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Me > (Ch11) Lichen planus and Lichnoid > Flashcards

(Ch11) Lichen planus and Lichnoid Flashcards

1
Q

Prevalence of LP

A

Oral 4%
Cutaneous 1%

Peak in middle aged F

75% overall pt have oral
75% of cutaneous LP pt —> have oral LP.
70% of vulvar LP pt —> have vaginal LP
10% of patients have nail LP
10% of oral –> have cutaneous
10% familial

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2
Q

Pathogenesis of LP

A

Pathogenesis due to CD8+ T-cells mediated autoimmune induced apoptosis of basal keratincytes from cross reaction with exogenous or endogenous antigens:
-viruses
-bacteria - local microbiome
-drugs
-contact allergens
-Autoantigens (like tumour antigens )
-Sweating disturbance

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3
Q

Triggers of LP

A
  1. Idiopathic
  2. Viral
  3. Contact allergens
  4. Drugs
  5. Chronic GVHD
  6. Malignancy
  7. Vaccines
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4
Q

Which viruses trigger LP

A

Hep C infection
Hep B vaccine
HHV- 6 and HHV-7
HSV and VZV
SARS-CoV-2
HPV

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5
Q

Which virus As/w ulcerative/erosive LP

A

Hep C

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6
Q

which trigger As/w oral and bollous LP in Children?

B -> Babbies -> Bollous

A

Hep B vaccine

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7
Q

what percentage of cases are familial ?

A

10%

earlier age of onset, ↑ relapse rate, ↑ oral LP.

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8
Q

Drugs triggers of LP

A

THAAQB
- TNFi
- HCTZ
- ACEi
- Antimalaria
-Quindine
-B-Blockers

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9
Q

Allergens induce LP

A

Dental restorations:
Mercury
Amalgam
Gold
Copper

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10
Q

what percentage of patient improve after removal of Allergen

A

95%

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11
Q

if patch test is negative do you still need to remove trigger?

A

yes
75% improve with trigger removal despite -ve patch test likely due to irritant nature of the trigger

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12
Q

What are Ps of LP

A

6Ps
Purple
Pruritic
Planus
Polygonal
Papule
plaque

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13
Q

What is the most common location for LP

A

Oral mucosa 75% of cases

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14
Q

percentage of oral LP developing cutaneous LP

A

10%

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15
Q

cutaneous common locations for LP

A

ventral wrist and forearms

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16
Q

List examples of vaccines As/w LP:

A

HBV vaccines
COVID-19 vaccines
influenza vaccines,
rabies vaccines

Interval few days to 5 months to develop LP , recommend to avoid further vaccinations.

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17
Q

histopath features of LP

A
  1. Orthokeratosis
  2. Wedge shaped hypergranulosis
  3. Irregular acanthosis (saw tooth)
  4. Civatte bodies at basal layers of epidermis
  5. Lichnoid interface dermatitis
  6. Increase Max-Joseph spaces.
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18
Q

Which cells if present in histopath indicate active disease LP?

A

Langerhans cells

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19
Q

DIF for LP shows?

A

shaggy fibronogen at BMZ
colloid bodies often stain for IgM, IgA, IgG or C3

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20
Q

Characteristic DIF finding of LP

A

colloid bodies often stain for IgM, IgA, IgG or C3

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21
Q

which type of LP has eosin in histopth

A

Drug induced
Hypertrophic

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22
Q

LP type with parakeratosis

A

Drug induced
Oral LP

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23
Q

LP type with colloid bodies beyond basal layers ?

A

drug induced

similar to EM, SJS/TEN and FDE
this to differentiate those from regular LP

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24
Q

LP vs lichen straitus in histopth

A

straitus has:
1. deep dermal inflammation/perifollicular (DLE)

  1. More lymphocyte exocytosis (PLEVA)
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25
Q

drug with longest latency to LP

A

Penicillamine 3y
B-blocker 1y
TNFi 3w-16m
Quinidine 4-6w

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26
Q

which ethnicity children has more LP

A

Arab

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27
Q

which primary immunodeficiency syndrome As/w LP

A

Good syndrome
- Thymomas + LP risk

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28
Q

Phases of pathogenesis of LP?

A

Induction phase
Evolution phase

  1. Induction phase:
    pathogens or endogenous ligands induce TLR of (keratinocytes and pDc)
    ↓
    release type 1 IFNs (e .g . IFN-α)
    to attract T cells
  2. the evolution phase
    -Attracted effector T cells release cytotoxic granules → perforin and granzyme B → apoptosis of keratinocytes
    - Also Fas/FasL interactions → apoptosis of keratinocytes
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29
Q

Which autoimmune disease has no increased incidence of other autoimmune diseases

A

Lichen Planus

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30
Q

which time of the year LP improves at ?

A

Winter

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31
Q

Genes As/w LP

A

HLA-DR1
HLA-DR6
HLA-DR9

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32
Q

Which HLA gene As/w Hep C in LP

A

HLA-DR6

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33
Q

Variants of LP

A
  1. Acute (exanthematous)
  2. Actinic
  3. Annular
  4. Atrophic
  5. Bullous
  6. Drug induced
  7. Genital
  8. Hypertrophic
  9. Oral
  10. inverse
  11. Linear
  12. Nail
  13. Overlap LP/LE
  14. Palmoplanter
  15. Pemphigoid
  16. Pigmentousus
  17. planopilaris/FFA
  18. Graham-Little-Piccardi-Leusseur
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34
Q

Average latency for drug induced LP?

A

1y

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35
Q

Acute LP resolves within

A

3-9 months

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36
Q

Actinic LP

A
  1. Middle eastern,indians and Africans
  2. Young age
  3. Sun exposed skin
  4. onset in summer/spring
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37
Q

Annular LP

A

Axilla (MC)
Penis (Asymptomatic)

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38
Q

Atrophic LP

A

morphia like on LE

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39
Q

Bullous LP

A

Blister on longstanding LP lesion

due to expanded max-joseph space

40
Q

Drug induced LP characteristics
vs Idiopathic

A
  1. Older Age of onset (10y)
  2. Absence of:
    a- typical cutaneous location
    b- mucosal lesions
    c- Wickham straie
  3. Generalized
  4. Photo distributed
  5. LP/Eczemtous/psoriastic lesions
  6. Path
41
Q

Drug induced LP path findings ?

A

Eosin
Parakeratosis
widespread apoptosis

42
Q

Genital LP

A

Men: annular asym
Female: erosive and painful

43
Q

what is the name of the syndrome of oral-genital LP

A

Vulvovaginal-Gingival syn

44
Q

Which LP variants have higher risk of SCC

A

volvuvaginal
Hypertrophic
Oral erosive

45
Q

Hypertrophic LP

A

LE
Average duration 6y
Eosin in path
risk of KA and SCC

46
Q

Risk factor for hypertrophic LP

A

stasis dermatitis

47
Q

Inverse LP

A

Axilla hyperpigmentation

48
Q

LP variants with axiliary involvement ?

A

Inverse LP
Annular

49
Q

Linear LP

A

Spontaneous no koebner
young adults
likely Somatic Mosaic

50
Q

Oral LP

A
  1. Reticular: MC, Asymptomatic , Bil buccal
  2. Atrophic, Erosive and Bollous: F, painful and SCC+/-GI&genital
  3. Hep C: tongue
  4. Smokers: plaque type
51
Q

Nail LP classic findings

A
  1. Longitudinal ridging
  2. Dorsal pterygium
  3. Fissuring
  4. Lateral thinning

kids may have 20 nail dystrophy

52
Q

LP/LE location

A

Acral Bullae

53
Q

LP pemphigus

A
  1. appears months after LP
  2. uninvolved skin
  3. Circulating IgG against BPAG2
  4. younger age
54
Q

LP pigmentosus

A
  • sun exposed skin
  • maybe after application of photoseitizers (mustard oil)
  • no preceding erythema
55
Q

LP pigmentosus vs EDP

A

only difference on path but:

LP: sun exposed and other LP lesions

EDP: truncal, younger age

56
Q

LPP characteristics

A

perifollicular hyperkeratosis with violacious rim

older female variant FFA

57
Q

features of Graham-Little-Piccardi-Leusseur

A
  1. Scalp scarring alopecia
  2. Axillary and pubic non scarring Alopecia
  3. LP
  4. Spiny follicular papules on skin
58
Q

Systemic tx for Generalized LP

A

MTX
Metronidazole

phototx

59
Q

Rx for resistant LP

A

Acetritin
CsA

60
Q

LPP tx

A

HCQ

61
Q

LP variants with higher likelihood of persistence ?

A

Hypertrophic
oral (especially ulcerative)
nail

62
Q

LP prognosis

A

resolves in 1-2y

63
Q

Variant of LP associated with T cell lymphoma

A

Lichenoid granulomatus dermatitis
triggered by meds

As/w T cell lymphoma , Sarcoidosis and RA

64
Q

How to diagnose Lichenoid granulomatus dermatitis

A

Biopsy showing granuloma
Multinucleated giant cells

65
Q

which group of patient at higher risk for Lichen striatus?

A

Atopic Female kids

66
Q

Can Lichen striatus recur?

A

NO recurrence, ONLY relapse.

67
Q

Prognosis of Lichen striatus

A

Self-limited ~1-2 Yrs
Leaves PIHypopigmentation

68
Q

Nail signs of Lichen striatus

A

Onycholysis, splitting, fraying +/- nail loss.

69
Q

Tx of Lichen striatus including nail?

A

TCS + occlusion
Tacrolimus in nail dystrophy

70
Q

Ddx of Lichen striatus

A

Linear LP
Linear porokeratosis
Linear psoriasis
ILVEN
linear lichen sclerosus
linear Darier
Blaschkitis (Trunk > extremities)
Linear GVHD

71
Q

Conditions As/w Lichen nitidus

A
  1. Down syndrome
  2. Crohn’s
  3. HBV
  4. HIV
  5. AD
72
Q

Distribution of Lichen nitidus

A

flexors arms, chest, abdomen, genitalia & dorsal hands.
Koebner phenomenon

73
Q

DDx Lichen nitidus

A

LP
Guttate lichen sclerosus
Lichen spinulosus
Frictional lichenoid dermatitis
Papular eczema
Verruca plana,
Lichen striatus
Colloid milium
Papular sarcoidosis
Lichenoid 2ry syphilis

74
Q

what is characteristic histopath sign of Lichen nitidus?

A

ball&claw configuration Well-circumscribed lymphocytic infiltrate

parakertosis
Atrophic epidermal cap
Absent granular layer
Eosin

75
Q

Lichen nitidus prognosis?

A

Self-limited ~1-8 Yrs

76
Q

Lichen nitidus Tx?

A

TCS + Ani-Histamines if itchy
Tacrolimus for peds
Generalized → phototherapy
DNCB

77
Q

Variants of Lichen nitidus?

A

Vesicular and hemorrhagic
Generalized
Palmoplantar
Linear
Follicular spines
Perforating
nail
oral

78
Q

Erythema Dyschromicum Perstans associated gene

A

HLA-DR4

79
Q

Erythema Dyschromicum Perstans epidemiology

A

M = F
At 1st - 3rd decade of life
Skin type 4/5

80
Q

Erythema Dyschromicum Perstans As/w

A

? Inhelation, contact or ingestion of pollutants: Ammonium nitrate, benzodiazepines, Pesticides
penicillin, infestations
HIV, whipworm
Thyroid

81
Q

Which lichenoid dermatitis present with oval macules follows cleavage lines ?

A

Erythema Dyschromicum Perstans

(symmetric)

82
Q

Erythema Dyschromicum Perstans histopath

A

Pigment incontinence
lichenoid dermatitis

83
Q

Ddx of Erythema Dyschromicum Perstans

A

PIH from:
Lichenoid drug eruption
PR (△ Epidermal pigment)
Parapsoriasis
FDE (△circular & brown)

84
Q

Erythema Dyschromicum Perstans prognosis and tx

A

? Spontaneous resolution; recur q2–3 Yrs

Resistent to Rx
Sun protection, TCS, retinoids, vitamin C/A, chemical peels, dapsone, antimalarials, Clofazimine, Griseofulvin, SCS, Isotretinoin, TXA

85
Q

Which lichenoid dermatitis has linear & reticulated pattern plaque that resolve in summer?

A

Keratosis Lichenoides Chronica

86
Q

how does Keratosis Lichenoides Chronica present on the face

A

greasy scaly eruption on upper face (seb derm-like or psoriasiform)

87
Q

Annular Lichenoid Dermatitis

A

Over groin & flanks

F = M
Kids + young adults
At 5–22 Yrs

88
Q

Which histopathologic feature of lichen planus corresponds to whickham striae?

A

Hypergranulosis

89
Q

What are 2 trichoscopic features of lichen planus?

A

Perifollicular erythema
Follicular spines (keratotic plugs)
Scarring

90
Q

In which other dermatologic condition can lichen planus-like lesions be seen?

A

Lichen planus-lupus overlap
Lichen planus pemphigoides
Graft-versus-host disease
Lichenoid drug eruption
Paraneoplastic pemphigus

91
Q

What dermatologic conditions cause dorsal pterygium? What are 3 classic conditions that cause ventral pterygium?

A

Dorsal pterygium: lichen planus, graft-versus-host disease, porphyria

Ventral pterygium: systemic scleroderma

92
Q

What are 2 systemic investigations to consider with patients affected by oral erosive lichen planus?

A

Endoscopy
Hepatitis C serology

93
Q

A 52 year-old female patient is assessed for recurrent oral lichen planus. She is also investigated for repeated pneumonias and a recent chest X-ray reveals a mediastinal mass. What is the suspected syndrome?

A

Good’s syndrome: thymoma, oral lichen planus, immunodeficiency

94
Q

How can lichen striatus be differentiated from lichen planus on pathology?

A

Lichen striatus affects adnexal structures.

95
Q

How does the prognosis of erythema dyschromicum perstans differ in children as opposed to adults?

A

Spontaneous resolution is seen in children within 2-3 years
Persistent in adults

96
Q

What are 3 clinical features differentiating lichen planus pigmentosus from erythema dyschromicum perstans?

A

Lichen planus pigmentosus:
Skin types III-IV
4-5th decade of life
Photodistribution or intertriginous
20% co-existence with classic lichen planus

Erythema dyschromicum perstans:
Skin types IV-V, Latin Americans
1-3rd decade of life
Sun protected distribution (trunk, proximal arms) + neck
Uncommon erythematous margins

97
Q

What are 5 clinical features of keratosis lichenoides chronica?

A

Violaceous keratotic lichenoid papules
Linear or reticulated pattern (resembles Chinese characters)

Involves limbs and trunk

Symmetric

Chronic and progressive course;

occasionally lesions regress during summer or with age

Resistant to treatment

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