Ch 10. Lichen plans and other lichenoid dermatoses Flashcards by Hannah Stirton

What is typical age of onset for Lichen Planus?

5th-6th decade
2/3 onset between 30-60
rare in kids

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How common is LP? Oral LP?

LP up to 1%
Oral LP 1-4%

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What % patients with cutaneous LP will get oral involvement

75%

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What % of patients presenting with only oral LP will go on to get cutaneous LP

10-20%

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Name 4 categories of triggers for LP

VIRUSES
-Hep C big one, most associated with oral
-HHV6/7, HSV, VZV, HPV
Vaccines
Contact allergens
-amalgam (mercury), copper, and gold
Drugs-see later cards

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Name the top 5 drugs to cause lichenoid drug

Gold
ACEi
Thiazide diuretics
Anti-malarial
Quinidine

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What are the classic sites of prediction for classic LP

Wrists-flexor
Forearm-flexor
Dorsal hands
Shins
Pre-sacral
Glans penis

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Name 6 classic characteristics of lichen planus

Polygonal
Violaceous
Flat toppes
Papules
Whickams striae-lacy reticulate network fine lines
Pruritic
PIH common
Koebner

Sometimes widely disperse, sometimes coalesced

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What 4 subtypes of LP tend to ne more persistent throughout life

Hypetrophic
Oral
Annular
Ulcerative oral

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Name 10 variants of lichen

Annular
Atrophic
Actinic
Acute/exanthematous
Hypertrophic
Eosive/ulcerative
Bullous LP
LP pemphigoides
Linear
Lichen planopilaris
Lichen Plans pigmentosus
Oral
Nail
Inverse
Vulvovaginal
DLE/LP overlap

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What is the natural course of eruptive/acute LP

Acute onset generalized eruption mostly on classic sites though, trunk, inner wrists, dorsal feet

Self resolves 3-9 months with hyperpigmentation

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What are the clinical features of actinic LP

red–brown plaques with an annular configuration, but melasma-like hyperpigmented patches have been observed

Sun exposed areas-face, dorsal arms, neck

Spring/summer

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Where are the top 4 sites of annular LP

Axilla>penis >extremity> groin

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Where does atrophic LP occur? What is likely happening? What do they look like?

intertriginous and lower extremities

likely resolving LP, maybe be exacerbated by TCS

papules coalesce to form larger plaques that over time become atrophic centrally, with residual hyperpigmentation.

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What is the difference between bullous LP and LP pemphigoides

Bullous LP–> vesicles and bullae develop within pre-existing lesions of LP as a result of intense lichenoid inflammation and significant epidermal damage

LP pemphigoides have circulating IgG autoantibodies directed against the 180 kDa BP antigen (BP180; BPAG2), as in idiopathic BP.
Compared to BP though, bullae can arise either within LP lesions or previously uninvolved skin, but the diagnosis of LP usually precedes the LP pemphigoides

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Where does hypertrophic LP occur? What does it look like?

Extremely pruritic, thick, hyperkeratotic plaques are seen primarily on the shins or dorsal aspect of the feet and may be covered by a fine adherent scale.

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Name a feature on path that may help differentiate hypertrophic LP

increased eosinophils

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What is the concern about hypertrophic LP

developing bcc

What is the morphology of inverse psoriasis

Pink to violaceous papules and plaques appear in intertriginous zones OR just hyperpigemtation

What is the presentation of lichen plans pigmentosus

brown to gray-brown macules develops into into diffuse or reticulate pigmentation

sun exposed areas face/neck , can have other locations

Name two variants of lichen plants pigmentosus

-LP inversus–> Also intertriginous variant-can be hard to tell from inverse variant of LP
-Linear variant along lines of blaschko

What is the difference between EDP and Lichen plants pigmentosus

EDP
- is often truncal involvement,
- a younger mean age of onset
-lack of either diffuse pigmentation or lack of coexisting LP lesions.

LPP
-other LP lesions on body
-more photo exposed
-LP lesions is seen in ~20% of patients with LP pigmentosus.
-Occasionally, small nests of keratinocytes are seen within the basal layer and these may be confused with nests of melanocytes.

What is the triad of Graham-Little–Piccardi–Lassueur syndrome

non-cicatricial loss of pubic and axillary hairs and disseminated spinous or acuminated follicular papules
2.typical cutaneous or mucosal LP
(3) scarring alopecia of the scalp with or without atrophy

What does linear LP refer to

LP lesions that spontaneously pop up in lines of blaschko–> NOT koebner

What % of patients have nail involvement in LP

10%

Name 4 nail findings in LP

Lateral thinning Longitudinal ridging and fissuring Dorsal pterygyium Pitting

Name 4 nail findings in LP

Lateral thinning Longitudinal ridging and fissuring Dorsal pterygyium Pitting

What are the 7 forms of oral LP? Which is most common?

Atrophic bullous Erosive Papular Pigmented Plaque like Reticular-most common

If oral LP, what do you need to ask about

Esophaagesal Vulvovaginal

What infection is associated with oral LP

Hep C

With Hep C associated LP, where does it often occur? Non Hep C oral LP?

tongue, labial mucosa, and gingivae Non hep C--> buccal mucosa

What 4 forms of LP are associated with SCC development

* Oral * Vulvar * Hypertrophic * Erosive

Where does ulcerative LP tend to occur

in palmar-plantar lesions

Most common form vulvovaginal LP

Erosive Often oral involvement too-->vulvovaginal-gingival syndrome

Name 5 clinical differences between LP and lichenoid drug

* Clinically for lichenoid drug: o Lesions are larger, often more psoriasiform o Wickham's striae are usually not apparent o Mucosal involvement is less common o Trunk and extremities are favoured over forearms, genitals o May be photo-distributed (photolichenoid drug)

What are seven histopathologic differences seen in a lichenoid drug eruption as compared to idiopathic lichen planus?

* Focal parakeratosis * Spongiosis * Interface change may be patchy * Epidermis may be thinned * Less pronounced hypergranulosis (wickham's striae) or even hypogranulosis * Cytoid bodies found in the upper granular cell layer (vs. spinous layer in LP) * Eosinophils * Plasma cells * Exocytosis of lymphoid cells * Perivascular infiltrate in the deeper dermis (especially photolichenoid reactions)

What are seven histopathologic differences seen in a lichenoid drug eruption as compared to idiopathic lichen planus?

Average latent period for drug induced LP

7 or 12 months

What do you see on pathology for giant cell lichenoid dermatitis?

multinucleated giant cells and histiocytes

Name 4 drugs associated with giant cell lichenoid dermatitis

ACE inhibitors, β-blockers, lipid-lowering agents, phenolphthalein, nonsteroidal anti-inflammatory drugs (NSAIDs).

List 10 features of classic lichen planus seen on histopathology

Hyperkeratosis Orthokeratosis Hypergranulosis-wdge shaped Basal cell degeneration Lichenoid infiltrate sub epidermal cleft-max Joseph spaces Necrotic keratonocytes Irregular acanthosis Sawtooth rete ridges Pigment incontinence Hypereosinophilia of keratinocytes in malphigian layer Civatte bodies in the basal layer Colloid bodies in the papillary dermis

What are two findings seen on direct immunofluorescence of classic lichen planus?

1) Linear fibrillary band of fibrin at the DEJ. 2) Cytoid bodies stain with IgM > IgG, IgA and C3.

What histopathologic finding relates to the Wickham's striae?

* Wedge-shaped hypergranulosis related to sweat ducts and hair follicles.

Avg remission time for most ppl for cutaneous LP

1 yr *not erosive lp, often doesn't remit