Acquired reactive perforating collagenosis in a patient with multiple comorbidities: a case report from Palestine

Perforating dermatoses comprise a heterogeneous group of skin disorders characterized by transepidermal elimination of dermal components such as collagen, elastic fibers, or fibrin, resulting in pruritic papulonodular lesions. Four established subtypes are identified: reactive perforating collagenosis (RPC), elastosis perforans serpiginosa, perforating folliculitis, and Kyrle disease. RPC can be hereditary, manifesting in childhood, or acquired (ARPC), which generally develops in maturity and is closely associated with systemic diseases, particularly chronic renal failure and diabetes mellitus.

A 55-year-old male who presented with symptoms of decompensated heart failure, type-2 diabetes, chronic renal failure, and hyperparathyroidism. During hospitalization, he complained of cutaneous pruritus and skin lesions all over his body. Physical examination revealed papules of varying sizes; some progressed into umbilicated nodules featuring central keratotic plugs. Histopathology revealed cup-shaped epidermal invaginations with necrotic debris and transepidermal extrusion of modified collagen, as confirmed by Masson's trichrome stain (MTS). Therefore, a diagnosis of ARPC was established for the first time.

The patient was treated with the Dermovate scalp application, S.C. omalizumab administered monthly, fexofenadine hydrochloride, and body moisturizers. Besides that, treatment for glucose control, fluid overload, and recovery of renal function was also applied. Following up after 1 month revealed minimal improvement in pruritus; however, there was no change in skin lesion status.

Acquired reactive perforating collagenosis remains a rare dermatologic disease. To the best of our knowledge, this represents the first reported case from Palestine. This case highlights the potential coexistence of ARPC with various systemic comorbidities, underscoring the need for comprehensive clinical assessment and exploration of underlying diseases in affected individuals. Furthermore, it highlights the importance of increased clinical awareness, particularly among physicians in similar settings, to consider ARPC in the differential diagnosis of pruritic cutaneous eruptions, especially in patients with associated comorbidities such as diabetes mellitus and chronic kidney disease.