ARTICLE
Lichen nitidus is a chronic dermatosis of unknown cause. It is clinically
characterized by the presence of pin-point- to pin-head-sized papules
which are asymptomatic and flesh-coloured with a flat, shiny surface [1].
However, there are some reports of lichen nitidus of purpuric appearance
[2-7]. In 1988, for example, Coulson et al. [7] reported a case
of lichen nitidus with hemorrhage on the palms, and termed it purpuric
palmar lichen nitidus.
We have recently seen a case of lichen nitidus with hemorrhage not only
on the palms but also on the thighs. We believe it should be classified
as purpuric lichen nitidus.
Case report
A 63-year-old Japanese man presented with an asymptomatic papular eruption
which had been present for 7-8 years. On physical examination, numerous
discrete, pinhead-sized, purpuric papules which did not blanch on diascopy
were found on the palms of the hands and on the skin of several fingers
(Fig. 1). The lesions
were most densely grouped over the thenar eminence and on the fingers.
Some of them had a central dimple. On the thighs, there were similar papules
which also took the form of discrete, lichenoid papules with a central
hemorrhage that were resistant to vitropression. Laboratory tests revealed
no abnormalities. The histopathologic features of the biopsied specimens
taken from the palm and the thigh showed similar changes characteristic
of lichen nitidus (Fig. 2).
There was a single dermal papilla filled with a dense circumscribed nest
of infiltrating cells closely attached to the
epidermis. The infiltrate consisted of mononuclear lymphocytes and histiocytes
and a few giant cells. The overlying epidermis was flattened and liquefaction
degeneration of the basal cell layer was present. The rete ridges on each
side of the lesions seem to clutch the infiltrate in a claw-like manner.
The vessels traversing the inflammatory region showed extensive changes
and were increased in number. The capillary walls were edematous, and
had a homogeneous, moderately eosinophilic appearance, and extravasation
of erythrocytes had occurred (Fig.
3). Electron microscopy revealed amorphous electron-dense deposits
along the outside of the endothelial cells in the capillaries of the lesion
(Fig. 4).
Discussion
All the eruptions in this case of lichen nitidus were demonstrated to
be purpuric papules. There have been six reports [2-7] of lichen nitidus
of purpuric appearance. The colours of the papules were red-brown, livid
red or dark tan, and were resistant to vitropression. Krook [3] reported
that, in generalized lichen nitidus, the colour of papules in some areas,
which was a dark tan or livid red, was resistant to vitropression. Histopathologic
examination of the vessels revealed extensive changes, particularly necrosis
of capillary walls with edema of adjacent tissue and subepidermal pools
of extravasated blood. Because of the nature of these vascular changes,
Krook [3] stated that the purpuric hemorrhages had occurred secondarily
to them. In addition, he demonstrated that stasis
of the upper arms caused hemorrhages in the papules on the forearm and
palm. Coulson et al. [7] reported a case involving the palms supporting
Krook's case. Jetton et al. [6] reported vesicular and hemorrhagic
lichen nitidus and demonstrated that rubbing or scratching converted some
of the lesions to small hemorrhagic papulovesicles after several hours.
In our patient, the papular lesions on the palms had showed purpura from
the time of onset, and their colour was resistant to vitropression. Histologically,
extensive degeneration of the vascular walls with extravasation of erythrocytes
was observed in the vessels of the lesions. Electron microscopy demonstrated
amorphous, electron-dense deposits along the outside of the endothelial
cells. Vascular alterations have commonly been encountered in lichen nitidus.
Kyrle and McDonagh [8] indicated the presence of altered vessels in lichen
nitidus and suggested that the granulomas were secondary to an embolic
process in such vessels. Lapis et al. [9], in a study of 43 cases
of lichen nitidus, reported extravasation of red blood cells in only 4
cases and frequent obscuring of blood vessels by the infiltrate, but stated
that endothelial proliferation with narrowing or obliteration of the lumen
was invariably present. Coulson et al. [7] reported a case of lichen
nitidus with hemorrhage on the palms, and termed it purpuric palmar lichen
nitidus. In our case, lichen nitidus with hemorrhage was present not only
on the palms but also on the thighs.
The eruptions in both lesions showed the same histological features,
and changes were clearly observed in the blood vessels of the lesions.
It is suggested that lichen nitidus with hemorrhage manifests various
lesions, and we propose the term purpuric lichen nitidus.
REFERENCES
1. Black MM. Lichen planus and lichenoid disorders. In: Textbook of
Dermatology. Rook AJ, Wilkinson DS, Ebling FJ, eds. 5th ed., vol.3.
Oxford: Blackwell Scientific Publications, 1992: 1698.
2. Michelson EM. Pigmented purpuric lichenoid dermatitis (Gougerot)
or generalized lichen nitidus. Arch Dermatol Syph 1909; 23: 396.
3. Krook G. Purpura in lichen nitidus generalisatus. Acta Dermato-Venereologica
1959; 39: 238-46.
4. Savin J, Samman PD. Lichen nitidus. Br J Dermatol 1970; 82:
423-4.
5. Porter DI, Samman PD. Lichen nitidus. Br J Dermatol 1970;
82: 424.
6. Jetton RL, et al. Vesicular and hemorrhagic lichen nitidus.
Arch Derm 1972; 105: 430-1.
7. Coulson IH, Marsden RA, Cook MG. Purpuric palmar lichen nitidus.
Clin Exper Dermatol 1988; 13: 347-9.
8. Pinkus F. Uber eine neue knotchenformige Hauteruption: Lichen nitidus.
Arch Dermat Syph 1907; 85: 11.
9. Kyrle J, McDonagh JER. Beitrag zur Kenntnis des Lichen nitidus (Pinkus).
Arch Dermt Syph 1909; 95: 11.
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