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E–CASE REPORT
Year : 2013  |  Volume : 58  |  Issue : 5  |  Page : 407
Palmar lichen planus mimicking tinea nigra


Department of Skin and VD, Topiwala National Medical College and BYL Nair Hospital, Mumbai, India

Date of Web Publication30-Aug-2013

Correspondence Address:
Chitra Nayak
Department of Skin and VD, OPD 14, Second Floor, OPD Building, Topiwala National Medical College and BYL Nair Hospital, Mumbai - 400 008
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.117339

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   Abstract 

Lichen planus (LP) is a chronic inflammatory skin disease characterized by polygonal, violaceous papules commonly involving flexural areas of the wrists, legs, and oral and genital mucous membranes. This report describes a patient who presented with asymptomatic black colored patches on both palms simulating Tinea nigra, a superficial fungal infection. She was previously diagnosed as allergic contact dermatitis and was being treated with potent topical steroid i.e. clobetasol propionate 0.05% and white soft paraffin. Dermatoscopy of the lesion showed brownish pigmentation along ridges of the dermatoglyphics. A biopsy from the lesional skin showed findings of lichen planus. Our case highlights the potential diagnostic confusion that can occur with unusual variants of palmoplantar lichen planus and importance of histopathology in diagnosis of such unusual lesions.


Keywords: Differential diagnosis, lichen planus, palmoplantar lichen planus, tinea nigra


How to cite this article:
Madke B, Doshi B, Wankhede P, Nayak C. Palmar lichen planus mimicking tinea nigra. Indian J Dermatol 2013;58:407

How to cite this URL:
Madke B, Doshi B, Wankhede P, Nayak C. Palmar lichen planus mimicking tinea nigra. Indian J Dermatol [serial online] 2013 [cited 2020 Jul 14];58:407. Available from: http://www.e-ijd.org/text.asp?2013/58/5/407/117339

What was known?
Lichen planus is a common inflammatory papulosquamous disorder. Classically, it is characterized by violaceous polygonal pruritic papules. Localized hyperpigmentation of palms is a rare presentation of lichen planus. Hyperpigmented palmar LP can pose a diagnostic difficulty.



   Introduction Top


Lichen planus is a chronic inflammatory skin eruption chiefly occurring in the middle age, i.e., 30-60 years of life, with no sex or racial differences. [1] Palmoplantar involvement is seen rarely with lichen planus and often does not have the classically morphology, making it difficult to establish the diagnosis. [2] Till date, there is a single case report of palmar lichen planus mimicking superficial fungal infection-tinea nigra. [3]

A 45-year-old healthy housewife presented to our OPD for an opinion on asymptomatic black colored patches present on both palms of two months duration. The lesions had appeared insidiously and were gradually increasing in size. There was no discomfort or itching. She denied any history of contact with any known allergens or drug intake. She also did not give history of any high risk sexual behavior or genital ulcer disease. Cutaneous examination showed a single, well-defined black-colored patch on the right hypothenar surface and three brownish colored patches on the left hypothenar eminence [Figure 1]. Few calluses were noted at the metacarpal head. There was absence of scaling and any surface changes on the lesion. There were no similar lesions on the soles. Rest of the cutaneous, oral, and genital evaluation was within normal limits. We considered a differential diagnosis of tinea nigra, resolved fixed drug eruption, pigmented contact dermatitis, and exogenous pigment. Potassium hydroxide (KOH) mount from the lesions was negative for fungal elements.
Figure 1: Well defined black to brownish colored patches on both the hypothenar eminences of palms

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Contact dermatoscopy of pigmented patch showed a hem-like pattern of pigment distribution along the ridges of the dermatoglyphics [Figure 2]. After obtaining informed consent, a biopsy was taken from one of the representative lesion under local anesthesia and was fixed in 10% buffered formalin. A hematoxylin and eosin stained section of skin biopsy showed hyperkeratotic stratum corneum and acanthotic epidermis with vacuolar changes of the basal layer. A band-like infiltrate comprising lymphohistiocytic infiltrate was evident at the dermo-epidermal junction [Figure 3]. Gomori-Methenamine Silver (GMS) stain of skin biopsy did not show presence of fungal hyphae. We prescribed topical clobetasol propionate (0.05%) cream along with white soft paraffin to be applied twice daily. The patient responded completely to the topical steroid cream and emollients [Figure 4].
Figure 2: Dermatoscopy of palmar lesion showing brown colored pigment along the ridges of dermatoglyphics in a hem like pattern

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Figure 3: H and E stained section of skin biopsy from the lesion showing hyperkeratotic stratum corneum, vacuolar change of basal layer with interface dermatitis composing of lymphocytic infiltrate abutting the basal layer. (×20)

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Figure 4: Same patient six weeks after treatment with topical steroids and white soft paraffin

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Palmoplantar lichen planus is a localized and rare variant of lichen planus. [4] Palmoplantar involvement in lichen planus was seen in 26% of their case series in a study done by Sanchez-Peres and colleagues. [5] In contrast to classical lichen planus, lichen planus of palms and soles does not demonstrate Wickham's striae and its typical polygonal lesion. [6] Many clinical variants of palmoplantar lichen planus have been described in the literature. The characteristic morphology of palmar and plantar lichen planus is that of pruritic papules and plaques, which are erythematosus and scaly with well-defined borders. Other clinical variants of palmoplantar lichen planus include pitted plaques, [7] ulcerative lesions, [8],[9] vesicle-like papule, [10] umbilicated papules, [11] punctate keratoderma, perforating palmar lichen planus, [12] and petechiae-like lesions. [13] The differential diagnosis for palmoplantar lichen planus includes verruca vulgaris, psoriasis, callus, punctate palmoplantar keratoderma, arsenical keratosis, papular syphilides, Kyrle disease, acrokeratosis paraneoplastica (Bazex syndrome), punctate porokeratosis, lichen simplex chronicus, and eczematous hand dermatitis. [14]

However, in contrast, our patient had non-itchy and non-palpable macular eruption with well-defined margins. In 2009, Mehta et al. had reported similar palmar pigmentation, which was proved to be lichen planus on histopathology. [3] Aytekin et al. reported hyperkeratotic palmar lichen planus associated with clenched fist, which resolved after topical salicylic acid and methylprednisolone ointment. [15] In our case, we considered a differential diagnosis of tinea nigra and exogenous pigment deposition (argyria). On closer inspection, we were able to notice that each of the patches had dot-like pigmentation involving the ridges more prominently and the same was confirmed with dermatoscopy. Diagnosis of isolated palmoplantar lichen planus is difficult, as it does not present with the classical violaceous papules and lacks Wickham's striae; thus, it can create a diagnostic confusion if other classical features are not evident elsewhere. On clinicopathological correlation, we reached the diagnosis of palmar lichen planus mimicking tinea nigra. The patient was counselled about the benign nature of the condition and was advised to apply topical steroid and emollients. To conclude, we report a case of palmar lichen planus with atypical presentation of localized pigmentation simulating tinea nigra.

 
   References Top

1.Sripathi H, Kudur MH, Prabhu S, Pai SB. Punctate keratotic papules and plaques over palm. Diagnosis: Hypertrophic lichen planus of palm. Indian J Dermatol Venereol Leprol 2010;76:449.  Back to cited text no. 1
    
2.Yasar S, Serdar ZA, Goktay F, Doner N, Tanzer C, Akkaya D, et al. The successful treatment of palmoplantar hyperkeratotic lichen planus with enoxaparin. Indian J Dermatol Venereol Leprol 2011;77:64-6.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Mehta V, Vasanth V, Balachandran C. Palmar involvement in lichen planus. Dermatol Online J 2009;15:12.  Back to cited text no. 3
    
4.Kim MJ, Choi M, Na SY, Lee JH, Cho S. Two cases of palmoplantar lichen planus with various clinical features. J Dermatol 2010;37:985-9.  Back to cited text no. 4
[PUBMED]    
5.Sanchez-Perez J, Rios Buceta L, Fraga J, Garcia-Diez A. Lichen planus with lesions on the palms and/or soles: Prevalence and clinicopathological study of 36 patients. Br J Dermatol 2000;142:310-4.  Back to cited text no. 5
    
6.Landis M, Bohyer C, Bahrami S, Brogan B. Palmoplantar lichen planus: A rare presentation of a common disease. J Dermatol Case Rep 2008;2:8-10.  Back to cited text no. 6
[PUBMED]    
7.Khandpur S, Kathuria SD, Gupta R, Singh MK, Sharma VK. Hyperkeratotic pitted plaques on the palms and soles. Indian J Dermatol Venereol Leprol 2010;76:52-5.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.Jiménez-Sánchez MD, Ferrándiz L, Moreno-Ramírez D, Vallejo-Benítez A, Camacho-Martínez F. Erosive Palmoplantar Lichen Planus. Actas Dermosifiliogr 2012;103:448-50.  Back to cited text no. 8
    
9.French LE, Masgrau E, Chavaz P, Saurat JH. Eccrine syringofibroadenoma in a patient with erosive palmoplantar lichen planus. Dermatology 1997;195:399-401.  Back to cited text no. 9
[PUBMED]    
10.Gündüz K, Inanir I, Türkdogan P, Sacar H. Palmoplantar lichen planus presenting with vesicle-like papules. J Dermatol 2003;30:337-40.  Back to cited text no. 10
    
11.Karakatsanis G, Patsatsi A, Kastoridou C, Sotiriadis D. Palmoplantar lichen planus with umbilicated papules: An atypical case with rapid therapeutic response to cyclosporin. J Eur Acad Dermatol Venereol 2007;21:1006-7.  Back to cited text no. 11
[PUBMED]    
12.Gutte R, Khopkar U. Perforating lichen planus. Indian J Dermatol Venereol Leprol 2011;77:515-7.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
13.Kim MJ, Choi M, Na SY, Lee JH, Cho S. Two cases of palmoplantar lichen planus with various clinical features. J Dermatol 2010;37:985-9.  Back to cited text no. 13
[PUBMED]    
14.Rotunda AM, Craft N, Haley JC. Hyperkeratotic plaques on the palms and soles. Palmoplantar lichen planus, hyperkeratotic variant. Arch Dermatol 2004;140:1275-80.  Back to cited text no. 14
    
15.Aytekin S, Turhanoglu AD, Ozkan M, Uzunlar AK. Clenched fist syndrome with palmar lichen planus. Int J Dermatol 2005;44:240-2.  Back to cited text no. 15
[PUBMED]    

What is new?
Lichen planus on the palms can present as well.defined hyperpigmented patches. A high index of clinical suspicion is needed for its diagnosis. Histological examination is must to reach a correct diagnosis. Palmar LP can pose a diagnostic dilemma for a naive physician.


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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