Clinical, dermoscopic and histopathologic features of genital and extragenital lichen sclerosus

Topical 5-aminolevulinic acid (ALA)-photodynamic therapy (PDT) for lichen sclerosus of face: case report and literature review

Lichen sclerosus (LS) is a chronic inflammatory dermatosis typical of the genital region, with rare involvement of extragenital areas and particularly the face. LS therapeutic management is challenging, and common therapies including topical and systemic corticosteroids, topical calcineurin inhibitors, surgery are often ineffective. Herein, we present a case of LS occurred in a 36-year-old girl with facial involvement resistant to therapy with systemic corticosteroids and topical tacrolimus. Considering the involvement of a sensitive area, the young age of the patient, and the consistent clinical experience in using photodynamic therapy for the treatment of facial skin disease, we started a treatment with topical 5-aminolevulinic acid (ALA)-photodynamic therapy (PDT) with a dosage of 37 J/cm2 once a month. We compared our case with eight other facial LS patients from the literature and treated differently.

Application and Comparison of Dermoscopy and Reflectance Confocal Microscopy in the Target Treatment of Genital Lichen Sclerosus: A Single-Arm Prospective Study

INTRODUCTION

The treatment of genital lichen sclerosus (GLS) remains challenging. Baricitinib has been introduced in the treatment of GLS, but there's no imaging evaluation for GLS patients treated with it. No comparison of dermoscopy and reflectance confocal microscopy (RCM) assessments in GLS has been conducted. We performed this study to evaluate the efficacy and safety of baricitinib for GLS and to compare the value of dermoscopy and RCM assessments in GLS.

METHODS

Participants were treated with baricitinib for 6 months and assessed at week 0, 2, 4, 6, 8, and every 4 weeks for the next 16 weeks. All patients were evaluated for clinical, dermoscopic, and RCM variables, with numeric scores assigned to each parameter.

RESULTS

Twenty-six GLS patients were included in this study. All patients achieved Investigator's Global Assessment score ≤ 1 (with ≥ 2-grade improvement) at week 20. The scores of pruritus and pain decreased since week 2 (both P < 0.05). The DLQI and VQLI scores significantly decreased since week 4 (both P < 0.0001). White structureless areas improved at week 2 and white shiny streaks and follicular plugs improved at week 4 under dermoscopic examination. Vessels (P < 0.001) and brown structureless areas (P = 0.003) increased at week 8. In RCM, inflammatory cells count significantly decreased at week 2 (100.03 ± 33.24, P < 0.0001), with substantial regression at week 8 (16.98 ± 5.54, P < 0.0001). Epidermal thickness increased at week 12 (157.44 ± 37.87 μm versus 134.13 ± 36.60 μm, P = 0.0284). Irregular papillae, spongiosis, and fiber structures improved at week 20, week 4, and week 6 (all P < 0.01). Transient hypercholesterolemia (11.54%), thrombocytosis (7.69%), and elevated alanine aminotransferase (7.69%) occurred during treatment.

CONCLUSION

Both dermoscopy and RCM can be useful and non-invasive adjuvant tools for the evaluation and therapeutic monitoring of GLS. We recommended white structureless areas under dermoscopy and inflammatory cells count under RCM as variables for dermatologic imaging evaluation for GLS. Baricitinib is effective and safe for GLS, while randomized controlled trials are warranted.

Histopathological differences between vitiligo and lichen sclerosus et atrophicus using quantitative immunohistochemical analysis

Introduction

Lichen sclerosus et atrophicus (LS) is rare skin condition characterized by the presence of whitish patches primarily affecting the genital and perianal areas, though it can occur other parts of the body. LS may result in skin depigmentation without textural changes and should be differentiated from vitiligo. However, the histopathological features of hypopigmentation during vitiligo and LS have rarely been compared and have not been precisely described using quantitative immunohistochemical analysis. This study, therefore, aimed to investigate and compare the pigmentary characteristics of LS and vitiligo lesions using histochemical and immunohistochemical staining.

Methods

We included 31 and 46 patients diagnosed with LS and vitiligo, respectively, at Ajou University Hospital between March 2009 and March 2020 in this study. Their medical charts and skin biopsy specimens were retrospectively reviewed. Additionally, Fontana-Masson staining for melanin and immunohistochemical staining for Melan-A, NKI/beteb, tyrosinase, and microphthalmia-associated transcription factor was performed.

Results

The melanin content, as well as the number of melanocytes was, in general, significantly higher in the epidermis of patients in the LS group compared with that in the vitiligo group. However, 22.6% of LS tissues showed less melanin pigmentation, 25.8% of LS specimens exhibited a lower number of melanocytes, and 29.0% of LS specimens demonstrated less melanocyte activity when compared with the average of vitiligo specimens.

Conclusion

As lower melanin pigmentation and the near absence number of melanocytes were also observed in several LS specimens, both the clinical and histological findings must be comprehensively reviewed to differentiate vitiligo from LS.

Dermatoscopy and Optical Coherence Tomography in Vulvar High-Grade Squamous Intraepithelial Lesions and Lichen Sclerosus: A Prospective Observational Trial

OBJECTIVE

This study aimed to examine potential discriminatory characteristics of dermatoscopy and dynamic optical coherence tomography (D-OCT) on vulvar high-grade squamous intraepithelial lesions (vHSIL) and lichen sclerosus (LS) compared with healthy vulvar skin.

METHODS

A prospective observational clinical trial was performed in 10 healthy volunteers, 5 vHSIL and 10 LS patients. Noninvasive imaging measurements using dermatoscopy and D-OCT were obtained at several time points, including lesional and nonlesional vulvar skin. Morphologic features of vHSIL and LS were compared with healthy controls. Epidermal thickness and blood flow were determined using D-OCT. Patients reported tolerability of each study procedure, including reference vulvar biopsies. The main outcome measures were feasibility and tolerability of imaging modalities, dermatoscopy and OCT characteristics, OCT epidermal thickness and D-OCT dermal blood flow.

RESULTS

The application of dermatoscopy and D-OCT is feasible and tolerable. In vHSIL, dermatoscopic warty structures were present. In LS, sclerotic areas and arborizing vessels were observed. Structural OCT in the vulvar area aligned with histology for hyperkeratosis and dermal-epidermal junction visualization. Currently, the OCT algorithm is unable to calculate the epidermal thickness of the uneven vulvar area. Dynamic optical coherence tomography showed statistically significant increased blood flow in LS patients (mean ± SD, 0.053 ± 0.029) to healthy controls (0.040 ± 0.012; p = .0024).

CONCLUSIONS

The application of dermatoscopy and D-OCT is feasible and tolerable in vHSIL and LS patients. Using dermatoscopy and D-OCT, the authors describe potential characteristics to aid differentiation of diseased from healthy vulvar skin, which could complement clinical assessments.

Extragenital lichen sclerosus: a comprehensive review of clinical features and treatment

Lichen sclerosus (LS) is a chronic inflammatory skin disease commonly affecting the anogenital area with less frequent extragenital occurrence. Extragenital LS cutaneous manifestations vary and precipitating factors are not well described. Recent evidence for etiology and clinical associations of extragenital LS provide insight into disease recognition and pathogenesis. Novel diagnostic techniques as well as treatment standardization have the potential to improve management of this rare condition. This review details both past and new insights into the pathogenesis, clinical manifestations, and treatment options of extragenital LS.

Extragenital lichen sclerosus: A comprehensive review

Lichen sclerosus (LS) is a chronic inflammatory mucocutaneous disease of unknown aetiology. About 85% of total cases of LS are genital cases, while extragenital form is seen in only 15-20% of cases. Extragenital LS (EGLS) can occur simultaneously with genital form; however, in 6% of the cases, only extragenital form has been described. Genetic, autoimmune, infectious, environmental and hormonal factors are implicated in its aetiology. Extragenital LS presents as asymptomatic white opalescent papules, which cluster in plaques and slowly progress over time resulting in parchment-like skin usually involving upper trunk, neck and shoulders. Lesions are frequently accompanied by purpura/haemorrhagic spots. The relationship with morphoea has been a topic of debate. Association with several autoimmune diseases has been observed. Diagnosis is usually based on clinical and dermoscopic examination and further supported by histopathological findings. LS needs to be differentiated from several other dermatological conditions such as discoid lupus erythematosus, vitiligo, mycosis fungoides (hypopigmented variant), lichen planus, graft-versus-host disease and morphoea depending upon the stage of the disease. Generally, extragenital LS is believed to lack carcinogenic potential. However, case reports with possible malignant transformation have been described. In this article, the authors have described a concise review of the extragenital form of LS.

A Case of Infantile Perianal Pyramidal Protrusion Masquerading As Imperforate Anus at Birth

Infantile perianal pyramidal protrusion (IPPP) is an uncommon and underreported benign cutaneous lesion characterized by a protrusion from the anal orifice. It is also believed to be often mistaken for other conditions. The unawareness of this lesion may be responsible for underreporting and an excessive concern both in providers and in parents. Timely diagnosis and reassurance need to be emphasized in the provider community. We report an interesting case of IPPP on the first day of life, which was erroneously diagnosed as imperforate anus at her delivery.

Dermatoscopic Features of Pigmentary Diseases in Ethnic Skin

Dermatoscopy is a non-invasive, handy tool, which is increasingly being used in diagnosis and prognostication of pigmentary dermatoses. Dermatoscopic changes in pigmentary pattern, scaling, and vasculature help us to differentiate among the myriad of hypo and hyper pigmentary diseases. This review gives a brief overview of the dermatoscopic features of pigmentary diseases, which are commonly encountered in clinical practice. We also provide a diagnostic approach based on salient dermatoscopic features.

Lichen Sclerosus and Phimosis - Discrepancies Between Clinical and Pathological Diagnosis and Its Consequences

OBJECTIVE

To assess the accuracy of clinical diagnoses and the true incidence of lichen sclerosus (LS) in patients with phimosis.

MATERIALS AND METHODS

The 92 adult male patients who were qualified for circumcision due to phimosis, were included in the study. The patients were diagnosed clinically by a urologist and dermatologist before the surgical procedure. After the circumcision, the resected foreskins were examined by 2 independent uropathologists.

RESULTS

Preoperative clinical diagnosis of LS was established in 54 patients (58.7%); healthy-looking skin in 26 (28.3%) and other penile diseases in 12 (13.1%) patients. After histopathological examination, the diagnosis of LS was established in 62 patients (67.4%), but only in 44 patients with previous LS clinical diagnosis. LS was histopathologically confirmed in 18 other patients with clinically diagnosed healthy skin (n = 17) or lichen planus (n = 1). Healthy skin was histopathologically confirmed in 10 cases in patients diagnosed clinically before as LS. Other 15 histopathological diagnoses were Zoon balanitis (n = 3), nonspecific balanitis (n = 5), lichen planus (n = 1), psoriasis (n = 1), invasive penile cancer (n = 3), Bowen's disease (n = 1), penile intraepithelial neoplasia 2 usual type (n = 1).

CONCLUSION

LS has been revealed as the most common histopathological diagnosis in patients undergoing circumcision in our study. Histopathological examination seems to be necessary to exclude this disease.

Clinical and Dermoscopic Assessment of Vulvar Lichen Sclerosus After 5-Aminolevulinic Acid Photodynamic Therapy：A Prospective Study

BACKGROUND

To date, there have been no satisfactory treatments to cure vulvar lichen sclerosus (LS). 5-Aminolevulinic acid photodynamic therapy (ALA-PDT) has been introduced in the treatment of vulvar lichen sclerosus (VLS), but no dermoscopic assessment has been conducted.

METHODS

The included patients received six ALA-PDT sessions at 2-week intervals. After the third and sixth treatment, all patients were evaluated for clinical and dermoscopic variables with numeric scores assigned to each parameter.

RESULTS

Twenty-four VLS patiens were included in this study. Both primary objective signs (lesion size and depigmentation) and subjective symptoms (itching and burning pain) were improved remarkably after the third treatment, and further improvements were obtained after the sixth treatment. Among the dermoscopic variables, the early changes were the decreased score of bright white or white-yellowish structureless areas and the increased score of vessels, and further changes of these two dermoscopic features were observed after the sixth treatment. There were no changes in pink structureless areas, white shiny streaks, follicular plugs, brown structureless areas, purple dots, and erosions after the third treatment, but after the sixth treatment, the scores of these dermoscopic features decreased significantly except that the score of brown structureless areas increased siginificantly. There was no change in the score of peppering blue-gray dots. Both pain and erosions during the treatment could be tolerated.

CONCLUSIONS

ALA-PDT is effective for VLS. In addition, dermoscopic assessment may be more precise for indicating minute changes invisible to unaided eyes which are useful to monitor the response to treatments.

Dermal Hemorrhage: A Clue to Lichen Sclerosus et Atrophicus

Lichen sclerosus et atrophicus (LSA) may present in a rare bullous and hemorrhagic form that is often difficult to recognize both clinically and histopathologically. Clinically, the lesions may be characterized by atrophic and ivory-white sclerotic plaques in both genital and extragenital regions. Histologically, fully developed lesions of LSA are characterized by a thinned, effaced epidermis with interface change, a wide band of hyalinization in the upper dermis, and a lymphohistiocytic infiltrate below the hyalinized area. Extensive vacuolar degeneration weakens the integrity of the dermoepidermal junction, which contributes to the development of marked edema in the papillary dermis and subepidermal vesiculation. With increased fragility of dermal capillaries, hemorrhage can accumulate within the bullae. Recognizing prominent upper dermal hemorrhage as a secondary change may lead to a prompt diagnosis of LSA. We present a case of extragenital LSA that mimics a dermal hemorrhage clinically and histologically in a 71-year-old Caucasian woman.

Dermoscopy of genital diseases: a review

The male and female external genital regions are anatomical areas in which various types of skin disorders may occur. Although most of these conditions can be diagnosed by means of clinical examination and an accurate medical history, in most cases further investigations with time-consuming and/or invasive procedures are needed in order to reach the correct diagnosis. Dermoscopy, as a modern non-invasive tool, is able to better diagnose pigmented and non-pigmented skin tumours along with various inflammatory and infectious skin and appendage disorders. The aim of this paper was to provide a review of the use of dermoscopy in genital disorders based on published data and to include personal experience gained from real life, focusing on any possible gender difference and whether disease mucosal/semimucosal dermoscopy features may differ from those observed on the skin. In conclusion, genital dermoscopy should always be considered during clinical inspection in order to enhance the diagnosis or to rule out those conditions that may look similar but that show a different dermoscopy pattern, thus narrowing down the differential diagnoses and avoiding unnecessary invasive investigations.

Dermoscopy of Inflammatory Genital Diseases: Practical Insights

Diagnosis of genital inflammatory disorders may be difficult for several reasons, such as their similar appearance, possible misdiagnosis with infectious and malignant conditions, and peculiar anatomic conditions that may lead to modification of clinical features. Dermoscopy could be included as a part of the clinical inspection of genital diseases to support diagnosis, as well as to ideally avoid unnecessary invasive investigation. Practical guidance for the use of dermoscopy in the assessment of the main inflammatory genital diseases is provided, namely for lichen sclerosus, lichen planus, psoriasis, lichen simplex chronicus, and plasma cell mucositis.

Combining topical tretinoin with mometasone furoate in the treatment of vulvar lichen sclerosus: Results of dermoscopic assessment

The main purpose of the present study was to compare the dermoscopic changes on vulvar lichen sclerosus (VLS) induced by two different 12-week treatment protocols, namely mometasone furoate 0.1% ointment plus tretinoin 0.05% cream in short-contact therapy (group A) versus the same corticosteroid plus emollient (group B). All dermoscopic images captured before and after treatment were assessed. Each dermoscopic variable selected for the study purpose was arbitrarily graded according to a 4-point scale by dermatologists blinded to both the time at which the images were captured and treatment allocation. Seventeen patients in group A and 15 in group B were included. The vessel mean dermoscopic scores increased significantly after treatment, whereas the scores of (a) patchy, structure-less, whitish areas, (b) whitish background, (c) comedo-like openings, and (d) purpuric blotches decreased. At the control visit, the two protocols did not differ significantly for any of the dermoscopic parameters, both in terms of mean score change and in the number of patients showing changes. Although the complementary action of the two molecules may suggest a therapeutic benefit, the association of tretinoin in short contact therapy with a potent corticosteroid did not induce significant changes in the dermoscopic features of VLS compared with the same corticosteroid alone.

Dermatoscopy and Reflectance Confocal Microscopy Correlations in Nonmelanocytic Disorders

Dermatoscopy and in vivo reflectance confocal microscopy are noninvasive techniques that provide a horizontal approach, with an en face view of the skin structures. Both techniques assist in the clinical diagnosis of a variety of inflammatory and infectious cutaneous disorders. In many cases, they have shown concordance. Their combined use represents, in several instances, a promising option to reach the final diagnosis without the need for invasive procedures.

Dermoscopy of Common Inflammatory Disorders

In addition to its "traditional" application for the early diagnosis of melanoma and nonmelanoma skin cancers, dermoscopy gains appreciation in fields beyond dermato-oncology. Nowadays, dermoscopy has been established as a reliable adjunctive tool to the everyday clinical practice of general dermatology. Morphology and distribution of vascular structures, background colors, follicular abnormalities, and the presence of scales are important features that should be evaluated. Clinical examination remains the undoubted mainstay of diagnosis in inflammatory and infectious diseases.

Alternative uses of dermoscopy in daily clinical practice: An update

Dermoscopy is a noninvasive diagnostic tool that is currently being used for neoplastic skin lesions, several inflammatory and infectious diseases, and skin appendage disorders. As the clinical applications of dermoscopy beyond pigmented lesions are constantly increasing, the aim of this article is to provide an update on this topic. This comprehensive review substantiates how several diseases may show peculiar dermoscopy features so as to enhance the diagnosis and avoid (in selected cases) unnecessary histologic confirmation. In other cases, dermoscopy features may be shared with other conditions, with the advantage of narrowing down the differential diagnosis by ruling out those dermatoses with similar clinical aspect but different dermoscopic presentation.

Lichen sclerosus associated with Nd:YAG laser therapy

Laser is the most efficient and popular method in hair removal. The most common side effects of laser assisted hair removal are pain, erythema, edema, hypopigmentation, hyperpigmentation, blistering, crusting, erosions, purpura, folliculitis, and scar formation ( 1 ). Herein, for the first time we describe a case of lichen sclerosus (LS) following hair removal with long pulsed 1064 nm Nd:YAG laser therapy.

Clinical and dermoscopic changes of vulvar lichen sclerosus after topical corticosteroid treatment

With the aim to assess changes in both clinical and dermoscopic features of vulvar lichen sclerosus (VLS) after a treatment with topical corticosteroid, 29 VLS patients treated with mometasone furoate 0.1% ointment for 12 weeks were evaluated for symptoms, objective signs and dermoscopic variables at baseline and treatment completion. Numeric scores were assigned to each parameter. Mean itching and burning values had decreased significantly at the 12-week control visit compared with baseline, as well as values referring to pallor, hyperkeratosis and purpuric lesions. Among the dermoscopic variables, the vessel score increased while the scores of patchy, structureless, whitish areas, whitish background, purpuric globules and scales decreased significantly after treatment. Scores referring to gray-blue dots, comedo-like openings and structures like ice slivers did not change significantly throughout the treatment. Based on these findings, dermoscopic features may change, even significantly, with topical corticosteroids and may be useful for monitoring the response to treatment.

A Unique Ocular Presentation of Extragenital Lichen Sclerosus

Lichen sclerosus is a chronic, debilitating, and recurring disease that is most commonly seen affecting the anogenital region. Extragenital locations of lichen sclerosus has been well documented, frequently seen in the shoulders, neck, trunk, breasts, and arms, however, infrequently of the face. Specifically, extragenital lichen sclerosus has been reported in several cases to be involving the infraorbital region, but to our knowledge it has never been found affecting the adnexa of the eye. To our understanding, this is the first documented report of a patient with extragenital lichen sclerosus of an eyelid.

Infantile perianal pyramidal protrusion: a case report with dermoscopy and ultrasound findings

Infantile perianal pyramidal protrusion, it is a rare benign cutaneous condition described in relatively recent times. It is considered to be under-reported in the pediatric literature because it is often mistaken for other conditions. The unawareness of this lesion may be responsible for an excessive concern both in physician and in parents, which leads to overly aggressive and unnecessary treatments. Thus its recognition has many implications regarding proper management and treatment.

We report a typical presentation of IPPP in which the diagnosis was based on the use of non-invasive diagnostic tools and in particular of dermoscopy and ultrasonography.