A Clinicopathological and Immunofluorescence study of Lichen Planus

Lakshmi Priya, G (2010) A Clinicopathological and Immunofluorescence study of Lichen Planus. Masters thesis, Madurai Medical College, Madurai.

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Abstract

INTRODUCTION : Lichen planus is a papulosquamous disease of the skin and mucous membranes. It is derived from two words, ‘leichen’ in Greek meaning tree moss and ‘planus’ in Latin meaning flat. Lichen planus is worldwide in distribution with a variable incidence. It is considered to be due to cell mediated immune response to an epidermal antigen in genetically predisposed persons. Lichen planus has been found to be associated with certain infections and autoimmune diseases. In its classic presentation, the disease is characterized by pruritic violaceous papules most commonly on the extremities of middle aged adults. It may be accompanied by oral and genital mucosal involvement. Hair and nails may also be affected. Besides the typical lesions, there are many variants of the disease. The course of the disease is unpredictable. It generally persists for a period of several months to years. Sometimes it may follow a chronic relapsing course. The duration varies according to the extent and site of involvement and the morphology of the lesions. Though this condition is mostly self-limiting, sometimes the patient may have considerable discomfort and disability. The lesions may heal with pigmentary changes and scarring. Malignant transformation may occur rarely. Biopsy of fully developed lesions of lichen planus shows characteristic histological changes. Characteristic staining patterns are observed in the immunofluorescence study of the lesions. Treatment options are based on the extent and severity of the disease. Symptomatic treatment is usually sufficient. In severe cutaneous and mucosal lichen planus, various other treatment approaches are useful. Glucocorticoids (topical, intralesional, systemic), cyclosporine, antimalarials, dapsone, thalidomide, azathioprine, phototherapy, doxycycline, interferons have been found to be effective. AIM OF THE STUDY : 1.To find out the clinical profile of lichen planus seen among patients attending the skin OPD. 2.To find out the dermatological and systemic associations and complications if any. 3.To correlate the clinical and histopathological features of various types of LP. 4.To know the immunofluorescence patterns of LP. MATERIALS AND METHODS : The material for this study was from the patients attending the skin OPD, Government Rajaji Hospital, Madurai Medical College, Madurai during the period from July 2008 to July 2009. Inclusion criteria : Patients diagnosed clinically as lichen planus during the study period. Exclusion criteria : Patients who did not give consent for biopsy were not subjected to biopsy procedure but were included in the study of the clinical profile. A total of 90 patients were clinically diagnosed as lichen planus during this period and were taken for the study. A detailed clinical history including duration, site of onset, symptoms, drug history, family history were elicited. A complete general examination, systemic examination and dermatological examination were made. Digital photographs were taken. The morphology and distribution of skin lesions, presence of any other associated diseases were noted. Concomitant affection of mucosa, hair, nails, palms, soles, genital involvement was meticulously p recorded. Laboratory investigations like urine examination, blood sugar, urea, creatinine, liver function tests, anti HCV antibody, blood VDRL and complete hemogram were done. Skin biopsy was done in 50 patients who gave informed consent. After thorough cleaning of the part to be biopsied with spirit, 2% lignocaine was infiltrated into the area and a bit of the lesional skin was removed by punch biopsy. The specimen were preserved in 10% formalin and submitted for histopathological examination to the department of Pathology, Madurai Medical College. Out of the 50 patients in whom histopathological examination was done, direct immunofluorescence study could be done in only 20 patients due to financial constraints. The lesional skin was biopsied and specimen preserved in Michel’s medium and sent to the department of Skin and STD, Kasturba hospital, Manipal. SUMMARY : Incidence: Lichen planus constituted 0.16 percent of the total patients diagnosed during the period of study. Age: 51% of patients were between 31-50 years of age. Childhood LP accounted for about 9% of cases. Sex: No sexual predilection was seen. Familial involvement& seasonal variation: There was no family history and seasonal variation was not seen. Morphology and distribution of lesions: Papules were present in 79% and plaques were present in 14% of the cases . Initial site of onset was limbs in 63% , trunk in21% ,face in 8%, oral mucosa in 6% and genital mucosa in 2% .Oral mucosa was involved in 21% .Nail involvement was noted in17%.Palmoplantar involvement was present in 20%.Koebner’s phenomenon was seen in 33%. Clinical patterns: Classical LP was the commonest seen in 60 cases followed by hypertrophic LP seen in 10 cases. A linear pattern was seen in 5 cases. A zosteriform pattern in trunk was present in one case of linear LP of the limb. 3 cases had LP pigmentosus ,4 patients had eruptive LP,1 had actinic LP and 2 patients had follicular LP. 1 patient had features of LE/LP overlap.Isolated oral LP and annular LP were present in 2 cases each. Histopathology: Histopathological features were consistent with classical LP in 30 cases , hypertrophic LP in 9 cases, Follicular LP in 2 , LP pigmentosus in 3, actinic LP in 1,oral LP in 2, LE/LP overlap in 1,drug induced LP in 2. Features of squamous cell carcinoma was present in the warty growth from a case of hypertrophic LP . Immunofluorescence: DIF study done in 20 patients showed ragged fibrinogen deposits in basement membrane zone in all the patients. Colloid bodies were seen in 60%. Linear IgG, C3 at the BMZ with shaggy fibrinogen was seen in the LE/LP overlap syndrome. Linear IgG,C3 at the BMZ with shaggy fibrinogen was also present in three cases of classical LP. Associations: In this study, the diseases which were found to be associated were diabetes mellitus, hypertension, hypothyroidism, vitiligo & alopecia areata .Interesting presentation of lichen planus in a case of albinism was seen. Malignant change: A case of hypertrophic LP developed squamous cell carcinoma. CONCLUSION : 1.The incidence of Lichen planus in this study was 0.16% . 2. Most of the patients were in 4th and 5th decade. 3. Classical type was the commonest followed by hypertrophic type & linear variant next in frequency. 4. Limbs were the most frequent initial site of onset. 5. Concomitant mucosal, genital, nail and palmoplantar involvement was common. 6. There was a complete correlation be tween clinical types and histo pathological features in all the 50 patients biopsied. 7. The characteristic findings of ragged fibrin at BMZ and colloid bodies with IgM and C 3 & to a lesser extent with other classes of immunoglobulins were observed in the immunofluorescence study. 8. A case of zosteriform lichen planus coexisting with linear LP was present. 9. Association of other immune mediated diseases was noted. 10. Malignant change was observed in a case of hypertrophic lichen planus. 11.Interesting presentation of lichen planus in a case of albinism was noted.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Lichen Planus ; Clinicopathological and Immunofluorescence study.
Subjects: MEDICAL > Dermatology Venereology and Leprosy
Depositing User: Subramani R
Date Deposited: 02 Mar 2018 03:22
Last Modified: 03 Mar 2018 02:21
URI: http://repository-tnmgrmu.ac.in/id/eprint/5970

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