Letter to the Editor
hypoplasia, alopecia, onychodysplasia, and squamous cell carcinoma.[5] Treatment options are limited. Some lesions may undergo spontaneous flattening with time. Small and localized lesions may be suitable candidates for surgery. Laser therapy, preferably ultra‑pulse CO 2 laser, is an excellent modality because the chances of pigmentary changes and scarring are minimal. Combined erbium/CO2 laser therapy has been shown to offer significant cosmetic improvement in PEODDN patients. Modalities such as topical steroids, retinoids, keratolytics, phototherapy, electrocautery, and cryotherapy have not shown any promising results.[4,5] The presence of two unusual findings, namely involvement of dorsum of the hand and presence of a focal lichenoid infiltrate in a case of PEODDN prompted the present report.
Acknowledgment The authors would like to thank Prof. M. Ramam for his valuable inputs in reviewing the case and clinic‑pathological correlation.
Avijit Mondal, Piyush Kumar1, Anupam Das2, Panchami Debbarman3, Rajesh Kumar Mandal4 Departments of Dermatology, College of Medicine and JNM Hospital, Kalyani; 1Katihar Medical College and Hospital, Bihar; 2Medical College and Hospital, Kolkata; 3Consultant Dermatologist, Mumbai; 4North Bengal Medical College and Hospital, Darjeeling, West Bengal
Solitary painful ulcerated plaque on the sole Sir, A 40‑year‑old lady presented with a painful ulcerated plaque over the sole of the right foot since four months [Figure 1]. She gave a history of thorn prick prior to onset of symptoms, followed by discoloration and ulceration. Multiple courses of antibiotic were prescribed without relief. Cutaneous examination revealed a single well‑defined plaque of 3 cm × 6 cm on the right sole. The surface of the plaque was ulcerated and crusted, with blackish hyperpigmentation and erythema. Mucocutaneous examination, and examination of the draining lymph nodes were unremarkable. Acral lentiginous melanoma, Bowen’s disease, lupus vulgaris, and atypical mycobacterial infection were considered in the clinical differentials. Punch biopsy was done from the margin of the lesion. Histological examination showed hyperkeratosis without parakeratosis, focal hypergranulosis, irregular Indian Dermatology Online Journal - March-April 2015 - Volume 6 - Issue 2
Address for correspondence: Dr. Piyush Kumar, Department of Dermatology, Katihar Medical College and Hospital, Karim Bagh, Katihar ‑ 854 105, Bihar, India. E‑mail: [email protected]
REFERENCES 1. 2.
3.
4.
5.
Kumar P, Mondal AK, Ghosh K, Mondal A, Gharami RC, Chowdhury SN. Multiple keratotic papules on palm. Dermatol Online J 2012;18:10. Stoof TJ, Starink TM, Nieboer C. Porokeratotic eccrine ostial and dermal duct nevus. Report of a case of adult onset. J Am Acad Dermatol 1989;20:924‑7. Bergman R, Lichtig C, Cohen A, Friedman‑Birnbaum R. Porokeratotic eccrine ostial and dermal duct nevus. An abnormally keratinizing epidermal invagination or a dilated, porokeratotically plugged acrosyringium and dermal duct? Am J Dermatopathol 1992;14:319‑22. Masferrer E, Vicente MA, Bassas‑Vila J, Rovira C, González‑Enseñat MA. Porokeratotic eccrine ostial and dermal duct naevus: Report of 10 cases. J Eur Acad Dermatol Venereol 2010;24:847‑51. Goddard DS, Rogers M, Frieden IJ, Krol AL, White CR Jr, Jayaraman AG, et al. Widespread porokeratotic adnexal ostial nevus: Clinical features and proposal of a new name unifying porokeratotic eccrine ostial and dermal duct nevus and porokeratotic eccrine and hair follicle nevus. J Am Acad Dermatol 2009;61:1060.e1‑14. Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.153021
acanthosis, mononuclear cell infiltration in upper dermis, and foci of basal layer degeneration [Figure 2a‑c]. Additionally, there were some changes consistent with reactive eccrine syringofibroadematosis. Routine laboratory tests including serum biochemistry panel were absolutely normal. Based on the clinical and histological findings, a diagnosis of ulcerative lichen planus (LP) of the sole was made. She was given intralesional triamcinolone at monthly interval and potent topical steroids under occlusion. There was a satisfactory response, but the lesions did not resolve completely at the end of 2 months. Oral prednisolone was then started at a dose of 1 mg/kg/day, resulting in rapid resolution of the lesion. She has been under regular follow up, and no recurrence has been noted. Ulcerative or erosive LP is a rare variant of LP that predominantly affects the oral cavity and genitalia. Plantar location is uncommon and only few cases have been reported in medical literature. It was first described by Friedman in 1921.[1] It is difficult to diagnose ulcerative LP of the sole, especially when it appears as an isolated finding as seen in
131
a
b
c
Figure 1: Single ulcerated plaque on sole
our case. It usually starts as erythema and bullae on the feet, eventually progressing to develop painful ulcers. Patients have chronic, progressive, crippling, erosive and ulcerative lesions resulting in scarring and deformities.[2] Atypical locations have been reported in a few cases, such as the pretibial zone and flexural areas.[3] Many authors have proposed the association of ulcerative LP and autoimmune diseases, mainly autoimmune thyroiditis, primary biliary cirrhosis, diabetes mellitus, rheumatoid arthritis, and Sjögren’s syndrome.[4] The clinical differentials include severe eczema, localized bullous pemphigoid on the soles, and plantar erythrodysesthesia caused by anticancer drugs like gefitinib.
Figure 2: (a) Hyperkeratosis without parakeratosis, acanthosis, hypergranulosis, and mononuclear cell infiltration in upper dermis (a; H and E, ×40). Note basal layer degeneration (b; H and E, ×400) and (c; H and E, ×400)
Shahid Hassan, Anupam Das1, Piyush Kumar Department of Dermatology, Katihar Medical College and Hospital, Katihar, Bihar, 1Department of Dermatology, Medical College and Hospital, Kolkata, West Bengal, India Address for correspondence: Dr. Piyush Kumar, Department of Dermatology, Katihar Medical College and Hospital, Karim Bagh, Katihar ‑ 854 105, Bihar, India. E‑mail: [email protected]
REFERENCES 1.
Since the condition is rare, a well‑accepted therapeutic modality is yet to be discovered. [5] Many modalities are reported to provide symptomatic relief without any long term cure rates, leading to recurrences. A few authors have found systemic steroids beneficial in the long term management of ulcerative LP. [6] There are reports of successful use of intralesional triamcinolone acetonide, low molecular weight heparin, [7] platelet‑derived growth factor, [1] and topical tacrolimus. Close follow‑up is required as verrucous carcinoma is known to develop in long‑standing cases of ulcerative LP; however, the exact incidence of malignancy is not yet known. Our case had additional features of reactive eccrine syringofibroadematosis on histopathology; the latter is a known association of ulcerative LP.[8]
132
2. 3.
4. 5.
6.
7.
Wollina U, Konrad H, Graefe T. Ulcerative lichen planus: A case responding to recombinant platelet‑derived growth factor BB and immunosuppression. Acta Derm Venereol 2001;81:364‑5. Chopra A, Jain C, Mamta, Bahl RK. Ulcerative lichen planus of the foot. Indian J Dermatol Venereol Leprol 1996;62:60‑1. Schepis C, Lentini M, Siragusa M. Erosive lichen planus on an atypical site mimicking a factitial dermatitis. Acta Derm Venereol 2010;90:185‑6. Tsuboi H, Katsuoka K. Ulcerative lichen planus associated with Sjögren’s syndrome. J Dermatol 2007;34:131‑4. Petropoulou H, Kontochristopoulos G, Kalogirou O, Panteri I, Zakopoulou N. Effective treatment of erosive lichen planus with thalidomide and topical tacrolimus. Int J Dermatol 2006;45:1244‑5. Goucha S, Khaled A, Bennani Z, Rammeh S, Zéglaoui F, Zermani R, et al. Erosive lichen planus of the soles: Effective response to prednisone. Dermatol Ther (Heidelb) 2011;1:20‑4. Neville JA, Hancox JG, Williford PM, Yosipovitch G. Treatment of severe cutaneous ulcerative lichen planus with low molecular weight
Indian Dermatology Online Journal - March-April 2015 - Volume 6 - Issue 2
Letter to the Editor 8.
heparin in a patient with hepatitis C. Cutis 2007;79:37‑40. French LE, Masgrau E, Chavaz P, Saurat JH. Eccrine syringofibroadenoma in a patient with erosive palmoplantar lichen planus. Dermatology 1997;195:399‑401.
Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.153022
Indian Dermatology Online Journal - March-April 2015 - Volume 6 - Issue 2
133
Copyright of Indian Dermatology Online Journal is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
hypoplasia, alopecia, onychodysplasia, and squamous cell carcinoma.[5] Treatment options are limited. Some lesions may undergo spontaneous flattening with time. Small and localized lesions may be suitable candidates for surgery. Laser therapy, preferably ultra‑pulse CO 2 laser, is an excellent modality because the chances of pigmentary changes and scarring are minimal. Combined erbium/CO2 laser therapy has been shown to offer significant cosmetic improvement in PEODDN patients. Modalities such as topical steroids, retinoids, keratolytics, phototherapy, electrocautery, and cryotherapy have not shown any promising results.[4,5] The presence of two unusual findings, namely involvement of dorsum of the hand and presence of a focal lichenoid infiltrate in a case of PEODDN prompted the present report.
Acknowledgment The authors would like to thank Prof. M. Ramam for his valuable inputs in reviewing the case and clinic‑pathological correlation.
Avijit Mondal, Piyush Kumar1, Anupam Das2, Panchami Debbarman3, Rajesh Kumar Mandal4 Departments of Dermatology, College of Medicine and JNM Hospital, Kalyani; 1Katihar Medical College and Hospital, Bihar; 2Medical College and Hospital, Kolkata; 3Consultant Dermatologist, Mumbai; 4North Bengal Medical College and Hospital, Darjeeling, West Bengal
Solitary painful ulcerated plaque on the sole Sir, A 40‑year‑old lady presented with a painful ulcerated plaque over the sole of the right foot since four months [Figure 1]. She gave a history of thorn prick prior to onset of symptoms, followed by discoloration and ulceration. Multiple courses of antibiotic were prescribed without relief. Cutaneous examination revealed a single well‑defined plaque of 3 cm × 6 cm on the right sole. The surface of the plaque was ulcerated and crusted, with blackish hyperpigmentation and erythema. Mucocutaneous examination, and examination of the draining lymph nodes were unremarkable. Acral lentiginous melanoma, Bowen’s disease, lupus vulgaris, and atypical mycobacterial infection were considered in the clinical differentials. Punch biopsy was done from the margin of the lesion. Histological examination showed hyperkeratosis without parakeratosis, focal hypergranulosis, irregular Indian Dermatology Online Journal - March-April 2015 - Volume 6 - Issue 2
Address for correspondence: Dr. Piyush Kumar, Department of Dermatology, Katihar Medical College and Hospital, Karim Bagh, Katihar ‑ 854 105, Bihar, India. E‑mail: [email protected]
REFERENCES 1. 2.
3.
4.
5.
Kumar P, Mondal AK, Ghosh K, Mondal A, Gharami RC, Chowdhury SN. Multiple keratotic papules on palm. Dermatol Online J 2012;18:10. Stoof TJ, Starink TM, Nieboer C. Porokeratotic eccrine ostial and dermal duct nevus. Report of a case of adult onset. J Am Acad Dermatol 1989;20:924‑7. Bergman R, Lichtig C, Cohen A, Friedman‑Birnbaum R. Porokeratotic eccrine ostial and dermal duct nevus. An abnormally keratinizing epidermal invagination or a dilated, porokeratotically plugged acrosyringium and dermal duct? Am J Dermatopathol 1992;14:319‑22. Masferrer E, Vicente MA, Bassas‑Vila J, Rovira C, González‑Enseñat MA. Porokeratotic eccrine ostial and dermal duct naevus: Report of 10 cases. J Eur Acad Dermatol Venereol 2010;24:847‑51. Goddard DS, Rogers M, Frieden IJ, Krol AL, White CR Jr, Jayaraman AG, et al. Widespread porokeratotic adnexal ostial nevus: Clinical features and proposal of a new name unifying porokeratotic eccrine ostial and dermal duct nevus and porokeratotic eccrine and hair follicle nevus. J Am Acad Dermatol 2009;61:1060.e1‑14. Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.153021
acanthosis, mononuclear cell infiltration in upper dermis, and foci of basal layer degeneration [Figure 2a‑c]. Additionally, there were some changes consistent with reactive eccrine syringofibroadematosis. Routine laboratory tests including serum biochemistry panel were absolutely normal. Based on the clinical and histological findings, a diagnosis of ulcerative lichen planus (LP) of the sole was made. She was given intralesional triamcinolone at monthly interval and potent topical steroids under occlusion. There was a satisfactory response, but the lesions did not resolve completely at the end of 2 months. Oral prednisolone was then started at a dose of 1 mg/kg/day, resulting in rapid resolution of the lesion. She has been under regular follow up, and no recurrence has been noted. Ulcerative or erosive LP is a rare variant of LP that predominantly affects the oral cavity and genitalia. Plantar location is uncommon and only few cases have been reported in medical literature. It was first described by Friedman in 1921.[1] It is difficult to diagnose ulcerative LP of the sole, especially when it appears as an isolated finding as seen in
131
a
b
c
Figure 1: Single ulcerated plaque on sole
our case. It usually starts as erythema and bullae on the feet, eventually progressing to develop painful ulcers. Patients have chronic, progressive, crippling, erosive and ulcerative lesions resulting in scarring and deformities.[2] Atypical locations have been reported in a few cases, such as the pretibial zone and flexural areas.[3] Many authors have proposed the association of ulcerative LP and autoimmune diseases, mainly autoimmune thyroiditis, primary biliary cirrhosis, diabetes mellitus, rheumatoid arthritis, and Sjögren’s syndrome.[4] The clinical differentials include severe eczema, localized bullous pemphigoid on the soles, and plantar erythrodysesthesia caused by anticancer drugs like gefitinib.
Figure 2: (a) Hyperkeratosis without parakeratosis, acanthosis, hypergranulosis, and mononuclear cell infiltration in upper dermis (a; H and E, ×40). Note basal layer degeneration (b; H and E, ×400) and (c; H and E, ×400)
Shahid Hassan, Anupam Das1, Piyush Kumar Department of Dermatology, Katihar Medical College and Hospital, Katihar, Bihar, 1Department of Dermatology, Medical College and Hospital, Kolkata, West Bengal, India Address for correspondence: Dr. Piyush Kumar, Department of Dermatology, Katihar Medical College and Hospital, Karim Bagh, Katihar ‑ 854 105, Bihar, India. E‑mail: [email protected]
REFERENCES 1.
Since the condition is rare, a well‑accepted therapeutic modality is yet to be discovered. [5] Many modalities are reported to provide symptomatic relief without any long term cure rates, leading to recurrences. A few authors have found systemic steroids beneficial in the long term management of ulcerative LP. [6] There are reports of successful use of intralesional triamcinolone acetonide, low molecular weight heparin, [7] platelet‑derived growth factor, [1] and topical tacrolimus. Close follow‑up is required as verrucous carcinoma is known to develop in long‑standing cases of ulcerative LP; however, the exact incidence of malignancy is not yet known. Our case had additional features of reactive eccrine syringofibroadematosis on histopathology; the latter is a known association of ulcerative LP.[8]
132
2. 3.
4. 5.
6.
7.
Wollina U, Konrad H, Graefe T. Ulcerative lichen planus: A case responding to recombinant platelet‑derived growth factor BB and immunosuppression. Acta Derm Venereol 2001;81:364‑5. Chopra A, Jain C, Mamta, Bahl RK. Ulcerative lichen planus of the foot. Indian J Dermatol Venereol Leprol 1996;62:60‑1. Schepis C, Lentini M, Siragusa M. Erosive lichen planus on an atypical site mimicking a factitial dermatitis. Acta Derm Venereol 2010;90:185‑6. Tsuboi H, Katsuoka K. Ulcerative lichen planus associated with Sjögren’s syndrome. J Dermatol 2007;34:131‑4. Petropoulou H, Kontochristopoulos G, Kalogirou O, Panteri I, Zakopoulou N. Effective treatment of erosive lichen planus with thalidomide and topical tacrolimus. Int J Dermatol 2006;45:1244‑5. Goucha S, Khaled A, Bennani Z, Rammeh S, Zéglaoui F, Zermani R, et al. Erosive lichen planus of the soles: Effective response to prednisone. Dermatol Ther (Heidelb) 2011;1:20‑4. Neville JA, Hancox JG, Williford PM, Yosipovitch G. Treatment of severe cutaneous ulcerative lichen planus with low molecular weight
Indian Dermatology Online Journal - March-April 2015 - Volume 6 - Issue 2
Letter to the Editor 8.
heparin in a patient with hepatitis C. Cutis 2007;79:37‑40. French LE, Masgrau E, Chavaz P, Saurat JH. Eccrine syringofibroadenoma in a patient with erosive palmoplantar lichen planus. Dermatology 1997;195:399‑401.
Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.153022
Indian Dermatology Online Journal - March-April 2015 - Volume 6 - Issue 2
133
Copyright of Indian Dermatology Online Journal is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
