2016.2-28

Palmar involvement in lichen planus

Gökçe Iş?l Kurmuş¹, Müzeyyen Gönül², Ahmet Tu?rul Su², Nesrin Gürçay³, Murat Alper³

1Department of Dermatology, I?d?r State Hospital, I?d?r, Turkey, 2Department of Dermatology, D?şkap? Y?ld?r?m Beyaz?t Education and Research Hospital, Ankara, Turkey, 3Department of Pathology, D?şkap? Y?ld?r?m Beyaz?t Education and Research Hospital, Ankara, Turkey

Corresponding author: Dr. Gökçe Iş?l Kurmuş, E-mail: isilkurmus@gmail.com
Submission: 16.07.2015 , Acceptance: 12.09.2015
DOI: 10.7241/ourd.20162.64


 

Sir,

Lichen planus (LP) is a chronic inflammatory dermatosis with numerous morphological patterns. Palmoplantar LP, acral, localized variant of disease is uncommon and does not usually have typical clinical characteristics of LP [13]. Because of presenting with various atypical clinical features, palmoplantar LP may create difficulty in diagnosis [2,3]. We describe a case of a 53-year-old man with hyperkeratotic, pruritic, erythematous, scaly plaques on both palms, especially in the hypothenar area.

CASE REPORT

A 53-year-old man was attended with hyperkeratotic, pruritic, erythematous, scaly plaques on both palms with one month history. The self and family history were unremarkable. On the dermatological examination, hyperkeratotic, erythematous, scaly plaques were observed on both mid-palms and hypothenar eminences, the fingertips were spared (Fig. 1). The other skin surfaces, hair, nails, and oral mucosa were normal. Routine laboratory tests including complete blood count, blood chemistry analysis, and urinalysis were normal. Serological tests for hepatitis B and C viruses, syphilis and autoimmune antibodies were negative. The potassium hydroxide (10% KOH) examinaton and mycologic cultures of scrapings from palmar lesions were also negative. Histopathological examination showed basal cell degeneration with a band-like lymphocytic infiltration in the upper dermis, focal hypergranulosis and irregular acanthosis with a saw-tooth like appearance on the epidermis (Fig. 2). The diagnosis of palmoplantar LP was made with clinical and histopathological features. The skin lesions of the patient improved with topical steroid ointment (0,05% clobetasol-17-propionate) twice a day for 2 months.

thumblarge
Figure 1: Hyperkeratotic, erythematous, scaly plaques were observed on both mid-palms and hypothenar eminences, the fingertips were spared.
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Figure 2: Basal cell degeneration with a band-like lymphocytic infiltrate in the upper dermis along with focal hypergranulosis and irregular acanthosis (H&E, 20X10).

DISCUSSION

The diagnosis of palmoplantar LP may be difficult, especially when palmar lesions presented as an isolated finding, because palmoplantar lesions do not demonstrate typical polygonal, pruritic lesions of LP and Wickham’s striae in contrast to LP lesions [35]. Several clinical variants of palmoplantar LP have been described, including erythematous scaly form, firm and rough, semi-translucent and waxy, erosive, hyperkeratotic, punctate keratosis-like, petechia-like and ulcerative forms [1,25]. The most common variant is erythematous scaly form in which yellowish, compact keratotic papules or papulonodules are seen on the palms [46]. The differential diagnosis of palmoplantar LP includes many dermatologic disorders such as psoriasis, lichen nitidus, acquired palmoplantar keratoderma, tinea, verruca vulgaris, callus, xanthomas, granuloma annulare, Reiter’s syndrome, syphilis, punctuate porokeratosis and arsenical keratosis [57]. Histopathological examination must be done for the differential diagnosis and histopathology usually shows the characteristic features of LP [35].

The first-line treatment of palmoplantar LP is topical or systemic corticosteroids. Other treatment modalities include topical tazarotene, systemic acitretin and cyclosporin therapies. Also, narrow-band ultraviolet B, psoralen and ultraviolet A therapy (PUVA) and PUVA bathing and 308-nm excimer laser therapies may be effective. Surgical treatment with excision and grafting may be used in painful erosive cases [1,47]. The present patient was treated with topical steroid ointment (%0,05 clobetasol-17-propionate) twice a day. After 2 months, the skin lesions had improved.

The current report was presented a case of palmar LP because of its rarity and clinical diversity. In conclusion, this case emphasizes to clinicians that palmoplantar LP must be thought among the differantial diagnoses of the palmoplantar lesions and histopathological examination is essential to establish diagnosis.

CONSENT

The examination of the patient was conducted according to the Declaration of Helsinki principles. Written informed consent was obtained from the patient for publication of this article.

REFERENCES

1. Kim MJ, Choi M, Na SY, Lee JH, Cho S, Two cases of palmoplantar lichen planus with various clinical featuresJ Dermatol 2010; 37: 985-9.

2. Landis M, Bohyer C, Bahrami S, Brogan B, Palmoplantar lichen planus: A rare presentation of a common diseaseJ Dermatol Case Rep 2008; 2: 8-10.

3. Sánchez-Pérez J, Rios Buceta L, Fraga J, García-Díez A, Lichen planus with lesions on the palms and/or soles: prevalence and clinicopathological study of 36 patientsBr J Dermatol 2000; 142: 310-4.

4. Kim YS, Kim MH, Kim CW, Shin DH, Choi JS, Kim KH, A case of palmoplantar lichen planus mimicking secondary syphilisAnn Dermatol 2009; 21: 429-31.

5. Gutte R, Khopkar U, Predominant palmoplantar lichen planus: A diagnostic challengeIndian J Dermatol 2014; 59: 343-7.

6. Zeng YP, Sun QN, Liu YH, Fang K, Lichen planus with palmoplantar involvement: rapid therapeutic response to acitretinEur J Dermatol 2011; 21: 632-3.

7. Madke B, Doshi B, Wankhede P, Nayak C, Palmar lichen planus mimicking tinea nigraIndian J Dermatol 2013; 58: 407.

Notes

Source of Support: Nil,

Conflict of Interest: None declared.


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