Hypertrophic Lichen planus L43.81

Extremely therapy-resistant, eminently chronic and (punctually) intensely pruritic, usually symmetrically localized, verrucous "variant" of classic lichen ruber, occurring especially in the area of the lower extremities; less frequently on the back of the hand.

A verrucous transformation may also occur secondarily in cases of long-standing classical lichen ruber.

S.u. Lichen planus. In most cases, the oversubscribed component is probably the expression of a special form of reaction due to an orthostatic factor.

Localized or disseminated, rarely in a linear (blaschkoid) arrangement, 0.2-3.0 cm in size, sometimes up to 10 cm in size, coarse, grayish-white, also red or red-brown, sometimes also deep-brown, sharply demarcated, wart-like papules, plaques or nodules, which can confluence to form extensive areas. The areas are always sharply demarcated and thus differ from chronic dermatitis (e.g., in stasis dermatitis).

The leading clinical symptom is a very unpleasant, permanent itching, which is described as pricking or drilling. Constant reactive scratching of the lesions may be a triggering factor for the verrucous component of lichen ruber verrucosus. This mechanism is known as the itch-scratch cycle. In some cases, scarring areas can be seen in the plaques.

Not infrequently, triggering factors can be held responsible for the verrucous transformation of lichen planus. Thus, chronic venous insufficiency, as well as constant scratching, can be considered as a maintaining trigger factor for lichen planus verrucosus of the lower leg.

Complicating, although rare, lesional ulcers may occur (explanation: keratinolytic, blistering component under the verrucous plaques, initially masking subepithelial blistering).

Image of lichen ruber with conspicuous compact orthohyperkeratosis, with massive irregular epidermal hyperplasia. The infiltrate is variably dense, tending to be sparse with focus on the tips of the rectal ridges. In contrast to nonverrucous lichen planus, the verrucous variant may have a relevant number of eosinophilic granulocytes. Rarely, plasma cells as well.

Lichen simplex chronicus: gfls. hsitological clarification

Lichen amyloidosus:

eczema, lichenified

squamous cell carcinoma (see fig.): this DD has to be clarified histologically if necessary

Chronic prurigo: confluent plaques or nodules are typical for lichen ruber verrucosum. This is not observed in chronic prurigo.

potent glucocorticoids (e.g. class IV glucocorticoids) under occlusion (2 times/day 2-4 hours).

Alternatively: Vit D3 - analogues under occlusion.

Supplementary: Inject the foci with glucocorticoids such as triamcinolone crystal suspension 10-40 mg (e.g. Volon A): Draw up suspension with 2-4 ml 1% scandicain in a syringe and apply intrafocally.

Supplementary: Consistent wearing of compression bandages in the presence of chronic venous insufficiency.

Eminently chronic course. The average duration of the disease is 6 years. After years of persistence, intralesional keratoacanthomas or squamous cell carcinomas may develop (Campanati A et al. 2003). In this respect, regular clinical controls are necessary.

1. Alomari A et al (2014) The significance of eosinophils in hypertrophic lichen planus. J Cutan Pathol 41:347-352
2. Audhya M et al (2014) Verrucous lichen planus: a rare presentation of a common condition. Dermatol Reports 3:5113
3. Campanati A et al (2003) A case of hypertrophic lichen ruber planus of the leg complicated by a squamous cell carcinoma. Int J Dermatol 42: 415-416
4. Castano E et al (1997) Verrucous carcinoma in association with hypertrophic lichen planus. Clin Exp Dermatol 22: 23-25
5. De Paola M et al (2014) Unilateral hypertrophic lichen planus successfully treated with topical calcipotriol. G Ital Dermatol Venereol 149: 274-276.
6. Dossi Cataldo MT et al (2015) Pigmentosus hypertrophic lichen planus with blaschkoian distribution, 3 clinical subtypes in a single patient. Med Clin (Barc) doi:10.1016
7. Giesecke LM et al (2003) Giant keratoacanthoma arising in hypertrophic lichen planus. Australas J Dermatol 44: 267-269
8. Ghosh S et al (2014) Squamous cell carcinoma developing in a cutaneous lichen planus lesion: a rare case.Case Rep Dermatol Med doi: 10.1155/2014/205638.
9. Musumeci ML et al (2014) Multiple reactive keratoacanthomas in a patient with hypertrophic lichen planus treated with cyclosporine: successful treatment with acitretin. Indian J Dermatol Venereol Leprol 80: 374-376.