Download MBBS Dermatology PPT 17 Lichen Planus Pityriasis Rosea Lecture Notes

--- Content provided by​ FirstRanker.com ---

Pityriasis Rosea

Lichen Planus
Leichen ? tree moss ; planus ? flat
Coined by Sir William James Erasmus Wilson in 1869

--- Content provided by‍ FirstRanker.com ---

Idiopathic, inflammatory disorder affecting skin ,

mucous memb , nails & hair.

--- Content provided by‍ FirstRanker.com ---

Chronic course with relapses and remissions

Affects 0.5% of the population
Age group affected: 30 ? 60 years
rare in children

--- Content provided by‌ FirstRanker.com ---

ETIOLOGY :

1. Idiopathic
2. Familial associations: HLAA3, A5, B7, DR1 and

--- Content provided by FirstRanker.com ---

DRB*0101.

3. Drugs causing LP like eruptions ? gold salts, beta blockers,

--- Content provided by​ FirstRanker.com ---

antimalarials, thiazides, furosemide, spironolactone, penicil amine

4. Dental amalgams
5. Infections ? HCV
6. Betel leaf, areca nut use in South East Asia - oral LP

--- Content provided by⁠ FirstRanker.com ---

PATHOGENESIS

The exact pathomechanisms are unclear
Autoimmunity is clearly suggested to be central in

--- Content provided by‌ FirstRanker.com ---

pathogenesis in LP

1. LP ? specific antigen recognition
2. Cytotoxic Lymphocyte Activation
3. Keratinocyte Apoptosis

--- Content provided by⁠ FirstRanker.com ---

CLINICAL FEATURES

firm, shiny, polygonal, 1?3 mm diameter papules, red to

--- Content provided by⁠ FirstRanker.com ---

violet

6 P's --- purple, pruritic, polygonal, plane topped,

papules, plaques

--- Content provided by‍ FirstRanker.com ---

Pruritus: mild irritation, to continuous severe itching

interfering with sleep

--- Content provided by​ FirstRanker.com ---

distribution: isolated/grouped, linear/annular
resolved lesions: greyish brown due to
deposition of melanin in the superficial dermis.

--- Content provided by FirstRanker.com ---

Sites : volar aspect of the wrists, lumbar region,

ankles, shins, scalp, palms, soles.

Oral and genital mucosa

--- Content provided by‌ FirstRanker.com ---

- WICKHAM'S STRIAE :on

BROCQ'S

--- Content provided by​ FirstRanker.com ---

close inspection a trace of

PHENOMENON:

--- Content provided by‍ FirstRanker.com ---

thin white lines seen on

Subepidermal

the surface of the lesions

--- Content provided by‍ FirstRanker.com ---

hemorrhage

following scraping

--- Content provided by FirstRanker.com ---

of a classical LP

lesion

KOEBNER'S PHENOMENON

--- Content provided by⁠ FirstRanker.com ---

Development of

lesions in

--- Content provided by‍ FirstRanker.com ---

previously normal

skin that has been

subjected to trauma

--- Content provided by FirstRanker.com ---

HISTOPATHOLOGY

--- Content provided by‍ FirstRanker.com ---

TYPES OF LP

MORPHOLOGY

SITE

--- Content provided by⁠ FirstRanker.com ---

SPECIAL

HYPERTROPHIC

--- Content provided by‌ FirstRanker.com ---

SKIN

ACTINIC

ATROPHIC

--- Content provided by‍ FirstRanker.com ---

MUCOSAL

LP

--- Content provided by​ FirstRanker.com ---

(ORAL, GENITAL)

PEMPHIGOIDES

GUTTATE( ERUPTIVE)

--- Content provided by​ FirstRanker.com ---

PALMOPLANTAR

LP PIGMENTOSUS

--- Content provided by⁠ FirstRanker.com ---

ANNULAR

NAIL

LINEAR

--- Content provided by‌ FirstRanker.com ---

SCALP

VESICULOBULLOUS

--- Content provided by​ FirstRanker.com ---

INVERSE

FOLLICULAR
ULCERATIVE/EROSIVE

--- Content provided by‌ FirstRanker.com ---

HYPERTROPHIC LP

Hypertrophic or warty

lesions

--- Content provided by‌ FirstRanker.com ---

Lower limbs, especially

around the ankles

--- Content provided by⁠ FirstRanker.com ---

Severely itchy
Must be distinguished

from lichen simplex

--- Content provided by‍ FirstRanker.com ---

chronicus and lichen

amyloidosis

--- Content provided by FirstRanker.com ---

GUTTATE LP

Lesions are widely

scattered, discrete, size

--- Content provided by‌ FirstRanker.com ---

(1?2 mm)

Differentiate from

--- Content provided by‍ FirstRanker.com ---

guttate psoriasis

ANNULAR LP

very narrow rim of

--- Content provided by FirstRanker.com ---

activity with a

depressed, slightly

--- Content provided by FirstRanker.com ---

atrophic centre

characteristically found

on the penis

--- Content provided by​ FirstRanker.com ---

BULLOUS LP

blisters arise only on or

--- Content provided by​ FirstRanker.com ---

near the lesions of LP

short duration
HPE - severe liquefaction

--- Content provided by FirstRanker.com ---

degeneration of the basal

cell layer. Subepidermal

--- Content provided by⁠ FirstRanker.com ---

bulla with typical changes

of LP

direct and indirect

--- Content provided by‍ FirstRanker.com ---

immunofluorescence

negative.

--- Content provided by​ FirstRanker.com ---

FOLLICULAR LP

Follicular lesions
Scalp
Intensely itchy

--- Content provided by‌ FirstRanker.com ---

scarring alopecia


ACTINIC LP

--- Content provided by​ FirstRanker.com ---

Lichen planus

subtropicus ?

dark skinned, tropical

--- Content provided by​ FirstRanker.com ---

countries

welldefined

--- Content provided by‍ FirstRanker.com ---

annular/discoid patches,

with a deeply

hyperpigmented centre &

--- Content provided by FirstRanker.com ---

surrounded by a striking

hypopigmented zone

--- Content provided by​ FirstRanker.com ---

Sunexposure :central to

the pathogenesis

LICHEN PLANUS PIGMENTOSUS

--- Content provided by⁠ FirstRanker.com ---

India, Middle East
macular

hyperpigmentation:

--- Content provided by‍ FirstRanker.com ---

slate grey to

brownish black

--- Content provided by‍ FirstRanker.com ---

face, neck and

upper limbs

--- Content provided by⁠ FirstRanker.com ---

LICHEN PLANUS PEMPHIGOIDES

acute and generalized
large bullae on both involved

--- Content provided by⁠ FirstRanker.com ---

and uninvolved skin.

HPE: subepidermal bulla

without evidence of LP

--- Content provided by​ FirstRanker.com ---

Direct IF: linear deposition of

IgG, C3 along basement

--- Content provided by FirstRanker.com ---

membrane zone in

perilesional skin

Immunoelectron

--- Content provided by⁠ FirstRanker.com ---

microscopy: deposition of

IgG,C3 in the base of the

--- Content provided by⁠ FirstRanker.com ---

bulla (unlike BP- roof )

LICHEN PLANUS: PALMS, SOLES

lesions are firm, rough

--- Content provided by FirstRanker.com ---

with a yellowish hue

broadly sheeted or

--- Content provided by‌ FirstRanker.com ---

punctate

diagnosis is very

difficult; syphilis,

--- Content provided by​ FirstRanker.com ---

psoriasis, callosities

and warts must be

--- Content provided by‌ FirstRanker.com ---

excluded
MUCOSAL LESIONS

Seen in 30?70% cases; may be isolated
Sites:

--- Content provided by FirstRanker.com ---

buccal mucosa,
tongue (most often involved)
genitalia- the penile shaft, glans penis, prepuce,

--- Content provided by‌ FirstRanker.com ---

scrotum, vulva

perianal

--- Content provided by‍ FirstRanker.com ---

Patterns Of Mucosal Involvement

? Reticulate ? most common
? Atrophic

--- Content provided by‌ FirstRanker.com ---

? Hypertrophic
? Erosive/Ulcerative
? Plaque-like
? Papular
? Bullous

--- Content provided by⁠ FirstRanker.com ---

ORAL LP

--- Content provided by​ FirstRanker.com ---

Reticulate

pattern(M/C)

--- Content provided by⁠ FirstRanker.com ---

White streaks, often

forming a lacework.

inner surface of the

--- Content provided by⁠ FirstRanker.com ---

cheeks, gum

margins, lips.

--- Content provided by FirstRanker.com ---

Associated oral

candidiasis

--- Content provided by​ FirstRanker.com ---

VULVAL LP

welldemarcated

erosions/erythematous areas at

--- Content provided by‍ FirstRanker.com ---

the vaginal introitus

hyperkeratotic border of lesions;

--- Content provided by‍ FirstRanker.com ---

Wickham's striae in the

surrounding skin

vaginal inflammation

--- Content provided by‍ FirstRanker.com ---

pain/burning, scarring/loss of

normal architecture

involvement of other mucosa

--- Content provided by‍ FirstRanker.com ---

NAIL INVOLVEMENT

10% cases. Fingernails > toenails
initially 2/3 fingernails, subsequently remaining

--- Content provided by⁠ FirstRanker.com ---

digits.

Exaggerated longitudinal lines, linear depressions
Adhesion between the epidermis of the dorsal

--- Content provided by FirstRanker.com ---

nail fold and the nail bed: pterygium unguis

complete shedding

--- Content provided by‌ FirstRanker.com ---

Exaggerated

Pterygium unguis

--- Content provided by​ FirstRanker.com ---

longitudinal lines

PROGNOSIS / COMPLICATIONS

Lesions resolve with pigmentation that may last for

--- Content provided by FirstRanker.com ---

many months

Recurrent episodes

--- Content provided by‌ FirstRanker.com ---

Oral & hypertrophic lesions may be premalignant

Scarring alopecia
TREATMENT of LP

--- Content provided by FirstRanker.com ---

:

TOPICAL

PHOTOTHERAPY

--- Content provided by⁠ FirstRanker.com ---

SYSTEMIC

TCS

--- Content provided by‍ FirstRanker.com ---

PUVA

STEROIDS

IMMUNOMODULATORS

--- Content provided by FirstRanker.com ---

RETINOIDS

TRETINOIN

--- Content provided by FirstRanker.com ---

STEROID SPARING

(ORAL LESION)

DRUGS

--- Content provided by​ FirstRanker.com ---

LIDOCAINE(ORAL

TETRACYCLINES

--- Content provided by‌ FirstRanker.com ---

LESION)
VIT.D ANALOGUES

DAPSONE

--- Content provided by FirstRanker.com ---

METRONIDAZOLE

GRISEOFULVIN
THALIDOMIDE
BIOLOGICALS

--- Content provided by‍ FirstRanker.com ---

TREATMENT LADDER:

CUTANEOUS

--- Content provided by‌ FirstRanker.com ---

First line
Limited: very potent corticosteroids topical (eg.clobetasol

propionate ointment 0.05%);

--- Content provided by​ FirstRanker.com ---

Widespread: systemic prednisolone 0.5?1 mg/kg per day

until improvement

Second line

--- Content provided by FirstRanker.com ---

Prednisolone 0.5?1 mg/kg per day until improvement
Acitretin 30 mg per day for 8 weeks
PUVA /UVB: two to three times a week ? systemic

retinoids

--- Content provided by FirstRanker.com ---

TREATMENT LADDER: ORAL

First line
Symptomatic : very potent corticosteroids
Soluble prednisolone tablets, 5 mg in 15 mL water, mouthwash tds or

--- Content provided by FirstRanker.com ---

betamethasone soluble tablets 0.5 mg

Severe erosive LP: prednisolone 0.5?1 mg/kg per day
Second line

--- Content provided by​ FirstRanker.com ---

Papular ,plaquelike white forms no erosions: topical retinoids
Resistant to topicals: prednisolone 0.5?1 mg/kg
Third line
Steroid dependent/resistant erosive LP: Azathiprine, MMF, Mtx,

--- Content provided by‌ FirstRanker.com ---

Cyclosporin A

TREATMENT LADDER: NAILS

< four nails

--- Content provided by‌ FirstRanker.com ---

superpotent corticosteroids
Severe nail involvement :
monthly intralesional injection of triamcinolone acetonide (0.5

?10 mg/mL) in the periungual sites.

--- Content provided by FirstRanker.com ---

oral prednisolone (0.5?1 mg/kg/day)


LICHEN NITIDUS

--- Content provided by‌ FirstRanker.com ---

pinpoint to pinheadsized

papules,

--- Content provided by FirstRanker.com ---

flesh coloured, with a flat,

shiny surface. Remain

discrete

--- Content provided by⁠ FirstRanker.com ---

asymptomatic
forearms, penis, abdomen,

chest, buttocks.

--- Content provided by‍ FirstRanker.com ---

selflimiting, no treatment

intense, circumscribed,

--- Content provided by⁠ FirstRanker.com ---

infiltrate of lymphocytes,

histiocytes & few Langhans

cells situated immediately

--- Content provided by​ FirstRanker.com ---

below a flattened epidermis.

The rete ridges at the margin

--- Content provided by​ FirstRanker.com ---

of the infiltrate are elongated

to encircle it

liquefaction degeneration of

--- Content provided by FirstRanker.com ---

the basal cell layer.
PITYRIASIS ROSEA

Pityriasis ? scales ; Rosea ? pink ( Gilbert )

--- Content provided by FirstRanker.com ---

Acute , self-limiting disease , probably

infective in origin.

Children & young adults with a slight female

--- Content provided by⁠ FirstRanker.com ---

preponderence.

Minimal symptoms - pruritus

--- Content provided by​ FirstRanker.com ---

ETIOLOGY:

1. Viral : HHV 7 ; HHV 6 ? reactivation
2. Drugs : Metals ( Ar, Bi, Au)

--- Content provided by FirstRanker.com ---

Lithium
Methopromazine
Metronidazole
Barbiturates
Clonidine

--- Content provided by​ FirstRanker.com ---

Captopril etc.

CLINICAL FEATURES

HERALD PATCH

--- Content provided by‌ FirstRanker.com ---

primary plaque/mother

patch.
Sharply defined

--- Content provided by⁠ FirstRanker.com ---

erythematous annular

plaque with a peripheral

col arette of scales.

--- Content provided by⁠ FirstRanker.com ---

M/C Site ? thigh,upper

arm,trunk or neck

--- Content provided by⁠ FirstRanker.com ---

Within 5-15 days
Generalised eruption

? discrete oval

--- Content provided by⁠ FirstRanker.com ---

lesions similar to the

herald patch but

smaller in size

--- Content provided by​ FirstRanker.com ---

Upper chest & back ? Christmas /Inverted Fir

tree pattern.

--- Content provided by‍ FirstRanker.com ---

Face,scalp ? children
Palms ? rare, scaly red plaques / diffuse

redness / /small vesicles.

--- Content provided by⁠ FirstRanker.com ---

Oral ? ill defined red patches


Atypical / Morphological Variants:

--- Content provided by‌ FirstRanker.com ---

papules / vesicles / papulovesicular
urticarial
erythema multiforme like
pustular
purpuric

--- Content provided by FirstRanker.com ---

lichenoid
exfoliative dermatitis


Epidermis ? patchy parakeratosis, spongiosis.

--- Content provided by‍ FirstRanker.com ---

Dermis (upper) ? edema , mononuclear cel infiltrate ( exocytosis into

epidermis forming subcorneal pustules.

TREATMENT :

--- Content provided by FirstRanker.com ---

Acyclovir ( 800mg 5 times a day x 1 week)
Erythromycin (500mg qid x 2 weeks- adult

40mg/kg div.doses ? child)

--- Content provided by⁠ FirstRanker.com ---

Oral antihistamines
Topical steroids- mid potent
Topical antipruritic lotions
UVB.

--- Content provided by FirstRanker.com ---

THANKYOU