|Year : 2021 | Volume
| Issue : 2 | Page : 100-108
A cross-sectional observational study of clinicodermatoscopic features in cutaneous lichen planus in Indian skin
Ashiwini S Tatawati, Bhavana R Doshi MD, DDV, FIDD , Basavapurada Swamy Manjunathswamy
Department of Dermatology, Venereology and Leprosy, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
|Date of Submission||08-Mar-2020|
|Date of Decision||20-Oct-2020|
|Date of Acceptance||06-Jan-2021|
|Date of Web Publication||22-Jul-2021|
Dr. Bhavana R Doshi
Associate Professor, Department of Dermatology, Venereology and Leprosy, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka 590010
Source of Support: None, Conflict of Interest: None
Background: Lichen planus (LP) is a papulosquamous skin disorder characterized by violaceous polygonal papules and plaques associated with itching. Dermoscopy in LP shows variable forms of whitish structures that correlate with Wickham striae (WS), vascular structures, and pigmentary changes that aid in its diagnosis. Aim: To study the correlation between clinical and dermatoscopic features in cutaneous variants of LP in Indian skin. Method: Patients with LP presenting over a period of 1 year were included. Dermoscopy of the lesions in polarized mode was done using video dermatoscope − Dino-Lite Premier AM4113ZT model. Both clinical and dermoscopy findings were photographed, recorded, and studied. Result: Fifty-six percent patients (39/70) had classical LP (CLP), 14% patients (10/70) had hypertrophic LP which were the most common clinical variants. Reticulate pattern of WS was the most common pattern observed in 40% (28/70) cases and a new rosette pattern of WS was observed in 13% (9/70) cases. Nonvascular findings such as WS, comedo-like openings, and grey blue dots showed statistically significant association with CLP. Among the pigmentary findings, pepper-like pigmentation was seen in 64% (25/39) CLP and reticulate pattern of pigmentation in 85% (6/7) cases of LP pigmentosus. Perifollicular pigmentation showed statistical significance in 100% cases of lichen planopilaris. Conclusion: In view of consistent dermoscopic features observed in LP, it aids as a valuable noninvasive diagnostic tool, many a times obviating the need for skin biopsy. Limitations: Small sample size and the exclusion of lesions of LP over the nails, genitals, and oral mucosa.
Keywords: Dermatoscopy, lichen planus, rosette pattern, Wickham striae
|How to cite this article:|
Tatawati AS, Doshi BR, Manjunathswamy BS. A cross-sectional observational study of clinicodermatoscopic features in cutaneous lichen planus in Indian skin. Pigment Int 2021;8:100-8
| Introduction|| |
Lichen planus (LP) is an inflammatory mucocutaneous condition characterized by distinct morphological and histopathological features. Classically presents as itchy lesions described as “pruritic, purple, polygonal, planar, papules, and plaques.” Dermoscopy is a method of visualizing subsurface skin patterns. The dermoscopic examination of LP helps in clinching the diagnosis and noting the improvement during follow-up. However, these features may vary in patients with fair and dark skin. A study of dermoscopic features of LP in Fitzpatrick skin type IV–V encountered in Indian population are few, hence we undertook this study to correlate clinical and dermatoscopic features of cutaneous LP.
| Materials and methods|| |
After the institutional ethics committee approval, during the study period of 1 year between January 1, 2018 and December 31, 2018 a total of 70 treatment naïve cases, irrespective of age and sex with clinical features of LP were included. Those cases with lesions of LP occurring solely over the oro-genital mucosa or only the nail were excluded. The sample size was calculated using the formula
where, n is the sample size required, p is the proportion or prevalence, E is the error, and Z is the value corresponding to level of confidence required.
In an Indian study by Makhecha et al., the prevalence of cutaneous lichen planus in LP was 77%, that is, p = 0.77. The absolute error when taken as 10% with 95% confidence level, the sample size was calculated to be
An informed written consent form was obtained after which detailed history was collected and dermatological and systemic examination was carried out. Clinical photographs of the lesions were taken. Diagnosis of LP was made after clinical examination. Clinically doubtful cases were included only after confirmatory biopsy report. Dermoscopic examination of the lesions was performed using the video dermatoscope − Dino-Lite Premier digital microscope AM4113ZT model by AnMo Electronics Corporation, Taiwan, using 50× and 200× optical magnification in polarized mode and photographs were recorded. The data and photographic record was noted in a predesigned pro forma and the dermoscopic findings were correlated with the clinical findings. The data was analyzed with R i386 3.5.1 software and Microsoft excel. Data was summarized as mean ± SD for continuous variable and categorical variables were represented using percentages. Comparison of categorical variable with severity is done using Fisher test and chi-square tests. P-value <0.05 was considered as significant.
| Results|| |
Out of 70 subjects, a majority, that is, 31% (22/70) was in the age group of 31 to 40 years (mean age: 40.33, age range 11–75 years). No gender predilection was noted (M:F–1:1). The mean duration of illness was within 1 to 6 months seen in 5.71% (53/70) subjects.
Majority of the subjects complained of itching 54.29% (38/70) while 10% (7/70) cases reported no itching at the time of presentation. The lesions of LP were located most commonly over lower limbs in 68% (48/70) cases, followed by 58% (41/70) cases over upper limb, and least commonly seen over the palmoplantar areas 5% (4/70).
Koebner phenomenon (KP) was seen in 50% (35/70) cases. Associated conditions with LP seen in our subjects were 12.86% (9/70) with diabetes, 11.43% (8/70) with hypertension, 2.86% (2/70) with thyroid disease, and least 1.43% (1/70) having underlying cardiovascular disease.
Of the clinical variants of cutaneous LP encountered, majority were of classical LP (CLP) 55.71% (39/70), hypertrophic LP (HLP) was seen in 14.29% (10/70) and both coexistent CLP and HLP was seen in 12.86% (9/70), while 10% (7/70) were of LP pigmentosus. Actinic LP and lichen planopilaris was seen in 2.86% (2/70) cases each, with a single case of linear LP 1.43% (1/70) as depicted in [Table 1].
|Table 1 The cutaneous variants of LP with the frequency of clinical occurrence|
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The dermoscopy findings were divided into vascular, nonvascular, and pigmentary findings.
Vascular findings in the form of red dots were seen in 68.57% (48/70) of the total subjects whereas red lines were seen in 55.71% (39/70) subjects.
Nonvascular findings studied were Wickham striae (WS), comedo-like openings, and grey blue dots. Among the total of 70 subjects, WS were seen in 86% (50/70) subjects and were absent in 14% (20/70) subjects. The most common pattern of WS observed was the reticulate pattern seen in 40% (28/70) cases [Figure 1]a and b, followed by the radial streaming pattern seen in 32.86% (23/70). Other patterns of WS observed were the rosette pattern in 12.86% (9/70) cases [Figure 2]a and b, venation pattern in 5.71% (4/70) cases, and linear pattern of WS in 8.57% (6/70) cases with annular [Figure 3]a and b and structureless pattern of WS in 4.29% (3/70) cases each respectively. Interestingly we observed a new rosette or petaloid pattern of WS in 12.86% (9/70) cases, which is so far not mentioned in literature. The various patterns of WS observed in our study are enlisted in [Table 2].
|Figure 1 (a) Lesion of classical lichen planus. (b) Reticulate pattern of Wickham striae in the same lesion on dermoscopy at 50× magnification in polarized mode.|
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|Figure 2 (a) Lesion of classical lichen planus. (b) Petaloid pattern of Wickham striae in the same lesion on dermoscopy at 50× magnification in polarized mode.|
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|Figure 3 (a) Lesion of annular lichen planus. (b) Annular pattern of Wickham striae in the same lesion on dermoscopy at 50× magnification in polarized mode.|
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We also observed combinations of different patterns of WS in individual patient in our study as described in [Table 3] , such as radial with rosette pattern in 4% (3/70) cases, reticulate and radial pattern along with reticulate and annular pattern in 3% (2/70) cases each respectively. The combination of reticulate with rosette and with linear was seen in 1% (1/70) cases each. The triple combination pattern was observed in the same patient included the reticulate with radial and annular pattern of WS, reticulate with venation and rosette pattern of WS, and radial with rosette and linear pattern of WS in 1% (1/70) cases each.
|Table 3 Different patterns and combinations of Wickham striae on dermoscopy|
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Comedo-like opening was seen in 31.43% (22/70) of subjects and grey blue dots were seen in 31.43% (22/70) of subjects.
Pigmentary findings observed in our study were in the form of pepper-like pigmentation in 48% (34/60) cases of cutaneous LP, followed by brown globules in 40% (28/60) cases of cutaneous LP. Though reticulate pigmentation was seen in 11.66% (7/60), it was observed 100% (7/7) cases of LP pigmentosus. Perifollicular pigmentation was seen in 4.29% (3/60) cases which is shown in [Table 4].
Red dots were commonly seen in 79% (31/39) CLP followed by cases with combination of CLP and HLP in 88% (8/9). Cases of linear LP and lichen planopilaris in our study showed absence of red dots. Red dots were significantly associated with lesions of LP (P <0.05) though red lines were not significantly associated with the lesions. However, it was observed to be a consistent feature in actinic LP 100% (2/2), linear LP 100% (1/1), and lichen planopilaris 100% (1/1). [Table 5] shows the correlation between the clinical variants and vascular (red dots and red lines) findings.
|Table 5 Correlation between clinical variants and vascular findings (red dots and red lines) and nonvascular findings (comedo-like opening and grey blue dots) on dermoscopy|
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Comedo-like opening was seen 100% (9/9) in cases with combination of CLP and HLP and 80% (8/10) in cases with HLP [Figure 4]a and b. Grey blue dots were most commonly associated with cases having a combination of CLP and HLP 88% (8/9) and individually 40% (4/10) in cases of HLP and 25% (10/39) in cases of CLP [Figure 5]a and b. LP lesions were significantly associated with occurrence of nonvascular features (comedo-like opening and grey blue dots) with P < 0.05 as shown in [Table 6].
|Figure 4 (a) Lesion of hypertrophic lichen planus. (b) Comedo-like opening (blue arrow) in the same lesion on dermoscopy at 50× magnification in polarized mode.|
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|Figure 5 (a) Lesion of classical lichen planus. (b) Grey blue dots in the same lesion on dermoscopy (blue arrow) at 50× magnification in polarized mode.|
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|Table 6 Correlation between clinical variants and nonvascular findings (comedo-like opening and grey blue dots) on dermoscopy|
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In our study, brown globules and pepper-like pigmentation showed significant association with lesions of LP (P < 0.05). Brown globules were associated with actinic LP in 100% cases (2/2), linear LP in 100% (1/1), followed by HLP in 80% (8/10) cases. Pepper-like pigmentation was significantly associated with linear LP 100% (1/1), followed by CLP 64% (25/39), actinic LP 50% (1/2) [Figure 6]a and b, and least in HLP 22% (2/10) and was absent in lesions of LP pigmentosus and lichen planopilaris. Reticulate pigmentation was associated with LP pigmentosus 86% (6/7), respectively [Figure 7]a and b followed by lichen planopilaris 50% (1/2) and was absent in other variants. In our study we observed that perifollicular pigmentation was associated with lichen planopilaris 100% (2/2) [Figure 8]a and b, followed by LP pigmentosus 14% (1/7) and was absent in other clinical variants of LP.
|Figure 6 (a) Lesion of actinic lichen planus. (b) Pepper-like pigmentation in the same lesion on dermoscopy at 50× magnification in polarized mode.|
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|Figure 7 (a) Lesion of lichen planus pigmentosus on the face. (b) Reticulate pigmentation on dermoscopy at 50× magnification in polarized mode.|
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|Figure 8 (a) Lesions of lichen planopilaris. (b) Perifollicular pigmentation on dermoscopy at 50× magnification in polarized mode.|
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| Discussion|| |
In our study, majority of patients 31% (22/70) were in the age group of 31 to 40 years and least 7% (5/70) in age group of 21 to 30 years (mean 40.33, age range 11–70 years). Maximum patients observed in abovementioned studies were also in the range of 31 to 40 years as in our study.,,
In our study, majority of subjects 75% (53/70) presented with duration of lesions ranging between 1 and 6 months and about 10% (7/70) had lesions between 7 and 12 months duration (mean 8.13 months). These findings were consistent with the studies by Bhattacharya M et al. (74%) and Singh OP et al. (85%).
KP was seen in 50% (35/70) of our cases, mostly over the trauma-prone areas and areas accessible for scratching. Bhattacharya et al. also similarly observed KP in 51% of cases with CLP.
In our study, CLP accounted for 55% (39/70) of cases, followed by 14% (10/70) of HLP [Figure 2], 12% (9/70) cases of both coexisting CLP and HLP, 10% (7/70) cases of LP pigmentosus, and the least number of cases with 1.43% (1/70) by linear LP. In a study by Bhattacharya et al., CLP was the commonest presentation (47.4%), followed by HLP (14.2%), actinic LP (11%), and linear LP (4%). Garg et al. showed 30% subjects of CLP, 20% of HLP, 14% of LP pigmentosus, 4% of actinic LP, and 4% of lichen planopilaris. In all the above studies, CLP was the most common clinical variant encountered similar to the findings in our study.
Vascular findings using dermoscopy in our study showed red dots in 68% (48/70) and red lines in 55% (39/70) patients. Red dots were mostly seen in the patient with CLP 79% (31/39), followed by HLP 60% (6/10), actinic LP 50% (1/2), and were absent in cases of lichen planopilaris and LP pigmentosus. Red lines were seen in patient of actinic LP (100%), lichen planopilaris (100%), linear LP (100%), and CLP (56%). Vazquez-Lopez et al. observed that red lines 3 (12%) and dotted vessels 20 (80%) were more frequently found in CLP. In a study by Güngör et al. of 170 CLP lesions, red dots were noted in 27 lesions (15.9%) and radial linear vessels in 19 lesions (11.1%). Further, in cases of actinic LP and LP pigmentosus no vascular findings were seen on dermoscopy in their study. In a study by Garg et al. of 50 patients, out of 15 cases of CLP lesions 3 cases (20%) showed red dots and out of 10 lesions of HLP, 2 (20%) showed red dots whereas lesions of actinic LP and LP pigmentosus showed no vascular findings. The findings of red dots were seen maximum in CLP and were absent in cases of LP pigmentosus as mentioned in above studies as well as in our study.
WS in lesions of LP was seen in a total of 60 out of 70 (86%) subjects in our study and was absent in 10 out of 70 (14%) cases of lichen planopilaris and LP pigmentosus. Majority 40% (28/70) of subjects had reticulate pattern of WS in the lesions of LP followed by radial streaming pattern of WS 32% (23/70), the rosette pattern 13% (9/70), linear pattern 8% (6/70), and venation pattern 5.71% (4/70). Also, in 13 subjects, WS was observed in multiple or overlapping patterns in the same patients. In a study by Lallas et al., white crossing lines (WS) were seen exclusively in LP in 24 out of 25 patients (96%) and showed significant p P-value. The study by Güngör et al. showed WS in 89.4% of CLP followed by 40% cases of lichen planopilaris and was found to be absent in LP pigmentosus and actinic LP. In a study by Garg et al., WS was seen in 14 CLP cases (93.3%), 9 HLP cases (90%), 2 actinic LP cases (50%), and was absent in LP pigmentosus cases. Most common pattern of WS observed was the reticulate pattern (64.7%) followed by linear (7.6%), radial (5.2%), and annular pattern (1.1%), and combination was observed in 1.7% cases. The findings in our study were near similar to abovementioned study by Garg P et al. In our study, we came across a rosette/petaloid pattern of WS, which has not been mentioned till date in the literature. This rosette pattern was also seen in combination with other patterns of WS in the same patients group. Rosette pattern of WS was commonly seen only with lesions of less than 1 month duration, but it did not show a statistical significance with respect to duration, probably due to the smaller sample size of our study.
Comedo-like opening was seen in 31.43% (22/70) of our patients and most commonly in those with 80% (8/10) HLP and 12% (5/39) of CLP. We observed significant association between the HLP and comedo-like openings in our study. In the study by Garg et al., comedo-like openings were noted in 50% of HLP and 20% of CLP and were found to be significantly associated with the clinical subtypes. The study by Hanumaiah et aland Joseph also showed comedo-like openings to be significantly associated with HLP 86% (26/30). The significant association of comedo-like opening in HLP was similar to the studies mentioned above.
In our study, 31.43% (22/70) patients had grey blue dot finding which was mostly seen in HLP 40% (4/10) and CLP 25% (10/39). Vazquez-Lopez et al. observed 20% of CLP had grey blue dots and found to be absent in other variants of LP. Garg et al. in their study showed 13% of CLP with grey blue dots and absent in other variants. The findings in our study with respect to grey blue dots in CLP cases were nearly similar to abovementioned studies; however, its significant association with HLP was seen in our study only.
Pepper like-pigmentation was seen in 48.57% (34/70) of our patients, among which it was most commonly observed in 64% (25/39) of CLP, 50% (1/2) of actinic LP, and 20% (2/10) of HLP. Garg et al. reported pepper-like pigmentation in LP pigmentosus (28.57%), CLP and HLP had 20% each, respectively. Pepper-like pigmentation was seen more commonly in CLP in our study and is nearly similar to abovementioned studies.
In our study, we observed lichen planopilaris 100% (2/2) showed perifollicular pigmentation. However, the study by Güngör et al. showed perifollicular pigmentation in 53.3% lichen planopilaris. Friedman et al. also observed in 53% cases of lichen planopilaris and that perifollicular pigmentation was significantly associated with the diagnosis.
In our study, we observed that significant number of LP pigmentosus patients 85.71% (6/7) showed reticulate pattern of pigmentation similar to that of the study by Gupta etaland Sharma, where 70% of LP pigmentosus showed reticulate pigmentation. However, Güngör et al. observed reticulate pattern of pigmentation only in 20% LP pigmentosus and 1.1% of CLP.
| Conclusion|| |
This study demonstrates the consistency of dermoscopy patterns in different clinical variants of LP. The use of dermoscopy helps in best visualization of WS, blood vessels, and pigmentary changes in cases of LP and aids in reducing unnecessary biopsies required in diagnosing LP. The strength of associations of some dermoscopic features such as red dots, WS, perifollicular pigmentation, and reticulate pigmentation have been repeatedly confirmed by several other observational studies as is also in our study. A new rosette/petaloid-like pattern of WS was observed in our study over lesions having shorter duration of onset (less than 6 months).
The limitation of our study includes a smaller sample size, hence to conclude the significance of findings on dermoscopy of LP a study with larger sample size would be required. Another limitation of the study was the exclusion of lesions of LP over the nails, genitals, and oral mucosa.
The study was assessed and approved by the institutional review board.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]