CLINICAL HISTORY:

Signs and symptoms:  A 73 year old man presented with asymptomatic dark brown patches in the axillary area for 3 months duration.

Previous Treatment:  None

Other information:  There was no history of prolonged sunexposure or trauma in that area. Patient denied any symptoms of pain or pruritus. Patient past medical history includes hypertension with atenolol being his only medication.

PHYSICAL EXAM:

On physical exam, there were well demarcated brown mottled patches in both axillae. There was no involvement of the extremities, nail or oral mucosa. (figure 1,2)

Left axilla

Right axilla

LABORATORY TESTS:

Autoantibodies and complete blood workup was performed resulting in negative or within normal limits outcome.

DERMATOHISTOPATHOLOGY:

Several biopsies were performed showing (figure 3) focal atrophy in the epidermis, a band like lymphocytic infiltrate associated with pigmented macrophages and interface vacuolar change. A PAS stain was negative for fungal elements, and immunoperoxidase staining for mycosis fungoides was negative as well (figure 4,5).

DIFFERENTIAL DIAGNOSIS:

1.   Acanthosis nicrgans
2.   Erythema dyschromicum perstans
3.   Mycosis fungoides
4.   Axillary granular parakeratosis
5.   Lichen planus

SCROLL DOWN FOR ANSWER AND DISCUSSION.

CORRECT DIAGNOSIS:

Lichen Planus Pigmentosus-Inversus

DISCUSSION:

Lichen Planus Pigmentosus-Inversus (LPP) is a rare clinical variant of lichen planus that presents as slate gray, brownish-black, or brown macules, papules, patches, or reticulated hyperpigmentation primarily found on sunexposed areas of the face and neck and flexural folds. Lichen Planus Pigmentosus (LPP) was first described in 1974 by Bhutani et al.1 in Indian patients as a pigmentary disorder similar to erythema dyschromicum perstans (EDP), or ashy dermatosis. The cause of LPP is currently unknown.It has been strongly suggested that lichen planus may be associated with hepatitis C virus (HCV). In a 2009 study, Al-Mutairi et al.3 evaluated thirty-three LPP patients in Kuwait. Of the patients, twenty (60%) were seropositive for HCV with significantly higher liver enzymes (AST and ALT). Since LPP is considered to be in the spectrum of lichenoid disorders, it is not surprising that this study supports a possible association between LPP and HCV. Therefore, when a diagnosis of LPP is suspected or confirmed, conservative laboratory workup may include serological testing for HCV. Lichen planus has been associated with type IV hypersensitivity, which may also play a role in LPP. This should be taken into consideration when developing a plan of treatment.

TREATMENT:

There are no specific standard treatment for LPP. Topical steroids, keratolytics, prednisone, griseofulvin, and chloroquine have been used with inconsistent results. Tacrolimus ointment showed promising results in one study, with improvement of seven out of thirteen patients (53.8%) with LPP3.

REFERENCES:

1. LK Bhutani, TR Bedi, RK Pandhi, NC Nayak. Lichen Planus Pigmentosus. Dermatologica, 1974; 149: 43-50.
2. L Pock, L Jelinkova, L Drjik, S Abrhamova, S Vojtechovska, D Sezemska, I Borodacova, J Hercogova. Lichen planus pigmentosus-inversus. Journal of the European Academy of Dermatology and Venereology, 2001; 15(5): 452-454.
3. N Al-Mutairi, M El-Khalawany. Clinicopathological characteristics of lichen planus pigmentosus and its response to tacrolimus ointment: an open label, non-randomized, prospective study. Journal of the European Academy of Dermatology and Venereology, 2009; online publication.
4. ME Vega, L Waxtein, R Arenas, T Hojyo, L Dominguez-Soto. Ashy dermatosis and lichen planus pigmentosus: a clinicopathologic study of 31 cases. International Journal of Dermatology, 1992; 31(2): 90-94
5. Lichen Planus Pigmentosus-Inversus: A Case Report. Journal of the American Academy of Dermatology, 2010; 62(3): Supplement 1.
6. Kashima A, Tajiri A, Yamashita A, Asada Y, Setoyama M. Two Japanese cases of lichen planus pigmentosus-inversus, Int J Dermatol. 2007 Jul;46(7):740-2.
7. Cho S, Whang KK. Lichen planus pigmentosus presenting in zosteriform pattern. J Dermatol. 1997 Mar;24(3):193-7.
8. Chuang TY, Stitle L, Brashear R, Lewis C. Hepatitis C virus and lichen planus: A case-control study of 340 patients. J Am Acad Dermatol. Nov 1999;41(5 Pt 1):787-9.
9. Shengyuan L, Songpo Y, Wen W, Wenjing T, Haitao Z, Binyou W. Hepatitis C virus and lichen planus: a reciprocal association determined by a meta-analysis. Arch Dermatol. Sep 2009;145(9):1040-7.
10. Bigby M. The relationship between lichen planus and hepatitis C clarified. Arch Dermatol. Sep 2009;145(9):1048-50.

Additional Comment:

© Copyright 2003-2006 by AOCD Grand Rounds

Top of Page