|Year : 2014 | Volume
| Issue : 1 | Page : 25-27
Lichen planus presenting as generalized reticulate pigmentation with sole involvement
Surabhi Sinha1, Rashmi Sarkar2, Vijay K Garg2
1 Department of Dermatology, STD and Leprosy, Dr. Ram Manohar Lohia Hospital, New Delhi, India
2 Department of Dermatology, Venereology and Leprology, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
|Date of Web Publication||26-Jun-2014|
C 403, Sabka Ghar C.G.H.S., Plot No. 23, Sector 6, Dwarka, New Delhi 110 075
Source of Support: None, Conflict of Interest: None
A 61-year-old Indian male presented with gradually progressive generalized reticulate brownish pigmentation of the trunk, upper limbs, and lower limbs. The face and neck area were conspicuously spared. There was no oral, scalp or nail involvement. However, the soles showed bilaterally symmetrical well-demarcated erythematous hyperkeratotic plaques. There was no history of violaceous pruritic lesions over the body. Histopathological features of the trunk as well as sole lesions were consistent with findings of lichen planus (LP). LP pigmentosus is a variant of LP seen in Indian and other darker-skinned populations and most commonly presents as diffuse pigmentation over sun-exposed areas, mainly the face and neck. Our patient, however, presented with reticulate pattern of pigmentation, sparing the face and neck, along with lesions over both the soles. Such a manifestation in the absence of typical lesions of LP is very rare and to our knowledge this is the first such case reported from the Indian subcontinent.
Keywords: Generalized, lichen planus, palms, reticulate pigmentation, soles
|How to cite this article:|
Sinha S, Sarkar R, Garg VK. Lichen planus presenting as generalized reticulate pigmentation with sole involvement. Pigment Int 2014;1:25-7
| Introduction|| |
Lichen planus (LP) is an inflammatory papulosquamous disease characterized clinically by purplish pruritic polygonal papules and plaques on the skin and histologically by a dense band-like mononuclear infiltrate at the dermo-epidermal junction and basal layer vacuolization. LP can present with a variety of clinical manifestations that are well-documented in literature. LP pigmentosus is a variant seen in Indian, Latin American and other dark-skinned populations. It is mostly diffuse and affects the face and neck most commonly. Here, we report a case of LP pigmentosus, presenting as generalized reticulate pigmentation, an extremely rare manifestation. In addition, the face and neck were significantly unaffected and there was involvement of the soles, making it an even rarer presentation.
| Case Report|| |
A 61-year-old Indian male patient presented with a 5 years history of gradually progressive moderately pruritic brownish pigmentation over his trunk and limbs. The lesions first started developing as discrete macules over the chest, later coalescing into a network - like pattern and spreading over the abdomen, back, upper and lower limbs [Figure 1]a]. The face and neck were, however, spared. The patient did not recall any pruritic violaceous lesions preceding or occurring simultaneously with the pigmentation. In the 1 year prior to presentation, the patient developed thick reddish nonitchy lesions over the soles, mainly over the heels. There was no involvement of the palms, scalp, mucosae or the nails. He had used topical steroid preparations occasionally with partial relief in the past but had no history of indigenous or herbal medication use or of mustard oil application. There was no history of long term exposure to ultraviolet radiation or local heat application. Furthermore, there was no history of occupational exposure to coal tar/asphalt or mineral oil. The patient did not complain of darkening of the pigmentation on sun-exposure.
On examination, the patient was of average built and nutritional status. General physical examination did not reveal any significant findings. Mucocutaneous examination showed generalized reticulate brownish pigmentation over the trunk, upper and lower limbs, with maximal pigmentation over the abdomen and lateral aspects of the trunk [Figure 1]b]. The lesions did not have erythematous borders typical of erythema dyschromicum perstans (EDP). The face and neck were spared and there was no flexural accentuation. There was no evidence of atrophy or telangiectasia. There were no violaceous papules or plaques over the body. Both the soles showed well-demarcated erythematous hyperkeratotic plaques with hyperpigmented borders present over the hind foot, sparing the forefoot up to the balls of the metatarsals [Figure 1]c]. The palms and nails did not show any lesions. The scalp and oral and genital mucosae were not affected. There was no significant lymphadenopathy.
|Figure 1: (a) Photograph of the patient showing generalized reticulate pigmentation involving the chest, abdomen and upper limbs, (b) Close-up view of the lateral aspect of the trunk showing the reticulate nature of the pigmentation, and (c) View of the soles showing well-demarcated erythematous hyperkeratotic plaques with hyperpigmented borders, mostly involving the posterior part of the soles|
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Routine laboratory investigations, including hemogram were within normal limits. Viral markers of hepatitis, antinuclear antibody, anti-Smith antibody, and thyroid function tests were all normal. A chest radiograph and an electrocardiogram were also carried out, both of which were normal. Patch test to Indian Standard Series and Cosmetic Series did not yield any positive results. Two 4 mm biopsies were taken - one from lateral aspect of the chest and the other from the affected area of the sole. Hematoxylin and eosin staining of the biopsy specimen taken from the chest revealed a thin to atrophic epidermis, focal hypergranulosis, vacuolar alteration and degeneration in the basal layer, prominent pigment incontinence and moderate lymphocytic infiltrate in the upper dermis [Figure 2]a]. The biopsy from the sole showed compact hyperkeratosis, hypergranulosis, irregular acanthosis, basal layer vacuolization and perivascular lymphocytic infiltrate [Figure 2]b]. There were no fungal elements seen in the epidermis. Both the biopsies were consistent with the diagnosis of LP. Poikiloderma, EDP and Riehl's melanosis were ruled out due to lack of typical clinical features and a negative patch test (for Riehl's melanosis). Postinflammatory hyperpigmentation was considered unlikely due to lack of history of any eruption over such a widespread body area by the patient. Thus, the patient was diagnosed as having generalized reticulate LP pigmentosus along with sole involvement.
|Figure 2: (a) H and E, (×400) of the biopsy taken from the chest showing a thin to atrophic epidermis, focal hypergranulosis, vacuolar alteration and degeneration in the basal layer, prominent pigment incontinence and moderate lymphocytic infiltrate in the upper dermis, and (b) H and E, (×400) of the biopsy from the sole showing compact hyperkeratosis, hypergranulosis, irregular acanthosis, basal layer vacuolization and perivascular lymphocytic infiltrate|
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| Discussion|| |
Lichen planus is known to present in a variety of clinical forms. Different clinical patterns may reflect either different ethnic, genetic and eliciting factors, different extents of skin responses to immunological stimuli, different sites of involvement or different stages of the same disease progress, as mentioned earlier by Lin et al.  This would thus explain the atypical presentation and distribution of lesions seen in our patient.
Lichen planus pigmentosus is a variant of uncertain etiology seen in Indian, Middle-Eastern and other dark - skinned populations. The etiopathogenesis of the disease has not been clearly elucidated. Various factors have been postulated to play a role, including, sunlight (as patients have reported darkening of the pigmentation following sun-exposure), mustard and amla oil, henna and hair dyes. , It involves chiefly the sun-exposed areas that is, the face and neck. It is mostly diffuse (77.4%), but reticular (9.7%), blotchy (7.3%) and perifollicular (5.6%) forms are also seen.  Our patient presented with reticulate pigmentation in a generalized distribution, seen only rarely in LP pigmentosus. Importantly, the pigmentation was predominantly present over the abdomen and lateral aspects of the trunk and spared the face and neck. Further, there was no flexural accentuation (unlike LP pigmentosus inversus) or aggravation on sun-exposure. There were no lesions typical of LP.
Well-demarcated hyperkeratotic plaques with histological features consistent with LP were present over both the soles in our patient. Palm and sole involvement is uncommon in LP and has been reported only in a single case series and few case reports.  Such an association of generalized reticular pigmentation without typical LP lesions and involving the soles has not been reported earlier. The cases presenting with reticulate pigmentation due to LP that have been reported till date have been summarized in [Table 1]. Lin et al. had reported the occurrence of generalized reticulated dark-brown pigmentation on the trunk, face and limbs along with few typical LP lesions and yellowish deep-seated papules on the palms and soles in a Chinese woman.  Generalized reticular pigmentation with typical LP lesions was also reported by Ozden et al.  However, their patient had no palm or sole involvement.
The differential diagnosis in our patient included ashy dermatosis, poikiloderma and erythema ab igne. The last possibility was ruled out as there was no history of local heat application or ultraviolet radiation. Chakrabarti and Chattopadhyay had reported a patient with slowly progressive diffuse nonpruritic bluish-black discoloration over face, neck, arms, and trunk that they diagnosed as ashy dermatosis of unknown etiology.  Our patient had pruritus and reticulate brownish pigmentation. Sayal et al. had described an Indian patient with LP who developed reticulate hyper- and hypo-pigmentation, atrophy and telangiectasia (i.e. poikilodermatous changes) 4 years after developing LP lesions.  However, our patient had no evidence of atrophy or telangiectasia.
| Conclusion|| |
This is an unusual case of LP pigmentosus with generalized reticulate pigmentation along with sole involvement in the absence of typical lesions of LP. To the best of our knowledge, this is the first such case reported from the Indian subcontinent.
| References|| |
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|4.||Sánchez-Pérez J, Rios Buceta L, Fraga J, García-Díez A. Lichen planus with lesions on the palms and/or soles: Prevalence and clinicopathological study of 36 patients. Br J Dermatol 2000;142:310-4. |
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|6.||Chakrabarti N, Chattopadhyay C. Ashy dermatosis: A controversial entity. Indian J Dermatol 2012;57:61-2. |
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[Figure 1], [Figure 2]