JEADV
LETTER TO THE EDITOR
Lichen planus pigmentosusinversus: 5 Turkish cases Editor Lichen planus pigmentosus-inversus (LPP-I) is a rare clinic variant of lichen planus pigmentosus (LPP) which particularly affects the intertriginous and flexural areas and skin folds in light-skinned individuals that presents as asymptomatic to mildly pruritic, hyperpigmented macules and/or patches.1 Approximately 20 cases have been reported to date1–7 and here we present five new cases of LPP-I. Case 1 was a 40-year-old Turkish woman, presented with asymptomatic brown macules located on axilla, on the groin, sub-mammarian area, antecubital and popliteal fossae for almost 3 months (Fig. 1a). Case 2 was 45-year-old Turkish woman, presented with slightly pruritic brown macules and patches located on the axilla, sub-mammarian area, and skin folds of 2-month duration (Fig. 1b). Case 3 was 61-year-old Turkish man, presented with asymptomatic hyperpigmented macules on both axilla for 1-month duration (Fig. 1c). Case 4 was 67-year-old Turkish woman, presented with asymptomatic brown macules on the axilla, sub-mammarian, groin and skin folds for a year (Fig. 1d). Case 5 was 55-year-old Turkish man, presented as slightly pruritic brown macules on the axilla and groin for 3 months (Fig. 1e).
In our all cases, the lesions were a few mm to a few cm in diameter and the long axes of the lesions were along the lines of cleavage. Oral or nail lesions were absent, and the history of previously inflammatory processes in affected areas, internal malignancies and trauma, and medicine usage were not present. The histological examinations based on the punch biopsies taken from the lesions showed epidermal atrophy, vacuolar alteration of basal layer, and pigmentary incontinence in the upper dermis (Fig. 2a,b,c). The inflammatory infiltrates of lymphocytes in the upper dermis were moderate for two cases, whereas they were dense in the remaining three cases. Immunohistochemical examinations have revealed that the lymphocytic infiltrate is composed of CD8 (+) T cells (Fig. 2d). LPP is a relatively rare variant of lichen planus and characterized by the presence of the hyperpigmented, dark-brown macules in the sun exposed or flexural-fold areas of the body.8 Pock et al. reported seven cases with LPP-I as a variant of LPP arising in intertriginous areas.1 The differential diagnosis of LPP-I includes LPP and LP actinicus both affect the dark-skinned races of patients and are generally located in the sun-exposed areas.4,8 Other conditions include fixed drug eruption, acanthosis nigricans, and ashy dermatosis.9 Histopathological examination typically shows epidermal atrophy, vacuolar alteration of the basal layer, variable dense of lymphocyte infiltration, pigmentary incontinence and melanophages in the superficial dermis. In our cases we have found similar histopathological results, as well.
(c)
(b)
(a)
(d)
(e)
Figure 1 Hyperpigmented macules and patches are located on the right axilla (a) on the sub-mammarian area (b) on the right axilla (c) on the sub-mammarian area (d) and on the right groin (e).
JEADV 2014
© 2014 European Academy of Dermatology and Venereology
Letter to the editor
2
(a)
(b)
(c)
(d)
It is thought that LPPI is the result of direct T-lymphocytemediated cytotoxic activity against basal keratinocytes, as in classic LP.4,10 In our three cases, we performed immunohistochemical staining and observed CD8 (+) T-cell infiltration as well as it has been observed in the literature.2,6 The treatment of LPP-I is unknown. In some cases reported in the literature, the lesions disappeared spontaneously within several months.2 Nevertheless, treatment with topical calcineurin inhibitors, medium or high potency corticosteroids are recommended to accelerate the healing process.4 We applied topical steroid (mometasone furoate) to our patients twice a day and monitored them for almost three months. The improvement was moderate in two cases and minimal in the rest. In conclusion, we have described a rare case of LPPI in Turkish patients with diagnosis based on intertriginous locations and histologic findings. N. Dizen Namdar,1,* E. Kural,2 O. Pulat,3 M.H. Metineren,4 G. Sarici1 1
Department of Dermatology, School of Medicine, Dumlupinar University, Kutahya, Turkey, 2Dermatology Clinic, Eren Surgical Medical Center, Istanbul, Turkey, 3Pathology Clinic, State Hospital, Bartin, Turkey, 4 Department of Pathology, School of Medicine, Dumlupinar University, Kutahya, Turkey *Correspondence: N. Dizen Namdar. E-mail: [email protected]
JEADV 2014
Figure 2 Histologically, epidermal atrophy, vacuolar alteration of basal layer, dense lichenoid lymphocytic infiltration with pigmentary incontinence and melonophages in the upper dermis (H&E, 9200) (a, b) vacuolar alteration of the basal layer, dense lymphocytic, lichenoid infiltrate and prominent pigmentary incontinence in the upper dermis (H&E, 9400) (c) Immunohistochemical examination revealed that the lymphocytic infiltrate is composed of CD8 (+) T cells (9100) (d).
References 1 Pock L, Jelinkova L, Drlik L et al. Lichen planus pigmentosus-inversus. J Eur Acad Dermatol Venereol 2001; 15: 452–454. 2 Kashima A, Tajiri A, Yamashita A, Asada Y, Setoyama M. Two Japanese cases of lichen planus pigmentosus-inversus. Int J Dermatol 2007; 46: 740–742. 3 Kim BS, Park KD, Chi SG et al. Two cases of lichen planus pigmentosusinversus arising from long-standing lichen planus-inversus. Ann Dermatol 2008; 20: 254–256. 4 Bennassar A, Mas A, Julia M, Iranzo P, Ferrando J. Annular plaques in the skin folds: 4 cases of lichen planus pigmentosus- inversus. Actas Dermosifiliogr 2009; 100: 602–605. 5 Gaertner E, Elstein W. Lichen planus pigmentosus-inversus: case report and review of an unusual entity. Dermatol Online J 2012; 18: 11. 6 Uyar B, Sivrikoz ON. A case of lichen planus pigmentosus-inversus. Turkderm Archieves of The Turkish Dermatol Venerol 2012; 46: 160–162. 7 Nijhawan RI, Borkin MS, Wilentz SE. Lichen planus pigmentosus-inver sus involving the post-auricular sulci. Dermatol Online J 2013; 19: 14. 8 Bhutani LK, Bedi TR, Pandhi RK, Nayak NC. Lichen planus pigmentosus. Dermatologica 1974; 149: 43–50. 9 Vega ME, Waxtein L, Arenas R, Hojyo T, Dominguez-Soto L. Ashy dermatosis and lichen planus pigmentosus: a clinicopathologic study of 31 cases. Int J Dermatol 1992; 31: 90–94. 10 Shai A, Halevy S. Lichen planus and lichen planus-like eruptions: pathogenesis and associated diseases. Int J Dermatol 1992; 31: 379–384. DOI: 10.1111/jdv.12828
© 2014 European Academy of Dermatology and Venereology
LETTER TO THE EDITOR
Lichen planus pigmentosusinversus: 5 Turkish cases Editor Lichen planus pigmentosus-inversus (LPP-I) is a rare clinic variant of lichen planus pigmentosus (LPP) which particularly affects the intertriginous and flexural areas and skin folds in light-skinned individuals that presents as asymptomatic to mildly pruritic, hyperpigmented macules and/or patches.1 Approximately 20 cases have been reported to date1–7 and here we present five new cases of LPP-I. Case 1 was a 40-year-old Turkish woman, presented with asymptomatic brown macules located on axilla, on the groin, sub-mammarian area, antecubital and popliteal fossae for almost 3 months (Fig. 1a). Case 2 was 45-year-old Turkish woman, presented with slightly pruritic brown macules and patches located on the axilla, sub-mammarian area, and skin folds of 2-month duration (Fig. 1b). Case 3 was 61-year-old Turkish man, presented with asymptomatic hyperpigmented macules on both axilla for 1-month duration (Fig. 1c). Case 4 was 67-year-old Turkish woman, presented with asymptomatic brown macules on the axilla, sub-mammarian, groin and skin folds for a year (Fig. 1d). Case 5 was 55-year-old Turkish man, presented as slightly pruritic brown macules on the axilla and groin for 3 months (Fig. 1e).
In our all cases, the lesions were a few mm to a few cm in diameter and the long axes of the lesions were along the lines of cleavage. Oral or nail lesions were absent, and the history of previously inflammatory processes in affected areas, internal malignancies and trauma, and medicine usage were not present. The histological examinations based on the punch biopsies taken from the lesions showed epidermal atrophy, vacuolar alteration of basal layer, and pigmentary incontinence in the upper dermis (Fig. 2a,b,c). The inflammatory infiltrates of lymphocytes in the upper dermis were moderate for two cases, whereas they were dense in the remaining three cases. Immunohistochemical examinations have revealed that the lymphocytic infiltrate is composed of CD8 (+) T cells (Fig. 2d). LPP is a relatively rare variant of lichen planus and characterized by the presence of the hyperpigmented, dark-brown macules in the sun exposed or flexural-fold areas of the body.8 Pock et al. reported seven cases with LPP-I as a variant of LPP arising in intertriginous areas.1 The differential diagnosis of LPP-I includes LPP and LP actinicus both affect the dark-skinned races of patients and are generally located in the sun-exposed areas.4,8 Other conditions include fixed drug eruption, acanthosis nigricans, and ashy dermatosis.9 Histopathological examination typically shows epidermal atrophy, vacuolar alteration of the basal layer, variable dense of lymphocyte infiltration, pigmentary incontinence and melanophages in the superficial dermis. In our cases we have found similar histopathological results, as well.
(c)
(b)
(a)
(d)
(e)
Figure 1 Hyperpigmented macules and patches are located on the right axilla (a) on the sub-mammarian area (b) on the right axilla (c) on the sub-mammarian area (d) and on the right groin (e).
JEADV 2014
© 2014 European Academy of Dermatology and Venereology
Letter to the editor
2
(a)
(b)
(c)
(d)
It is thought that LPPI is the result of direct T-lymphocytemediated cytotoxic activity against basal keratinocytes, as in classic LP.4,10 In our three cases, we performed immunohistochemical staining and observed CD8 (+) T-cell infiltration as well as it has been observed in the literature.2,6 The treatment of LPP-I is unknown. In some cases reported in the literature, the lesions disappeared spontaneously within several months.2 Nevertheless, treatment with topical calcineurin inhibitors, medium or high potency corticosteroids are recommended to accelerate the healing process.4 We applied topical steroid (mometasone furoate) to our patients twice a day and monitored them for almost three months. The improvement was moderate in two cases and minimal in the rest. In conclusion, we have described a rare case of LPPI in Turkish patients with diagnosis based on intertriginous locations and histologic findings. N. Dizen Namdar,1,* E. Kural,2 O. Pulat,3 M.H. Metineren,4 G. Sarici1 1
Department of Dermatology, School of Medicine, Dumlupinar University, Kutahya, Turkey, 2Dermatology Clinic, Eren Surgical Medical Center, Istanbul, Turkey, 3Pathology Clinic, State Hospital, Bartin, Turkey, 4 Department of Pathology, School of Medicine, Dumlupinar University, Kutahya, Turkey *Correspondence: N. Dizen Namdar. E-mail: [email protected]
JEADV 2014
Figure 2 Histologically, epidermal atrophy, vacuolar alteration of basal layer, dense lichenoid lymphocytic infiltration with pigmentary incontinence and melonophages in the upper dermis (H&E, 9200) (a, b) vacuolar alteration of the basal layer, dense lymphocytic, lichenoid infiltrate and prominent pigmentary incontinence in the upper dermis (H&E, 9400) (c) Immunohistochemical examination revealed that the lymphocytic infiltrate is composed of CD8 (+) T cells (9100) (d).
References 1 Pock L, Jelinkova L, Drlik L et al. Lichen planus pigmentosus-inversus. J Eur Acad Dermatol Venereol 2001; 15: 452–454. 2 Kashima A, Tajiri A, Yamashita A, Asada Y, Setoyama M. Two Japanese cases of lichen planus pigmentosus-inversus. Int J Dermatol 2007; 46: 740–742. 3 Kim BS, Park KD, Chi SG et al. Two cases of lichen planus pigmentosusinversus arising from long-standing lichen planus-inversus. Ann Dermatol 2008; 20: 254–256. 4 Bennassar A, Mas A, Julia M, Iranzo P, Ferrando J. Annular plaques in the skin folds: 4 cases of lichen planus pigmentosus- inversus. Actas Dermosifiliogr 2009; 100: 602–605. 5 Gaertner E, Elstein W. Lichen planus pigmentosus-inversus: case report and review of an unusual entity. Dermatol Online J 2012; 18: 11. 6 Uyar B, Sivrikoz ON. A case of lichen planus pigmentosus-inversus. Turkderm Archieves of The Turkish Dermatol Venerol 2012; 46: 160–162. 7 Nijhawan RI, Borkin MS, Wilentz SE. Lichen planus pigmentosus-inver sus involving the post-auricular sulci. Dermatol Online J 2013; 19: 14. 8 Bhutani LK, Bedi TR, Pandhi RK, Nayak NC. Lichen planus pigmentosus. Dermatologica 1974; 149: 43–50. 9 Vega ME, Waxtein L, Arenas R, Hojyo T, Dominguez-Soto L. Ashy dermatosis and lichen planus pigmentosus: a clinicopathologic study of 31 cases. Int J Dermatol 1992; 31: 90–94. 10 Shai A, Halevy S. Lichen planus and lichen planus-like eruptions: pathogenesis and associated diseases. Int J Dermatol 1992; 31: 379–384. DOI: 10.1111/jdv.12828
© 2014 European Academy of Dermatology and Venereology
