Case Report
Open Access
Annular Lichen Planus On Penis Treated With Topical
Pimecrolimus 1%
G Pehlivanov1, N Tsekova-Traykovich1, I Bakardzhiev2*, A Argirov¹, G Manolova1, I Krasnaliev3
1Department of Dermatology and Venereology, Medical University –Sofia, Bulgaria
2Medical College, Medical University- Varna, Bulgaria
3Department of Pathology, Medical University- Varna, BulgariaFrance
2Medical College, Medical University- Varna, Bulgaria
3Department of Pathology, Medical University- Varna, BulgariaFrance
*Corresponding author: Assoc. Prof. Ilko Bakardzhiev, Medical College ,Medical University of Varna, Tsar Osvo boditel 84, Bulgaria, Tel: +359 888 768
413; E-mail :
@
Received: June 15, 2016; Accepted: June 18, 2016; Published: June 22, 2016
Citation: Pehlivanov G, Tsekova-Traykovich N, Bakardzhiev I, Argirov A, Manolova G, et al. (2016) Annular Lichen Planus On Penis
Treated With Topical Pimecrolimus 1%. Clin Res Dermatol Open Access 3(4): 1-3. DOI: http://dx.doi.org/10.15226/2378-1726/3/4/00135
Abstract
Lichen planus (LP) is an idiopathic inflammatory disease of the
skin and mucous membranes. Classical LP is characterized by pruritic,
violaceous papules that favor the extremities. Annular lichen planus
(ALP) is a long-recognized clinical variant of lichen planus, but is
often considered uncommon in occurrence. ALP commonly involves
the male genitalia but also has a predilection for intertriginous areas
such as the axilla and groin folds. Distal aspects of the extremities,
and less commonly the trunk, may also be involved. We report the
case of 38 year-old uncircumcised male patient who addressed our
clinic for multiple asymptomatic annular lesions on the glans penis
and corpus penis and whitish linear bilateral and symmetric lines on
buccal mucosa with 2 years duration. During this period the patient
was treated several times with antifungal and corticosteroid drugs
without improvement. Diagnosis was based on clinical features
and histological examination. The patient was treated with topical
pimecrolimus 1% with significant improvement after 3 weeks.
Keywords: Lichen Planus (LP); Annular Lichen Planus (ALP); Penis
Keywords: Lichen Planus (LP); Annular Lichen Planus (ALP); Penis
Introduction
Lichen planus is a cell-mediated immune response of unknown
origin, affecting skin, mucous membranes, scalp and nails. It
may be found with other diseases of altered immunity, such
as ulcerative colitis, alopecia areata, vitiligo, dermatomyositis,
morphea, lichen sclerosis, and myasthenia gravis. The term
lichen planus was initially introduced by Erasmus Wilson in 1869
to describe the condition that had been previously named leichen
ruber by Hebra. [1] Classical LP is characterized by pruritic,
violaceous papules that favor the extremities. [1] It has different
variants based on the morphology of the lesions and the site of
involvement.
Case Report
38-year-old man, uncircumcised, heavy smoker was
admitted in our clinic. He denied drug abuse and bisexuality.
Clinically multiple asymptomatic annular lesions different in size,
with slightly raised edge and typically purple to white in color
and central portion with skin-color were presented on glans penis and corpus penis (Figure 1). There was no lesion anywhere
else on the skin. Whitish linear bilateral and symmetric lines on
buccal mucosa were observed. The first lesion was appeared 2
years before as reddish-purple papul which spread peripherally
and the central area was resolved. After a period of 6 months the
patients noticed the changes on oral mucosa like mild discomfort
and altered sensitivity. He was treated several times for Candida
balanitis with Fluconazol topical and systemic without clinical
improvement. He was also treated with topical corticosteroids
for a long time without clinical improvement.
Microscopy and culture spices were negative for Candida spp. and other microorganisms. Serologies for hepatitis B and C, syphilis, and HIV were negative. Histological examination of a biopsy specimen was consistent for Lichen planus. Eipdermal acanthosis with both hyper- orthokeratosis and hypergranulosis were observed. There was also a band-like lymphocytic infiltrate at dermal- epidermal junction with hydropic degeneration of the basal layer with which apoptotic bodies were seen (Figures 2,3,4]. Direct immune fluorescence was negative. Topical pimecrolimus in combination with immune stimulant drug ( lactofer and colastrum) were prescribed, which led to significant clinical improvement after 3 weeks of treatment (Figures 5, 6).
Microscopy and culture spices were negative for Candida spp. and other microorganisms. Serologies for hepatitis B and C, syphilis, and HIV were negative. Histological examination of a biopsy specimen was consistent for Lichen planus. Eipdermal acanthosis with both hyper- orthokeratosis and hypergranulosis were observed. There was also a band-like lymphocytic infiltrate at dermal- epidermal junction with hydropic degeneration of the basal layer with which apoptotic bodies were seen (Figures 2,3,4]. Direct immune fluorescence was negative. Topical pimecrolimus in combination with immune stimulant drug ( lactofer and colastrum) were prescribed, which led to significant clinical improvement after 3 weeks of treatment (Figures 5, 6).
Discussion
Annular lichen planus (ALP) is a long-recognized clinical
variant of lichen planus, but is often considered uncommon in
occurrence. ALP was first reported in literature by Dr. Galloway
in 1899 as distinct from lichen planus of annular type. [2]
The mechanism of genesis of annular lesion is still unknown,
probably expressions of ICAM-1 and TNF-alpha in the peripheral
keratinocytes and dermal infiltrated cells play important role. [3]
There is not data for race and gender predisposition in literature.
The eruption initially occurred as lichen-papules, then enlarged,
and finally developed annular manifestations with raised edges
and central cleraing. ALP commonly involves the male genitalia
but also has a predilection for intertriginous areas such as the axilla
and groin folds. [4, 5] Distal aspects of the extremities, and less
commonly the trunk, may also be involved. Typical lichen papuls
Figure 1: Multiple annular lesions different in size, with slightly raised
edge, typically purple to white in color and central portion with skincolor.
Figure 2: Hyperkeratosis, hypergranulosis, band-like lymphocytic infiltrate
at the dermal-epidermal junction, HE 4x10.
Figure 3: Lichenoid infflitrate composed of lymphocytes and histiocytes,
HE 10x10.
may be observed on the other skin surface. Mucous membranes
can also be affected. Although classic LP is pruriginous, ALP
proceed without subjective complaints. The main problem is
psicho-sexual disorders like in our patients. Diagnosis is based on clinical presentation and histological examination- eipdermal
acanthosis with both hyper- orthokeratosis and hypergranulosis,
band-like lymphocytic infiltrate at dermal- epidermal junction
with hydropic degeneration of the basal layer with apoptotic
bodies. There is a wide range of differential diagnoses,
particularly Candida balanitis, circinate balanitis in patients with
SARA, Reiter Syndrome, balanits with other genesis, granuloma
annulare, psoriasis on penis, Lichen sclerosus, syphilis etc. [6,
7] Mid- to high potency topical corticosteroids are the first line
Figure 4: Hypergranulosis, spongiosis, vacuolar degeneration of the
basal layer, melanophages, HE 10x10.
Figure 5: Annular lesions – 3 weeks after treatment with Pimecrolimus
1%.
Figure 6: 6 weeks after treatment with Pimecrolimus 1%.
treatment in patients with ALP, but when they are use in genital
area they hide a risk for atrophy and hemorrhages so maybe use
of topical pimecrolimus can be effective. [8, 9, 10]
Conclusion
This description highlights the importance of patients
presenting annular lesion on penis be routinely required to
undergo further medical examination for Canddida spec., Sexually
transmitted infections and if is necessary to perform the biopsy
because the exact diagnosis is basis for proper treatment. To
our knowledge this is the first case of ALP reported in literature
treated with topical pimecrolimus with significant clinical
improvement.
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