BASIC/CLINICAL SCIENCE
Spectrum of Dermoscopic Patterns in Lichen Planus: A Case Series from China Cheng Tan*, Zhong-Sheng Min*, Yanning Xue, and Wen-Yuan Zhu Background: Dermoscopy has been shown to be a promising method to faciiitate the diagnosis of lichen pianus (LP| outside of China. Objective: To investigate the spectrum of dermoscopic patterns in Chinese LP patients. Methods: The clinical data and dermoscopic patterns of nine LP cases with a total of 43 lesions were evaluated. Results: To the naked eye, 20.97% of the lesions exhibited graying Wickham striae (WS); however, 37.5% presented with white streaks of annular, reticular, or leaf venation patterns under dermoscopy. Blue-white veils were occasionally observed in the center. Pigment patterns varied from dots, globules, and peppered pigment to pigmented lines, which were unrelated to the pigment network of the skin. At the periphery of the WS, red fine lines ran parallel to the delicate white streaming lines. Conclusions: WS exhibits five morphological patterns (leaf venation, reticular, white dots, circular and radial streaming) and three color patterns (homogeneous crystalline white, blue-white veil and yellowish-white). The pigment patterns consisted of dots/ globules, peppered pigments and pigment, streaming lines. Contexte: La dermatoscopie s'est révélée, à l'extérieur de la Chine, un examen prometteur dans la pose du diagnostic de lichen plan (LP). Objectif: L'étude visait à examiner les différentes formes dermatoscopiques de LP, observées chez des patients chinois. Méthode: II y a eu évaluation de données cliniques ainsi que des différentes formes dermatoscopiques de LP, observées dans 9 cas, qui totalisaient 43 lésions. Résultats: Après examen, 20.97% des lésions présentaient, à l'œil nu, des stries de Wickham grisâtres, tandis que 37.5% présentaient, à la dermatoscopie, des stries blanches de forme annulaire ou réticulaire ou encore des nervures en forme de feuille. Des voiles blanc bleuté ont parfois été observés au centre. La pigmentation prenait la forme de points, de globules, d'amas parsemés de points pigmentés, ou de filets pigmentés, toutes des formes non liées au réseau de pigmentation de la peau. À la périphérie des stries de Wickham, de petites lignes rouges couraient parallèlement aux fins filets blancs. Conclusions: Les stries de Wickham se présentaient sous cinq grandes formes (nervures en forme de feuille, points réticulaires ou blancs, filets circulaires ou radiaux) et en trois couleurs (blanc cristallin homogène, voile blanc bleuté, blanc jaunâtre). La pigmentation prenait la forme de points, de globules, d'amas parsemés de points pigmentés, ou de filets pigmentés.
ERMOSCOPY is a well-established diagnostic tool to improve the clinical recognition of a broad spectrum of skin disorders, including melanoma, basal cell carcinoma, and seborrheic keratosis. Lichen planus (LP) is an
D
*The two authors contributed equally to the manuscript. From the Department of Dermatology, Jiangsu Provincial Hospital of Traditional Chinese Medicine, Jiangsu, China. Address reprint requests to: Cheng Tan, Department of Dermatology, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, Nanjing 210029, Chirm; e-mail: [email protected].
DOI 10.2310/7750.2013.13049 © 2014 Canadian Dermatology Association
acute or chronic infiammatory skin disorder that is characterized by discrete, violaceous to brownish, polygonal papules or pigmented macules. The well-known histopathologic features of LP are hyperkeratosis with thickening of the granular cell layer, lymphocytic infiltration at the epidermal-dermal junction, and scattered melanophages in the superficial dermis. The depth of all of these pathologic changes can theoretically be reached by the light of the dermoscope. Vazquez-Lopez and colleagues published two LP case series related to its dermoscopic features and demonstrated the capacity for dermoscopy to improve the clinical diagnosis of LP.'"^ To explore the dermoscopic features of LP, the present study recruited nine Chinese LP patients.
DECKER^ Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 1 (January/February), 2014: pp 28-32
spectrum of Dermoscopic Patterns in Lichen Planus
Patients and Methods
Results
The present study included nine consecutive patients (a total of 43 lesions) with a clinical diagnosis of LP who were treated at the Department of Dermatology of Jiangsu Provincial Hospital of Traditional Chinese Medicine between March 2010 and February 2012. The mean age ofthe patient group was 32.0 years (range 1848 years). Data related to clinical diagnosis and their demographic features were eoUected and are shown in Table 1. The same dermatologist investigated each patient according to a set protocol. The diagnosis was established clinically and confirmed by the histopathologic examination of a skin biopsy specimen in all primary LPs and in other doubtful cases. Dermoscopic examination was performed by a polarized-light handheld dermascope (Dermlite DLIOO, 3Gen LLC, San Juan Capistrano, CA), which permitted visualization of skin at a 10-fold magnifieation without an interface solution. Images were obtained by a digital camera (Cannon 980 IS, Cannon Corp, Tokyo, Japan). A pattern analysis was performed, including dermoscopic patterns for Wiekham striae (WS), pigmentation, and vascular changes.
LP presents clinically as shiny, violaceous, polygonal papules with overlying white scales (WS). Skin biopsies revealed characteristie findings of lymphocytic infiltration at the epidermal-dermal junction and damage to the basal cell layer. The associated epidermal changes include hyperkeratosis with hypergranulosis or atrophie epidermis. Melanophages were noted in the superfieial dermis. A diagnosis of LP was reached based on its typical clinical appearance and a biopsy of the skin lesion. The spectrum of dermoscopic patterns is summarized in Table 2.
WS Dermoscopic Patterns Among all 43 lesions, WS could be observed by the naked eye in nine (20.93%) patients. Under dermoseopy, a significantly higher rate of detection was achieved, identifying 37.21% of the patients (x^ = 2.76, p < .01). Meanwhile, dermoseopy ensured a mueh clearer visibility ofthe WS than was possible with the naked eye, even after spreading the skin with paraffin oil (Figure 1). Most ofthe WS consisted of a grid of crystalline white striae under dermoseopy, 25.00% of which were reticular or arborizing in shape (Figure 2B). Leaf
Table 1. Clinical Data of Nine Lichen Planus Patients
Case
Sex
Age Duration (yr) (mo) LP Subtype
1
M
33
4
AGLP
2
M
28
8
LPP
3
E
45
2
AGLP
4
M
27
24
CLLP
5
M
18
10
LLP
6
E
36
17
LPP
7
F
29
16
LPP
8
M
24
13
LPE
48
LPP
Clinical Features
Dark red papules, brownish macules or dots Dark brown macules with variable sizes Red to violet polygonal papules, some coalesce to plaque Red to violet polygonal papules that do not coalesce Unilaterally distributed red papulomacules or fine pigmented macules Gray macules interspersed with mild milia-sized papules Numerous pigmented macules, mostly nail sized Agminated papules and hair loss patches with irregular border; there was no obvious scale Brown or gray patches with irregular borders
Locations Trunk and extremities Eace and neck
Lesion Number
WS Counts with Naked Eye Eye/ Dermoseopy
9
3/5
4
0
Eace, neck, and extremities Eeet
6
2/2 .
6
2/3
Right forearm
4
0/1
Armpits, neck, and the inguinal region Trunk and feet
5
1/2
2
0/2
Scalp
3
1/1
Neck and face
4
0
AGLP = acute generalized lichen planus; CLLP = chronic localized lichen planus; LLP = linear lichen planus; LP = lichen planus; LPF = lichen planus foUicularis; LPP = lichen planus pigmentosus; WS = Wiekham striae.
' Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No I (January/February), 2014: pp 28-32
29
Min et al
Table 2. Speetrum of Dermoscopie Patterns in Liehen Planus Number of Lesions (%)
Pattern WS patterns (-H) (n = 16) Morpbology Leaf venation* Reticular Wbite dots/starry sky* Cireular Radial streaming* Color Gray wbite Homogeneous crystalline wbite Gray-white H- blue-white veü* Homogeneous crystalline white -H bluewhite veil* Yellowisb white WS patterns ( - ) ( « = 27) Pigment pattern (-H) (n = 33) Pigment dots/globules Peppering pigments* Pigment streaming line* Pigment dots -n pigment streaming line* Pigment dots -1- peppering pigments* Pigment pattern ( - ) (« = 10) Vascular pattern (-t-) (n = 15) Red dots Red streaming line to WS Vascular pattern ( —) (n = 28)
6 (37.50) 4 (25.00) 2 (12.50) 1 (6.25) 1 (6.25) 6 3 4 2
(37.50) (18.80) (25.00) (12.50)
1 (6.20)
23 (69.70) 3 (9.10) 1 (3.00) 4 (12.10) 10 (30.30)
8 (53.3) 7 (46.7)
WS = Wiekham striae. *Unreported and undefined pattern. venation patterns were ejchibited in six lesions (37.50%); such patterns are characterized by delicate, secondary striae branching from the centered WS venation. All of the venations were linked together at either end, mimicking the crystal structure of snow (Figure 2D).
Figure 2. Demonstrations of the lesions on the lumbar region of patient 1, as well as their eorresponding dermoseopic patterns and pathologic changes. A, Red to purple papules disseminated on the sacrum, ß, Dermoscopie changes corresponding to the circled lesion in A, shown as crystalline white, reticular striae, interspersed with red dots. On the periphery, there were paralleled white and fine projections. Blue-white veils were noted among the Wiekham striae (WS). C, Illustration of the pathologic changes of the circled lesion in A, which exhibited interfaee dermatitis with wedge-shaped hypergranulosis (hematoxylin-eosin stain,X40 original magnifieation). D, Dermoseopically, the brown lesion on the left arm presented with a leaf venation pattern. Eine, secondary striae were branched from the centered main WS venation. All WS venations were linked together at either end, mimieking the erystal strueture of snow.
Gray-white and homogeneous crystalline white were the first two dominating dermoscopic patterns of color found in the WS (37.50% and 18.80%, respectively). In six lesions, the WS had a structureless blue-white area, four (25.00%) lesions had a gray-white color, and two (12.50%) lesions showed a homogeneous crystalline white stria (see Figure 2B). Yellowish white was found only once (6.25%). A majority of the WS was anastomosed and displayed as a follicular-centered, homogeneous white dot (accounting for 12.50% of the total). A starry sky pattern was proposed to represent these clustered white dots with peppering pigmented dots highlighting the background (Figure 3A). The remaining presentations were circular (6.25%) and radial streaming (6.25%).
Pigment Patterns
Figure 1. Wiekham striae (WS) on the dorsum of the hand. A, Implicitness of WS even if paraffin ou is applied to the lesion. B, Radial-streaming WS under dermoseopy. '30
LP may evolve into gray to dark brown macules in sunexposed or flexural areas (Figure 4A). In our research, 33 lesions (76.74%) had dermoscopic pigment patterns that were unrelated to the pigment network of the skin.
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 1 (January/February), 2014: pp 28-32
spectrum of Dermoscopic Patterns in Lichen Planus
Figure 3. Specific dermoscopic patterns of lichen planus. A, Under dermoscopy, Wickham striae (WS) appeared as a follicular-centered, homogeneous white dot. The "starry sky pattern" is a term proposed to signify these perilesional white dots, with peppering pigmented dots highlighting the background. B, Delicate pigmented lines streamed a waned WS, with a homogeneous erythema serving in the background.
whereas 23 (53.49%) presented as almost uniformly sized, pigmented dots predominantly at the papilla in the dermis (see Figure 4, A and B) that histologically corresponded to the melanophages at the same site (Figure 4C). A pattern
of peppering pigments signifies fine pigment particles that might be overlooked, even under dermoscopy, wdthout a second examination (Figure 4D). We ascribed three (9.09%) to this pattern. Additionally, we observed pigmented streaming lines that were in close vicinity to the waned WS, with a homogeneous erythema serving as its background (Figure 3B). In four lesions (12.12%), we also noted that the pigment dots coexisted with the pigment streaming line. A combination of pigment dots and peppering pigments was demonstrated in 10 lesions (30.30%).
Vascular Patterns Only 15 (34.88%) lesions had abnormal vascular changes under dermoscopy. A red dot was the most common finding and was noted in eight lesions (53.33%). At the periphery of the WS, red fine lines ran in parallel to the delicate white streaming lines (46.67%).
Discussion
Figure 4. Illustrations of lesions on the neck with their corresponding dermoscopic and pathologic changes. A, Dark brown macules on the neck with unclear margins. B, Dermoscopic patterns of the circled lesion in A. Note the heavily pigmented dots of a uniformed size, the majority of which correspond to the locations of the dermal papilla. C, Pathologic changes of the circled lesion in A presented with interface dermatitis, as well as melanophages in the superficial dermis (hematoxylin-eosin stain,X100 original magnification). D, Peppering fine pigments under the dermoscope.
Violaceous polygonal papules, WS, and pigmented macules are pathognomonic signs for LP. The clinical diagnosis of LP may not always be easy and implicates a variety of differential diagnoses, including some benign lesions, psoriasis, syphilis, lupus erythematosus, acanthosis nigra, and other pigmentary skin disorders.^ In such a condition, dermoscopy or skin biopsy may be helpful to confirm the diagnosis. As early as 1895, Louis Frédéric Wickham described the distinctive sign of WS as reticular streaks, dots, or other varied configurations superimposed on an LP papule.'' Since then, WS has been regarded as one of the diagnostic hallmarks of LP. Almost a century later, in 1990, Braun developed the first handheld dermoscope. This device is primarily used for the examination of pigmented skin lesions. However, it can also assist clinicians in assessing amelanotic lesions, including LP. The present study offers further evidence that dermoscopy can enhance the observation of WS over the naked eye. Summerly and colleagues proposed that the abnormal functioning of keratinocytes is conducive to the pathogenesis of WS,^ whereas Ryan and colleagues believe that a reduced vascular web in the superficial dermis should at least be partly responsible.* Darier, however, correlated the finding of WS with hypergranulosis.^ Four lesions presented with dermotoscopically reticular and round WS, which is compatible with previously published s.^'^'^ In this study, we defined two new dermoscopic
• Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 1 (January/February), 2014: pp 28-32
31
Min et al
patterns, which will enable the better characterization of WS. The "starry sky pattern" is a new term that we propose to signify clustered, follicular white dots of WS. As most cases of wedge-shaped hypergranulosis tended to occur at the center of the hair folhcle, we believe that the starry sky pattern is possibly a sequela of hypergranulosis. The "leaf venation pattern" was another descriptor that we defined in six lesions to feature delicate secondary striae branching from the central WS venation. To further define this pattern, all of the venations were linked together at either end, mimicking the crystal structure of snow. This research showed that the most common dermoscopic characteristics of WS seem to be white in color, shaped in reticular striae, and intermingled with red dots. Additionally, we found delicate white lines to be projecting from the periphery of the WS and bluewhite veils occasionally developed in it. We believe that the latter was a reflection of deep-seated melanophages or veins in the dermis. A nonstructured yellowish white color was another variant that appeared in the WS center, and Ackerman linked this color to the pathologic changes of spongiosis in the epidermis or basilar cell degeneration.'° These pigment patterns are generally dermoscopic markers of melanocytic proliferation. Vazquez-Lopez and colleagues found that the most frequent dermoscopic criteria for LP were pigment dots, globules, and diffused hyperpigmentation.'"" Apart from these changes, we were able to identify uniformly sized and pigmented dots scattered in the lesions, the majority of which corresponded to the sites of the dermal papilla. The term "peppering pigments pattern" was created to signify these fine gray particles that might be overlooked under dermoscopy without a second examination. The "pigment dots to papilla pattern" was suggested to represent the grouped melanophages around the vessels in the dermal papillae. The peppering pigments pattern, however, may represent an exhibition of diffused, singular melanophages in the superficial dermis. Eor the first time, we found delicate pigmented lines streaming around a waned WS, with a homogeneous erythema serving as the background. It is likely that this pattern indicates a regressive stage of LP, during which melanophages predominantly infiltrate superficial dilated capillaries. The vascular patterns were much simpler in LP, consisting of interspersed red dots and streaming red lines, paired with WS peripheral pigment lines.^''^
Î32
This research accentuates the variability of dermoscopic patterns in the clinical diagnosis of LP. Dermoscopy is a noninvasive technique that currently provides the best visualization of WS, melanophages, and blood vessels in cases of LP. Discriminating among these pathognomonic signs helps achieve an accurate diagnosis and reduces unnecessary biopsies of LP patients.
Acknowledgment Einancial disclosure of authors: This research was supported by the National Natural Science Eoundation of China (Grant No. 81173400), the 333 High-Level Personnel Training Project of Jiangsu Province, and the Summit of the Six Top Talents Program of Jiangsu Province. Einancial disclosure of reviewers: None reported.
References 1. Vazquez-Lopez F, Maldonado-Seral C, Lopez-Escobar M, PerezOliva N. Dermoscopy of pigmented lichen planus lesions. Clin Exp Dermatol 2003;28:554-5, doi:10.1046/i.l365-2230.2003.01302.x. 2. Vazquez-Lopez F, Manjon-Haces JA, Maldonado-Seral C, et al. Dermoscopic features of plaque psoriasis and lichen planus: new observations. Dermatology 2003;207:151-6, doi:10.1159/ 000071785. 3. Lehman JS, Tollefson MM, Gibson LE. Lichen planus. Int J Dermatol 2009;48:682-94, doi: 10.111 l/j. 1365-4632.2009.04062.X. 4. Wickham L. Sur un signe pathognomonique du lichen du Wuson (lichen plan). Ann Dermatol Syphiligr (Paris) 1895;6:517-520. 5. Summerly R, Wuson Jones E. The microarchitecture of Wickham's striae. Trans St Johns Hosp Dermatol Soc 1964;50:157-161. 6. Ryan T. Lichen planus, Wickham's striae and blood vessels. Br J Dermatol 1971;85:497-498. 7. Darier J. Precis de Dermatologie. Paris: Masson et Cie; 1909. p. 366. 8. Liebman TN, Rabinovitz HS, Dusza SW, Marghoob AA. White shiny structures: dermoscopic features revealed under polarized light. I Eur Acad Dermatol Venereol 2012;26:1493-7. 9. Vazquez-Lopez E, Alvarez-Cuesta C, Hidalgo-Garcia Y, PerezOliva N. The handheld dermatoscope improves the recognition of Wickham striae and capillaries in lichen planus lesions. Arch Dermatol 2001;137:1376. 10. Ackerman AB, Ragaz A. The lives of lesions. New York: Masson USA, Inc.; 1984. p. 252. 11. Vazquez-Lopez F, Vidal AM, Zalaudek 1. Dermoscopic subpattems of ashy dermatosis related to lichen planus. Arch Dermatol 2010; 146:110, doi:10.1001/archdermatoL2009.300. 12. Vazquez-Lopez F, Gomez-Diez S, Sanchez J, Perez-Oliva N. Dermoscopy of active lichen planus. Arch Dermatol 2007;143: 1092, doi:I0.1001/archderm.l43.8.1092.
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 1 (January/February), 2014: pp 28-32
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Spectrum of Dermoscopic Patterns in Lichen Planus: A Case Series from China Cheng Tan*, Zhong-Sheng Min*, Yanning Xue, and Wen-Yuan Zhu Background: Dermoscopy has been shown to be a promising method to faciiitate the diagnosis of lichen pianus (LP| outside of China. Objective: To investigate the spectrum of dermoscopic patterns in Chinese LP patients. Methods: The clinical data and dermoscopic patterns of nine LP cases with a total of 43 lesions were evaluated. Results: To the naked eye, 20.97% of the lesions exhibited graying Wickham striae (WS); however, 37.5% presented with white streaks of annular, reticular, or leaf venation patterns under dermoscopy. Blue-white veils were occasionally observed in the center. Pigment patterns varied from dots, globules, and peppered pigment to pigmented lines, which were unrelated to the pigment network of the skin. At the periphery of the WS, red fine lines ran parallel to the delicate white streaming lines. Conclusions: WS exhibits five morphological patterns (leaf venation, reticular, white dots, circular and radial streaming) and three color patterns (homogeneous crystalline white, blue-white veil and yellowish-white). The pigment patterns consisted of dots/ globules, peppered pigments and pigment, streaming lines. Contexte: La dermatoscopie s'est révélée, à l'extérieur de la Chine, un examen prometteur dans la pose du diagnostic de lichen plan (LP). Objectif: L'étude visait à examiner les différentes formes dermatoscopiques de LP, observées chez des patients chinois. Méthode: II y a eu évaluation de données cliniques ainsi que des différentes formes dermatoscopiques de LP, observées dans 9 cas, qui totalisaient 43 lésions. Résultats: Après examen, 20.97% des lésions présentaient, à l'œil nu, des stries de Wickham grisâtres, tandis que 37.5% présentaient, à la dermatoscopie, des stries blanches de forme annulaire ou réticulaire ou encore des nervures en forme de feuille. Des voiles blanc bleuté ont parfois été observés au centre. La pigmentation prenait la forme de points, de globules, d'amas parsemés de points pigmentés, ou de filets pigmentés, toutes des formes non liées au réseau de pigmentation de la peau. À la périphérie des stries de Wickham, de petites lignes rouges couraient parallèlement aux fins filets blancs. Conclusions: Les stries de Wickham se présentaient sous cinq grandes formes (nervures en forme de feuille, points réticulaires ou blancs, filets circulaires ou radiaux) et en trois couleurs (blanc cristallin homogène, voile blanc bleuté, blanc jaunâtre). La pigmentation prenait la forme de points, de globules, d'amas parsemés de points pigmentés, ou de filets pigmentés.
ERMOSCOPY is a well-established diagnostic tool to improve the clinical recognition of a broad spectrum of skin disorders, including melanoma, basal cell carcinoma, and seborrheic keratosis. Lichen planus (LP) is an
D
*The two authors contributed equally to the manuscript. From the Department of Dermatology, Jiangsu Provincial Hospital of Traditional Chinese Medicine, Jiangsu, China. Address reprint requests to: Cheng Tan, Department of Dermatology, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, Nanjing 210029, Chirm; e-mail: [email protected].
DOI 10.2310/7750.2013.13049 © 2014 Canadian Dermatology Association
acute or chronic infiammatory skin disorder that is characterized by discrete, violaceous to brownish, polygonal papules or pigmented macules. The well-known histopathologic features of LP are hyperkeratosis with thickening of the granular cell layer, lymphocytic infiltration at the epidermal-dermal junction, and scattered melanophages in the superficial dermis. The depth of all of these pathologic changes can theoretically be reached by the light of the dermoscope. Vazquez-Lopez and colleagues published two LP case series related to its dermoscopic features and demonstrated the capacity for dermoscopy to improve the clinical diagnosis of LP.'"^ To explore the dermoscopic features of LP, the present study recruited nine Chinese LP patients.
DECKER^ Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 1 (January/February), 2014: pp 28-32
spectrum of Dermoscopic Patterns in Lichen Planus
Patients and Methods
Results
The present study included nine consecutive patients (a total of 43 lesions) with a clinical diagnosis of LP who were treated at the Department of Dermatology of Jiangsu Provincial Hospital of Traditional Chinese Medicine between March 2010 and February 2012. The mean age ofthe patient group was 32.0 years (range 1848 years). Data related to clinical diagnosis and their demographic features were eoUected and are shown in Table 1. The same dermatologist investigated each patient according to a set protocol. The diagnosis was established clinically and confirmed by the histopathologic examination of a skin biopsy specimen in all primary LPs and in other doubtful cases. Dermoscopic examination was performed by a polarized-light handheld dermascope (Dermlite DLIOO, 3Gen LLC, San Juan Capistrano, CA), which permitted visualization of skin at a 10-fold magnifieation without an interface solution. Images were obtained by a digital camera (Cannon 980 IS, Cannon Corp, Tokyo, Japan). A pattern analysis was performed, including dermoscopic patterns for Wiekham striae (WS), pigmentation, and vascular changes.
LP presents clinically as shiny, violaceous, polygonal papules with overlying white scales (WS). Skin biopsies revealed characteristie findings of lymphocytic infiltration at the epidermal-dermal junction and damage to the basal cell layer. The associated epidermal changes include hyperkeratosis with hypergranulosis or atrophie epidermis. Melanophages were noted in the superfieial dermis. A diagnosis of LP was reached based on its typical clinical appearance and a biopsy of the skin lesion. The spectrum of dermoscopic patterns is summarized in Table 2.
WS Dermoscopic Patterns Among all 43 lesions, WS could be observed by the naked eye in nine (20.93%) patients. Under dermoseopy, a significantly higher rate of detection was achieved, identifying 37.21% of the patients (x^ = 2.76, p < .01). Meanwhile, dermoseopy ensured a mueh clearer visibility ofthe WS than was possible with the naked eye, even after spreading the skin with paraffin oil (Figure 1). Most ofthe WS consisted of a grid of crystalline white striae under dermoseopy, 25.00% of which were reticular or arborizing in shape (Figure 2B). Leaf
Table 1. Clinical Data of Nine Lichen Planus Patients
Case
Sex
Age Duration (yr) (mo) LP Subtype
1
M
33
4
AGLP
2
M
28
8
LPP
3
E
45
2
AGLP
4
M
27
24
CLLP
5
M
18
10
LLP
6
E
36
17
LPP
7
F
29
16
LPP
8
M
24
13
LPE
48
LPP
Clinical Features
Dark red papules, brownish macules or dots Dark brown macules with variable sizes Red to violet polygonal papules, some coalesce to plaque Red to violet polygonal papules that do not coalesce Unilaterally distributed red papulomacules or fine pigmented macules Gray macules interspersed with mild milia-sized papules Numerous pigmented macules, mostly nail sized Agminated papules and hair loss patches with irregular border; there was no obvious scale Brown or gray patches with irregular borders
Locations Trunk and extremities Eace and neck
Lesion Number
WS Counts with Naked Eye Eye/ Dermoseopy
9
3/5
4
0
Eace, neck, and extremities Eeet
6
2/2 .
6
2/3
Right forearm
4
0/1
Armpits, neck, and the inguinal region Trunk and feet
5
1/2
2
0/2
Scalp
3
1/1
Neck and face
4
0
AGLP = acute generalized lichen planus; CLLP = chronic localized lichen planus; LLP = linear lichen planus; LP = lichen planus; LPF = lichen planus foUicularis; LPP = lichen planus pigmentosus; WS = Wiekham striae.
' Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No I (January/February), 2014: pp 28-32
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Min et al
Table 2. Speetrum of Dermoscopie Patterns in Liehen Planus Number of Lesions (%)
Pattern WS patterns (-H) (n = 16) Morpbology Leaf venation* Reticular Wbite dots/starry sky* Cireular Radial streaming* Color Gray wbite Homogeneous crystalline wbite Gray-white H- blue-white veü* Homogeneous crystalline white -H bluewhite veil* Yellowisb white WS patterns ( - ) ( « = 27) Pigment pattern (-H) (n = 33) Pigment dots/globules Peppering pigments* Pigment streaming line* Pigment dots -n pigment streaming line* Pigment dots -1- peppering pigments* Pigment pattern ( - ) (« = 10) Vascular pattern (-t-) (n = 15) Red dots Red streaming line to WS Vascular pattern ( —) (n = 28)
6 (37.50) 4 (25.00) 2 (12.50) 1 (6.25) 1 (6.25) 6 3 4 2
(37.50) (18.80) (25.00) (12.50)
1 (6.20)
23 (69.70) 3 (9.10) 1 (3.00) 4 (12.10) 10 (30.30)
8 (53.3) 7 (46.7)
WS = Wiekham striae. *Unreported and undefined pattern. venation patterns were ejchibited in six lesions (37.50%); such patterns are characterized by delicate, secondary striae branching from the centered WS venation. All of the venations were linked together at either end, mimicking the crystal structure of snow (Figure 2D).
Figure 2. Demonstrations of the lesions on the lumbar region of patient 1, as well as their eorresponding dermoseopic patterns and pathologic changes. A, Red to purple papules disseminated on the sacrum, ß, Dermoscopie changes corresponding to the circled lesion in A, shown as crystalline white, reticular striae, interspersed with red dots. On the periphery, there were paralleled white and fine projections. Blue-white veils were noted among the Wiekham striae (WS). C, Illustration of the pathologic changes of the circled lesion in A, which exhibited interfaee dermatitis with wedge-shaped hypergranulosis (hematoxylin-eosin stain,X40 original magnifieation). D, Dermoseopically, the brown lesion on the left arm presented with a leaf venation pattern. Eine, secondary striae were branched from the centered main WS venation. All WS venations were linked together at either end, mimieking the erystal strueture of snow.
Gray-white and homogeneous crystalline white were the first two dominating dermoscopic patterns of color found in the WS (37.50% and 18.80%, respectively). In six lesions, the WS had a structureless blue-white area, four (25.00%) lesions had a gray-white color, and two (12.50%) lesions showed a homogeneous crystalline white stria (see Figure 2B). Yellowish white was found only once (6.25%). A majority of the WS was anastomosed and displayed as a follicular-centered, homogeneous white dot (accounting for 12.50% of the total). A starry sky pattern was proposed to represent these clustered white dots with peppering pigmented dots highlighting the background (Figure 3A). The remaining presentations were circular (6.25%) and radial streaming (6.25%).
Pigment Patterns
Figure 1. Wiekham striae (WS) on the dorsum of the hand. A, Implicitness of WS even if paraffin ou is applied to the lesion. B, Radial-streaming WS under dermoseopy. '30
LP may evolve into gray to dark brown macules in sunexposed or flexural areas (Figure 4A). In our research, 33 lesions (76.74%) had dermoscopic pigment patterns that were unrelated to the pigment network of the skin.
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 1 (January/February), 2014: pp 28-32
spectrum of Dermoscopic Patterns in Lichen Planus
Figure 3. Specific dermoscopic patterns of lichen planus. A, Under dermoscopy, Wickham striae (WS) appeared as a follicular-centered, homogeneous white dot. The "starry sky pattern" is a term proposed to signify these perilesional white dots, with peppering pigmented dots highlighting the background. B, Delicate pigmented lines streamed a waned WS, with a homogeneous erythema serving in the background.
whereas 23 (53.49%) presented as almost uniformly sized, pigmented dots predominantly at the papilla in the dermis (see Figure 4, A and B) that histologically corresponded to the melanophages at the same site (Figure 4C). A pattern
of peppering pigments signifies fine pigment particles that might be overlooked, even under dermoscopy, wdthout a second examination (Figure 4D). We ascribed three (9.09%) to this pattern. Additionally, we observed pigmented streaming lines that were in close vicinity to the waned WS, with a homogeneous erythema serving as its background (Figure 3B). In four lesions (12.12%), we also noted that the pigment dots coexisted with the pigment streaming line. A combination of pigment dots and peppering pigments was demonstrated in 10 lesions (30.30%).
Vascular Patterns Only 15 (34.88%) lesions had abnormal vascular changes under dermoscopy. A red dot was the most common finding and was noted in eight lesions (53.33%). At the periphery of the WS, red fine lines ran in parallel to the delicate white streaming lines (46.67%).
Discussion
Figure 4. Illustrations of lesions on the neck with their corresponding dermoscopic and pathologic changes. A, Dark brown macules on the neck with unclear margins. B, Dermoscopic patterns of the circled lesion in A. Note the heavily pigmented dots of a uniformed size, the majority of which correspond to the locations of the dermal papilla. C, Pathologic changes of the circled lesion in A presented with interface dermatitis, as well as melanophages in the superficial dermis (hematoxylin-eosin stain,X100 original magnification). D, Peppering fine pigments under the dermoscope.
Violaceous polygonal papules, WS, and pigmented macules are pathognomonic signs for LP. The clinical diagnosis of LP may not always be easy and implicates a variety of differential diagnoses, including some benign lesions, psoriasis, syphilis, lupus erythematosus, acanthosis nigra, and other pigmentary skin disorders.^ In such a condition, dermoscopy or skin biopsy may be helpful to confirm the diagnosis. As early as 1895, Louis Frédéric Wickham described the distinctive sign of WS as reticular streaks, dots, or other varied configurations superimposed on an LP papule.'' Since then, WS has been regarded as one of the diagnostic hallmarks of LP. Almost a century later, in 1990, Braun developed the first handheld dermoscope. This device is primarily used for the examination of pigmented skin lesions. However, it can also assist clinicians in assessing amelanotic lesions, including LP. The present study offers further evidence that dermoscopy can enhance the observation of WS over the naked eye. Summerly and colleagues proposed that the abnormal functioning of keratinocytes is conducive to the pathogenesis of WS,^ whereas Ryan and colleagues believe that a reduced vascular web in the superficial dermis should at least be partly responsible.* Darier, however, correlated the finding of WS with hypergranulosis.^ Four lesions presented with dermotoscopically reticular and round WS, which is compatible with previously published s.^'^'^ In this study, we defined two new dermoscopic
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Min et al
patterns, which will enable the better characterization of WS. The "starry sky pattern" is a new term that we propose to signify clustered, follicular white dots of WS. As most cases of wedge-shaped hypergranulosis tended to occur at the center of the hair folhcle, we believe that the starry sky pattern is possibly a sequela of hypergranulosis. The "leaf venation pattern" was another descriptor that we defined in six lesions to feature delicate secondary striae branching from the central WS venation. To further define this pattern, all of the venations were linked together at either end, mimicking the crystal structure of snow. This research showed that the most common dermoscopic characteristics of WS seem to be white in color, shaped in reticular striae, and intermingled with red dots. Additionally, we found delicate white lines to be projecting from the periphery of the WS and bluewhite veils occasionally developed in it. We believe that the latter was a reflection of deep-seated melanophages or veins in the dermis. A nonstructured yellowish white color was another variant that appeared in the WS center, and Ackerman linked this color to the pathologic changes of spongiosis in the epidermis or basilar cell degeneration.'° These pigment patterns are generally dermoscopic markers of melanocytic proliferation. Vazquez-Lopez and colleagues found that the most frequent dermoscopic criteria for LP were pigment dots, globules, and diffused hyperpigmentation.'"" Apart from these changes, we were able to identify uniformly sized and pigmented dots scattered in the lesions, the majority of which corresponded to the sites of the dermal papilla. The term "peppering pigments pattern" was created to signify these fine gray particles that might be overlooked under dermoscopy without a second examination. The "pigment dots to papilla pattern" was suggested to represent the grouped melanophages around the vessels in the dermal papillae. The peppering pigments pattern, however, may represent an exhibition of diffused, singular melanophages in the superficial dermis. Eor the first time, we found delicate pigmented lines streaming around a waned WS, with a homogeneous erythema serving as the background. It is likely that this pattern indicates a regressive stage of LP, during which melanophages predominantly infiltrate superficial dilated capillaries. The vascular patterns were much simpler in LP, consisting of interspersed red dots and streaming red lines, paired with WS peripheral pigment lines.^''^
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This research accentuates the variability of dermoscopic patterns in the clinical diagnosis of LP. Dermoscopy is a noninvasive technique that currently provides the best visualization of WS, melanophages, and blood vessels in cases of LP. Discriminating among these pathognomonic signs helps achieve an accurate diagnosis and reduces unnecessary biopsies of LP patients.
Acknowledgment Einancial disclosure of authors: This research was supported by the National Natural Science Eoundation of China (Grant No. 81173400), the 333 High-Level Personnel Training Project of Jiangsu Province, and the Summit of the Six Top Talents Program of Jiangsu Province. Einancial disclosure of reviewers: None reported.
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