Abstract
A 76-year-old woman with a known history of systemic lupus erythematosus (SLE), managed by azathioprine and low-dose prednisone, and atrial fibrillation on apixaban presented with a 30-year-history of a non-healing, painful, left leg ulcer that had started in an area with clinically and tissue-confirmed lupus-related small vessel vasculitis. She had been managed with regular debridement and compression, in addition to intermittent antibiotics for recurrent infection.
Blood pressure, pulse, and temperature were 91/62 mmHg, 103 beats per minute, and 98.6 °F, respectively. As shown in Panel A, the physical exam revealed multiple full thickness ulcers over the left medial distal leg (black arrows), the largest of which measured 8 × 4.5 cm (blue arrow) with nodular changes, induration, fibrinous cap, and surrounding erythema, but no foul-smelling discharge. Scattered left leg varicose veins (green arrows) and mild ankle edema were also noticed. The rest of the exam was unremarkable.
Pertinent laboratory results included a white blood cell count of 10.6 × 1000/mm3, hemoglobin of 7.7 g/dL, platelet count of 518 × 1000/mm3, an elevated erythrocyte sedimentation rate of 80 mm/hour, and C-reactive protein of 4.5 mg/L. Wound culture was unremarkable. Left lower extremity venous ultrasound revealed chronic nonocclusive thrombosis of the left common femoral, femoral, and popliteal veins. Segmentally incompetent left greater saphenous vein between the distal thigh and distal calf was observed. As shown in Panel B, a punch biopsy revealed full replacement of the epidermis by malignant cells (black arrows) consistent with squamous cell carcinoma (SCC) with positive margins.
Management included non-adhesive foam dressing and compression wraps. She was continued on appropriate apixaban dosage and was referred to a dermatologist for appropriate SCC treatment.
Marjolin’s ulcer (MU) is a rare type of cutaneous SCC arising from chronic nonhealing wounds, first described by Marjolin in 1828. 1 MU have been reported with old burns, chronic osteomyelitis, post-traumatic wounds, decubitus ulcers, venous stasis ulcers, lupus-related skin disease, and chronic fistulas.1,2 The average latency period from the time of skin damage to malignancy development is around 30 years, which is consistent with our case. 2 Hypothesized pathophysiology include immune system impairment and chronic irritation seen in scar tissue. 1 A large international SLE cohort study showed increased association between SLE and non-melanoma skin cancers. 3 However, the correlation between discoid lupus and MU has been rarely reported. 4 As seen in our patient, nodule formation, induration, and ulceration at a scar site are the classic triad that suggest the diagnosis which mostly involves a lower extremity. 1 Biopsy should always be considered in any chronic ulcer to rule out malignant transformation.1,2 Mohs surgery, wide local excision with 1–2 cm margins, and amputation are commonly used treatment options. 1
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Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
