Pruritus as an unusual symptom in multiple piloleiomyoma

A 30-year-old woman presented with multiple pruritic raised skin lesions at the proximal part of her left arm for the past 15 years. At the age of 15, the patient noticed red nodules accompanied with severe pruritus over the arm, which started to spread and involved the dorsal aspect of her scapula (Figure 1). They had been increasing in number during the past 15 years. There was no history of pain either spontaneously or in response to cold, tactile, or emotional stress, with no bleeding or oozing. There was no family history of similar skin lesions; however, she had a history of gynecologic problems for 10 years, and examination of her uterus showed uterine leiomyomas. The patient complained about severe pruritus. This symptom was exaggerated with sun exposure, cold, emotional stress, and rough cloths. It was so severe that it caused sleep disturbances. Clinical examination showed multiple pink and red nodules ranging from 5 mm to 20 mm over the above-described sites. The lesions were firm, smooth, not mobile, and nontender, with no pain on touch. Routine hematologic and biochemical investigations were normal. Kidney and pelvic ultrasonography showed myomatous uterus and normal kidneys. Microscopic examination of one of the nodules in hematoxylin and eosin-stained sections showed proliferation of smooth muscle cells with fascicular aspect in dermis. These cells had thin, elongated eel-like nuclei with blunt edges (Figure 2 and Figure 3). The diagnosis of leiomyoma was made and the patient was referred for surgical excision. Due to the extension and site of the lesions, the plastic surgeon did not recommend surgical procedure and the patient was treated with an antihistamine (loratadine 10 mg/d).