History:

 A solitary plaque with moderate-severe itching, well-demarcated, red in the center and hyperpigmented at the periphery with thick adherent unevenly distributed scales and scratch marks (excoriations) all in favor of lichen simplex chronicus. When asked the patient admitted that itching was paroxysmal and more at rest and quite periods and almost disappears during activities. So characteristics of itching in addition to the morphology are both in favor of LSC. Skin biopsy showed marked hyperkeratosis associated with foci of parakeratosis, prominent granular cell layer, elongated and irregularly thickened epidermal rete ridges, mild spongiosis, perivascular and interstitial inflammation with histiocytes, lymphocytes and occasional eosinophils in superficial dermis and papillary dermal fibrosis with nerve hyperplasia. A super-potent topical CS in ointment base (Clobetasole propionate) under polyethylene occlusion twice daily and Doxepin one tablet per day gave modest improvement, so intralesional CS 5 mg per ml was injected intralesionally on two occasions 3 weeks apart with excellent response followed by topical CS once daily or on need with oral doxepin.