Lichen Nitidus

Back

Background

Lichen nitidus is a relatively rare, chronic skin eruption that is characterized clinically by asymptomatic, flat-topped, skin-colored micropapules (see image below).[1] Lichen nitidus mainly affects children and young adults.[2]



View Image

Multiple skin-colored shiny papules associated with lichen nitidus.

Pathophysiology

The skin is the primary organ system affected. Mucous membranes and nails[3] also might be involved. Lichen planus can clinically mimic lichen nitidus and can sometimes coexist with lichen nitidus.

Etiology

The etiology of lichen nitidus is unknown. Controversy exists regarding the relationship between lichen planus and lichen nitidus.[4]

Epidemiology

Frequency

The frequency of lichen nitidus is unknown because of its uncommon occurrence. In a study of skin diseases in blacks over a 25-year period, the incidence of lichen nitidus was 0.034%.[5]

Race

No racial predilection is reported.

Sex

No sexual predilection exists. However, generalized variants appear to occur predominantly in females.

Age

Lichen nitidus may affect any age group, but it most commonly develops in childhood or early adulthood.

Prognosis

Lichen nitidus is a benign disease with no associated mortality or complications. Lichen nitidus may remain active for several years; however, spontaneous resolution usually occurs.

History

Lichen nitidus is usually an asymptomatic eruption; however, patients occasionally complain of pruritus. Familial cases have been described.[6]

Physical Examination

The primary lesions consist of multiple 1- to 3-mm, sharply demarcated, round or polygonal, flat-topped, skin-colored shiny papules that often appear in groups (see image below).



View Image

Multiple shiny lichens over the penis.

The Köbner phenomenon (or an isomorphic response) may be observed, as shown below. This phenomenon causes the occasional linear pattern of the lesions associated with lichen nitidus.



View Image

Köbner phenomenon in lichen nitidus.

The most common sites of involvement are the trunk, flexor aspects of upper extremities, dorsal aspects of hands (see image below), and genitalia. Infrequently, the lower extremities, palms, soles, face, nails, and mucous membranes may be affected. Nail changes include pitting, ridging, splitting, and linear striations.



View Image

Lichen nitidus.

Clinical variants of lichen nitidus include generalized,[7] linear, actinic,[8] perforating,[9, 10] keratodermic,[11, 12] vesicular,[13] and purpuric[10] /hemorrhagic[13] forms.

Reported associated diseases include atopic dermatitis,[14] lichen planus,[15] condyloma,[16] amenorrhea,[17] Crohn disease,[18, 19] , juvenile chronic arthritis,[20] and Down syndrome.[21, 22]

Procedures

A skin biopsy for histopathologic examination may be obtained to confirm the clinical diagnosis.

Histologic Findings

The papule of lichen nitidus consists of a lymphohistiocytic inflammatory cell infiltrate that lies in close proximity to the epidermis and is associated with basal cell hydropic degeneration. The overlying epidermis is flattened and parakeratotic. At the lateral margins of the papule, the rete ridges extend downward and seem to hug the inflammatory infiltrate, which may be granulomatous.

Approach Considerations

No therapeutic modality has been rigorously evaluated for the treatment of lichen nitidus because of the rarity, lack of significant symptomatology, and disappearance of this disease within one or several years. Reported therapies, mostly from isolated case reports, include topical and systemic steroids, topical tacrolimus,[23, 24, 25] systemic cetirizine,[26] levamisole,[26] etretinate, acitretin,[27] itraconazole,[28] cyclosporine, topical dinitrochlorobenzene,[29] psoralen plus UV-A light,[30] and narrow-band UV-B light.[31, 32, 33]

Prednisone (Deltasone)

Clinical Context:  Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.

Methylprednisolone (Solu-Medrol, Depo-Medrol)

Clinical Context:  Methylprednisolone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Class Summary

Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

Cetirizine (Zyrtec)

Clinical Context:  Cetirizine forms complex with histamine for H1-receptor sites in blood vessels, GI tract, and respiratory tract.

Class Summary

Antihistamines act by competitive inhibition of histamine at the H1 receptor. They mediate bronchial constriction, mucous secretion, smooth muscle contraction, edema, hypotension, CNS depression, and cardiac arrhythmias.

Acitretin (Soriatane)

Clinical Context:  Acitretin is a retinoic acid analog, like etretinate and isotretinoin. Etretinate is the main metabolite and has demonstrated clinical effects close to those seen with etretinate. Its mechanism of action is unknown.

Class Summary

Retinoids have the ability to modulate cell proliferation.

Author

Zeina Tannous, MD, Associate Professor and Chair, Lebanese American University; Chief of Dermatology, University Medical Center, Rizk Hospital, Lebanon; Visiting Associate Professor in Dermatology, Harvard Medical School; Clinical Associate in Dermatology, Massachusetts General Hospital

Disclosure: Nothing to disclose.

Specialty Editors

Michael J Wells, MD, FAAD, Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Disclosure: Nothing to disclose.

Warren R Heymann, MD, Head, Division of Dermatology, Professor, Department of Internal Medicine, Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD.

Additional Contributors

David P Fivenson, MD, Associate Director, St Joseph Mercy Hospital Dermatology Program, Ann Arbor, Michigan

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Nelly Rubeiz, MD, to the development and writing of this article.

References

  1. Liu ET, Laver N, Heher K, Chen V. Lichen Nitidus of the Eyelids. Ophthalmic Plast Reconstr Surg. 2017 Jul/Aug. 33 (4):e85-e86. [View Abstract]
  2. Ho JD, Al-Haseni A, Rosenbaum MT, Goldberg LJ. Hyperkeratotic and hypertrophic lichen nitidus. Dermatol Online J. 2017 Oct 15. 23 (10):[View Abstract]
  3. Bettoli V, De Padova MP, Corazza M, Virgili A. Generalized lichen nitidus with oral and nail involvement in a child. Dermatology. 1997. 194(4):367-9. [View Abstract]
  4. Cho EB, Kim HY, Park EJ, Kwon IH, Kim KH, Kim KJ. Three cases of lichen nitidus associated with various cutaneous diseases. Ann Dermatol. 2014 Aug. 26(4):505-9. [View Abstract]
  5. Hazen HH. Syphilis and skin diseases in the American Negro: personal observations. Arch Dermatol Syph. 1935. 31:316.
  6. Kato N. Familial lichen nitidus. Clin Exp Dermatol. 1995 Jul. 20(4):336-8. [View Abstract]
  7. Al-Mutairi N, Hassanein A, Nour-Eldin O, Arun J. Generalized lichen nitidus. Pediatr Dermatol. 2005 Mar-Apr. 22(2):158-60. [View Abstract]
  8. Glorioso S, Jackson SC, Kopel AJ, Lewis V, Nicotri T Jr. Actinic lichen nitidus in 3 African American patients. J Am Acad Dermatol. 2006 Feb. 54(2 Suppl):S48-9. [View Abstract]
  9. Itami A, Ando I, Kukita A. Perforating lichen nitidus. Int J Dermatol. 1994 May. 33(5):382-4. [View Abstract]
  10. Yoon TY, Kim JW, Kim MK. Two cases of perforating lichen nitidus. J Dermatol. 2006 Apr. 33(4):278-80. [View Abstract]
  11. Munro CS, Cox NH, Marks JM, Natarajan S. Lichen nitidus presenting as palmoplantar hyperkeratosis and nail dystrophy. Clin Exp Dermatol. 1993 Jul. 18(4):381-3. [View Abstract]
  12. Yáñez S, Val-Bernal JF. Purpuric generalized lichen nitidus: an unusual eruption simulating pigmented purpuric dermatosis. Dermatology. 2004. 208(2):167-70. [View Abstract]
  13. Jetton RL, Eby CS, Freeman RG. Vesicular and hemorrhagic lichen nitidus. Arch Dermatol. 1972 Mar. 105(3):430-1. [View Abstract]
  14. Lestringant GG, Piletta P, Feldmann R, Galadari I, Frossard PM, Saurat JH. Coexistence of atopic dermatitis and lichen nitidus in three patients. Dermatology. 1996. 192(2):171-3. [View Abstract]
  15. Kawakami T, Soma Y. Generalized lichen nitidus appearing subsequent to lichen planus. J Dermatol. 1995 Jun. 22(6):434-7. [View Abstract]
  16. Scheinfeld NS, Lehman D. Condyloma with lichen nitidus. Skinmed. 2005 May-Jun. 4(3):177-8. [View Abstract]
  17. Taniguchi S, Chanoki M, Hamada T. Recurrent generalized lichen nitidus associated with amenorrhea. Acta Derm Venereol. 1994 May. 74(3):224-5. [View Abstract]
  18. Kano Y, Shiohara T, Yagita A, Nagashima M. Erythema nodosum, lichen planus and lichen nitidus in Crohn's disease: report of a case and analysis of T cell receptor V gene expression in the cutaneous and intestinal lesions. Dermatology. 1995. 190(1):59-63. [View Abstract]
  19. Scheinfeld NS, Teplitz E, McClain SA. Crohn's disease and lichen nitidus: a case report and comparison of common histopathologic features. Inflamm Bowel Dis. 2001 Nov. 7(4):314-8. [View Abstract]
  20. Bercedo A, Cabero MJ, Garcia-Consuegra J, Hernado M, Yaez S, Fernandez-Llaca H. Generalized lichen nitidus and juvenile chronic arthritis: an undescribed association. Pediatr Dermatol. 1999 Sep-Oct. 16(5):406-7. [View Abstract]
  21. Henry M, Metry DW. Generalized lichen nitidus, with perioral and perinasal accentuation, in association with Down syndrome. Pediatr Dermatol. 2009 Jan-Feb. 26(1):109-11. [View Abstract]
  22. Botelho LF, Magalhães JP, Ogawa MM, Enokihara MM, Cestari Sda C. Generalized Lichen nitidus associated with Down's syndrome: case report. An Bras Dermatol. 2012 May-Jun. 87(3):466-8. [View Abstract]
  23. Dobbs CR, Murphy SJ. Lichen nitidus treated with topical tacrolimus. J Drugs Dermatol. 2004 Nov-Dec. 3(6):683-4. [View Abstract]
  24. Park J, Kim JI, Kim DW, Hwang SR, Roh SG, Kim HU, et al. Persistent generalized lichen nitidus successfully treated with 0.03% tacrolimus ointment. Eur J Dermatol. 2013 Nov-Dec. 23(6):918-9. [View Abstract]
  25. Teichman JMH, Mannas M, Elston DM. Noninfectious Penile Lesions. Am Fam Physician. 2018 Jan 15. 97 (2):102-110. [View Abstract]
  26. Sehgal VN, Jain S, Kumar S, et al. Generalized lichen nitidus in a child's response to cetirizine dihydrochloride/levamisol. Australas J Dermatol. 1998 Feb. 39(1):60. [View Abstract]
  27. Lucker GP, Koopman RJ, Steijlen PM, van der Valk PG. Treatment of palmoplantar lichen nitidus with acitretin. Br J Dermatol. 1994 Jun. 130(6):791-3. [View Abstract]
  28. Libow LF, Coots NV. Treatment of lichen planus and lichen nitidus with itraconazole: reports of six cases. Cutis. 1998 Nov. 62(5):247-8. [View Abstract]
  29. Kano Y, Otake Y, Shiohara T. Improvement of lichen nitidus after topical dinitrochlorobenzene application. J Am Acad Dermatol. 1998 Aug. 39(2 Pt 2):305-8. [View Abstract]
  30. Randle HW, Sander HM. Treatment of generalized lichen nitidus with PUVA. Int J Dermatol. 1986 Jun. 25(5):330-1. [View Abstract]
  31. Do MO, Kim MJ, Kim SH, Myung KB, Choi YW. Generalized lichen nitidus successfully treated with narrow-band UVB phototherapy: two cases report. J Korean Med Sci. 2007 Feb. 22(1):163-6. [View Abstract]
  32. Kim YC, Shim SD. Two cases of generalized lichen nitidus treated successfully with narrow-band UV-B phototherapy. Int J Dermatol. 2006 May. 45(5):615-7. [View Abstract]
  33. Park JH, Choi YL, Kim WS, et al. Treatment of generalized lichen nitidus with narrowband ultraviolet B. J Am Acad Dermatol. 2006 Mar. 54(3):545-6. [View Abstract]

Multiple skin-colored shiny papules associated with lichen nitidus.

Multiple shiny lichens over the penis.

Köbner phenomenon in lichen nitidus.

Lichen nitidus.

Multiple skin-colored shiny papules associated with lichen nitidus.

Multiple shiny lichens over the penis.

Köbner phenomenon in lichen nitidus.

Lichen nitidus.