The diagnostic process of Kyrle’s disease in a 65-year-old patient

A 65-year-old patient was admitted to the ward for the diagnosis and treatment of hyperkeratotic papules, located around the follicles and forming plaques, as well as erosions covered with crusts up to 1.5 cm in diameter. The lesions were located in the dorsal part of the hands, forearms, with single foci on the lower legs (Figures 1 A, B). The patient reported itching within the lesions. The patient’s medical history is about 1 year long.
The patient had cardiologic and internal organ diseases. The medical history included the following: hypertension, ischaemic heart disease, paroxysmal atrial fibrillation, secondary diabetes (glycaemia 10.84 mmol/l), secondary hyperparathyroidism (PTH - 549 pg/ml; hypocalcaemia 2.06 mmol/l, hyperphosphataemia 2.49 mmol/l, and hyperkalaemia 5.61 mmol/l), chronic kidney disease (creatinine 939.1 µmol/l), chronic hepatitis B without delta virus, and previous acute pancreatitis. Furthermore, the patient had a cardiac pacemaker implanted due to third-degree atrioventricular block and coronary artery bypass grafting (CABG). The patient has been under insulin therapy for many years and haemodialysed for 7 years. The differential diagnosis included the following: reactive acquired perforating collagenosis, perforating folliculitis, elastosis perforans serpiginosa, and the perforating form of granuloma. During the diagnostics, the patient was tested for antinuclear antibodies using indirect immunofluorescence, obtaining a homogeneous positive result with a titre of 1 : 320, and the same method was used to determine if any antibodies were directed against his own neutrophils (ANCA) – no antibodies were detected in the 1 : 20 ANCA titre. The blood serum was tested for antibodies for pemphigus/pemphigoid – negative results for IgA and IgG with a 1 : 20 titre. In addition, the total IgE was negative.
During further diagnosis of skin lesions, a videodermatoscopic examination of the efflorescence revealed a zonal, concentric pattern, including the following: a central crust, a hyperkeratotic sheath, an unstructured pink area, and a few blood vessels (Figures 1 C, D). A skin specimen was collected for histopathological evaluation, which revealed the following: acanthosis and hyperkeratosis in the epidermis, especially around the follicles, and hyperplasia with inflammatory granulation deep into the skin. On the edge of the specimen, the epidermis was covered with a crust that may indicate ulceration or exit of the...


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