Lichen planus

Lichen Planus: What is New in Diagnosis and Treatment?

Lichen planus (LP), an idiopathic, multifaceted chronic inflammatory disease with a heterogeneous clinical presentation, affects approximately 0.5-1% of the population. The various clinical manifestations of LP fall into three broad categories, namely cutaneous, appendageal, and mucosal, with further subclassification depending on the morphology and distribution patterns of individual lesions. There is mounting evidence that LP has systemic associations, including autoimmune conditions, glucose intolerance, dyslipidemia, and cardiovascular disorders. Cutaneous hypertrophic and mucosal forms of LP are at a heightened risk for malignant transformation. Familiarity with these potential associations in conjunction with long-term follow-up and regular screening could lead to a timely diagnosis and management of concomitant conditions. In addition, the frequent quality of life (QoL) impairment in LP underscores the need for a comprehensive approach including psychological evaluation and support. Several treatment strategies have been attempted, though most of them have not been adopted in clinical practice because of suboptimal benefit-to-risk ratios or lack of evidence. More recent studies toward pathogenesis-driven treatments have identified Janus kinase inhibitors such as tofacitinib, phosphodiesterase-4 inhibitors such as apremilast, and biologics targeting the interleukin-23/interleukin-17 pathway as novel therapeutic options, resulting in a dramatic change of the treatment landscape of LP. This contemporary review focuses on the diagnosis and management of LP, and places emphasis on more recently described targeted treatment options.

Comparative study of the efficacy of azathioprine, dapsone, and NB-UVB phototherapy as steroid-sparing modalities in generalised lichen planus

Background Generalised lichen planus (GLP) is a chronic disease with an overall prevalence of 1% requiring longer treatment. Limited studies are available on GLP and its treatment in the literature, unlike oral lichen planus. Objective To determine the best steroid-sparing treatment modality for GLP by comparing the efficacy, response, safety, side effects, and remission with azathioprine, dapsone, and narrowband UV-B (NB-UVB) along with their impact on itching severity and life quality. Methodology Open-label, prospective, comparative, interventional study on generalised lichen planus patients treated with systemic steroids along with one of three steroid-sparing modalities. Totally 90 patients were studied including 30 patients each who received azathioprine (Group A), dapsone (Group B), and narrow band UVB (NB-UVB) (Group C), respectively, for 16 weeks. Itch severity index (ISI) and Dermatology life quality Index (DLQI) were assessed at baseline and week 24. All patients received oral prednisolone until there was no more active disease. Response was assessed in terms of occurrence of new lesions, flattening of lesions, post-inflammatory hyperpigmentation (PIH), and grading of lesions two weeks once for 6 months followed by six months of follow-up after treatment completion. Results Females outnumbered males in all 3 groups. Mean patient ages (34, 38, and 34) and the presence of one or more co-morbidities (50%, 42.3%, 37.5%) in Groups A, B, and C, respectively, were comparable. ISI and DLQI improvement at 24 weeks were greatest with NB-UVB, followed by azathioprine and dapsone in that order; the differences in improvement between groups showed high statistical significance. At week 24, occurrence of new lesions (0%, 0%, 3.8%), flattening (100% - all groups), PIH (100% - all groups), grade 3 lesions i.e. poor response, resolution of 20-50% of lesions (7.1%, 11.5%, 0%), grade 2 lesions i.e. partial response, resolution of 50-90% of lesions (35.7%, 76.9%, 8.3%) and grade 1 lesions i.e. complete response, resolution of >90% lesions (57.1%, 11.5%, 91.3%) were noted in Groups A, B and C, respectively; the differences in the extent of resolution of lesions between the groups were highly significant statistically. Remission was seen in 100%, 76.9%, and 87.5% in Groups A, B, and C, respectively, after six months. Limitations The sample size was small. Only 3 treatment options were compared in this study but many more options have been used for lichen planus. Long term follow-up is required. Conclusions NB-UVB with oral steroids showed a better response in terms of improvement in DLQI, ISI, disease control, and side effects than azathioprine and dapsone. Azathioprine showed a faster response and more prolonged remission. Dapsone showed poor response with multiple side effects.

Coexistence of severe peripheral ulcerative keratitis and lichen planus: case report

Introduction and importance

Ocular involvement in lichen planus is highly uncommon, primarily affecting the eyelids, conjunctiva, and less frequently, the cornea. Peripheral ulcerative keratitis (PUK), a rare subtype form of corneal lichen planus, has been reported only once in the literature.

Case presentation

The authors report details of a 34-year-old man with confirmed cutaneous lichen planus who developed severe PUK, a rare ocular manifestation of lichen planus. Despite initial worsening with corticosteroids, successful resolution of PUK was achieved with topical Cyclosporin and azathioprine over 2 months but with a final visual acuity limited to light perception.

Clinical discussion

To the best of our knowledge, very rare cases have been reported of the coexistence of severe PUK and lichen planus. Lichen planus should be considered in any case of PUKs associated with cutaneous-mucosal manifestations cyclosporin and azathioprine are crucial for effective management and favorable outcomes in such cases.

Conclusion

This case aims to show the importance of dermatological examination in the presence of any peripheral ulcerative keratitis. It also sheds light on the therapeutic difficulties and the prognosis of this rare form of ocular lichen planus.

Oral and non-oral lichen planus show genetic heterogeneity and differential risk for autoimmune disease and oral cancer

Lichen planus (LP) is a T-cell-mediated inflammatory disease affecting squamous epithelia in many parts of the body, most often the skin and oral mucosa. Cutaneous LP is usually transient and oral LP (OLP) is most often chronic, so we performed a large-scale genetic and epidemiological study of LP to address whether the oral and non-oral subgroups have shared or distinct underlying pathologies and their overlap with autoimmune disease. Using lifelong records covering diagnoses, procedures, and clinic identity from 473,580 individuals in the FinnGen study, genome-wide association analyses were conducted on carefully constructed subcategories of OLP (n = 3,323) and non-oral LP (n = 4,356) and on the combined group. We identified 15 genome-wide significant associations in FinnGen and an additional 12 when meta-analyzed with UKBB (27 independent associations at 25 distinct genomic locations), most of which are shared between oral and non-oral LP. Many associations coincide with known autoimmune disease loci, consistent with the epidemiologic enrichment of LP with hypothyroidism and other autoimmune diseases. Notably, a third of the FinnGen associations demonstrate significant differences between OLP and non-OLP. We also observed a 13.6-fold risk for tongue cancer and an elevated risk for other oral cancers in OLP, in agreement with earlier reports that connect LP with higher cancer incidence. In addition to a large-scale dissection of LP genetics and comorbidities, our study demonstrates the use of comprehensive, multidimensional health registry data to address outstanding clinical questions and reveal underlying biological mechanisms in common but understudied diseases.

Esophageal Lichen Planus: A Descriptive Multicenter Report

GOALS

To better understand the characteristics, treatment approaches, and outcomes of patients with esophageal lichen planus (ELP).

BACKGROUND

ELP is a rare, often unrecognized and misdiagnosed disorder. Data on this unique patient population are currently limited to small, single-center series.

STUDY

A multicenter, retrospective descriptive study was conducted of adults diagnosed with ELP over a 5-year period, between January 1, 2015, and October 10, 2020, from 7 centers across the United States.

RESULTS

Seventy-eight patients (average age 65 y, 86% female, 90% Caucasian) were included. Over half had at least 1 extraesophageal manifestation. Esophageal strictures (54%) and abnormal mucosa (50%) were frequent endoscopic findings, with the proximal esophagus the most common site of stricture. Approximately 20% had normal endoscopic findings. Topical steroids (64%) and/or proton pump inhibitors (74%) dominated management; endoscopic response favored steroids (43% vs. 29% respectively). Almost half of the patients required switching treatment modalities during the study period. Adjunctive therapies varied significantly between centers.

CONCLUSIONS

Given its at times subtle clinical and endoscopic signs, a high index of suspicion and biopsy will improve ELP diagnosis, especially in those with extraesophageal manifestations. Effective therapies are lacking and vary significantly. Prospective investigations into optimal treatment regimens are necessary.

Oral Baricitinib in the Treatment of Cutaneous Lichen Planus

Background

Cutaneous lichen planus (LP) is a recalcitrant, difficult-to-treat, inflammatory skin disease characterized by pruritic, flat-topped, violaceous papules on the skin. Baricitinib is an oral Janus kinase (JAK) 1/2 inhibitor that interrupts the signaling pathway of interferon (IFN)-γ, a cytokine implicated in the pathogenesis of LP.

Methods

In this phase II trial, twelve patients with cutaneous LP received baricitinib 2 mg daily for 16 weeks, accompanied by in-depth spatial, single-cell, and bulk transcriptomic profiling of pre-and post-treatment samples.

Results

An early and sustained clinical response was seen with 83.3% of patients responsive at week 16. Our molecular data identified a unique, oligoclonal IFN-γ, CD8+, CXCL13+ cytotoxic T-cell population in LP skin and demonstrate a rapid decrease in interferon signature within 2 weeks of treatment, most prominent in the basal layer of the epidermis.

Conclusion

This study demonstrates the efficacy and molecular mechanisms of JAK inhibition in LP. Trial Registration Number : NCT05188521.

Wickham striae on skin appendages: a helpful dermoscopic feature

Lichen planus (LP) is a chronic inflammatory disease, clinically characterized by purpuric, itchy papules that typically spread on the trunk and extremities. Other body sites can also be affected, including mucosal membranes, nails, and the scalp. The use of dermoscopy is essential in determining the diagnosis of LP, as it may highlight pathognomonic features such as Wickham striae (WS). WS are thin, pearly white structures arranged in a reticular pattern that is observed over LP lesions and histologically correspond to epidermal hypergranulosis. WS is usually most visible on the oral mucosa but can also cover almost every active LP papule. Here, we report two cases of biopsy-proven LP that show WS on dermoscopy in two specific sites: the scalp and proximal nail fold.

The Use of Janus Kinase Inhibitors for Lichen Planus: An Evidence-Based Review

BACKGROUND

Lichen Planus (LP) is a dermatological disorder characterized by violaceous papules that affect the cutaneous region, nails, scalp, and mucous membranes. Current molecular and clinical studies point to the Janus Kinase-signal transducer and activator of transcription (JAK-STAT) pathway as a potential effector of LP pathology.

OBJECTIVE

This systematic review summarizes the current reported literature outcomes for patients receiving JAK inhibitors to treat LP.

METHODS

MEDLINE and Embase were searched on 16 October, 2022, and 15 original articles were included, with 56 LP patients.

RESULTS

(mean age: 54.5 years, range: 26-81 years, male: 26.8%). The treatment outcomes were included for the following JAK inhibitors: tofacitinib (n = 30), baricitinib (n = 16), ruxolitinib (n = 12), and upadacitinib (n = 2). Patient outcomes were classified into complete resolution, partial resolution, and no resolution. Patients achieving complete resolution represented 25% (n = 4/16) in the baricitinib group, 10% (n = 3/30) in the tofacitinib group, 16.7% (n = 2/12) in the ruxolitinib group, and 100% (2/2) in the upadacitinib group. Partial resolution patients represented 31.3% (n = 5/16) of baricitinib patients, 60% (n = 18/30) of tofacitinib patients, and 83% (n = 10/12) of ruxolitinib patients. 43.8% (n = 7/16) of baricitinib patients and 10% (n = 9/30) of tofacitinib patients had no resolution of lesions.

CONCLUSION

This review also highlights the significance of utilizing a uniform outcome measure for LP, as it aids in reporting more generalizable results, reduces reporting bias, and ultimately lead to improved clinical outcomes for LP patients.

Unmet Medical Needs in Chronic, Non-communicable Inflammatory Skin Diseases

An estimated 20-25% of the population is affected by chronic, non-communicable inflammatory skin diseases. Chronic skin inflammation has many causes. Among the most frequent chronic inflammatory skin diseases are atopic dermatitis, psoriasis, urticaria, lichen planus, and hidradenitis suppurativa, driven by a complex interplay of genetics and environmental factors. Autoimmunity is another important cause of chronic skin inflammation. The autoimmune response may be mainly T cell driven, such as in alopecia areata or vitiligo, or B cell driven in chronic spontaneous urticaria, pemphigus and pemphigoid diseases. Rare causes of chronic skin inflammation are autoinflammatory diseases, or rheumatic diseases, such as cutaneous lupus erythematosus or dermatomyositis. Whilst we have seen a significant improvement in diagnosis and treatment, several challenges remain. Especially for rarer causes of chronic skin inflammation, early diagnosis is often missed because of low awareness and lack of diagnostics. Systemic immunosuppression is the treatment of choice for almost all of these diseases. Adverse events due to immunosuppression, insufficient therapeutic responses and relapses remain a challenge. For atopic dermatitis and psoriasis, a broad spectrum of innovative treatments has been developed. However, treatment responses cannot be predicted so far. Hence, development of (bio)markers allowing selection of specific medications for individual patients is needed. Given the encouraging developments during the past years, we envision that many of these challenges in the diagnosis and treatment of chronic inflammatory skin diseases will be thoroughly addressed in the future.

The genomic and proteomic landscape in oral lichen planus versus oral squamous cell carcinoma: a scoping review

BACKGROUND

Oral lichen planus (OLP), a World Health Organization (WHO)-classified oral potentially malignant condition, confers a 1% risk of transformation to oral squamous cell carcinoma (OSCC). There does not appear to be a consensus understanding of the underlying molecular events. This scoping review aimed to identify critical molecular pathways and highlight gaps in existing knowledge on malignant transformation in OLP.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines, a comprehensive literature search and methodical screening identified 61 relevant studies detailing molecular differences between OLP and OSCC.

RESULTS

Molecular changes shared between OLP and OSCC included those affecting cellular proliferation (altered p53 expression, hypermethylation of p16/CDKN2A, MYC gains, increased ki-67), apoptosis (increased bcl-2 and survivin expression), extracellular matrix (ECM) remodeling (increased matrix metalloproteinase [MMP] expression), and transcriptional control (altered bmi1 and microRNA [miRNA] expression). In addition, some molecular alterations accumulated incrementally from control to OLP to OSCC or were present in higher-risk erosive variants of OLP or transformed OLP. Few studies included rigorous diagnostic inclusion criteria or unbiased discovery methods.

CONCLUSIONS

Results of this review support the potentially malignant nature of OLP and imply that molecular events associated with malignant transformation may be heterogeneous. In addition, findings in this review highlight the need for additional studies using rigorous diagnostic inclusion criteria and unbiased discovery methods to further understand this process.

Nail lichen planus: A review of clinical presentation, diagnosis and therapy

Lichen planus is a multifaceted disease of complex etiopathogenesis. Nails are involved in up to 10% of patients with lichen planus. Although most cases are mild, serious consequences may occur due to rapid progression of the disease, the high risk of scarring, and the resulting irreversible damage to the nail structure. Permanent damage of at least one nail occurs in approximately 4-12% of patients with nail lichen planus. In this narrative review, we emphasize the pathophysiology of nail lichen planus, the emergent nature of the disease, and the spectrum of different clinical manifestations. Diagnosis of nail disease in general, and of nail lichen planus in particular, is rapidly evolving. This review provides a comprehensive account of the non-invasive and invasive diagnostic techniques and treatment options reported in the literature, with emphasis on the efficacy and safety of the drugs used, the associated evidence, and the factors to be taken into account in planning and providing adequate treatment. The role of aesthetic and camouflage options is also summarized.

Anatomically distinct fibroblast subsets determine skin autoimmune patterns

The skin serves as a physical barrier and an immunological interface that protects the body from the external environment^1-3. Aberrant activation of immune cells can induce common skin autoimmune diseases such as vitiligo, which are often characterized by bilateral symmetric lesions in certain anatomic regions of the body^4-6. Understanding what orchestrates the activities of cutaneous immune cells at an organ level is necessary for the treatment of autoimmune diseases. Here we identify subsets of dermal fibroblasts that are responsible for driving patterned autoimmune activity, by using a robust mouse model of vitiligo that is based on the activation of endogenous auto-reactive CD8⁺ T cells that target epidermal melanocytes. Using a combination of single-cell analysis of skin samples from patients with vitiligo, cell-type-specific genetic knockouts and engraftment experiments, we find that among multiple interferon-γ (IFNγ)-responsive cell types in vitiligo-affected skin, dermal fibroblasts are uniquely required to recruit and activate CD8⁺ cytotoxic T cells through secreted chemokines. Anatomically distinct human dermal fibroblasts exhibit intrinsic differences in the expression of chemokines in response to IFNγ. In mouse models of vitiligo, regional IFNγ-resistant fibroblasts determine the autoimmune pattern of depigmentation in the skin. Our study identifies anatomically distinct fibroblasts with permissive or repressive IFNγ responses as the key determinant of body-level patterns of lesions in vitiligo, and highlights mesenchymal subpopulations as therapeutic targets for treating autoimmune diseases.

Lichen Planus

Lichen planus (LP) is a T cell-mediated disease affecting the stratified squamous epithelia of the skin and/or mucus membrane. Histologically, the disease is characterized by a lichenoid inflammatory infiltrate and vacuolar degeneration of the basal layer of the epidermis. LP has three major subtypes: Cutaneous, mucosal and appendageal LP. Rarely, it may affect the nails in the absence of skin and/or mucosal changes. LP may also be induced by several drugs, typically anti-hypertensive medication or be associated with infections, particularly viral hepatitis. The diagnosis is based on the clinical presentation and characteristic histological findings. Although the disease is often self-limiting, the intractable pruritus and painful mucosal erosions result in significant morbidity. The current first-line treatment are topical and/or systemic corticosteroids. In addition, immunosuppressants may be used as corticosteroid-sparing agents. These, however are often not sufficient to control disease. Janus kinase inhibitors and biologics (anti-IL-12/23, anti-IL17) have emerged as novel future treatment options. Thus, one may expect a dramatic change of the treatment landscape of LP in the near future.

Plantar Lichen Planus: An Atypical Presentation at a Young Age

Lichen planus is a chronic lichenoid dermatosis commonly encountered by dermatologists worldwide, affecting skin, mucosa, and scalp. The current case describes a rare variant of lichen planus, plantar lichen planus, in a 17-year-old male who presented with erythematous scaly plaques on the sole for two years associated with walking discomfort. The lesion was subjected to skin biopsy and a diagnosis of lichen planus was made considering the histopathological and clinical findings. Plantar lichen planus can often be misdiagnosed. Treating plantar lichen planus can be a therapeutic challenge and, thus, more insight is needed regarding treatment protocol or outcome of such cases.

Pediatric lichen planus: a systematic review of 985 published cases

BACKGROUND

Lichen planus (LP) is a chronic inflammatory disorder usually occurring in middle-aged adults. Data are scarce in the pediatric population.

OBJECTIVE

To describe the patients' characteristics, clinical presentation, and management of pediatric LP.

METHODS

A systematic literature review of pediatric LP was performed in the Medline and Cochrane databases up to February 1, 2020. Demographic and clinical data were extracted for analysis, in addition to laboratory and histology findings, treatments used, and response to treatment. LP pemphigoides (LPP) was further pooled for a subcategory analysis.

RESULTS

One hundred and sixty-four articles were included representing 985 patients. The most common country of origin was India. The most common clinical signs were flat-topped papules (51%); the linear variant was present in 9%. Oral involvement was present in 22%. The most commonly used treatment was topical corticosteroids followed by systemic corticosteroids. The mean duration of treatment was 124.4 days. LPP patients had a short disease duration before diagnosis (4.1 months, P < 0.001) and failed previous treatment more frequently (P < 0.001). Systemic corticosteroids were more often prescribed in this subgroup (75%, P < 0.001) with more recurrence after treatment (31%, P = 0.048).

LIMITATIONS

Lack of randomized controlled studies, in addition to publication bias.

CONCLUSION

In children, LP had a wide polymorphous clinical presentation, and the reported cases were mostly from India. The linear variant was more common and the oral mucosa was less affected in children. LPP, a rare subtype in children, was treated with systemic corticosteroids and recurred more frequently.

Lichen planus - a clinical guide

Lichen planus (LP) is a chronic lichenoid inflammatory disorder of the skin, mucosa and of the appendages. LP is classically characterized by the presence of a rich infiltration of inflammatory T cells, which migrate in the upper part of the dermis, arranged in a band-like pattern. Different sub types of the disease have been so far described. Albeit LP is clinically well defined, the disease still represents a therapeutic enigma. Especially with regard to mucosal or scalp affecting LP types, which often present a recalcitrant and treatment unresponsive course, efficacious therapeutic options are still lacking. Thus, LP represents a disease with a high psychosocial burden. Yet, development in the deciphering of LP pathogenesis reveals possible new druggable targets, thus paving the way for future therapeutic options. In this clinical guide, we summarize the current clinical knowledge and therapeutic standards and discuss the future perspective for the management of LP.

Evaluation of inner ear and hearing functions in lichen planus patients

BACKGROUND

Lichen planus (LP), which affects skin, nails, hair, and mucosal surfaces, is a chronic, autoimmune, and inflammatory disease, and autoimmune diseases may affect the inner ear.

AIMS

This study aims to investigate hearing and inner ear functions of the LP patients.

PATIENTS/METHODS

The present study was formed by 49 patients who were clinically and histopathologically diagnosed with LP and did not receive any treatment. The healthy group consisted of 52 healthy individuals. Pure tone audiometry (PTA) and distortion product otoacoustic emission tests were used in the hearing evaluation.

RESULTS

At frequencies of 1, 2, 4, 6, and 8 kHz in the right ear and 0.5, 1, 2, 4, 6, and 8 kHz in the left ear in PTA, the lichen group's hearing thresholds were higher than the healthy group's. Upon comparing the hearing thresholds of LP patients with oral mucosa involvement and LP patients without oral mucosa involvement, there were significant differences between the groups at 1, 4, and 8 kHz in the right ear and at 0.25, 0.5, 2, 4, 6, and 8 kHz in the left ear.

CONCLUSION

Because of the increasing hearing thresholds, we think that hearing and inner ear functions of LP patients, particularly with oral mucosal involvement, are negatively affected.

Successful systemic treatment outcomes of lichen planus: A single-center retrospective review

Lichen planus (LP) affects up to 4% of adults and can cause significant distress and morbidity, especially to those with persistent disease. As many as 20% of patients with LP may exhibit widespread or recalcitrant disease necessitating systemic treatment options. We sought to evaluate the effectiveness of systemic treatments for severe and recalcitrant LP not responsive to topical corticosteroids or calcineurin inhibitors. Over a 10-year period, 374 patients with cutaneous and mucosal LP were evaluated at a major regional tertiary medical center; 94 qualified for inclusion in the study. In all, 26 (28%) patients achieved remission, 52 (55%) experienced stable disease control, and 16 (17%) failed all attempted treatments. Among medications most trialed, intramuscular triamcinolone (IM TAC), hydroxychloroquine, and methotrexate were most successful with 79%, 61%, and 42% respective response rates. In contrast, oral corticosteroids and dapsone were less frequently successful at rates of 24% and 20%. IM TAC represented the highest level of treatment success and was statistically significant compared to other systemic treatments (P < .01). Among adjuvant therapies, intralesional triamcinolone (IL TAC) demonstrated higher success (71%) than oral corticosteroids (29%). Based on this multi-year evaluation, we recommend that clinicians consider IM TAC as a first-line systemic option for severe or refractory LP, with hydroxychloroquine as the steroid-sparing treatment of choice. For patients requiring adjuvant therapy, IL TAC should be considered to hasten response and symptom relief. Patients with severe or widespread disease may benefit from earlier initiation of systemic therapy to prevent significant morbidity and impact on daily function.

Novel and rare forms of oesophagitis

Our understanding of inflammatory diseases of the gastrointestinal tract, including those of the oesophagus, has expanded in recent years. Once attributed almost exclusively to gastro-oesophageal reflux disease or infection, it is now recognised that oesophagitis may occur due to a variety of distinct disease entities. Many of these conditions cause debilitating and persistent symptoms, impacting upon quality of life and necessitating ongoing surveillance and treatment. This review will consider the clinical, endoscopic and histopathological features of these novel and rare forms of oesophagitis.

Induction of High Endothelial Venule-like Vessels in Oral and Cutaneous Lichen Planus: A Comparative Study

Lichen planus (LP) is a chronic inflammatory mucocutaneous disease involving the oral mucosa and skin. Both oral LP (OLP) and cutaneous LP (CLP) are histopathologically characterized by dense subepithelial lymphocyte infiltrates; however, the mechanisms underlying lymphocyte recruitment to sites of LP lesions are not fully understood. Here, we assessed the induction of peripheral lymph node addressin (PNAd)-expressing high endothelial venule (HEV)-like vessels in 19 OLP and 17 CLP cases. To do so, we performed immunohistochemical staining for PNAd and CD34, followed by quantitative analysis. We also conducted triple immunohistochemistry for PNAd and either CD3 and CD20 or CD4 and CD8 to identify the lymphocyte subset preferentially recruited via HEV-like vessels. PNAd-expressing HEV-like vessels were induced in and around lymphocyte aggregates in all cases of OLP and in 10 of 17 CLP cases, and these vessels were more frequently observed in OLP relative to CLP. Although the number of T-cells attached per HEV-like vessel exceeded the number of B-cells in both OLP and CLP, the number of CD4⁺ T-cells attached was greater than the number of CD8⁺ T-cells only in OLP. These findings combined suggest that PNAd-expressing HEV-like vessels play a more important role in the pathogenesis of OLP compared with CLP.

Dermatologic sequelae of breast cancer: From disease, surgery, and radiation

The care of breast cancer patients is important to dermatologists. Breast cancer's initial presentation, clinical progression, and its associated treatments can result in a variety of cutaneous complications. Dermatologists may be the first to identify a breast cancer diagnosis, as a subset of patients first present with direct extension of an underlying tumor or with a cutaneous metastasis. The surgical treatment of breast cancer also begets a variety of skin sequelae, including postoperative lymphedema, soft tissue infections, seromas, pyoderma gangrenosum, and scarring disorders. Moreover, breast cancer radiation treatment commonly results in skin changes, which can range from mild and temporary dermatoses to chronic and disfiguring skin ulceration, fibrosis, and necrosis. Radiation may also precipitate secondary malignancies, such as angiosarcoma, as well as rarer dermatologic diseases, such as radiation-induced morphea, lichen planus, and postirradiation pseudosclerodermatous panniculitis. Finally, breast cancer is also associated with an array of paraneoplastic phenomena, including Sweet's syndrome and the rarer intralymphatic histiocytosis. Herein, we review the dermatological manifestations of breast cancer, including conditions associated with its presentation, progression, and treatment sequelae. Chemotherapy-induced cutaneous side effects are beyond the scope of this review. This article provides a comprehensive review for dermatologist to be able to identify, diagnose, and manage breast cancer patients from initial presentation to treatment monitoring and subsequent follow-up.

[Squamous cell carcinoma arising in oral lichen planus : Report of two cases]

Beim Lichen planus handelt es sich vermutlich um eine chronisch inflammatorische, immunologisch induzierte mukokutane Dermatose. Der Lichen planus mucosae manifestiert sich am häufigsten in der Mundhöhle. Diverse Triggerfaktoren wie bakterielle oder virale Infektionen, Medikamente oder physikalische Reize werden bei der Entstehung der Erkrankung diskutiert. Auch eine Assoziation mit Infektionen durch humane Papillomviren wurde beschrieben, ein kausaler Zusammenhang ist jedoch nicht hinreichend belegt. Als fakultative Präkanzerose kann sich auf dem Boden eines Lichen planus mucosae ein Plattenepithelkarzinom entwickeln, die maligne Transformationsrate ist aber gering. Das Risiko der malignen Transformation ist signifikant erhöht bei Patienten mit oralem Lichen planus, die rauchen, vermehrt Alkohol konsumieren oder an Hepatitis C erkrankt sind. Wir beschreiben 2 Patienten, bei denen sich lokal fortgeschrittene Plattenepithelkarzinome auf dem Boden eines langjährig bestehenden oralen Lichen planus entwickelten. Beide Fälle wurden erfolgreich durch radikale Tumorresektion mit anschließender Rekonstruktion und adjuvanter Radiatio/Radiochemotherapie behandelt.

Lichen planus of the external auditory canal: Treatment options and review of literature

Medical topic therapies can relieve symptoms associated with lichen planus of external auditory canal. Further, bone‐anchored hearing devices represent an optimal solution for hearing restoration in otic lichen planus.

Epidemiologic and Clinical Differences Between Classic and Hypertrophic Lichen Planus in Nigeria

Introduction. Lichen planus is a chronic inflammatory skin disease known to have several clinical variants with attended variable clinical outcomes. Certain complications have been observed in the hypertrophic type, which were not found in association with the classic variant.

Objective: To identify the epidemiologic and clinical differences between the classic and hypertrophic lichen planus and clinical correlates.

Material and Methods. Of 104 participants with lichen planus included in the study, 49 had classic and 55 hypertrophic lichen planus. Demographic and clinical information was obtained. Diagnosis of lichen planus was made clinically and confirmed with histology. The participants were screened for metabolic syndrome, hepatitis B, and C.

Results: Mean age of all patients was 37.20±13.39 years, with no age and gender differences between the participants with classic and hypertrophic lichen planus. Classic lichen planus was more likely to be painful, (8.2% vs 0.0, p=0.046), generalized (95.9% vs 16.4%, p<0.001), involve the oral mucosa (38.8% vs 0.0, p<0.001), the nails (38.8% vs 1.8, p<0.001), present with kobnerisation (55.1% vs 5.5%,<0.001), Wickhiam striae (69.4% vs 16.4%, p<0.001), associated with Hepatitis B vaccination (16.3% vs 3.6%, p<0.028) and anti HCV positivity (16.3% vs 0.0%, p=0.002). Hypertrophic lichen planus was significantly associated with impaired glucose tolerance/diabetes mellitus (16.4% vs 2.0%, p=0.013), dyslipidemia (74.5% vs 40.8%, p=0.001) and saw-tooth histologic appearance compared to classic type.

Conclusion: Hypertrophic lichen planus is more likely to be associated with metabolic complications compared to the classic type. Further studies are needed to loink this difference t chronic inflamation.

Miscellaneous Perianal Afflictions

This article provides an overview of hidradenitis suppurativa, lichen planus, lichen sclerosis, calcinosis cuti, pyogenic granuloma, intertrigo, and seborrheic keratosis. This article also focuses on recognition and management of these pleomorphic afflictions of the perianal region.

Serotonin Expression in Lichen Planus Lesions and Its Relationship with Depression/Anxiety

Background

Psychological factors such as stress, depression, and anxiety have been documented to contribute to the development of lesions in lichen planus (LP).

Objective

To evaluate the relationship between serotonin expression in LP lesions and depression/anxiety.

Methods

Forty patients (22 females, 18 males) with LP and 20 healthy control subjects were included in this study. The severity of LP was assessed with the palmar method (using the measurement of affected body surface area [BSA]). The depression and anxiety scores were measured with Beck's depression inventory (BDI) and Beck's anxiety inventory (BAI). The expression of serotonin was determined via immunohistochemistry in LP lesions and in the control group skin using a monoclonal antibody to serotonin.

Results

The skin biopsies of the LP patients had significantly higher levels of serotonin than those of the control subjects (p<0.001). In the LP patients, and there was a positive correlation between serotonin expression and LP severity (p=0.022). Based on the results from the BDI and BAI, there was a significant relationship between the severity of depression/anxiety and intensity of serotonin expression (p<0.001).

Conclusion

Data from this study suggest that serotonin may have a possible role in the pathogenesis of LP. Further, the relationship between serotonin expression in acute cutaneous lesions and the depression/anxiety scores indicates that serotonin may be a mediator for the association of LP and depression/anxiety simultaneously. There is a need for more specific studies showing the expression of serotonin in the lichen planus to demonstrate the cause or effect.

Hypertrophic recurring lichen planus of the external auditory canal

INTRODUCTION

We report a case of unilateral progressive primary hypertrophic lichen planus of the external auditory canal requiring several surgical interventions to deal with constant pruritus, otorrhoea, stenosis and conductive hearing loss.

CASE SUMMARY

A 58-year-old woman was initially treated with meatoplasty for suspected chronic obliterating otitis externa. She remained symptom-free for 5 years, before the disease recurred, affecting other body surfaces as well. Otorrhoea, conductive hearing loss and pruritus worsened, and a canal wall down tympanomastoidectomy was performed, removing the skin of the external auditory canal and the tympanic membrane completely. Lichen planus was confirmed histopathologically.

DISCUSSION

Very few surgical results have been published on stenosis of the external auditory canal caused by lichen planus. Complete medial external auditory canal skin elevation and removal with postoperative split-skin grafting is advised for initial treatment. We discuss treatment options and surgical outcome after initial surgical failure.

Lichen planus: altered AIM2 and NLRP1 expression in skin lesions and defective activation in peripheral blood mononuclear cells

BACKGROUND

Lichen planus (LP) is an inflammatory skin disease with unknown aetiology. Activation by pathogen-associated molecular patterns or environmental stimuli may activate some components of inflammasomes that contribute to the inflammatory process in LP lesions.

AIM

To characterize the inflammasomes in skin lesions and peripheral blood mononuclear cells (PBMCs) of patients with LP under Toll-like receptor (TLR) activation.

METHODS

In total, 15 patients with LP and 14 healthy controls (HCs) were enrolled in the study. Inflammasome expression in skin was evaluated by real-time PCR and immunohistochemistry, while ELISA was used to assess the production of interleukin (IL)-1β by PBMCs under stimulation with TLR4 and TLR7/TLR8 agonists and adenosine triphosphate (ATP).

RESULTS

Compared with the levels in HC samples, increased expression of the inflammasome AIM2 was verified in both epidermal and dermal sections of LP skin lesions, whereas NLRP1 and IL-β expression levels were enhanced in the dermis. LP skin lesion samples exhibited higher AIM2 transcript levels, similar NLRP1 levels and lower pro-IL-1β mRNA levels compared with HC samples. We verified that, compared with PBMCs from HC subjects, PBMCs from patients with LP produced similar amounts of IL-1β after induction by TLR4 agonists but lower IL-1β levels after induction by TLR7/TLR8 agonists, regardless of the addition of ATP.

CONCLUSION

Alterations in innate immunity, such as inflammasome component expression in skin lesions and PBMCs, were observed in patients with LP. Further investigations of dysfunctional inflammasome activation and the chronic inflammatory status of LP are required.

Immune Privilege Collapse and Alopecia Development: Is Stress a Factor

Hair is a defining mammalian feature that serves as a hallmark of human communication. Given the critical significance of hair in social, religious, and political contexts, it is important to understand factors that play a role in hair loss disorders. The hair follicle is an immune privileged site, and mounting evidence suggests that the collapse of immune privilege contributes to the pathogenesis of autoimmune hair loss disorders, including alopecia areata and lichen planopilaris. This review comprehensively appraises the current literature to shed light on mechanisms for immune privilege collapse, and examines the role of neurogenic stress in triggering this process.

The Measurement of Serum Tumor Necrosis Factor-alpha Levels in Patients with Lichen Planus

Background:

Lichen planus is a common mucocutaneous inflammatory skin disease with a multifactorial etiology. Cytokines have a key role in its pathogenesis. In our study, we aimed to investigate the relationship between the disease severity and levels of the tumor necrosis factor alpha (TNF-α) cytokine which was considered as a primary cytokine that initiates the cytotoxicity.

Materials and Methods:

A total of 34 patients with lichen planus who were 18 year or older and gender-matched healthy controls were included in the study. Serum TNF-α levels were measured by human TNF-α enzyme-linked immunosorbent assay test kits and the values in the two groups were statistically compared.

Results:

The mean serum TNF-α levels were higher in the patient group than that in the control group. Serum TNF-α levels were not associated with oral mucosal involvement and gender. However, it was observed that the level of TNF-α was higher in older ages, both in patient and in control groups.

Conclusion:

It is thought that TNF-α, a proinflammatory cytokine, may have an important role in the pathogenesis of lichen planus.

Up-regulation of HMGB1 and TLR4 in skin lesions of lichen planus

Lichen planus (LP) is a chronic, mucocutaneous inflammatory disease of an unknown aetiology. The disease has been associated with certain viruses, and the factors such as DAMPs (damage-associated molecular patterns) and PAMPs (pathogen-associated molecular patterns) may also contribute to the inflammatory response in LP. HMGB1 (high mobility group box 1 protein) is one of the major DAMPs that induces inflammation and could trigger LP disease. The present study was aimed to examine TLR4, RAGE and HMGB1 production in epidermis or dermis by immunohistochemistry and the respective expression of these targets in the skin lesions of patients with LP. Moreover, we measured HMGB1 serum levels by ELISA. The results showed similar profile of expression by HMGB1 and TLR4, which are decreased at epidermis and up-regulated at dermis of skin lesions of LP patients that was sustained by intense cellular infiltration. RAGE expression was also increased in dermis of LP. Although there is increased RAGE protein levels, a decreased RAGE transcript levels was detected. Similar HMGB1 serum levels were detected in the LP and control groups. This study demonstrates that HMGB1 and TLR4 could contribute to the inflammatory LP process in skin.

Case Report: Dermoscopic features of oral lichen planus - the evolution of mucoscopy

Dermoscopy, a non-invasive technique for cutaneous diagnosis is being increasingly studied in various disorders of the skin, nails and scalp. However, it has been under-utilized for the diagnosis and characterization of mucosal disorders. The dermoscopic characterization of cutaneous lichen planus and its variants has been well documented with Wickham’s striae constituting the hallmark of the condition. However, the dermoscopic features of oral lichen planus with hand-held or videodermoscopy remain to be elucidated. We present the case of a young adult man who presented with asymptomatic white lacy lesions over a bluish-black background over the tongue, patchy hyperpigmentation of the buccal mucosae and gingivae, and longitudinal melanonychia involving some nails. History of intake of any drugs preceding the lesions, smoking, chewing of betel nut and dental implants was negative. Family history was non-contributory. There were no cutaneous lesions suggestive of lichen planus. Mucoscopy (dermoscopy of the mucosa, oral in this case) and onychoscopy were done followed by biopsy from the tongue that confirmed the diagnosis of lichen planus. Oral mucoscopy of the tongue revealed a tri-colored pattern with structureless veil-like grey-white areas (modified Wickham’s striae), well-demarcated red glossy erosions, and violaceous-to-brown clods. Additionally, vascular pattern of dotted and linear to curved vessels along the borders of leukoplakia-like areas and erosions were observed. Onychoscopy confirmed lichen planus-associated melanonychia. Dermoscopy also proved useful in conveniently ruling out other disorders typified by mucosal and nail pigmentation such as Laugier Hunziker syndrome and drug-induced changes. Although direct oral microscopy has been used in defining features of oral lichen planus, to the best of our knowledge this case is the first report on mucoscopy or dermoscopy of oral lichen planus