Prurigo nodularis and lichen simplex chronicus

2024 British Association for Sexual Health and HIV (BASHH) UK national guideline on the management of vulval conditions

BackgroundThe management of vulval disorders in Genitourinary Medicine (GUM) clinics requires targeted approaches due to the wide range of conditions affecting the vulva. Vulval diseases encompass various aetiologies, including dermatoses, pain syndromes, and pre-malignant conditions, necessitating specialized care often involving multidisciplinary collaboration.PurposeThis guideline aims to provide evidence-based recommendations for the diagnosis and management of specific vulval conditions that may present in GUM clinics. The focus is on conditions commonly managed by Genitourinary Physicians, either independently or in partnership with other specialists, depending on available local expertise. Additionally, guidance on onward referral is included to ensure optimal patient care.Study SampleThe guideline primarily addresses the management of individuals aged 16 years and older presenting to GUM clinics with non-infective vulval conditions.Data CollectionRecommendations within this guideline are derived from a review of existing literature, clinical expertise, and consensus among specialists. Emphasis is placed on diagnostic tests and treatment regimens tailored to the following conditions: Lichen sclerosus, Lichen planus, Eczema, Lichen simplex, Psoriasis, Vulval high-grade squamous intraepithelial lesions (previously vulval intraepithelial neoplasia), Vulval pain syndromes, and Non-sexually acquired acute genital ulceration (Ulcer of Lipschütz).ConclusionsThis guideline offers practical recommendations for the effective management of specific vulval disorders in GUM settings. It is not intended to be a comprehensive review of all vulval diseases but rather a focused resource to assist clinicians in providing high-quality, patient-centred care. Onward referral pathways are also outlined to support collaborative and multidisciplinary management of complex cases.

Hypertrophic Lichen Planus and Hypertrophic Skin Lesions Associated with Histological Lichenoid Infiltrate: A Case Report and Literature Review

Hypertrophic lichen planus (HLP) is a chronic inflammatory skin condition defined by verrucous, pruritic, papules and plaques usually affecting the lower limbs. The diagnosis of HLP is primarily clinical. However, due to its feasible generalized presentation and similarities with other hypertrophic cutaneous disorders, histological evaluation is often necessary. Many dermatological conditions that present with a hypertrophic clinical appearance can arise from a histological lichenoid infiltrate (HCLI). Hence, we provide an overview of the clinical, histopathological, and prognostic features of selected HCLI, including HLP, hypertrophic lichenoid dermatitis, hypertrophic lichen sclerosus (HLS), lichen simplex chronicus (LSC), squamous cell carcinoma (SCC), keratoacanthoma (KA), pseudoepitheliomatous hyperplasia (PEH), viral warts, and lupus erythematosus/lichen planus (LE/LP) overlap. Choosing the appropriate procedure and the anatomical site for an incisional biopsy requires thoughtful consideration to ensure sufficient depth and improve diagnostic accuracy by identifying the histological features specific to each hypertrophic condition.

Atypical Location of Lichen Simplex Chronicus

Lichen simplex chronicus (LSC) is a chronic itch condition, severely impacting many patients' quality of life. The burden of this condition has been referred to as debilitating, which can lead to a sequela of chronic anxiety, depression, and stress. LSC is characterized by intractable scratching and manipulation of the skin, resulting in symmetrically thickened, scaly plaques. LSC is extremely common and is one of the most common dermatological chief complaints in clinics. This case report highlights a 68-year-old male patient presenting for an evaluation of eczema on his back associated with unrelenting pruritus in a location that he could not reach, ultimately diagnosed as LSC upon histological evaluation. Patients can experience severe suffering from chronic itching, often compared to that of chronic pain conditions. Because of this, this case emphasizes the importance of prompt diagnosis and treatment and to suspect LSC in hyperpigmented pruritic plaques, regardless of bodily location.

Genetic analyses unravel the causal association of cytokine levels on lichen simplex chronicus risk: insights from a mendelian randomization study

Lichen simplex chronicus (LSC) presents a challenge in dermatology due to its elusive pathogenic mechanisms. While associations between circulating inflammatory cytokines and LSC were observed, the definitive causal dynamics remain to be elucidated. Our study used a two-sample Mendelian randomization (MR) approach to investigate causal relationships. We applied a suite of MR methodologies, including IVW, Weighted Median, MR-Egger, Weighted Mode, Simple Mode, MR-PRESSO, and the Steiger test, to ensure robust causal inference. Our analysis confirmed the causal impact of genetically determined cytokine levels on LSC risk, particularly MMP-10 (OR = 0.493, P = 0.004) and DNER (OR = 0.651, P = 0.043) in risk attenuation. We also found a positive causal correlation between GDNF levels (OR = 1.871, P = 0.007) and LSC prevalence. Notably, bidirectional causality was observed between DNER and LSC. Consistency across various MR analyses and sensitivity analyses confirmed the absence of horizontal pleiotropy, validating the causal estimates. This pioneering MR investigation unveils a novel genetically anchored causal relationship between the circulating levels of MMP-10, DNER, and GDNF and LSC risk. Although further validation is requisite, our findings augment the understanding of cytokine mediation in LSC and underscore prospective avenues for research.

Psychopathology Associated with Chronic Pruritus: A Systematic Review

There are no previous studies of the psychopathology associated with different aetiologies of chronic pruritus. A systematic review was performed of cohort and case-control studies comparing healthy controls with patients with chronic pruritus related to primary dermatoses, systemic diseases, psychogenic pruritus, idiopathic pruritus, prurigo nodularis and/or lichen simplex chronicus. The review was registered in PROSPERO and performed according to the PRISMA statement, which allowed the inclusion of 26 studies. The quality of eligible studies was assessed using the modified Newcastle-Ottawa Scale. Most of the studies concern primary dermatoses and systemic diseases. Sleep disorders are a common comorbidity interrelated with pruritus, anxiety and depressive symptoms, in primary dermatoses. Sleep disorders are linked with pruritus and depressive symptoms in end-stage renal disease and hepatobiliary disease. Depressive and anxiety symptoms are associated with psychogenic pruritus. Psychogenic pruritus, lichen simplex chronicus and some primary dermatoses are linked with personality characteristics. Further studies are required to explore in depth the psychopathology linked with psychogenic pruritus and prurigo nodularis, as well as psychopathology linked with other primary dermatoses and systemic disorders associated with chronic pruritus, and to better differentiate psychogenic pruritus from psychopathological characteristics linked with other aetiologies of chronic pruritus, in order to improve the management of patients with chronic pruritus.

Effectiveness of 0.1% mometasone furoate under hydrocolloid dressing versus 0.1% mometasone furoate in patients with lichen simplex chronicus

There was a lack of high-quality, evidence-based treatment for lichen simplex chronicus (LSC). Topical steroid under hydrocolloid dressing treatment was investigated mostly in observational studies without investigation of the cost-effectiveness and the methodology of application also varied without standardisation. To investigate the cost-effectiveness of topical steroid under hydrocolloid dressing in the treatment of moderate to severe lichen simplex chronicus (LSC). The study aimed to provide a clear methodology that was replicable. A single-blinded randomized controlled trial was carried out to compare the efficacy of 0.1% mometasone furoate cream with or without hydrocolloid dressing in patients suffering from moderate to severe LSC. Physician Global Assessment (PGA) score, Eczema Area and Severity Index (EASI) individual components score were assessed by a Dermatologist through clinical photos at week 0, 2, and 4. Pruritis Numerical Rating Scale (PNRS) was rated. Forty adult patients were recruited. The group with hydrocolloid dressing showed superior treatment efficacy. 20 out of 20 patients benefited from the hydrocolloid dressing with topical steroid while only 6 out of 20 patients benefited from topical steroid alone at week 2 regarding PGA. Similar result was obtained at week 4. Extra HK$ 132 was needed for each patient in hydrocolloid with topical steroid group. The number needed to treat (NNT) was 1.43 (95% CI: 1.42-1.44) at week 2 and 1.42 (95% CI: 1.41-1.44) at week 4 regarding PGA score improvement of ≥2. NNT analysis supported the cost-effectiveness of adjunctive hydrocolloid dressing usage as the first-line treatment in patients with moderate to severe LSC. This study added evidence to LSC treatment with a detailed and reproducible methodology.

Follicular keratosis of the face in pediatric patients of color

BACKGROUND/OBJECTIVES

Follicular keratosis (FK) is a poorly understood disorder presenting with multiple, grouped hyperkeratotic follicular papules typically affecting the chin or jawline. This study describes the clinical presentation, histopathology, management, and outcomes of a series of pediatric patients of color with FK of the face, thought to be related to rubbing or friction on the skin.

METHODS

Retrospective review of 20 pediatric patients with FK of the face who presented to our pediatric dermatology practice between April 2019 and October 2021.

RESULTS

Twenty patients (mean age 12.1 years, 13 females), all self-identified as Black/African American, were included. All presented with an initially asymptomatic, hyperpigmented patch containing multiple hyperkeratotic follicular papules, located on the cheek, chin, upper lip, and/or jawline. Five patients endorsed a history of rubbing the site. Nine patients had onset of the lesions during the COVID-19 pandemic. Treatments included topical vitamin D analogs, corticosteroids, and/or retinoids. Topical vitamin D analogs and retinoids improved the texture and hyperpigmentation of the follicular lesions in only four patients, while topical corticosteroids had no effect. Histopathological examination of two patients revealed multiple dilated follicles containing keratinized material and associated with a sparse dermal inflammatory infiltrate in one patient and granulomatous inflammation within the dermis in the other.

CONCLUSIONS

In our cohort of pediatric patients with FK, patients of color were preferentially affected, and all cases were associated with hyperpigmentation. Some patients presented during the COVID-19 pandemic suggesting that friction from facial mask wearing may have induced or exacerbated this uncommon condition.

Vulvar Neurodermatitis in a Postmenopausal African-American Patient: A Case Report

Lichen simplex chronicus commonly presents as a distressing vaginal lesion caused by severe, cyclical itch-scratch behavior. Lichen simplex chronicus is diagnosed by obtaining a detailed medical history, performing a physical exam, and recording of self-reported symptoms. Lichen simplex chronicus can be treated by corticosteroids, immunomodulators, antiepileptics, antihistamines, antidepressants, and phototherapy. Our case describes a 55-year-old female patient who presented to a clinic with recurrent vaginal itching, combined with compulsive scratching behavior that disrupted daily functioning. Physical examination revealed hypertrophic nodules located on the labia minora with scaling and hyperpigmentation. And the patient was diagnosed with lichen simplex chronicus. Empirical treatment with behavioral modifications and clobetasol propionate cream with an occlusive dressing produced significant improvements in symptoms at a six-month follow-up. Lichen simplex chronicus can have unusual presentations and; therefore, must be carefully differentiated from infectious and malignant skin lesions.

Lichen simplex chronicus of the eyelid: A case report and literature review

Purpose

To report a case of lichen simplex chronicus (LSC) of the eyelid and to perform a literature review on this topic.

Observations

A 59-year-old African American man presents with chronic and recalcitrant recurrent chalazion of both upper eyelids despite aggressive medical management. An incision and drainage procedure was performed along with biopsy of the eyelid, which was found to be consistent with LSC. A thorough review of the English literature pertaining to LSC of the eyelids was performed by querying PubMed and Google Scholar. Though two clinical reports of LSC of the eyelid were found in older literature, only one such case confirmed by biopsy has been reported until now.

Conclusions

LSC of the eyelid is rare and this is the first reported case that is associated with chronic and recalcitrant chalazion.

More than a skin disease: stress, depression, anxiety levels, and serum neurotrophins in lichen simplex chronicus

BACKGROUND

Lichen simplex chronicus is a dermatological condition due to excessive scratching, with few studies on psychoneuroimmunology.

OBJECTIVE

We aimed to estimate the levels of stress, depression, and anxiety, and to measure serum levels of neurotrophins in patients with lichen simplex chronicus, and to correlate these parameters with the severity of the disease and pruritus.

METHODS

Thirty-six patients with lichen simplex chronicus and 36 age- and sex-matched healthy controls were included. Each participant was administered the Hospital Anxiety and Depression Scale and Perceived Stress Scale questionnaires, along with a visual analog scale for pruritus. Levels of neurotrophins (brain-derived neurotrophic factor, neurotrophin-3, nerve growth factor, glial cell line-derived neurotrophic factor) were determined by ELISA assays.

RESULTS

The scores of Perceived Stress Scale-10, Hospital Anxiety and Depression Scale were statistically higher in patients (p < 0.05 for all). The serum levels of all neurotrophins were significantly lower in patients compared to healthy controls (p < 0.05 for all). Disease severity showed no correlation with all four neurotrophins. In linear regression models applied for increased visual analog scale-pruritus scores and disease severity these two variables were statistically significant predictors (p = 0.043).

STUDY LIMITATIONS

A direct causal relationship was not addressed.

CONCLUSION

Lichen simplex chronicus patients are at risk of increased levels of stress, anxiety, depression, and present decreased levels of neurotrophins, that may suggest a role in the pathophysiology of this disorder.

Keratin 17 is Not Always a Marker of Proliferation of Keratinocytes in Skin Diseases

Purpose

Keratin 17 (K17) is an embryonic keratin and overexpression is seen in psoriasis, which is a hyperproliferation skin disease. Nonetheless, whether it is also highly expressed in other proliferative skin diseases remains unclear. The aim of this study is to explore the expression of K17 in cutaneous lichen planus (CLP), lichen simplex chronicus (LSC), and prurigo nodularis (PN).

Methods

A total of 20 skin samples from CLP lesions, 20 from LSC lesions, 20 from PN lesions, and 10 healthy adult skin tissues were obtained. Then, the expression of K17 was analyzed using immunohistochemistry on paraffin-embedded tissue sections. Furthermore, quantitative and semi-quantitative immunohistochemical scores of K17 were independently evaluated under a microscope by 2 dermatologists.

Results

Immunohistochemical analysis revealed that in normal skin, K17 was minimally expressed. Nevertheless, it was highly expressed in all epidermal layers in CLP lesions (P-value <0.01), and negatively expressed in LSC and PN lesions (all P-value >0.05). The average gray value of K17 in CLP was 151.153±13.985 (P-value <0.001), while the average values of K17 in LSC and PN were 178.720±12.001 and 181.316±8.920, respectively (all P-value >0.05).

Conclusion

K17 is potentially expressed in certain inflammatory skin diseases, including psoriasis and lichen planus. Besides, it is not always a marker of hyperproliferation of keratinocytes in skin diseases.

Primary Localized Cutaneous Amyloidosis of Keratinocyte Origin: An Update with Emphasis on Atypical Clinical Variants

Amyloid is a protein derived from at least 20 different substances. Once misfolded, it results in a group of cutaneous and systemic conditions. Primary localized cutaneous amyloidosis of keratinocyte origin is a very common subtype that can manifest either as lichen or macular amyloidosis, lacking systemic involvement. Lichen amyloidosis often presents as multiple hyperpigmented papules on the lower extremities whereas macular amyloidosis is classically characterized by dark brown rippled macules on the interscapular area. Review of the literature reveals that in addition to the classical presentation of primary localized cutaneous amyloidosis there exists a plethora of various manifestations that can be grouped into either geographic or morphologic categories. This review provides clinicians with the intimate knowledge of these presentations and summarizes the available treatment modalities.

Interleukin 36 expression in psoriasis variants and other dermatologic diseases with psoriasis-like histopathologic features

BACKGROUND

Elevated epidermal interleukin (IL)-36 expression distinguishes psoriasis from eczematous dermatitis, but other psoriasiform dermatitides (PDs) have not been thoroughly investigated for IL-36 expression. In this study, we assess the IL-36 staining pattern (IL36-SP) in psoriasis variants and other PDs including lichen simplex chronicus (LSC), prurigo nodularis (PN), lichen planus (LP), tinea, pityriasis rubra pilaris (PRP), mycosis fungoides (MF), pemphigus foliaceus (PF), acute generalized exanthematous pustulosis (AGEP), impetigo (IMP), and syphilis (SY).

METHODS

IL-36 immunostaining was performed on 307 cases of psoriasis and various PDs. IL36-SP in the upper epidermis was graded on a scale of 0-4.

RESULTS

High IL36-SP occurred in all variants of psoriasis, as well as in AGEP, PRP, PN, tinea, IMP, and LP (P > 0.05). SY, PF, LSC, and MF showed a lower IL36-SP (P ≤ 0.05) compared with psoriasis.

CONCLUSION

All variants of psoriasis exhibit high IL36-SP. IL-36 staining can assist in differentiating MF, PF, SY, and LSC from psoriasis, particularly MF and LSC, which have consistent low IL-36 expression. AGEP, PRP, tinea, IMP, PN, and LP exhibit high IL-36 expression similar to psoriasis, indicating Th17 activation in these diseases.

Cupping for neurodermatitis: A protocol of systematic review and meta-analysis

BACKGROUND

Neurodermatitis is a common inflammatory and allergic disease, characterized by itching and lichenification plaque. Some studies have reported cupping therapy (CT) for the treatment of neurodermatitis. However, the effectiveness and safety are still uncertain. This study aims to evaluate the efficacy and safety of CT for the treatment of patients with neurodermatitis.

METHODS

We will retrieve the following electronic databases systematically: Pubmed, Web of Science, Embase, the Cochrane Library, Chinese Scientific Journal Database, China National Knowledge Infrastructure Database, Chinese Biomedical Literature Database, and Wanfang database from their inception to December 2020. Other literature resources will be manually searched. Published randomized controlled trials (RCTs) and quasi-randomized controlled trials (q-RCTs) on the topic will be retrieved by 2 investigators independently. We will apply a fixed-effect model or random effect model basis on the heterogeneity test and employ with RevMan 5.3 software for data synthesis. The total clinical effective rate will be selected as the primary outcome, skin disease quality of life index score, recurrence rate, and adverse events as secondary outcomes.

RESULTS

This study will comprehensively summarize the high-quality trials to determine the efficacy and safety of CT for the treatment of patients with neurodermatitis.

CONCLUSION

Our systematic review will present evidence for the efficacy and safety of CT to neurodermatitis patients.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/6DCM3.

Matrix stimulation in chronic pruritus: A randomized controlled study

Chronic pruritus is one of the main symptoms in dermatology. We investigated a new intervention for chronic pruritus by neurostimulation through matrix electrodes. In this randomized controlled trial, 29 patients with chronic pruritus caused by a variety of dermatological diseases were allocated to an experimental group (EG; n = 14, 4-Hz neurostimulation of the itching area through matrix electrodes) or the control group (CG; n = 15, placement of matrix electrodes without neurostimulation). Outcome measures were the itching sensation as measured by a Numerical Rating Scale immediately after the intervention and the intermediate effect measured by the average itching sensation on the day before the intervention compared with the average itching sensation on day 1, 2 and 3 after the intervention. Regarding the short-term effect on itching, the anova showed a significant interaction effect for the 5-min stimulation with a larger reduction in the EG with a large effect size of d = 1.10. The average reduction in itching intensity was 78.2% for the EG compared with 34.3% for the CG. For the intermediate effect, no significant interaction was found (F = 1.721, P = 0.199). Comparing the itching sensation at day 0 with day 3, the interaction effect showed a statistical trend toward a greater reduction in the EG (F = 3.178, P = 0.086; statistical trend, d = 0.69). This study proved that neurostimulation through matrix electrodes is effective in the short-term reduction of itching in patients with chronic pruritus caused by dermatological diseases. Additional studies are needed with larger patient pools and covering longer study periods.

Lichen Simplex Chronicus on the Scalp: Broom Fibers on Dermoscopy; Gear Wheel Sign and Hamburger Sign on Histopathology

Lichen simplex chronicus (LSC) is characterized by lichenification of the skin because of primary excessive scratching. Herein, we present two cases of scalp LSC with a patch showing localized hair loss and paroxysmal severely itching on that area. Dermoscopy examined the presence of broom hair fibers while histopathological examination revealed gear wheel sign, hair shafts split in two (the hamburger sign), and decrease in the size of the sebaceous glands.

Prurigo nodularis: Epidemiology and clinical features

Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized by intensely pruritic, hyperkeratotic nodules that favor the extensor surfaces of the extremities and the trunk. In addition to its significant impact on quality of life, many patients with PN are recalcitrant to therapy because there are currently no therapies approved by the US Food and Drug Administration. In the first article of this 2-part continuing medical education series, we describe the broader epidemiology, patient demographics, physical examination findings, and symptoms to aid in the timely recognition and diagnosis of PN. Furthermore, we quantify the burden of comorbidities in PN by discussing the broad spectrum of systemic diseases and mental health conditions that have been associated with this condition. The second article of this 2-part series focuses on the pathogenesis of PN and provides detailed algorithms for comprehensive work-up and management.

Diagnostic Workup and Evaluation of Patients with Prurigo Nodularis

Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized oftentimes by symmetrically distributed, severely pruritic nodules. Currently, the pathophysiology of PN remains to be fully elucidated, but emerging evidence suggests that neuroimmune alterations play principal roles in the pathogenesis of PN. There are several associated etiologic factors thought to be associated with PN, including dermatoses, systemic, infectious, psychiatric, and neurologic conditions. We conducted a systematic literature review to evaluate the clinical presentation, diagnosis, and etiologic factors of PN. In this review, we discuss common differential diagnoses of PN and recommend an evidence-based, standardized diagnostic evaluation for those with suspected PN.

Pruritus in allergy and immunology

Although evolutionarily conserved to expel ectoparasites and aid in the clearance of toxins and noxious environmental stimuli from the host, the type 2 immune response can become pathologic in the setting of a variety of allergic disorders. Itch can be a behavioral extension of type 2 immunity by evoking scratching and, in the setting of disease, can become chronic and thus highly pathologic as well. Classically, our understanding of itch mechanisms has centered around the canonical IgE-mast cell-histamine axis. However, therapies aimed at blocking the histaminergic itch pathway have been largely ineffective, suggesting the existence of nonhistaminergic itch pathways. Indeed, recent advances in itch biology have provided critical new insight into a variety of novel therapeutic avenues for chronic itch in the setting of a number of allergic disorders. Here we highlight how these new developments will likely inform the problem of pruritus in a variety of well-established and emerging conditions in the field of allergy.

Trichoteiromania: Good Response to Treatment with N-Acetylcysteine

Lichen simplex chronicus on the scalp, also known as trichoteiromania, can be difficult to manage, as the therapeutic options are limited to topical or intralesional glucocorticoids. We describe a patient with trichoteiromania, presenting three lichenified pruriginous plaques on different regions of the scalp, associated with fracture and loss of hair shafts. Prior treatment with potent topical glucocorticoids was ineffective. However, treatment with oral N-acetylcysteine (NAC) 1,200 mg/day resulted in complete hair regrowth within 16 weeks. NAC is a safe drug with a good tolerance profile that could be a therapeutic option for patients with trichoteiromania. The potential of NAC has not been completely elucidated, thus more studies will be necessary to confirm its efficacy in the long term for some psychodermatological conditions.

Male Genital Dermatology: A Primer for the Sexual Medicine Physician

INTRODUCTION

The dermatologic conditions affecting the male genitalia are diverse and range from normal variants and benign growths to overt malignancy. Unfortunately, there is a dearth of urologic dermatology training in most residency programs, and many dermatologic lesions with a classic appearance on other areas of the body may have atypical presentations on the genitalia. Patients may present to a variety of physicians without receiving a definitive diagnosis, which can be highly distressing to the afflicted individual.

AIM

To provide sexual medicine physicians tools to aid in the evaluation and diagnosis of urologic dermatology lesions, whether they are limited to the genitalia or part of a widespread systemic disease.

METHODS

Comprehensive review of the literature pertaining to genital dermatology in men.

MAIN OUTCOME MEASURE

We stratify each condition into 1 of 5 groups (normal variants and benign lesions, inflammatory lesions, transmissible lesions, premalignant lesions, and malignant lesions) and focus on presentation and prevalence of these conditions.

RESULTS

Sexual medicine physicians should emphasize the non-pathologic nature of normal variants of genital anatomy (ie, penile hyperpigmentation, pearly penile papules) and stress that removal of these lesions is only appropriate for cosmetic purposes. Benign genital growths (ie, sebaceous cysts, seborrheic keratoses) may not require intervention, but they should be monitored for atypical features and infection. In contrast, transmissible (ie, herpes, syphilis) and inflammatory (ie, psoriasis) lesions may necessitate prompt intervention to reduce transmission and complications of late-stage disease. Premalignant and malignant lesions may mimic many of the aforementioned conditions; it is important that patients receive routine follow-up after treatment. All suspicious non-healing or ulcerating lesions should undergo pathologic evaluation to rule out malignancy.

CONCLUSION

Urologic dermatology can be a diagnostic challenge for sexual medicine physicians. This review simplifies the diagnostic approach and emphasizes pathologic features of each condition to guide management. Gabrielson AT, Le TV, Fontenot C, et al. Male genital dermatology: A primer for the sexual medicine physician. Sex Med Rev 2019;7:71-83.

Prurigo nodularis: a physician survey to evaluate current perceptions of its classification, clinical experience and unmet need

BACKGROUND

Prurigo nodularis (PN) is a chronic skin condition characterized by intensely pruritic, hyperkeratotic papulonodular lesions that dramatically impairs patients' quality of life. Management of the condition is challenging, and there is no approved therapy in the United States or in Europe.

OBJECTIVE

The key aim of this survey was to examine current perceptions of PN diagnosis and management among members of the European Academy of Dermatology and Venereology (EADV).

METHODS

The survey comprised 29 questions, including multiple choice and open responses, and was sent to clinicians via e-mail during December 2016. The survey results were collected and analysed.

RESULTS

Responses were received from 30 participants from 14 countries, of whom 22 (73.3%) were members of the EADV Task Force Pruritus. The majority (73.3%) considered PN to be a distinct condition, and the preferred description to explain the most common pathogenesis was 'chronic pruritus leading to chronic scratching' (80.0%). Pruritic nodules (n = 23/30, 76.7%) and scratching (n = 12/30, 40.0%) were the most common descriptors used to characterize PN. Most respondents (60.0%) reported seeing ≤5 unique PN patients per month, the majority of whom (68.8%) visited a physician ~2-4 times per year. PN patients reported to the respondents that they experienced persistent, severe pruritus, with a mean ± SD numeric rating scale score of 7.8 ± 1.2, lasting for >6 months in 82.3% of patients and >2 years in 51.0%. The most frequently prescribed therapies by survey respondents for PN symptoms were antihistamines (90.0%), antidepressants (90.0%), gabapentinoids (86.7%) and immunosuppressants (86.7%). Respondents agreed upon the need for new PN therapies (56.7%), revised PN classification and terminology (23.3%) and better understanding of PN pathophysiology (20.0%).

CONCLUSION

EADV Task Force Pruritus notes several challenges that must be met to improve symptoms and quality of life for patients with PN.

Lichen simplex chronicus on the scalp: exuberant clinical, dermoscopic, and histopathological findings

Lichen simplex chronicus is a skin disease that mostly affects female patients, with a peak incidence between ages 35 and 50 years. On the scalp, it appears as a single or multiple oval lesions, showing scaling and hair shaft loss or breakage. An important dermoscopic feature of the disease are the "broom fibers." Histopathology reveals the "hamburger" and the "gear wheel" signs. The aim of this report is to demonstrate a case of lichen simplex chronicus on the scalp with typical and exuberant clinical, dermoscopic, and histopathological findings.

Lichen Simplex Chronicus as an Essential Part of the Dermatologic Masquerade

A 48 years old female patient had been suffering from the lesions presented for four years. They have started as small, pruritic patches which had been mechanically irritated and grew up in time. The patient had no associated comorbidities or allergies, and she was not under any medication. On physical examination, she presented one erythematous, exudative plaque, with dimensions of 2.5/4 cm, located on the proximal phalanx and interphalangeal articulation of the left thumb. All histopathological features were consistent with the diagnosis of lichen simplex chronicus. Some lesions of lichen simplex chronicus exhibit signs of pseudocarcinomatous, infundibular and sometimes eccrine ductal proliferation of keratinocytes. Although the pseudoinfiltrative aspect of the epithelial proliferation and its pronounced degree might mimic a well-differentiated lesion of squamous cell carcinoma, a lack of cellular atypia and atypical mitotic figures are features that do not support this diagnosis. On the other hand, long lasting lesions of lichen simplex chronicus may lead to alterations in the processes of keratinocyte proliferation and differentiation and eventually give rise to malignant transformation. The best treatment management is a psychodermatological approach, a combination of skin care with psychotherapy, in order to prevent relapses.

Differences Between Men and Women in Chronic Scratching: A Psychodermatologic Study in Lichen Simplex Chronicus

INTRODUCTION

Chronic scratching is common to many skin disorders. Being a female and presenting a high level of psychopathology are risk factors for chronic scratching. Yet, it is unclear why. Certain personality characteristics that are more prevalent in women are also known to influence emotional states (i.e. emotional tension).

OBJECTIVE

The present study aims to explore whether these personality styles might help understand why gender and emotional distress are associated with scratching.

MATERIAL AND METHODS

We compared the personality patterns of 103 patients (69.9% women) diagnosed with Lichen Simplex Chronicus, against a sample of healthy individuals.

RESULTS

Significant differences were found in the personality styles of men and women with LSC. Women were more pessimistic, oriented to fulfil the needs of others, traditional, insecure, submissive, and reserved, with moderate (d=.43) to strong (d=.96) size effects ranges. Some of these differences, such as in traditionalism, dutifulness, other-orientation, and pessimism, were also observed when compared with healthy men and women, with small (d=.03) to moderate (d=.47) size effects ranges.

CONCLUSIONS

These psychological factors may help explain the mechanisms underlying gender differences in chronic scratching, at least in Lichen Simplex Chronicus. The findings might open new avenues for research and treatment.

Lesions With an Epidermal Hyperplastic Pattern: Morphologic Clues in the Differential Diagnosis

In this report, we review the most common entities that show a epidermal hyperplastic pattern in the biopsy. These entities include inflammatory, reactive, infectious, hamartomatous, and tumoral conditions, each with a very different prognosis. Therefore, an approach based on the classic "patterns and clues" tools used in dermatopathology can bring a lot of information to the dermatopathologist or the general pathologist evaluating these lesions.

Lichen Simplex Chronicus Associated With Erectile Dysfunction: A Population-Based Retrospective Cohort Study

Background

An association between lichen simplex chronicus (LSC) and sexual dysfunction was explored. However, no data are available from investigations into the relationship between erectile dysfunction (ED) and LSC.

Objectives

This retrospective population-based cohort study aimed to clarify the risk of ED associated with LSC.

Methods

By using the Taiwan National Health Insurance Research dataset, we identified 5611 male patients who had been newly diagnosed with LSC from 2000 to 2004. The date of diagnosis was identified as the index date. LSC patients with incomplete demographic information or with a history of ED before the index date were excluded. In total, 22444 age-matched patients without LSC were randomly selected as the non-LSC group based on a 1:4 ratio. Subsequence occurrence of ED was measured until 2011. The association between LSC and the risk of developing ED was estimated using Cox proportional hazard regression model.

Results

After adjusting for age and comorbidities, patients with LSC had a 1.74-fold greater risk of developing ED compared with those without LSC (95% confidence interval=1.44–2.10). LSC patients with comorbidities including diabetes, hyperlipidemia, hypertension, cardiovascular disease, peripheral arterial disease, chronic obstructive pulmonary disease, chronic kidney disease, depression, and anxiety were at a higher risk of ED compared with the non-LSC patients without comorbidities.

Conclusions

LSC confers a greater risk in the development of ED. Physicians should be aware of the potential of ED occurrence in LSC patients.

Increased risk of lichen simplex chronicus in people with anxiety disorder: a nationwide population-based retrospective cohort study

BACKGROUND

The cingulate cortex is the main area in the brain involved in pruritus processing and is deactivated after scratching. Lichen simplex chronicus (LSC) is a common pruritic skin disorder characterized by skin lichenification following excessive scratching. Psychological factors may contribute to both the development and persistence of LSC.

OBJECTIVES

To estimate the hazard ratio (HR) of LSC in people with anxiety disorders compared with the general population.

METHODS

In this nationwide population-based retrospective cohort study we identified a total of 69 386 people, who formed the anxiety cohort, by using the Taiwan National Health Insurance Research Database from 2000 to 2009. The comparison cohort was composed of randomly selected people frequency matched for age (within 5-year intervals), sex and index date (the date of anxiety diagnosis) based on a 1 : 2 ratio. The risk of LSC was estimated as HRs and 95% confidence intervals (CIs) using the Cox proportional hazards model.

RESULTS

After adjusting for age, sex and LSC-associated comorbidities, the people with anxiety had a 1·41-fold greater risk of developing LSC compared with the people in the comparison cohort (HR 1·41, 95% CI 1·30-1·52, P < 0·0001). In particular, individuals with obsessive-compulsive disorder had a significantly increased risk of developing LSC (HR 1·72, 95% CI 1·03-2·88, P = 0·0395).

CONCLUSIONS

This study demonstrates that having an anxiety disorder is associated with an increased risk of LSC. Psychological factors were found to contribute to LSC. We recommend combining the management of LSC and psychological disorders to achieve favourable outcomes.

Use of transcutaneous electrical nerve stimulation for chronic pruritus

Pruritus is a distressing symptom in many dermatological as well as systemic conditions, and it is sometimes very chronic and relapsing. Transcutaneous electrical nerve stimulation (TENS) is an inexpensive form of analgesia that could also ameliorate itching. This study aimed to evaluate TENS efficacy in patients with pruritus due to some types of chronic eczema, and in patients with chronic hepatic disease. Ten patients with atopic dermatitis (AD), 20 patients with lichen simplex chronicus (LSC), and 16 patients with chronic liver disease having chronic distressing pruritus received three sessions of TENS weekly for 12 sessions, and the effect on the visual analogue scale (VAS) scores was recorded after 2 weeks of therapy, at treatment end, and after an additional month for follow up. There was a statistically significant decline in the mean VAS score for studied groups at weeks 2 and 4 of therapy compared to baseline, but the improvement was more significant in patients with AD, and LSC (p < 0.001 for both) than in those with chronic liver disease (p < 0.01) who also showed an early re-elevation of VAS score on follow up. TENS therapy holds promise as a palliative, alternative, safe and inexpensive treatment for patients with some chronic pruritic conditions.

Psychological stress with long-standing allergic dermatitis causes psychodermatological conditions in mice

Psychological factors have long been assumed to be involved in the pathogenesis of allergic skin diseases. The effects of psychological stress on allergic contact dermatitis (ACD) have been experimentally well investigated; however, the effects of ACD on stress responses are largely unknown. Here, we report that preceding chronic ACD dramatically affects the behavioral and physiological stress responses to social isolation (a psychological stressor). In male BALB/c mice, social isolation combined with long-standing (>2 months) ACD by repeated hapten application caused characteristic symptoms, including chronic dermatitis from persistent self-scratching, behavioral changes related to fear/anxiety, and elevated serum IgE levels. The symptoms were maintained by social isolation alone without further hapten application after the onset, and were improved by resocialization. Treatment with topical corticosteroids exacerbated chronic scratch dermatitis, whereas it was effective for chronic ACD. These results show that the symptoms represent a de novo development of a specific disease state and not a mere exacerbation of a preexisting allergic inflammation. With this experimental protocol, similar results were obtained in several other strains of mice. This murine model provides a tool for investigating the pathogenesis and treatment of allergic skin disease with psychodermatological aspects.

Sex-related differences in SLIGRL-induced pruritus in mice

AIMS

Pruritus is a common symptom of skin diseases, and is associated with impaired sleep quality and a considerable reduction in the patient's quality of life. Recently, it was reported that there are sex-specific differences in scratching behavior in chronic pruritus patients. Namely, female chronic pruritus patients scratch more and have significantly more scratch lesions than male patients. However, few animal studies have examined sex-related differences in scratching behavior. Thus, the present work investigated sex-related differences in animal pruritus using pruritogens, which are often used to create experimental animal models of itching.

MAIN METHODS

Acute pruritus was induced in ICR mice by a single intradermal injection of histamine, 4-methylhistamine, serotonin, compound 48/80, substance P (SP), or the proteinase-activated receptor-2 (PAR-2)-activating peptide SLIGRL-NH2. Chronic pruritus was induced by 5 weeks of the repeated application of 2,4,6-trinitro-1-chlorobenzene (TNCB) to BALB/c mice.

KEY FINDINGS

Female mice showed significantly higher scratching counts in SLIGRL-NH2-induced pruritus than male mice. Conversely, there was no obvious sex-related difference in scratching behavior for the other pruritogens examined.

SIGNIFICANCE

These results indicate that sex-related differences may exist in the pruritogen-responsive neurons that transmit the itch signal induced by SLIGRL-NH2, but not by histamine or 5-HT.

Efficacy of treatment with oral alitretinoin in patient suffering from lichen simplex chronicus and severe atopic dermatitis of hands

Lichen simplex chronicus (LSC) is a skin disorder characterized by chronic itching and scratching, which can lead to thick, leathery, brownish skin, sometimes with papules and can be associated with atopic eczema. We report the case of a 52-year-old man with a 45-year atopic condition and presenting LSC in his dorsum. After a 3-month treatment with alitretinoin at the daily dosage of 30 mg, we have observed a moderate improvement of the hand eczema together with a substantial clinical improvement of LSC and an almost complete resolution of pruritus. We want to report this peculiar case to suggest the use of oral alitretinoin for LSC.

An unusual presentation of herpes simplex virus type 1 infection in a child

We describe an 11-year-old girl presenting with lichen simplex chronicus (LSC) and acute bilateral carpal tunnel syndrome (CTS) following herpes simplex virus type 1 (HSV-1) infection as evidenced by serological data and by detection of HSV-1 DNA in the blood with the use of PCR. Based on the literature search, this case represents the first childhood case of LSC and acute bilateral CTS following HSV-1 infection. The experience with this patient emphasizes the importance of serological tests and PCR as well as the other laboratory techniques for the accurate diagnosis and management of the disease.

Treatment of prurigo nodularis with pregabalin

WHAT IS KNOWN AND OBJECTIVE

Prurigo nodularis (PN) is a chronic skin condition that is difficult to treat. Pregabalin is one of the possible treatments for PN but its safety and efficacy are not well defined. We aimed to assess the efficacy of pregabalin in patients with PN.

METHODS

Thirty patients (10 men, 20 women; mean age 51.6 ± 9.39 years) were treated with pregabalin (75 mg/day) for 3 months. Efficacy was classified as (i) successful (disappearance of the pruritus and reduction of nodules); (ii) slight improvement/reduction of the nodules, that is, number and/or flattening, no disappearance of itching; or (iii) unsuccessful.

RESULTS

Twenty-three patients (76%) responded successfully after 3 months of treatment. There was a statistically significant difference between visual analogue scale scores before and after 1 month treatment period (8·15 ± 2·04 and 1·5 ± 1·12, respectively; P < 0·0001). Pregabalin was generally well tolerated with only six (20%) patients reporting side effects. No patient showed any renal insufficiency.

WHAT IS NEW AND CONCLUSION

In our study, pregabalin was effective for the treatment of PN. However, given the open and non-controlled study design used, a properly powered randomized controlled validation study is called for.

Quality of life of patients with neurodermatitis

BACKGROUND

Neurodermatitis is a common chronic skin disease. Although not life-threatening, it can produce an important psychosocial burden, sleep disturbance and sexual dysfunction. Patients with neurodermatitis tend to have poor social skills or interpersonal resources and a lack of flexibility. However quality of life (QoL) of patients with neurodermatitis has seldom investigated. The objective of this study is to assess the impact of neurodermatitis on patients' QoL using the Dermatology Life Quality Index questionnaire, and assess its feasibility and internal consistency.

METHODS

One hundred and fifty consecutive outpatients seeking treatment for neurodermatitis and 250 patients with psoriasis in the Department of Dermatology, the Second Hospital of Xi'an Jiaotong University, were assessed for eligibility for this prospective study from July 1, 2011 to September 30, 2011. Demographic data and disease-related characteristics were collected.

RESULTS

The overall mean DLQI score for neurodermatits (9.34) was lower than that for psoriasis (13.32) (P < 0.001). Patients with neurodermatitis scored significantly lower for all items except Q1 (symptoms) and Q9 (sexual difficulties). No strong relationship between disease-related characteristics and quality of life could be found. The inter-item correlation averaged 0.415 and Cronbach's alpha was 0.889, indicating high internal consistency.

CONCLUSION

This is the first study to attempt to measure the impact of neurodermatitis for both male and female patients on QoL. Neurodermatitis moderately affected the QoL of the patients.

Occurrence of squamous cell carcinoma in an area of lichen simplex chronicus: case report and pathogenetic hypothesis

BACKGROUND

Lichen simplex chronicus is a common skin disorder characterized by circumscribed, lichenified, pruritic plaque secondary to local repetitive trauma, notably rubbing and scratching.

OBJECTIVE

We describe a case of a squamous cell carcinoma arising in a patient with a long-lasting history of lichen simplex chronicus and discuss the potential role of the microenvironment in predisposing the malignant transformation.

CONCLUSION

Here we propose a hypothesis in which rubbing and scratching contribute to an excess of inflammatory mediators, which in turn may lead to alterations in the processes of keratinocyte proliferation and differentiation.

Lichen Simplex Chronicus That Accompanies Anogenital Warts during the Childhood

Anogenital warts and lichen simplex chronicus (LSC) are rarely seen during the childhood. A 9-year-old girl has been presented to hospital by her parents with itching in the anogenital area. There were anogenital warts and a different erythematous lesion in the perianal region. On the pulpa of the right thumb, there was a wart extending under the nail. The lesions are surgically removed. The results of the histopathological examination were reported as condyloma acuminata and LSC. Children with anogenital warts should be examined carefully to discover the transmission route and other possible concomitant cutaneous diseases.