Lichen sclerosus

Vulvar lichen sclerosus and squamous cell carcinoma: a cohort, case control, and investigational study with historical perspective; implications for chronic inflammation and sclerosis in the development of neoplasia

The histological changes of lichen sclerosus (LS) are frequently found in association with vulvar squamous cell carcinoma (SCC). The importance of chronic inflammation and scarring in oncogenesis is well recognized. Thirty-two patients with symptomatic vulvar LS and 60 with vulvar SCC were studied. Paraffin sections of vulvar LS, and three controls groups (acute scars, normal vulva, and vulvar lichen simplex chronicus [LSC]) were investigated with a panel of seven tissue markers and for DNA content in areas without vulvar intraepithelial neoplasia (VIN). All published cases to date of vulvar LS associated with SCC were reviewed. Of the cohort of symptomatic vulvar LS patients (mean/median age, 60 years), 9% developed VIN lesions and 21% invasive SCC; symptomatic LS preceded the carcinoma by a mean of 4 years (range, 1 to 23 years). Second and third primary tumors developed in three of these patients. Of the series of 60 patients presenting with vulvar SCCa, the clinical setting and histological features of SCCs associated with LS were significantly distinctive compared with SCCas without LS: SCCs associated with LS occurred in an older age-group (74 v 65 years; P = .01), were located on the clitoris (41% v 5%; P = .003), were of conventional SCCa type (85% v 57%; P = .02), were associated with a prominent fibromyxoid stromal response (46% v 10%; P = .004), were not associated with VIN 3 (SCC in situ) (5% v 67%; P = .02) and diffusely expressed tumor suppressor gene product p53 (43% v 19%; P = .01) and cytokine TGF-beta (33% v 9%; P = .05). The epidermis of vulvar LS was similar to that of acute scars and differed significantly compared with normal vulva with respect to keratinocytic expression of markers to keratin AE 1, involucrin and filaggrin, epidermal thickness (0.13 mm [LS] v 0.05 mm [normal]; P < .03), and proliferative index by PCNA and Mib-1 labeling (53/60 [LS] v 15/19 [normal] per 200 basal cells [bc]; P < .003). Vulvar LS showed significantly higher expression of p53 than all three control groups (80 [LS] v 3 [normal]/44 [acute scar]/28 [LSC] per 200 bc; P < .008), and aneuploidy (33% v diploid controls) in the absence of VIN. Comparing LS with and without associated SCCa found significant increases in age of patients (74 v 66 years; P = .001), and DNA aneuploidy (52% v 11%; P = .0001) and no differences in epidermal thickness, sclerotic thickness, proliferative index, or p53 expression. However, those cases of LS with an aneuploid DNA content showed significantly elevated p53 expression (88 v 60/200 bc; P = .01) and epidermal thickness (0.16 v 0.11 mm; P = .005) compared with LS with a diploid DNA content. Review of published cases supports an association between LS and vulvar SCC. The phenomenon of chronic inflammation and scarring giving rise to carcinoma has been well documented. Vulvar lichen sclerosus (LS) is an inflammatory dermatosis characterized by clinicopathologic persistence and hypocellular fibrosis (sclerosis). A subset of vulvar SCCs is significantly associated with the presence of LS and diffusely express the p53 gene product. Keratinocytes affected by LS show a proliferative phenotype and can exhibit markers of neoplastic progression such as increased p53 expression and DNA aneuploidy. As a chronic scarring inflammatory dermatosis, vulvar LS could act as both "initiator and promoter" of carcinogenesis, explaining the frequent coexistence of these diseases. Because keratinocytes of LS significantly express tumor suppressor gene p53 protein, the p53 gene may be involved early in this proposed pathway of carcinogenesis.

Adult skin disease in the pediatric patient

The incidence of many skin diseases peak in adulthood, and these disorders may be difficult to recognize when they do present in childhood. Their clinical features may be distinct in pediatric patients, and they may be managed differently in children as compared to adults. Therefore, it is important that dermatologists are able to identify "adult" skin disease in the pediatric patient, and know how to appropriately manage these problems in young patients. The epidemiology, clinical features, differential diagnosis, and management of the following "adult" skin diseases in children are reviewed: psoriasis, lichen planus, rosacea, Sweet's syndrome, and mucosis fungoides. Distinctive features of lichen sclerosus and immunobullous diseases in childhood will also be briefly discussed.

Lichen sclerosus following the lines of Blaschko

A case of lichen sclerosus that developed in a pattern corresponding to the lines of Blaschko is described. This pattern of extragenital lichen sclerosus has not, to our knowledge, previously been reported and could result from an epidermal clone with altered androgen sensitivity supporting a hormonal pathogenesis for this disease.

Spindle and pseudoglandular squamous cell carcinoma arising in lichen sclerosus of the vulva

An 83-year-old woman presented with a vulval mass. Radical vulvectomy was performed and histology showed a unique mixed picture of spindle, pseudoglandular and classical squamous cell carcinoma arising in vulval lichen sclerosus.

Scleroderma-like disorders

Scleroderma-like disorders are widely disparate conditions mimicking either systemic sclerosis or cutaneous localized scleroderma, not infrequently displaying features of both. Some are exclusively sclerotic, some scleroatrophic with prevailing sclerosis or atrophies. The recognition of scleroderma-like disorders is of practical importance because by establishing the cause of the disease, it is possible to introduce an effective therapy, as in scleredema Buschke or scleredema diabeticorum, sclerodermiform porphyria, Borrelia burgdorferi-induced sclerodermiform acrodermatitis atrophicans, sclerodermiform phenylketonuria, drug-induced conditions, and so on. Scleroderma-like disorders strongly suggest that the pathogenesis of skin sclerosis and internal involvement may be divergent, and of various causes. Some of them, such as atrophoderma Pasini-Pierini or progressive facial hemiatrophy, frequently overlapping with scleroderma, make the differentiation very difficult, if at all possible, and the diagnosis is often arbitrary. Some, as sclerodermiform graft-versus-host reaction, point to the autoimmune origin of scleroderma. The amply-covered congenital sclerodermiform conditions present a large spectrum of still not widely known and extremely heterogeneous syndromes, associated with numerous anomalies and/or malignancies.

Lichen sclerosus et atrophicus of the oral cavity: report of two cases

Lichen sclerosus et atrophicus is a depigmenting mucocutaneous disease most frequently affecting the female genitalia. Genital lesions are symptomatic and may be functionally debilitating. Oral lesions are of little significance other than the esthetic concerns of perioral lesions. In view of the rarity of reported cases, one lesion of the labial mucocutaneous area and a second of the palate are presented along with a description of the disease's clinical and histopathologic findings and a brief review of the literature. The lip lesion was partially resolved with topical corticosteroids and was then fully eliminated with topical testosterone. Histologic verification and examination for the simultaneous occurrence or absence of oral and the more common genital-cutaneous lesions is essential if meaningful information in the medical-dental literature is to be obtained in the future.

A study of clinical and aetiological factors and possible associations of lichen sclerosus in males

Lichen sclerosus is a chronic skin condition with a predilection for the genital area. In the present study, 35 male patients with lichen sclerosus were interviewed and examined. Blood screens were performed and histology was requested if not already performed. The findings indicate that lichen sclerosus in males exists as a spectrum of disease, ranging from a mild form with white plaques and few symptoms to a severe form with inflammation, atrophy and scarring with possible urological consequences. In many areas it differs from the condition in females; the association with autoimmune disease is weaker and there is less perianal and extragenital involvement. The association with malignancy in males is of lesser significance than initially believed.

Dermatoses of the glans penis and prepuce

A wide range of infectious, neoplastic, and inflammatory dermatoses can affect the glans penis or prepuce. Some are unique to the genitalia. Other more common dermatoses may have a unique appearance when they involve genital skin and mucosa. A thorough understanding of regional anatomy and a systematic diagnostic approach are helpful in the management of a refractory penile dermatosis. We review embryology and regional anatomy, drug-induced eruptions, allergic and irritant dermatitis, infection, neoplasia, and traumatic and inflammatory dermatoses as they relate to the glans and prepuce. Our discussion focuses on the clinical features, office laboratory studies, and histopathologic findings that assist in diagnosis and treatment.

Anogenital skin diseases of childhood

Evaluation of anogenital lesions in children is a challenging problem. The differential diagnosis includes a spectrum of traumatic, infectious, neoplastic, and genetic disorders. The possibility of sexual abuse should always be considered and investigated as indicated. A systematic work-up will expedite the correct diagnosis and limit unnecessary anxiety for parents, children, and physicians. Referral to a center that provides specialized service for the evaluation and treatment of these disorders may be indicated.