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A case of zosteriform lichen planus developing after extracorporeal shockwave lithotripsy

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A case of zosteriform lichen planus developing after extracorporeal shockwave lithotripsy
Enver Turan1, Alaaddin Akay2, Yavuz Yesilova1, Gül Türkçü3
Dermatology Online Journal 18 (9): 9

1. Harran University Faculty of Medicine, Department of Dermatology, Sanliurfa, Turkey
2. Ministry of Health Batman Regional Government Hospital, Department of Urology, Batman, Turkey
3. Dicle University Faculty of Medicine, Department of Pathology, Diyarbakir, Turkey


Lichen planus is a relatively common papulosquamous skin disease of unknown etiology. It is characterized by flat-topped, shiny pinkish-purple papules and plaques on the skin or mucous membranes. The zosteriform type is a rare variant of lichen planus with dermatomal or zonal distribution. A 29-year-old female patient was admitted to our clinic with a 2-month history of a pruritic eruption on the dermatomes on the left between T6–T10. Based on clinical and histological findings, the patient was diagnosed with zosteriform lichen planus. The patient had undergone extracorporeal shock wave lithotripsy (ESWL) for left kidney stones two weeks before the appearance of the lesions. There was no history of skin diseases with dermatomal distribution including herpes zoster in the lesion area. This condition was considered as an isomorphic response following ESWL.


Lichen planus (LP) is an inflammatory dermatosis in which cell-mediated immune responses play a role. It is often seen in middle-aged adults and it tends to appear on the flexor surfaces of the extremities. In classic LP, the scalp, mucous membranes, and nails are other areas that can be affected. Itchy, red or purple colored papules and plaques that show symmetrical distribution are the characteristic lesions of LP [1]. In contrast to these typical features, some clinical variants of LP show linear or zosteriform distributions that create difficulty in diagnosis. Whereas the reason for this altered distribution is not known, koebnerization, embryonic mutation, environmental triggers, abnormal cell clones, and the isotopic response of Wolf have been suggested as possible causes [2, 3].

Case report

Figure 1Figure 2
Figure 1. Flat-topped, brown colored papule and plaque lesions on the left T6–T10 dermatome field.

Figure 2. Magnified view of a lichenoid papule.

Figure 3
Figure 3. Lesion surfaces show orthohyperkeratosis, slight hypergranulosis, band-shaped mononuclear cell infiltration, and in some regions, the presence of melanophages (H&E x100).

A 29-year-old female patient presented to our clinic complaining of purple-brown colored skin eruptions and itchiness on her flank of the left side of her body. These complaints had started approximately two months previously. The patient had undergone extracorporeal shock wave lithotripsy (ESWL) for a left renal calculus two weeks before the lesions appeared. There was no medical history of dermatosis (herpes zoster, etc.) that might have caused an isotopic response or that might have caused koebnerization of a lesion (e.g., trauma, infection, UV exposure). The dermatological examination revealed that the lesions, were raised, flat-topped, shiny brownish colored papules and plaques limited to the left side of the lumbar and epigastric area in the region of the T6–T10 dermatomes (Figures 1 and 2). The scalp, nails, and mucosa (oral and anogenital regions) were normal. Results of liver and kidney function tests and full urine and blood analyses done in the laboratory were within normal limits. No pathologic findings were seen on chest X-ray and abdominal ultrasonography examinations. The patient’s erythrocyte sedimentation rate was at 20 mm/hour. Serological test results for viral hepatitis, HIV, and syphilis were negative, as were tests for herpes zoster (VZV IgG/IgM). Tests of punch biopsy materials taken from the lesion area, showed orthohyperkeratosis, slight hypergranulosis, and band-shaped monocular cell infiltration along the dermo-epidermal junction. Occasionally, melanophages and necrotic keratinocytes were found (Figure 3). The patient was diagnosed with zosteriform LP according to the clinical and histopathological findings and was treated with an oral antihistamine and topical steroid.


LP is a papulosquamous dermatosis that typically is characterized by papules and plaques, with a planar surface and purple violet color. The eruption frequently occurs on the legs and distal extremities. It is frequently seen in middle-aged adults and may affect mucosa, scalp, and nails. Its etiology is unknown, but the possibility that it arises in relation to a T-cell mediated immune response is becoming gradually accepted. Histological features include saw-toothed retes, mononuclear cell infiltration, and hyperkeratosis. In addition, hypergranulosis of the epidermis and vacuolar degeneration in the basal layer is observed. Characteristic colloid particles (Civatte body) are seen in the dermo-epidermal or papillary dermis [4].

More than 20 clinical types of LP have been defined so far, according to lesion form. Zosteriform LP is a variant characterized by a unilateral, linear or zosteriform dispersal. The reason for the linear or segmental distribution is thought possibly to be Wolf isotopic response, which progresses in the healed territories of herpes zoster lesions or a hypothetical koebnerization connected with trauma [5, 6, 7].

The isotopic response is the development of a second dermatitis that is unconnected to a previous illness in the field of recovery after any dermatitis. It was first reported by Wolf and colleagues in 58 cases. Of these, 38 cases showed the development of extensive dermatitis after herpes zoster infection [8]. There are many cases of zosteriform LP in the literature that have been presented as a Wolf isotopic response, but these cases did not show a dermatomal distribition. Perhaps these cases could better be described as linear or Blaschkoian LP cases [9, 10].

Linear or zosteriform LP cases are seen extremely rarely in skin that has never been traumatized. Some researchers claim that no cases can be claimed as zosteriform LP except for the cases that develop as an isotopic response after herpes zoster infection [7]. On the other hand, Lutz and colleagues have reported two zosteriform LP cases in which the presence of varicella zoster or herpes simplex viruses could not be detected by the polymerase chain reaction [11]. In addition, many de novo LP cases have been discussed in the literature on this subject.

The ESWL procedure consists of crushing kidney and urinary system calculi through the use of sound waves, which are produced from a source outside of the body as shock waves. This procedure has been used successfully for approximately 30 years for percutaneous treatment of kidney and ureteral calculi [12]. LP exhibiting the koebner phenomenon (isomorphic response) represents new lesion development in a field of skin without lesions after specific or nonspecific trauma, but in a patient with the preexisting dermatosis. The literature presents cases of development of the koebner phenomenon following exposure to high-energy irradiation, Grenz rays, UVA, UVB, and pulse dye laser treatments, indicating that a considerable number of factors can be responsible [13]. However, although petechiae and ecchymosis have been reported after ESWL, the development of the isotopic response (Wolff) or the isomorphic response (koebnerization) and LP have not been previously reported in relation to this therapy.

In reality, it is often very difficult to identify the cause of linear or zosteriform LP. The distribution of lesions on our patient was limited to the field that fits to the T6–T10 dermatomes and did not cross the midline. The patient history revealed no trauma that would explain a zosteriform distribution of lesions or a history of herpes zoster. No situation that would cause the isotopic response or isomorphic response except for the ESWL procedure was indicated. In this case, ESWL was evaluated as a possible trigger that led to the phenomenon.


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