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Successive linear, generalized, and oral lichen planus in a patient with chronic hepatitis C infection*

2003; Elsevier BV; Volume: 49; Issue: 6 Linguagem: Inglês

10.1016/s0190-9622(03)01579-2

1097-6787

CPT Sean T. Gunning, LTC George W. Turiansky,

Autoimmune and Inflammatory Disorders

Considered a rare variant of lichen planus (LP), linear LP (LLP) is described as a linear arrangement of violaceous flat-topped papules and plaques sometimes following the lines of Blaschko. It is thought to occur in 0.24%1Herd R.M. McLaren K.M. Aldridge R.D. Linear lichen planus and lichen striatus—opposite ends of a spectrum. Clin.Dermatol. 1993; 18: 335-337Google Scholar to 0.62%2Altman J. Perry H.O. The variations and course of lichen planus.Arch Dermatol. 1961; 84: 179-191Crossref PubMed Scopus (179) Google Scholar, 3Katz M. Weinrauch L. Differentiating vesicular lichen planus and lichen striatus.Cutis. 1987; 40: 151-153PubMed Google Scholar of patients with LP. Chronic hepatitis caused by the hepatitis C virus (HCV) is associated with both generalized4Chuang T.Y. Stitle L. Brashear R. Lewis C. Hepatitis C virus and lichen planus a case-control study of 340 patients.J Am Acad Dermatol. 1999; 41: 787-789Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, 5Mokni M. Rybojad M. Puppin Jr, D. Catala S. Venezia F. Djian R. et al.Lichen planus and hepatitis C virus.J Am Acad Dermatol. 1991; 24: 792Abstract Full Text PDF PubMed Scopus (123) Google Scholar and mucosal LP.6Mignogna M.D. LoMuzio L. Favia G. Mignogna R.E. Carbone R. Bucci E. Oral lichen planus and HCV infection a clinical evaluation of 263 cases.Int J Dermatol. 1998; 37: 575-578Crossref PubMed Scopus (113) Google Scholar, 7Nago Y. Sata M. Abe K. Tanikawa K. Kameyama T. Immunological evaluation in oral lichen planus with chronic hepatitis C.J Gastroenterol. 1997; 32: 324-329Crossref PubMed Scopus (29) Google Scholar We found only 1 previously published case report describing a patient with LLP and concurrent hepatitis C infection.8Jury C.S. Munro C.S. Linear lichen planus related to hepatitis C infection?.Br J Dermatol. 2000; 142: 836-837Crossref PubMed Scopus (19) Google Scholar We report a second case of LLP in a patient with chronic active hepatitis as a result of HCV. Interestingly, the patient subsequently had generalized and oral LP develop. A 54-year-old Hispanic woman, with a history of generalized LP 5 years earlier, presented with a 9-week history of a worsening pruritic, violaceous, papular eruption in a linear distribution on the left lower aspect of her trunk (Fig 1). The patient denied scratching the area and had no mucosal, hair, or nail involvement. A biopsy specimen demonstrated saw-tooth acanthosis, wedge-shaped hypergranulosis, basal vacuolar change, a bandlike infiltrate involving the papillary dermis consisting of lymphocytes, Civatte bodies, and pigment incontinence. These findings were consistent with a diagnosis of LP. Medical history was significant for a diagnosis of chronic active hepatitis as a result of HCV RNA genotype 2B by polymerase chain reaction analysis approximately 2 years before presentation. In addition, the patient had a history of hepatitis A virus infection and had a positive test result for hepatitis A virus antibody. Abnormal laboratory findings at the time of examination included a HCV RNA load of 338,000 (0-600 IU/mL), aspartate aminotransferase of 98 (14-50 U/L), and alanine aminotransferase of 129 (9-52 U/L). She was followed up by hepatology but has not received treatment for her chronic hepatitis to date. The patient was treated with clobetasol ointment 0.05% to the affected area twice daily for 2 weeks with rapid clearing of the eruption. Follow-up after 4 months revealed resolution of the LLP except for residual postinflammatory hyperpigmentation. However, multiple, pruritic, violaceous, flat-topped papules on the trunk and extremities, and erosive gingival lesions successively developed that, by histology and direct immunofluorescence, represented generalized and oral LP, respectively. Linear lichenoid lesions may occur in the setting of LP in areas of koebnerization as a consequence of scratching secondary to intense pruritis. However, isolated lichenoid bands or streaks that are too wide to be readily attributed to koebnerization have been well described.9Krasowska D. Schwartz R. Lecewicz-Torun B. Generalized lichenoid drug eruption following Blaschko lines.Int J Dermatol. 2001; 40: 774-776Crossref PubMed Scopus (21) Google Scholar LLP has been described as occurring in a zosteriform distribution,10Ang P. Tay Y.K. Giam Y.C. Pruritic linear eruption on a child.Arch Dermatol. 2000; 142: 836-837Google Scholar in areas of prior zoster scarring as an isotopic response,11Turel A. Ozturckan S. Sahin M.T. Turkdogan P. Wolf's isotopic response a case of zosteriform lichen planus.J Dermatol. 2002; 29: 339-342PubMed Google Scholar following the lines of Blaschko,12Krasowska D. Pietrzak A. Lecewicz-Torun B. Unilateral multiple linear lichen planus following the Blaschko lines recurring after deliveries.Dermatology. 2001; 202: 340Crossref PubMed Scopus (20) Google Scholar and mimicking creeping eruption.13Taniguchi Y. Minamikawa M. Shimizu M. Ando K. Yamazaki S. Linear lichen planus mimicking creeping eruption.J Dermatol. 1993; 20: 118-121PubMed Google Scholar Some authors consider LLP an intermediate entity between LP and lichen striatus.14Rubio F.A. Robayna G. Herranz P. de Lucas R. Hernandez-Cano N. Contreras F. et al.Linear lichen planus and lichen striatus is there an intermediate form between these conditions?.Clin Exp Dermatol. 1997; 22: 61-62PubMed Google Scholar The main clinical differential diagnosis includes lichen striatus and lichenoid drug reactions although other entities such as linear psoriasis, linear epidermal nevi, and linear porokeratosis may be considered. In contrast to lichen striatus, LLP is extremely pruritic and may last greater than a year. Lichenoid drug reactions may be impossible to differentiate clinically and histologically from LLP; a medication history and the presence of focal parakeratosis, eosinophils, and plasma cells may support the former diagnosis. The cause of LLP is unknown. Cases associated with Blaschko-like distributions have been proposed to be because of postzygotic somatic mutations.15Mizoguchi S. Setoyama M. Kanzaki T. Linear lichen planus in the region of the mandibular nerve caused by an allergy to palladium in dental metals.Dermatology. 1998; 196: 268-270Crossref PubMed Scopus (39) Google Scholar These mutations may predispose vulnerable cells to developing LLP after a specific immunologic trigger. Other authors have reported LLP lesions after administration of ibuprofen,9Krasowska D. Schwartz R. Lecewicz-Torun B. Generalized lichenoid drug eruption following Blaschko lines.Int J Dermatol. 2001; 40: 774-776Crossref PubMed Scopus (21) Google Scholar associated with dental metal allergy,15Mizoguchi S. Setoyama M. Kanzaki T. Linear lichen planus in the region of the mandibular nerve caused by an allergy to palladium in dental metals.Dermatology. 1998; 196: 268-270Crossref PubMed Scopus (39) Google Scholar, 16Sasaki G. Yokozeki H. Katayama I. Nishioka K. Three cases of linear lichen planus caused by dental metal compounds.J Dermatol. 1996; 23: 890-892PubMed Google Scholar recurring after multiple deliveries,12Krasowska D. Pietrzak A. Lecewicz-Torun B. Unilateral multiple linear lichen planus following the Blaschko lines recurring after deliveries.Dermatology. 2001; 202: 340Crossref PubMed Scopus (20) Google Scholar as an isotopic response in areas of prior zoster,11Turel A. Ozturckan S. Sahin M.T. Turkdogan P. Wolf's isotopic response a case of zosteriform lichen planus.J Dermatol. 2002; 29: 339-342PubMed Google Scholar and related to HCV infection.8Jury C.S. Munro C.S. Linear lichen planus related to hepatitis C infection?.Br J Dermatol. 2000; 142: 836-837Crossref PubMed Scopus (19) Google Scholar Of the few cases reported in the English-language literature, only a few have been investigated with hepatitis serologies.4Chuang T.Y. Stitle L. Brashear R. Lewis C. Hepatitis C virus and lichen planus a case-control study of 340 patients.J Am Acad Dermatol. 1999; 41: 787-789Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, 10Ang P. Tay Y.K. Giam Y.C. Pruritic linear eruption on a child.Arch Dermatol. 2000; 142: 836-837Google Scholar, 12Krasowska D. Pietrzak A. Lecewicz-Torun B. Unilateral multiple linear lichen planus following the Blaschko lines recurring after deliveries.Dermatology. 2001; 202: 340Crossref PubMed Scopus (20) Google Scholar, 17Hartl C. Steen K.H. Wegner H. Seifert H.W. Bieber T. Unilateral linear lichen planus with mucous membrane involvement.Acta Derm Venereol. 1999; 79: 145-146Crossref PubMed Scopus (22) Google Scholar We believe our case is noteworthy because it represents the second reported association between LLP and concurrent HCV infection. Our case also represents the first report of the successive development of generalized and oral LP in a patient with established LLP and hepatitis C infection. Although the origin of LLP may be multifactorial, concurrent HCV may represent a specific risk factor for developing the linear form of LP in addition to generalized and oral LP. Future reports may further elucidate the relationship between LLP and HCV infection.