Multimodal management of eruptive squamous atypia in a patient with chronic immunosuppression: A case report
DOI:
https://doi.org/10.25251/765j8m50Keywords:
acitretin, azathioprine, clobetasol, eruptive, 5-fluorouracil, immunosuppresion, keratoacanthoma, squamousAbstract
Introduction: Eruptive squamous atypia (ESA) is an uncommon, clinically aggressive, but histologically ambiguous dermatologic condition. It is characterized by the abrupt emergence of multiple keratoacanthoma-like lesions, typically manifesting in sun-exposed or previously traumatized skin.1 The condition predominantly affects immunosuppressed patients, and its management remains poorly defined.
Case Presentation: We report the case of a 61-year-old woman with a 25-year history of autoimmune hepatitis treated with azathioprine, who presented with recurrent, painful, hyperkeratotic papules along her extremities. Prior to her presentation to dermatology, she underwent more than 15 surgical excisions for biopsy-proven squamous cell carcinomas (SCCs), many of which reappeared at prior biopsy or excision sites, despite clear margins. Biopsies consistently revealed well-differentiated squamous proliferations with keratoacanthomatous characteristics. Considering the clinical morphology, eruptive nature, distribution along prior sites of trauma, and lesion recurrence, a diagnosis of ESA was established.
Intervention and Outcomes: A non-operative treatment plan was initiated, combining alternating courses of topical clobetasol ointment and 5-fluorouracil cream, intralesional Kenalog injections, and ultimately with the addition of an oral systemic retinoid, acitretin. The patient experienced marked clinical improvement, including reduced lesion count, cessation of new eruptions, and the avoidance of further surgical intervention. Over 12 months of follow-up, no new invasive SCCs were detected, and the therapy was well-tolerated without adverse events.
Conclusion: ESA remains an underrecognized entity with significant diagnostic and therapeutic challenges. This case demonstrates that a multimodal medical approach with systemic retinoid therapy and topical immunomodulatory agents, can effectively halt disease progression. Early clinical recognition of ESA is essential to minimize procedural burden and improve outcomes.
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Copyright (c) 2026 Michael Anderson, Mia Harris, Tiffany Mayo (Author)
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