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The Lichenoid Reaction Pattern M Ramaml, Asha Kubba'? The lichenoid reaction Pattern M Ramaml, Asha Kubba'? Sri Lanka lournal of Dermatology, 2002, 6,20-26 There is some confusion about the origin of the It is easier to bring these diverse conditions term lichen to describe skin diseases but it appears to together based on the histopathological appearance. characteristic of lichenoid have been a popular name for many conditions. An Histologically, the defining cell damage2-3. The damage impressive list of dermatoses that begin with the term tissue reactions is basal or liquefactive degeneration, Iichen or lichenoid could be colled from the index of a occurs by apoptosis processes that appear to be mediated by different major textbook (Table 1)1. It is difficult to conceive of a pathogenetic mechanisms. Apoptosis, a special type way to unify atl these conditions but there are some of single cell death, consists of the condensation features that some of these diseases share. These fea- of single cells followed by active budding and tures are also shared by diseases that do not have fragmentationa. Unlike necrosis, cell membranes and lichen in their names. Briefly, the common clinical organelles remain intact till late in the apoptosis. On denominator is the presence of small papules, purple light microscopy, apoPtotic keratinocytes appear as and histologically, damage to the or skin coloured, pink, shrunken globules (known as Civatte bodies) basal keratinocytes. which may show pyknotic nuclear remnants. The Civatte bodies may be phagocytosed by other keratinocytes and macrophages or may drop down into the papillary dermis as colloid bodies. Liquefac- Table 1. tive degeneration leads to keratinocyte damage by the Lichen amyloidosus accumulation of fluid within basal cells. On micros- aPpear swollen and vacu- Lichen aurcus copy, the keratinocytes olated. It appears that apoptosis is mediated by Lichen fibromdcinodosis cellular immunity and liquefactive degeneration by Lichen myxoedematosus humoral immunity. Lichen nitidus Other histological accompaniments of the Lichen nuchae lichenoid reaction are an infiltrate of lymphocytes and Lichen pigmentosus melanin incontinence. The lymphoeytes are present the Lichen planopilaris in the papillary dermis closely applied to undersurface of the epidermis and infiltrating the Lichen planus lower layers in some disorders. Apototic keratinocytes Lichen planus pemphigoides are sometimes found in close contact with lympho- Lichen planus pigmentosus cytes, an appearance referred to as satellite cell In some diseases, the infiltrate obscures the Lichen purpuricus necrosis. junction between the epidermis and dermis, an Lichen rubber moniliformis appearance that has been referred to as interface der- Lichen sclerosus et atroPhicans matitis. Some accounts exclude this group of disor- Lichen scrofulosorum ders from the lichenoid reaction Pattern but we have chosen to use a broader definition. Other cells, chiefly Lichen simplex histiocytes, may be part of the infiltrate. Melanin in- Lichen simplex chronicus continence refers to the presence of melanin within Lichen spinulosus melanophages of the upper dermis. This results from unit by basal cell Lichen striatus disruption of the epidermal-melanin damage. Once it occurs, melanin incontinence per- et reticularis Lichen verrucosus sists for long periods and in some situations may serve Lichenoid drug eruPtions as the only histological signpost of a lichenoid reac- Lichenoid melanodermatitis tion in the past, t Associate professor, Department of Dermatology and Venereology, All lndia Institute of Medical Scietces, New Delhi 1L0 029, India, email: [email protected] 2 Consultant Dermatopathologist, Delhi Dermpath Lab. T-25, Green Park Main, New Delhi 11N16, lndia. The lichenoid reaction pattern 27 The sequence in which they appear and the On the scalp and at other hair-bearing sites, slightly pathogenetic significance of these histological findings purple, follicular papules are seen when lichen is unclear but they constitute a recognizable pattern. planus involves the hair follicles. These papules heal with follicular scarring and a blue-black pigmenta- The clinical features that correspond to these find- tion of the recently scarred area is a useful clue. Scar- ings are dependent on whether the lichenoid reaction ring is also a helpful diagnostic sign when the nails is acute or chronic. The prototype disease is lichen are affected.and a pterygium is highly suggestive of planus which represents the chronic type of lichenoid lichen planus. Other less specific signs include rough- reaction dnd is characterized by small, purple papules. ening of the surface of the nail plate, Iongitudinai In addition, skin coloured or shiny, minute papules ridging and thinning. may also occur and have exactly the same histo- pathological appearance. Occasionally, a lesion may H stologically, there is a dense upper dermal band show a combination of shiny papules and violaceous of lymphocytes that is closely applied to the epider- papules. ln such lesions, the shiny papules are aggre- mis but does not invade its. The basal keratinocytes gated closely together and show a purple coloration show evidence of injury as necrotic pink cells with a at the censer of the lesion while papules tend to remain pyknotic nucleus or as vacuolated ceils. The necrotic skin coloured and discrete at the periphery. We have cells drop down into the epidermis as colloid or Civatte also seen shiny macules that have the colour and sheen bodies. The basal cell damage may lead to the appear- of fine lichenoid papules. They may represent evolv- ance of a split between the epidermis and the dermis, ing or subsiding lesions, The, clinical appearance the so-called Max-]oseph space. The damage to basal is also modified by the site of the lesion; the character- keratinocytes of the rete ridges leads to a saw-tooth istic purple colour is hardly yisible at sites such as the appearance. Melanin is found within macrophages scalp and nail. Ii:r these locations, other clues such as in the upper dermis. There is compact orthokeratosis scarring alopecia and pterygium provide clues to a and hypergranulosis which is wedge shaped over the lichenoid process. acrotrichia and acrosyringia. In acute lesions, the clinical appearance is domi- When lichen planus affects the hair follicles, oral nated by erythema. The brown-black colour of epider- mucosa or nail, the changes are essentially similar mal necrosis is often seen in erythema multiforme and but the appearance must be interpreted in the light of fixed drug eruption. It is overshadowed by dermal the normal histology of the area. necrosis presenting as a necrotic crust in pityriasis lichenoides et varioliformis acuta (PLEVA). The sub- In follicular lesions of lichen planus (ichen sidence of an acr$e lichenoid reaction is characteristi- planopilaris), the lymphocytic infiltrate is seen around cally followed by a persistent pigmentation which the hair follicle with damage to the basal cells of the represents the melanin incontinence that is prone to follicular epithelium. This may occur in isolation or occur in these dermatoses. in conjunction with involvement of non-follicular epidermis. Lichen planopilaris heals with scarring of An account of some of the major diseases that follicles and biopsies of late lesions show selerosed belong to this group and which are likely to be encoun- follicular units. tered in clinical practice follows. Lichen planus of the oral mucosa shows changes Lichen planus similar to cutaneous lesions. The finding of parak- eratosis is not compatible with a diagnosis of lichen Lichen planus is the prototype of a lichenoid tissue planus on the skin but it is a normal feature of oral reaction. The typical clinical lesion is an itchy, mucosa and is seen in oral lichen planus. Basal cell violaceous papule that shows whitish streaks known damage is less prominent than in cutaneous lesions, as Wickham striae. The papules occur on the legs, the wrists and the lower back but may develop at any site Lichen planus hypertrophicus demonstrates and can present.as a generalized eruption. At all these compact hyperkeratosis and acanthosis. The dermal sites, they retain their characteristic appearance. How- infiltrate of lymphocytes is not band-like and is local- ever, the presentation of the disease may be modified ized to the tips of the rete ridges with damage to the by the site. overlying basal keratinocytes. Papillary fibrosis is frequent. On the palms and soles, lichen planus is skin coloured and hyperkeratotic and diagnosis is diffi- Lichenoid drug eruptions cult when lesions are confined to this site. On the mucosa, there is a white or violaccous plague. White Itchy, violaceous papules that resemble idiopathic plaques may be lacy and reticular. Some white plaques lichen planus may develop following exposure to show violaceous discoloration. Erosions are frequent. certain drugs. Some drugs may cause oral lesions of Vol. 5, 2002 E E I I t i r 22 M Ra-tnam, Asha Kubba i I i lichen planus, alone or in association with skin lesions. biopsies that showed features indistinguishable from i The list of drugs implicated is long and includes lichen nitidus and the diagnosis was established by : thiazide diuretics, i antimalarials, gold, streptomycin, the Mantoux test and response to therapy. i isoniazid, ethambutol and beta blockers among many othersT. a Oral lichenoid eruptions are induced by a Lichen striatus : smaller number of drugs8 including lithium carbonatee : and imatiniblo. (Histologically, lichenoid drug
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