Lichen planus etc.

Question 1

Histologic findings of lichen planus

Answer 1

orthohyperkeratosis
Wedge-shaped hypergranulosis
Irregular acanthosis w/ saw tooth rete ridges
vacuoles in basal layer (d/t apoptosis)
Band-like lymphocytic infiltrate
vacuoles in basal layer extending or “falling” into superficial dermis (civatte bodies/ cytoid or colloid bodies)

Question 2

Epidemiology (age, m vs f, race) of LP

Answer 2

Most common onset in 5th/ 6th decade
2/3 of pt’s get 30-60yo
women > M in some studies

mucosal involvement seen in up to 75% of cutaneous LP pt’s
10-20% of pts who only present with oral LP develop cutaneous LP

cutaneous LP affects 1% of adults
mucosal LP affects up to 4% of adults

Question 3

Basic LP pathogenesis (model)

Answer 3

various triggers (viral, contact allergen, drug, idiopathic) -> basal keratinocytes express Ag -> T cells target Ag -> lower level basal keratinocytes begin to apoptose

Question 4

Which hepatitis is implicated in which type of LP?

Answer 4

Hep C

Oral ulcerative/ erosive LP

Question 5

Which contact allergens are a/w LP?

Answer 5

mercury amalgam, copper, gold all a/w oral LP

Question 6

Which drugs a/w LP?

Answer 6

HCTZS
BBlockers
ACE inhibitors
antimalarials
TNF-alpha inhibitors
NSAIDS
penicillamine

Question 7

Koebnerization in LP?

Answer 7

VERY common

Question 8

How does hypertrophic and drug induced LP look differently than regular LP (histo)

Answer 8

has eosinophils
Lacks parakeratosis

Question 9

How do EM, FDE, SJS/TEN differ from LP histologically?

Answer 9

EM, FDE, SJS/TEN all have SUPRAbasiar apoptotic keratinocytes
LP has basilar apoptotic keratinocytes

Question 10

Treatment for LP?

Answer 10

RULE OUT DRUG ERUPTION LP - take a good drug history
These drug LP eruptions may persist for MONTHS after starting therapy and after drug discontinuation!

Question 11

First line actual Tx for LP

Answer 11

topical steroids/ intralesional steroids
can use systemic roids for severe LP eruption

Question 12

Treatment ladder AFTER steroids for LP

Answer 12

TCI’s: best for oral lichen planus (tacrolimus )
MTX: useful for generalized LP
Acitretin: effective in Recalcitrant LP
Metronidazole!!!: Generalized LP
Hydroxychloroquine: mainly for Alopecia/ LPP
Oral cyclosporine: Recalcitrant cases
Phototherapy

Question 13

Prognosis of LP?

Answer 13

Most cases (60%) resolve in 1 -2 years

Question 14

Oral (ulcerative), hypertrophic and nail LP tend to last ____

Answer 14

chronic disease

**Increased SCC risk in hypertrophic, oral and vulvovaginal LP

Question 15

What clinical feature is associated with the “Wedge-shape” hypergranulosis seen histologically?

Answer 15

Wickhams striae

Question 16

Make sure to ask oral LP patients about _____ AND examine for other lesions where?

Answer 16

Esophageal symptoms (SCC can develop)
vulvovaginal lesions - genital exam!

Question 17

Which variant of LP?

Answer 17

Lichen planus actinicus

Worldwide (most in Middle Eastern & Indian patients), young adults & children
Sun-exposed sites: forehead, face, neck, dorsal arms/hands in spring/summer
Red-brown annular plaques or melasma-like appearance

Question 18

Which variation of LP is seen?

Answer 18

Annular

Question 19

Which variation of LP?

Answer 19

Acute exanthematous/ eruptive LP

Question 20

which version of LP?

Answer 20

Atrophic

Question 21

Which variation of LP?

What would histology and DIF findings be ?

What pathological basis is this similar to?

Answer 21

LP Pemphigoides

Histo and DIF similar to BP

IgG Ab’s against BP180 (BPAG2)

Question 22

Which variation of LP?

What secondary risks are associated with this variation of LP?

Answer 22

Hypertrophic LP

SCC’s (Keratoacanthoma also)

Question 23

Which variation of LP?

Answer 23

Inverse LP

pink violaceous papules and plaques in axillae/ inguinal/ inframammary folds

Question 24

Which variation of LP?

Answer 24

LP Pigmentosus
brown gray-brown macules / patches on sun-exposed areas of face/neck/flexures/ intertriginous zones (LP Pigmentosus inversus)

No inflammatory phase - no erythema
Skin types 3-4

Question 25

Which variation of LP?

Answer 25

Lichen planopilaris (LPP) Perifollicular hyperkeratosis, erythema, scale, "Follicular convergence or Doll's hairs"

Question 26

What type of hair loss?

Answer 26

Frontal fibrosing alopecia progressive frontotemporal recession, lateral eybrow loss, post-menopausal women treat with 5alpha reductase inhibitors (finasteride)

Question 27

What is graham-little-piccardi syndrome?

Answer 27

Multifocal scarring alopecia on scalp nonscarring alopecia of axilla and groin disseminated spiny follicular papules plus cutaneous OR mucosal LP

Question 28

Describe this

Answer 28

NAIL LP lateral thinning, longitudinal ridging/ fissuring Dorsal pterygium

Question 29

Lichen striatus vs. linear LP Lichen striatus seen in \_\_\_\_, whereas linear LP is seen in Difference in residual after treatment: LS leaves \_\_\_\_pigmented spots, Linear LP leaves \_\_\_pigmented spots

Answer 29

LS seen in kids, usually affects extremity linear LP see in adults LS leaves hypopigmented spots, linear LP (most all types of LP) leave hyperpigmented spots Both dist. along lines of Blaschkoid

Question 30

Describe lesions seen and talk about differential How long does this last? Does it itch?

Answer 30

This is Lichen nitidus, DDx includes lichen sclerosus, lichen spinulosis, lichen planus, papular eczema (KP) Describe: numerous discrete, skin-colored uniform, pinhead-sized flat papules with shiny surface distributed on on flexor aspects of arms, chest, abd, genitals, dorsal hands May itch, likely resolved within 1-2 years

Question 31

What is this diagnosis? Ddx of this?

Answer 31

Erythema dyschromicum perstans Gray-brown patches on trunk/ prox arm, follows skin tension lines *exclusively seen in skin type 3 or 4* asymptomatic slate-gray-brown ovaloid macules and patches, progresses slowly +/- rim of erythema, **usually symmetric/ follows skin cleavage lines** Pathology: multiple dermal melanophages **treatment:? Clofazamine**

Question 32

What is disease talk about epidemiology

Answer 32

Actinic lichen Nitidus aka *summertime actinic lichenoid eruption* young adults, skin types 4/5 affects after prolonged sun

Question 33

Does lichen nitidus koebnerize? How about lichen planus?

Answer 33

Question 34

what is this

Answer 34

Benign lichenoid kerasosis (BLK)

Question 35

Difference between bullous LP and LP pemphigoides?

Answer 35

bullous LP affects older adults, blisters form AT PREVIOUS sites of LP LP pemphigoides pt's have BPAG2 (BP180) autoantibodies, like idiopathic BP bulla arise anywhere on the body in LP pemphigoides and happens at a younger age typically

Question 36

“Classic locations of LP"

Answer 36

Wrists, flexor forearms, presacral area, lower legs, genitals

Question 37

What is seen

Answer 37

Lichen striatus – histopathologic features. In addition to hyperkeratosis with focal parakeratosis, both a lichenoid and a perivascular and periadnexal lymphocytic infiltrate extending into the deeper dermis is seen. ***_you should see the***_ _***bandlike lichenoid infiltrate, with eccrine gland inflammation_*** ***_You should also see lichenoid/ perivascular and_** _periadnexal lymphocytic infiltrate extending into deep dermis_*

Question 38

What is seen histologically

Answer 38

Lichen nitidus – histopathologic features. Note the typical “ball and claw” configuration for the infiltrate and epidermis, respectively. There is thinning of the epidermis that overlies the infiltrate. Several Langhans giant cells are within the infiltrate (inset). **A discrete interstitial aggregate of mononuclear cells expands one dermal papilla to form the typical lesion of LN. This expansion causes adjacent rete ridges to bow outward and this creats the collarette of inflammatory cells (ball n claw)** ***there is epidermal thinning overlying the colarette, there is basal cell vacuoles, rarely necrotic keratinocytes, parakeratosis overlying the epidermal thinning***

Question 39

Histological differences between LP and drug induced LP

Answer 39

In drug eruption LP → Parakeratosis, NORMAL granular layer, eosinophils, perivascular AND / OR bandlike lymphocytic infiltrate+ plasma cells within infiltrate Both conditions show (civatte bodies, wedge shaped hypergranulosis and hyperkeratosis) **but only drug eruption will have eos**

Question 40

Lichen planus leaves behind \_\_\_\_pigmented spots Lichen Striatus leaves behind ____ pigmented spot

Answer 40

LP → hyperpigmented L Striatus → hypopigmented, CAN involve nail, think eccrine gland inflammation