Clinical Challenge: Deeply Hyperpigmented, Slightly Raised Papules - MPR

Clinical Challenge: Deeply Hyperpigmented, Slightly Raised Papules

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A 30-year-old Hispanic woman presents for evaluation of a pruritic eruption on her legs and back that developed 2 months previously. She denies any history of systemic disease, including hepatitis and illicit drug use, as well as any prior history of skin disorders. A short course of oral prednisone, administered elsewhere, helped alleviate the pruritus; however, the condition flared with tapering of the drug. Examination reveals scattered, deeply hyperpigmented, slightly raised papules of the affected areas. She states that these sites were initially reddened in color. No oral lesions are noted.

Lichen planus is a pruritic disorder of unknown etiology that classically presents as violaceous papules on the wrists and ankles. The pathogenesis is believed to involve an abnormal immune response.1 The condition tends to wax and wane in intensity and...

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Lichen planus is a pruritic disorder of unknown etiology that classically presents as violaceous papules on the wrists and ankles. The pathogenesis is believed to involve an abnormal immune response.1 The condition tends to wax and wane in intensity and may remit spontaneously after a variable time period. Oral involvement is characterized by white lacey discoloration of the buccal mucosa and at times by refractory ulcerations. A significant percentage of those with lichen planus test positive for hepatitis C.2,3 Lichen planus may be precipitated by taking certain drugs, including beta-blockers, nonsteroidal anti-inflammatory drugs, and angiotensin-converting enzyme inhibitors.

Lichen planus most commonly affects middle-aged individuals and occurs with equal frequency in males and females.5 A racial predilection has not been demonstrated, and literature review found no studies citing an increased incidence in the adult Hispanic population. In darker-skinned individuals, postinflammatory hyperpigmentation is characteristically present, as evidenced by this case. The patient in this case received intramuscular triamcinolone acetonide and was prescribed clobetasol cream to be used as topical therapy.

Stephen Schleicher, MD, is an associate professor of medicine at the Commonwealth Medical College in Scranton, Pennsylvania, and an adjunct assistant professor of dermatology at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. He practices dermatology in Hazleton, Pennsylvania.

References

1. Hussein M. Evaluation of angiogenesis in normal and lichen planus skin by CD34 protein immunohistochemistry: preliminary findings. Cell Biol Int. 2007;31:1292-1295.

2. Shengyuan L, Songpo Y, Wen W, Wenjing T, Haitao Z, Binyou W. Hepatitis C virus and lichen planus: a reciprocal association determined by a meta-analysis. Arch Dermatol. 2009;145:1040-1047.

3. Bigby M. The relationship between lichen planus and hepatitis C clarified. Arch Dermatol. 2009;145:1048-1050.

4. Halevy S, Shai A. Lichenoid drug eruptions. J Am Acad Dermatol. 1993;29:249-255.

5. Bhattacharya A, Kaur I, Kumar B. Lichen planus: a clinical and epidemiological study. J Dermatol. 2000;27:576-582.