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Make the Diagnosis - April 2015
Diagnosis: Lichen Planus
Lichen planus is a common inflammatory condition involving the skin, nails, mucous membranes, and hair follicles. It has no racial predilection, and often affects men and women aged 20-60 years. It is less common in children, who account for only 4% of cases. The lesions are often atypical.
Clinically, patients often present with erythematous to violaceous small, flat-topped, polygonal papules that may coalesce into plaques. Lesions are generally pruritic, and may be tender or painful. Older lesions may be hyperpigmented. White streaks known as Wickham striae can cross the surface of lesions. These striae also can be present orally, such as in the patient described here. Oral lesions also may be atrophic or erosive.
Common body locations with involvement are the inner wrists, legs, torso, or genitals (glans penis). The face is rarely involved. Nail changes, such as longitudinal ridging and splitting, onycholysis, red lunula, yellow nail syndrome, and pterygium formation, can occur.
Lichen planus often spontaneously resolves on its own, with 2/3 of patients resolving in a year. Mucous membrane disease tends to be more chronic. The etiology of lichen planus is unknown. It may have an autoimmune mechanism in which T cells induce keratinocytes to undergo apoptosis. Between 4% and 60% of lichen planus patients also have hepatitis C infections. The differential diagnosis for cutaneous lesions include lichenoid drug eruption, guttate psoriasis, syphilis, and pityriasis lichenoides et varioliformis acuta. Oral lesions may resemble candidiasis, leukoplakia, malignancies, and bullous disease.
Topical and intralesional steroids are often effective for localized disease. Systemic corticosteroids can be useful when lesions are widespread. Phototherapy, isotretinoin, acitretin, hydroxychloroquine, and oral immunosuppressive agents (such as cyclosporine and mycophenolate mofetil) all have been described in the treatment of lichen planus.
Diagnosis: Lichen Planus
Lichen planus is a common inflammatory condition involving the skin, nails, mucous membranes, and hair follicles. It has no racial predilection, and often affects men and women aged 20-60 years. It is less common in children, who account for only 4% of cases. The lesions are often atypical.
Clinically, patients often present with erythematous to violaceous small, flat-topped, polygonal papules that may coalesce into plaques. Lesions are generally pruritic, and may be tender or painful. Older lesions may be hyperpigmented. White streaks known as Wickham striae can cross the surface of lesions. These striae also can be present orally, such as in the patient described here. Oral lesions also may be atrophic or erosive.
Common body locations with involvement are the inner wrists, legs, torso, or genitals (glans penis). The face is rarely involved. Nail changes, such as longitudinal ridging and splitting, onycholysis, red lunula, yellow nail syndrome, and pterygium formation, can occur.
Lichen planus often spontaneously resolves on its own, with 2/3 of patients resolving in a year. Mucous membrane disease tends to be more chronic. The etiology of lichen planus is unknown. It may have an autoimmune mechanism in which T cells induce keratinocytes to undergo apoptosis. Between 4% and 60% of lichen planus patients also have hepatitis C infections. The differential diagnosis for cutaneous lesions include lichenoid drug eruption, guttate psoriasis, syphilis, and pityriasis lichenoides et varioliformis acuta. Oral lesions may resemble candidiasis, leukoplakia, malignancies, and bullous disease.
Topical and intralesional steroids are often effective for localized disease. Systemic corticosteroids can be useful when lesions are widespread. Phototherapy, isotretinoin, acitretin, hydroxychloroquine, and oral immunosuppressive agents (such as cyclosporine and mycophenolate mofetil) all have been described in the treatment of lichen planus.
Diagnosis: Lichen Planus
Lichen planus is a common inflammatory condition involving the skin, nails, mucous membranes, and hair follicles. It has no racial predilection, and often affects men and women aged 20-60 years. It is less common in children, who account for only 4% of cases. The lesions are often atypical.
Clinically, patients often present with erythematous to violaceous small, flat-topped, polygonal papules that may coalesce into plaques. Lesions are generally pruritic, and may be tender or painful. Older lesions may be hyperpigmented. White streaks known as Wickham striae can cross the surface of lesions. These striae also can be present orally, such as in the patient described here. Oral lesions also may be atrophic or erosive.
Common body locations with involvement are the inner wrists, legs, torso, or genitals (glans penis). The face is rarely involved. Nail changes, such as longitudinal ridging and splitting, onycholysis, red lunula, yellow nail syndrome, and pterygium formation, can occur.
Lichen planus often spontaneously resolves on its own, with 2/3 of patients resolving in a year. Mucous membrane disease tends to be more chronic. The etiology of lichen planus is unknown. It may have an autoimmune mechanism in which T cells induce keratinocytes to undergo apoptosis. Between 4% and 60% of lichen planus patients also have hepatitis C infections. The differential diagnosis for cutaneous lesions include lichenoid drug eruption, guttate psoriasis, syphilis, and pityriasis lichenoides et varioliformis acuta. Oral lesions may resemble candidiasis, leukoplakia, malignancies, and bullous disease.
Topical and intralesional steroids are often effective for localized disease. Systemic corticosteroids can be useful when lesions are widespread. Phototherapy, isotretinoin, acitretin, hydroxychloroquine, and oral immunosuppressive agents (such as cyclosporine and mycophenolate mofetil) all have been described in the treatment of lichen planus.
This case and photo were submitted by Dr. Damon McClain, a dermatologist in Camp Lejeune, N.C. A 34-year-old male presented with a 1-month history of an itchy rash on his penis and feet. Upon physical examination, these lesions were seen orally. Blood work, including hepatitis serologies, was negative. His skin lesions improved with topical steroids.
Make the Diagnosis - March 2015
Diagnosis: Bleomycin-induced flagellate hyperpigmentation
Bleomycin is an antineoplastic agent. Most reported side effects involve the lung and skin since these organs have lower concentrations of the enzyme that detoxifies bleomycin. Other dermatologic side effects of bleomycin include Raynaud's phenomenon, hyperkeratosis, nailbed changes, and peeling of the skin on the palmar and plantar surfaces.
Flagellate erythema has been described in relation to bleomycin treatment along with other reported associations with peplomycin (a bleomycin derivative), docetaxel, dermatomyositis, adult-onset Still's disease, and shiitake mushroom dermatitis. The rash may appear following administration of bleomycin by any route and has been shown to be dose independent. Onset occurs anytime from 1 day to several months after exposure to the offending agent. Patients typically present with history of itching followed by the appearance of red linear streaks, which are most commonly found on the trunk. Over time, the erythema will resolve to postinflammatory hyperpigmentation.
The exact cause is unknown, but it is thought that scratching causes vasodilation with bleomycin accumulating in the skin. Diagnosis is made by physical examination of the characteristic appearance of the rash along with the history of chemotherapy. A skin biopsy may be performed. In most cases, the rash resolves spontaneously within 6-8 months. Severe rashes may warrant discontinuation of bleomycin. Using antihistamines and topical and oral corticosteroids in conjunction with bleomycin may reduce the incidence of flagellate erythema/hyperpigmentation.
Diagnosis: Bleomycin-induced flagellate hyperpigmentation
Bleomycin is an antineoplastic agent. Most reported side effects involve the lung and skin since these organs have lower concentrations of the enzyme that detoxifies bleomycin. Other dermatologic side effects of bleomycin include Raynaud's phenomenon, hyperkeratosis, nailbed changes, and peeling of the skin on the palmar and plantar surfaces.
Flagellate erythema has been described in relation to bleomycin treatment along with other reported associations with peplomycin (a bleomycin derivative), docetaxel, dermatomyositis, adult-onset Still's disease, and shiitake mushroom dermatitis. The rash may appear following administration of bleomycin by any route and has been shown to be dose independent. Onset occurs anytime from 1 day to several months after exposure to the offending agent. Patients typically present with history of itching followed by the appearance of red linear streaks, which are most commonly found on the trunk. Over time, the erythema will resolve to postinflammatory hyperpigmentation.
The exact cause is unknown, but it is thought that scratching causes vasodilation with bleomycin accumulating in the skin. Diagnosis is made by physical examination of the characteristic appearance of the rash along with the history of chemotherapy. A skin biopsy may be performed. In most cases, the rash resolves spontaneously within 6-8 months. Severe rashes may warrant discontinuation of bleomycin. Using antihistamines and topical and oral corticosteroids in conjunction with bleomycin may reduce the incidence of flagellate erythema/hyperpigmentation.
Diagnosis: Bleomycin-induced flagellate hyperpigmentation
Bleomycin is an antineoplastic agent. Most reported side effects involve the lung and skin since these organs have lower concentrations of the enzyme that detoxifies bleomycin. Other dermatologic side effects of bleomycin include Raynaud's phenomenon, hyperkeratosis, nailbed changes, and peeling of the skin on the palmar and plantar surfaces.
Flagellate erythema has been described in relation to bleomycin treatment along with other reported associations with peplomycin (a bleomycin derivative), docetaxel, dermatomyositis, adult-onset Still's disease, and shiitake mushroom dermatitis. The rash may appear following administration of bleomycin by any route and has been shown to be dose independent. Onset occurs anytime from 1 day to several months after exposure to the offending agent. Patients typically present with history of itching followed by the appearance of red linear streaks, which are most commonly found on the trunk. Over time, the erythema will resolve to postinflammatory hyperpigmentation.
The exact cause is unknown, but it is thought that scratching causes vasodilation with bleomycin accumulating in the skin. Diagnosis is made by physical examination of the characteristic appearance of the rash along with the history of chemotherapy. A skin biopsy may be performed. In most cases, the rash resolves spontaneously within 6-8 months. Severe rashes may warrant discontinuation of bleomycin. Using antihistamines and topical and oral corticosteroids in conjunction with bleomycin may reduce the incidence of flagellate erythema/hyperpigmentation.
This case and photo were submitted by Dr. Damon McClain, a dermatologist in Camp Lejeune, N.C., and by Parteek Singla. A 26-year-old male presented with asymptomatic hyperpigmented streaks on his back. He was receiving chemotherapy for testicular cancer. He received dexamethasone with his first chemotherapy treatment and had no cutaneous eruption at that time. He was not given a steroid with his second dose of chemotherapy. The lesions began an hour after that dose. Initially, the lesions were red and pruritic, and then they turned brown. The patient had no nailfold changes on examination. He had no other medical problems and reported that he had not eaten any unusual foods.
