How would you diagnose this patient’s 3-year rash?

A 68-year-old female presented with a 3-year history of an asymptomatic 6 cm macular patch on her right breast. She said that the results of a previous biopsy had come back negative and that she has had normal mammograms subsequent to the rash. She is otherwise healthy and has no other rashes.

How would you diagnose this patient?

A. Morphea
B. Lichen sclerosus 
C. Dermatophyte infection
D. Vitiligo
E. Paget’s disease

(Answer and discussion on next page)

Answer: Morphea

An outside review of the histopathology reports supported the clinical diagnosis of morphea. This benign condition usually runs a self-limited course of several months to years and is typically not responsive to therapy, though anecdotal reports exist of occasional successes. 

Differential diagnosis. Dermatophyte infections typically are pruritic and will continue to enlarge. Vitiligo would have a more pronounced depigmentation than is seen here. Paget’s disease would be expected to be more erythematous. Lichen sclerosus is in the differential and requires a skin biopsy for differentiation.