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Pityriasis Lichenoides et Varioliformis Acuta and Psoriasis Vulgaris: Mere Coincidence or a Rare Association? Yi‑Di Liu, Yue‑Ping Zeng, Ya‑Nan Wang, Wen‑Ling Zhao, Yue‑Hua Liu, Li Li Department of Dermatology, Peking Union Medical College Hospital, Beijing 100730, China

To the Editor: A 23‑year‑old otherwise healthy male presented with diffuse, erythematous, nonpruritic papules on the trunk and extremities, which gradually developed over 1 month [Figure 1a and 1b]. The patient was afebrile and had no other systemic symptoms. His personal and family histories were unremarkable. He denied any drug intake or episode of infection before the onset. Head, hands, feet, and mucosa were spared. No lymphadenopathies were detected. Histopathological examination revealed full‑thickness epidermal necrosis, parakeratosis, vacuolization of the basal layer, and superficial perivascular infiltration of lymphocytes and histiocytes in the dermis. Exocytosis was prominent, and intraepidermal red blood cells could be seen [Figure 1c]. A diagnosis of pityriasis lichenoides et varioliformis acuta (PLEVA) was established. He was prescribed with oral prednisolone (30 mg/d) for 2 weeks, and complete remission was obtained. A follow‑up visit at 3 years later showed no evidence of recurrence of PLEVA. Five years after the onset of PLEVA, some new erythematous scaling plaques appeared on his chest with no symptoms. Physical examination revealed multiple symmetrical, varying‑sized, well‑defined erythematous plaques with characteristic silvery‑white scales on the scalp, trunk, axillae, and upper limbs [Figure 1d and 1e]. Auspitz’s sign was noted. Nails and joints were spared. Histopathological examination revealed confluent parakeratosis with neutrophil aggregates (Munro microabscess), diminution of the granular cell layer, acanthosis, papillary edema, tortuous and dilated capillaries, and a superficial perivascular chronic inflammatory infiltration, consistent with psoriasis vulgaris [Figure 1f]. He was treated with topical calcipotriol compounds, which resulted in excellent response. Pityriasis lichenoides (PL) is an uncommon group of self‑limited inflammatory dermatitis with clinical manifestations over a continuous spectrum. PLEVA and PL chronica (PLC) are generally considered to be the two ends of this spectral disease.[1] Although PLEVA is considered to be a lymphoproliferative reaction, its etiology remains unknown. It may be an inflammatory response triggered by extrinsic agents, an inflammatory response secondary to T‑cell dyscrasia, or an immune complex‑mediated hypersensitivity.[1] The most widely accepted hypothesis invokes an immunologic response Access this article online Quick Response Code:

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DOI: 10.4103/0366-6999.199837

Chinese Medical Journal ¦ February 20, 2017 ¦ Volume 130 ¦ Issue 4

to a variety of antigens, including microbial pathogens, certain drugs, and vaccinations.[1] Psoriasis is a very common immune‑inflammatory dermatosis that can be provoked by environmental triggers. The pathologic process is considered as consequences of immunological dysfunction, which involves an intimate crosstalk between the innate and the adaptive immune systems.[2] Psoriasis can be provoked by nonspecific triggers such as trauma, chemical irritants, and infections.[2] Th1, Th2, Treg, and Th17 cells are important immune cells that play a pathologic role.[2] PL and psoriasis are considered to be completely different disease entities, and there have been only two cases of PL associated with psoriasis reported in literature. In both cases, PLC developed as a side effect of biologic agents during the treatment of psoriasis.[3,4] To the best of our knowledge, this is the first reported case of co‑occurrence of PLEVA and psoriasis. The co‑occurrence is most probably coincidental given the long time span between their manifestations. However, both diseases having T lymphocytic reaction and environmental trigger involved in their pathogenesis suggest that the underlying cause may be an unidentified environmental factor or intrinsic immunologic disturbance. Presumably, the immune status of the patient’s skin facilitates the initiation of both diseases in somehow predisposed humans. Alternatively, the psoriasis might be induced by PLEVA through mechanisms similar to that of isomorphic reaction, as the reaction sometimes takes years to occur.[5] PLEVA might activate pathogenic T cells that were able to induce psoriatic plaque in a predisposed patient. However, further research on the mechanism of both diseases is needed to confirm the hypothesis.

Financial support and sponsorship

The National Natural Science Foundation of China (No. 81371731).

Conflicts of interest

There are no conflicts of interest. Address for correspondence: Dr. Li Li, Department of Dermatology, Peking Union Medical College Hospital, Beijing 100730, China E‑Mail: [email protected]

This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. © 2017 Chinese Medical Journal  ¦  Produced by Wolters Kluwer ‑ Medknow

Received: 20-10-2016 Edited by: Yi Cui How to cite this article: Liu YD, Zeng YP, Wang YN, Zhao WL, Liu YH, Li L. Pityriasis Lichenoides et Varioliformis Acuta and Psoriasis Vulgaris: Mere Coincidence or a Rare Association?. Chin Med J 2017;130:501-2. 501

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Figure 1: (a) Erythematous papules on the trunk and extremities. (b) Close‑up view of the papules on the chest. (c) Histopathologic examination confirms pityriasis lichenoides et varioliformis acuta (H and E staining, original magnification ×50). (d) Erythematous plaques with silvery‑white scales on the trunk, axillae, and upper limbs. (e) Close‑up view of the plaques. (f) Histopathologic examination confirms psoriasis (H and E staining, original magnification ×50).

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Solorzano‑Mariscal R. Adalimumab‑induced pityriasis lichenoides chronica that responded well to methotrexate in a patient with psoriasis. Actas Dermosifiliogr 2016;107:167‑9. doi: 10.1016/j. ad.2015.07.011. 4. Newell  EL, Jain  S, Stephens  C, Martland  G. Infliximab‑induced pityriasis lichenoides chronica in a patient with psoriasis. J Eur Acad Dermatol Venereol 2009;23:230‑1. doi: 10.1111/j.1468‑3083.2008.0 2818.x. 5. Sagi L, Trau H. The Koebner phenomenon. Clin Dermatol 2011;29:231‑6. doi: 10.1016/j.clindermatol.2010.09.014.

Chinese Medical Journal  ¦  February 20, 2017  ¦  Volume 130  ¦  Issue 4

Pityriasis Lichenoides et Varioliformis Acuta and Psoriasis Vulgaris: Mere Coincidence or a Rare Association?

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