Ashy dermatosis and lichen planus pigmentosus: a clinicopathologic study of 31 cases

Psychosocial burden of lichen planus pigmentosus is similar to vitiligo, but greater than melasma: A cross-sectional study from a tertiary-care center in north India

BACKGROUND

Lichen planus pigmentosus can have a negative impact on the quality of life; however, this has not been studied in detail.

OBJECTIVES

To study the quality of life in patients with lichen planus pigmentosus and compare it with patients with vitiligo and melasma.

METHODS

This was a cross-sectional study conducted in a tertiary-care center in north India from January 2018 to May 2019. Patients ≥ 18 years of age with lichen planus pigmentosus (n = 125), vitiligo (n = 113) and melasma (n = 121) completed the Dermatology Life Quality Index (DLQI) questionnaire and answered a global question on the effect of disease on their lives. In addition, patients with vitiligo completed the Vitiligo Impact Scale (VIS)-22 questionnaire, while those with lichen planus pigmentosus and melasma filled a modified version of VIS-22.

RESULTS

The mean DLQI scores in patients with lichen planus pigmentosus, vitiligo and melasma were 10.9 ± 5.95, 9.73 ± 6.51 and 8.39 ± 5.92, respectively, the difference being statistically significant only between lichen planus pigmentosus and melasma (P < 0.001). The corresponding mean modified VIS-22/VIS-22 scores were 26.82 ± 11.89, 25.82 ± 14.03 and 18.87 ± 11.84, respectively. This difference was statistically significant between lichen planus pigmentosus and melasma, and between vitiligo and melasma (P < 0.001 for both). As compared to vitiligo, patients with lichen planus pigmentosus had a significantly greater impact on "symptoms and feelings" domain (P < 0.001) on DLQI, and on "social interactions" (P = 0.02) and "depression" (P = 0.04) domains on VIS-22. As compared to melasma, patients with lichen planus pigmentosus had significantly higher scores for "symptoms and feelings," "daily activities," "leisure" and "work and school" domains of DLQI, and all domains of VIS-22. Female gender was more associated with impairment in quality of life in patients with lichen planus pigmentosus, while lower education, marriage, younger age and increasing disease duration showed a directional trend.

LIMITATIONS

Use of DLQI and modified version of VIS-22 scales in the absence of a pigmentary disease-specific quality-of-life instrument.

CONCLUSION

Patients with lichen planus pigmentosus have a significantly impaired quality of life. The psychosocial burden of lichen planus pigmentosus is quantitatively similar to that of vitiligo, but significantly greater than melasma.

Oral mycophenolate mofetil in the treatment of acquired dermal macular hyperpigmentation: An open-label pilot study

BACKGROUND

Literature on treating acquired dermal macular hyperpigmentation is sparse.

AIMS AND OBJECTIVES

To assess treatment response of mycophenolate mofetil in patients having acquired dermal macular hyperpigmentation.

MATERIAL AND METHODS

In this open-label, pilot study, patients of acquired dermal macular hyperpigmentation affecting at least the face and/or neck were included. Each participant was treated with mycophenolate mofetil 2 g/day for 24 weeks, with a follow-up of 12 weeks. Two aspects of disease severity were measured: activity (appearance of new lesions/extension of existing lesions), and degree of hyperpigmentation (measured using 'dermal pigmentation area and severity index'). Patient satisfaction was assessed on a scale of 0-10.

RESULTS

Forty-three of 46 patients who were prescribed mycophenolate, completed the study (40 females, 6 males; mean disease duration 2.8 ± 1.4 years). Amongst 20 (43.5%) patients with active disease, stability was achieved in 17, after a mean duration of 6.1 ± 2.5 weeks (range 4-12 weeks; median 4; IQR 4 weeks). Mean dermal pigmentation area and severity index at baseline was 18.8 ± 7.1 and decreased to 13.7 ± 6.3 at 24th week (27.5 ± 14.7%; P < 0.001). A significant decreasing trend in dermal pigmentation area and severity index (P < 0.001) was observed, and first significant difference from baseline was noted at the 16th week (P 0.008). Less than 10%, >10-20%, >20%-30%, >30%-40%, >40%-50%, and >50% reduction in dermal pigmentation area and severity index was observed in 8, 5, 4, 15, 10 and 1 patients/patient respectively. The maximum mean grade of pre-treatment dermatoscopic severity was 3 ± 0.7, and decreased to 2.1 ± 0.8 on the face (P < 0.001) and 2.4 ± 0.7 on the neck (P < 0.001) post-treatment. There were 9 (20.1%) non-responders. Self-assessment scores of the rest of the patients fell in the range of moderate/fair improvement (>5 to 7). No significant correlation was seen between patient satisfaction score and degree of reduction in dermal pigmentation area and severity index (r -0.39). Three developed adverse effects (leucopenia, n = 1; transaminitis and hyperbilirubinemia, n = 2) that resolved following discontinuation of mycophenolate.

CONCLUSION

Mycophenolate mofetil appears to be a promising treatment option in acquired dermal macular hyperpigmentation.

Ashy Dermatosis and Lichen Planus Pigmentosus: The Histopathological Differences

Background

Ashy dermatosis (AD) and lichen planus pigmentosus (LPP) are both acquired macular pigmentation of uncertain aetiology. Despite the controversy surrounding their entities, recent global consensus has concluded that they are 2 different diseases with distinct clinical presentations. Nevertheless, there are limited data on their histopathological comparisons.

Objective

To evaluate the differences in histopathological findings between AD and LPP.

Methods

Electronic records and photographs of patients with the diagnosis of AD or LPP from January 2008 to December 2018 were retrospectively reviewed by a dermatologist. Patients were then classified into groups with AD and LPP, based on the clinical descriptions from the recent consensus. Those with history/clinical presentations suggestive of other causes of macular pigmentation were excluded. The histopathological diagnosis of AD and LPP was then reevaluated by a blinded dermatopathologist.

Results

One hundred and twenty-four patients with acquired macular pigmentation were identified; 24 were excluded due to clinical history or photographs being inconsistent with AD or LPP. Of the remaining 100 patients, 71 had clinical findings consistent with LPP while 29 had AD. The prevalence of epidermal hyperkeratosis was significantly higher in LPP when compared to AD (33.8% vs. 0%, p < 0.001), as well as epidermal hypergranulosis (35.2% vs. 0%, p < 0.001), lichenoid dermatitis (49.3% vs. 7.1%, p < 0.001), perifollicular infiltration (47.9% vs.10.3%, p < 0.001), and perifollicular fibrosis (35.2% vs. 10.3%, p=0.01). In addition, the degree of pigmentary incontinence was more severe in LPP (21.1% vs. 3.5%, p=0.015). For AD, vacuolization of the epidermal basal cell layer was more common (96.4% vs. 77.5%, p=0.02).

Conclusions

Although most cases of AD and LPP can be diagnosed clinically, in doubtful cases, histopathological findings of lichenoid dermatitis, epidermal hyperkeratosis/hypergranulosis, and moderate to severe pigmentary incontinence can help distinguish LPP from AD.

Histological Evaluation of Acquired Dermal Macular Hyperpigmentation

Context:

An umbrella term, acquired dermal macular hyperpigmentation (ADMH), has been proposed to denote conditions including ashy dermatosis, erythema dyschromicum perstans, lichen planus pigmentosus, and idiopathic macular eruptive pigmentation.

Aims:

To classify the patients manifesting ADMH on the basis of histology.

Settings and Design:

In this retrospective, cross-sectional study, histology specimens of patients of ADMH, who underwent skin biopsy in our institution from 1.1 2015 to 31.12.2017, were included after obtaining ethical clearance.

Materials and Methods:

The histology specimens of patients of ADMH were reviewed by the pathologist and classified. Clinical features of individual patient were collected from previous records and the data analyzed.

Statistical Analysis Used:

Pearson's Chi-square test was used to determine significance of association between age of onset and duration of pigmentation with histology type.

Results:

Three patterns of histology were identified in the study group (17 males and 13 females). Type 1: Basal cell degeneration and moderate to dense inflammation (12 patients, 40%), type 2: Significant pigment incontinence and sparse inflammation without basal cell degeneration, (12 patients, 40%), and type 3: sparse inflammation without basal cell degeneration or significant pigment incontinence (six patients, 20%). Statistically significant association was noted between age of onset of pigmentation and histology type (P value, 0.02).

Limitations:

Main limitation was the small sample size.

Conclusions:

Prospective studies evaluating the clinical progression and dermoscopy features and analyzing serial biopsies of ADMH patients may confirm whether the histology patterns observed represent different stages of same disease process or are different entities.

Erythema dyschromicum perstans: A case report and systematic review of histologic presentation and treatment

Objective

Erythema dyschromicum perstans (EDP) can be difficult to diagnose and treat; therefore, we reviewed the literature to assess whether histology can be used to differentiate lichen planus pigmentosus (LPP) from EDP and determine which treatments are the most effective for EDP. We also present a case of a patient who was treated successfully with narrow-band ultraviolet B (NB-UVB).

Methods

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was conducted up to July 2017 using four databases.

Results

Histologic analyses from the literature reveal a significant percentage of melanophages, lymphocytic infiltrates, and basal vacuolar degeneration in EDP, and a significant histologic overlap with LPP. The review of the literature on treatment outcomes showed that NB-UVB and tacrolimus were effective with minimal side effects. Clofazimine was effective, but demonstrated significant-to-intolerable side effects. Griseofulvin, isotretinoin, and dapsone provided unsatisfactory results as lesions recurred after discontinuation. Lasers were largely ineffective and may cause postinflammatory hyperpigmentation and fibrosis.

Conclusion

A diagnosis of EDP should not be based on histologic findings alone. Clinical history, morphology, and distribution should be used to differentiate EDP and LPP. NB-UVB and tacrolimus are promising treatments for EDP with minimal side effects. This is the first report to our knowledge of sustained resolution of EDP after treatment with NB-UVB at long-term follow-up of 4 years. Larger studies are needed to confirm these findings.

A global consensus statement on ashy dermatosis, erythema dyschromicum perstans, lichen planus pigmentosus, idiopathic eruptive macular pigmentation, and Riehl's melanosis

Ashy dermatosis (AD), lichen planus pigmentosus (LPP), erythema dyschromicum perstans (EDP), and idiopathic eruptive macular pigmentation are several acquired macular hyperpigmentation disorders of uncertain etiology described in literature. Most of the published studies on these disorders are not exactly comparable, as there are no clear definitions and different regions in the world describe similar conditions under different names. A consensus on the terminology of various morphologies of acquired macular pigmentation of uncertain etiology was a long-felt need. Several meetings of pigmentary disorders experts were held to address this problem. A consensus was reached after several meetings and collation of e-mailed questionnaire responses and e-mail communications among the authors of publications on the above conditions. This was achieved by a global consensus forum on AD, LPP, and EDP, established after the 22nd International Pigment Cell Conference held in Singapore in 2014. Thirty-nine experts representing 18 countries participated in the deliberations. The main focus of the deliberations was terminology of the conditions; as such, we present here the consensus statement of the forum and briefly review the available literature on the subject. We have not attempted to discuss treatment modalities in detail.

A retrospective clinico-pathological study comparing lichen planus pigmentosus with ashy dermatosis

BACKGROUND/OBJECTIVES

Controversy persists as to whether lichen planus pigmentosus and ashy dermatosis are separate clinical entities. This study was conducted to examine the clinicopathological features and treatment outcome of the two conditions.

METHODS

A retrospective medical chart review of all patients who were diagnosed with lichen planus pigmentosus or ashy dermatosis was conducted. The information collected included the participants' age at onset, site of onset, duration of disease, presence of precipitating factors, distribution of disease, pigmentation and presence of symptoms. In patients from whom a biopsy was taken the histopathological reports were included.

RESULTS

Altogether 26 patients with ashy dermatosis and 29 with lichen planus pigmentosus were included in the study. Compared with ashy dermatosis, lichen planus pigmentosus had a more localised distribution with a preponderance for facial involvement, compared with the truncal preponderance in ashy dermatosis. Ashy dermatosis tended to have a more stable clinical course than lichen planus pigmentosus, which was more likely to wax and wane. The utility of histopathology in differentiating between the two conditions is low.

CONCLUSION

Ashy dermatosis and lichen planus pigmentosus, as defined in this study, appear to be two separate clinical entities with distinguishable clinical features and natural histories.

Hyperpigmented Upper Eyelid: A Clue to the Diagnosis of Facial Lichen Planus Pigmentosus in a Patient with Frontal Fibrosing Alopecia

Facial lichen planus pigmentosus (LPPig), a rare variant of classic lichen planus, was first described in patients with frontal fibrosing alopecia (FFA) by Dlova [Br J Dermatol 2013; 168: 439-442] in 2013. The diagnosis of facial LPPig is sometimes not easy, since clinical signs and histopathological features may frequently be confused with melasma or postinflammatory hyperpigmentation. We describe a case of a postmenopausal black woman diagnosed with FFA who presented with an identical brown-grayish pigmentation of the face and upper eyelids and typical dermoscopy analysis on both regions. We suggest that the hyperpigmentation of the upper eyelid with typical LLPig dermoscopy (upper eyelid sign) may be a clue for the diagnosis of LPPig and may avoid a scar-causing face biopsy.

Fenofibrate-Induced Lichenoid Drug Eruption: A Rare Culprit

A lichenoid drug eruption is a rare side effect which can occur following the administration of several different medications. Here we describe a unique case of fenofibrate as the causative agent of a lichenoid drug eruption. This case highlights a rare and clinically significant dermatologic side effect of fenofibrate. In addition, we report a potential familial association which underscores the potential for underlying genetic mechanisms to be contributory to lichenoid drug eruptions. A reminder of the physical characteristics of lichen planus, knowledge of the temporal relation between administration of medications and a lichenoid drug eruption, recognition of the effect of UV exposure on lichenoid drug eruptions, and realization for the potential of symptoms to persist despite discontinuation of an offending agent can aid practitioners in promptly diagnosing lichenoid drug eruptions and initiating appropriate therapy.

Ashy dermatosis with involvement of mucous membranes

Ashy dermatosis is a rare condition, of unknown aetiology, in which mucous membranes are typically spared. The authors report the case of a 57-year-old female with a history of asymptomatic gray-bluish macules located on the trunk and oral mucosa. There were no relief changes on examination. Skin biopsies from the oral mucosa and trunk were performed and both were compatible with ashy dermatosis. The patient started treatment with oral clofazimine but due to the absence of clinical improvement the drug was discontinued three months later. This case report illustrates an atypical case of ashy dermatosis owing to the involvement of mucous membranes, which is rarely described in the literature.

Facial Hyperpigmentation in Skin of Color: Special Considerations and Treatment

Differences in cutaneous diseases in people of color call for nuanced evaluation and management. One of the most common dermatological complaints from patients with skin of color is dyspigmentation, particularly hyperpigmentation. The challenge for clinicians is to establish correct diagnoses along with consistently successful treatments to meet the needs of the increasingly diverse population served. This review focuses on facial hyperpigmentation and outlines the most common skin disorders and treatment options.

Coexistence of nail lichen planus and lichen planus pigmentosus

We describe a fifty-six-year old, Afro-descendent female patient showing dystrophy of her twenty nails and hyperchromic, asymptomatic macule on her face. Histopathological examination of the macule showed vacuolization of the basal layer, melanophages in the superficial dermis and lymphoplasmocytic inflammatory infiltrate. Nail biopsy revealed orthokeratotic hyperkeratosis and lichenoid inflammatory infiltrate. Lichen planus pigmentosus is an uncommon variety of lichen planus. It is characterized by typical hyperpigmented macules on the face and neck. Nail changes might be present in 10% of lichen planus cases, but no associations with lichen planus pigmentosus have been described. We report a case of lichen planus in twenty nails associated with lichen planus pigmentosus on the patient's face.

Acquired Bilateral Dyspigmentation on Face and Neck: Clinically Appropriate Approaches

Facial dyspigmentation in Asian women often poses diagnostic and therapeutic challenges. Recently, a distinctive bilateral hyperpigmentation of face and neck has occasionally been observed. This study was performed to investigate the clinico-pathological features of this dyspigmentation as well as proper treatment approaches. We retrospectively investigated the medical records including photographs, routine laboratory tests, histopathologic studies of both lesional and peri-lesional normal skin and patch test of thirty-one patients presented acquired bizarre hyperpigmentation on face and neck. The mean age of patients was 52.3 years and the mean duration of dyspigmentation was 24.2 months. In histologic evaluations of lesional skin, a significantly increased liquefactive degeneration of basal layer, pigmentary incontinence and lymphocytic infiltration were noted, whereas epidermal melanin or solar elastosis showed no statistical differences. Among 19 patients managed with a step-by-step approach, seven improved with using only topical anti-inflammatory agents and moisturizer, and 12 patients gained clinical benefit after laser therapy without clinical aggravation. Both clinical and histopathologic findings of the cases suggest a distinctive acquired hyperpigmentary disorder related with subclinical inflammation. Proper step-by-step evaluation and management of underlying subclinical inflammation would provide clinical benefit.

Lichen Planus Pigmentosus: The Controversial Consensus

A pigmented variant of lichen planus (LP) was first reported from India in 1974 by Bhutani et al. who coined the term LP pigmentosus (LPP) to give a descriptive nomenclature to it. LP has a number of variants, one of which is LPP. This disease has also later been reported from the Middle East, Latin America, Korea, and Japan, especially in people with darker skin. It has an insidious onset. Initially, small, black or brown macules appear on sun-exposed areas. They later merge to form large hyperpigmented patches. The disease principally affects the sun-exposed areas of the body such as the face, trunk, and upper extremities. The oral mucosa may rarely be involved. However, the palms, soles, and nails are not affected. Histologically, the epidermis is atrophic along with vacuolar degeneration of basal cell layer. The dermis exhibits incontinence of pigment with scattered melanophages and a sparse follicular or perivascular infiltrate. There is a considerable similarity in histopathological findings between LPP and erythema dyschromicum perstans. However, there are immunologic and clinical differences between the two. These observations have led to a controversy regarding the identity of the two entities. While some dermatologists consider them to be the same, others have opined that the two should be considered as distinctly different diseases. A number of associations such as hepatitis C virus infection, frontal fibrosing alopecia, acrokeratosis of Bazex and nephrotic syndrome have been reported with LPP. A rare variant, LPP inversus, with similar clinical and histopathological findings was reported in 2001. As opposed to LPP, this variant occurs in covered intertriginous locations such as groins and axillae and mostly affects white-skinned persons.

Low-dose oral isotretinoin therapy in lichen planus pigmentosus: an open-label non-randomized prospective pilot study

BACKGROUND

Lichen planus pigmentosus (LPP) is a cosmetically distressing pigmentary disorder often posing a therapeutic challenge. Isotretinoin has been shown to be effective in oral and cutaneous LP, but its role in LPP is yet unknown.

OBJECTIVE

To evaluate the efficacy and safety of isotretinoin in the management of LPP.

METHODS

In this prospective study, 32 clinically and histologically proven patients with LPP were recruited. Subjects were treated with fixed low-dose (20 mg/day) oral isotretinoin once daily for 6 months along with topical sunscreens. Response was graded as mild (<25%), moderate (26-50%), and good (>50%) improvement based on decrease in intensity and progression of hyperpigmentation.

RESULTS

Twenty-seven patients (17 females and 10 males), aged 20-62 years, completed the study. Twenty-three (85.2%) patients had active disease and pruritus at presentation. Treatment outcome was moderate improvement in 15 patients (55.7%) followed by good in seven (21.8%) and mild in two (6.2%). Pruritus subsided at the earliest at 9-14 days, and disease stabilized by 4-6 weeks in treatment-responsive patients. Patients with a shorter duration (≤5 years) of disease and limited body area involvement had a better outcome.

CONCLUSIONS

Low-dose isotretinoin seems to be a promising treatment modality in stabilizing and decreasing the pigmentation in LPP particularly in early and limited disease.

Clinical and histological aspect of erythema dyschromicum perstans in Korea: A review of 68 cases

Erythema dyschromicum perstans (EDP) is a hypermelanotic disorder of the idiopathic variety characterized by blue-gray macules in healthy individuals. It has been described mainly in patients from tropical areas of Central and South America. Our aim was to evaluate EDP in Korea through the analysis of retrospective case series with EDP and to describe the clinical and histopathological features. It was a retrospective study (2002-2012) of EDP confirmed by review of clinical photographs and biopsy specimens. The files of 68 patients with EDP from six tertiary medical centers in Korea were included in this study. Of the 68 patients, 29 were male and 39 female. The age of patients ranged 3-76 years (mean, 33.9). Clinically, the majority of patients had lesions on the trunk (n = 47, 69.1%); the neck was affected in 27 cases, the upper extremities in 26, the face in 22 and the lower extremities in 16. Peripheral erythematous borders were observed in 12 patients (17.6%) and 11 patients had itching sensation at the lesion. Histopathologically, dermal melanophages and pigment incontinence were the most common findings. A follow up of more than 1 year was obtained in 51 patients. Of these, only one patient experienced complete clearance without recurrence. Our study illustrates the clinical and histopathological findings of EDP in Koreans. Our multicenter data may contribute to the understanding of EDP.

Ashy dermatosis in an 8-year-old Indian child

Ashy dermatosis is a disorder of pigmentation, characterized by asymptomatic symmetric ashy gray-colored macules, in the first to third decade of life. It can, however, affect children sometime. But, there is a paucity of similar cases in Indian children. We present a case of ashy dermatosis in an 8-year-old Indian girl who presented to skin OPD with areas of ashy pigmentation, which were distributed symmetrically. Skin biopsy was consistent with lichenoid pattern histology. This case has been reported to highlight the rarity of ashy dermatosis in Indian children.

Ashy dermatosis: a controversial entity

We present here the case of a young Indian male with slowly progressive, diffuse darkening of the face, arms, neck, and trunk. The patient was not taking any medication and there was no history of any previous skin disease and the mucous membrane was not involved. These findings are consistent with a diagnosis for ashy dermatosis of unknown etiology.

Spectrum of non-infectious erythematous, papular and squamous lesions of the skin

BACKGROUND

Dermatopathologists base their diagnostic approach on the tissue reaction pattern. This study mainly includes the interpretation of two major tissue reaction patterns, the psoriasiform and the lichenoid reactions, with clinicopathological correlation.

AIMS

To analyze the spectrum of non-infectious erythematous papular and squamous lesions of the skin at our institute, study the age, sex and anatomic distribution pattern and classify the lesions into major categories; determine the incidence of each subcategory.

MATERIALS AND METHODS

STUDY PERIOD

two years; prospective, sample size: 161 cases, proforma filled.

RESULTS

The lesions comprised 15.80% of the total load of surgical pathology and 30.99% of total number of skin biopsies. The highest percentage was in the 30-40 year age group (28.6%) with a male preponderance of 60.25%. The extremities were most frequently involved (67.79%). Lichenoid lesions were the commonest (46.57%) with lichen planus 26.7% and psoriasis vulgaris-19.88% being the most frequent. There were 5.6% seropositive cases. Correlation with the histopathological diagnosis was positive in 97.52% cases and negative in 2.48% cases.

CONCLUSION

The contribution of histopathology to the final diagnosis was significant. It confirmed the diagnosis in 92.55% and gave the diagnosis in 4.97% cases.

A Case of Lichen Planus Pigmentosus-inversus in a Korean Patient

Lichen planus pigmentosus-inversus is a rare variant of lichen planus pigmentosus. The eruption of lichen planus pigmentosus-inversus occurs mainly in the flexural regions and presents with brownish macules and patches. Here we describe the case of a 31-year-old Korean woman who presented with hyperpigmented lesions over her antecubital and popliteal area and groin. Physical examination revealed multiple brownish macules and patches on the intertriginous area without pruritis, and histologic findings showed a regressive pattern of lichen planus. These clinical and histological findings were consistent with a diagnosis of lichen planus pigmentosus-inversus.

Clinicopathological characteristics of lichen planus pigmentosus and its response to tacrolimus ointment: an open label, non-randomized, prospective study

BACKGROUND

Lichen planus pigmentosus (LPP) is an uncommon variant of lichen planus, for which no effective treatment is available. Objectives The aim of this study was to determine the clinical, epidemiological and histopathological characteristics of LPP patients in Kuwait.

METHODS

Thirty-three LPP patients who attended the Dermatology outpatient clinics at Farwaniya Hospital, Kuwait from the year 2002 to 2008 were studied for clinical, epidemiological and histopathological findings. Thirteen of these patients were treated with topical tacrolimus 0.03%. Ointment applied topically twice daily for the duration varying from 6 to 12 weeks.

RESULTS

Of the 33 patients, 21 were men and 12 were women. The duration of eruption ranged from 6 weeks to 3 years. The face and neck were the commonest sites, affecting 18 (54.5%) patients. The pattern of pigmentation was diffuse in 18 (54.54%) patients, reticular in seven (21.2%), blotchy in five (15.2%), linear in two (6.1%) and perifollicular in one (3%). Twenty patients had positive serology for hepatitis C virus (HCV), with significantly higher serum liver enzymes (ALT and AST). Of the 13 patients, who were treated with tacrolimus Ointment, seven (53.8%) showed appreciable lightening of the pigmentation after an average of 12 weeks.

CONCLUSIONS

We conclude that HCV may be one of the factors associated with LPP, in those who have a tendency to develop LPP. However, this possible association should be interpreted carefully. In addition, tacrolimus ointment could have a beneficial role in the treatment of LPP.

Pigmentary Disorders in Latin America

Pigmentary disorders with hypopigmentation/depigmentation or hyperpigmentation may have special manifestations in Latin America. Most pigmentary disorders are commonly observed in all areas of Latin America, but a few are particularly seen in tropical and subtropical regions. In most pigmentary disorder ailments described, multiple factors involved in their pathogenesis are known, but etiology remains elusive. Some pigmentary disorders have peculiar clinical expressions and, in spite of being restricted to certain geographical areas, they may be observed in other world areas because of frequent traveling of affected patients. Therapy of most of these ailments is difficult or remains unknown.

Two Japanese cases of lichen planus pigmentosus-inversus

Case 1 was a 51-year-old Japanese woman. She presented with an asymptomatic brown macule located on the right axilla of 2 months' duration. The smooth macule was 2 cm in diameter with a sharp demarcation (Fig. 1A). Case 2 was a 62-year-old Japanese man. He presented with asymptomatic, symmetric, gray-brown macules located on the groin, axillae, and popliteal region of 6 months' duration. The smooth macules were several millimeters to centimeters in diameter and sharply demarcated (Fig. 1B). Oral or nail lesions, previous inflammatory processes in affected areas, and internal malignancies were absent. A causal relationship with drugs, recent sun exposure, or trauma could not be identified. Findings for work-up, including blood cell count, fasting blood sugar levels, liver function, serum electrolyte levels, serum electrophoresis, urinalysis, antinuclear antibodies, and serological examinations for human hepatitis viruses and syphilis, were within normal limits or negative. The lesions gradually disappeared without medication within 6 months. Biopsy specimens showed a lymphocytic infiltrate with basal vacuolar changes and prominent melanin incontinence in the upper dermis (Fig. 2A). The band-like lymphocytic infiltrate was moderate in Case 1 and mild in Case 2. Immunohistochemistry showed infiltrative CD8(+) T lymphocytes with keratinocytic damage, indicating cytotoxic injury of the keratinocytes (Fig. 2B). Both the epidermis and the upper dermis contained CD1a(+) cells (Fig. 2C). The keratinocytes focally and weakly expressed HLA-DR (Fig. 2D). These findings were identical in samples from both patients.

Immunopathologic study of erythema dyschromicum perstans (ashy dermatosis)

Erythema dyschromicum perstans (EDP) is a pigmentary disease of unknown etiology in which damage to basal cells is thought to be mediated by adhesion molecules. The aim of this study was to characterize the histopathology and immunopathology of EDP. Forty-three patients from Medellín, Colombia, with the diagnosis of EDP were evaluated. Skin biopsy specimens were obtained for histopathology and immunohistochemistry, using monoclonal antibodies directed against the following markers: CD4, CD8, CD56, CD1a, CD68, CLA, HLA-DR, ICAM-1 and LFA-1alpha. A dermal lymphocytic infiltrate was observed in all cases, with a perivascular location in 86%. Other histologic features included melanophages in all specimens, vacuolization of the basement membrane zone (BMZ) 58% and exocytosis of lymphocytes (53.5%). The mean number of total leukocytes was 1510 cells mm-2 of tissue. There was a predominance of CD8+ T lymphocytes in the dermis and HLA-DR+, ICAM-1+ keratinocytes in the epidermis. Exocytosis of cutaneous lymphocyte antigen (CLA)+cells was observed in areas of BMZ damage, suggesting that response to antigenic stimulation may play a role in the development of EDP.

HLA-DR association with the genetic susceptibility to develop ashy dermatosis in Mexican Mestizo patients

BACKGROUND

Ashy dermatosis, also known as erythema dyschromicum perstans, is an acquired benign disease, characterized by blue-gray pigment patches with erythematous borders. The cause is still unclear, but probably has an immunologic basis.

OBJECTIVE

The aim of this study was to determine gene frequencies of the HLA-DR alleles in Mexican patients with ashy dermatosis and compare them with ethnically matched healthy control subjects to reveal the genetic susceptibility to develop ashy dermatosis.

METHODS

We included 23 consecutive patients with clinical and histopathologic confirmed diagnosis of erythema dyschromicum perstans. Patients and control subjects received a questionnaire to determine their ethnic origin and a peripheral blood sample was taken for DNA extraction. Finally, Genetic HLA-DRB1 was performed by polymerase chain reaction sequence-specific oligonucleotide reverse dot blot hybridization.

RESULTS

Of the 23 patients included in this study, 65% were women and 35% were men. We observed that the disease was located in the trunk in 17 patients (74%) and the upper limbs in 15 patients (65%). The most frequent allele was HLA-DR4 (65%) (pC < 1 x 10(-6), odds ratio = 6.0, 95% confidence interval = 2.8-12.7) whereas in control subjects it was 23%. The most frequent molecular subtype in both patients and healthy control subjects was DRB1( *)0407, being statistically significant after comparing the two groups (pC < 1 x 10(-6), odds ratio = 7.0, 95% confidence interval = 3.1-15.8).

LIMITATIONS

Since this is a disease strongly influenced by ethnicity, extrapolation to other ethnic groups is limited.

CONCLUSIONS

Many factors influence the ethiopathogenesis of erythema dyschromicum perstans, but it is strongly suggested to have an important genetic susceptibility conferred by genes located within the major histocompatibility complex region.

A study of 124 Indian patients with lichen planus pigmentosus

Lichen planus pigmentosus is a fairly common disorder of pigmentation in Indians, but reports comprising a sizeable number of patients are lacking in the literature. We now describe the clinical and epidemiological features and histopathological findings for 124 lichen planus pigmentosus patients. A retrospective analysis of medical records of patients attending our centre during the past 12 years was undertaken. Of the 124 patients (56 male, 68 female), the majority (48.4%) had the disease for 6 months to 3 years. The face and neck were the commonest sites affected with pigmentation varying from slate grey to brownish-black. The pattern of pigmentation was mostly diffuse (77.4%), followed by reticular (9.7%), blotchy (7.3%) and perifollicular (5.6%). Lichen planus was noted in 19 patients with typical histopathological changes of the disorder. Lichen planus pigmentosus, a distinct clinical entity commonly encountered in the Indian population, should be considered in the spectrum of lichenoid disorders as a variant of lichen planus.