Isolated lichen planus of the nails associated with primary biliary cirrhosis

Long-term impact of certain coexisting extrahepatic unisystem and multisystem manifestations on trends in incidence of liver cirrhosis in treatment-naïve patients with chronic hepatitis C: A nested case-control study

Diabetes mellitus (DM) was found to be more common in hepatitis C virus (HCV)-related cirrhotic males. However, the association between DM, or other extrahepatic manifestations (EHMs), and liver cirrhosis is still undetermined. We used a large-scale long-term study to analyze the cirrhosis risk of treatment-naïve HCV patients with EHMs as compared to those without. In this retrospective nested case-control study, we identified 11 872 treatment-naïve patients with chronic HCV between 2001 and 2013 from Taiwan National Health Insurance Research Database and divided them into patients with (cases) and without cirrhosis (controls). All patients were followed up from the index month (exact month of diagnosis) to the end of 2013, death, or study outcome, whichever occurred first. The cases and controls were 1:6 propensity score matched for age, sex, and exact month of diagnosis; finally, 8078 patients (1154 with and 6924 without cirrhosis) were included in the analysis. The presence of coexisting EHMs and a new diagnosis of cirrhosis was analyzed. Adjusted hazard ratios (HRs) and cumulative incidence for cirrhosis were calculated in conditional Cox regression models after propensity score matching. Patients with high-cirrhosis-risk EHMs, such as DM (HR: 1.72, 95% CI: 1.51-1.96, P < .001), HCD (HR: 1.45, 95% CI: 1.27-1.67, P < .007), CKD (HR: 1.21, 95% CI: 1.05-1.38, P < .001), hyperlipidemia (HR: 0.53, 95% CI: 0.46-0.60, P < .001), lichen planus (HR: 2.71, 95% CI: 1.56-4.72, P < .001), and palpable purpura (HR: 2.67, 95% CI: 2.13-3.35, P < .001) exhibited significantly higher risk of liver cirrhosis than those without. Cumulative incidence (P < .001) of liver cirrhosis by pairwise comparisons of multiple high-cirrhosis-risk EHMs, and that of lichen planus was the highest. Our study provided direct estimates of specific HCV-associated EHM time trends of cirrhosis risk, with an upward trend in incidence. Lichen planus was at the top of the list of single-EHM comparisons, and the maximum combination of certain EHMs was the greatest risk factor across a different array of multi-EHM comparisons for liver cirrhosis development.

Trachyonychia and Twenty-Nail Dystrophy: A Comprehensive Review and Discussion of Diagnostic Accuracy

BACKGROUND/AIMS

The term trachyonychia, also known as twenty-nail dystrophy, is used to describe thin, brittle nails with excessive longitudinal ridging. The term twenty-nail dystrophy has been incorrectly applied to other conditions that can affect all twenty nails. Therefore, we have conducted a comprehensive review of the clinical features of trachyonychia and have included a discussion regarding the diagnostic accuracy of this condition in the literature.

METHODS

In November and December 2015, we conducted a thorough literature search using the following search terms: 'trachyonychia', 'twenty nail dystrophy', and 'sandpaper nails'. Articles that reported the epidemiology, disease associations, clinical presentation, histopathology, and treatment options for trachyonychia were included. Particular attention was given to case reports to identify misdiagnosed cases of twenty-nail dystrophy.

RESULTS

Our preliminary search yielded 184 results with 72 unique articles ultimately selected for review. Excluded articles included 27 articles in languages other than English, 18 commentaries or reviews, and 67 irrelevant articles. Twelve additional articles described nail abnormalities clinically different from trachyonychia.

CONCLUSION

Many other conditions can cause widespread nail dystrophy. The specific characteristics of trachyonychia need to be considered to make the diagnosis of twenty-nail dystrophy.

Lichen planus localized to the nails

BACKGROUND

Lichen planus may rarely be localized to the nails.

OBJECTIVE

A case of ungual lichen planus is reported that was misdiagnosed as onychomycosis.

METHODS

A 52-year-old woman had progressive nail dystrophy for 13 months that was unresponsive to oral terbinafine. A nail biopsy was performed.

RESULTS

Histopathologic findings were consistent with lichen planus.

CONCLUSION

Onychomycosis may be confused clinically with other causes of nail dystrophy. It is important to confirm the diagnosis of onychomycosis with appropriate laboratory or histologic analysis.

Preliminary investigation of the association of oral lichen planus and hepatitis C

OBJECTIVE

The aim of this investigation was to determine if an association exists between hepatitis C virus and oral lichen planus.

STUDY DESIGN

Three groups of subjects were selected: 505 patients with hepatitis C virus infection (group 1), 100 patients with oral lichen planus (group 2), and a randomly selected control group (age- and gender-matched) of 100 healthy subjects (group 3). The prevalence of oral lichen planus was determined in groups 1 and 3, and the prevalence of hepatitis C virus infection was established in groups 2 and 3.

RESULTS

The prevalence of oral lichen planus was 3.36% (n = 17) in group 1 and 1% (n = 1) in the control group; the prevalence of hepatitis C virus infection was 23% (n = 23) in group 2, and 5% (n = 5) in the control group. No significant differences were observed in the incidence of oral lichen planus in group 1 between those patients who received interferon and those who did not. The 17 patients in group 1 who manifested oral lichen planus and hepatitis C virus infection simultaneously exhibited a marked tendency to have only reticular lesions (70.6%), with involvement of the buccal mucosa in 88.2% of these patients, the tongue in 29.4%, and the gingiva in 11.8%. Analyzing a randomized subgroup of 143 patients from group 1 (subgroup 1) that was matched by age and gender with groups 2 and 3, we found that the incidence of oral lichen planus in patients with hepatitis C virus infection (subgroup 1) was greater than in the control group (5.59% vs 1%), though this was not statistically significant (chi2 = 0.119; p = 0.06). In contrast, group 2 exhibited a statistically significant higher incidence of hepatitis C virus infection (23%) than the controls (5%; chi2 = 0.259, p = 0.0002).

CONCLUSIONS

The prevalence of hepatitis C virus infection in patients with oral lichen planus was greater than in the control series. In our opinion this observation warrants the investigation of potential concomitant hepatitis C virus infection in patients with oral lichen planus.

Case report: acanthosis nigricans in association with primary biliary cirrhosis: resolution after liver transplantation

A case is described of a 58 year old Caucasian male with primary biliary cirrhosis (PBC) who first presented with acanthosis nigricans of both axillae, skin pigmentation, which was pronounced over the posterior surface of the neck, and generalized pruritus. Following orthotopic liver transplantation for progressive liver disease, the skin pigmentation, pruritus and acanthosis nigricans resolved. It is believed that this is the first reported case of acanthosis nigricans occurring in association with PBC, a phenomenon that resolved after liver transplantation.

Oral lichen planus and chronic liver disease: a clinical and morphometric study of the oral lesions in relation to transaminase elevation

Serum transaminase levels (serum glutamic-oxaloacetic transaminase or serum glutamic-pyruvic transaminase) were found to be altered in 40 (21.39%) of 187 patients with oral lichen planus. The patients with oral lichen planus who had altered transaminase levels were on average older than those without liver disorders and exhibited a higher percentage of erosive lesions (p < 0.05) and tongue involvement. Histologically, no statistically significant differences were noted in the extension of inflammatory infiltration or in connective tissue density; nevertheless, the latter was greater in patients without altered transaminase levels. Finally, among those patients with altered liver test results and erosive lichen planus, serum glutamic-oxaloacetic transaminase and serum glutamic-pyruvic transaminase levels were found to be higher than levels in those patients without erosions. This indicates that behavior of the oral lesions is more aggressive as the degree of liver alteration increases. We emphasize that of the 40 patients with altered transaminase levels (all later proved to reflect chronic hepatitis through complementary diagnostic methods), 28 had hepatitis C virus infection.

Primary biliary cirrhosis presenting with granulomatous skin lesions

A case is described of primary biliary cirrhosis in a 59 year old woman who initially presented with a rash over her lower legs 18 months before diagnosis. Skin biopsy examination showed non-caseating granulomas of the sarcoid type. It is believed that this is the first reported case of primary biliary cirrhosis presenting with a granulomatous rash.

Isolated lichen planus of the nails treated with etretinate

A 46-year-old Japanese man with isolated lichen planus of the nails is reported. The affected nails were all of the fingernails and the third and fourth toenails of both feet. Histologically, the ventral part of the proximal nail folds showed mild band-like cell infiltration below the epidermis, and the nail beds (ventral matrix) showed hypergranulosis and epidermal-dermal interphase activity with liquefaction degeneration of basal cells and a band-like cell infiltration consisting of lymphoid cells and histiocytes. Systemic use of etretinate in combination with application of steroid lotion was evaluated as very effective. Although the use of retinoids for lichen planus of the nails remains only a suggested method of treatment, a positive trial should be attempted, since this disorder sometimes results in severe nail damage.