Dermatology Online Journal

A clinical and epidemiological study of lichen planus among Egyptians of AL-Minya province
Tag-El -Din Anbar MD¹, Manal Barakat MD¹, and Sahar F Ghannam MD PhD²
Dermatology Online Journal 11 (2): 4

1. AL-Minya University Hospital, Al ÐMinya, Egypt2. Faculty of Medicine, Alexandria University, Egypt. manalbarakat2003@yahoo.com

---

Abstract

Background: Lichen planus (LP) is a papulosquamous disease that affects skin and mucous membranes. It may also affect hair and nails. From the middle east, studies concerning its prevalence and clinical characteristics are few. This study presents the clinical and epidemiological pattern of LP among the Egyptian people. We analyzed the clinical and epidemiological data obtained from 50 LP patients who attended the dermatology outpatient clinic of al-Minya University Hospital, al-Minya, Egypt over a 1-year period. Lichen planus was present in 0.28 percent of the patients (females 44 %, males 56 %). The age range was 10-65 years; the majority fall in the 21-50 age group. Presentations include actinic LP (36 %), classic LP (30 %), hypertrophic LP (12 %), guttate LP (6 %), atrophic LP (4 %), follicular LP (4 %), and isolated oral LP (8 %). Pruritus was the chief complaint of 50 percent of these patients. In 56 percent of patients, limbs were the initial site of onset.

---

Introduction

Lichen planus (LP) is a papulosquamous disease of the skin and mucous membranes. In its classic presentation, it is characterized by pruritic violaceous papules most commonly on the extremities of middle-aged adults. It may be accompanied by oral and genital mucous membrane involvement and hair and nail involvement. Its course is generally self limited to a period of several months to years, but it may last indefinitely [1]. Lichen planus is worldwide in distribution with variable incidence [2].

There are many published reports from the middle-east that evaluated various aspects of LP [3-12]. However, studies concerned with the clinical and epidemiological pattern of LP are few [13]. In an attempt to overcome this gap, we performed a study the pattern of LP in patients attending the dermatology outpatient clinic of al-Minya University Hospital in al-Minya, a province in upper (southern) Egypt.

Patients and methods

The study involved 50 LP patients who attended the dermatology outpatient clinic of al-Minya University Hospital over a period of 1 year (January to December 2002). Clinical diagnosis was supported by histopathologic examination of biopsies taken from the patients. For each patient, a separate case sheet was completed including: personal history, disease history (onset, duration, sun exposure), and drug history. A thorough clinical examination of the skin, genitalia, mucous membranes, hair and nails was performed regarding morphology and distribution of the lesions. This was followed by photographing of lesions.

Results

Figure 1	Figure 2
Actinic LP on the face of a female patient (Fig. 1).
Classic LP with resolving hyperpigmented lesions on one side and still active lesions on the other side of the body (Fig. 2).

Figure 3	Figure 4
Hypertrophic LP with excoriated lesions from scratching (Fig. 3).
Guttate LP with Koebner on forearms (Fig. 4).

Figure 5	Figure 6
Atrophic LP annular lesions with atrophic center and raised borders (Fig. 5).
Follicular LP associated with cicatricial alopecia of scalp with keratotic follicles (Fig. 6).

Figure 7	Figure 8
Follicular LP on forearms with spinous follicular papules (Fig. 7).
Follicular LP on dorsum of hand with spinous follicular papules (Fig. 8).

Figure 9
Zostriform LP affecting the chin, right shoulder and the arm (FIg. 9).

Over a 1-year period, we diagnosed 50 patients with LP. These patients comprised 0.28 percent of all patients (17,940 patients) who attended the clinic during the study period. Their ages ranged from 10 to 65 years (mean ± SD 41.36 ± 14.71. The majority of patients (33 or 66 %) fall in the age group from 21-50 years. There were 28 males (56 %) and 22 females (44 %), a male:female ratio of 1.3: 1 (Table 1).

The duration of the disease varied from 1 month to 3 years. In this study, childhood LP was presented only by a 10-year-old boy. Familial LP was not observed. Most of the patients gave irrelevant history about drug intake including analgesics for headache or arthralgia and contraceptive pills taken by some of the female patients.

Clinical examination revealed that 18 (36 %) of patients have actinic LP, 15 (30 %) classic LP, 6 (12 %) hypertrophic LP, 3 (6 %) guttate LP, 2 (4 %) atrophic LP and 2 (4 %) follicular LP (lichen planopilaris). There were 4 patients (8 %) who had isolated oral LP without cutaneous lesions (Table 2).

The initial site of onset was limbs in 28 (56 %) patients, face in 14 (28 %), mouth in 4 (8 %), trunk (back) in 2 (4 %), and scalp in 2 (4 %).

Hair involvement was detected in the 2 follicular LP (lichen planopilaris) patients in the form of cicatricial-alopecia patches involving the scalp. Nail changes were present in 9 (18 %) patients. Longitudinal ridging was the commonest change (in 8 cases) and occurred either alone or in combination of other changes as loss of one nail plate, splitting, discoloration, and pterygium. Pterygium was detected in 3 (6 %) patients and it was the only change in one patient of the three (table 3).

Figure 10	Figure 11
Pterygium of the index finger (Fig. 10).
Oral LP A: Reticular white type. B: Ulcerative type (Fig. 11).

Patients with isolated oral LP (4 patients) were all referred from the dentistry clinic where diagnosis was proved through histopathologic examination of lesions. Two patients complained of mouth soreness found to be associated with buccal and gingival erosions and ulcers (Fig. 11). The other 2 patients showed reticular white lesions on the buccal mucosa. Oral-mucosal involvement also occurred in association with cutaneous lesions in 11 (22 %) patients in the form of reticular white lesions involving the buccal mucosa (table 3).

Figure 12	Figure 13
Genital LP A: Pinhead violaceous papules on penis. B: Annular lesions on penis (Fig. 12)
Large scratch mark on forearm of a classic LP (Fig. 13).

Genital lesions were observed in 12 (24 %) patients, 11 (22 %) males and 1 (2 %) female. In males, genital LP appeared as annular and small papular lesions on the penis (Fig. 12). In the female patient, there were violaceous papules affecting the labia majora associated with severe pruritus (table 3).

Pruritus was the chief complaint of 25 (50 %) patients; it was reported to be severe in patients with hypertrophic LP (table 3). Twenty-one (42 %) patients were rubbing their lesions to gain relief, four (8 %) patients were scratching rather than rubbing their lesions, this was evidenced by the presence of excoriated LP lesions in 3 patients with hypertrophic LP (Fig 3) and the scratch marks on the forearm of a patient with classic LP (Fig 13).

Some patients showed peculiar findings. In a case of classic LP, there was resolving hyperpigmented lesions on one side of the body and still active violaceous lesions on the other side (Fig. 2). One of the 2 atrophic LP patients showed annular lesions with raised borders and atrophic centers, especially on the forarms (Fig. 6). In addition to cicatricial alopecia, one of the 2 follicular LP patients showed follicular spinous lesions on the dorsa of the hands and forearms (Figs. 7, 8).

Discussion

Lichen planus is a papulosquamous disease that characteristically involves skin and mucous membranes; it may also affect hair and nails. The prevalence of LP is unknown, however, it is thought to be less than 1 percent of the population [1]. This study finds its prevalence to be 0.28 percent among patients attending the outpatient clinic of our department.

Some authors report that LP usually appears during the 5th or 6th decade [1], others reported that most cases seen are in the 30-60 age group [2]. Involvement at a younger age is found in this series; the age of patients ranged from 10-65 years with a mean age of 41.36, and the majority of patients (66 %) fall in the age group of 21-50 years. This finding supports the suggestion that younger patients tend to be affected in tropical countries [14].

Lichen planus appears is said to affect females preferentially [1], however, the male: female ratio (1.3: 1) recorded here reflects no significant difference in sex distribution.

It is reported that childhood LP is rare [2] and familial LP is not common [15]. In the present study, childhood LP presented 2 percent of LP patients and familial LP was not found. Our study revealed no seasonal variation in the incidence of LP, in contrast to one study that reported an increased LP incidence between January and July [16] and another that reported this increase to occur between April and September [17].

Studies reveal predominance of the classic type among LP patients followed by the hypertrophic and the actinic varieties [18, 19, 20]. Our study shows predominance of actinic LP (36 %) followed by classic LP (30 %), and hypertrophic LP (12 %). The predominance of the actinic variety among patients might be attributed to al-Minya being a sunny province. The recorded percentage of actinic LP by this study (36 %) is very close to that recorded in 1965 from Egypt by El-Zawahry (40 %) [21].

Limbs are the most prevalent site of onset of LP as stated by Altman and Perry who reported a frequency of 89 percent [22]. This was the case in our study, but we report a much lower frequency of initial limb affection of 56 percent.

Hair involvement was reported in 4 percent of our patients, who were diagnosed as having follicular LP (lichen planopilaris), presenting with patches of cicatricial alopecia of the scalp. Cicatricial alopecia is the eventual complication of follicular LP [23]. In addition to having cicatricial alopecia, 1 of these patients had large plaques of violacous spiny follicular papules on the upper extremities. Such a presentation has been reported previously [5].

It said that specific nail involvement occurs in about 10 percent of patients with LP [24]; pterygium is a classic sign of nail LP [1]. Nail changes were seen in 18 percent of our patients. Pterygium was detected only in 6 percent of the patients. Apart from pterygium formation, these changes are neither specific nor pathognomonic because most of these patients practice manual work.

It is said that up to 65 percent of LP patients with cutaneous lesions have oral mucosal involvement [25], and that isolated oral LP presents in 15-35 percent of LP [22, 26]. We recorded a lower percentage of oral mucosal involvement. Oral LP associated with cutaneous lesions was detected in 22 percent of our patients, and isolated oral LP was detected in 8 percent of patients. From the different types of oral lesions, the reticular type was the most prevalent and the buccal mucosa was the most common site affected, an observation supported by the literature [1, 27].

Involvement of the genitalia has been reported in 25 percent of male patients with LP; the percentage of genital involvement in females is unknown [28]. We observed genital involvement in 22 percent if males and 2 percent of females.

Lichen planus tends to be intensely pruritic [1]. When pruritus is present, it ranges from mild irritation to severe intolerable Itching; hypertrophic lesions tend to itch severely. Paradoxically, even when itching is severe, one seldom finds evidence of sctatching as the patient rubs rather than scratches to gain relief. Itching at sites without visible skin lesions can occur. Itching was a main complaint of 50 percent of our patients, which was severe in patients with hypertrophic lesions (12 %). Itching was relieved by rubbing in 42 percent and by scratching in 8 percent of patients. Scratching was sometimes evidenced by excoriations and scratch marks.

In our study, the incidence of LP was 0.28 percent. Both sexes are equally affected, especially in the age range of 21 to 50 years old. We found a predominance of the actinic type of LP that we attribute to the sunny nature of our province. Oral LP occurred in 8 percent of patients without cutaneous lesions and in 22 percent of patients with cutaneous LP, a lower percentage than previously reported. Our finding of 22 percent of male patients to have genital lesions is close to that previously reported. Hair and nails involvement occurs less frequently than skin and mucous membrane involvement. The initial site of onset is commonly the limbs. Pruritus is the chief complaint of 50 percent of patients.

References

1. Boyed AS, Neldner KH. Lichen planus. J Am Acad Dermatol 1991; 25: 593-619.

2. Black MM. Lichen planus and lichenoid disorders. In: Textbook Of Dermatology. RH Champion, JL Burton and FJG Ebling (eds.), 5th ed., vol 3, Blackwell Scientific Publications, Oxford,1992, 1675.

3. Ragab NF, Youssef NM, El-Zawahry HR, et al. Direct and indirect immunofluorescence studies in lichen planus. Localization of lichen planus specific antigen. Egypt J Derm & Ven 1989; 9: 53-67.

4. Salem G. Oral LP among 4277 patients from Gizan, Saudi Arabia. Community Dent Oral Epidemiol 1989; 17: 322-324.

5. Matta M, Kibbi A-G, Khattar J, et al. Lichen planopilaris: A clinicopathologic study. J Am Acad Dermatol 1990; 22: 594-598.

6. Al-Fouzan AS, Hassab-El-Naby HMM. Lichen planus vs lichen planus actinicus: A comparative immunofluorescent study. Egypt J Derm & Ven 1993; 13: 21-25.

7. Soliman M, El-Zawahry B, Rateb A, et al. Immunological study of lichen planus. Egypt J Derm & Ven 1993; 13: 15-19.

8. Roitberg-Tambur A, Friedmann A, Korn S, et al. Serologic and molecular analysis of the HLA system in Israeli Jewish patients with oral erosive LP. Tissue Antigens 1994; 43: 219-223.

9. White AG, Rostom AI. HLA antigens in Arabs with lichen planus. Clin Exp Dermatol 1994; 19: 236-237.

10. El-Tonsy MH, Anber TE, El-Domyati MM, et al. Lichen planus-a histopathological and immunohistochemical study. Egypt J Derm & Ven 1995; 15: 45-50.

11. Gorsky M, Raviv M, Moskona D, et al. Clinical characteristics and treatment of patients with oral lichen planus in Israel. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996; 82: 644-649.

12. Ibrahim HA, Baddour MM, Morsi MG, et al. Should we routinely check for hepatitis B and C in patients with lichen planus or cutaneous vasculitis? East Mediterr Health J 1999; 5: 71-78.

13. Kanwar AJ, Belhaj MS. Lichen planus among Arabs-a study from Libya. J Dermatol 1984; 11: 93-96.

14. Dostrovsky A, Sagher F. Lichen planus in subtropical countries. Arch Dermatol Syphilol 1949; 59: 308-328.

15. Katzenelson V, Lotem M, Sandbank M. Familial lichen planus. Dermatologica 1990; 180: 166-168.

16. Beer WE, Maschin D. The seasonal incidence of lichen planus. Trans St. Johns Hosp Dermatol Soc 1960; 54: 69-72.

17. Alabi GO, Akinsanya JB. Lichen planus in tropical Africa. Trop Geogr Med 1981; 33: 143-147.

18. Singh OP, Kanwar AJ. Lichen planus in India: an appraisal of 441 cases. Int J Dermatol 1976; 15: 752-756.

19. Vijayasingam SM, Lim KB, Yeoh KH, et al. Lichen planus: a study of 72 cases in Singapore. Ann Acad Med Singapore 1988; 17: 541-544.

20. Bhattacharya M, Kaur I, Kumar B. Lichen planus: A clinical and epidemiological study. J Dermatol 2000; 27: 576-582.

21. El-Zawahry M. Lichen planus tropicus. Dermatol Int 1965; 4: 92-95.

22. Altman J, Perry HO. The variation and course of lichen planus. Arch Dermatol 1961; 84: 179-191.

23. Mehregan DA, Van Hale HM, Muller SA. Lichen planopilaris: Clinical and pathologic study of forty-five patients. J Am Acad Dermatol 1992; 27: 935-942.

24. Samman PS. The nails in lichen planus. Br J Dermatol 1961; 73: 288-292.

25. Strauss RA, Fattore L, Soltani K. The association of mucocutaneous lichen planus and chronic liver disease. Oral Surg Oral Med Oral Pathol 1989; 68: 406-410.

26. Woo TY. Systemic isotretinoin treatment of oral and cutaneous lichen planus. Cutis 1985; 35: 390-391.

27. Murti PR, Daftary DK, Bhonsle RB, et al. Malignant potential of oral lichen planus: observation in 722 patients from India. J Oral Pathol 1986; 15: 71-77.

28. Arndt KA. Lichen planus. In: Dermatology In General Medicine. TB Fitzpatrick, AZ Eisen, K Wolff, et al. (eds.), 3rd ed., McGraw-Hill, New York,1987, 967.

© 2005 Dermatology Online Journal