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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 186-187

Unilateral lichen planus pigmentosus inversus: a rare presentation

Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission27-Aug-2020
Date of Decision27-Jan-2021
Date of Acceptance16-Apr-2021
Date of Web Publication24-Nov-2021

Correspondence Address:
Dr. Muthu Sendhil Kumaran
Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/Pigmentinternational.Pigmentinternational_

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Keywords: Flexural, inversus, lichen planus pigmentsosus

How to cite this article:
Kamat D, Sendhil Kumaran M. Unilateral lichen planus pigmentosus inversus: a rare presentation. Pigment Int 2021;8:186-7

How to cite this URL:
Kamat D, Sendhil Kumaran M. Unilateral lichen planus pigmentosus inversus: a rare presentation. Pigment Int [serial online] 2021 [cited 2022 Jul 1];8:186-7. Available from: https://www.pigmentinternational.com/text.asp?2021/8/3/186/330896


Lichen planus pigmentsosus (LPP) inversus is an unusual variant of LPP with fewer cases of unilateral distribution reported worldwide. In a retrospective cohort from our center, flexural lesions were present in only 2 of 76 (2.6%) cases.[1] We report a rare case of unilateral LPP inversus that like other variants had poor response to treatment.

A 45-year-old female presented with 1-year duration of multiple, slightly pruritic, well-defined slate grey macules on the left axilla [Figure 1]. There were no prior inflammatory lesions. The grey macules coalesced together with few smaller discrete macules in the periphery and lacked surrounding erythema. Dermatoscopy showed diffuse grey brown pigmentation with few brownish granular dots [Figure 2]a. Other flexures, nails, mucosa, and scalp were spared. Histopathology demonstrated a lichenoid reaction pattern with prominent pigment incontinence [Figure 2]b. The diagnosis of LPP inversus was made and patient started on topical 0.05% tacrolimus cream daily at night. Due to unsatisfactory response after 4 months of treatment, patient was advised to discontinue the cream.
Figure 1 Slate grey macules over left axilla

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Figure 2 (a) Dermoscopy showing diffuse grey brown pigmentation with few brownish dots (circle) and globules (square) with sparing of skin creases (triangles; DL3N, 10×). (b) Lichenoid reaction pattern with prominent pigment incontinence (Hematoxylin and Eosin stain, 40×)

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Inverse LPP initially described by Pock et al.[2] in 2001 is a rare variant of LPP. In their report of LPP inversus, upto 10% of cases had lesions outside the flexural areas. Humid environment, sweating, ill-fitting garments leading to koebnerization have all been postulated as triggering factors. Some authors have also reported the simultaneous presence of LP and LPP.[3]

LPP inversus presents with slate grey to brown macules commonly located in the axillae and groin. Other flexures such as neck, anticubital fossae, auricular sulcus, and infra-mammary areas can also be involved.[4] In most cases, lesions are bilaterally symmetrical with only few reports of unilateral LPP.[5] Concurrent presence of atypical variants such as linear and flexural LPP has also been reported.[6] The usual differential diagnoses include ashy dermatosis, acanthosis nigricans, fixed drug eruptions, erythrasma, and post inflammatory hyperpigmentation. Dermoscopic features described in LPP include brown to bluish dots, globules, and blotches that vary with the severity of pigmentation. These features are also common to Riehl’s melanosis, pigmented contact dermatitis, and ashy dermatosis.[7] The histopathology findings are similar to that found in LP like band-like lichenoid pattern of inflammatory infiltrate composed of lymphocytes and prominent pigment incontinence and melanophages in the upper dermis. Few differences compared to LP include less prominent hypergranulosis and variable amount of inflammatory infiltrate.[1]

Other atypical variants of LPP include linear,[8] zosteriform,[9] and follicular.[10] The phenomenon of koebnerization has also been described in LPP.[11]The overall response to treatment in all variants of LPP has been poor. Topical steroids and topical tacrolimus have been tried in earlier reported cases. There have been few reports of spontaneous resolution over few weeks to months.[1]

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kumaran M, Mahajan R, Parsad D. Lichen planus pigmentosus: a retrospective clinico-epidemiologic study with emphasis on the atypical variants. Pigment Int 2014;1:90.  Back to cited text no. 1
Pock L, Jelinkova L, Drlik L et al. Lichen planus pigmentosus-inversus. J Eur Acad Dermatol Venereol 2001;15:452-4.  Back to cited text no. 2
Chen S, Sun W, Zhou G, Chen S, Lu X. Lichen planus pigmentosus-inversus: report of three Chinese cases and review of the published work. J Dermatol. 2015;42:77-80.  Back to cited text no. 3
Ohshima N, Shirai A, Saito I, Asahina A. Lichen planus pigmentosus‐inversus occurring extensively in multiple intertriginous areas. J Dermatol 2012;39:412-4.  Back to cited text no. 4
Patel K, Arballo O, Wohltmann W. Unilateral hyperpigmented flexural lesion in the left axilla. JAAD Case Rep 2020;6:131-2.  Back to cited text no. 5
Bishnoi A, Parsad D, Saikia UN, Kumaran MS. Coexistence of linear and inversus variants of lichen planus pigmentosus: a rare occurrence. Indian J Dermatol 2019;64:152-4.  Back to cited text no. 6
[PUBMED]  [Full text]  
Vinay K, Bishnoi A, Parsad D, Saikia UN, Sendhil Kumaran M. Dermatoscopic evaluation and histopathological correlation of acquired dermal macular hyperpigmentation. Int J Dermatol 2017;56:1395-9.  Back to cited text no. 7
Das A, Mishra V, Podder I, Kumar P, Das D, Das NK. Linear lichen planus pigmentosus: a rare entity with an illusory presentation. Pigment Int 2014;1:100-2.  Back to cited text no. 8
  [Full text]  
Manjunath S, Kamat D, Kumaran MS. Multidermatomal zosteriform lichen planus pigmentosus-a unique presentation. Int J Dermatol 2019;58:343-4.  Back to cited text no. 9
Daroach M, Guliani A, Keshavmurthy V, Vishwajeet V, Saikia UN, Kumaran MS. Follicular lichen planus pigmentosus in blaschkoid pattern: superimposed segmental mosaicism. Indian J Dermatol Venereol Leprol 2020;86:305-7.  Back to cited text no. 10
[PUBMED]  [Full text]  
Manjunath S, Kamat D, Kumaran MS. Koebnerization and lichen planus pigmentosus: is it a reality? Pigment Int 2019;6:115-6.  Back to cited text no. 11
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  [Figure 1], [Figure 2]


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