Letter: Generalized lichen nitidus successfully treated with pimecrolimus 1 percent creamTehran University of Medical Sciences, Imam Hospital
Susan Farshi MD MPH, Parvin Mansouri MD
Dermatology Online Journal 17 (7): 11
An eight-year-old child presented with generalized popular eruptions of two years duration. The diagnosis was lichen nitidus with pathologic confirmation. The lesions were successfully reduced and flattened by pimecrolimus 1 percent cream for 8 weeks.
Lichen nitidus (LN) is an uncommon, usually asymptomatic, chronic eruption characterized by the presence of multiple, tiny, discrete, shiny, flesh colored flat papules 2-3 mm in diameter that are predominantly observed on the chest, abdomen, glans penis, and upper extremities [1, 2, 3]. The etiology of LN is unknown and no laboratory abnormalities or associations with systemic disease have been established . Multiple clinical variants of LN have been described, including keratodermic, vesicular, hemorrhagic, purpuric, perforating, palmoplantar and generalized forms [1-3, 5, 6]. The disorder is most often localized and only a few cases of generalized LN have been reported [2, 5-8]. We report a case of generalized LN that improved but did not completely clear with application of pimecrolimus 1 percent cream for eight weeks.
|Figure 3. The lesions on the trunk of the child before (A) and after (B) treatment with pimecrolimus 1 percent cream for 2 months.|
An eight-year-old child presented to the hospital for evaluation of a non-pruritic, generalized cutaneous eruption that had been present for two years. Physical examination revealed multiple flesh-colored and tan-brown papules, from 1 to 2 mm in diameter, on the child's torso, extremities, body, and face, as seen in Figure 1. There was no evidence of mucocutaneous or palmoplantar involvement. The child did not have any associated systemic complaints. The patient's medical history was unremarkable and he had not been taking any other medication over the previous 2 years. The laboratory tests also were normal. A skin biopsy was performed. The diagnosis was LN, which was confirmed by pathology.
Sections of the skin biopsy showed slight hyperkeratosis, acanthosis, and foci with vacuolization of the basal layer; the epidermis was relatively thinned over the infiltrate. Rete ridges adjacent to dermal infiltrate were elongated and infolding. Discrete focus of inflammatory cells consisted of histiocytes, lymphocytes, and occasionally multinucleated giant cells that filled the papillary dermis. There was perifollicular fibrosis admixed with some lymphocytic infiltration in the mid dermis (Figure 2).
The lesions were improved with application of pimecrolimus 1 percent cream twice daily for 8 weeks. Figure 3 shows lesions on the body of the child before (Figure 3A) and after (Figure 3B) treatment with pimecrolimus 1 percent cream for 8 weeks. Any side effect of the drug was not seen in our patient.
Lichen nitidus is a chronic popular eruption of the skin that most commonly affects children and young adults , but has been reported in the elderly. Generalized LN is a rare subtype of LN characterized by multiple, skin-colored, shiny, dome-shaped papules occurring over the entire body . The differential diagnosis of LN includes keratosis pilaris, lichen planus, follicular eczema, verruca plana, pityriasis rubra pilaris, phrynoderma (vitamin A deficiency), lichen simplex chronicus, prurigo nodularis, psoriasis , and papular mucinosis . Histopathological evaluation is helpful to confirm the diagnosis. Because LN is usually asymptomatic and resolves without any sequelae, no treatment is required in most cases. Although, LN tends to be asymptomatic and usually resolves spontaneously in a year, the clinical course of generalized LN is unpredictable and there is no effective or tolerable treatment for generalized LN in children [2, 8, 10]. Persistent lesions and those that are refractory to various treatments can pose therapeutic challenges . Systemic and topical corticosteroids , dinitrochlorobenzene (DNCB), diphenylcyclopropenone immunotherapy, astemizole, itraconazole, isoniazid, enoxaparin, and psoralen and ultraviolet A (PUVA) phototherapy have all been tried [2, 11]. Sun exposure and narrow band UVB (NBUVB) therapy have been reported to be helpful in treating LN [8, 9, 12]. Successful treatment of LN with tacrolimus 0.1 percent ointment has been reported in one case in 2004 . The topical calcineurin inhibitors tacrolimus and pimecrolimus have an effect on various cells of the cutaneous immune system, specifically on T cells, by inhibiting the phosphatase calcineurin and preventing the transcription of proinflammatory cytokines .
Although the exact mechanism of pimecrolimus in the treatment of LN is unknown, anti-inflammatory and immunumodulatory effects have been suggested. Our patient responded to a short course of topical pimecrolimus cream but more controlled studies are needed.
Acknowledgement: The authors indebted to thank Dr. Zahra Safaie-Naraghi for her help in preparing of the pathologic pictures.
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