A case of lichen aureus successfully treated with 595 nm wavelength pulsed-dye laser.

BACKGROUND: Lichen aureus (LA) is a variant of pigmented purpuric dermatosis (PPDs) that typically presents with the acute onset of a solitary, unilateral, purple to rust-yellow colored lichenoid patch or plaque on lower extremities. Treatment remains challenging and is based on anecdotal case reports often with poor results. AIMS: Describe a case of LA successfully treated with 595 nm wavelength pulsed-dye laser (PDL). PATIENT/METHOD: A 46-year-old woman with segmental LA was treated using a 595 nm PDL at a uniform spot size of 10 mm, with pulse durations of 10 milliseconds and fluence of 6 J/cm2. The patient had received previous treatments with no improvement. RESULTS: Clearance was archived after three sessions with PDL. Sessions were performed at intervals of 4 weeks, with no serious adverse events nor recurrence. CONCLUSION: We hypothesize the favorable clinical outcome with PDL is due to the affinity of the wavelength for oxyhemoglobin (allowing uniform vessel penetration and energy delivery to fragile capillaries and intraluminal blood) and to its anti-inflammatory profile. PDL seems to be an alternative for patients with progressive LA that have failed other therapies.

Lichenoid pseudovesicular papular eruption on nose: A papular facial dermatosis probably related to actinic lichen nitidus or micropapular polymorphous light eruption.

BACKGROUND: Facial papules are a feature of several clinical conditions and may present both diagnostic and therapeutic challenges. AIM: To describe a grouped papular eruption on the nose and adjoining cheeks that has not been well characterized previously. MATERIALS AND METHODS: A series of consecutive patients with a papular eruption predominantly involving nose and cheeks were evaluated, treated and followed up prospectively at tertiary care centers. Demographic details, clinical features, histopathology and response to treatment were recorded. RESULTS: There were five men and six women (mean age 29.9 ± 6.9 years) who had disease for a mean duration of 17.3 ± 11.1 months. All patients presented with a predominantly asymptomatic eruption of monomorphic, pseudovesicular, grouped, skin colored to slightly erythematous papules prominently involving the tip of nose, nasal alae, philtrum and the adjoining cheeks. A total of 15 biopsies from 11 patients were analyzed and the predominant finding was a dense, focal lymphoid infiltrate restricted to the upper dermis with basal cell damage and atrophy of the overlying epidermis. The eruption ran a chronic course from several months to years. LIMITATIONS: Direct immunofluorescence could not be performed except in one case. Immunohistochemical stains for CD4 and CD8 could not be done owing to nonavailability. Phototesting was undertaken in one patient only. CONCLUSION: Small grouped papules on the nose and adjoining skin with a lichenoid histopathology appear to represent a distinct clinicopathological entity. It may be related to actinic lichen nitidus/micropapular variant of polymorphous light eruption.

Lichen planus and lichenoid dermatoses: Conventional and emerging therapeutic strategies.

Having reviewed the diverse clinical subtypes of lichenoid disease and the postulated molecular basis thereof in the first article in this 2-part continuing medical education series, we discuss herein the existing and emerging treatment strategies in the most common clinical forms of lichenoid inflammation and provide an overview of their pharmacodynamics and evidence base. The scope of this review is not to exhaustively discuss treatment modalities for all lichenoid variants discussed in the previous article of this series. Instead, the focus will be on frequently encountered subtypes of lichen planus and on linking mechanisms of disease with mechanisms of drug action. Future directions and potential avenues for translational research will also be discussed.

[Lichen nitidus and lichen striatus]. / Lichen nitidus und Lichen striatus.

Lichen nitidus is a rare, chronic dermatosis which occurs more often in children than in adults. It presents with tiny, monomorphous, lichenoid, mostly asymptomatic papules in regional or disseminated distribution which show a pathognomonic histological pattern. The pathogenesis is unclear; however, immunologic phenomena and genetic factors are under discussion. In rare cases, an association with other dermatoses and systemic diseases has been described. Moreover, medical treatments have been incriminated as triggers. Considering the self-limited course in mostly young patients, treatment must be thoroughly weighed. Possible therapeutic options include topical corticosteroids and calcineurin inhibitors as well as oral antihistamines, corticosteroids and narrow-band ultraviolet B phototherapy. Lichen striatus is an acquired, usually asymptomatic dermatosis occurring mostly in preschool children. The characteristic feature is the arrangement of small, flat, light red- to skin-colored papules along the lines of Blaschko. Therefore, a postzygotic mutation of epidermal progenitor cells induced to express new surface antigens by trigger factors as infections, vaccinations or trauma with consecutive immune reaction is assumed. Nail involvement of the affected limb can rarely occur. Lichen striatus usually heals without scarring within several months, so that therapies with severe side effects are obsolete. Mild topical corticosteroids or calcineurin inhibitors may be used, especially if patients exceptionally suffer from pruritus. A postinflammatory hypopigmentation can persist for months to years.

Improvement of erythema dyschromicum perstans using a combination of the 1,550-nm erbium-doped fractionated laser and topical tacrolimus ointment.

BACKGROUND AND OBJECTIVE: Erythema dyschromicum perstans (EDP) is a cosmetically distressing, acquired pigmentary disorder of unknown etiology for which few successful therapies exist. Herein, we present the successful use of non-ablative fractional photothermolysis in combination with topical tacrolimus ointment. STUDY DESIGN/PATIENTS AND METHODS: A 35-year-old female with biopsy-confirmed EDP underwent a series of fractionated non-ablative treatment sessions utilizing the 1,550 nm erbium-doped fiber laser in combination with topical tacrolimus ointment over a period of 5 months. RESULTS: The patient's EDP improved by greater than 75% and results were maintained at the 8-month follow-up visit. CONCLUSION: The combination of non-ablative fractional photothermolysis and topical tacrolimus ointment is a potential safe and effective therapeutic option for erythema dyschromicum perstans. Additional prospective, comparative studies are warranted. Lasers Surg. Med. 49:60-62, 2017. © 2016 Wiley Periodicals, Inc.

Keratosis lichenoides chronica: Case-based review of treatment options.

Keratosis lichenoides chronica (KLC) is a rare dermatological condition characterized by keratotic papules arranged in a parallel linear or reticular pattern and facial lesions resembling seborrheic dermatitis or rosacea. The clinical, histological and therapeutic information on 71 patients with KLC retrieved through a PubMed search plus one our new case were analyzed. KLC affects patients of all ages, with a modest male predominance. Pediatric cases represent about one quarter of patients. Diagnosis is usually delayed and histologically confirmed. All patients have thick, rough and scaly papules and plaques arranged in a linear or reticular pattern, on limbs (>80%) and trunk (about 60%). Face involvement is described in two-thirds of patients. Lesions are usually asymptomatic or mildly pruritic. Other manifestations, such as palmoplantar keratoderma, mucosal involvement, ocular manifestations, nail dystrophy, are reported in 20-30% of patients. Children present more frequently alopecia. No controlled trials are available. Results from small case series or single case reports show that the best treatment options are phototherapy and systemic retinoids, alone or in combination, with nearly half of patients reaching complete remission. Systemic corticosteroids as well as antibiotics and antimalarials are not effective.

Effectiveness of acupressure on pruritus and lichenification associated with atopic dermatitis: a pilot trial.

BACKGROUND: Pruritus is a debilitating aspect of atopic dermatitis (AD). Acupuncture has been reported to diminish pruritus, but self-administered acupressure has not been previously evaluated. OBJECTIVES: To evaluate the effectiveness of acupressure on the severity of eczema in a pilot trial. METHODS: Adult patients with AD were randomised to an intervention group (acupressure with standard of care) or a control group (standard of care alone). Subjects in the intervention group performed acupressure using a 1.2 mm acupellet at the LI11 point, applying pressure for 3 min three times per week for 4 weeks. The severity of itching and AD at baseline and at 4 weeks were measured on a visual analogue scale (VAS), the Investigator's Global Assessment (IGA) and the Eczema Area and Severity Index (EASI). RESULTS: Fifteen subjects were enrolled, 12 of whom completed the study between November 2009 and May 2011. There was no significant change between baseline and follow-up survey scores within the control group. In the investigation group there was a decrease in the VAS score (p=0.05) and EASI lichenification (p=0.03), although without significant change in the overall EASI score. Comparison of the scores between groups showed a greater decrease in VAS in the experimental group than in the control group (p=0.04), and a decrease in the IGA (p=0.03) and EASI lichenification score (p=0.03). The overall EASI scores were unchanged. CONCLUSION: Subjects using acupressure at LI11 for 4 weeks had improvement in pruritus and lichenification. Acupressure may prove to be an easily administered alternative treatment, but larger-scale studies are needed to confirm these preliminary findings.

[Keratosis lichenoides chronica in two siblings with marked response to UVB phototherapy]. / Deux cas de kératose lichénoïde chronique dans une même fratrie. Réponse favorable à la photothérapie UVB.

BACKGROUND: Keratosis lichenoides chronica (KLC) is a rare chronic keratinisation disorder. Out of almost 60 published cases of KLC, only two report its occurrence in siblings. We report a new case in which a brother and sister present KLC that improved markedly with UVB phototherapy. PATIENTS AND METHODS: A 10-year-old girl presented with hyperkeratotic papules symmetrically arranged in a reticular pattern on the face and the extremities. Onset occurred at the age of six months. For a number of years, minimum sunlight was allowed owing to a diagnosis of lupus. However, KLC was our first diagnostic assumption, confirmed by an elbow lesion biopsy sample. The patient's brother, one and a half years old, had been presenting similar lesions since the age of two months. Sibship was demonstrated by DNA analysis using short tandem repeat markers. No consanguinity was found. After one month of narrow-band UVB phototherapy, most of the papules had flattened. DISCUSSION: KLC is uncommon in childhood and familial occurrence is very rare. Clinically, thick keratotic papules arranged in parallel lines or small networks cover the dorsal aspects of the limbs symmetrically. The face may be affected by a seborrhoea-like dermatitis. Histology typically shows alternating acanthosis and atrophy, with focal parakeratosis. An extensive lichenoid lymphohistiocytic and plasmocytic infiltrate is demonstrated in the dermis. The course is chronic. Spontaneous resolution may occur. Sunlight has been shown to be effective in the few paediatric cases reported. Narrow-band UVB phototherapy appears to be an effective therapeutic option.

Oral lichen planus and oral lichenoid lesions: diagnostic and therapeutic considerations.

Several therapeutic agents have been investigated for the treatment of oral lichen planus (OLP). Among these are corticosteroids, retinoids, cyclosporine, and phototherapy, in addition to other treatment modalities. A systematic review of clinical trials showed that particularly topical corticosteroids are often effective in the management of symptomatic OLP lichen planus. Systemic corticosteroids should be only considered for severe widespread OLP and for lichen planus involving other mucocutaneous sites. Because of the ongoing controversy in the literature about the possible premalignant character of OLP, periodic follow-up is recommended. There is a spectrum of oral lichen planus-like ("lichenoid") lesions that may confuse the differential diagnosis. These include lichenoid contact lesions, lichenoid drug reactions and lichenoid lesions of graft-versus-host disease. In regard to the approach to oral lichenoid contact lesions the value of patch testing remains controversial. Confirmation of the diagnosis of an oral lichenoid drug reaction may be difficult, since empiric withdrawal of the suspected drug and/or its substitution by an alternative agent may be complicated. Oral lichenoid lesions of graft-versus-host disease (OLL-GVHD) are recognized to have an association with malignancy. Local therapy for these lesions rests in topical agents, predominantly corticosteroids.

Successful treatment of lichen amyloidosis with combined bath PUVA photochemotherapy and oral acitretin.

Lichen amyloidosis (LA) is a chronic, pruritic skin disorder characterized by brownish-grey papules on extensor surfaces of legs and rarely on the trunk. Thioflavin T-positive amyloid deposits are found in the papillary dermis of affected skin, which is the only organ involved. A variety of therapeutic regimens for lichen amyloidosis have been described; however, in many cases with only limited effect. We report on two patients with lichen amyloidosis with typical clinical symptoms not responding to local treatment. A combined regimen with bath psoralen ultraviolet A (PUVA) and oral acitretin was initiated, resulting in nearly complete resolution of the papules and impressive relief from the severe pruritus. The beneficial response has persisted for 8 months. The suggested combined therapy with bath PUVA photochemotherapy and oral acitretin represents an efficacious and practical treatment modality for lichen amyloidosis with long-lasting effects.

Medium dose long-wavelength ultraviolet A (UVA1) phototherapy for the treatment of acute and chronic graft-versus-host disease of the skin.

Long-wavelength ultraviolet A (340-400 nm UVA1) phototherapy has been reported to be effective in atopic dermatitis, localized scleroderma and other T-cell-derived skin diseases. UVA1 as an adjunct to systemic immunosuppressive treatment was found to be safe, and effective in 10 patients with chronic cutaneous (seven lichenoid and three sclerodermoid) graft-versus-host disease (GVHD) after stem cell transplantation. Complete and partial responses were achieved in six (60%), and in three (30%) patients, respectively. One patient had improvement of sclerotic skin lesions. At a median follow-up of 14 months, two patients with lichenoid lesions relapsed. Both responded to another treatment cycle. Furthermore, we treated seven patients with UVA1 as primary therapy for acute cutaneous GVHD grades II and III in a pilot experience. Five patients had a complete response with no relapse at a median follow-up of 9 months after UVA1. Two patients showed no response and systemic steroids had to be started. UVA1 therapy is feasible, well tolerated and can be effective in treating chronic as well as acute GVHD confined to the skin thereby avoiding systemic steroids. Our results should be confirmed in larger studies and the effectiveness of UVA1 compared to other established treatment modalities.

Successful treatment of oral lesions of chronic lichenoid graft-vs.-host disease by the addition of low-level laser therapy to systemic immunosuppression.

We report a case of severe oral stomatitis caused by lichenoid chronic graft-vs.-host disease in which low-level laser therapy applied to the oral mucosa, in addition to standard systemic immunosuppressive treatment, resulted in quick healing and symptomatic relief.

Prospects for ultraviolet A1 phototherapy as a treatment for chronic cutaneous graft-versus-host disease.

BACKGROUND AND OBJECTIVES: Standard or investigative immunosuppressive therapies for cutaneous chronic graft-versus-host disease (GVHD) may prove not only ineffective but also cause serious adverse effects. Repeated exposure of the skin to ultraviolet radiation in the wavelength range 340-400 nm (so-called ultraviolet A1) was recently reported to have a strong local (intracutaneous) immunomodulatory activity. This study was undertaken to evaluate efficacy and safety of this phototherapy. DESIGN AND METHODS: Nine patients with cutaneous (4 lichenoid and 5 sclerodermoid) GVHD and mild or no other organ involvement were enrolled. All patients had developed serious drug toxicity and/or opportunistic infections. Phototherapy was administered three times a week. RESULTS: Complete remission was seen in 5 (2 lichenoid and 3 sclerodermoid) cases and a partial improvement in 4 (2 lichenoid and 2 sclerodermoid) after having received 15.8+/-3.8 (lichenoid GVHD) or 21.6+/-8.0 (sclerodermoid GVHD) sessions of phototherapy. Adverse effects were not registered. At follow-up (range: 6-25 months), two patients with sclerodermoid lesions relapsed after 5 months but responded to another treatment cycle. Patients with lichenoid GVHD showed relapses within one month and prolonged maintenance phototherapy was needed. Problems of drug toxicity and opportunistic infections improved as phototherapy allowed the reduction or interruption of systemic drug therapies. INTERPRETATION AND CONCLUSIONS: Ultraviolet A1 phototherapy may be considered as an appropriate therapeutic approach for sclerodermoid GVHD with no or mild involvement of internal organs. Patients with lichenoid GVHD should be treated only if they develop serious adverse effects to immunosuppressive therapies and opportunistic infections because of the carcinogenic hazard of high cumulative doses of ultraviolet A1 radiation.

[Keratosis lichenoides chronica. Bath PUVA therapy]. / Keratosis lichenoides chronica Erfolgreiche Therapie mit Bade-PUVA.

We describe the case of a 51-year-old male patient with characteristic lesions of keratosis lichenoides chronica confined to the back of his hands and feet. The lichenoid papules, linear hyperkeratotic ridges and erythematosquamous plaques appeared first in early childhood and recurred after a short episode of spontaneous remission. They didn't respond to various topical treatment modalities over the years. After a local PUVA therapy all lesions disappeared with no recurrence for over two years now. Our case report indicates a new promising indication for bath-PUVA-therapy.

Keratosis lichenoides chronica in childhood.

Keratosis lichenoides chronica (KLC) is a rare chronic disorder of keratinization characterized by lichenoid hyperkeratotic papules arranged in a linear pattern, erythematosquamous plaques and seborrhea-like dermatitis on the face. We report a 2-year-old girl diagnosed with KLC whose lesions, arranged in symmetrical linear fashion, improved after sunlight exposure during the summer.

Lichen amyloidosis presenting as a papular pruritus syndrome in a human-immunodeficiency-virus-infected man.

A human-immunodeficiency-virus (HIV)-positive man presented with pruritic erythematous and flesh-colored papules on his arms and trunk of 1 year's duration. The lesions had previously been treated with oral ketoconazole and topical emollients with no improvement. Microscopic evaluation of lesional skin from his left forearm showed lichen amyloidosis. The patient was started on ultraviolet B phototherapy which he received for 2 weeks without improvement. Lichen amyloidosis should be added to the differential diagnosis of papular pruritus syndrome in HIV-positive individuals.