A clinicoepidemological study of Lichen planus pigmentosus and its association with metabolic syndrome and cutaneous manifestations in Indian population

Rozy Badyal; Ramesh Kumar Kushwaha; Arti Singh Rajput; Suresh Kumar Jain; Asha Nyati; Devendra Yadav

doi:10.4103/Pigmentinternational.Pigmentinternational_

ORIGINAL ARTICLE

Year : 2020 | Volume : 7 | Issue : 1 | Page : 26-31

A clinicoepidemological study of Lichen planus pigmentosus and its association with metabolic syndrome and cutaneous manifestations in Indian population

Rozy Badyal, Ramesh Kumar Kushwaha, Arti Singh Rajput, Suresh Kumar Jain, Asha Nyati, Devendra Yadav
Department of Dermatology, Venereology and Leprology, Government Medical College, Kota

Date of Submission	04-Jan-2019
Date of Decision	27-Feb-2019
Date of Acceptance	12-May-2019
Date of Web Publication	10-Jul-2020

Correspondence Address:
Dr. Suresh Kumar Jain
Department of Dermatology, Venereology and Leprology, Government Medical College, Kota, 324005, Rajasthan

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/Pigmentinternational.Pigmentinternational_

Abstract

Background: Lichen planus pigmentosus (LPP) is considered an infrequent variant of Lichen planus (LP) clinically characterized by insidious onset of discrete, ill-defined, and dark brown or slate gray macules, primarily appearing over sun-exposed areas and flexures. Materials and method: This was a cross-sectional study conducted over a period of 1 year from July 2017 to July 2018 among the patients attending the OPD of the Department of Dermatology, Government Medical College, Kota, India. This study evaluated the LPP and its association with metabolic syndrome and cutaneous manifestations. Serum high-density lipoprotein (HDL)-cholesterol (HDL-C) and triglycerides (TG) were measured with enzymatic procedures. Plasma glucose was measured using hexokinase method. Results: There were 16 (32.0%) males and 34 (68.0%) females affected with LPP. Majority of the patients were in the age group of 40 to 49 years [15 (30.0%)] and above 50 years [16 (32.0%)]. Diabetes mellitus type 2 was reported among 17 (34.0%), hypertension among five (10.0%), and obesity among five (10.0%) patients. Increased low-density lipoprotein (LDL) and very LDL was found among 15 (30.0%) patients and decreased HDL was found among 19 (38.0%) patients. Conclusion: A 34.0% prevalence of metabolic syndrome was found in patients with LP. Central obesity, increased fasting blood sugar (FBS), and low HDL-C were the metabolic syndrome parameters found to be more common in patients with LP in our study.

Keywords: dermascopy, lichen planus pigmentosus, metabolic syndrome

How to cite this article:
Badyal R, Kushwaha RK, Rajput AS, Jain SK, Nyati A, Yadav D. A clinicoepidemological study of Lichen planus pigmentosus and its association with metabolic syndrome and cutaneous manifestations in Indian population. Pigment Int 2020;7:26-31

How to cite this URL:
Badyal R, Kushwaha RK, Rajput AS, Jain SK, Nyati A, Yadav D. A clinicoepidemological study of Lichen planus pigmentosus and its association with metabolic syndrome and cutaneous manifestations in Indian population. Pigment Int [serial online] 2020 [cited 2023 Mar 26];7:26-31. Available from: https://www.pigmentinternational.com/text.asp?2020/7/1/26/289331

Introduction

Lichen planus pigmentosus (LPP) has been described as a condition of unknown etiology that clinically differs from the classic lichen planus (LP) by exhibiting dark brown macules and/or papules, mottled or reticulated hyperpigmentation, and a longer clinical course. The most common sites of involvement are the face and neck and the flexural folds.^[1],[2] The most common pattern of pigmentation is diffuse, whereas less common patterns include reticular, blotchy, unilateral linear, and perifollicular patterns.

Pruritus may be present in the early active stage, and disease often runs a prolonged clinical course. LPP is frequently reported in Indians, recently described among Latin Americans, Middle Easterners, Koreans, and Japanese.^[3],[4]

It affects not only sun-exposed areas of the face and neck but also sun-protected flexural skin, such as the axillae and inguinal areas. It is common in middle-aged patients with dark skin and is rare in Caucasians. LPP causes emotional stress due to its aesthetic appearance and chronic nature. Moreover, it may be associated with other disorders such as hepatitis C virus (HCV)-induced liver disease, endocrinopathies, and autoimmune diseases as well as other variants of LP and its sequelae.^[5],[6],[7]

LP has been associated with metabolic disorders such as dyslipidemia and diabetes mellitus.^[8] Antioxidant defense mechanisms are significantly altered in LP causing an increase in oxidative damage to lipids, protein, and DNA, which may be involved in inflammatory processes of the disease.^[9] Epidermal cells in LP have shown abnormalities in enzymatic activity and defective carbohydrate expression.^[10] As a relatively common immune-mediated disorder, LP may serve as an external indicator of underlying immune and metabolic dysfunction.

The objective of this study was to evaluate the LPP and its association with metabolic syndrome and cutaneous manifestations.

Materials and method

This was a cross-sectional study conducted over a period of 1 year from July 2017 to July 2018 among the patients attending the OPD of the Department of Dermatology, Government Medical College, Kota, India. Data were collected from all the patients in a pretested structured questionnaire and the data were analyzed using appropriate statistical software. Venous blood samples were taken at enrolment visit after the patients had fasted overnight. Serum high-density lipoprotein (HDL)-cholesterol (HDL-C) and triglycerides (TGs) were measured with enzymatic procedures. Plasma glucose was measured using hexokinase method. Metabolic syndrome was identified in the presence of three or more criteria of the modified National Cholesterol Education Program: Adult Treatment Panel III (NCEP-ATP III) guidelines [Table 1]. The data was entered into the Microsoft Excel and the statistical analyses were performed with the SPSS/PC software (version 21.0 for Windows; SPSS Inc., Chicago, IL, USA).

Table 1 Modified National Cholesterol Education Program: Adult Treatment Panel III criteria for clinical diagnosis of metabolic syndrome

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Results

There were 16 (32.0%) males and 34 (68.0%) females. The lesions were found to be maximum in the age group of 40 to 49 years [15 (30.0%)] and above 50 years [16 (32.0%)]. Oral lesions were found among 13 (26.0%) patients. Associated LP was found among 14 (28.0%) patients. Family history was positive among two (4%) patients. Pruritus was found among 10 (20.0%). History of dye and history of amla and heena application was reported by eight (16.0%) patients each [Figure 1] and [Figure 2] and [Table 2].

Figure 1 (A) Lichen planus pigmentosus lesions on face with oral lichen planus. (B) Lichen planus pigmentosus start with lesions on periorbital area. (C) Ill-defined round to oval grayish macules present over the trunk.

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Figure 2 (A) Diffuse slate–gray pigmentation on neck spreading to face with palmoplantar lichen planus. (B) Lichen planus pigmentosus lesions on trunk.

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Table 2 Demographic data of study participants

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Diabetes mellitus type 2 was reported among 17 (34.0%), hypertension among five (10.0%), and obesity among five (10.0%) patients. Increased LDL and VLDL was found among 15 (30.0%) and decreased HDL was found among 19 (38.0%) patients.

Acanthosis nigricans were found among two (4.0%) patients.

Dermoscopy showed dots and globules that were found among 20 (42.5%), blue–gray dots found among eight (21.6%), blue–gray globules found among six (12.7%), and pseudonetwork among 13 (35.1%). Woods lamp examination was found to be positive among five (10.0%) patients.

Discussion

LP is an immune-mediated disease and antigens are processed by Langerhans cells and then presented to T lymphocytes. Several cytokines such as tumor necrosis factor-alpha, interleukin (IL)-6, IL-10, and IL-4 are involved in pathogenesis of LP that explains its association with lipid metabolism disturbances such as increased serum TG and decreased HDL-C, which in turn increases cardiovascular risk.^[9] As a common inflammatory disorder affecting 0.22% to 5% of population worldwide, LP may serve as an external indicator of underlying immune and metabolic dysfunction.^[11] There was a paucity of literature regarding the prevalence of metabolic syndrome among the patients with LPP.

In the present study, there was a female preponderance with a female-to-male ratio of 2.1:1 for LPP. LP affects 0.5% of the general population with predominance in women. Nosratzehi et al.,^[12] Panchal et al.,^[9] and Atefi et al.^[13] found LP predominant in females [Table 3].

Table 3 Comparison of metabolic syndrome in lichen planus and its variant in previous studies

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Its onset is usually in the fourth and fifth decades of life as reported in the literature that was also found in the present study. In the study by Zakaria et al.,^[14] 38.8% of patients with LP were in the fourth decade and the mean age was found to be 33.7 ± 11.2 years that was similar to the present study. Manzoor et al.^[15] also observed that the age of the patients varied from 15 to 54 years with 80% of the patients belonging to the 20 to 40 years age group.

In LPP inversus, brown homogeneous areas that represent epidermal pigmentation have been described on dermoscopy in addition to gray–brown or gray–blue dots and globules that represent pigmentary incontinence and melanophages in the papillary dermis. These gray dots are initially grouped in a diffuse black pepper-like pattern, but with time, they converge to form reticular, linear, and cobblestone patterns. White dots are secondary to lack of pigmentation in the follicular openings, and the absence of pigment in skin furrows may be due to lack of exposure to friction.^{[16],[17],[18]}

In histopathology, vacuolar degeneration of the epidermal basal cell layer, band-like lichenoid or perivascular lymphocytic infiltrates in the papillary dermis, as well as superficial pigmentary incontinence and melanophages are seen in LPP. Other less common findings are hyperkeratosis and epidermal atrophy. In older lesions, marked pigmentary incontinence, melanophages, decrease in vacuolar degeneration, and slight perivascular lymphocytic infiltrate are observed. Immunofluorescence reveals globular deposition of immunoglobulin M in the papillary dermis and dermal–epidermal junction in a minority of cases.^[5],[6],[7]

In our study, hypertension was present among 10.0% and obesity among 10.0% patients. Increased LDL and VLDL was found among 30.0% patients and decreased HDL was found among 38.0% patients. Current study showed high prevalence of diabetes mellitus and impaired glucose tolerance of 34.0% and 28%, respectively, in patients with LPP.

Nosratzehi et al.^[14] investigated the relationship between impaired glucose tolerance or diabetes and the pattern of distribution of lichenoid lesions. In the study by Hashba et al.,^[19] it was noted that hypertension was present among 18.6% patients, elevated fasting blood glucose in 54.3%, hypertriglyceridemia among 34.3%, and decreased HDL-C in 56.8% females and 36.4% males, which was quite similar to the present study.

Arias–Santiago et al.^[20] reported a significant higher prevalence of hypertriglyceridemia and decreased HDL-C in patients with LP. Higher values of TG and low levels of HDL-C were associated with transition from atheroma to atherothrombosis and thereby increased cardiovascular risk.^[20] Polic et al.^[21] have shown that dietary regulation of the imbalanced concentrations of serum lipids leads to improvement in clinical signs of LP, thus confirming the connection between dyslipidemia and LP.

Baykal et al.^[22] found that among the various metabolic syndrome parameters, fasting blood glucose and diastolic blood pressure were seen to be significantly higher in patients with LP. Increased fasting blood sugar (FBS) was noted among 52.6% patients with skin LP and 59% patients with oral LP; but there was no statistical significance. The association between oral LP and diabetes was first reported by Grispan et al.^[23] Lopez-Jornet et al.^[24] reported a higher prevalence of diabetes mellitus in oral LP. The majority of female patients in this study had low HDL-C level, but it was found to be normal in most of the male patients. However, in contrast to this study, a significantly lower HDL-C values were reported in male patients with oral LP in a case–control study by Lopez-Jornet et al.^[24]

HCV,^[25] mustard oil, amla oil, henna, and hair dye could be precipitating factors in predisposed individuals. The association between HCV and LP has been extensively reviewed and the results suggest that LP, mainly the oral type, is significantly associated with HCV infection in certain geographic areas.^[26] Regarding LPP, the prevalence of positive serology for HCV is 60.6% in one study.^[25] However, it would be difficult to conclude that there is a positive association between the two conditions in regions with a high prevalence of HCV infection.

The knowledge about the pathogenesis of LP and various cytokines involved could potentially explain the link between LP and metabolic syndrome and its various components. Our study, thus, highlights that chronic inflammation in patients with LP might explain the association with dyslipidemia. The presence of metabolic syndrome and its components markedly increase the risk of cardiovascular events. Therefore, it is important to advise our patients to adopt healthy lifestyle choices as an easy first step to help prevent comorbidities and improve the general health of population.

Conclusion

A 34.0% prevalence of metabolic syndrome was found in patients with LPP. Central obesity, increased FBS, and low HDL-C were the metabolic syndrome parameters found to be more common in patients with LPP in our study. As increased waist circumference is an easily measurable parameter, it may be taken as an indicator for the occurrence of metabolic syndrome in patients with LPP and a guide to look for the presence of other components of metabolic syndrome. Chronic inflammation in patients with LP might explain its association with metabolic syndrome and its various components. Screening of patients with LPP for metabolic syndrome might be useful in detecting individuals at risk and initiating preventive measures to protect against the development of cardiovascular disorders later in life.[27]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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