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Generalized annular lichen planus with a unique morphology in a patient seropositive for HIV Sayantani Chakraborty, MD,a Joyeeta Chowdhury, MD,a Abhishek De, MD,b and Ramesh C. Gharami, MDc Kolkata, West Bengal, India Key words: annular; generalized; HIV; intracyclic; lichen planus; polycyclic.

INTRODUCTION Human immunodeficiency virus (HIV) infection is often associated with an array of skin manifestations, which are frequently more severe and present more atypically than those observed in nonHIV-infected persons. Some of them are acquired immune deficiency syndrome (AIDS) defining, and those such as seborrheic dermatitis, dermatophytosis, herpes simplex, and psoriasis may present in an exaggerated manner.1 Lichen planus (LP) is a common inflammatory dermatosis of unknown origin that presents in a variety of morphologic patterns. Many clinical variants, such as atrophic, hypertrophic, eruptive, linear, and annular, have been described in literature.2 Annular LP (ALP) is often considered one of the rare clinical forms. Various authors report that approximately 7% to 10% of LP lesions may have an annular morphology.3 Here, we report a case of generalized ALP unique in morphology in a patient with HIV infection.

CASE REPORT A 36-year-old HIV-positive man presented with multiple annular violaceous plaques for 6 months. The lesions started appearing over the left leg and knee and gradually spread to involve the other leg, thighs, scrotum, both the upper limbs, trunk, axillae, and back within 6 months. The lesions started as small reddish to violet-colored papules and plaques that slowly extended peripherally to reach an annular configuration (Fig 1). Sizes of the lesions were between 0.5 cm and 6 cm. There was a narrow rim of raised erythematous border surrounding the lesions. Some lesions were polycyclic (Fig 2). The central part showed violaceous color without any atrophy. Some of them were From the Department of Dermatology, Nil Ratan Sircar Medical Collegea; Department of Dermatology, IPGMERb; and Department of Dermatology, Medical College & Hospital.c Funding sources: None. Conflicts of interest: None declared. Correspondence to: Sayantani Chakraborty, MD, 107 Green Park Block A, Jessore Road, Kolkata-700055, West Bengal, India. E-mail: [email protected].

Abbreviations used: AIDS: ALP: HIV: LP:

acquired immune deficiency syndrome annular lichen planus human immunodeficiency virus lichen planus

unique with one or two intracyclic rings at the center. Hair, nail, oral, and genital mucosa were not involved. Laboratory investigations found a raised erythrocyte sedimentation rate and eosinophil count. Fungal elements were not detected. Antinuclear antibody test was found to be negative. Serology results for syphilis and hepatitis were negative. The patient was euglycemic, and his renal and liver function tests were also within normal limits. Chest x-ray and ultrasonography of the abdomen were normal. The patient was reactive to HIV1 with CD4 count of 208/mL3. Skin biopsy from the center of the annular plaque on routine hematoxylin-eosin stain found orthokeratotic hyperkeratosis, mild acanthosis, and effacement of the rete ridges with basal layer degeneration, colloid bodies, Max-Joseph’s canal, bandlike infiltrate with lymphohistiocytes along the dermoepidermal junction with pigment incontinence, and disruption of dermal collagen at places (Fig 3). Direct immunofluorescence from the lesions showed IgM and C3 deposits. Despite being on antiretroviral therapy for 6 weeks, the lesions did not change. The patient was started on a course of a high potency topical corticosteroid. Most of the lesions showed healing over a period of 4 to 6 weeks, leaving postinflammatory hyperpigmentation in concentric fashion without atrophy. JAAD Case Reports 2015;1:251-3. 2352-5126 Ó 2015 by the American Academy of Dermatology, Inc. Published by Elsevier, Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/). http://dx.doi.org/10.1016/j.jdcr.2015.04.008

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Fig 1. Presence of multiple annular and polycyclic lesions with an elevated erythematous outer border and violaceous center over the anterior aspect of the chest.

Fig 2. Annular plaque with a thin erythematous outer border and the violaceous center shows the presence of an arcuate erythematous intracyclic incomplete ring.

DISCUSSION The annular form of LP is a rare, chronic variant that features circinate lesions with elevated borders.4 ALP commonly develops as an arcuate grouping of individual papules or peripheral extension of clustered papules with central clearing. This form tends to occur more frequently in the black population and is commonly located on the penis, scrotum, and groin.3,4 Annular atrophic LP is characterized by several small violaceous papules slowly enlarging peripherally with atrophic center and raised border.5,6 The patient being reported presented with an unusual morphology of ALP in which large generalized annular lesions were seen without much prominent central atrophy. Some of the lesions also showed unique concentric and polycyclic configurations. Generalized eruptions of ALP are known to be rare.7 Although different morphologic variants of LP, including oral, linear,8 and hypertrophic,9 were

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Fig 3. Orthokeratotic hyperkeratosis, mild acanthosis, and effacement of the rete ridges with basal layer degeneration, colloid bodies, Max-Joseph’s canal, bandlike infiltrate with lymphohistiocytes along the dermoepidermal junction with pigment incontinence and disruption of dermal collagen at places. (Hematoxylin-eosin stain; original magnification: 1003.)

described in association with HIV, such an unusual morphology and distribution of ALP in association with HIV has not been described in literature to date, to the best of our knowledge. Differentiation from similar lesions of granuloma annulare, disseminated porokeratosis, superficial dermatophytoses, and secondary syphilis, which may be a common association in HIV-infected patients, should be done. Histopathology and direct immunofluorescence confirms the diagnosis of LP. Although the association of ALP with diseases like hepatitis B, hepatitis C,10 Sneddon syndrome,11 Crohn’s disease,12 and drug intake has been reported in literature, an association of generalized ALP in an HIV-infected patient with such a unique morphology has not yet been reported, to our knowledge. REFERENCES 1. Sadick NS, McNutt NS, Kaplan MH. Papulosquamous dermatoses of AIDS. J Am Acad Dermatol. 1990;22:1270-1275. 2. Boyd AS, Neldner KH. Lichen planus. J Am Acad Dermatol. 1991;25:593-619. 3. Altman J, Perry HO. The variations and course of lichen planus. Arch Dermatol. 1961;84:179-191. 4. Popkin DL, Greene RE, Fung JF. Widespread annular eruption in a Black manequiz case. Arch Dermatol. 2005;141(1):93-98. 5. Friedman DB, Hashimoto K. Annular atrophic lichen planus. J Am Acad Dermatol. 1991;25:392-394. 6. Morales-Callaghan Jr A, Martınez G, Aragoneses H, Miranda-Romero A. J Annular atrophic lichen planus. J Am Acad Dermatol. 2005 May;52(5):906-908. 7. Crovato F, Nazzari G, Desirello G. Lichen planus with annular disposition. Ann Dermatol Venereol. 1985;112:551. 8. Ruiz Villaverde R, Blasco Melguizo J, Naranjo Sintes R, Serrano Ortega S, Dulanto Campos MC. Multiple linear

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lichen planus in HIV patient. J Eur Acad Dermatol Venereol. 2002;16(4):412-414. 9. Pardo RJ, Kerdel FA. Hypertrophic lichen planus and light sensitivity in an HIV-positive patient. Int J Dermatol. 1988;27(9): 642-644. 10. Giuliani M, Lajolo C, Sartorio A, Scivetti M, Capodiferro S, Tumbarello M. Oral lichenoid lesions in HIV-HCV-coinfected

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subjects during antiviral therapy: 2 cases and review of the literature. Am J Dermatopathol. 2008;30(5):466-471. 11. Lipsker D, Piette JC, Laporte JL, Maunoury L, Frances C. Annular atrophic lichen planus and Sneddon’s syndrome. Dermatology. 1997;195(4):402-403. 12. Reich HL, Nguyen JT, James WD. Annular lichen planus: A case series of 20 patients. J Am Acad Dermatol. 2004;50(4):595-599.

Generalized annular lichen planus with a unique morphology in a patient seropositive for HIV.

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