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Annular atrophic lichen planus of the lip

  • Author(s): Sugashima, Yumi
  • Yamamoto, Toshiyuki
  • et al.
Main Content

Letter: Annular atrophic lichen planus of the lip
Yumi Sugashima, Toshiyuki Yamamoto
Dermatology Online Journal 18 (2): 14

Department of Dermatology, Fukushima Medical University, Fukushima, Japan

Abstract

Annular atrophic lichen planus is a rare form of lichen planus, clinically characterized by a circumscribed annular configuration. We report herein a 32-year-old female who developed depressed plaques on the lips. Physical examination showed well-circumscribed, erythematous plaques on the lower lip. The border was slightly elevated and the inner portion was depressed and atrophic. Also, a bean-sized well-circumscribed plaque with slightly elevated border was found on the upper lip. A biopsy specimen revealed that the epithelium of the mucous membrane was reduced in thickness and a mononuclear cell infiltration invaded the basement membrane of the epithelium. This is the first case of annular atrophic lichen planus involving the lip. She was treated with 0.1 percent tacrolimus ointment once daily, which resulted in a beneficial effect.



Introduction

Annular lichen planus sometimes assumes central atrophy with slight depression, which is called annular atrophic lichen planus (AALP). We describe herein a case of AALP that involved the lip.


Case report


Figure 1Figure 2
Figure 1. Clinical appearance. Annular plaques were located on the upper and lower lips (arrow). Marked depression was seen in the lower lip.

Figure 2. Histologic view showing liquefaction of basal layers and cellular infiltrates in the papillary dermis (H&E, x200).

A 32-year-old female visited our hospital, complaining of symptomless erythematous macules on the lip. Three months previously, she noticed erythema on the lower lip, which gradually spread to involve the upper lip. On physical examination, well-circumscribed, erythematous plaques were located on the right side of the lower lip (Figure 1). The border was slightly elevated and the inner portion was depressed and atrophic. Also, a bean-sized well-circumscribed plaque with slightly elevated border was found on the upper lip. There were no other similar appearing lesions elsewhere on her body, including genitalia. A biopsy specimen revealed that the epithelium of the lesional mucous membrane was reduced in thickness and demonstrated a mononuclear cell infiltration (Figure 2).


Figure 3aFigure 3b
Figure 3. Cellular infiltrates are positive for (3a) CD4 and (3b) CD8 (x200).

Many of the inflammatory cells invaded the epithelium and the basement membrane showed liquefaction. Dyskeratotic cells were scattered in the epithelium. The results of immunohistochemistry revealed a number of CD3-, CD4-, and CD8-positive T cells (Figures 3a and 3b). Results of laboratory examination revealed positive antinuclear antibody (1:160, homogenous and nuclear pattern), but otherwise no abnormal data. HCV antibody was negative.


Figure 4
Figure 4. Sufficient improvement was obtained by topical tacrolimus ointment after 6 months.

Patch testing with metal standard patch test series (Torii Pharmaceutical Co. Ltd., Tokyo, Japan) revealed a positive reaction for zinc after 48 h. She had many dental metals in her teeth, some of which contained zinc. She refused the removal of the dental fillings. After informed consent, we applied 0.1 percent tacrolimus ointment (Protopic®, Astellas Pharmaceutical Co. Ltd., Tokyo), which gradually improved the lesion (Figure 4).


Discussion

Lichen planus is an idiopathic inflammatory disease of the skin and mucous membranes, characterized by an autoimmune attack mediated by CD8+ T cells. There are several uncommon clinical features of lichen planus and the annular type is one of the variants. Furthermore, annular lichen planus rarely presents with central atrophy, which is reported as annular atrophic lichen planus [1-9]. So far, several cases have been reported, which occurred on the trunk, extremities, knees, elbows, and fingers. However, this is the first case of annular atrophic lichen planus occurring on the lip. Eleven cases of AALP have been reported occurring from ages 19 to 77 (mean age: 50.8). Out of these, 6 were males and 5 were females. The frequently involved sites are the trunk and extremities. Disease duration ranges from 2 months to 25 years. The central atrophy in AALP may result from the elastolytic activity of the inflammatory cells [1, 5].

Topical corticosteroids have been the main treatment for ALLP, which often result in little response, especially in long-standing cases. Topical tacrolimus is a therapeutic option, which is known to have a dramatic effect in oral lichen planus. Tacrolimus inhibits calcineurin, which consequently suppresses activation and differentiation of T cells as well as other proinflammatory cytokines. In our case, partial improvement was achieved by topical tacrolimus, which may be absorbed through the mucous epithelium to produce a reduction in T lymphocytes infiltrating in the upper dermis. Early treatment, just a few months after onset in our case, may have favored the beneficial outcome.

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