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Table of Content-Volume 12 Issue 2 - November 2019


 

 

Lichen planus: A comprehensive histopathological study

 

Ramesh Waghmare1, Vikas Kavishwar2*, Vivek Parameshwar3

 

1Assistant Professor, 2Professor(Additional), 3Ex- Junior Resident, Department of Pathology, Topiwala National Medical College (TNMC) and B. Y. L. Nair Charitable Hospital.

Email: rameshpathmumbai@gmail.com, kavishwarvikas@gmail.com, choodamani.parameshwar@gmail.com

 

Abstract               Background and Objectives: Lichen Planus is a commonly encountered papulosquamous disorder in our country. The chronic course of this disorder with its relatively unknown pathogenesis and variable presentations make its diagnosis important. Histopathologic assessment is the gold standard for diagnosis making studies like this all the more important. Material and Methods: 152 clinically diagnosed cases of LP were taken into consideration. The biopsies were then subjected to tissue processing and H and E staining. The sections were then examined microscopically for a specific set of parameters. Results: Maximum number of cases were seen in the age group of 31- 40 years. Lichen Planus was diagnosed in 68 males and 84 females with a male to female ratio of 1:1.23. Classic lichen planus was the most common variant. Among the microscopic parameters dermal inflammation was observed in 99% cases, 95% cases had band like lymphocytic infiltrate in dermo epidermal junction, 81% cases had vacuolar alteration of basal layer, 75% cases had melanin incontinence and 65% cases had hypergranulosis. Conclusion: Establishment of a specific set of microscopic parameters will help in accurate diagnosis of the perplexing entity “Lichen Planus”.

Key Words: Lichen Planus, Histopathology.

 

INTRODUCTION

The word Lichen Planus comes from the Greek word Lichen meaning “tree moss” and Latin word Planus meaning “flat”1. Lichen Planus is a relatively common idiopathic subacute or chronic inflammatory disease involving the skin, mucous membranes and nails.2, characterized by polygonal flat-topped, violaceous papules and plaques 3. Although Lichen Planus is relatively clinically well defined in general population; nevertheless its pathogenesis is not exactly defined.4 Also there have not been many studies conducted in India. A histopathological study for diagnosis will help us in understanding the diagnostic histological features, instituting proper therapy and thus vary the prognosis significantly which is the primary aim of this study.

 

MATERIALS AND METHOD

152 clinically diagnosed cases of LP were taken into consideration in approximately 5 years during the study conducted in the Department of Pathology at this tertiary care institute. Skin biopsies were taken from each of these cases in the Department of Dermatology. The biopsies were then subjected to tissue processing comprising of fixation, dehydration, clearing, embedding, cutting and finally haematoxylin and eosin staining. The sections were then examined microscopically for a specific set of parameters and a histopathological assessment was done. Statistical assessment was carried out using percentage analysis for various parameters.

 

 

 

RESULTS

In the present study, the clinical diagnosis of lichen planus was made in 152 cases. The average number of lesions was 2 and average size of the lesions was 11 mm in these cases. Maximum number of cases- 34 cases or 22% were seen between 31- 40 years of age and minimum number of cases- 5 cases or 3% were seen above 70 years of age. Lichen Planus was diagnosed in 68 males (45%) and 84 females (55%) with a male to female ratio of 1:1.23. Out of the 152 cases of lichen planus, different variants were noticed were. These were 138 cases or 91% of classic lichen planus, 6 cases or 4% of hypertrophic lichen planus, 5 cases or 3% of follicular lichen planus, 2 cases or 1% of lichen planus pigmentosis and 1 case or 1% genital lichen planus. Among all the cases of lichen planus, most common site involved was lower limb with 71 cases (47%) and the least common site was the chest with 1 case (1%) (Figure1). The microscopic parameters are very essential in determining the type of lesion. Among these, most of the cases having lichen planus had dermal inflammation i.e. 151 (99%) cases, 144 (95%) cases had band like lymphocytic infiltrate in dermo epidermal junction, 123 (81%) cases had vacuolar alteration of basal layer, 114 (75%) cases had melanin incontinence and 99(65%) cases had hypergranulosis.


Table 1: Comparison of Microscopic parameters in Lichen Planus

Parameters- Microscopy

Present study (%)

(2017)

Parihar A. et.al (%)(3) (2015)

Kaurambaiah KP. et.al (%)(5) (2017)

Gurusamy L. et.al (%)(7). (2016)

Hosamane S. et.al (%)(4)

(2016)

Epidermis

 

Acanthosis

72

94

-

78

42.10

Parakeratosis

11

-

11.76

-

15.78

Hyperkeratosis

42

-

100

84

31.57

Orthokeratosis

23

100

-

-

21.05

Hypergranulosis

65

96.5

76.47

80

52.63

Elongated rete Ridges

5

-

-

-

-

Basket woven stratum corneum

32

-

-

-

-

Follicular plugging and thinning

12

-

-

-

-

Dermo-epidermal junction

 

Vacuolar alteration of basal layer

81

100

100

100

57.89

Band like lymphocytic infiltrate in dermo epidermal junction

95

94

76.47

-

42.10

Melanin incontinence

75

99

-

-

-

Dermis

 

Dermal Inflammation

99

-

-

-

57.89

Vascular change

43

-

-

-

-

Dermal appendageal inflammation

24

-

-

-

-

 

1

Figure 1: Male:Female ratio, Variants, Age group and Site of Lesions in Lichen Planus

 

2

Figure 2: Lichen planus erythematous papules and macules; Figure 3: Band like infiltrate at dermo- epidermal junction; Figure 4: Hepergranulosis and melanin incontience

 DISCUSSION

LP has worldwide distribution and incidence varies from 0.2–1% 2,5. There have not been many Indian studies stating its prevalence. As per Bhattacharya M. et.al and Gurusamy L. et.al, LP represents 0.38% and 0.16% respectively of all dermatology out patients in our country 6,7. With regard to age groups affected, in our study, maximum number of cases 34 (22%) were seen between 31- 40 years of age, followed by 30 (20%) cases in the age group of 21-30 years. A minimum number of cases were seen above 70 years of age that is 5 (3%) cases. This is similar to what Karumbaiah KP. et.al found, which was the age group of 31-40 years being most commonly affected and accounting for 41.17% cases8. On the other hand, Bhattacharya M. et.al found the age group of 31-40 years being most commonly affected (25%) and Kanwar and Singh observed the age group of 21- 30 years to be affected the most (28.57%) 6,9. Even the least affected age group varied as compared to our study tough there was consensus among other studies with regard to this aspect. Both Bhattacharya M. et.al and Kanwar and Singh found the age group of 0-10 years to be least affected (1.29% and 4.54% respectively) 6,9. Hence it can be seen that with regards to age distribution, there is a disparity among various studies. As per literature there is no sex predilection for this disease 3,10. In our study, lichen planus was diagnosed in 68 males and 84 females, females being more affected than males, with a male to female ratio of 1:1.23. This is similar to Kyriakis KP. et.al who also found a ratio of 1:1.2611. Heath L. et.al found it to be still higher at 1:1.5 (12). On the other hand, Bhattacharya M. et.al, Kanwar and Singh, Karumbaiah KP. et.al and Younas M. et.al found males to be more commonly affected than females with a male: female ratio of 1.2:1,1.5:1, 1.83:1 and 2:1 respectively 6, 8, 9, 13. Thus we can see that there is variability in sex predilection too among various studies. Out of the 152 cases of Lichen Planus in this study, the different variants which were observed were lichen planus (classic) having 138 cases (91%), hypertrophic lichen planus consisting of 6 cases (4%), follicular lichen planus comprising of 5 cases (3%), lichen planus pigmentosis having 2 cases (1%) and 1 case (1%) of genital lichen planus. This was similar to the findings of both Bhattacharya M. et.al and Kanwar and Singh who reported 47.4% and 74.61% of lichen planus (classic) type, 14.2% and 12.7% of hypertrophic LP and 2.6% and 1.81% cases of follicular LP respectively 6,9. Though, Parihar A. et.al reported maximum cases of lichen planus (classic) (61%), they found lichen planus pigmentosus to be more frequent (27.5%) followed by follicular LP (11.5%) 3. Thus it can be concluded that classic lichen planus is the most common variant. Among all the cases of lichen planus in the current study, the most common site involved was the lower limb 71 cases (47%), followed by upper limb 37 cases (25%) and the least common site was the chest i.e. 1 case (1%). This resembled the findings of Parihar A. et. al and Gurusamy L. et.al who too observed lower limbs as the most common site of lesion at 77.2% and 63% respectively 3,7. Conversely, Bhattacharya M. et.al found upper limb as the most affected site(47.4%) 6. In literature, lower limb involvement commonly has been postulated due to venous stasis which correlates with our findings 3. Most of our cases presented as erythematous popular lesions (Figure2). With regards to microscopic parameters, 151(99%) cases having lichen planus had dermal inflammation. Other common findings were 144(95%) cases consisted of band like lymphocytic infiltrate in dermo epidermal junction (Figure3), 123(81%) cases had vacuolar alteration of basal layer, 114(75%) cases had melanin incontinence and hypergranulosis was observed in 99(65%) cases (Figure4). Table1 gives a comparison of findings of our study with other similar studies. From the above comparative table it can be seen that vacuolar alteration of basal layer is a consistent finding as per all the studies. Other features like band like lymphocytic infiltrate at dermo epidermal junction, melanin incontinence and hypergranulosis are also seen in significant number of cases. A combination of all these parameters can thus be used to accurately diagnose lichen planus and its variants.

 

CONCLUSION

Lichen Planus is a commonly encountered papulosquamous disorder the aetiopathogenesis of which is not well understood. It also has a clinical overlap with other disorders making its clinical diagnosis challenging. The definitive diagnosis is only by histopathological examination. Hence identifying a specific group of microscopic parameters with a clinical correlation will be the best method of diagnosis, making the need of such studies all the more important.

 

REFERENCES

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