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Table of Contents 
CASE REPORT
Year : 2015  |  Volume : 60  |  Issue : 6  |  Page : 596-599
Lichen planus pemphigoides presenting preferentially over preexisting scars: A rare instance of isotopic phenomenon


1 Department of Dermatology, Katihar Medical College, Katihar, Bihar, India
2 Department of Dermatology, Medical College and Hospital, Kolkata, Kolkata, West Bengal, India
3 Mahatma Gandhi Missionary New Bombay Hospital and Research Center, Vashi, Navi Mumbai, India

Date of Web Publication5-Nov-2015

Correspondence Address:
Anupam Das
Building "PRERANA", 19, Phoolbagan, Kolkata 700 086, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.169133

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   Abstract 

An 18-year-old girl presented with multiple itchy hyperpigmented papules and plaques, along with tense blisters over the lower limbs and buttocks for last 3 months. These papules, plaques, and bullae were mostly localized to preexisting scars. The histopathological findings from papule and bulla were consistent with lichen planus (LP) and bullous pemphigoid, respectively. Direct immunofluorescence (DIF) of perilesional skin around bulla showed linear deposition of IgG and C3. Considering clinical, histopathological and DIF findings, diagnosis of LP pemphigoides (LPP) was made. The preferential localization of LPP lesions over preexisting scars was a very interesting finding in our case an extremely rare instance of the isotopic phenomenon.


Keywords: Bullous lichen planus, lichen planus pemphigoides, Wolf′s isotopic response


How to cite this article:
Kumar P, Savant SS, Das A, Hassan S, Barman PD. Lichen planus pemphigoides presenting preferentially over preexisting scars: A rare instance of isotopic phenomenon. Indian J Dermatol 2015;60:596-9

How to cite this URL:
Kumar P, Savant SS, Das A, Hassan S, Barman PD. Lichen planus pemphigoides presenting preferentially over preexisting scars: A rare instance of isotopic phenomenon. Indian J Dermatol [serial online] 2015 [cited 2021 Dec 4];60:596-9. Available from: https://www.e-ijd.org/text.asp?2015/60/6/596/169133

What was known?

  • Lichen planus pemphigoides (LPP) is considered to occur as a result of an autoimmune response to basement membrane antigens BPAg2 and BPAg1, unmasked due to basal layer damage in lichen planus
  • LPP is clinically characterized by tense bullous lesions over both lichenoid plaques and normal appearing skin.



   Introduction Top


The term "isotopic response" connotes the occurrence of a new skin disorder at the site of another, unrelated, and already healed skin disease. [1] Since the introduction of this phenomenon in dermatology, a variety of dermatoses have been reported to demonstrate this response. We hereby describe a young girl who developed lesions of lichen planus pemphigoides (LPP) over preexisting atrophic scars, an example of "Wolf's isotopic response." To the best of our knowledge, such a clinical presentation of lichen planus (LP) pemphigoides is not documented yet in the English literature.


   Case Report Top


An 18-year-old girl presented with multiple itchy hyperpigmented papules and plaques, along with intermittent blisters over the lower limbs and buttocks for last 3 months [Figure 1] and [Figure 2]. There was no history of drug intake prior to the onset of skin lesions. Past history was significant for painful ulcers over the lower limbs and buttocks 6 years back. These ulcers were associated with fever, myalgia, and arthralgia. She had consulted another institute for these ulcers. The diagnosis of pyoderma gangrenosum was made (as evident from documents available with patient), and she was treated for a year, resulting in complete resolution of ulcers. The ulcers had healed leaving atrophic scars. Mucocutaneous examination revealed multiple atrophic scars over the buttocks and lower limbs. The surface of scars was notable for multiple lichenified plaques and tense bullae. The bulla was noted over both lichenified plaques and otherwise normal appearing skin of scars. Interestingly, most of the lichenified plaques and bullae were found over preexisting scars only [Figure 3]. Scalp, hairs, nails, and mucosae were spared. The clinical differentials were bullous LP and LPP. Skin biopsy was done from multiple sites, for both histopathological examination and direct immunofluorescence (DIF). The histological features of lichenified plaque were orthokeratotic hyperkeratosis, acanthosis, wedge shaped hypergranulosis, basal layer degeneration and band-like of infiltrate of lymphocytes in the papillary dermis; thus corroborating with a diagnosis of LP [Figure 4]a-c. Histopathology of bulla showed a subepidermal bulla with eosinophilic infiltrate; which were suggestive of bullous pemphigoid (BP) [Figure 5]a-c. The scar tissue was characterized histologically by the presence of abundant collagen fibers without any features of inflammation [Figure 6]. DIF from plaque showed a linear pattern of deposition of IgG and C3 along the basement membrane zone [Figure 7]. DIF from the perilesional skin surrounding a bulla showed linear IgG and C3 along basement membrane zone; a feature suggestive of BP [Figure 8]. Thus, in conjunction with the clinical, histopathological and DIF findings, the final diagnosis for our case was LP pemhigoides developing over preexisting scars, as an isotopic phenomenon.
Figure 1: Atrophic scars with overlying lichenoid papules and plaques; and tense bulla on lower limbs

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Figure 2: Atrophic scars with overlying lichenoid papules and plaques on buttocks

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Figure 3: Close-up of lesions on the leg. Lesions are restricted to area of scar only

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Figure 4: Histopathology from plaque showing hyperkeratosis, hypergranulosis, saw toothing of rete ridges, band-like infiltration in upper dermis (a) (H and E, ×40) and (b) (H and E, ×100) with basal layer degeneration (c) (H and E, ×400)

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Figure 5: Histopathology from bulla showing partial loss of epidermis including basal layer (a) (H and E, ×40) and (b) (H and E, ×100) and plenty of eosinophils in split (c) (H and E, ×400)

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Figure 6: Histopathology from scar showing unremarkable epidermis, increased collagen in dermis and no inflammatory cells (H and E, ×40)

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Figure 7: Direct Immunofluorescence from plaque showing linear deposition of Ig G and C 3 along basement membrane zone

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Figure 8: Direct Immunofluorescence from perilesional skin of bulla showing linear deposition of Ig G and C3 along basement membrane zone

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   Discussion Top


LPP is an uncommon variant of BP, clinically manifested with bullous lesions over papules and plaques of LP, as well as on the uninvolved skin. It was first described by Kaposi in 1892 as a classical case of LP complicated by extensive bullous dermatosis; which was termed as "LPP." It can be precipitated by certain medications like cinnarizine, captopril, ramipril, psoralen and ultraviolet A (PUVA), simvastatin, and antituberculous medications. [2] IgG autoantibodies against both BPAg2 and BPAg1 are thought to play a pivotal role in the development of the dermatosis. The widely accepted mechanism proposed is that LP or sometimes, PUVA causes damage to basal cells leading to unmasking of hidden antigens; thus paving the pathway for the formation of antibodies and development of lesions of BP. [3],[4] A report described the correlation of levels of antibodies against BPAg2 with the disease activity in LPP. [5] The clinical differentials include bullous LP and LP in association with erythema multiforme. The salient points of difference between LPP and bullous LP have been summarized in [Table 1].
Table 1: BLP and LPP: A comparison


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   Results Top


DIF testing show a smooth linear distribution of immunoreactants (C3, IgG, IgM, and IgA) along the basement membrane zone of dermoepidermal junction. However, a unique 200 kD antigen has been recognized on the epidermal side of salt split skin of patients with LPP and thus, LPP may represent a clinically distinct entity and not merely, a co-existence of LP and BP. [6] Effective treatment modalities include topical and systemic steroids, tetracycline, nicotinamide, [7] dapsone, isotretinoin, methotrexate and other immunosuppressive drugs. [8] The prognosis is good, with complete resolution achieved with on-time therapy. The recurrence rate is found to be low in comparison to BP. This could be explained by the hypothesis that LPP has a unique antigenic target and thus, represents a distinct entity from BP. [9]

Numerous atypical presentations and associations have been documented in the context of LPP. LPP has been reported in association with keratoacanthoma and colon adenocarcinoma. [10] A unilateral presentation has also been reported. [11] Another interesting report described the evolution of LPP into pemphigoid nodularis. [12]

The occurrence of a different or unrelated dermatological disease at the site of the healed disease is termed as an isotopic phenomenon. [1] The proposed etiologies of isotopic response include viral, immunologic, neural, vascular and locus minoris resistentiae (a site of lessened resistance). Most cases of isotopic response have been described in herpes zoster scars. [13] However, development of LPP over preexisting scars is extremely unique and to the best of our knowledge, is not described in the English literature.

It is a well-known fact that bulla formation in LPP is mediated by immunological damage against BP antigen along basement membrane zone. The predilection of the blisters to develop on the lower extremities could be explained by sluggish circulation in those regions. In our case, scars involving the dermis and subcutaneous tissue with largely unaffected epidermis might have altered the blood circulation in that particular area. This could explain the preferential deposition of immunoglobulins in the scar area and subsequent bulla formation.

Acknowledgement

The authors would like to thank Dr. Satish S. Savant and Dr. Rajiv Joshi for their help in getting direct immunofluorescence done in our patient. The authors would like to thank Prof. M. Ramam for his valuable inputs in a review of the case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Wolf R, Wolf D, Ruocco E, Brunetti G, Ruocco V. Wolf's isotopic response. Clin Dermatol 2011;29:237-40.  Back to cited text no. 1
    
2.
Harting MS, Hsu S. Lichen planus pemphigoides: A case report and review of the literature. Dermatol Online J 2006;12:10.  Back to cited text no. 2
    
3.
Demirçay Z, Baykal C, Demirkesen C. Lichen planus pemphigoides: Report of two cases. Int J Dermatol 2001;40:757-9.  Back to cited text no. 3
    
4.
Kuramoto N, Kishimoto S, Shibagaki R, Yasuno H. PUVA-induced lichen planus pemphigoides. Br J Dermatol 2000;142:509-12.  Back to cited text no. 4
    
5.
Barnadas MA, Roé E, Dalmau J, Alomar A, Martínez L, Gelpí C. Lichen planus pemphigoides: Detection of anti-BP 180 antibodies by ELISA and immunoblotting tests. J Eur Acad Dermatol Venereol 2010;24:1360-1.  Back to cited text no. 5
    
6.
Okochi H, Nashiro K, Tsuchida T, Seki Y, Tamaki K. Lichen planus pemphigoides: Case report and results of immunofluorescence and immunoelectron microscopic study. J Am Acad Dermatol 1990;22:626-31.  Back to cited text no. 6
    
7.
Fivenson DP, Kimbrough TL. Lichen planus pemphigoides: Combination therapy with tetracycline and nicotinamide. J Am Acad Dermatol 1997;36:638-40.  Back to cited text no. 7
    
8.
Duong B, Marks S, Sami N, Theos A. Lichen planus pemphigoides in a 2-year-old girl: Response to treatment with methotrexate. J Am Acad Dermatol 2012;67:e154-6.  Back to cited text no. 8
    
9.
Zaraa I, Mahfoudh A, Sellami MK, Chelly I, El Euch D, Zitouna M, et al. Lichen planus pemphigoides: Four new cases and a review of the literature. Int J Dermatol 2013;52:406-12.  Back to cited text no. 9
    
10.
Hamada T, Fujimoto W, Okazaki F, Asagoe K, Arata J, Iwatsuki K. Lichen planus pemphigoides and multiple keratoacanthomas associated with colon adenocarcinoma. Br J Dermatol 2004;151:252-4.  Back to cited text no. 10
    
11.
Sapadin AN, Phelps RG, Fellner MJ, Kantor I. Lichen planus pemphigoides presenting with a strikingly unilateral distribution. Int J Dermatol 1998;37:942-6.  Back to cited text no. 11
    
12.
Sakuma-Oyama Y, Powell AM, Albert S, Oyama N, Bhogal BS, Black MM. Lichen planus pemphigoides evolving into pemphigoid nodularis. Clin Exp Dermatol 2003;28:613-6.  Back to cited text no. 12
    
13.
Madke B, Doshi B, Pande S, Khopkar U. Phenomena in dermatology. Indian J Dermatol Venereol Leprol 2011;77:264-75.  Back to cited text no. 13
[PUBMED]  Medknow Journal  

What is new?
Lichen planus pemphigoides in our case was largely restricted to preexisting atrophic scars. Wolf′s isotopic response in LPP has probably not been described earlier in the medical literature. Furthermore, we have tried to explain Wolf′s isotopic response in our case.


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Figure 8], [Table 1]

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