A case of acrodermatitis chronica atrophicans in the United States without European travel

Summary: Acrodermatitis chronica atrophicans (ACA) is a late-stage manifestation of Lyme borreliosis that is most commonly caused by Borrelia afzelii. Most common in Europe, where it affects 10% of Lyme disease patients, ACA is rare in the United States. We present a case of a 71-year-old woman with a four-year history of bilateral foot discoloration and progressive foot enlargement, increasing from size 7 to size 9, accompanied by pain to the touch over the past year. She reported many tick bites in the past and some rashes on her legs seven years prior, but never an obvious “bull’s-eye rash.” Notably, she had never traveled outside the United States. A punch biopsy of her right foot revealed a sclerosing dermatosis with a plasmacytic infiltrate, consistent with ACA. A Lyme antibody panel was positive for IgM and IgG, and she was treated with doxycycline 100 mg BID for 28 days. ACA does not resolve spontaneously, and advanced stages are more treatment-resistant, highlighting the importance of early diagnosis. This case emphasizes that ACA can occur in the United States, even without European travel, underscoring the need for increased awareness of this possibly underrecognized manifestation of Lyme disease.