Linear Forehead Dermatitis

 The patient is an otherwise healthy 30 yo man in good general health.  For two months he has had a slightly pruritic dermatitis on his forehead.

Clinically, we considered En Coup de Sabre (Linear scleroderma)

Dermatoscopic Image: (Courtesy of Makayla Powers PA-C)

Punch biopsy showed:
Lichenoid interface and perifollicular dermatitis with postinflammatory pigment alteration.  No features of localized scleroderma.  These findings are suggestive of discoid L.E. or linear L.P.
Photomics courtesy of David Jones, MD, Berkshire Medical Center, Pittsfield, Massachusetts.

Treatment was initiated with clobetasol ointment.  Will switch to tacrolimus ointment if response is good.

 References
1. Rodriguez E et. Al. Acute Onset Linear Lichen Planus Pigmentosus of the Forehead: A Case Series  J Drugs Ddermatol 2023 Jan 1;22(1):94-97.  Free Full Text

2. Khelifa E.  Linear sclerodermic lupus erythematosus, a distinct variant of linear morphea and chronic cutaneous lupus erythematous. Int J Dermatol 2011 Dec;50(12):1491-5. PMID 22097995

3. Reference suggested by Dr. Sontheimer.  Dao DP, Sahni DR, Sontheimer DR. Linear discoid lupus erythematous simulating en coup de sabre morphea in a female chronic granulomatous disease carrier. Dermal Online J. 2023 Dec 15;29(6). Free Full Text. 

4. Das A et al. Linear lesions in dermatology: a clinicoaetiopathological study. Clin Exp Dermatol 2021 Dec;46(8):1452-1461. PMID: 34022084 

5. Urur YG. Et. Al. Dermoscopic Characteristics of Cutaneous Lupus Erythematosus According to Subtype, Lesion Location, Lesion Duration, and CLASI Score. Dermatol Pract Concep. 2024 Jan 1;14(1):e2024040. Free Full Text.

Unusual Linear Dermatosis

Presented by Dr. Wagdy El Kifty

Giza Skin Specialist Centre

Pamukkale Baths

The patient is a 38 year-old businesswoman who presents with a six-month history of a progressive linear dermatitis that began on her left hand and has spread centripetally over the ensuing months.  It is mildly pruritic. She takes no medications by mouth.  The rash began shortly after she visited the Pamukkale baths in Southwestern Turkey with her family.  At a Turkish bath, attendants scrape and abrade one's skin for a vigorous exfoliation.

She saw another dermatologist in Amman, Jordan three months ago and a biopsy was performed.

O/E:  The patient has Type IV skin

There is a linear dermatitis which follows Blaschko’s lines.  Acrally, it is erythematous, but more centrally it is hyperpigmented.  On her back the pattern is whorled.

Clinical Images:

 

Pathology:  We have not received the slide, but it was signed out as “Lichen planus.”

Diagnosis: Blaschkolinear Lichen Planus.

Discussion:   There are a number of rare and overlapping blaschkolinear dermatoses.  Histologically, some have features of lichen planus and some lichen striatus, with considerable overlap.  These are usually self-limited and resolve over time, but some can be followed by post-inflammatory hyperpigmentation in darker individuals.  Association with underlying pathology has not been found.

Questions: Do you have any specific comments?  It appears that potent topical corticosteroids can be helpful. Do you have any experience treating a similar patient?

References:

1. Adult blaschkolinear acquired inflammatory skin eruption (BLAISE) with simultaneous features of lichen striatus and blaschkitis.

Raposo I. et. al Dermatol Online J. 2018 Jan 15;24(1 Full Text.

Abstract

Blaschkitis and lichen striatus are generally distinguished in the literature by the age of onset, lesion distribution, and histopathology. However, there is currently no clear consensus among authors about whether to consider blaschkitis and lichen striatus different clinical entities or a spectrum ofthe same disease. We present a case of adult BLAISE with features of both lichen striatus and blaschkitis, which seems to support the theory that these clinical entities may in fact represent a spectrum of the same pathological process.

           

2. Lichen planus-like dermatosis with Blaschko line distribution: a case report. Stojanović S, Jovanović M, Vucković N. Acta Dermatovenerol Alp Pannonica Adriat. 2008 Sep;17(3):137-8. Full Text.

Abstract: The authors describe the case of a healthy 46-year-old woman with a unilateral linear papular band on the left side of the trunk that followed the lines of Blaschko from the lower back extending to the left anterior side of her abdomen. The lesions were flat-topped, slightly elevated, violaceous, agglomerated lichenoid papules. The biopsy specimen demonstrated the typical histology of lichen planus. A working diagnosis of linear lichen planus was confirmed. Because congenital and/or nevoid skin disorders in a blaschkolinear distribution may have a delayed onset after birth, these lesions must be differentiated from acquired dermatoses following the lines of Blaschko. This distinction should be made in cases with isolated lesions, such as the case presented here.

3. Linear lichen planus. Batra P.

Dermatol Online J. 2008 Oct 15;14(10):16. Full Text.

      

A Case for Diagnosis

The patient is a 58 yo woman with asymptomatic lesions under breasts, in the axillae and groin.  She is on no medications,  She has breast cancer seven years ago treated with lumpectomy and chemotherapy (no radiation) and has been off therapy for 6 years.

O/E:  slightly hyperpigmented macules in affected areas.  KOH negative.

Clinical Photos:

Left axilla

Pathology:  2 representative punch biopsies were taken. 

≈

Report: Focal basal layer vacuolization, a mild superficial perivascular and focally band-like lymphocytic infiltrate with rare eosinophils, papillary dermal fibrosis, numerous melanophages, and telangiectasia, consistent with a lichenoid interface dermatitis with post-inflammatory hyperpigmentation.

NOTE: The differential diagnosis could include lichen planus (possibly lichen planus pigmentosus) or a lichenoid drug eruption.

Diagnosis: Lichen Planus Variant.  Is this annular atrophic lichen planus?

Reference:
Annular atrophic lichen planus.

Morales-Callaghan A Jr1, et. al. J Am Acad Dermatol. 2005 May;52(5):906-8.

Abstract: We describe a new case of annular atrophic lichen planus. Annular atrophic lichen planus is a rare variant of lichen planus that is clinically characterized by violaceous plaques of annular morphology with central atrophy and histopathologic findings of annular and atrophic lichen planus, respectively. There have been 4 cases of this entity reported previously.

Nonspecific Oral and Genital Lesions

Abstract:  92 year-old woman with 6 year history of painful oral and genital lesions

HPI:  The patient is an otherwise healthy and alert 92 year old woman with painful erosions of tongue and vulva for six years. She has marked pain with eating and urination.  Mouth lesions preceded genital lesions by a few years.  She has been followed for erosive lichen planus but it is unclear if any biopsies were positive.  She has lost weight because her painful tongue causes her to avoid eating.  She has been treated with clobetasol ointment,  Viscous Lidocaine was not effective.

O/E:  Erosive lesions of tongue and labia.  No bullae noted. Remainder of cutaneous exam unremarkable.

Clinical Photos:

Pathology:  Biopsy of genital labial skin shows papillary dermal fiborsis and a mild superficial perivascular mixed inflammatory cell infiltrate.  No lichenoid infiltrate.  Direct immunofluorescence from perilesional skin was negative.  PASD negative for fungi.

Diagnosis:  Painful erosions mouth and genitalia.  At present no support for lichen planus or bullous process histologically.

Questions:  What are your thoughts? Her oral pain makes eating difficult and negatively affects her quality of life.  Are there other therapies that we could consider?

Lichen Nitidus

Presented by Yoon Cohen, D.O.

Abstract: 13 year-old boy with a few years history of lichen nitidus

HPI:  This is a 13 year-old Hispanic boy who presented for treatment of warts. During the exam, multiple small white shiny dots were noticed. The patient has been aware of these asymptomatic lesions for the past few years.  He had been given triamcinolone 0.1% ointment bid, but forgot to apply it because it did not bother him. 

O/E:  There  are multiple pinhead-sized 1 mm white shiny flat-topped papules in an oval shape on the right knee.  

Dermatoscopic Photo:

Multiple small white circles
The dermoscopic image taken with the Canfield Dermatoscope with iPhone attachment

Diagnosis:
Lichen nitidus

Discussion:
While there are many dermoscopic studies on the skin cancers, there is a growing interest of dermoscopic features on other skin diseases such as inflammatory diseases, connective tissue disorders, or even psychogenic related skin diseases. Lichen nitidus is easily recognized clinically with experienced eyes. With my own interest in dermoscopy, I report an interesting dermoscopic finding of lichen nitidus. There are 1-2 mm multiple small white circles which represent subepidermal infiltrate of lymphocytes, histiocytes, and multinucleated giant cells in the dermal papillae. 

Lichen nitidus was first described by Pinkus in 1907. Lichen nitidus, which means shiny papules, is a relatively uncommon, asymptomatic, chronic eruption, consisting of minute sharply demarcated skin-colored papules. It has a predilection for males (4:1) and the mean age of onset was 7 yrs for males and 13 yrs for females. Typically, patients present for assessment with an asymptomatic or mildly pruritic eruption. The eruption may be localized to one or more areas or generalized in distribution. The pathogenesis of lichen nitidus is unknown. It was originally believed to be a form of tuberculid and more recently considered to be a variant of lichen planus. Histologially, lichen nitidus is characterized by a circumscribed collection of inflammatory cells in the papillary dermis that abuts the overlying epidermis. The inflammatory infiltrate consists of lymphocytes, histiocytes, and multinucleated giant cells. DIF negative.  Most cases require no treatment due to the asymptomatic nature of the eruption and tendency for spontaneous resolution. For symptomatic cases, moderately potent or potent topical steroid therapy may help. There are a number of anecdotal reports of improvement or clearance with narrow band UVB phototherapy, extensive sunlight exposure, oral astemizole, oral cetirizine-levamisol combination, topical dinitrochlorobenzene, itraconazole and oral cyclosporin. Oral retinoids have been used successfully in the treatment of palmoplantar lichen nitidus.

Reference:

Schachner LA, Hansen RC. Pediatric Dermatology. 4th edition. 2011
L. Nitidus eMedicine (free open access)

Comment: By DJ Elpern.  This is the first report of the dermatoscopic appearance of L. nitidus.  Yoon Cohen deserves credit for this observation.