43

CASE FILES www.aestheticmed.co.uk

Aesthetic Medicine • April 2014

S K I N / D E R M AT O L O G Y

A 51-year-old Indian man presented with a three-year history of asymptomatic hyperpigmentation on the frontalis area of his face. The lesion was violaceous in colour, had an irregular margin. He was a restaurant owner who went back home to India for a few months every summer. The patient was otherwise healthy and denied any history of infection or trauma. He carried a previous laboratory

examination, which showed a full blood count and blood chemistry within normal range. The patient had seen many previous doctors who had prescribed hydroquinone preparations and topical steroids without improvement in the pigmentation. He had no other medical problems and was not taking any systemic medications. Also anti-nuclear antibody and other systemic lupus erythematosus profiles were all negative.

On physical examination, there were violaceous hyperpigmented patches on his forehead (Figure 1), eyelids and temporal areas. He also had hyperpigmented lesions in the dorsal surfaces and cleft areas of his hands (Figure 2). All these areas of hyperpigmentation were noted to be in areas of sun exposure. There was no associated mucous membrane or nail involvement.

A punch biopsy was taken from the margin of lesion on the forehead to aid in the diagnosis. Low power magnification of the specimen showed hyperplasia of the epidermis with a band-like inflammatory infiltration in the upper dermis. Histological examination demonstrated an atrophic epidermis with mild hyperkeratosis and orthokeratosis (Figure 3). Basilar vacuolization, a band like lymphocytic infiltrate, and marked pigmentary incontinence were present. >

Dr Patrick Treacy shares some of his most challenging cases

Dr Treacy’s

CASEBOOKDR PATRICK TREACYDr Patrick Treacy holds a H.Dip in Dermatology and a BTEC in Laser technology and skin resurfacing. He is Irish Regional Representative of the British College of Aesthetic Medicine. He is a renowned international guest speaker and features regularly on national television and radio programmes.

>>

“Quote to go in here”

44

CASE FILES www.aestheticmed.co.uk

Aesthetic Medicine • April 2014

S K I N / D E R M AT O L O G Y

COMMENT Based on the clinical findings in his fingers a provisional diagnosis of Lichen Planus was made. Additionally, because the violaceous lesions developed on his forehead, which is a sun exposed area, and was atrophic in appearance the suspicion of LPA (lichen planus actinicus) existed. This is a photodistributed variant of lichen planus that most often occurs in dark-complexioned young adults of Middle Eastern descent. (1) Four morphologic patterns have been clinically described in the literature including: summertime actinic lichenoid eruption, lichen planus atrophicus annularis, lichen planus tropicus, and lichenoid melanodermatitis (2). Although the etiology of this disease has not been determined, the lesions often are exacerbated by sun exposure and may improve spontaneously in the winter months (3).The lesions of lichen planus actinicus usually occur on the forehead, face, neck, and the extensor surfaces of the arms and hands. (3-4).The lateral aspect of the forehead is the most common site of presentation. (5).Clinically, lichen planus actinicus resembles the lesions found in discoid lupus erythematosus (DLE), granuloma annulare, melasma, morphea, secondary syphilis, lichenoid drug eruption and polymorphous light eruption and should be differentiated by histopathologic and immunofluorescence (IF) findings (5). In DLE, the liquefaction, degeneration or thickening of the basal layer is more prominent and IF finding or autoantibody in a blood test may be the conclusive factor. In melasma, melanin synthesis in epidermal layer and the number of melanocytes are increased.

The histologic features of lichen planus actinicus are consistent with findings in classic lichen planus. (2-5) Hyperkeratosis of the stratum corneum, hypergranulosis, basal cell vacuolization, and Civatte bodies usually are present. Although clinically similar to cutaneous lupus and polymorphous light eruption, lichen planus actinicus can be distinguished histologically from these photodermatoses. Lichen planus actinicus lacks follicular plugging, thickening of the basement membrane, and the periadnexal inflammatory infiltrate seen in cutaneous lupus erythematosus. (3-4). Clinical manifestations such as the site of lesion, age or the history of sun exposure should be examined for final diagnosis. Finally, the patient with lichenoid drug eruption should have a history of medication.

TREATMENTThe cause of actinic LP is still unknown but sunlight might be the major precipitating factor. Several modalities such as topical corticosteroid, 4,6 hydroxychloroquine , intralesional corticosteroid injection, grenz ray, arsenic compounds or antimalarial agent have been applied for the treatment of actinic LP. (5-8). Acitretin, used in combination with topical steroids and sun avoidance, also has resulted in complete resolution of lesions without recurrence. (9) Van der Shroeff et all, induced actinic LP by using repeated doses of UVB radiation on the back. So sunscreen is considered necessary for treatment. (10). Although psoralen-UVA, isotretinoin, systemic corticosteroids, cyclosporine, and dapsone have been used to treat classic lichen planus, there are currently no reports of their use in lichen planus actinicus. (11-12).Recently topical 0.1% pimecrolimus cream have been reported to be successful in a case of actinic LP (12). This patient was successfully treated with PIGMANORM ® Crème WIDMER with active ingredients Hydroquinone 5.0g. Tretinoin 0.1g. Hydrocortisone 1.0g. AM

REFERENCES 1. Zanca A, Zanca A. Lichen planus actinicus. Int J Dermatol.

1978;17:506-508.

2. Salman SM, Kibbi AG, Zaynoun S. Actinic lichen planus. J Am Acad Dermatol. 1989;20:226-231.

3 Shanna B. Meads, MD; Joy Kunishige, BS; Francisco A. Ramos-Caro, MD; Ashraf M. Hassanein, MD, PhD Cutis. 2003;72:377-381.

4. Katzenellenbogen I. Lichen planus actinicus (lichen planus in subtropical countries). Dermatologica. 1962;124:10-20.

5. Dilaimy M. Lichen planus subtropicus. Arch Dermatol. 1976;112:1251-1253.

6. Bedi TR. Summertime actinic lichenoid eruption. Dermatologica. 1978;157:115-125.

7. Verhagen AR, Koten JW. Lichenoid melanodermatitis. a clinicopathological study of fifty-one Kenyan patients with so-called tropical lichen planus. Brit J Dermatol. 1979;101:651-658.

8. Boyd A, Neldner K. Lichen planus. J Am Acad Dermatol. 1991;25:593-619.

9. Jansen T, Gambichler T, von Kobyletzki L, et al. Lichen planus actinicus treated with acitretin and topical corticosteroids. J Eur Acad Dermatol Venereol. 2002;16:174-175.

10 Van der Shroeff JG, Schothorst AA, Kanaar P. Induction of actinic lichen planus with artificial UV sources. Arch Dermatol 1983;119:498-500.

11. Baker H, Almeyda J. Lichen planus actinicus. Brit J Dermatol. 1970;82:426-427.

12 Ezzedine K, Simonart T, Vereecken P, Heenen M. Facial actinic lichen planus following the Blaschko’s lines: successful treatment with topical 0.1% pimecrolimus cream. J Eur Acad Dermatol Venereol 2009;23:458-459.

HISTOLOGY REPORTSkin with a prominent lichenoid superficial dermal infiltrate, composed predominantly of lymphocytes. Vacuolar interface change with associated basal apoptotic keratinocytes and focal lymphocyte exocytosis are present. The most striking feature is marked pigment incontinence in the dermis. The features are those of lichen planus actinus – a variant of lichen planus in which lesions are limited to sun exposed areas.

Prof. Kieran Sheahan, Consultant Histopathologist, St. Vincent’s University Hospital, Elm Park, Dublin 4.

Dr Linda Mulligan, Pathology Registrar, St. Vincent’s University Hospital, Elm Park, Dublin 4.

“Quote to go in here”