Clenched fist syndrome with palmar lichen planus

Abstract

A 16‐year‐old girl had a 4‐year history of hyperkeratosis and fissures on the palm. The skin lesions had gradually progressed to thick hyperkeratosis with mild pruritus, diffusely covering the right palm, and leading to flexion contractures of the fingers with mild pain. There was no family history of similar lesions. Her father had died 4 years previously. Dermatologic examination revealed hyperkeratosis, scaling, a mild yellow color, fissures, and maceration on the palm and volar surface of the fingers of the right hand (Fig. 1). There was an approximately 3 cm × 4 cm hyperkeratotic lesion on the palm of the left hand.Hyperkeratosis with a mild yellow color, scaling, fissures, maceration on the palm and palmar surface of the fingers, and flexed fingers of the right handimageFlexion contractures were found at the metacarpophalangeal and proximal interphalangeal joints of the three fingers of the right hand (Fig. 1). There was no pain, tenderness in the joints of the fingers, or palpable nodular lesions on the palmar surface of the hand. Forced extension was difficult, and there was pain with passive extension. Radiography of the patient's hands revealed no abnormality, other than the clenched fingers. Electromyography of the upper extremities was normal.There were no lesions of the oral mucosa. The nails and scalp were normal. The patient showed very poor eye contact, and responded tersely and somewhat reluctantly to questions about her medical history.The patient was evaluated by psychiatry, but did not meet the diagnostic criteria for any mental disorder. There was a schizoid personality characteristic on both the structured clinical interview for DSM‐IV personality disorders (SCID‐II) and the Minnesota Multiphasic Personality Inventory (MMPI). In addition, there was an increase in scores on the hostility and resentment/aggression subscales of the MMPI.The results of routine laboratory tests were within normal limits or negative, including the venereal disease research laboratory (VDRL) test.A skin biopsy specimen showed histopathologic changes of lichen planus (orthokeratotic hyperkeratosis, focal hypergranulosis, acanthosis, papillomatosis, and vacuolization with dense lymphocytic reaction at the dermo‐epidermal junction) (Fig. 2).Hyperkeratosis, acanthosis, papillomatosis, and vacuolization with dense lymphocytic reaction at the dermo‐epidermal junction (hematoxylin and eosin, × 100)imageThe patient was treated with topical 5% salicylic acid and 0.1% methylprednisolone aceponate ointment. Static splinting plus stretching was used for hand therapy. Active assisted motion was employed. The treatment produced a remarkable reduction in the skin lesions (Fig. 3), but no improvement in the flexion posture of the hand. The psychiatric and clinical findings were thought to be consistent with clenched fist syndrome and lichen planus.Normal appearing left hand after treatmentimage