Extragenital lichen sclerosus: Clinical, dermoscopic, confocal microscopy and histologic correlations Francesco Lacarrubba, MD,a Giovanni Pellacani, MD,b Anna Elisa Verzı, MD,a Mario Pippione, MD,c and Giuseppe Micali, MDa Catania, Modena, and Turin, Italy

CLINICAL PRESENTATION A 30-year old man presented with a 6-month history of asymptomatic whitish lesions progressively increasing in number. Clinical evaluation revealed the presence of multiple whitish, slightly elevated papules and plaques localized on the upper part of the trunk (Fig 1, A).

DERMOSCOPIC APPEARANCE All lesions were examined, revealing the same aspect, namely well demarcated, whitish, homogenous areas associated with the presence of yellow circles, corresponding to comedo-like openings (Fig 1, B).

Fig 1. Extragenital lichen sclerosus. A, Clinical picture showing multiple whitish, atrophic papules and plaques of the trunk. B, Dermoscopic aspect of one lesion showing a well demarcated, whitish, homogenous area associated with the presence of yellow circles (comedo-like openings).

From the Department of Dermatology, University of Catania,a Department of Dermatology, University of Modena and Reggio Emilia,b Modena, and Dermopathology Unit, Gradenigo Hospital,c Turin, Italy. Publication of this article was supported by 3Gen. Funding sources: None. Conflicts of interest: None declared.

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Reprint requests: Giuseppe Micali, MD, Dermatology Clinic, University of Catania, AOU Policlinico-Vittorio Emanuele, Via Santa Sofia, 78-95123 Catania, Italy. E-mail: [email protected] J Am Acad Dermatol 2015;72:S50-2. 0190-9622/$36.00 ª 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.07.008

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CONFOCAL MICROSCOPIC APPEARANCE In vivo reflectance confocal microscopy (Vivascope 3000) performed in multiple lesions revealed hyperkeratosis, round dark structures containing bright amorphous material, corresponding to keratinfilled invaginations, and atrophy of the epidermis. In the upper dermis, scattered bright inflammatory cells were present, as well as coarse collagen structures in bundles (Fig 2).

Fig 2. Extragenital lichen sclerosus. In vivo reflectance confocal microscopy of a lesion (A, Epidermal level; B, Upper dermis) showing the presence of round dark structures containing bright amorphous material, corresponding to keratin-filled invaginations, and scattered, very bright inflammatory cells.

HISTOLOGIC DIAGNOSIS Histopathologic examination of one lesion showed orthohyperkeratosis with follicular plugging, atrophy of the epidermis, and flattening of the rete ridges. In the dermis, a lichenoid lymphocytic infiltrate and homogenization of the collagen were evident (Fig 3).

Fig 3. Extragenital lichen sclerosus. Histopathology showing orthohyperkeratosis with follicular plugging, atrophy of the epidermis, and flattening of the rete ridges. In the dermis, presence of a lichenoid lymphocytic infiltrate and homogenization of the collagen (Hematoxylin-eosin stain; original magnification: 310).

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KEY MESSAGE Extragenital lichen sclerosus is a chronic inflammatory dermatosis that is characterized by the presence of white papules and atrophic plaques. Both dermoscopy and confocal microscopy may be useful for in vivo noninvasive differential diagnosis, with those dermatoses showing similar clinical aspect, such as morphea.1 The whitish homogenous area and the comedo-like openings seen at dermoscopy correspond to the histopathologic features of epidermis atrophy, fibrosis of the upper dermis, and follicular plugging.2 Reflectance confocal microscopy reveals microscopic details closely correlated to histologic features: hyperkeratosis and epidermal atrophy are seen with both techniques; keratin-filled invaginations correspond to follicular plugging, and inflammatory cells correspond to the lichenoid infiltrate.

REFERENCES 1. Shim WH, Jwa SW, Song M, Kim HS, Ko HC, Kim MB, et al. Diagnostic usefulness of dermatoscopy in differentiating lichen sclerous et atrophicus from morphea. J Am Acad Dermatol 2012;66:690-1. 2. Garrido-Rios AA, Alvarez-Garrido H, Sanz-Munoz C, Aragoneses-Fraile H, Manchado-Lopez P, Miranda-Romero A. Dermoscopy of extragenital lichen sclerosus. Arch Dermatol 2009;145:1468.

Extragenital lichen sclerosus: clinical, dermoscopic, confocal microscopy and histologic correlations.

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