{"paper_id":"44f7de67-9245-438f-8488-479bad9f67e8","body_text":"Submit Manuscript | http://medcraveonline.com\nIntroduction\nEndometriosis is the presence of functional endometrial tissue \nwith endometrial glands and stroma found outside the uterine cavity. \nThe disorder is quite common with an estimated prevalence of 10-\n15% of all fertile women. Typical symptoms include pelvic pain and \nimpaired fertility.1 Most common sites involve the ovaries, uterosacral \nligaments, ovarian fossa, pouch of Douglas and the bladder. 2 \nCutaneous endometriosis is the presence of endometrial tissue in \nthe skin and can be divided into primary and secondary cutaneous \nendometriosis. \nPrimary cutaneous endometriosis refers to endometriosis \ndeveloped spontaneously without any prior surgery. Its pathogenesis \nremains unclear. Theories include hematogenic or lymphatic \nspreading, seeding through anatomical and physiological structures \nsuch as the umbilicus and the differentiating of primitive pluripotent \nmesenchymal stem cells to endometrial tissue. Secondary cutaneous \nendometriosis is located in postoperative scars such as cesarean \nsections, hysterectomy or laparoscopy. The prevailing hypothesis \nstands that endometrial cells dislocate during surgery through the \nprocess of seeding.3 \nCutaneous endometriosis is rare and comprise less than 1% of all \nreported cases of extra-uterine endometriosis. 4 The presentation is \nunspecific, a discolored nodular mass which can mimic hypertrophic \nor keloid scarring, dermatofibroma, dermatofibrosarcoma protuberans \nor malignant metastatic cancer from the umbilicus, a so-called Sister \nMary Joseph’s nodule. \nThe disorders rarity and ability to mimic other conditions presents \ndiagnostic difficulties. The diagnosis is confirmed histopathologically. \nTreatment options include hormonal therapy and surgical excision \nwith wide marginal.3 \nA few case studies report of malignant transformation into \nendometrial carcinoma. The prevalence as well as the pathophysiology \nof this is unknown. Genetic, immunological and hormonal factors \nhave been implicated.5,6 \nCase report\nWe present a 43-year-old woman with menarche at the age of \nnine. Since her menstrual debut she has suffered from menorrhagia, \nmetrorrhagia and dysmenorrhea causing hospitalization on multiple \noccasions. A previous history of multiple ruptured ovarian cysts was \nrecorded throughout her teenage years. Hormonal treatment with birth \ncontrol pills was initiated but discontinued due to adverse side effects. \nShe had difficulties becoming pregnant, and had two spontaneous \nabortions. With the help of IVF treatment, she became pregnant at the \nage of 29. She underwent an elective caesarian and delivered a healthy \nfemale offspring. A few days after surgery a red papule appeared on \nthe right side of her abdominal scar. In the following years the papule \nand surrounding caesarian scar became noticeable tender during \novulation and menstruation. The tenderness and pain were reduced \nduring the period she was breastfeeding and the symptoms reappeared \nwhen she stopped. \nShe was referred to a dermatologist four years after her caesarian. At \nthe first visit a red nodule, measuring 5x5mm, was noticed (Figure 1) \n(Figure 2). A 3mm punch biopsy (Figure 3) showed histopathological \nfindings including dermal endometrial glands surrounding by \ncytogenic stroma and blood. An immunohistochemical analysis \nconcluded that the glands were positive for ER, and the stroma CD-\n10+.\nFigure 1 A red papule on an abdominal scar after elective caesarean.\nObstet Gynecol Int J. 2022;13(6):349‒350. 349\n©2022 Kafi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which \npermits unrestricted use, distribution, and build upon your work non-commercially.\nCutaneous endometriosis presented in a 43-year-old \nwoman’s caesarian scar\nVolume 13 Issue 6 - 2022\nPegah Kafi,1 Carl Swartling2 \n1Kungsholmens Skin Clinic, Sweden\n2Hyperhidros Clinic, Sweden \nCorrespondence: Pegah Kafi, Kungsholmens Skin Clinic, \nWarfvinges Väg 35, 112 51 Stockholm, Sweden, \nEmail \nReceived: November 05, 2022 | Published: November 18, \n2022\nAbstract\nCutaneous endometriosis is a rare skin condition with the presence of endometrial tissue \nin the skin. The condition most often affect fertile women and symptoms typically include \ncyclical tenderness, pain or itch of the tissue during ovulation and menstruation. \nWe report a 43-year-old woman who presented with a red papule in a caesarian scar, with \nrecurring tenderness and pain following ovulation and menstruation. Histopathological \nfindings from a punch biopsy showed the presence of dermal endometrial glands surrounded \nby cytogenic stroma and blood. An immunohistochemical analysis further supported the \ndiagnosis with ER-positive glands and CD-10+ stroma. The patient was referred to a \ngynecological ward where a hormonal spiral was inserted. This hormonal therapy reduced \nthe patient’s clinical symptoms and improved her quality of life. \nSignificance: Cutaneous endometriosis is an uncommon skin condition with the presence \nof ovarian tissue on the skin. It most often affects fertile women and cause skin tissue \nto becomes tender and painful during ovulation and menstruation. This can have a great \nimpact on the patient’s quality of life. Treatment options include hormonal therapy and \nsurgery. \nKeywords: cutaneous endometriosis, endometriosis, primary cutaneous endometriosis, \nsecondary cutaneous endometriosis, hormone therapy\nObstetrics & Gynecology International Journal\nCase Report\n Open Access\n\n\nCutaneous endometriosis presented in a 43-year-old woman’s caesarian scar\n350\nCopyright:\n©2022 Kafi et al.\nCitation: Kafi P , Swartling C. Cutaneous endometriosis presented in a 43-year-old woman’s caesarian scar. Obstet Gynecol Int J. 2022;13(6):349‒350. \nDOI: 10.15406/ogij.2022.13.00675\nFigure 2 Dermatoscopic image of the red abdominal papule.\nFigure 3 Histopathological image of the 3mm punch biopsy. \nThese histopathological findings are congruent with the diagnosis \nof cutaneous endometriosis. A noticeable pain relief was noticed \nafter the punch biopsy was taken. At the first visit the patient scored \nDLQI of 5 and endometriosis assessment scale of EHP-30 of 97 out \nof 150. She was referred to a gynecological ward where ultrasound \nexcluded deep endometriosis. A hormonal spiral was inserted. The \nhormonal therapy greatly reduced the patients’ clinical symptoms of \ndysmenorrhea and improved her quality of life with a reduction in \nDLQI to 0. \nDiscussion\nOur case represents a fertile woman with a classical secondary \ncutaneous endometriosis in a cesarian scar. The symptoms of monthly \npain and swelling became less noticeable after punch biopsy as well \nas hormonal therapy was initiated. Total surgical removal of the \nremaining tissue was not considered necessary. Further gynecological \ninvestigation with ultrasound excluded pelvic involvement. After \ninitiating hormonal treatment, the patients’ symptoms were reduced \nand she had an improvement in quality of life, reflected by a decrease \nin DLQI. \nReferral to a gynecologist is highly recommended in order \nto evaluate the extend of endometriosis in the pelvic region, \nuterocutaneous fistulas and to assess treatment options such as \nsurgical removal and hormonal therapy with gonadotropin-releasing \nhormone agonists or danazol. In some cases where surgery is \nneeded preoperative hormonal treatment can be considered in \norder to minimize the lesion. The overall prognosis is considered \nfavorable. There is a risk of recurrence once non-surgical treatment \nis discontinued. \nConclusion\nCutaneous endometriosis should be kept in mind as a differential \ndiagnosis when a patient presents with cyclical painful papules, \nnodules and tumors. \nAcknowledgments\nNone.\nFunding \nNone.\nConflicts of interest \nThere are no conflicts of interest.\nReferences\n1. Tsamantioti ES, Mahdy H. Endometriosis. StatPearls; 2022.\n2. Sharma A, Apostol R. Cutaneous endometriosis. Treasure Island (FL): \nStatPearls Publishing; 2022.\n3. Raffi L, Suresh R, McCalmont TH, et al. Cutaneous endometriosis. Int J \nWomens Dermatol. 2019;5(5):384–386.\n4. Victory R, Diamond MP, Johns DA. Villar’s nodule: a case report and \nsystematic literature review of endometriosis externa of the umbilicus. J \nMinim Invasive Gynecol. 2007;14(1):23–32.\n5. Nezhat F, Apostol R, Mahmoud M, et al. Malignant transformation \nof endometriosis and its clinical significance. Fertil Steril . \n2014;102(2):342–344.\n6. Nezhat FR, Apostol R, Nezhat C, et al. New insights in the \npathophysiology of ovarian cancer and implications for screening and \nprevention. Am J Obstet Gynecol. 2015 Sep;213(3):262–267.","source_license":"CC0","license_restricted":false}