Lichen simplex chronicus L28.0

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Follicular keratosis of the chin; Lichen chronicus simplex; lichen chronicus vidal; Lichenification geante; lichen nuchae; lichen vidal; localized circumscribed neurodermatitis; neurodermatitis circumscripta; Neurodermatitis from rubbing; Pretibial pruritic papular dermatosis; Transcribed neurodermatitis; Verrucous lichen simplex chronicus; Vidal's disease

History
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Vidal, 1886

Definition
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Characteristic, but unspecific, eminently chronic, circumscribed, chafing-induced, itchy, plaque-like, inflammatorylichenoid reaction pattern of the skin, which is morphologically clinically decisively influenced by the different localizations and the chronic mechanical irritation. In the literature, different names have been coined for the lichen simplex chonicus in different regions (see below), but they are not to be considered as independent entities.

Etiopathogenesis
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Unresolved

A minus variant of the atopic eczema is discussed.

However, atopic stigmata can be completely absent.

Relationships to gastro-intestinal disorders, liver diseases, cholecystopathies, diabetes mellitus are described

Psychogenic factors: the symptoms are often complained about, but with patient enquiry, scratching can be an automated, pleasurable (almost erotic) action.

Manifestation
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w>m; First manifestation in middle and higher adulthood, less often in childhood.

Localization
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Mainly neck region(Lichen nuchae): "thoughtful" rubbing of the neck areas

Chin region(follicular keratosis of the chin): support of the chin on the hands;

extensor sides of forearms

Extensor sides of lower legs(Pretibial pruritic papular dermatosis): Rubbing the lower legs against each other

Elbows: Support

Insides of the thighs and the ankle regions (frequent rubbing of the ankle parts against each other; a verrucous component is possible - verrucous lichen simplex chronicus)

Sacrum (chafing effects in idiopathic itching - s.a Notalgia paraesthetica)

Scrotum and vulva (here, occlusive effects due to close-fitting clothes are also a trigger - Chan MP et al. 2015).

Clinical features
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The main symptom is the strong (sometimes agonizing) itching, which can increase in stressful situations. There are 10-15 cm large, roundish or oval, more rarely oblong or striped plaques, typically with a three-zone structure: central lichenification, peripheral lichenoid nodules, peripheral hyperpigmentation. The plaques are composed of 0.1-0.2 cm large, solid, flat, gray to brown-reddish or skin-colored, often scratched, lichenoid papules. When looking at the lesions from the side, a dull (lichenoid) shine of the lesions can often be seen. The three-zone structure gives way to a homogeneous flatness of the coarse papules/plaques when a verrucous component is superimposed (severe itching with consecutive rubbing effects).

Histology
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Pronounced, clumsy acanthosis with irregular elongation of the mostly bulbously raised reteleasts. Severe orthohyperkeratosis with focal parahyperkeratosis. Wide capillaries in the papillary stratum and in the upper dermis. Predominantly vascular, but also diffuse, rather sparse lymphohistiocytic infiltrate. Mostly distinct fibrosis of the dermis, with collagen bundles running vertically to the epidermis. The histological picture requires an exact clinical correlate for its interpretation.

Differential diagnosis
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Therapy
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The disease generally proves to be extremely resistant to therapy. Therapeutic guidelines:

The therapy of Lichen simplex chronicus is to be applied as a long-term strategy!

It should be made clear that this is an eminently chronic disease!

If necessary, a psychotherapist should be involved in the therapy at an early stage!

Antihistamines can be used against itching. The success is moderate. Ointments containing glucocorticoids are better, e.g. betamethasone valerate R029 or creams or ointments containing triamcinolone acetonide.

In case of secondary infections combination therapeutics like clioquinol-containing glucocorticoid-externa(e.g. locacorte-vioform) or triclosan/glucocorticoid-combinations (duogal cream) are indicated.

Occlusal bandages can be applied repeatedly for short periods.

Alternative: Tacrolimus-containing topicals (0.03% protopic ointment).

Good results can be achieved with multiple injections of glucocorticoid crystal suspension (Volon A 10 crystal suspension mixed with 1% xylocaine).

In a suitable localization, cryosurgery (open spray procedure, 1-2 times short freezing) can be used and, if necessary, combined with triamcinolone acetonide injection. Own experiences are quite positive.

A therapy with coal tar is often not reasonable for ambulant patients. However, a 2-5% coal tar ointment is effective. If accepted by the patient, it can be used alternately with a glucocorticoid externum.

With suitable localisation, local PUVA therapy can be used. In case of genital localisation we recommend, in addition to the above mentioned measures, the consistent application of sitz baths, possibly with tanning additives (e.g. Tannosynt).

Dermatological climate therapy (North Sea baths) brings very good results in some cases.

Radiation therapy
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Phototherapy is effective in Lichen simplex chronicus, especially narrow band UVB.

Progression/forecast
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Chronic intermittent course.

Note(s)
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Clinic and histology are decisive for the diagnosis. The absence or presence of signs of atopy (increase in IgE levels, sensitization in the epicutaneous and prick test) does not help in the diagnosis!

In the case of genital or perianal lichen simplex chronicus it is recommended to wear suitable underwear that does not fit tightly.

Literature
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  1. Chan MP et al (2015) Vulvar dermatoses: a histopathologic review and classification of 183 cases. J Cutan catholic 42: 510-518
  2. Fartasch M et al (2000) Current status of the interdisciplinary model project "Neurodermatitis Education for Children and Adolescents". dermatologist 51: 299-301
  3. Lotti T et al(2008) Prurigo nodularis and lichen simplex chronicus. Dermatol Ther 21:42-46.
  4. Niedner R (2003) Topical corticosteroids versus topical inhibitors of calcineurin. dermatologist 54: 338-341
  5. Pandhi D et al (2001) Lupus vulgaris mimicking lichen simplex chronicus. J Dermatol 28: 369-372
  6. Tan ES et al(2015) Effective treatment of scrotal simplex chronicus with 0.1% tacrolimus ointment: an observational study. Journal of the European Academy of Dermatology and Venereology 29:1448-1449.
  7. Vidal E (1886) Du lichen (lichen, prurigo, strophulus). Ann Dermatol Syphilogr (Paris) 7: 133-154
  8. Virgili A et al (2003) Evaluation of contact sensitization in vulvar lichen simplex chronicus. A proposal for a battery of selected allergens. J Reprod Med 48: 33-36

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Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020