Lichen Nitidus 1_0212 Derm Dx
Lichen Nitidus 2_0212 Derm Dx
A 24-year-old man presents complaining of “bumps” located on the shaft of his penis. He is not sure how long the bumps have been present and denies itch or other discomfort.
The patient is otherwise healthy and not taking any medications. He is sexually active with women and has had two partners in the past year. Family history is noncontributory.
On physical exam, he is well nourished, well developed and in no acute distress. His exam is significant only for multiple small, slightly raised, flat-topped, shiny, round to polygonal, skin-colored papules on the dorsal surface of his penile shaft. What’s your diagnosis?
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Lichen nitidus is an uncommon inflammatory skin condition known to affect individuals of all ages but is most prevalent in preschool and school aged children. The condition is characterized by a chronic eruption of small, round to polygonal, shiny, skin-colored papules located primarily on the dorsal hands, flexor forearms, chest, penis and abdomen. Less commonly the face, neck, palms, soles, nails and mucus membranes are involved.
Lichen nitidus lesions are generally asymptomatic. The Koebner phenomenon, in which trauma (such as a scratch) causes papules to erupt, is known to play a role in onset. The majority of patients experience eruptions that last less than one year, but some can persist for up to eight years. Lichen nitidus etiology is unknown but is not believed to be associated with any acute or chronic diseases, infections or laboratory abnormalities. There does not appear to be a clear genetic association.
Some experts feel that lichen nitidus is a variant of lichen planus, whereas others view it as a distinct dermatologic entity with multiple unique clinical, pathologic and epidemiologic characteristics. Most significantly, lichen nitidus is generally asymptomatic, whereas lichen planus is frequently very pruritic. On biopsy, lichen nitidus lesions have a pathognomonic appearance in which the epidermis appears to be “clutching” a ball of inflammatory cells.1, 2
The diagnosis is based on the appearance of small, shiny, skin-colored papules in the distribution described above. When the diagnosis is in doubt, skin biopsy is diagnostic.
Pearly penile papules are pearly, white (even on dark skinned individuals), dome-shaped papules located exclusively around the corona of the glans penis, and should not be confused with lichen nitidus. Genital herpes presents with groups of painful purulent or hemorrhagic vesicles that lead to erosions. Condyloma accuminata (genital warts) have a warty appearance that should be distinguished from the discrete and shiny papules of lichen nitidus.1, 2
Most patients clear lichen nitidus within one to several years and do not require treatment. In our practice, we feel the best strategy is to simply reassure patients of the benign, non-contagious and self-limited nature of the condition.
If there is significant pruritis, topical corticosteroids and oral antihistamines are helpful. There are anecdotal reports of improvement with topical calcineurin inhibitors, oral retinoids and phototherapy. 1, 2
Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine in Houston.
1. Bolognia J, Jorizzo JL, Rapini RP. “Chapter 12: Lichen Planus and Lichenoid Dermatosis.” Dermatology. St. Louis, Mo.: Mosby/Elsevier, 2008.
2. James WD, Berger TG, Elston DM et al. “Chapter 12: Lichen Planus and Related Conditions.” Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.