Quiz 13: What is your diagnosis?

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Diagnosis: Quiz 13

Quiz 13

Answer: Lichen planus

Criteria for diagnosis histopathologically:  Zones of wedge-shaped hypergranulosis beneath compact orthokeratosis, with foci of thinning and vacuolar alteration of the basal layer of the epidermis that houses necrotic keratocytes and that is partially obscured by a dense band-like lymphocytic infiltrate, in company with fibroplasia of the papillary dermis are findings of lichen planus.

Differential diagnosis histopathologically:  Lichenoid mycosis fungoides, lichenoid drug eruption, lichenoid lupus erythematosus, and persistent pigmented purpuric dermatitis of Gougerot-Blum have to be considered in the differential diagnosis.

Criteria for diagnosis clinically:  Disseminated flat-topped violaceous papules and plaques are characteristic of lichen planus.

Differential diagnosis clinically:  A lichenoid drug eruption and other papular rashes like, for example, secondary syphilis, guttate psoriasis, or pityriasis rosea, have to be excluded by biopsy.

Clinicopathologic correlation:  The papules are a consequence of epidermal hyperplasia and of the dense inflammatory infiltrate in the papillary dermis.

Options for therapy predicated on knowledge of histopathologic findings:  Topical steroids in ointments or creams are the first therapeutic option. However, if the lesions are widespread, as in this patient, PUVA therapy or systemic therapy with corticosteroids has to be considered.

1) Other diseases that present histopathologically with a lichenoid lymphocytic infiltrate include discoid lupus erythematosus, lichenoid purpura of Gougerot and Blum, lichenoid secondary syphilis, and lichenoid mycosis fungoides. Discoid lupus erythematosus is associated with a smudged and thickened epidermal basement membrane. Lichenoid purpura of Gougerot and Blum is characterized by extravasated erythrocytes and/or siderophages in the papillary dermis, and lichenoid secondary syphilis is characterized by parakeratosis, a granulomatous infiltrate, and the presence of plasma cells. In mycosis fungoides lymphocytes are scattered in the spinous zone of an epidermis that shows no or only little spongiosis.

2) Clinically, lichenoid drug eruption, pityriasis rosea, secondary syphilis, and psoriasis are included within the differential diagnosis. Pityriasis rosea is usually limited to the trunk, and the scales of it take the form of collarettes. Secondary syphilis usually presents as widespread papular rash that typically involves the palms. Psoriasis often affects the extensor surface of the extremities, and lesions are covered by coarse scales, which when being removed, reveal an erythematous base with tiny punctuate bleeding points (Auspitz sign).

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