Dermatology Online Journal

Lichen Planus of the Eyelids. A report of 5 cases
Rajeev Sharma MD¹, Neeraj Singhal MD²
Dermatology Online Journal 7(1):5

1. Consultant Dermatologist, Bishen Skin Centre, Aligarh, 2. Nirmal Skin Clinic Muzzafarnagar, India

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Abstract

Involvement of the eye and related structures is rarely reported in lichen planus. Only eleven cases with eyelid involvement are reported in the literature. Lesions on the eyelids may be the only manifestation of lichen planus or it may be a part of the disease process present on other parts of the body. When only eyelids are involved, clinical diagnosis may be difficult. Lichen planus should be considered in the differential diagnosis of erythematous papular lesions on the eyelids.

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Introduction

Lichen planus rarely involves the ocular structures. Only a few cases are reported in the literature. [1,2,3] Ocular involvement may occur in the form of lesions on the eyelids or as cicatricial conjunctivitis. [1,3,4] If the first few lesions of lichen planus appear on the eyelids, clinical diagnosis may be difficult.[5] However, subsequently, lesions of lichen planus usually appear elsewhere on the body. [2,3,6,7]

We report five cases of lichen planus with eyelid involvement.

Case report

Figure 1
Figure 1. Violaceous papules on the left upper eyelid.

Case 1

An otherwise healthy 48 year old woman developed erythematous lesions on her left upper eyelid (Figure 1) 20 days before presentation. Her condition was diagnosed as contact dermatitis and treatment was begun with topical applications of triamcinolone acetonide ointment (0.1%). When reviewed after two weeks, the patient had the typical morphological features of lichen planus on the left eyelid and similar lesions on the ankles, wrists, lower legs and forearms. The mucosal surfaces were clear.

A skin biopsy taken from the wrist lesion revealed typical features and confirmed the diagnosis of lichen planus. Complete blood cell count, urinalysis and serum chemistry, including blood sugar and liver function tests, were all normal. Serologies for Hepatitis B and C virus were negative. She was advised to apply clobetasol propionate 0.05% cream twice daily to the lesions on the wrists, the forearms, the ankles and the lower legs. After two weeks, active lesions were still present, but by ten weeks of tapering doses, complete resolution with hyperpigmentation was achieved. Eyelid lesions cleared with topical applications of triamcinolone acetonide ointment (0.1%) for 6 weeks.

Figure 2
Figure 2. Lichen planus lesions and milia.

Case 2

A 17 year old girl had itchy lesions on the right upper eyelid for about fifteen days. She had also noticed a few similar lesions on the left upper eyelid four days earlier. On examination, she was found to have violaceous papules on the upper eyelids that were more prominent on the right upper eyelid.(Figure2) There were multiple milia on, as well as away from the violaceous lesions. Histologic examination of a biopsy confirmed the diagnosis of lichen planus. Complete blood cell count, urinalysis and serum chemistry, including blood sugar and liver function tests, were all normal. Serologies for Hepatitis B and C virus were negative. She was prescribed triamcinolone acetonide (0.1%) ointment for local application and the lesions started resolving with hyperpigmentation after 8 weeks. Milia were extracted before starting application of the topical corticosteroid.

Case 3

A 20 year old man developed itchy lesions on the left upper eyelid and periorbital area 25 days prior to presentation. Over the past week he had also noticed a few itchy lesions on the lower legs. On examination, there were violaceous papules on the left upper eyelid and periorbital area. Similar lesions were present on the ankles and lower legs. A biopsy specimen taken from the left leg showed features typical of lichen planus. Complete blood cell count, urinalysis and serum chemistry, including blood sugar and liver function tests, were all normal. Serologies for Hepatitis B and C virus were negative. He was treated with triamcinolone acetonide (0.1%) for eyelid lesions while clobetasol propionate (0.1%) cream was prescribed for lesions on the lower limbs. The response was similar to case 2 except for a delayed clearance of limb lesions.

Figure 3
Figure 3. Lichen planus lesions on both upper eyelids.

Case 4

A 28 year old woman complained of the development of violaceous lesions on her left upper eyelid for 6-days. She had similar lesions on the ankles, wrists, lower legs, forearms and trunk for the last eight months. There was no mucosal involvement. The lesions conformed to the morphological features of lichen planus.

A skin biopsy taken from a lesion on the leg confirmed the diagnosis of lichen planus. Complete blood cell count, urinalysis and serum chemistry, including blood sugar and liver function tests, were all normal. Serologies for Hepatitis B and C virus were negative. Application of clobetasol propionate 0.05% cream locally twice daily to the lesions on the wrists, the forearms, the ankles and the lower legs was prescribed. After two weeks, she still had active lesions, but further applications of decreasing potency of corticosteroids for twelve weeks showed complete resolution with hyperpigmentation. Lesions on the eyelid cleared with topical applications of triamcinolone acetonide ointment (0.1%) for 4 weeks.

Case 5

A 42 year old family physician noticed the development of violaceous lesions on her left upper eyelid for one month. He had similar lesions on the ankles, wrists, lower legs, and forearms for the last eight months. There was no mucosal involvement. Lichen planus was the clinical diagnosis. He had Hepatitis B about 3 years earlier.

A skin biopsy taken from the left wrist confirmed the diagnosis of lichen planus. Complete blood cell count, urinalysis and serum chemistry, including blood sugar and liver function tests, were all normal. Serologies for both Hepatitis B and Hepatitis C virus were negative. He began treatment of the wrists, the forearms, the ankles and the lower legs with clobetasol proprionate 0.05% cream. After twenty weeks of use of corticosteroids of decreasing potency, complete resolution with hyperpigmentation was achieved. Lesions on the eyelid cleared with topical applications of mometasone furoate ointment (0.1%) for 7 weeks.

Discussion

Lichen planus is a commonly encountered papulosquamous dermatosis. The commonly involved sites are the flexor surfaces, trunk and oral or genital mucosa. Lesions on the eyelids have been rarely described in the literature.[2,3,5,8] Of the nine cases reported prior to 1995, only two had lesions limited to the eyelids.[3] Altman and Perry reported eyelid involvement in two of their 307 patients.[1] Conjunctival involvement has been reported previously.[4,6] However, our cases had no clinical evidence of conjunctival involvement. Isolated lesions are often misdiagnosed but fortunately such lesions are usually followed by appearance of lesions at typical sites, as in three of our cases.[2,3,5,7] In case two, since there were no lesions elsewhere, histologic confirmation of an eyelid lesion was obtained. In cases four and five, lesions appeared on the eyelids after the patient developed widespread, longstanding lichen planus.

The lesions of lichen planus on the eyelids have been classified into three types: [5] (1) Classic lilac-colored slightly delled papules with filigree scaling associated with similar lesions elsewhere, (2) annular papules or small medallion plaques often with similar lesions elsewhere and (3) lesions occurring solely on the eyelids.

In cases with papular lesions on the eyelids, the differential diagnosis must include lichen planus along with lupus erythematosus, psoriasis vulgaris, and contact dermatitis.

References

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

2. Vogel PS, James WD. Lichen planus of the eyelid: an unusual clinical presentation. J Am Acad Dermatol 1992;27(4):638-9. PubMed

3. Itin PH, Buechner SA, Rufli T. Lichen planus of the eyelids. Dermatology 1995;191(4):350-1. PubMed

4. Neumann R, Dutt CJ, Foster CS. Immunohistopathologic features and therapy of conjunctival lichen planus. Am J Ophthalmol 1993;115(4):494-500. PubMed

5. Michelson HE, Laymon C. Lichen planus of the eyelids, Arch Dermatol. 1938;37: 27-29.

6. Luhr AF. Lichen planus of the conjunctiva, Am J Ophthalmology. 1924;7:456-457.

7. Camisa C, Meisler DM. Immunobullous diseases with ocular involvement. Dermatol Clin 1992;10(3):555-70. PubMed

8. Touraine A, Renault P. Lichen plan cirane des paupieres, Bull Soc Franc Dermatol Syph. 1937;44:303-305.

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