists of a combination of topical corticosteroids and patient education utilizing cognitive therapy strategies. Other examples of LA therapy include intralesional steroids, dimethyl sulfoxide, topical calcineurin inhibitors, systemic retinoids, ultraviolet light phototherapy, cyclosporine, dermabrasion, and laser therapy, with variable results (Bolognia et al., 2012).




Bolognia J. L., Jorizzo J. L., Schaffer J. V. (2012). Dermatology (3rd ed.). Atlanta, GA: Elsevier. [Context Link]


Lin M. W., Lee D. D., Lin C. H., Huang C. Y., Wong C. K., Chang Y. T., Tsai S. F. (2005). Suggestive linkage of familial primary cutaneous amyloidosis to a locus on chromosome 1q23. The British Journal of Dermatology, 152(1), 29-36. [Context Link]


Roman M., Jacob S. E. (2015). Teledermatology: Virtual access to quality dermatology care and beyond. Journal Dermatology Nurses Association, 6(6), 285-287. [Context Link]


Sezer E., Erkek E., Sahin S. (2014). Widespread pruritic papules on the trunk and extremities. Dermatology Practical & Conceptual, 4(1), 51-52. [Context Link]


1The standardized teledermatology reader report format is available for authors on the submissions Web site and outlined in Table 1. [Context Link]