LETTERS TO THE EDITOR
Cornoid Lamellation
Associated With Lichen
Sclerosus
To the Editor:
Although cornoid lamellation is
the histological feature that characterizes
porokeratosis, it is not limited to poro-
keratosis and may be encountered in
a wide range of other inflammatory and
neoplastic skin diseases.1 A cornoid
lamella reflects disordered progression
of epidermal cells to cornification and
should be regarded as one of the “minor
tissue reactions” in a variety of other
inflammatory skin disorders.2 Cornoid
lamellation has recently been revisited
to define the large clinicopathological
spectrum of porokeratosis and to estab-
lish nonporokeratotic conditions in
which cornoid lamellas can appear.3
We report for the first time cornoid
lamella in association with lichen sclerosus
(LS), which seems to reflect an incidental
finding, and has to be recognized and
differentiated from porokeratosis.
A 51-year-old man presented to the
Dermatology clinics with asymptomatic,
large lichenified plaques developing
within an erythematous surface affecting
his upper arm and shoulder (Figs. 1A, B).
The lesions initially appeared as small pink
plaques, which then enlarged and evolved
with whitish scaling, which did not
respond to antifungals. A biopsy taken
from the upper arm showed extensive
eosinophilic homogenization of the papil-
lary and superficial reticular dermis, imme-
diately beneath the epidermis and focal
vacuolization of the dermal–epidermal
junction, with scant superficial perivascu-
lar lymphocytic infiltrate (Fig. 2A). The
epidermis was slightly atrophic, and no
necrotic keratinocytes were observed.
Marginated on the sides of the atrophic
epidermis, we could focally note vertical
columns of parakeratosis overlying areas
of epidermis with loss of the granular layer
and dyskeratotic cells (Figs. 2B–D).
The authors declare no conflicts of interest.
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FIGURE 1. Clinical features of extragenital LS. Coalescing erythematous macules with
ivory white surface and well-defined borders (A). Higher magnification of the lesion
shows ivory white surface of the lesions, slightly scaly (B).
Cornoid lamella, characterized by
a tilted vertical column of parakeratosis
overlying an area of hypogranulosis with
dyskeratotic cells, can be subtle and
easily overlooked clinically and can
histologically hinder the diagnosis. Cor-
noid lamellation is a constant histologi-
cal marker of porokeratosis. Different
subtypes of porokeratosis are well char-
acterized based on the number, size, and
distribution of the annular lesions or
papules and the prominence and distri-
bution of the cornoid lamellas.3 How-
ever, it is also accepted in the literature
that cornoid lamellation is not pathogno-
monic of porokeratosis and can also be
found in a variety of inflammatory or
neoplastic conditions,1 in which it repre-
sents a distinctive histologic reaction pat-
tern that reflects disordered progression
of epidermal cells to cornification.
Inflammatory disorders including psoria-
sis, lichen planus–like keratosis, Wong
type-dermatomyositis, keratosis lichen-
oides chronica, porokeratotic variant of
Grover disease and Fox–Fordyce dis-
ease, hamartomas such as porokeratotic
eccrine ostial dermal duct nevus, and in-
herited disorders of the keratinization
have been described in association with
real cornoid lamellation,3 in addition to
a wide spectrum of other skin lesions
including scars, viral warts, seborrheic
keratosis, milia, solar keratosis, squa-
mous cell carcinoma in situ, and basal
cell carcinoma. In these particular
settings, it has been related to genetic
instability resulting from an unidentifi-
able trigger.
LS is a chronic inflammatory der-
matosis that results in epidermal atrophy
of unknown etiology. Both, genital or
extragenital presentations have been
described, with a clear predilection for
the vulva. First described by Darier,4 LS
is defined as a vacuolar interface derma-
titis with the presence of homogenized
eosinophilic acellular zone within the
superficial dermis.5 The association of
LS with other epithelial alterations is
usually interpreted as secondary. Most
commonly, vulvar LS, which is predom-
inantly a pruritic condition, frequently
results in a superimposed lichen simplex
chronicus and excoriations. Similarly, the
presence of atrophy in cutaneous lesions
of LS is also a common finding.6 Inter-
estingly, no studies have previously re-
ported the association between LS and
cornoid lamellation. This case is the first
to describe a plaque of extragenital LS
associated with the presence of cornoid
lamellas in the margins. We interpret it as
an incidental finding secondary to the
epithelial alterations occurring in LS;
however, genetic instability may play
a role in the coincidental manifestation
of these lesions. Because the diagnosis
of early and evolving lesions of LS with-
out the hallmark sclerosis can be prob-
lematic, the purpose of this case is to
highlight a new histopathological feature
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Letters to the Editor Am J Dermatopathol  Volume 0, Number 0, Month 2016

FIGURE 2. Microscopic findings of the lesion show a slightly atrophic epidermis with hyperkeratosis (A), and dermal sclerosis,
with vacuolar interface changes and a light perivascular lymphocytic infiltrate underlying the sclerosis (B). Two tilted cornoid
lamellas are seen overlying the lateral edge of the atrophic epidermis (C). An area of dyskeratotic keratinocytes with hypo-
granulosis is present under the vertical column of parakeratosis (D).

that can overlap with LS and delay its
diagnosis.
Maria C. Garrido, MD, PhD*
Veronica Monsalvez, MD†
Jose L. Rodriguez-Peralto, MD,
PhD*
*Department of Pathology,
Hospital Universitario 12 de Octubre,
Instituto de Investigación I+12,
Facultad de Medicina,
Universidad Complutense,
Madrid, Spain
†Department of Dermatology,
Hospital Universitario 12 de Octubre,
Instituto de Investigación I+12,
Madrid, Spain
REFERENCES
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3. Biswas A. Cornoid lamellation revisited: apro-
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4. Darier J. Lichen plan sclereux. Ann Dermatol.
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Mod Pathol. 1998;11:844–854.

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