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| LETTER TO EDITOR |
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| Year : 2016 | Volume
: 3
| Issue : 2 | Page : 114-115 |
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Lichen planus pigmentosus masquerading as ‘Raccoon eyes’
Amanjot K Arora1, Muthu S Kumaran1, Uma N Saikia2, Tarun Narang MD 1
1 Department of Dermatology, Venereology and Leprology, PGIMER, Sector-12, Chandigarh, India
2 Histopathology, PGIMER, Sector-12, Chandigarh, India
| Date of Web Publication | 27-Dec-2016 |
Correspondence Address:
Dr. Tarun Narang
Assistant Professor, Department of Dermatology, Venereology and Leprology, PGIMER, Sector-12, Chandigarh 160 012
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2349-5847.196305
How to cite this article:
Arora AK, Kumaran MS, Saikia UN, Narang T. Lichen planus pigmentosus masquerading as ‘Raccoon eyes’. Pigment Int 2016;3:114-5 |
Sir,
Lichen planus pigmentosus (LPP) is an uncommon variant of lichen planus occurring in middle-aged individuals presenting as hyperpigmented macules especially over the head and neck. Recently, involvement of atypical sites and morphologic presentation by LPP have been stressed. Herein, we present one such case.
A 44-year-old housewife presented with progressively worsening asymptomatic hyperpigmentation in the periorbital area for the last 3 months. There was no history of trauma, inflamed skin lesions or drug intake prior to the onset of pigmentation. Clinical examination revealed ill defined slate grey patches involving the medial aspect of both lower eyelids and lateral aspect of the right upper eyelid. Similarly, faint, ill-defined slate grey macules were also observed over the perioral region [Figure 1]. On dermoscopic examination brownish grey pigment dots were observed sparing the eccrine openings [Figure 2]. | Figure 1: Well-defined slate grey patches in the periorbital and perioral area
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 | Figure 2: Dermoscopic examination of periorbital lesions showing brownish grey pigment dots sparing the eccrine openings
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Patch and photopatch tests were done with the Indian standard series, cosmetic series and the patient’s own cosmetic products, which included an eye pencil and a cold cream. They showed a positivity of 1+ only to nickel at 96 hours with no photoaccentuation. Histopathology demonstrated a thin epidermis with focal basal cell vacuolar degeneration. Upper dermis demonstrated marked melanin incontinence with numerous melanophages and perivascular and perifollicular lymphocytic infiltrate suggesting LPP [Figure 3]. The patient was prescribed mid potent topical steroids and sunscreen. All her earlier cosmetics were discontinued. At one month of follow-up, the patient reported stabilization of disease activity with minimal improvement in hyperpigmentation. | Figure 3: Photomicrograph showing thin epidermis with focal basal cell vacuolar degeneration. Upper dermis shows marked melanin incontinence with numerous melanophages and perivascular and perifollicular lymphocytic infiltrate (Haematoxylin and Eosin stain ×20)
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Periorbital hyperpigmentation (POH) can be ascribed to various causes: idiopathic POH [also known as idiopathic cutaneous hyperchromia of the orbital region] or secondary POH due to genetic tendency, excessive pigmentation akin to dermal melanocytosis, post-inflammatory hyperpigmentation secondary to atopic, allergic contact dermatitis, pigmented cosmetic dermatitis (PCD; also known as Riehl’s melnosis), an extension of pigmentary demarcation lines over the face, excessive subcutaneous vascularity, and tear trough associated with ageing.[1],[2]
LPP is commonly found in Fitzpatrick phototypes III–V, especially in patients of Indian, Latin American or Middle Eastern origin.[3] It presents as homogenously coloured brown to slate blue to steel grey ill-defined macules located most commonly on the face and neck region with pre-auricular and temple regions being the areas of initial affliction.[3] Atypical presentations of LPP, which have been described so far in literature, include blaschkoid, zosteriform, segmental, and inversus patterns.[4] However, this peculiar pattern of periocular involvement mimicking a Raccoon’s eye, as in our case, has not been described so far. Main differential diagnosis includes PCD, which presents with a clinically overlapping picture that can pose a diagnostic enigma. It is a non-eczematous allergic contact dermatitis, secondary to allergens in cosmetics such as fragrances (e.g. benzyl salicylate, cinnamic derivative, balsam of Peru), pigments, and lanolin applied to the sites affected.[3] Tienthavorn et al.[3] reported patch test positivity in 80% cases with PCD and only 36.36% cases of LPP with nickel sulfate being the most common allergen. Although nickel allergy may be the most prevalent on patch testing this group of patients, it is usually of no clinical relevance.[5] Similarly, although lichenoid infiltrate is encountered most commonly in LPP, it may not be found always.[3] Thus, pigmentary disorders affecting the face cannot be delineated by specific histopathological or patch testing criteria.
This report portends to exemplify that LPP presents in various unusual patterns of distribution. Thus, atypical patterns of LPP should be kept in mind while dealing with disorders of hyperpigmentation, especially over the face, to avoid any delay in diagnosis and treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Sarkar R. Idiopathic cutaneous hyperchromia at the orbital region or periorbital hyperpigmentation. J Cutan Aesthet Surg 2012;5:183-4.  [ PUBMED]  |
| 2. | Besra L, Jaisankar TJ, Thappa DM, Malathi M, Kumari R. Spectrum of periorbital dermatoses in South Indian population. Indian J Dermatol Venereol Leprol 2013;79:399-407. [ PUBMED] |
| 3. | Tienthavorn T, Tresukosol P, Sudtikoonaseth P. Patch testing and histopathology in Thai patients with hyperpigmentation due to Erythema dyschromicum perstans, Lichen planus pigmentosus, and pigmented contact dermatitis. Asian Pac J Allergy Immunol 2014;32:185-92. |
| 4. | Mahajan R, Kumaran MS, Parsad D. Lichen planus pigmentosus: A retrospective clinico-epidemiologic study with emphasis on the atypical variants. Pigment Int 2014;1:90-4. |
| 5. | Thyssen JP, Linneberg A, Menné T, Nielsen NH, Johansen JD. No association between nickel allergy and reporting cosmetic dermatitis from mascara or eye shadow: A cross-sectional general population study. J Eur Acad Dermatol Venereol 2010;24:722-5. |
[Figure 1], [Figure 2], [Figure 3]
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