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Dermatology 5th year, 4ht lecture (Dr. Ali El-Ethawi)


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The lecture has been given on May 8th, 2011 by Dr. Ali El-Ethawi.

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Dermatology 5th year, 4ht lecture (Dr. Ali El-Ethawi)

  1. 1. Lichen planus & lichenoids 5 th class lecture By DR. Ali El-ethawi specialist Dermatologist M.B.CH.B , F.I.C.M.S , C.A.B.D
  2. 2. Lichen planus (LP) <ul><li>Definition ;its common ,pruritic inflammatory disease of the skin ,mucous membrane & hair follicle . </li></ul><ul><li>Primary skin lesion ;almost characteristic& pathognomonic ;( 5P ) Pruritic, Purple ,Plane, Polygonal Papule. </li></ul><ul><li>Characterized by flat-topped (Latin planus , “flat”), pink to violaceous, shiny, pruritic polygonal papules. </li></ul><ul><li>Wickham striae ; white streaks on the surface of these papules. </li></ul><ul><li>Site of predilection ; flexor of wrist ,trunk, medial thigh ,shins ,dorsal of hands & glans of penis . </li></ul><ul><li>Certain morphologic patterns favor certain locations, </li></ul><ul><li>e.g; annular lesion favor glans of penis & keratotic lesion favor shins. </li></ul><ul><li>Kobner phenomenon ;+ve </li></ul><ul><li>Nail changes occur in 5%-10% of LP patients </li></ul>
  3. 3. LP on wrist
  4. 5. LP in mucous membrane <ul><li>Oral LP ; </li></ul><ul><li>either erosive (ulcer) or </li></ul><ul><li>non erosive (white lacy lines or dots or white plauqes) </li></ul><ul><li>occur inside check . </li></ul><ul><li>The most common form oral LP is ulcerative </li></ul><ul><li>Its more common in female . </li></ul><ul><li>The genital skin may be similarly affected. </li></ul>
  5. 6. Oral LP
  6. 7. <ul><li>occurrence : Worldwide; incidence <1%. </li></ul><ul><li>Age of Onset ; 30–60 years. </li></ul><ul><li>Sex: Females > males. </li></ul><ul><li>Race: all races. Hypertrophic LP more common in blacks. </li></ul><ul><li>Etiology: Idiopathic in most cases but cell mediated immunity plays a major role. </li></ul><ul><li>Drugs; β -blockers, Antimalarials, Thiazide diuretics, Furosemide, Spironolactone, Penicillamine. </li></ul><ul><li>metals (gold, mercury) </li></ul><ul><li>infection: [hepatitis C virus (HCV)] </li></ul><ul><li>HLA-associated genetic susceptibility </li></ul><ul><li>LP –like reaction may occur in chronic graft versus host disease </li></ul>
  7. 8. Variations in LP include the following <ul><li>Hypertrophic LP : </li></ul><ul><li>These extremely pruritic lesions are most often found on the extensor surfaces of the lower extremities, especially around the ankles . Hypertrophic lesions are often chronic; residual pigmentation and scarring can occur when the lesions eventually clear </li></ul><ul><li>Atrophic LP : Atrophic LP is characterized by a few lesions, which are often the resolution of annular or hypertrophic lesions </li></ul><ul><li>Erosive LP : These lesions are found on the mucosal surfaces and evolve from sites of previous LP involvement </li></ul><ul><li>Follicular LP : Lichen planopilaris is characterized by keratotic papules that may coalesce into plaques . This condition is more common in women than in men. </li></ul><ul><li>A scarring alopecia may result. </li></ul><ul><li>Annular LP : LP papules that are purely annular are rare . Annular lesions with an atrophic center can be found on the buccal mucosa and the male genitalia </li></ul>
  8. 9. <ul><li>Linear LP : </li></ul><ul><li>Isolated linear lesions may form a zosteriform lesion, or they may develop as a Köbner effect </li></ul><ul><li>Actinic LP : </li></ul><ul><li>LP in regions, such as Africa, the Middle East, and India . </li></ul><ul><li>This mildly pruritic eruption </li></ul><ul><li>it presents in the spring &summer </li></ul><ul><li>Most lesions occur on the face , v-shape of the neck &back of the hand or lower extremity . </li></ul><ul><li>usually spares the nails, the scalp, the mucous membranes, and covered areas . </li></ul><ul><li>Lesions are either annular type or melasma- like or lichen nitidus –like. </li></ul><ul><li>It effect young age . </li></ul>
  9. 10. Actinic LP
  10. 11. Histology of LP <ul><li>Epidermis; </li></ul><ul><li>Hyperkeratosis of the stratum corneum. prominent granular layer . </li></ul><ul><li>Basal layer degeneration. </li></ul><ul><li>Saw -tooth appearance of the dermoepidermal Junction. </li></ul><ul><li>Dermis; </li></ul><ul><li>Colloid bodies in upper dermis . </li></ul><ul><li>Band –like superficial dermal lymphocytic infiltrate </li></ul>
  11. 12. Complications <ul><li>Oral ulcerations have the potential to become malignant (SCC) . The incidence of oral SCC in individuals with oral LP is increased (5%); patients should be followed at regular intervals. </li></ul><ul><li>Nail & hair loss can be permanent </li></ul><ul><li>Hypertrophic lesions may leave residual hyperpigmentation </li></ul><ul><li>Vulvar lesions can be pruritic and painful </li></ul>
  12. 13. COURSE <ul><li>Cutaneous LP: usually persists for months , </li></ul><ul><li>but in some cases, for years . </li></ul><ul><li>hypertrophic LP on the shins } --often persists for decades </li></ul><ul><li>oral LP . </li></ul>
  13. 14. Treatment <ul><li>RX can be difficult . </li></ul><ul><li>Local; </li></ul><ul><li>Potent topical steroid with occlusion for cutaneous lesions </li></ul><ul><li>IL triamcinolone (3mg/ml ) for cutaneous or mucosal lesions </li></ul><ul><li>Cyclosporine and Tacrolimus Solutions Retention“ mouthwash” for severely symptomatic oral LP. </li></ul><ul><li>Systemic; </li></ul><ul><li>Systemic sedative Antihistamine ; e.g; hydroxyzine </li></ul><ul><li>Systemic steroid ( oral prednisolone ) can be used for some sever generalized pruritic cases. </li></ul><ul><li>Cyclosporine In very resistant and generalized cases, 5 mg/kg per day will induce rapid remission, quite often not followed by recurrence </li></ul><ul><li>Phototherapy ;PUVA can be used in generalized or resistant to topical therapy </li></ul><ul><li>Systemic retinoid ( acitretin ;1mg/kg/day) is helpful as adjunctive therapy in sever cases (oral, hypertrophic) but with topical RX . </li></ul><ul><li>Other Treatments </li></ul><ul><li>Mycophenolate mofetil, </li></ul><ul><li>heparin analogues (enoxaparin) in low doses </li></ul><ul><li>azathioprine. </li></ul>
  14. 15. Lichen nitidus <ul><li>Chronic inflammatory disease characterized by pinhead size ,shiny ,flat topped ,pale ,discrete papules </li></ul><ul><li>Pruritus are minimal or absent . </li></ul><ul><li>Koebner phenomenon +ve. </li></ul><ul><li>Sites ;chiefly on penis & lower abdomen ,inner surfaces of the thigh &flexor surfaces </li></ul><ul><li>Course ;slowly progressive with tendency to remission </li></ul><ul><li>Cause; unknown </li></ul><ul><li>H/P; characteristic histological appearance , dermal papillae are widen & contain dense infiltrate of lymphocytes, histocytes& melanophages. </li></ul><ul><li>RX; is often not necessary because the asymptomatic ,but potent topical steroid can be used if the lesion symptomatic </li></ul>
  15. 16. Lichen nitidus
  16. 17. Lichen striatus <ul><li>Its common self –limited eruption that seen primarily in children . </li></ul><ul><li>C/F; lesions begin as small papules that are erythamtous & slightly scaly </li></ul><ul><li>In more darkly pigmented persons ,hypopigmenation is prominent </li></ul><ul><li>Lesions following lines of Blaschko </li></ul><ul><li>An extremity is more commonly involved </li></ul><ul><li>Nail involvement can occur </li></ul><ul><li>D.DX; linear LP, linear psoriasis , linear epidermal nevus ,plane wart. </li></ul><ul><li>RX; is usually not necessary ,topical steroid ,topical tacrolimus ointment may accelerate the resolution of lesions </li></ul>
  17. 18. Lichen striatus
  18. 19. Lichen sclerosus et atrophicus <ul><li>LSA is a chronic atrophic disorder mainly of the anogenital skin of females but also of males and of the general skin. </li></ul><ul><li>age ; its a disease of adults, but also occurring in children 1–13 years of age. </li></ul><ul><li>Sex :Females ten times more often affected than males. </li></ul><ul><li>Etiology ; is unknown, but reports some reports have documented an association of DNA of Borrelia spp. </li></ul><ul><li>C/F ; the lesions either genital (vulva , In uncircumcised males penis ,perineum +/or perianal skin) or extragenital (most frequent site on upper back ,chest) . </li></ul><ul><li>Its either white polygonal &flat topped papules ,plaques or white atrophic patches </li></ul><ul><li>Some times surface of the lesion --follicular ,black ,horny plugs resemble comedones . </li></ul><ul><li>In female ,the white patches circling the vulva &anus taking on a hourglass shape around the orifices. </li></ul><ul><li>This lesions surround by erythamtous to violeous halo or margin . </li></ul><ul><li>Nongenital LSA usually asymptomatic; genital symptomatic. Itching can be very sever especially anogenital region of female . </li></ul>
  19. 20. <ul><li>D.DX ; guttate morphea ,vitiligo ,atrophic LP </li></ul><ul><li>Management ;is very important, as this disease can cause a devastating atrophy of the labia minora and clitoral hood. </li></ul><ul><li>Potent topical steroid (clobetasol propionate) have proved effective for genital LSA (6–8week ) </li></ul><ul><li>In males, circumcision relieves symptoms of phimosis and can result in remission. </li></ul><ul><li>course ; waxes and wanes. </li></ul><ul><li>In girls it may undergo spontaneous resolution. </li></ul><ul><li>in women it leads to atrophy of the vulva and in men to phimosis. </li></ul><ul><li>Complication ; </li></ul><ul><li>*scarring </li></ul><ul><li>* squamous cell carcinoma ; Patients should be checked for the occurrence of SCC of the vulva and penis </li></ul>
  20. 21. LSA ;extragenital
  21. 22. LSA; effect the of the glans penis
  22. 23. LSA on female genitalia ,the white patches circling the vulva &anus taking on a hourglass shape around the orifices.