DOI: 10.1111/pde.

13915

Pediatric
CASE REPORT Dermatology

Pediatric generalized lichen nitidus treated with natural

sunlight therapy

Hannah Berman BA1  | Allison Truong MD2 | Carol E. Cheng MD2

1
David Geffen School of Medicine at
University of California, Los Angeles, Abstract
California Lichen nitidus is a benign inflammatory dermatosis that typically presents in a localized
2
Division of Dermatology, Department
distribution. We present the rare case of a 6‐year‐old boy with a 1‐year history of gen‐
of Medicine, University of California, Los
Angeles, California eralized lichen nitidus with limited access to narrowband ultraviolet B phototherapy.
Over the course of a summer, he had complete and lasting resolution of generalized
Correspondence
Hannah Berman, BA, David Geffen School lichen nitidus after daily natural sunlight exposure. This case demonstrates a rare vari‐
of Medicine at University of California,
ant of lichen nitidus and a practical treatment alternative to in‐office phototherapy.
2001 Santa Monica Blvd, Suite 1070, Santa
Monica, CA 90404.
Email: Hberman@mednet.ucla.edu KEYWORDS
exanthem, phototherapy

1 |  I NTRO D U C TI O N
Lichen nitidus (LN) is an uncommon idiopathic eruption character‐
ized by small, shiny papules typically on the trunk, extremities, neck,
or genitalia.1,2
It is self‐limited and thus requires no treatment unless
symptomatic. Generalized LN is a rare subtype with a more variable
course, and treatment may be offered to improve a patient's cos‐
metic outcome and quality of life. 1,2
patient lived too far from a phototherapy center. As an alternative
to in‐office NB‐UVB, we suggested natural sunlight therapy with
15 minutes of judicious exposure daily. We also prescribed tacro‐
limus 0.03% ointment daily to the face and fluocinolone acetonide
0.01% oil daily to the body. The patient returned to clinic 3 months
later with complete resolution of the eruption after swimming in
an outdoor pool for 30 minutes daily during peak summer months
(June‐August), with remission persisting 10 months following termi‐
nation of treatment at the time of last follow‐up (Figure 2).

2 |  C A S E R E P O RT
A 6‐year‐old boy, skin phototype 3, with a history of atopic derma‐
titis, presented with a 1‐year duration of numerous, pruritic, 1‐mm,
skin‐colored to pink papules involving the face, neck, chest, abdo‐
men, back, buttocks, and upper and lower extremities. The rash de‐
veloped following a viral respiratory illness during a family vacation
to China. The patient had previously been treated with triamcinolone
0.1% lotion and crisaborole 2% ointment for several months without
improvement. A punch biopsy of lesional skin was performed at his
initial visit. Histology demonstrated chronic granulomatous dermal
inflammation with an overlying thinned clawlike epidermis, consist‐
ent with LN (Figure 1).
The family desired treatment due to the chronicity of the erup‐
tion and associated pruritus. Narrowband ultraviolet B (NB‐UVB)
therapy was recommended but was not practical because the
3 | D I S CU S S I O N
Lichen nitidus is a rare, cutaneous condition presenting with an
eruption of 1‐ to 2‐mm shiny, round, or flat‐topped papules, typi‐
cally on the trunk, chest, upper extremities, and genitalia.1,2 Lesions
range from pink to tan‐brown or violaceous depending on the pa‐
tient's skin type, may be associated with pruritus, and classically dis‐
play the Koebner phenomenon.3,4 The condition is most commonly
seen in children and young adults and affects both genders equally.
Generalized LN (GLN) is a rare subtype of LN, presenting with a
widespread distribution pattern, and of unknown etiology, although
associations between the generalized version of LN and several ge‐
netic diseases have been reported—most notably Down syndrome.5
A skin biopsy can confirm the diagnosis of LN, although classic pres‐
entations can be made on clinical examination alone.

Pediatric Dermatology. 2019;00:1–3. © 2019 Wiley Periodicals, Inc. |  1

wileyonlinelibrary.com/journal/pde  
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2       Pediatric
Dermatology
(A) (B)
F I G U R E 1   Histopathology (A, B) generalized lichen nitidus lesion classically displaying a thinned “clawlike” epidermis with elongated rete
ridges surrounding an enlarged underlying inflammatory dermal infiltrate. C, Close‐up of underlying inflammatory infiltrate
(A) (B)
Localized LN is typically self‐limited and treatment is unneces‐
sary, but in GLN, the duration is more unpredictable, and treatment
is often pursued. Published reports on pediatric GLN describe multi‐
ple treatment approaches but do not demonstrate a clear consensus
on a standard treatment strategy. Successful treatments described
include NB‐UVB phototherapy with or without topical steroids, top‐
ical calcineurin inhibitors, acitretin, and isolated instances of success
with isotretinoin, isoniazid, or biscoclaurine alkaloids with jumi‐
haidoku‐to (an alternative herbal detoxifying agent).1,2,4,6-11
Of the reported pediatric cases, five were successfully treated
with narrowband phototherapy, one of which additionally included
topical steroids, demonstrating some promise in this treatment
regimen.1,6,7 There are also a few reports of both pediatric and
adult cases of GLN where treatment involved natural sunlight, in‐
cluding a 19‐year‐old girl who experienced improvement of symp‐
toms using corticosteroids and moderate sun exposure and one
report of a 6‐year‐old patient with a multiyear history of LN, which
went into remission after summer sun exposure.12,13 Additionally,
there was one adult case in which a patient noticed improvement
of a papular rash in areas of sun exposure, after which he saw a
BERMAN et al.
(C)
F I G U R E 2   A, Abdomen and chest
before natural sunlight treatment. B,
Complete resolution of lesions shown
after natural sunlight treatment
dermatologist and received a diagnosis of GLN and was treated
further with topical steroid agents.14 In circumstances where in‐
office phototherapy is not feasible, natural light therapy can be
considered based on geographic location of the patient, time of
year of presentation, and ability for patient to spend time out‐
doors. To minimize variability of UV dosing, we recommend sun
exposure during mid‐day between the hours of 11 o'clock in the
morning to 2 o'clock in the afternoon, and to adjust exposure time
based on season, with summer months requiring shorter daily ex‐
posure times than winter months.15
This case highlights a unique treatment approach in a case of
pediatric GLN in which lightbox phototherapy was not feasible and
midpotency topical steroids alone did not lead to improvement.
However, natural sunlight in conjunction with low‐potency topical
steroid treatment resulted in complete and sustained resolution of
the eruption. The limitation of this case included the concurrent
use of two treatment modalities; however, as the patient did not
respond initially to topical steroids, this suggests efficacy in ultra‐
violet light. Thus, this case reinforces the utility of natural sunlight
therapy as a useful tool in the dermatologist's armamentarium.
BERMAN et al.
I N FO R M E D CO N S E NT
We attest to following the principles outlined in the Declaration of
Helsinki and have received informed consent by the patient's guard‐
ian to publish this manuscript and associated photographs.
ORCID
Hannah Berman  https://orcid.org/0000-0003-4614-1821
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How to cite this article: Berman H, Truong A, Cheng CE.
Pediatric generalized lichen nitidus treated with natural
sunlight therapy. Pediatr Dermatol. 2019;00:1–3. https​://doi.
org/10.1111/pde.13915​