International Journal of Surgery Case Reports 114 (2024) 109177

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International Journal of Surgery Case Reports

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Case report

Chemotherapy-induced zosteriform lichen planus following mastectomy: A

rare case report
Zuha Shyma a, *, Ankitha Adiga b, Myfanwy Joanne D'Souza b, Adarsh V.V. a
a
Department of Pharmacy Practice, Karavali College of Pharmacy, Vamanjoor (post), Mangalore 575028, Karnataka, India
b
Department of Dermatology, Father Muller Medical College, Mangalore 575028, Karnataka, India

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Zosteriform Lichen Planus represents a relatively uncommon variant of LP. It is characterized by a
Dermatology distinctive distribution following Blaschko's line and involving multiple dermatomes, setting it apart as a unique
Adverse drug reaction manifestation. There have been several cases of cutaneous LP reported, but relatively few of them presented as
Koebner phenomenon
zosteriform LP. To our knowledge, this is the first documented case of zosteriform LP as an adverse drug reaction.
Blaschko's line
Presentation of case: A 62-year-old female presented to the dermatology clinic with asymptomatic hyperpig­
mented patches that exhibited gradual spreading. The patient had a history of breast cancer and underwent a
mastectomy procedure, chemotherapy, adjuvant therapy, and radiation treatment. A dermatological examina­
tion revealed the presence of multiple hyperpigmented, ill-defined macules arranged linearly on the left flank
and inner thigh.
Discussion: A biopsy confirmed the diagnosis as Lichen Planus. The patient's condition significantly improved
following a nine-week topical steroid with dose tapering.
Conclusion: Zosteriform LP is a rare adverse skin reaction associated with chemotherapeutic drugs. The immu­
nosuppression induced by chemotherapy may trigger T-cell activation, leading to a lichenoid tissue reaction. A
thorough patient history assessment is essential for the management of such adverse reactions.

1. Introduction
Lichen Planus (LP) is a relatively common papulosquamous skin
disorder of undetermined etiology. An unusual variant, known as zos­
teriform lichen planus, may manifest spontaneously or at the site of a
prior herpes zoster or varicella-zoster virus infection. LP is recognized as
an immune-mediated disorder affecting both mucosal membranes and
the skin. The distinct feature of zosteriform LP is its distribution, which
follows Blaschko's lines and encompasses multiple dermatomes, setting
it apart from conventional LP [1].
Drug-induced LP, also known as lichenoid drug eruption, is a rare
cutaneous adverse effect associated with various medications [2]. The
condition presents as a symmetrical eruption of flat-topped, violaceous,
or erythematous papules resembling lichen. The latent period between
initiating the suspected drug and the onset of cutaneous lesions can
range from weeks to over a year, influenced by factors such as drug
dosage, host reaction, drug class, and concomitant medications. There
have been several cases of cutaneous LP reported, but relatively few of
them presented as zosteriform LP. To our knowledge, this is the first
documented case of zosteriform LP as an adverse drug reaction [3]. The
work has been reported in line with the SCARE criteria [4].
2. Presentation of case
A 62-year-old Asian female presented to the dermatology clinic with
asymptomatic multiple hyperpigmented patches, which were gradually
spreading in nature. The patient had a past medical history of breast
cancer and underwent treatment for it. A Trucut biopsy from the left
breast was suggestive of infiltrating ductal carcinoma. She underwent
left modified radical mastectomy axillary dissection under general
anesthesia. She received chemotherapy- 4 cycles of Epirubicin (150 mg)
+ cyclophosphamide(1100 mg) and 4 cycles of paclitaxel (300 mg),
along with adjuvant therapy which included antiemetic, proton pump
inhibitor, and systemic steroid. She was started on T. Letrozole 2.5 mg
and later received radiotherapy to the left chest wall, supraclavicular
and axillary regions. One month after radiotherapy, dermatological

Abbreviations: LP, Lichen Planus.

* Corresponding author.
E-mail address: zuhashyma@gmail.com (Z. Shyma).

https://doi.org/10.1016/j.ijscr.2023.109177
Received 3 November 2023; Received in revised form 9 December 2023; Accepted 11 December 2023
Available online 19 December 2023
2210-2612/© 2023 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
Z. Shyma et al. International Journal of Surgery Case Reports 114 (2024) 109177

examination showed multiple hyperpigmented, well-defined macules

and papules in a whorled and linear fashion extending from the left
infra-mammary area, the lower left side of the abdomen (as shown in
Fig. 1) over the left inner thigh reaching the left mid-calf area as shown
in Fig. 1B. The lesions occurred spontaneously without any prior herpes
zoster or varicella-zoster virus infection.
In order to confirm the diagnosis, an incisional skin biopsy was done
from the left inner thigh for a histopathological examination. As shown
in Fig. 2, the epidermis showed hyperkeratosis, wedge-shaped hyper­
granulosis, and vascular alteration of the basal layer, with a moderate
degree of lymphocytic infiltrate seen at the dermo-epidermal junction
with pigment incontinence confirming Lichen Planus. The distribution
of the lesion is multi-dermatomal (T 11, T 12, L1-L3). It was found to
follow Blaschko's lines (Fig. 1C), and so she was diagnosed with Zos­
teriform Lichen Planus induced by chemotherapy. Causality assessment
indicated a “possible” relationship, with a score of 4 on the WHO's
(World Health Organization) Naranjo Causality assessment scale. The
development of zosteriform lichen planus is plausible due to
chemotherapy-induced immunosuppression. The patient was prescribed
a nine-week regimen of topical steroids (betamethasone 0.05 % + zinc
sulfate 0.5 %). Subsequently, the patient's condition exhibited marked
improvement (Fig. 3).

3. Discussion

Lichen Planus (LP) remains a common papulosquamous skin condi­

tion with an unknown etiology. Zosteriform LP, characterized by a
dermatomal arrangement and adherence to Blaschko's lines, represents
an unusual variant and may be explained as Köebner phenomenon [5].
Such cases may be underreported due to the variable latent period be­
tween drug initiation and the appearance of cutaneous lesions. Thor­
oughly reviewing medication use over the preceding 12 to 14 months is
imperative in diagnosing drug-induced lichen planus [6]. Drugs can
induce lichen planus by acting as haptens that attach to keratinocytes or
melanocytes, subsequently triggering a cytotoxic T lymphocyte response
[7].
Lichen Planus is generally regarded as an idiopathic disease. The
prevailing theory suggests that contact with exogenous substances, such
as viruses, medications, or allergens, modifies epidermal self-antigens
and activates cytotoxic CD8+ T cells. This interaction between altered
and normal self-antigens on basal keratinocytes leads to T-cell targeting
and apoptosis. In the context of chemotherapy-induced immunosup­
pression, T-cell activation is likely to have played a role in triggering the
lichenoid tissue reaction. Even though Chemotherapy-induced hyper­
pigmentation is widespread regardless of race, it is more frequent and
prominently seen among dark-skinned individuals [8]. The identifica­
tion of the specific drug or drugs responsible for adverse skin reactions
can be challenging, particularly in cases involving multiple drugs, as
seen in this case [9].
Since radiation was specifically administered in chest region,
occurrence of lesion beyond chest region nullifies the relation between
radiation therapy and zosteriform lichen planus.
Lichenoid drug eruptions typically resolve within weeks to months
after discontinuation of the offending drug. Symptomatic patients with
limited skin area involvement are recommended to receive topical cor­
ticosteroids, while oral corticosteroids are advised for extensive, symp­
tomatic disease. In cases where systemic corticosteroids are
contraindicated, oral retinoids may serve as an alternative.
Healthcare providers should be vigilant, as drug use may underlie
certain LP cases, and consultation with treating physicians is essential
[10]. Withdrawal of the suspected drug leading to the gradual disap­ Fig. 1. A: Well-defined macules and papules extending from the left infra-
pearance of lesions serves as confirmation of the diagnosis. Previous mammary area, the lower left side of the abdomen.
B: Well-defined macules and papules over the left inner thigh reaching the left
reports have detailed Pembrolizumab-Induced Lichen Planus and
mid-calf area.
Lichenoid reactions induced by Adalimumab [11,12]. However, this
C: lesions showing Blaschko's lines.
case represents, to our knowledge, the first documented case of zos­
teriform lichen planus induced by chemotherapy.

2
Z. Shyma et al.
Fig. 2. Histopathological appearance of Lichen Planus.
Fig. 3. Improvement in patient condition post 9 week follow up.
4. Conclusion
Zosteriform lichen planus is a potential adverse skin reaction asso­
ciated with chemotherapeutic drugs. Thorough patient history assess­
ment and vigilance in monitoring for such reactions are crucial for
timely diagnosis and management.
Consent form
Written informed consent was obtained from the patient for publi­
cation of this case report and any accompanying images. A copy of the
written consent is available with the corresponding for review by the
3
International Journal of Surgery Case Reports 114 (2024) 109177
Editor-in-Chief of this journal upon request.
Provenance and peer review
Not commissioned, externally peer reviewed.
Ethical approval
The Father Muller Institutional Ethics Committee (FMIEC) of Father
Muller Research Centre, Kankanady, Mangalore, Karnataka, India,
approved the case report for publication on 14th September 2023 with
approval number FMIEC/CCM/497/2023.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Author contribution
Zuha Shyma - Writing - review & editing, Writing - original draft,
Conceptualization, Investigation.
Ankitha Adiga - Conceptualization, Investigation, Writing - review
& editing.
Myfanwy Joanne D'Souza - Conceptualization, Investigation,
Writing - review & editing.
Adarsh VV - Writing - review & editing.
Guarantor
Zuha Shyma.
Research registration number
N/A.
Conflict of interest statement
The authors declare that they have no conflict of interest.
Acknowledgment
We would like to thank Father Muller Medical College Hospital and
Karavali college of pharmacy for their unwavering response throughout
the work. We would like to extend our thanks to Abdullah Zaawari for
his assistance in proofreading the final manuscript.
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