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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 75-82

Clinical, dermoscopic, and histopathological correlation of lichenoid dermatoses


Department of Dermatology, Ramaiah Medical College, Bengaluru, Karnataka, India

Date of Web Publication28-Nov-2019

Correspondence Address:
Dr. Praveen Kumar Shanmugam Reddy
189/T2, 3rd Main, 2nd Cross, 1st Block, Koramangala, Bengaluru - 560 034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdpdd.ijdpdd_71_18

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  Abstract 


Context: Lichenoid disorders are diverse, and the use of a noninvasive tool like dermoscopy could highlight the pathology in the deeper skin. The present study aimed to compare the accuracy of clinical and dermoscopic findings with histopathology in making a diagnosis of lichenoid dermatoses. Settings and Design: This is a prospective cross-sectional observational study of consecutive, clinically suspected cases of lichenoid skin eruption. Subjects and Methods: Forty patients with various clinical features and dermoscopic features were enrolled. Skin biopsy was taken from all the cases, and the clinical, dermoscopic, and the histopathological correlation was made. Results: Classical lichen planus (CLP) was the most common entity reported (30%), followed by hypertrophic LP (HLP) (15%) and lichen nitidus (15%). Radiating lines were the most common structures seen in as compared with HLP. Comedo-like lesions were significantly seen in HLP than CLP. Compact hyperkeratosis was seen in 66.67% of CLP and in all cases of HLP. There was a significant association in HLP, between blue and black structures on dermoscopy as compared with pigmented melanophages in dermoscopy. Chi-square test was used as a method of comparison, and SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc. was used. Conclusion: Dermoscopic findings give a vital clue about the underlying histopathology which can aid a physician in his/her diagnosis.

Keywords: Dermatoses, dermoscopy, histopathology, lichenoid


How to cite this article:
Reddy PK, Sumathy TK, Shyamprasad AL, Shivaswamy KN, Suparna MY. Clinical, dermoscopic, and histopathological correlation of lichenoid dermatoses. Indian J Dermatopathol Diagn Dermatol 2019;6:75-82

How to cite this URL:
Reddy PK, Sumathy TK, Shyamprasad AL, Shivaswamy KN, Suparna MY. Clinical, dermoscopic, and histopathological correlation of lichenoid dermatoses. Indian J Dermatopathol Diagn Dermatol [serial online] 2019 [cited 2019 Dec 16];6:75-82. Available from: http://www.ijdpdd.com/text.asp?2019/6/2/75/271948




  Introduction Top


Interface dermatitis encompasses a group of conditions, in which the primary pathology lies at the dermo-epidermal junction. They are of two distinct types: vacuolar and lichenoid [1] Lichen planus (LP) is the prototype of the lichenoid interface dermatitis, wherein the most striking feature is the presence of a dense band-like infiltrate in the papillary dermis, with the predominant cell type being lymphocytes. At times, this band can overshadow basal cell vacuolization.[2] The infiltrate can also have a predominance of other cell types such as eosinophils (lichenoid drug eruptions), plasma cells (lichenoid actinic keratosis), melanophages (LP pigmentosus), and histiocytes (lichen nitidus).[2],[3]

This study was undertaken with the primary objective of studying the clinical, dermoscopic, and histopathological features of lichenoid dermatoses. As a secondary objective, specific dermoscopic features which could help in establishing a diagnosis of lichenoid dermatoses were also noted. These dermoscopic features may not only help in the elucidation of diagnosis, but also be of use in day-to-day clinical practice situations, where the patient may be unwilling for a biopsy.


  Subjects and Methods Top


After obtaining a clearance from the institutional ethical review board, forty consecutive patients with a suspected lichenoid dermatosis were enrolled over a period of 1 year, after taking a written informed consent. A detailed history of any previous treatments for the skin complaints and systemic diseases was documented. Any allergy to lignocaine, bleeding diathesis, and patients on anticoagulants and cardiac illness were excluded from the study. A detailed clinical examination of the lesion and the study of the morphology, distribution, and pattern were studied. The dermatoscopes used were (1) Dermlite (DL3N) which had 18 white light-emitting diodes (LEDs) (12 polarized, 6 nonpolarized, and 10 orange polarized LEDs). (2) DermaIndia (BW-788), comprised of a 2-megapixel sensor and a magnification of up to ×200, with 4–8 inbuilt LED light sources. A 5-mm punch biopsy from the lesion studied was taken for histopathological examination which was done by the same observer. The clinical features and dermatoscopic features of the lesions were correlated with the corresponding histopathological findings. The results were analyzed from the data obtained.

Statistical analysis

The average was taken as a measure of central tendency due to the absence of extreme variables. Chi-square test was chosen as a test of comparison of qualitative data. SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc. was used for analysis.


  Results Top


Classical LP (CLP) was the most common entity reported (30%) [Table 1], followed by hypertrophic LP (HLP) (15%) and lichen nitidus in 15% cases. Nearly 77.5% of cases were LP and its variants, and the other conditions comprised of 22.5% of cases. Lichen nitidus was seen in 15% of cases. There were two cases of LP pigmentosus (5%) and lichen planopilaris (5%) which were reported.
Table 1: Distribution of various types of lichenoid disorders

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Dermoscopic analysis revealed that the nonvascular findings were more commonly reported than the vascular findings [Table 2]. The distribution of various nonvascular findings is summarized in [Table 3]. White structures were the most common finding in CLP (91.67%) and HLP (100%). Brown pigmentation was the most common finding in CLP (83.34%) and HLP (100%). The dermoscopy showed comedo-like lesions, white structures, and brown dots in all cases of HLP. The comedo-like lesions could be due to the underlying dilated follicular ostia, hyperkeratosis, and hypergranulosis (HG). Radiating lines were the most common structures seen in CLP as compared with HLP [Table 4]. Comedo-like lesions were significantly higher in HLP than CLP [Table 4].
Table 2: Vascular and non-vascular Dermoscopic findings

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Table 3: Dermoscopic findings showing vascular, non-vascular and pigmentation

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Table 4: Comparison of various dermoscopic and histopathological findings in classical lichen planus and hypertrophic lichen planus

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All cases of lichen nitidus had a brown shadow at the center of lesion which could be highlighted with the polarized version of dermoscopy. Brown dots were the most common finding in all cases of LP pigmentosus, which showed a “hem-like” pattern. Blue-black pigmentation and perifollicular pigmentation were seen in all cases of lichen planopilaris, which also had a targetoid pattern around the hair follicles. Melanin incontinence were seen in all cases of LP pigmentosus and lichen planopilaris.

On histopathology, vacuolar degeneration and lichenoid infiltrate were seen in all cases of CLP, HLP, and lichen nitidus [Table 5]. Compact hyperkeratosis (CHK) was seen in 66.67% of CLP and in all cases of HLP. All cases of HLP also showed classical HG. The wedge-shaped HG and saw-toothing of rete ridges were seen in 50% and 25% of cases of CLP, respectively. The Max–Josephs space was seen only in 16.67% of cases of CLP.
Table 5: Various histopathological findings in different clinical types

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[Table 4] shows the comparison between the association of white structures with CHK in CLP and HLP. [Table 4] also shows the association of gray-blue structures and brown dots with pigmented melanophages in CLP and HLP, respectively. There was a significant association in HLP, between blue and black structures on dermoscopy as compared with pigmented melanophages in dermoscopy.


  Discussion Top


The term lichenoid dermatoses encompasses a group of disorders which clinically resemble LP and histopathologically show a lichenoid reaction pattern.[4],[5] Most of these entities show basal cell degeneration and a band-like inflammatory infiltrate that abuts the dermo-epidermal junction. There are subtle clues that the eyes provide to the clinician, and dermoscopy can give an eagle eye view of the underlying histopathological pattern and sometimes may act as a substitute to a skin biopsy in the diagnosis of lichenoid dermatoses. The differentiation of LP from other lichenoid dermatoses is essential because many entities have different modalities of treatment.[6],[7]

Dermoscopic features studied included vascular (red dots and globules), nonvascular (radiating linear bands, white structures, brown dots, corn-pearls, and comedo-like lesions), and pigmented lesions (brown, gray-blue, blue-black, and perifollicular types).

Nonvascular structures were more common than vascular lesions in the present study.

The various histopathological changes studied were CHK, laminated hyperkeratosis, HG, acanthosis, spongiosis, saw-toothed appearance, vacuolar degeneration, lichenoid infiltrate, pigmented melanophages, perivascular infiltrate, follicular plugging, Max–Josephs space, and civet bodies.[8],[9] The vacuolar degeneration and lichenoid infiltrate were seen in all cases of CLP, HLP, and linear and generalized LP. However, the Max–Josephs space and civate bodies were seen in only 16.67% and 8.34% of cases, respectively. Vacuolar degeneration and lichenoid infiltrate were seen in all cases.

CLP was the most common entity, which was corresponding to the results obtained in studies by Singh and Kanwar,[10] Bhattacharya et al.,[11] Abdallat and Maaita,[12] and Anbar et al.[13] In CLP, white structures (91.67%) and radiating linear bands (41.67%) [Figure 1] and [Figure 2] (41.67%) were the most common finding [Figure 2] and [Figure 3]a, b]. HLP [Figure 4] was seen in 15% of cases. Dermoscopic features of HLP showed comedo-like lesions [Figure 5], brown dots [Figure 5], and white structures in all patients. This was in accordance with studies by Haldar and Khopkar,[14] Vázquez-López et al.,[15] and Garg et al.[7] Comedo-like openings in HLP can be correlated with the underlying CHK, HG, and dilated follicular ostia, in HLP [Figure 6].
Figure 1: Classical lichen planus showing violaceous papules and plaques over the back with Koebner's phenomenon

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Figure 2: Dermoscopy (dermlite DL3N; nonpolarized, 10×) showing violaceous patch with whitish scales and Wickham's striae

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Figure 3: (a and b) Dermoscopy (dermlite DL3N; nonpolarized, ×10) showing violaceous patch with whitish scales and Wickham's striae (c) histopathology image (×45) of classical lichen planus showing hyperkeratosis, acanthosis, and saw-toothing of rete-ridges with band-like lichenoid infiltrate

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Figure 4: Violaceous plaques and nodules with the central area of depigmentation over the right lower leg

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Figure 5: Dermoscopy (dermlite DL3N; polarized, magnified version of ×10) showing comedo-like openings (blue arrow), dilated blood vessels (red arrow), and brown pigment globules (yellow bracket)

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Figure 6: Histopathology (×45) of hypertrophic lichen planus showing marked hyperkeratosis, acanthosis, dilated follicular ostia, hypergranulosis, and lichenoid infiltrate

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The radiating lines were more common in CLP as compared to HLP in the present study.

However, comedo-like lesions were seen in all cases on HLP as compared to CLP. Brown pigmentation was seen in all cases of HLP as compared to 83.34% of cases in CLP. Blue-black pigmentation was also seen more commonly in HLP (66.67%) as compared to 16.67% of CLP.

The radiating lines and white structures are seen due to the underlying CHK in histopathology, and the blue-black or brown pigmentation is due to the pigmented melanophages in histopathology [Figure 3]c.[12] These findings were in consistent with studies by Haldar et al.[14] and Garg et al.[7] Comedo-like openings in HLP can be correlated with the underlying CHK and HG in HLP [Figure 6], as seen in he studies by Haldar et al.,[14] Ankad et al.,[16] and Garg et al.[7]

In the present study, pigmented melanophages were seen more commonly in CLP (91.67%) than HLP (83.34%). All cases of acute widespread generalized LP showed pigmented melanophages. The association of pigmented melanophages with blue-black structures in HLP was significant.

Dermoscopic findings which give a clue of HLP are the comedo-like lesions [Figure 5], white structures, and blue-black pigmentation as compared to CLP and acute widespread generalized LP. This finding was also seen in a study by viral Thakkar et al.[17] and Garg et al.[7]

Lichen nitidus [Figure 7] was reported in 15% of cases. The radiating linear bands (66.67%) and white structures (50%) were the most common findings in lichen nitidus. The dermoscopy of lichen nitidus also showed multiple well-demarcated circles, some of which showed a brown shadow at the center [Figures 8]. The well-demarcated circles correlate with the epidermal acanthosis and the brown shadow correlates with the foci of lymphocytes and epithelioid cells in the dermal papillae [Figure 9]. The brownish shadow was also reported by Malakar et al.[18]
Figure 7: Multiple pin-point papules of lichen nitidus, over the dorsum of the hand

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Figure 8: Dermoscopy (dermlite DL3N; polarized, magnified version of × 10) showing whitish structure with a central brown shadow

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Figure 9: Histopathology of lichen nitidus showing infiltrate of lymphocytes and epitheloid cells between rete ridges in a “claw-clutching a ball” appearance (45x)

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Two cases of lichen planopilaris were reported in this study [Figure 10]. The dermoscopic features noted in lichen planopilaris were perifollicular scaling and bluish dots and globules with bluish patches around hair folicle, and few of the bluish structures showed a targetoid appearance [Figure 11]. The targetoid pattern of pigmentation suggests melanin incontinence and circular arrangement around peri-follicular areas.[19]
Figure 10: Clinical image of lichen planopilaris showing cicatricial alopecia with a hyperpigmented violaceous appearance

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Figure 11: Dermoscopy (dermlite DL3N; nonpolarized, magnified version of ×10) of lichen planopilaris showing bluish dots and globules and patch in perifollicular area with arrow pointing toward “targetoid appearance”

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There were two cases of LP pigmentosus reported in the present study. One of the patients had hyperpigmented brownish-black hyperpigmented patches on the flexor aspects of the arm and forearm [Figure 12]. Dermoscopy showed linear bands of brownish-black pigmentation, with few of them showing a “hem-like” pattern [Figure 13]. This pattern was also reported by Neema and Jha.[20] However, there was no erythematous hue noted in any of the patients. The histopathology showed epidermis with basket weave hyperkeratosis and basal cell vacuolization. Subepidermal area showed perivascular infiltrate with exocytosis of lymphocytes and prominent melanin pigment incontinence in the upper dermis [Figure 14].
Figure 12: Clinical image of lichen planus pigmentosus with hyperpigmented brownish-black pigmentation over the flexor aspect of the forearm and arm

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Figure 13: Dermoscopic (dermlite DL3N; polarized, magnified version of ×10) image showing brownish dots and globules with a hem-like pattern (shown in arrow)

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Figure 14: Histopathology (45x) of lichen planus pigmentosus showing pigment globules in the upper dermis (arrow)

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LP pigmentosus is characterized by discrete and confluent macules in sun-exposed areas, where lesions have diffuse borders. Erythema dyschromicans perstans (EDP) can occur also on covered areas as well, and the lesions have an elevated erythematous border, like a “piece of string” which can be highlighted on dermoscopy. On histopathological examination, the pigment deposition is seen in superficial dermis in LP pigmentosus as compared to EDP,[21] where it is seen in the deeper dermis.

There was one case of lichenoid photodermatitis which showed a violaceous border [Figure 15] at the periphery of the whitish structure in dermoscopy. This was also a new finding in this study.
Figure 15: Dermoscopy (DermaIndia, BW-788; nonpolarized ×40) showing whitish structure with a bluish rim at the periphery

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The dermatoscope dermlite (DL3N) had a better magnification, resolution, and clarity compared to BW-788. The DL3N could highlight the surface morphology as well as the pigmentary changes (which were better delineated with the polarized light).


  Conclusion Top


Dermoscopy is a noninvasive tool in the armamentarium of a dermatologist and provides vital clues in the diagnosis of various dermatological entities.[21] The subtle surface features that are highlighted can give valuable information about the underlying pathological process to the treating physician. The various clues can even differentiate morphological types of lichenoid dermatoses and can at times replace skin biopsy in patients who are not fit to undergo a minor invasive procedure. This is essential as the treatment of various lichenoid dermatoses is different.

In the present study, CLP shows radiating lines and Wickham's striae in dermoscopy as compared to comedo-like lesions and blue-black pigmentation in HLP. These findings can be correlated with the histopathology in these entities and provide vital clues in diagnosis to the clinician. The new findings highlighted are the brown shadow in lichen nitidus in dermoscopy, which correlates with the subepidermal infiltrate of lymphocytes and epitheloid cells, and the targetois bluish pigmentation around the hair follicles in dermoscopy is a clue to lichen planopilaris. A violaceous border seen in lichenoid photodermatitis is a clue to treating dermatologist, in assessing the pin-point papules of lichenoid photodermatitis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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1.
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Güngör Ş, Topal IO, Göncü EK. Dermoscopic patterns in active and regressive lichen planus and lichen planus variants: A morphological study. Dermatol Pract Concept 2015;5:45-53.  Back to cited text no. 3
    
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Garg P, Kaur T, Malhotra SK, Singh A. Study of the dermoscopic findings and their correlation with histopathological findings in various lichenoid dermatoses. J Clin Exp Dermatol Res 2105;6:308.  Back to cited text no. 7
    
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David W. The Lichenoid reaction pattern (Interface dermatitis). In: Weedon's Skin Pathology. 3rd ed. China: Churchill Livingstone Elsevier; 2010. p. 38-42.  Back to cited text no. 9
    
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Singh OP, Kanwar AJ. Lichen planus in India: An appraisal of 441 cases. Int J Dermatol 1976;15:752-6.  Back to cited text no. 10
    
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Abdallat SA, Maaita TJ. Epidemiological and clinical features of lichen planus in Jordanian patients. Pak J Med Sci 2007;23:92-4.  Back to cited text no. 12
    
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Anbar TE, Barakat M, Ghannam SF. A clinical and epidemiological study of lichen planus among Egyptians of Al-Minya province. Dermatol Online J 2005;11:4.  Back to cited text no. 13
    
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Haldar SS, Khopkar U. Dermoscopy of lichen planus. In: Khopkar U, Valia A, editors. Lichen Planus, 1st edn. New Delhi: Jaypee Brothers; 2013. pp. 148-62  Back to cited text no. 14
    
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Vázquez-López F, Manjón-Haces JA, Maldonado-Seral C, Raya-Aguado C, Pérez-Oliva N, Marghoob AA, et al. Dermoscopic features of plaque psoriasis and lichen planus: New observations. Dermatology 2003;207:151-6.  Back to cited text no. 15
    
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Ankad BS, Beergouder SL, Sujana L. Dermoscopy of hypertrophic lichen planus. Austin J Dermatol 2014;1:2.  Back to cited text no. 16
    
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Thakkar V, Haldar SS. Trichoscopy of patchy alopecia. In: Khopkar U, editor. Dermoscopy and Trichoscopy in Diseases of the Brown Skin. 1st ed. New Delhi: Jaypee Brothers; 2012. p. 182-201.  Back to cited text no. 17
    
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Malakar S, Save S, Mehta P. Brown shadow in lichen nitidus: A dermoscopic marker! Indian Dermatol Online J 2018;9:479-80.  Back to cited text no. 18
    
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Sonthalia S, Errichetti E, Kaliyadan F, Jha AK, Lallas A. Dermoscopy of lichen planus Pigmentosus in Indian patients – Pitfalls to avoid. Indian J Dermatol Venereol Leprol 2018;84:311-3.  Back to cited text no. 19
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20.
Neema S, Jha A. Lichen planus pigmentosus. Pigment Int 2017;4:48-9. Available from: http://www.pigmentinternational.com/textasp?2017/4/1/48/208354 [Last accessed on 2019 Sep 06].  Back to cited text no. 20
    
21.
Jiyun Jung E, Unbyul Cho E, Unjoo Park K, Wangho Kim K, Kim W. Atypical dermoscopic findings in patients diagnosed with lichen planus by histological examination. Dermatol Sinica 2017;35:20-4.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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