CHAPTER 6

TOPIC :Lichenoid
eruptions
LUCTURER :DR HASSAN
MBBS
Lichen planus
 Lichen planus is a relatively common pruritic papular
dermatosis involving the flexor surfaces, mucous
membranes and genitalia. The cause is unknown, but
an immune pathogenesis is suggested by the finding of
IgM at the dermo-epidermal junction and an
association with some autoimmune diseases.
Pathology
 In lichen planus, the granular layer is thickened, basal
cells show liquefaction degeneration and lymphocytes
infiltrate the upper dermis in a band-like fashion .
Clinical presentation
 Two-thirds of cases occur in the 30-60-year-old age
group. It is uncommon at the extremes of age, and the
sex incidence is equal. Lichen planus tends to start on
the limbs. It may spread rapidly to become generalized
within 4 weeks, but the commoner localized forms
progress more slowly.
Cont……
 Typical lesions are very itchy flat-topped
polygonal papules, a few mm in diameter,
which may show a surface network of delicate
white lines (Wickham's striae). Initially, the
papules are red, but they become violaceous .
The eruption is symmetrical and affects:
 forearms and wrists
 lower legs and thighs
 genitalia
 palms and sole
Variants of lichen planus
 A number of variants of lichen planus exist:
Annular: found in 10% of cases, commonly on
the glans penis.
 « Atrophic: rare, may be seen with

hypertrophic lesions.
 « Bullous: blisters appear infrequently in

lichen planus.
Cont……..
 Follicular:may occur with typical lichen
planus; can affect scalp alone .
 Hypertrophic: verrucous plaques affect the

lower legs or arms may persist for years.

 Mucous membrane: any mucosal surface may

be affected, with or without lesions elsewhere .

Complications
 Lichen planus may be complicated by: m Nail
involvement: found in 10% of patients. Longitudinal
grooving and pitting are reversible, but
dystrophic/atrophic lesions can produce scarring or
permanent nail loss. m Scalp lesions: may be follicular,
but pseudopelade-like permanent
Management
 Lichen planus disease is self-limiting in most
patients. Moderate to high potency topical
steroids usually produce symptomatic
improvement. Oral lesions are helped by a
steroidcontaining paste (e.g. Adcortyl in
Orabase).
Cont……
 Hypertrophic lichen planus may require
highly potent topical steroids, sometimes
under occlusion, or intralesional steroid
injection.
Cont……
 Extensive involvement, ulcerative mucous membrane
lesions or a potentially scarring nail dystrophy warrant
a trial of oral prednisolone (in a dose of 10-40 mg/d)
for 1 to 3 months. Long-term systemic steroids are not
justified. PUVA may help resistant cases.
Lichen sclerosus
 Lichen sclerosus is an uncommon disorder
typified by white lichenoid atrophic lesions on
the genitalia. Although associated with
autoimmune disease, the cause is unknown.
Pathology
 The epidermis may be thickened, thinned or
hyperkeratotic. The upper dermis is oedematous,
hyalinized and acellular. Lymphocytes infiltrate the
lower dermis.
Clinical presentation
 Lichen sclerosus occurs ten times more
frequently in women. It is commonest in
middle-age, although it may develop in
childhood (with a better prognosis). Genital
lesions are almost invariable, but involvement
of the trunk or arms is seen.
Cont….
 Individual lesions are a few mm in diameter,
porcelain white and slightly atrophic and may
aggregate into wrinkled plaques .
Hyperkeratosis, telangiectasia, purpura and
even blistering occur.
Cont….
 Vulval and perianal lesions cause itching and soreness.
Involvement in the male results in urethral stricture and
phimosis (balanitis xerotica obliterans). Occasionally,
lesions are found in the mouth. Lichen sclerosus is
chronic and usually permanent. Spontaneous resolution
is most likely at puberty in childhood cases.
Differential diagnosis
 Female genital involvement may resemble
lichen simplex chronicus , Bowen's disease ,
and extra-mammary Paget's disease. Male
genital lesions mimic lichen planus, psoriasis
and some rare inflammatory and premalignant
forms of balanitis .
Complications
 Dysuria and dyspareunia are a problem in females, and
males may experience recurrent balanitis and ulceration
of the glans. Squamous cell carcinoma develops
infrequently in the longstanding lesions of both sexes.
Management
 Non-genital lesions require no treatment. In
female genital involvement, a mild- to
moderatepotency steroid cream (with or
without an antiseptic/antibiotic) will reduce
the itch.
Cont…..
 Vulvectomy is contraindicated in
uncomplicated cases. Treatment is similar for
the male genital lesions, although
circumcision is performed if phimosis
develops. Both sexes need long-term follow-
up and biopsy of any suspicious areas
Lichen nitidus
 Lichen nitidus is an uncommon eruption of
minute monomorphic flesh-coloured
papules. The aetiology is unknown. Histology
reveals a lymphohistiocytic infiltrate which
expands a single dermal papilla
Clinical presentation and management

 The eruption is asymptomatic, often noticed

by chance, and usually occurs in children or
young adults. Uniform pinhead-sized
papules, which may be grouped, are seen on
the forearms, penis, abdomen and buttocks.
Cont……
 The main differential diagnosis is lichen
planus (with which it may coexist) and
keratosis pilaris . Treatment is usually
unnecessaiy. Lichen nitidus may resolve in
weeks or persist indefinitely.
Lichen planus-like drug eruptions
 An eruption resembling lichen planus can
follow the ingestion of several drugs.
Clinical presentations
 A lichen planus-like rash has been recognized with
gold and mepacrine therapy for many years. The
eruption, which can be severe, is often more
hypertrophic and hyperpigmented than true lichen
planus and, on histology/ shows a greater number
of eosinophils. Resolution after withdrawal of the
drug is often slow. Table 2 lists some of the drugs
responsible.
Lichenoid eruptions
Summery
 Lichen planus is a relatively common pruritic
papular eruption which resolves in most
cases within 18 months.
 • Lichen planus-like drug eruption resembles
lichen planus but is more persistent; it is
seen, for example, with gold, chloroquine and
chlorothiazide.
Cont….
 Lichen nitidus is a rare, asymptomatic eruption of fine
monomorphic papules on the abdomen, arms and penis.
 « Lichen sclerosus is mostly found in women, and
frequently affects the genitalia. Long-term follow-up is
necessary due to the risk of malignant change.
Table 2 Drugs causing a lichen
pianus-like eruption
Type of agent Drug

Antiarthritic Gold, penicillamine, naproxen

Antibiotic Streptomycin, tetracycline

Antimalarial Chloroquine, mepacrine, quinine

Antituberculous Isoniazid, ethambutol

Diuretic Thiazides, frusemide

ACE inhibitor Captopril