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CASE REPORT
Year : 2022  |  Volume : 23  |  Issue : 2  |  Page : 150-152

An unusual case of isolated unilateral palmar lichen nitidus


Department of Dermatology, HBTMC and Dr. R. N. Cooper Municipal General Hospital, Mumbai, Maharashtra, India

Date of Submission02-Mar-2021
Date of Decision03-Nov-2021
Date of Acceptance17-Jan-2022
Date of Web Publication30-Mar-2022

Correspondence Address:
Dr. Shreya Singh
Room No. 704, 7th Floor, Shree Mangal CHS, GD Ambedkar Road, Bhoiwada, Parel, Mumbai . 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.ijpd_33_21

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  Abstract 


Lichen nitidus (LN) is a benign chronic eruption characterized by numerous asymptomatic papules on the body, clustered at specific sites of predilection like the dorsum of hands, abdomen, and genitalia. A 10-year-old boy presented to us with asymptomatic roughness of the left palm for 2 years. Clinical examination revealed multiple discrete pin-point papules over the left palm. Histopathological examination revealed focal lichenoid granuloma with overlying parakeratosis suggestive of LN. Hence, we are reporting this case of LN which required histopathology for confirmation due to its atypical presentation and distribution.

Keywords: Lichen nitidus, palmar, unilateral


How to cite this article:
Singh S, Rambhia K, Makhecha MB. An unusual case of isolated unilateral palmar lichen nitidus. Indian J Paediatr Dermatol 2022;23:150-2

How to cite this URL:
Singh S, Rambhia K, Makhecha MB. An unusual case of isolated unilateral palmar lichen nitidus. Indian J Paediatr Dermatol [serial online] 2022 [cited 2022 May 17];23:150-2. Available from: https://www.ijpd.in/text.asp?2022/23/2/150/341471




  Introduction Top


Lichen nitidus (LN) is a relatively rare chronic inflammatory disorder, characterized by pinpoint to pinhead-sized shiny, usually asymptomatic papules, most commonly distributed over the dorsal hands/forearms, penis, peri-umbilically, on thighs, and buttocks.[1] Sometimes, they may also be found on the palms, soles, nail, and mucosa.[2] Lesions on the palms or soles present as multiple tiny papules or chronic fissured eczema.[3] Palmar lesions may resemble pompholyx or become purpuric. Such unusual presentations might not be associated with the classical lesions of LN elsewhere, so a biopsy becomes mandatory for confirmation of the diagnosis.


  Case Report Top


A 10-year-old boy presented to the dermatology outpatient department with complaints of multiple asymptomatic, discrete, pin-head-sized lesions on his left palm for the last 2 years [Figure 1]a. There was no history of prior trauma. There was no personal or family history of atopy. On examination, the left palm had multiple discrete, spiny, hyperkeratotic papules sized about 1.5–2 mm and scaling on middle one-third [Figure 1]b. There was no tenderness on palpation. Rest of the cutaneous examination and all routine biochemical investigations were within normal limits. Dermoscopy was done using the Dinolite videodermoscope which revealed multiple discrete crateriform depressions interrupting the palmar dermatoglyphics at ×20 [Figure 2]a and peripheral scaling was appreciated at ×70 [Figure 2]b. Parental consent for photographs and biopsy was obtained. Skin biopsy from one of the lesions demonstrated focal lichenoid granulomatous infiltrate comprising lymphocytes, histiocytes and a few epithelioid cells in the papillary dermis abutting the dermo-epidermal junction. There was focal parakeratosis along with the absence of granular layer above the focus of granuloma which was suggestive of LN [Figure 3].
Figure 1: (a) Note the unilaterality. (b) Multiple discrete, pin-head sized, hyperkeratotic papules

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Figure 2: (a) Dermoscopy (×20): Multiple crateriform pits interrupting the dermatoglyphics. (b) Dermoscopy (×70): Peripheral scaling

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Figure 3: H and E, stained vertical section of affected skin at ×40 magnification showing focal lichenoid granulomatous infiltrate in the papillary dermis

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  Discussion Top


LN is an idiopathic, chronic inflammatory skin disorder characterized by asymptomatic, grouped, shiny, flat-topped papules occurring on the trunk, flexor aspect of upper extremities, dorsa of hands, buttocks, and penis. Clinical variants include actinic (found in sun-exposed areas), follicular, generalized, keratodermic (resembles chronic eczema with fissuring), linear, purpuric/hemorrhagic, perforating (characterized by transepidermal elimination), spinous (multiple hyperkeratotic spicules are present), and vesicular (resembles pompholyx).

Palmar lesions in LN are a rare entity, with only a few case reports worldwide[4],[5] [Table 1]. The most common clinical presentations observed are the classical punctate papules or the chronic hyperkeratotic fissured eczema type which most commonly involves the thenar and hypothenar eminences. A discrete parakeratotic plug indenting the underlying spinous layer is a feature consistent with palmar LN, not usually found in biopsies from lesions elsewhere.[6]
Table 1: Cases of palmar LN reported worldwide till date

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Mimics of the palmar lesions of LN include the deep-seated vesicles of pompholyx; the shallow pits seen in pitted keratolysis; the hyperkeratotic, hyperpigmented plaques of perforating lichen planus; the slightly scaly patches with pits seen in acrosyringeal lichen planus (the dilated acrosyringium surrounded by lymphocytic infiltrate, along with a parakeratotic plug); the pruritic fissured plaques of chronic hyperkeratotic eczema and porokeratotic eccrine ostial and dermal duct nevus (occurs exclusively in adults). Darier's disease and nevoid basal cell carcinoma may also present with pitted papules and plaques, but these lesions are skin colored to yellowish, and other cutaneous manifestations of the disease are present.

Whatever be the morphology, the histopathological examination has always helped in clinching the diagnosis in all the earlier cases reported as well as in our case. Classically, each papule of LN consists of a circumscribed granulomatous infiltrate composed of lymphocytes, monocytes and a few multinucleated epithelioid histiocytes. The dermal infiltrate often extends slightly into the overlying epidermis, which shows focal parakeratosis, hypogranulosis, vacuolar alteration of the basal cell layer, and focal subepidermal clefting. At the sides of the infiltrate, rete ridges tend to bend downward and inward as if to clutch the infiltrate in the manner of a "claw clutching a ball."[7]

LN is asymptomatic and resolves without scarring or hyperpigmentation, hence, treatment is usually not required. Topical steroids, topical tacrolimus, or phototherapy have been reported to be effective in some cases of LN. However, palmar LN has a chronic course and is generally refractory to treatment.

This case of LN is unique in more than one aspects: palmar involvement, early age of onset (the mean age of onset of palmar LN as reported by previous literatures is around 43.7 years whereas our patient presented at 10 years),[4],[8] unilaterality and no associated classical lesions anywhere else on the body. It emphasizes the need to keep a high index of suspicion for LN while coming across a case of isolated unilateral palmar papules irrespective of the presence of similar lesions elsewhere in the body. The invaluable role of histopathology in solving diagnostic confusion is also highlighted.

Declaration of consent

The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s) of the patient. In the form the parent(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
James WD, Elston DM, Berger TG. Andrew's Diseases of the Skin: Clinical Dermatology. 11th ed. United Kingdom: Saunders Elsevier; 2011. p. 222-3.  Back to cited text no. 1
    
2.
Park SH, Kim SW, Noh TW, Hong KC, Kang YS, Lee UH, et al. A case of palmar lichen nitidus presenting as a clinical feature of pompholyx. Ann Dermatol 2010;22:235-7.  Back to cited text no. 2
    
3.
Griffiths C, Barker J, Bleiker T, Chalmers R, Creamer D. Rook's Textbook of Dermatology, Ninth Edition. Chichester, West Sussex, UK: Wiley-Blackwell;2016.   Back to cited text no. 3
    
4.
Bear CL, Willsteed EM, Zagarella SS. Lichen nitidus confined to one palm. Australas J Dermatol 1989;30:41-2.  Back to cited text no. 4
    
5.
Podder I, Mohanty S, Chandra S, Gharami RC. Isolated palmar lichen nitidus – A diagnostic challenge: First case from Eastern India. Indian J Dermatol 2015;60:308-9.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Coulson IH, Marsden RA, Cook MG. Purpuric palmar lichen nitidu – An unusual though distinctive eruption. Clin Exp Dermatol 1988;13:347-9.  Back to cited text no. 6
    
7.
Elder, David E, Walter F. Lever. Lever's Histopathology of the Skin. Philadelphia: Wolters Kluwer; 2015. p. 221-2.  Back to cited text no. 7
    
8.
Gandhi V, D'Souza P, Gujral S, Ramam M. Lichen nitidus of palms and soles. Indian J Dermatol Venereol Leprol 1998;64:34-6.  Back to cited text no. 8
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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