A 31-year-old young man presented to the department of dermatology (Southwest Hospital, Army Medical University, Chongqing, China) because of unhealed ulcers on his right waist and right leg for more than six months. The patient had tattoos on his right waist and lower leg five years ago. The area with red dye appeared induration after 1 year, accompanied by local redness and itching, without obvious heat pain and systemic symptoms. He visited a local hospital for a diagnosis considering hypertrophic scars or foreign body granuloma, but no biopsy or histopathological examination was performed. One year ago, he received several local superficial radiation treatments at a local hospital, and the induration did not go away. Six months ago, the patient underwent surgery to remove the induration at a local hospital. The excised tissue was not examined for pathology and etiology. After surgery, the patient's wound healing was poor, and obvious swelling exudation and erosion gradually appeared in the wound area, and finally formed deep ulcers. He was treated with oral minocycline, rifampicin, clarithromycin, and topical fusidic acid cream and polymyxin B ointment, and regularly received dressing change at the wound care clinic in the local hospital. But the ulcer still did not heal or even aggravate, and large patchy erythema with pruritus surrounding the ulcer. The patient was otherwise healthy and had nothing unusual in his past history. Physical examination revealed a 0.8x1.8 cm ulcer on the inner lower third of the right leg, with small amount of yellow exudate on the ulcer base, large patchy erythema with edema around the ulcer, and blue tattoos near the ulcer (Figure 1A). Another 1.5x2.0 cm ulcer, with a deep surface and regular margin, was seen on the right side of the loin, and large flaky dry desquamation erythema surrounding the ulcer, blue Chinese character tattoos were nearby (Figure 1B).
Histopathological examination of the ulcer of the right leg showed epidermal hyperkeratosis with incomplete keratosis, the stratum spinosum was hypertrophic (Figure 2A), the dermis was permeated with dense lymphocytes and numerous eosinophils infiltrated, some histiocytes and neutrophils were also seen (Figure 2B), no obvious inflammatory cell infiltration was observed in subcutaneous tissue. Fungal culture and nucleic acid tests of tuberculosis and atypical mycobacterium were negative with the tissue. Only staphylococcus epidermidis was positive in wound secretion culture. Routine blood tests, blood glucose, liver and kidney function, and autoantibody spectrum were all negative. Chest radiographs and abdominal ultrasonography showed no abnormal findings. However, serum total IgE was 621.00IU/ mL, significantly higher than the upper limit of normal value (165 IU/mL). The specific IgE detection showed that dust mite allergen specific IgE level was grade 5 (50-100 IU/mL), and Artemisia allergen specific IgE level was grade 3 (17.5-50 IU/mL), ragweed allergen specific IgE and cockroach allergen IgE were both grade 1 (0.35-0.75 IU/mL), a detected content under 0.35 U/mL was considered negative reactivity. He denied any previous history of allergic disease, but his father and sister had a history of allergic rhinitis, and his sister's daughter had a history of infantile eczema. His atopy background was defined. After ruling out other possibilities, we speculated that his chronic non-healing ulcers might be related to the atopic inflammation.
A history of hypertension and abnormal renal function were excluded, and the patient was treated with cyclosporine 200mg/day, combined with halometasone cream and moisturizing care for the erythema surrounding the ulcer. One month later, ulcers were completely healed, and the erythema around the ulcer subsided, leaving only pigmentation (Figure 3A and B). The patient's itching symptoms were also significantly relieved, and the self-report was satisfied with the treatment effect. After maintaining the original dose for 2 weeks, the cyclosporine dosage was reduced to 100mg/day, and the dose was maintained for 2 weeks, then it was eventually stopped. Intermittent topical application of 0.1% tacrolimus cream maintains topical anti-inflammatory effects for two months. Ulcer and its surrounding eczema lesions did not recur at a follow-up visit 3 months later.