Dermatology Online Journal

Report of a new case with four skin diseases
Javad Golchai and Afshar Ramezanpour
Dermatology Online Journal 9 (1): 15

Department of Dermatology, Razi Hospital, Gilan, Iran

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Abstract

A 70 year old man is presented with four distinct skin diseases that were diagnosed concomitantly. Lichen planus, vitiligo, lichen sclerosis, and disseminated actinic porokeratosis were all diagnosed clinically and histologically in this man, who was otherwise healthy.

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Introduction

Lichen planus (LP) and vitiligo are common skin diseases, but an association of these disorders with other uncommon diseases such as lichen sclerosis et atrophicus (LSA) and disseminated superficial actinic porokeratosis (DSAP) has not been reported. We present a case in which the clinical and histopathological features of all four of these disorders were evident. The etiologies of these later two diseases are still unclear, but there may be an association with autoimmune disorders as with lichen planus and vitiligo.

Case Report

A 70-year-old man complained of depigmented patches on the left shoulder for seven years, which gradually spread on the hands and lumbosacral area (Figure 1). He also exhibited pigmented patches with keratotic borders on the face, trunk, and limbs that he had noticed for approximately five years (Figures 1,2). A white pruritic, sclerotic plaque had appeared on the shaft of his penis about one year before presentation (Figure 3). He also complained of itchy, violaceous papules and plaques on the flexor surface of his wrists, ankles, forearms, and dorsal hands (Figures 4,5).

Upon clinical examination, depigmented patches on the left shoulder, lumbosacral area, and dorsum of the hands as well as diffuse pigmented lesions on the face, trunk, and limbs were seen. In addition, a white sclerotic plaque on the penis with extension to the meatus was observed. Violaceous papules and plaques on the wrists, ankles, and flexor surfaces of the forearm and dorsum of the hands were also seen. White reticular patches were present on both buccal mucosae, which were asymptomatic.

The patient appeared cachectic, but no other significant findings were noted in the history or upon physical examination. Laboratory studies including chest X-ray, liver function tests, and hepatitis C serology were normal. Iron deficiency anemia (chronic hypochromic microcytic anemia) was the only laboratory abnormality. Skin biopsy specimens revealed vitiligo, porokeratosis, LSA, and LP.

Figure 1	Figure 2
Fig. 1 Depigmented patches on the shoulder of patient and pigmented patches with keratotic border on the trunk.
Fig. 2 Pigmented patches with keratotic border on the face.

Figure 3	Figure 4
Fig. 3 White sclerotic plaque on the penis.
Fig. 4 Itchy violet papules and plaques on the flexor area of the wrist.

Figure 5	Figure 6
Fig. 5 Itchy violet papules and plaques on the hands.
Fig. 6 Parakeratotic column(coronoid lamellae) , atrophy of epidermis and severe infiltration.

Figure 7	Figure 8
Fig. 7 Atrophy of epidermis, hydropic basal cell degeneration, severe edema of superior dermis and infiltration of middle dermis.
Fig. 8 Hyperkeratosis, thickening in the granular layer, acanthosis of epidermis with vacuolar changes in basal layer and lichenoid infiltration in the superior dermis.

Figure 9	Figure 10
Fig. 9 Reticular white patches on the buccal membrane.
Fig. 10 Epithelium achanthosis, lymphocytic infiltrate in the dermis and focal degeneration in the basal layer.

Discussion

Although lichen planus, vitiligo, lichen sclerosis et atrophicus, and porokeratosis occur sporadically, the unique coincidence of these four dermatological disorders is very rare and has not already been reported.

Coexistance of cutaneous lichen sclerosis and lichen planus has been reported.[1] A case of morphea and lichen planus, localized to the lip mucosa, in a patient with vitiligo, has also been reported.[2] The association of vitiligo and lichen planus [3,4] and the association of vitiligo and alopecia areata were reported.[5,6,7] Pityriasis rubra pilaris, lichen planus, alopecia universalis, and vitiligo have been found together in a patient with chronic viral hepatitis C.[8] Coincidence of vitiligo, alopecia areata, onychodystrophy, localized scleroderma, and lichen planus was discussed.[9] A patient with porokeratosis Mibelli with rapidly expanding vitiligo and long-standing chronic active hepatitis has also been noted.[10] Although some believe that coexistance of lichen planus and vitiligo is coincidental,[11] others believe that the association of these skin diseases may indicate a pathogenetic relationship.[3] Reports of several skin diseases with probable autoimmune etiologies associated with Hepatitis C virus infection suggest a stimulatory role of the Hepatitis C virus in these conditions.[8,10,12]

However, the patient reported here did not have evidence of Hepatitis C, but had an interesting combination of four skin diseases which have not been reported together.

References

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2. Melato M, Gorgi N Rizzardi C, Maglione M, Associated localization of morphea and lichen planus of the lip in a patient with vitiligo. Minerva stomatol 2000;49(11-12):549-54.

3. Rubisz-brezezinska J, Buchner SA, Itin P. Vitiligo associated with lichen planus. Is there a pathogenic relationship? Dermatology 1996; 192(2):176-8.

4. Ortonne JP, Perrot H, Thivolet J. Clinical and statistical study of 100 patients with vitiligo. II association lesion. Sem-hop 1976; 52(11):679-86.

5. Conte A, Iinverardi D, Loconsole F, et al. A retrospective study of 200 cases of lichen planus. G Ita Dermatol Venerol 1990;125(3):85-9

6. DE Padova MP, Veronesi S. Andriani GC, Minghetti G. Alopesia areata associated with onychodystrophy, vitiligo and lichen rubber planus. G Ital Dermatol Venerol 1987;122(4):191-2.

7. Aloi PG, Colonna SM, Manzoni R. Association of lichen rubber planus, alopesia areata and vitiligo. G Ital Dermatol venerol 1987;122(4):197-200.

8. Cechi R, Giomi A, Tuci F, et al . Pityriasis rubra pilaris, lichen planus, alopesia universalis and vitiligo. Dermatology 1994; 188(3):239-40.

9. Brenner W, Diem E, Gschnait F. Coincidence of vitiligo, alopesia areata, onychodystrophy, localized scleroderma and lichen planus. Dermatological 1979;150(4):356-60.

10. Dipple E, Haas N, Czarnetzki BM. Porokeratosis of mibelli associated with active chronic hepatitis and vitiligo. Acta Dermatol Venerol 1994;74(6):463-4

11. Proter SR, Scully C, Eveson JW. Coexistence of lichen planus and vitiligo is coincidental. Cin Exp Dermatol 1994;19(4):300.

12. Podanyi B, Lengyel G, et al. Skin disease associated with chronic hepatitis C. Orv Hetil 1998;136(44):2633-7.

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