Lichen Planus Due to Hirudotherapy

Lichen planus is a traumatic (koebner positive), chronic, inflammatory and autoimmune disease affecting the oral and genital mucosa, scalp and nails. The Food and Drug Administration approved the use of medical leeches for therapeutic purposes (hirudotherapy) in 2004 to ensure flap nutrition in plastic surgery. A 34-year-old male patient was admitted to our dermatology outpatient clinic with a swollen, itchy and purple-coloured rash on legs and back for a month, and white and reticulated plaques in the mouth. It was learned that a week earlier, eight leeches was applied to both knees and ankles to alleviate knee and leg pain. The patient had no history of drug use. A punch biopsy was taken from the patient with a preliminary diagnosis of lichen planus and lichenoid drug reaction. The histopathological examination showed hyperkeratosis, irregular acanthosis and hypergranulosis. Systemic methylprednisolone, levocetrizine and topical methylprednisolone aceponate were planned for the therapy. To the best of our knowledge, the appearance of lichen planus after hirudotherapy was never reported in literature. Hence, physicians should keep in mind that lichen planus and similar dermatoses could be triggered due to hirudotherapy. The fact that lichen planus appeared a week after hirudotherapy does not necessarily mean that leeches were the cause of this phenomenon. Accordingly, it could be deduced that lichen planus was probably developed as a result of leech therapy.

Liquen plano, estudio retrospectivo en un hospital pediátrico / Lichen planus, retrospective study in a pediatric hospital

Introducción: El liquen plano (LP) es una enfermedad inflamatoria crónica, de etiología desconocida, que puede afectar la piel, los anexos y las mucosas. Objetivo: Describir las características epidemiológicas y clínicas y el tratamiento realizado en los pacientes con diagnóstico clínico e histopatológico de LP, valorados en el Servicio de Dermatología del Hospital de Pediatría "Prof. Dr. Juan P. Garrahan" en los últimos 33 años. Diseño:Estudio descriptivo, retrospectivo y transversal. Materiales y métodos: Se revisaron las historias clínicas de los pacientes con diagnóstico histopatológico de LP atendidos en el Hospital desde agosto de 1987 hasta febrero de 2020 y se analizaron las variables epidemiológicas, clínicas y de tratamiento. Resultados: Se incluyeron datos de 26 pacientes, 18 de los cuales eran varones (69,3%). La media de edad en el momento del diagnóstico fue de 9,6 años. Presentaron la variedad de LP clásico 24 pacienes (93%). El compromiso ungueal y de la mucosa bucal se observó en 2 pacientes (7,7%). Ninguno tuvo asociación a fármacos ni a infecciones. En cuanto al tratamiento recibido, 4 pacientes (15,4%) tuvieron pérdida del seguimiento; 13 (50%) realizaron tratamiento tópico; 6 (23%), tratamiento sistémico y 3 (11,5%), tratamiento combinado. El promedio de seguimiento fue de 6 meses y se obtuvo una respuesta favorable en el 68% de los pacientes. Conclusiones: El LP es una patología de baja frecuencia en la infancia. No se encontró asociación a medicamentos ni a enfermedades infecciosas como se describe en la población adulta. Su curso es crónico y, en los pacientes que tuvieron un adecuado seguimiento, se obtuvo una buena respuesta al tratamiento indicado.

Introduction: Lichen planus (LP) is a chronic, inflammatory disease of unknown etiology, which can affect skin, adnexal tissues and mucosa. Objective: to describe the clinical, epidemiological characteristics and the treatment received by patients with clinical and histopathological diagnosis of LP, seen at the Dermatology Service of Pediatric Hospital "Prof. Dr. Juan P. Garrahan" in the last 33 years. Design: Descriptive, retrospective and cross-sectional study. Materials y methods: We reviewed the clinical history of patients with histopathological diagnosis of LP that were treated at our hospital from August 1987 to February 2020 and analysed the epidemiological, clinical and treatment variables. Results: Data of 26 patients were included in this study 18 of which are males (69.3%). The mean age of diagnosis was 9.6 years. 24 patients (93%) presented the classical type of LP. Ungual and mucosal compromise were observed in 2 patients (7.7%) and none had associations with infections or drugs. Regarding treatment, 4 patients (15.4%) did not continue follow-ups, 13 patients (50%) had topical treatment, 6 (23%) had systemic treatment and 3 patients (11.5%) received combined treatment. The average follow-up time was 6 months and 68% of patients had favorable outcome. Conclusions: LP is an uncommon pathology in children. During this study we did not find any etiologic relations with use of drugs or infectious diseases as is described in de adult population. Its course is chronic and in the patients that had a proper follow-up a good response to the indicated treatment was obtained.

[A patient with perfectly aligned itching papules of the back after hijama therapy]. / Een patiënte met huidafwijkingen na hijama-therapie.

A 31-year-old woman was seen at our clinic with itching papules of the back after hijama treatments. Hijama treatments consist of superficially cutting the skin followed by cupping and are applied for a diversity of complaints, including pain. Our patient initially presented with sensitive and burning sensations at the cutting sites, but recently, the cutting sites started to itch as well. At physical examination, we saw perfectly aligned papules with a sign of Wickham's striae on her back where the skin had been cut. Further examination revealed comparable, solitary papules on the inside of her wrist, flank and chest. A skin biopsy confirmed the diagnosis lichen planus. The patient was prescribed betamethasone cream and we advised against further hijama treatments.

[Lichen ruber planus : Better understanding, better treatment!] / Lichen ruber planus : Besser verstehen, besser behandeln!

Lichen ruber, also called lichen ruber planus or lichen planus (LP), is a noncontagious inflammatory skin disease. LP is the main representative and namesake of the group of lichenoid diseases, which are characterized by small papules often accompanied by severe itching. With 65% of cases, LP is primarily a disease of the mucous membranes. In 20% of the cases, the disease is found on the skin and mucous membranes; skin involvement alone is seen in only about 10% of cases. Cutaneous LP has a very favorable 1­year prognosis of almost 80% healing as opposed to the mucosa and the adnexal organs. Histologically, keratinocytes with vacuolar degeneration, leaving behind apoptotic Kamino bodies and the characteristic band-shaped lymphocytic infiltrate at the dermatoepithelial junction, are common to lichenoid diseases. The horny layer is firm and compact and the stratum granulosum is thickened as a correlate of the Wickham stripes. The molecular pathogenesis, still partially hypothetical, assumes trigger factors leading to the presentation of intrinsic or foreign antigens. The triggered inflammation becomes independent in the sense of a classical cell-mediated autoimmune disease. Other autoimmune diseases are often associated with LP. Classical anti-inflammatory-immunosuppressive therapeutic concepts dominate with systemic retinoids ranking first in the highest evidence class for cutaneous LP with limitations in treatment of both mucosal and adnexal LP. More recently, interesting and new complementary phototherapeutics have been identified.

Concepts and controversies in the treatment of cutaneous lichen planus.

Cutaneous lichen planus (CLP) is a chronic autoimmune disease classically associated with severely pruritic, polygonal, violaceous, flat-topped papules and plaques. Subtypes such as hypertrophic and bullous lichen planus and lichen planus pigmentosus have been described. Treatment can be challenging, and prospective controlled studies are lacking. Corticosteroids remain the major options for topical and systemic treatment, although some non-steroidal options exist. Phototherapy, especially with narrow band ultraviolet B (NB-UVB), is effective, but caution must be taken because of the risk of keobnerization. Methotrexate and retinoids are an option for extensive disease, and are relatively well tolerated. Other treatments that have been investigated include sulfasalazine, low molecular weight heparin, griseofulvin, hydroxychloroquine, metronidazole and dapsone.

Lichen Planus Pigmentosus-like Reaction to Guasha.

BACKGROUND AND OBJECTIVE: Lichen planus pigmentosus (LPP) is an uncommon variant of lichen planus (LP) that manifests as macular hyperpigmentation involving chiefly the face and upper limbs. Although its etiology has not been fully elucidated, a relationship with hepatitis C infection, restrictive underwear, localized friction, and sun exposure have been proposed. Rarely, exposure to mustard oil, amla oil, henna, or hair dyes has been reported. CONCLUSION: We herein describe an LPP-like reaction to Guasha.

Lichen planus of the lower limbs: successful treatment with psoralen cream plus ultraviolet A photochemotherapy.

Lichen planus (LP) classifies into different subtypes depending on morphology and localization. Localized LP of the lower limb (LPLL) manifests a great challenge due to persistent itching, therapeutic resistance and the risk to develop into SCC. We report two cases with LPLL refractory to standard topical therapy, which were successfully treated with psoralen cream plus UVA photochemotherapy (cream-PUVA). We propose cream-PUVA as an alternative therapeutic option effective for localized LP of the lower limbs.

Lichen planus secondary complications associated with the use of biologic therapy for rheumatoid arthritis.

OBJECTIVES: Biologic therapy such as Etanercept, which is a tumor necrosis factor alpha (TNF-α) inhibitor, has been extensively used as election therapy in rheumatoid arthritis. The purpose of this case presentation was to inform about the possibility that lichen planus lesions could potentially become complicated by secondary infections in patients treated with Etanercept. Furthermore, we aimed at analyzing if the complication of the cutaneous lesion was coincidental or it was due to the immunosuppressive systemic therapy, and whether the infected lesion would respond to antibiotic therapy. CASE SUMMARY: The patient was a 59-year-old woman with rheumatoid arthritis and that have had lichen planus lesions for approximately 25 years. Only recently, she had been received immunosuppressive therapy (Etanercept and Methotrexate). Further on, the lichen planus flared up with a secondary infection determined by a Methicillin-sensitive Staphylococcus aureus. Uncommon myocardial complications were also characteristic of this case. RESULTS: While a case report described already the appearance of lichen planus following Etanercept therapy (Battistella M et al., 2008), the possibility that the lesion could become secondary complicated following this therapy was never reported before, according to our knowledge. Additionally, we describe in this case the interplay between Etanercept therapy and hypertrophic cardiomyopathy. CONCLUSIONS: Our case is not a lichen planus induced by Etanercept, but it is aggravated and secondary infected with Methicillin-sensitive Staphylococcus during the therapy. The additional cardiac complication (hypertrophic cardiomyopathy) may represent solely an evolutive sign of rheumatoid arthritis and therefore not influenced by Etanercept.

Lichen planus: an update and review.

Lichen planus (LP) is a papulosquamous eruption of the skin, scalp, nails, and mucous membranes. Although LP is more common in adults, it has become an established pediatric disorder. Its classic presentation is characterized by 4 p's: purple, polygonal, pruritic papules. Histopathologic examination reveals characteristic interface dermatitis. Although its pathogenesis is not fully understood, there is evidence that an imbalance of immunologic cellular reactivity is central. Lichen planus usually resolves within a few months. Treatment that primarily consists of topical and/or oral steroids will expedite recovery and alleviate symptoms. Resolution of this cutaneous disease often is accompanied by postinflammatory hyperpigmentation. Long-term sequelae of LP in the pediatric population are rare, but cutaneous atrophy and pterygium unguis may occur.

Disseminated hypertrophic lichen planus: relevant response to acitretin.

Hyperthrofic lichen planus is considered a variant of lichen planus with marked epidermal hyperplasia in response to persistent itch. It is clinically, characterized by symmetric hyperkeratotic plaques, of purplish-grey color, often located in the pretibial region. Intense pruritus, refractoriness to conventional treatments and the possibility of association of the long-term injuries with squamous cell carcinoma requires an effective treatment. The first-line treatment is corticosteroids which can be applied either topically or systemically. Other therapeutic modalities proposed are: NB-UVB phototherapy or PUVA, immunosuppressive drugs and systemic retinoids, notably acitretin. We report a case with exuberant clinical presentation of hyperthrofic lichen planus with excellent response to acitretin after nine months of treatment.

Líquen plano hipertrófico disseminado: relevante resposta à acitretina / Disseminated hypertrophic lichen planus: relevant response to acitretin

O líquen plano hipertrófico é uma variante do líquen plano, com pronunciada hiperplasia epidérmica em resposta à coçadura persistente. Clinicamente, caracterizam-se por placas hiperceratósicas, simétricas, de coloração cinza-violácea, com predileção pela região pré-tibial. O prurido intenso, a refratariedade aos tratamentos convencionais e a possibilidade de associação de um carcinoma epidermoide às lesões de longa duração impõem um tratamento eficaz. Os corticoides são considerados o tratamento de primeira linha e podem ser aplicados topicamente ou empregados de forma sistêmica. Outras modalidades terapêuticas propostas são a fototerapia com UVB-NB ou PUVA, imunossupressores e retinoides sistêmicos, com destaque para a acitretina. Relatamos um caso com apresentação clínica exuberante e excelente resposta à acitretin, totalizando um seguimento de nove meses.

Hyperthrofic lichen planus is considered a variant of lichen planus with marked epidermal hyperplasia in response to persistent itch. It is clinically, characterized by symmetric hyperkeratotic plaques, of purplish-grey color, often located in the pretibial region. Intense pruritus, refractoriness to conventional treatments and the possibility of association of the long-term injuries with squamous cell carcinoma requires an effective treatment. The first-line treatment is corticosteroids which can be applied either topically or systemically. Other therapeutic modalities proposed are: NB-UVB phototherapy or PUVA, immunosuppressive drugs and systemic retinoids, notably acitretin. We report a case with exuberant clinical presentation of hyperthrofic lichen planus with excellent response to acitretin after nine months of treatment.

Liquen plano / Lichen planus

El liquen plano (LP) es una dermatosis inflamatoria crónica que afecta a la piel, membranas mucosas, pelo y uñas; de etiología desconocida, en cuya patogenia existe un daño autoinmunitario mediado por linfocitos T frente a los queratinocitos basales que expresan autoantígenos alterados en su superficie. Se presenta con diferentes patrones clínicos, como LP oral, LP anular, LP lineal, LP atrófico, LP hipertrófico, LP ampollar, LP pigmentoso, LP actínico. Su presentación clásica se caracteriza por pápulas poligonales o placas, pruriginosas, de coloración violácea, superficie brillante, surcada por estrias blanquecinas, característicamente distribuidas en forma simétrica sobre todo en las superficies flexoras de la muñeca, tobillos y muslos. Evoluciona por brotes y su curso es autolimitado, se resuelve en un periodo de meses a años, pero puede persistir indefinidamente. Existen múltiples opciones de tratamiento que incluyen corticoides tópicos, intralesionales y sistémicos, retinoides, fototerapia, inmunomoduladores tópicos y en casos graves o resistentes al tratamiento, la ciclosporina, metotrexato y fotoféresis extracorpórea.

Lichen planus (LP) is a chronic inflammatory dermatosis that affectsthe skin, mucous membranes, hair and nails; of unknown aetiology, whose pathogenesis is autoimmune damage mediated by T cells against basal keratinocytes that express autoantigens altered on its surface. It comes with different clinical patterns, such as oralLP, LP annularis, LP linearis, LP, LP verrucosus, bullosa LP, LP pigmentosus, LP actinicus. Classical presentation is characterized bypolygonal papules or plaques, pruritic, violet colour, glossy surface, drained by whitish stretch marks, characteristically distributed in symmetrical form especially in surface flexors of the wrist, ankles and thighs. It evolves by outbreaks and its course is self-limited, resolving in a period of months to years, but may persist indefinitely. There are multiple treatment options including steroids topics, miscellaneous and systemic, retinoids, phototherapy, immunomodulators topical and in cases of severe or resistant to treatment, ciclosporin, methotrexate and photoferesis extracorporea.

Lichen planus and cicatricial conjunctivitis: disease course and response to therapy of 11 patients.

BACKGROUND: Lichen planus is an autoimmune, inflammatory dermatosis of unknown cause that affects the skin and mucous membranes. OBJECTIVE: The aim of this study was to report the clinical features and response to therapy in a series of patients with ocular lichen planus. METHODS: A retrospective chart review was performed to identify patients with ocular lichen planus. Information about clinical presentation, treatment, and therapeutic response was extracted from the medical records. RESULTS: Eleven patients with ocular lichen planus were identified. The diagnosis was confirmed histologically for 10 patients. Nine patients were women. The average time from onset of ocular symptoms to diagnosis was 4.1 years. Eight patients had mucous membrane involvement at other sites. Disease was well controlled in eight patients. CONCLUSION: Lichen planus should be considered in the differential diagnosis of cicatricial conjunctivitis, especially when severe lichen planus is noted at other sites.