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LETTER TO THE EDITOR
Ahead of print publication  

Unilateral linear lichen planus hypertrophicus along blaschko's lines


1 Department of Dermatology, AIIMS, Bathinda, India
2 Department of Dermatology, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
3 Consultant Dermatopathologist, Delhi Dermpath Laboratory, Delhi Dermatology Group, New Delhi, India

Date of Submission16-Apr-2020
Date of Decision18-May-2020
Date of Acceptance20-Jun-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Priya Kapoor,
Department of Dermatology, All India Institute of Medical Sciences, Bathinda, Punjab
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/idoj.IDOJ_254_20



How to cite this URL:
Kapoor P, Kumar S, Batrani M. Unilateral linear lichen planus hypertrophicus along blaschko's lines. Indian Dermatol Online J [Epub ahead of print] [cited 2020 Oct 31]. Available from: https://www.idoj.in/preprintarticle.asp?id=295435

Sir,

Lichen planus (LP) is an idiopathic inflammatory skin condition affecting the skin and mucosa. Certain unusual variants of LP may present a difficulty in diagnosis. We report two cases of localized, unilateral, linear LP hypertrophicus along the lines of Blaschko. To the best of our knowledge, a similar clinical presentation has been previously described only once.[1]

Case 1 was a 60-year-old female who presented with the complaint of raised lesions on the left ankle and left lower leg for 15 years. The lesions had gradually increased in number and size. These were pruritic but there was no pain or discharge. On examination, there were well-defined discrete to confluent hyperkeratotic nodules and plaques on the dorsal surface of left foot and anterior surface of left lower leg arranged in a Blaschko's linear pattern, extending about 5 cm above the ankle. The lesions were firm and nontender with crusting present on few lesions. The first and second toe nails of the left foot showed longitudinal melanonychia [Figure 1].
Figure 1: Hyperkeratotic nodules and plaques on the left foot and left lower leg arranged in a Blaschko's linear pattern

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Case 2 was a 60-year-old female who presented with raised itchy lesions on the right lower leg for 26 years. On examination, the medial aspect of the right lower leg showed hyperpigmented nodules and plaques arranged along the Blaschko's line [Figure 2].
Figure 2: Hyperpigmented nodules and plaques arranged along Blaschko's line on the medial aspect of the right lower leg

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There was no history of trauma, drug intake, preceding infection or comorbidity in any of the cases. Mucosal, scalp, and nail examinations were insignificant in these patients except for the involvement of toe nails in the first patient. There was no lymphadenopathy and systemic examination was essentially normal. Routine investigations including viral markers were normal. The differential diagnoses were sporotrichosis, hypertrophic LP, chromoblastomycosis, nodular prurigo, sporotrichoid leishmaniasis, and verruca vulgaris. Skin biopsy in both these patients showed marked orthokeratotic hyperkeratosis overlying irregular pseudoepitheliomatous epidermal hyperplasia. Hypergranulosis was present. Patchy band-like lymphocytic infiltrate was present in papillary dermis focally abutting the basal layer particularly along the rete ridges, showing squamatization and apoptotic keratinocytes. Granulomatous pathology and fungal elements were not seen. These features were consistent with LP hypertrophicus [Figure 3]a and [Figure 3]b.
Figure 3: (a) Orthokeratotic hyperkertosis covering epidermis showing pseudoepitheliomatous hyperplasia with hypergranulosis and patchy band-like lymphocytic infiltrate in papillary dermis (H and E, ×40); (b) Basal layer showing squamatization and scattered apoptotic keratinocytes (H and E, ×200)

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Hypertrophic LP, also known as LP verrucosus, is characterized by intensely pruritic, thick hyperkeratotic plaques seen primarily on the shins or dorsal surface of the foot. The lesions are commonly symmetric and tend to be chronic due to repetitive scratching. Chronic venous insufficiency contributes to its development. Histopathology shows marked hyperkeratosis, acanthosis, papillomatosis, and hypergranulosis. The interface vacuolar changes are often limited to the base of rete ridges. It is recalcitrant to treatment and some cases may undergo malignant transformation.

Apart from linear lichen planus (LLP), linear lesions along Blaschko's lines have also been reported in other variants of LP like lichen planus follicularis,[2] atrophic LP,[3] and lichen planus pigmentosus.[4] The explanation for the peculiar arrangement of lesions noted in our patients perhaps lies in the nature of Blaschko's lines and unmasking of the abnormal keratinocyte clones after an initiating event for LP.[5] To date, there is single case report describing unilateral, linear LP hypertrophicus.[1] The scarcity of data on unilateral, linear, and blaschkoid LP hypertrophicus prompted this report. Thus, hypertrophic LP should also be considered in the differentials of linear and Blaschkoid lesions in dermatology. Also, correct diagnosis and treatment of this variant of LP is important as there have been reports of malignant transformation in hypertrophic LP.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Wilson S, Pollinger T, Turiansky G. An atypical presentation of unilateral, linear, hypertrophic lichen planus in a patient with HIV. Pract Dermatol 2016;13:24-6.  Back to cited text no. 1
    
2.
Baker K, Pehr K. Linear lichen planopilaris of the trunk:First report of a case. J Cutan Med Surg 2006;10:136-8.  Back to cited text no. 2
    
3.
Lakshmi C, Divakaran J, Sivaraman A, Srinivas CR. Painful linear atrophic lichen a planus along lines of Blaschko. Indian J Dermatol 2006;51:42-3.  Back to cited text no. 3
  [Full text]  
4.
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. 4
  [Full text]  
5.
Long CC, Finlay AY. Multiple linear lichen planus in the lines of Blaschko. Br J Dermatol 1996;135:275-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

 
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