Thick and keratotic 
lesions on both shins - Clinical Advisor

Thick and keratotic 
lesions on both shins

Slideshow

  • Lichen Planus_0214 Derm Clinic 2

A man, aged 83 years, presented with thick bumps on his legs. The man had noticed a hard growth on his leg four weeks earlier and had no recollection of previous trauma to the area. Over the next week, more bumps appeared on the anterior surface of both legs. These growing lesions were described as intensely itchy, painful, and exquisitely tender when bumped.

Medical history included cardiovascular disease and hypothyroidism. Physical exam revealed approximately 15 keratotic papules, plaques, and nodules on both anterior shins. No evidence of any other lesions or dermatitis was seen elsewhere on the skin or in the mouth.



HOW TO TAKE THE POST-TEST: This Clinical Advisor CME activity consists of 3 articles. To obtain credit, you must also read Itchless, red, and crusted trunk papules and Blistering rash in the groin. Then take the post-test here .

HOW TO TAKE THE POST-TEST: This Clinical Advisor CME activity consists of 3 articles. To obtain credit, you must also read Itchless, red, and crusted trunk papules and Blistering rash in the groin. Then take the post-test here .Hematoxylin and...

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HOW TO TAKE THE POST-TEST: This Clinical Advisor CME activity consists of 3 articles. To obtain credit, you must also read Itchless, red, and crusted trunk papules and Blistering rash in the groin. Then take the post-test here .


Hematoxylin and eosin (H&E) stains performed on a deep-shave biopsy specimen revealed a lichenoid infiltrate at the tips of the rete ridges with dyskeratosis, pigment incontinence, and lack of cytologic atypia in the lesion. These findings confirmed the diagnosis of hypertrophic lichen planus (LP), also known as lichen planus verrucosus.

LP is an inflammatory disease with no known cause; however, an immunologic pathogenesis has been discussed. In addition, studies have indicated a link between LP and infection with the hepatitis C virus,1 as well as lichenoid-type dermatitis in response to certain medication. LP occurs worldwide and may have a small familial predisposition. Men and women are affected equally; patients are typically aged 20 years to 60 years.

LP usually presents with a rash consisting of characteristic shiny, polygonal, flat-topped, and violaceous papules. A reticulated white scale, known as Wickham’s striae, may be noted on close inspection. Although LP can appear anywhere on the skin and mucous membranes, the flexor surfaces of the extremities, particularly the wrists, are most commonly affected.

Hypertrophic LP, an uncommon variant of LP, presents with large hypertrophic or verrucous plaques with varying amounts of scale. The more classic violaceous, flat-topped papules may be noted at the edge of the lesion. These papules can range in size from several millimeters to several centimeters, with lesion spread and confluence encouraged by habitual scratching. Hypertrophic LP most commonly appears on the dorsal surface of the shins, ankles, and feet, often in a symmetric pattern. Frequently, hypertrophic LP appears against a background of chronic stasis dermatitis. The condition may develop in isolation or as part of a generalized LP eruption. Other variants of LP affect the oral mucosa, nails, and scalp.

The diagnosis of hypertrophic LP usually requires histopathologic confirmation, as this condition may resemble a verrucous psoriasis, hypertrophic lupus erythematosus, keratoacanthoma, or squamous cell carcinoma.

Classic LP usually lasts one to two years, but the hypertrophic variant often has a more protracted course, with one source reporting an average duration of six years in those whose lesions cleared.2 The goal of LP treatment is control, as there is no curative treatment. Treatment for classic LP involves topical therapy for more limited disease and systemic therapy for more generalized disease. Local treatment includes topical corticosteroids, such topical immunomodulators as tacrolimus (Prograf) and pimecrolimus (Elidel), and intralesional triamcinolone acetonide (Kenalog) injections. Systemic therapy may involve oral or intramuscular prednisone; an oral retinoid, such as isotretinoin 20 mg to 60 mg daily or acitretin (Soriatane) 0.5 mg/kg/day to 1.0 mg/kg/day; or, less commonly, an immunosuppressant, such as mycophenolate mofetil (CellCept) or cyclosporine (Gengraf, Neoral, Sandimmune). Phototherapy with psoralen plus UVA (PUVA) light or narrow-band UVB may also be considered.

For scattered individual lesions of hypertrophic LP, intra­lesional triamcinolone acetonide injections are the preferred treatment. Dosage ranges from 10 mg/mL to 40 mg/mL, with 0.1 mL to 0.3 mL per lesion, depending on lesion thickness and previous response. Alternatively, application of a potent topical corticosteroid under occlusion may be used. Caution must be used to avoid the adverse effect of cutaneous atrophy.

Many patients may require antipruritic therapy for comfort. Such nonsedating antihistamines as fexofenadine (Allegra) and/or hydroxyzine (Vistaril) may be useful adjuvant therapy, and diphen­hydramine may be recommended for nighttime relief.

If localized therapy fails to control the lesions and symptoms of hypertrophic LP, consider systemic treatment as indicated for generalized LP.

Rare cases of squamous cell carcinoma have been reported to evolve in lesions of hypertrophic LP on the lower leg.3 Clinicians should have a low threshold for biopsy of isolated resistant or growing lesions.

Even with treatment, hypertrophic LP often resolves with scarring and hyperpigmentation. Patients should be made aware of expected and realistic outcomes of this condition, which may be chronic or recurrent.

The man in this case was treated with once-monthly triamcinolone acetonide injections, starting at a concentration of 10 mg/mL. The patient ultimately benefited most from 0.1 mL to 0.3 mL at a concentration of 40 mg/mL injected into each lesion. Most of the papules, plaques, and nodules on his shins responded well and resolved with postinflammatory hyperpigmentation. On follow-up, the patient reported a significant decrease in itching and pain and was satisfied with the treatment outcome.

Esther Stern, NP-C, is a family nurse practitioner at Advanced Dermatology & Skin Surgery, P.C., in Lakewood, N.J.


HOW TO TAKE THE POST-TEST: This Clinical Advisor CME activity consists of 3 articles. To obtain credit, you must also read Itchless, red, and crusted trunk papules and Blistering rash in the groin. Then take the post-test here .


References

  1. Chuang TY, Stitle L, Brashear R, Lewis C. Hepatitis C virus and lichen planus: A case-control study of 340 patients. J Am Acad Dermatol. 1999;41:787-789.
  2. Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. 2nd ed. St. Louis, Mo.: Elsevier-Mosby; 2008:190.
  3. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, Pa.: Saunders Elsevier; 2011:214-215.
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