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E-IJD® - CASE REPORT
Year : 2016  |  Volume : 61  |  Issue : 6  |  Page : 700
Reticulate pigmentation associated with scarring alopecia in an elderly woman: An unusual manifestation of lichen planus pigmentosus


1 Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication9-Nov-2016

Correspondence Address:
Vinod Kumar Sharma
Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.193713

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   Abstract 

A 70-year-old woman presented with generalized reticulate pigmentation, scarring alopecia, and few discrete, violaceous plaques over the trunk and forearm. Dermoscopic evaluation of the reticulate plaque showed reticulate hyperpigmentation with multiple telangiectasias, and skin biopsy showed lichenoid interface dermatitis with marked pigment incontinence. Thus, a final diagnosis of poikiloderma due to lichen planus pigmentosus was considered.


Keywords: Lichen planus pigmentosus, poikiloderma, scarring alopecia


How to cite this article:
Sharma VK, Bhari N, Subhadarshani S, Taneja N, Deepak RK. Reticulate pigmentation associated with scarring alopecia in an elderly woman: An unusual manifestation of lichen planus pigmentosus. Indian J Dermatol 2016;61:700

How to cite this URL:
Sharma VK, Bhari N, Subhadarshani S, Taneja N, Deepak RK. Reticulate pigmentation associated with scarring alopecia in an elderly woman: An unusual manifestation of lichen planus pigmentosus. Indian J Dermatol [serial online] 2016 [cited 2019 Jun 20];61:700. Available from: http://www.e-ijd.org/text.asp?2016/61/6/700/193713

What was known?
Lichen planus pigmentosus usually presents as diffuse grayish hyperpigmented macules over the trunk and flexure aspects of extremities, but reticular, blotchy, and perifollicular forms are also seen.



   Introduction Top


Lichen planus pigmentosus is seen in Indian, Latin-American, and other dark-skinned populations, presenting as ill-defined, grayish hyperpigmented macules commonly affecting the face and neck. We report a case of an elderly woman, who presented with generalized reticulate pigmentation and scarring alopecia, in which a diagnosis of poikilodermatous lichen planus pigmentosus was established on the basis of dermoscopic and histological findings.


   Case Report Top


A 70-year-old woman presented with a 25-year history of reticulate pigmentation over the trunk and extremities. For the past 20 years, she also complained of erythema and burning sensation on exposure to sunlight. She also developed a loss of hair from the scalp and eyebrows with few itchy violaceous scaly plaques over the trunk and extremities in the past 10 years. There was no history of muscle weakness, oral ulcers, and joint pain. On examination, there was brownish reticulate pigmentation in a generalized distribution involving the trunk and extremities, sparing the mid-face. There were few skip areas on the chest [Figure 1]a. She also had scarring alopecia of the frontoparietal scalp and nonscarring alopecia of the eyebrows, axilla, and groin [Figure 1]b. In addition, there were multiple, discrete, well-defined, 3-4 cm-sized, violaceous, scaly plaques over the trunk and forearm [Figure 1]c. Oral cavity, palms, soles, nails, and genitals were found to be normal.
Figure 1: (a) Generalized brownish reticulate pigmentation involving the trunk and extremities with few skip areas on the chest. (b) Reticulate pigmentation also extending to the scalp associated with scarring alopecia. (c) Multiple, discrete, well-defined, 3-4 cm-sized, violaceous, scaly plaques over the trunk and forearm, resolving with reticulate pigmentation

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Her routine hematological and biochemical investigations were within normal limits. Antinuclear antibodies, anti-double-stranded DNA antibodies, muscle enzymes, 24 h urine protein analysis, and computed tomography scan of the chest and abdomen were found to be normal. Her skin biopsy from the reticulate hyperpigmented plaque showed atrophic epidermis and multiple dilated, congested capillaries in the papillary dermis [Figure 2]a. Biopsy from the alopecic patch over the scalp revealed epidermal atrophy and papillary dermal sclerosis with pigment incontinence. A skin biopsy from violaceous plaque showed compact hyperkeratosis, parakeratosis, irregular acanthosis, and mild papillary dermal fibrosis. A band-like lichenoid infiltrate was seen in the upper dermis at one end of the section. There was basal cell damage in this area with occasional necrotic keratinocytes and dermal melanophages. There were dilated capillaries in the papillary dermis [Figure 2]b and c. Direct immunofluorescence test was negative. Dermoscopic evaluation (Heine Mini 3000, nonpolarized, model no.-D-886.11.021, Germany) of the reticulate plaque over the chest showed the presence of dots and globules in a reticular pattern with the presence of atrophy and multiple telangiectasias [Figure 2]d. Based on the clinical, histological, and dermoscopic findings, a final diagnosis of poikiloderma due to lichen planus pigmentosus was made, and she was administered oral prednisolone (40 mg) which resulted in a significant improvement in pruritus and visible flattening of violaceous plaques within 1 month of the treatment. Prednisolone was gradually tapered after an improvement was seen in itchy plaques, and to some extent in hair growth, however, poikiloderma continued to persist.
Figure 2: Hematoxylin and eosin stain of the skin biopsy (a, ×200) from the reticulate pigmentation over the back showed epidermal atrophy and multiple, dilated, congested capillaries (b, ×200), (c, ×400) from the violaceous plaque over the back showed basal cell damage, pigment incontinence, and lichenoid infiltrate in the papillary dermis. (d) Dermoscopy (Heine Mini 3000, nonpolarized, ×10) of the reticulate plaque showed reticulate pigmentation, atrophy, and telangiectasias

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   Discussion Top


The most common pattern described for lichen planus pigmentosus is diffuse grayish hyperpigmented macules over the trunk and flexure aspects of extremities, but reticular, blotchy, and perifollicular forms are also seen. [1] The poikilodermatous form of lichen planus pigmentosus is rarely described.

Our patient presented with generalized reticulate pigmentation over the face, trunk, and extremities associated with scarring alopecia of the scalp and nonscarring alopecia of the body hairs. We considered an initial clinical diagnosis of poikiloderma due to cutaneous T-cell lymphoma, which was ruled out on the basis of histological and dermoscopic findings. Similarly, poikiloderma due to connective tissue disease was thought as a second differential diagnosis, but was not supported by the investigations. Graham Little-Piccardi-Lassueur syndrome was considered due to the presence of scarring alopecia of the scalp and nonscarring alopecia of the body, but follicular keratosis pilaris-like lesions were not seen. The presence of violaceous itchy plaques over the trunk, lichenoid changes in the histopathology, dermoscopic evaluation of the reticulate plaques showing reticular pigmentation, and atrophy with telangiectasia helped us to confirm our diagnosis. Association of these three presentations of lichen planus is rare where typical lichen planus lesions were seen in addition to the poikilodermatous lesions of lichen planus pigmentosus and cicatricial alopecia. [2],[3],[4],[5] Our case showed the presence of reticulate pigmentation; atrophy and telangiectasia could be demonstrated with the dermoscopic and histological evaluation. This finding is similar to the cases reported by Sinha et al. and Lin et al., where clinically, reticulate pigmentation was seen in the absence of atrophy and telangiectasia. [2],[3] Involvement of the scalp in the form of diffuse scarring alopecia with this cutaneous presentation is rarely reported. [3]


   Conclusion Top


Thus, poikiloderma is an atypical presentation of lichen planus pigmentosus. Histological and dermoscopic evaluation is essential to arrive at the diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

What is new?

Poikilodermatous form of lichen planus pigmentosus, associated with typical lichen planus lesions and cicatricial alopecia, is rare.



 
   References Top

1.
Kanwar AJ, Dogra S, Handa S, Parsad D, Radotra BD. A study of 124 Indian patients with lichen planus pigmentosus. Clin Exp Dermatol 2003;28:481-5.  Back to cited text no. 1
    
2.
Sinha S, Sarkar R, Garg VK. Lichen planus presenting as generalized reticulate pigmentation with sole involvement. Pigment Int 2014;1:25-7.  Back to cited text no. 2
  Medknow Journal  
3.
Lin MY, Chen LJ, Ma L, Wu WY, Xiang LH. Generalized reticulated hyperpigmentation induced by lichen planus. Clin Exp Dermatol 2009;34:e636-9.  Back to cited text no. 3
    
4.
Ozden MG, Yildiz L, Aydin F, Senturk N, Canturk T, Turanli AY. Lichen planus pigmentosus presenting as generalized reticulate pigmentation with scalp involvement. Clin Exp Dermatol 2009;34:636-7.  Back to cited text no. 4
    
5.
Sayal SK, Gupta CM, Malik AK. Lichen planus induced poikiloderma. Indian J Dermatol 2001;46:178-9.  Back to cited text no. 5
  Medknow Journal  


    Figures

  [Figure 1], [Figure 2]



 

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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
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