Lichen planus etc. Flashcards
Histologic findings of lichen planus
orthohyperkeratosis
Wedge-shaped hypergranulosis
Irregular acanthosis w/ saw tooth rete ridges
vacuoles in basal layer (d/t apoptosis)
Band-like lymphocytic infiltrate
vacuoles in basal layer extending or “falling” into superficial dermis (civatte bodies/ cytoid or colloid bodies)
Epidemiology (age, m vs f, race) of LP
Most common onset in 5th/ 6th decade
2/3 of pt’s get 30-60yo
women > M in some studies
mucosal involvement seen in up to 75% of cutaneous LP pt’s
10-20% of pts who only present with oral LP develop cutaneous LP
cutaneous LP affects 1% of adults
mucosal LP affects up to 4% of adults
Basic LP pathogenesis (model)
various triggers (viral, contact allergen, drug, idiopathic) -> basal keratinocytes express Ag -> T cells target Ag -> lower level basal keratinocytes begin to apoptose
Which hepatitis is implicated in which type of LP?
Hep C
Oral ulcerative/ erosive LP
Which contact allergens are a/w LP?
mercury amalgam, copper, gold all a/w oral LP
Which drugs a/w LP?
HCTZS
BBlockers
ACE inhibitors
antimalarials
TNF-alpha inhibitors
NSAIDS
penicillamine
Koebnerization in LP?
VERY common
How does hypertrophic and drug induced LP look differently than regular LP (histo)
has eosinophils
Lacks parakeratosis
How do EM, FDE, SJS/TEN differ from LP histologically?
EM, FDE, SJS/TEN all have SUPRAbasiar apoptotic keratinocytes
LP has basilar apoptotic keratinocytes
Treatment for LP?
RULE OUT DRUG ERUPTION LP - take a good drug history
These drug LP eruptions may persist for MONTHS after starting therapy and after drug discontinuation!
First line actual Tx for LP
topical steroids/ intralesional steroids
can use systemic roids for severe LP eruption
Treatment ladder AFTER steroids for LP
TCI’s: best for oral lichen planus (tacrolimus )
MTX: useful for generalized LP
Acitretin: effective in Recalcitrant LP
Metronidazole!!!: Generalized LP
Hydroxychloroquine: mainly for Alopecia/ LPP
Oral cyclosporine: Recalcitrant cases
Phototherapy
Prognosis of LP?
Most cases (60%) resolve in 1 -2 years
Oral (ulcerative), hypertrophic and nail LP tend to last ____
chronic disease
**Increased SCC risk in hypertrophic, oral and vulvovaginal LP
What clinical feature is associated with the “Wedge-shape” hypergranulosis seen histologically?
Wickhams striae
Make sure to ask oral LP patients about _____ AND examine for other lesions where?
Esophageal symptoms (SCC can develop) vulvovaginal lesions - genital exam!
Which variant of LP?
Lichen planus actinicus
Worldwide (most in Middle Eastern & Indian patients), young adults & children
Sun-exposed sites: forehead, face, neck, dorsal arms/hands in spring/summer
Red-brown annular plaques or melasma-like appearance
Which variation of LP is seen?
Annular
Which variation of LP?
Acute exanthematous/ eruptive LP
which version of LP?
Atrophic
Which variation of LP?
What would histology and DIF findings be ?
What pathological basis is this similar to?
LP Pemphigoides
Histo and DIF similar to BP
IgG Ab’s against BP180 (BPAG2)
Which variation of LP?
What secondary risks are associated with this variation of LP?
Hypertrophic LP
SCC’s (Keratoacanthoma also)
Which variation of LP?
Inverse LP
pink violaceous papules and plaques in axillae/ inguinal/ inframammary folds
Which variation of LP?
LP Pigmentosus
brown gray-brown macules / patches on sun-exposed areas of face/neck/flexures/ intertriginous zones (LP Pigmentosus inversus)
No inflammatory phase - no erythema
Skin types 3-4
Which variation of LP?
Lichen planopilaris (LPP)
Perifollicular hyperkeratosis, erythema, scale, “Follicular convergence or Doll’s hairs”
What type of hair loss?
Frontal fibrosing alopecia
progressive frontotemporal recession, lateral eybrow loss, post-menopausal women
treat with 5alpha reductase inhibitors (finasteride)
What is graham-little-piccardi syndrome?
Multifocal scarring alopecia on scalp
nonscarring alopecia of axilla and groin
disseminated spiny follicular papules
plus cutaneous OR mucosal LP
Describe this
NAIL LP
lateral thinning, longitudinal ridging/ fissuring
Dorsal pterygium
Lichen striatus vs. linear LP
Lichen striatus seen in ____, whereas linear LP is seen in
Difference in residual after treatment: LS leaves ____pigmented spots, Linear LP leaves ___pigmented spots
LS seen in kids, usually affects extremity
linear LP see in adults
LS leaves hypopigmented spots, linear LP (most all types of LP) leave hyperpigmented spots
Both dist. along lines of Blaschkoid
Describe lesions seen and talk about differential How long does this last? Does it itch?
This is Lichen nitidus, DDx includes lichen sclerosus, lichen spinulosis, lichen planus, papular eczema (KP)
Describe: numerous discrete, skin-colored uniform, pinhead-sized flat papules with shiny surface distributed on on flexor aspects of arms, chest, abd, genitals, dorsal hands
May itch, likely resolved within 1-2 years
What is this diagnosis?
Ddx of this?
Erythema dyschromicum perstans
Gray-brown patches on trunk/ prox arm, follows skin tension lines
exclusively seen in skin type 3 or 4
asymptomatic slate-gray-brown ovaloid macules and patches, progresses slowly +/- rim of erythema, usually symmetric/ follows skin cleavage lines
Pathology: multiple dermal melanophages
treatment:? Clofazamine
What is disease
talk about epidemiology
Actinic lichen Nitidus
aka summertime actinic lichenoid eruption
young adults, skin types 4/5
affects after prolonged sun
Does lichen nitidus koebnerize?
How about lichen planus?
what is this
Benign lichenoid kerasosis (BLK)
Difference between bullous LP and LP pemphigoides?
bullous LP affects older adults, blisters form AT PREVIOUS sites of LP
LP pemphigoides pt’s have BPAG2 (BP180) autoantibodies, like idiopathic BP
bulla arise anywhere on the body in LP pemphigoides and happens at a younger age typically
“Classic locations of LP”
Wrists, flexor forearms, presacral area, lower legs, genitals
What is seen
Lichen striatus – histopathologic features.
In addition to hyperkeratosis with focal parakeratosis, both a lichenoid and a perivascular and periadnexal lymphocytic infiltrate extending into the deeper dermis is seen.
you should see the*** ***bandlike lichenoid infiltrate, with eccrine gland inflammation
_You should also see lichenoid/ perivascular and_ periadnexal lymphocytic infiltrate extending into deep dermis
What is seen histologically
Lichen nitidus – histopathologic features.
Note the typical “ball and claw” configuration for the infiltrate and epidermis, respectively. There is thinning of the epidermis that overlies the infiltrate. Several Langhans giant cells are within the infiltrate (inset).
A discrete interstitial aggregate of mononuclear cells expands one dermal papilla to form the typical lesion of LN. This expansion causes adjacent rete ridges to bow outward and this creats the collarette of inflammatory cells (ball n claw)
there is epidermal thinning overlying the colarette, there is basal cell vacuoles, rarely necrotic keratinocytes, parakeratosis overlying the epidermal thinning
Histological differences between LP and drug induced LP
In drug eruption LP → Parakeratosis, NORMAL granular layer, eosinophils, perivascular AND / OR bandlike lymphocytic infiltrate+ plasma cells within infiltrate
Both conditions show (civatte bodies, wedge shaped hypergranulosis and hyperkeratosis) but only drug eruption will have eos
Lichen planus leaves behind ____pigmented spots
Lichen Striatus leaves behind ____ pigmented spot
LP → hyperpigmented
L Striatus → hypopigmented, CAN involve nail, think eccrine gland inflammation
