Patient Presentation
A 17-year-old boy presented with mildly pruritic, violaceous papules and plaques on the left side of his chest that had slowly extended over the past 6 months. He reported no pain and no history of applying topical substances. There was no history of a similar rash. He had chicken pox several years before, but his history was otherwise unremarkable. On examination, the rash, at first look, had a dermatomal distribution and consisted of violaceous plaques (see Figure 1). Hair, nails and mucus membrane examinations were normal.
WHAT IS YOUR DIAGNOSIS?
DIAGNOSIS: Lichen Planus
Skin eruptions can be generalized, involving the whole body, or localized, affecting a part of the body. Localized skin eruptions may have a dermatomal (zosteriform) or Blaschkoid distribution. The rash is dermatomal when distribution of the lesions follows a single spinal afferent nerve root; the classic example is herpes zoster.
Some skin diseases are known to present with a generalized or localized Blaschkoid distribution. The rash is described as having a Blaschkoid distribution when it follows the lines of Blaschko. Blaschko’s lines, also called the Lines of Blaschko, were first described by Alfred Blaschko.1 They are skin lines that are invisible under normal conditions. They become apparent when some diseases of the skin manifest themselves according to these patterns. They are longitudinally oriented on the limbs and circumferential on the trunk. Localized Blaschkoid eruption might look dermatomal or like a herpes zoster; hence the name zosteriform. Our patient had zosteriform lichen planus or lichen planus following Blaschko’s lines in a localized distribution.
Lichen planus (LP) a chronic mucocutaneous disease that affects skin and mucosal surfaces.1 It is sometimes associated with certain medications and diseases but is essentially of unknown origin. It is a relatively common disorder affecting middle-aged individuals;2 the average age of onset is about 50. It is evenly distributed worldwide and affects females more than males. Clinically, the disorder presents as pruritic, flat-topped, violaceous, polygonal papules most commonly on the flexural surfaces.2 The mucous membranes are involved in up to 65% of cases. Occasionally, nails can be affected as well.
There are many types of lichen planus according to the configuration, morphology of lesion and the site of involvement. Zosteriform lichen planus is a rare form of lichen planus that manifests in a zosteriform distribution. Sometimes lichen planus follows the lesion of herpes zoster as an isotopic response of Wolf.3
Lichen planus following a Blaschko line is diagnosed by its clinicopathological features. Lesions are characterized by shiny, violaceous, flat-topped, polygonal papules and plaques.
The histology of LP is characteristic and enables distinction from other skin conditions that may present in a linear or zosteriform distribution, such as lichen striatus, linear naevi and linear psoriasis. The histopathologic features distinguish lichen planus based on the presence of irregular acanthosis and colloid bodies in the epidermis with destruction of the basal layer. The upper dermis has a bandlike infiltrate of lymphocytes and histiocytes. Degenerating basal epidermal cells are transformed into colloid bodies. The rete ridges may appear flattened or effaced (‘saw-tooth’ appearance), and focal separation from the dermis may lead to Max Joseph spaces.
Differential Diagnosis
Contact dermatitis from poison ivy, severe herpes simplex virus (HSV) infection and herpes zoster are important differential diagnoses for a zosteriform eruption. However, these conditions can be ruled out by history and physical examination. All three diseases present with an acute rash that does not last longer than a few weeks, whereas, in the case presented, the eruption had a duration of many months.
The morphology in the incorrect three choices is more vesicular, whereas, in this case, it is commonly papular.
Treatment
Treatment modalities for lichen planus may depend on the type of the disease and its severity. A variety of medications have been used to relieve pruritus and induce remission of lichen planus.4 Topical or systemic steroids are commonly used. Other agents used in treating severe cutaneous or erosive LP have included acitretin, itraconazole, metronidazole, low-molecular-weight heparin (enoxaparin), tetracycline antibiotics, sulfasalazine, ultraviolet phototherapy, cyclophosphamide, azathioprine, methotrexate, recombinant IFN-α-2b, basiliximab, mycophenolate mofetil and systemic cyclosporine. In instances of limited involvement, topical steroids may be sufficient, as was the case with our patient.
Dr. Khalid Al Aboud is a dermatopathology fellow in the pathology department at Wake Forest University School of Medicine in Winston-Salem, NC.
Dr. Daifullah Al Aboud is assistant professor, dermatology department, College of Medicine, Taif University, Taif, Saudi Arabia.
Disclosure: The authors have no conflicts of interest or financial disclosures to report.
Patient Presentation
A 17-year-old boy presented with mildly pruritic, violaceous papules and plaques on the left side of his chest that had slowly extended over the past 6 months. He reported no pain and no history of applying topical substances. There was no history of a similar rash. He had chicken pox several years before, but his history was otherwise unremarkable. On examination, the rash, at first look, had a dermatomal distribution and consisted of violaceous plaques (see Figure 1). Hair, nails and mucus membrane examinations were normal.
WHAT IS YOUR DIAGNOSIS?
DIAGNOSIS: Lichen Planus
Skin eruptions can be generalized, involving the whole body, or localized, affecting a part of the body. Localized skin eruptions may have a dermatomal (zosteriform) or Blaschkoid distribution. The rash is dermatomal when distribution of the lesions follows a single spinal afferent nerve root; the classic example is herpes zoster.
Some skin diseases are known to present with a generalized or localized Blaschkoid distribution. The rash is described as having a Blaschkoid distribution when it follows the lines of Blaschko. Blaschko’s lines, also called the Lines of Blaschko, were first described by Alfred Blaschko.1 They are skin lines that are invisible under normal conditions. They become apparent when some diseases of the skin manifest themselves according to these patterns. They are longitudinally oriented on the limbs and circumferential on the trunk. Localized Blaschkoid eruption might look dermatomal or like a herpes zoster; hence the name zosteriform. Our patient had zosteriform lichen planus or lichen planus following Blaschko’s lines in a localized distribution.
Lichen planus (LP) a chronic mucocutaneous disease that affects skin and mucosal surfaces.1 It is sometimes associated with certain medications and diseases but is essentially of unknown origin. It is a relatively common disorder affecting middle-aged individuals;2 the average age of onset is about 50. It is evenly distributed worldwide and affects females more than males. Clinically, the disorder presents as pruritic, flat-topped, violaceous, polygonal papules most commonly on the flexural surfaces.2 The mucous membranes are involved in up to 65% of cases. Occasionally, nails can be affected as well.
There are many types of lichen planus according to the configuration, morphology of lesion and the site of involvement. Zosteriform lichen planus is a rare form of lichen planus that manifests in a zosteriform distribution. Sometimes lichen planus follows the lesion of herpes zoster as an isotopic response of Wolf.3
Lichen planus following a Blaschko line is diagnosed by its clinicopathological features. Lesions are characterized by shiny, violaceous, flat-topped, polygonal papules and plaques.
The histology of LP is characteristic and enables distinction from other skin conditions that may present in a linear or zosteriform distribution, such as lichen striatus, linear naevi and linear psoriasis. The histopathologic features distinguish lichen planus based on the presence of irregular acanthosis and colloid bodies in the epidermis with destruction of the basal layer. The upper dermis has a bandlike infiltrate of lymphocytes and histiocytes. Degenerating basal epidermal cells are transformed into colloid bodies. The rete ridges may appear flattened or effaced (‘saw-tooth’ appearance), and focal separation from the dermis may lead to Max Joseph spaces.
Differential Diagnosis
Contact dermatitis from poison ivy, severe herpes simplex virus (HSV) infection and herpes zoster are important differential diagnoses for a zosteriform eruption. However, these conditions can be ruled out by history and physical examination. All three diseases present with an acute rash that does not last longer than a few weeks, whereas, in the case presented, the eruption had a duration of many months.
The morphology in the incorrect three choices is more vesicular, whereas, in this case, it is commonly papular.
Treatment
Treatment modalities for lichen planus may depend on the type of the disease and its severity. A variety of medications have been used to relieve pruritus and induce remission of lichen planus.4 Topical or systemic steroids are commonly used. Other agents used in treating severe cutaneous or erosive LP have included acitretin, itraconazole, metronidazole, low-molecular-weight heparin (enoxaparin), tetracycline antibiotics, sulfasalazine, ultraviolet phototherapy, cyclophosphamide, azathioprine, methotrexate, recombinant IFN-α-2b, basiliximab, mycophenolate mofetil and systemic cyclosporine. In instances of limited involvement, topical steroids may be sufficient, as was the case with our patient.
Dr. Khalid Al Aboud is a dermatopathology fellow in the pathology department at Wake Forest University School of Medicine in Winston-Salem, NC.
Dr. Daifullah Al Aboud is assistant professor, dermatology department, College of Medicine, Taif University, Taif, Saudi Arabia.
Disclosure: The authors have no conflicts of interest or financial disclosures to report.
Patient Presentation
A 17-year-old boy presented with mildly pruritic, violaceous papules and plaques on the left side of his chest that had slowly extended over the past 6 months. He reported no pain and no history of applying topical substances. There was no history of a similar rash. He had chicken pox several years before, but his history was otherwise unremarkable. On examination, the rash, at first look, had a dermatomal distribution and consisted of violaceous plaques (see Figure 1). Hair, nails and mucus membrane examinations were normal.
WHAT IS YOUR DIAGNOSIS?
DIAGNOSIS: Lichen Planus
Skin eruptions can be generalized, involving the whole body, or localized, affecting a part of the body. Localized skin eruptions may have a dermatomal (zosteriform) or Blaschkoid distribution. The rash is dermatomal when distribution of the lesions follows a single spinal afferent nerve root; the classic example is herpes zoster.
Some skin diseases are known to present with a generalized or localized Blaschkoid distribution. The rash is described as having a Blaschkoid distribution when it follows the lines of Blaschko. Blaschko’s lines, also called the Lines of Blaschko, were first described by Alfred Blaschko.1 They are skin lines that are invisible under normal conditions. They become apparent when some diseases of the skin manifest themselves according to these patterns. They are longitudinally oriented on the limbs and circumferential on the trunk. Localized Blaschkoid eruption might look dermatomal or like a herpes zoster; hence the name zosteriform. Our patient had zosteriform lichen planus or lichen planus following Blaschko’s lines in a localized distribution.
Lichen planus (LP) a chronic mucocutaneous disease that affects skin and mucosal surfaces.1 It is sometimes associated with certain medications and diseases but is essentially of unknown origin. It is a relatively common disorder affecting middle-aged individuals;2 the average age of onset is about 50. It is evenly distributed worldwide and affects females more than males. Clinically, the disorder presents as pruritic, flat-topped, violaceous, polygonal papules most commonly on the flexural surfaces.2 The mucous membranes are involved in up to 65% of cases. Occasionally, nails can be affected as well.
There are many types of lichen planus according to the configuration, morphology of lesion and the site of involvement. Zosteriform lichen planus is a rare form of lichen planus that manifests in a zosteriform distribution. Sometimes lichen planus follows the lesion of herpes zoster as an isotopic response of Wolf.3
Lichen planus following a Blaschko line is diagnosed by its clinicopathological features. Lesions are characterized by shiny, violaceous, flat-topped, polygonal papules and plaques.
The histology of LP is characteristic and enables distinction from other skin conditions that may present in a linear or zosteriform distribution, such as lichen striatus, linear naevi and linear psoriasis. The histopathologic features distinguish lichen planus based on the presence of irregular acanthosis and colloid bodies in the epidermis with destruction of the basal layer. The upper dermis has a bandlike infiltrate of lymphocytes and histiocytes. Degenerating basal epidermal cells are transformed into colloid bodies. The rete ridges may appear flattened or effaced (‘saw-tooth’ appearance), and focal separation from the dermis may lead to Max Joseph spaces.
Differential Diagnosis
Contact dermatitis from poison ivy, severe herpes simplex virus (HSV) infection and herpes zoster are important differential diagnoses for a zosteriform eruption. However, these conditions can be ruled out by history and physical examination. All three diseases present with an acute rash that does not last longer than a few weeks, whereas, in the case presented, the eruption had a duration of many months.
The morphology in the incorrect three choices is more vesicular, whereas, in this case, it is commonly papular.
Treatment
Treatment modalities for lichen planus may depend on the type of the disease and its severity. A variety of medications have been used to relieve pruritus and induce remission of lichen planus.4 Topical or systemic steroids are commonly used. Other agents used in treating severe cutaneous or erosive LP have included acitretin, itraconazole, metronidazole, low-molecular-weight heparin (enoxaparin), tetracycline antibiotics, sulfasalazine, ultraviolet phototherapy, cyclophosphamide, azathioprine, methotrexate, recombinant IFN-α-2b, basiliximab, mycophenolate mofetil and systemic cyclosporine. In instances of limited involvement, topical steroids may be sufficient, as was the case with our patient.
Dr. Khalid Al Aboud is a dermatopathology fellow in the pathology department at Wake Forest University School of Medicine in Winston-Salem, NC.
Dr. Daifullah Al Aboud is assistant professor, dermatology department, College of Medicine, Taif University, Taif, Saudi Arabia.
Disclosure: The authors have no conflicts of interest or financial disclosures to report.
A 17-year-old boy presented with mildly pruritic, violaceous papules and plaques on the left side of his chest that had slowly extended over the past 6 months. He reported no pain and no history of applying topical substances. There was no history of a similar rash. He had chicken pox several years before, but his history was otherwise unremarkable. On examination, the rash, at first look, had a dermatomal distribution and consisted of violaceous plaques (see Figure 1). Hair, nails and mucus membrane examinations were normal.
