Chronic unrelieved ulcer on the anterior upper chest of an elderly woman

A 65-year-old woman presented with complaint of unremitting ulcer between her breasts from 6 months ago. Initially, it was manifested as the development of painless, firm, subcutaneous erythematous nodules that gradually enlarged and evolved into a chronic ulcer. She also had a history of mild weight loss. There was no history of anorexia, fever, cough, hemoptysis, or local trauma. On physical examination, a 6 by 4 cm ulcer was noted on her anterior upper chest, between breasts, with a little serous discharge and a granulation tissue at the base surrounded by densely erythematous woody margins with some telangiectasia (Figure 1). Breast examination showed a big pendulant breast with no palpable mass. She had also a 2 by 1 cm firm, mobile, non tender left axillary lymphadenopathy. The rest of her physical examination was normal. A previous diagnosis of frictional ulcer was made in her previous visit to the doctor, because she had big pendulant breasts and worn tight-fitting undergarments. She had no improvement with conservative treatments. Investigation revealed normal levels of complete blood count, ESR, VDRL, plasma glucose, a negative mantoux tuberculin test, and normal chest X-ray. Skin biopsy was performed.