Flat-topped Papules Research Articles

Roflumilast Cream 0.3% for the Treatment of Recalcitrant Lichen Nitidus

Introduction:
 Lichen nitidus is a rare chronic inflammatory condition that presents as shiny, flat-topped papules. The pathophysiology of lichen nitidus is not well understood but has been theorized to stem from allergens that cause antigen presenting cells to activate, thus causing a cell-mediated response that ultimately creates the distinct inflammatory papules1. Cytokines produced by this cell-mediated response may cause an increase in T-helper 2 cells which have the potential to produce the superficial dermal granulomas seen in lichen nitidus2. Currently, no FDA approved treatments for lichen nitidus exist. Due to the inflammatory nature of the disease, off-label therapies may include topical corticosteroids, topical calcineurin inhibitors and UV light1. Lichen nitidus can be a chronic condition and in cases where long term topical corticosteroid use is required, has been associated with hypopigmentation in African Americans. Roflumilast cream 0.3% is a highly selective, non-steroidal and potent topical phosphodiesterase 4 (PDE4) inhibitor approved in 2022 by the FDA for the treatment of psoriasis, including intertriginous disease. Here, we report the case of a 51-year-old African American patient with lichen nitidus that is pruritic and refractory to typical off-label treatments including emollients, triamcinolone and clobetasol. The patient was started on roflumilast cream 0.3% daily with complete resolution of lesions and pruritus in 4 weeks.
 
 Case Report:
 We report the case of a 51-year-old African American patient presenting to the clinic with a history of firm, pruritic, white colored papules on both of his hands that made it hard for him to drive. These lesions had been present for 2 years and did not respond to previous treatment with emollients and topical corticosteroids including triamcinolone cream 0.1% and clobetasol ointment 0.05% both twice daily. A biopsy was performed and demonstrated lymphocytic infiltrate in the upper dermis and the classic “claw and ball” configuration consistent with lichen nitidus. The patient was subsequently started on topical roflumilast 0.3% daily which resulted in complete resolution of lesions and pruritus within 4 weeks.
 
 Conclusion:
 We reported a case of a 51-year-old African American papules on both hands that were consistent with lichen nitidus. In this case, the patient’s lichen nitidus was refractory to topical corticosteroids and emollients. Long term corticosteroid use is also associated with hypopigmentation in this population. After starting topical roflumilast 0.3% daily, the patient reported complete resolution of the lesions and puritus. This report suggests reduction of inflammation with roflumilast cream 0.3%, can offer a treatment option for patients with lichen nitidus.

Líquen plano cutâneo extenso de início recente na infância após infecção assintomática por COVID-19: relato de caso

ABSTRACT Objective: The objective of this study was to describe a case of cutaneous lichen planus (LP) that appeared following COVID-19 infection. Case description: We report a case of extensive cutaneous classic familial LP in a 4-year-old male child after an asymptomatic serologically confirmed COVID-19 infection. The patient developed intensely itchy, purple, flat-topped papules and plaques, mainly on the dorsal surface of the hands, feet, forearms, and shins. Histopathological examination of the skin biopsy showed vacuolar and apoptotic degeneration of the basal cell layer with a band-like lymphocyte infiltrate at the dermo-epidermal junction and confirmed the diagnosis of LP. Comments: LP could be considered among the differential diagnoses of pediatric post-COVID inflammatory skin lesions, either in the patients recovering from COVID-19 infection or in the suspicious asymptomatic cases in close contact with COVID-19-infected patients.

Hypertrophic Lichen Planus in a 38-year-old Filipino Male: A Case Report

Abstract Hypertrophic lichen planus (HLP) is a papulosquamous eruption presenting with extremely pruritic hyperkeratotic flat-topped papules, plaques, and nodules. This is a case of 38-year-old male who presented with a 2-month history of generalized erythematous-to-hyperpigmented papules, patches, and plaques topped with white-to-gray oyster shell-like scales on a background of hyperpigmented macules and patches. There was no involvement of the conjunctival, otic, oral, and genital mucosae, and palmar and plantar aspects of the hands and feet. Dermoscopy showed reticular pearly white structures corresponding to the Wickham striae, comedo-like openings, blue-gray dots, brownish-black dots, and scales. Histopathologic examination revealed marked compact hyperkeratosis, wedge-shaped hypergranulosis, irregular saw-toothed epidermal acanthosis, scattered dyskeratotic keratinocytes, and superficial perivascular lichenoid infiltrate of lymphocytes, histiocytes, and melanophages. The patient was managed as a case of HLP. He was started on methotrexate 10 mg per week, bath psoralen photochemotherapy (PUVA) three times a week, betamethasone valerate 1mg/g cream twice a day for 2 weeks alternating with tacrolimus 0.1% ointment twice a day for another 2 weeks, 10% lactic acid, emollients, and sunscreen. After 6 months of treatment, there was almost 80% improvement of lesions and relief of pruritus.

“Wood-Bark Sign” in Dermoscopy of Aquagenic Syringeal Acrokeratoderma

“Wood-Bark Sign” in Dermoscopy of Aquagenic Syringeal Acrokeratoderma

Frictional Lichenoid Dermatitis

A previously healthy 4-year-old boy presented with a rash on his elbows and knees that over 3 weeks became pruritic and expanded to the posterior cervical region and hands. It appeared during the summer, while frequently wearing a thermal suit. The patient had no systemic symptoms and none of his cohabitants had a rash. Skin examination revealed flesh-colored to mildly erythematous flat-topped papules on the extensor surfaces of the elbows and knees, posterior cervical region and the dorsum of the hands (Figure 1). The findings were compatible with the diagnosis of frictional lichenoid dermatitis, no further studies were performed and the patient was treated with topical hydrocortisone during 2 weeks, with improvement. Frictional lichenoid dermatitis is probably underdiagnosed and it is a benign and self-limited disease with typical clinical presentation, so it is important to recognize it as not to prescribe unnecessary workup and medication.

35283 Mucocutaneous lichen planus following Moderna COVID-19 vaccination

A 33-year-old healthy female presented with an acute onset of a pruritic eruption of the trunk, extremities, oral and vulvovaginal mucosa 48 hours after administration of the first Moderna COVID-19 vaccination. Physical examination revealed multiple 3-10 mm violaceous, polygonal flat-topped papules and plaques on the trunk, feet, bilateral upper and lower extremities. Oral and genital examination revealed reticulated white plaques and superficial erosions of buccal and vulvovaginal mucosa. Microscopic examination of biopsies from an arm and vulvar mucosa demonstrated typical findings of lichen planus (LP) with epidermal hyperplasia, hypergranulosis, and dense lichenoid lymphocytic infiltrate of the superficial dermis.

Warty papules on the hands and feet: Acrokeratosis verruciformis of Hopf

A 47-year-old female was referred to our department because of skin-colored lesions located mainly on the dorsum of the hands and feet. The patient had no diseases and had not taken continuous medication. The lesions were present at birth and had increased in number since then. Four more members of the family, including the mother and the uncle (mother’s brother), had similar skin lesions. A dermatological examination revealed multiple flesh-colored, flat-topped papules, about 2–5 mm in size, which were reminiscent of flat warts on the dorsum of the hands and feet (Fig. 1). A nail examination revealed thickened nails with V-shaped nicks at their free margins on the fingers of both hands (Fig. 2). The patient declined skin biopsy. We retained the diagnosis of acrokeratosis verruciformis of Hopf (AVH). AVH is a rare inherited disorder of keratinization caused by an abnormal ATP2A2 gene [1,2]. Familial cases indicate an autosomal dominant pattern of inheritance, yet sporadic cases of the disease have also been reported [2]. It is characterized by multiple asymptomatic, flat-topped, skin-colored papules on the dorsum of the hands and feet. Other features may include pits on the palms and soles and nail dystrophy (pearly white nails or nails with longitudinal ridges and nicks in the free edge) [3]. AVH is diagnosed clinically, which becomes easier if there are family members with similar skin findings. Sometimes, a skin biopsy is performed to assist the diagnosis. The key features on histology are hyperkeratosis, hypergranulosis, acanthosis, papillomatosis, and circumscribed epidermal elevations known as church spires, which are a distinctive finding [1,2].

Recurrent fungating tumor and a chronic rash in an immunosuppressed transgender patient: a case of Buschke-Lowenstein condyloma and epidermodysplasia verruciformis.

A transgender female in her 40s with history of HIV and testicular cancer status post-genital X-irradiation presented with a perianal mass and pruritic rash across her chest. Physical examination revealed a bulky, verrucous tumor protruding outward from the anus involving the medial buttocks. Examination of the chest and arms showed numerous guttate, pink, flat-topped papules coalescing into plaques. Clinically and histologically the lesions were consistent with Buschke-Löwenstein condyloma (BLC) and acquired epidermodysplasia verruciformis (AEDV). Buschke-Löwenstein condyloma incisional biopsy tested negative for common low- and high-risk human papillomavirus (HPV) subtypes, including 6, 11, 16, and 18, possibly implicating beta HPV subtype or a less common pathogenic subtype. The patient underwent abdominoperineal resection of the BLC, which tested positive for low-risk HPV subtypes, suggesting the possibility of multiple implicated HPV subtypes in the same tumor. This case demonstrates a possible role of beta HPV or rarer HPV subtypes in the pathogenesis of verrucous carcinoma, particularly in the setting of immunosuppression.

Pediatric lichen planus: a systematic review of 985 published cases.

Lichen planus (LP) is a chronic inflammatory disorder usually occurring in middle-aged adults. Data are scarce in the pediatric population. To describe the patients' characteristics, clinical presentation, and management of pediatric LP. A systematic literature review of pediatric LP was performed in the Medline and Cochrane databases up to February 1, 2020. Demographic and clinical data were extracted for analysis, in addition to laboratory and histology findings, treatments used, and response to treatment. LP pemphigoides (LPP) was further pooled for a subcategory analysis. One hundred and sixty-four articles were included representing 985 patients. The most common country of origin was India. The most common clinical signs were flat-topped papules (51%); the linear variant was present in 9%. Oral involvement was present in 22%. The most commonly used treatment was topical corticosteroids followed by systemic corticosteroids. The mean duration of treatment was 124.4 days. LPP patients had a short disease duration before diagnosis (4.1 months, P < 0.001) and failed previous treatment more frequently (P < 0.001). Systemic corticosteroids were more often prescribed in this subgroup (75%, P < 0.001) with more recurrence after treatment (31%, P = 0.048). Lack of randomized controlled studies, in addition to publication bias. In children, LP had a wide polymorphous clinical presentation, and the reported cases were mostly from India. The linear variant was more common and the oral mucosa was less affected in children. LPP, a rare subtype in children, was treated with systemic corticosteroids and recurred more frequently.

Pediatric Vulvar Lichen Sclerosus—A Review of the Literature

Vulvar lichen sclerosus (VLS) is a chronic inflammatory condition affecting the anogenital region, which may present in a prepubertal or adolescent patient. The most popular theories are its autoimmune and genetic conditioning, although theories concerning hormonal and infectious etiology have also been raised. The most common presenting symptoms of VLS is vulva pruritus, discomfort, dysuria and constipation. In physical examination, a classic “Figure 8” pattern is described, involving the labia minora, clitoral hood, and perianal region. The lesions initially are white, flat-topped papules, thin plaques, or commonly atrophic patches. Purpura is a hallmark feature of VLS. The treatment includes topical anti-inflammatory agents and long-term follow-up, as there is a high risk of recurrence and an increased risk of vulvar cancer in adult women with a history of lichen sclerosus. This article reviews vulvar lichen sclerosus in children and provides evidence-based medicine principles for treatment in the pediatric population. A systematic search of the literature shows recurrence of VLS in children. Maintenance regimens deserve further consideration.

Clinical and dermatoscopic features of lichen planus balanoposthitis

Lichen planus (LP) is an inflammatory mucocutaneous disease characterized by pruritic, polygonal, violaceous, flat-topped papules. Wickham striae (WS) are a dermatoscopic and clinical hallmark of LP. Additional dermatoscopic findings include dotted and linear vessels, white and yellow dots, and pigmented structures. However, LP manifests with different clinical and dermatoscopic patterns according to the localization and the duration of the inflammation.1 Lichen planus balanoposthitis (LPBP) can be the sole presentation of the disease and is a risk factor for developing penile intraepithelial neoplasia.2 Dermatoscopy could facilitate the diagnosis of LPBP in uncertain cases. However, data on dermatoscopic features of LPBP are exceedingly limited.

More than meets the naked eye: an unusual psoriatic arthritis mimicry and the important role of dermoscopic examination

BackgroundPsoriatic arthritis (PsA) can manifest in various forms. This includes mimicry of other diseases. We describe an unusual mimicry of PsA.Case presentationWe report a case of a middle-aged lady who presented with severe pain and morning stiffness over the small joints of the left hand for 3 months and painless deformity of the affected joints 1 year before. She was under treatment for pruritic rash over her ankles and knees for the past 1 year as well. Physical examination revealed a fixed flexion deformity, swelling and tenderness of the left ring and little fingers’ distal interphalangeal (DIP) joints. Left hand radiograph showed sclerotic joint margin, narrowed joint space and marginal osteophytes of the affected DIP joints. Dermoscopic examination showed red- violaceous, flat-topped papules and plaques with minimal scales on both ankles; hyperpigmented scaly plaques over both knees and vertical fingernail ridges. Serum autoimmune screening and inflammatory markers were unremarkable. Left ankle skin biopsy showed features consistent of psoriasis. PsA was diagnosed. Weekly titrated oral methotrexate and topical steroid were started. The patient showed significant improvement after 1 month of treatment.ConclusionPsA is a great mimicker. Dermoscopy is an accessible and valuable tool to assess skin lesions in greater detail. Clinicians should be aware of coexisting diseases or misdiagnosis when patients do not respond to treatment.

Heck’s disease occurring after Epstein‐Barr virus‐associated smooth muscle tumors in an immunosuppressed child

A 10-year-old Guatemalan girl with past medical history of Epstein-Barr virus-associated smooth muscle tumors (EBV-SMT) and combined immunodeficiency presented for evaluation of painful intraoral lesions. On examination, she was noted to have multiple, white to flesh-colored, soft, flat-topped papules, and plaques on the buccal and labial mucosa. Human papillomavirus type 13 was detected on PCR with PGMY primers of previously biopsied buccal tissue, confirming a diagnosis of Heck's disease (multifocal epithelial hyperplasia). We present an immunosuppressed, pediatric patient with two rare, virus-associated neoplastic disorders that have not been previously reported to occur in the same individual.

Aquagenic (pseudo) keratoderma (aquagenic palmoplantar keratoderma, aquagenic wrinkling of palms)

Aquagenic palmoplantar keratoderma (APK) is an uncommon hereditary or sporadic condition that is characterized by edematous flat-topped papules appearing on palmar skin with wrinkling after brief water exposure. APK has been associated with cystic fibrosis (CF), presenting with the same mutations found in CF (usually ΔF508 of the CFTR gene), either homozygous or heterozygous. APK may be idiopathic or drug-induced. The diagnosis is easily made if one is aware of this entity. Topical aluminum hydroxide and botulinum toxin injections are the most commonly used treatments. The sporadic form may have a shorter course compared with the hereditary one, resolving spontaneously after a few years. The condition should no longer be considered a true keratoderma but rather a pseudo keratoderma, and in spite of the many different names found in the literature, the term “aquagenic (pseudo) keratoderma” seems to be the most appropriate one.

Case 2: Scalp Lesion and Neck Swelling in a Female Adolescent

1. Karin Lammert, MD* 2. Adam Dell, MD* 3. Merium Saidi, MD* 1. *Department of Pediatrics, University of Utah, Primary Children’s Hospital, Salt Lake City, UT A previously healthy 15-year-old female adolescent is admitted to the hospital with fever, neck swelling, and failure to improve while taking multiple antibiotic agents. One month ago she noticed a lump behind her left ear; it resolved spontaneously but recurred approximately 3 weeks later along with tenderness and fevers. Around this time she had a raised, scabbed lesion on her left scalp, which her sister lanced. Her pediatrician started the patient on amoxicillin/clavulanic acid. Five days later she presented to the emergency department with persistent fevers. A complete blood cell count was normal and a neck computed tomographic (CT) scan showed diffuse subcutaneous edema consistent with cellulitis, so she was started on cephalexin and trimethoprim/sulfamethoxazole and was discharged. However, her symptoms worsened, with continued fevers, vomiting, pharyngitis, and swelling of the area behind her left ear. She returned to the emergency department 3 days later and was admitted to the hospital for failure to improve with outpatient antibiotic drug therapy. The patient is otherwise healthy and up to date on immunizations. She lives with her parents and a younger sister on a farm in central Utah, with exposure to multiple farm animals. She reports that she has been camping recently and denies any insect bites. She has never been sexually active. She has tried marijuana but denies other illicit drug use. Physical examination reveals a tired-appearing teenager in no acute distress. The left parietal scalp has a 1×2-cm ulcer with flat-topped papules and overlying hemorrhagic crusts (Fig). There is diffuse swelling extending from the left mastoid process anteriorly to the angle of the mandible that is tender but without …

Genital Lesions Masquerading as Condyloma Acuminata: A Case Series Report

Herein we report three married women referred to Dermatology Clinic of Loghman Hakim Hospital, Tehran, Iran in 2017 for evaluation and treatment of genital warts. Two patients were complaining of flat-topped papules on their labia major and the third one was presented with asymptomatic papillary projections on her vestibule and inner aspect of both labia minora. Histological examination revealed the diagnosis of syringoma, lymphangioma circumscriptum (LC) and vestibular papillomatosis respectively. Familiarity with these uncommon conditions which clinically mimic genital warts helps to prevent labeling a patient with sexually transmitted disease before histological confirmation and prevent unnecessary treatment.

Lichenoid eruptions in children: A retrospective study

Background: Lichenoid eruptions are a diverse group of inflammatory dermatoses, characterized clinically by flat-topped papules which resemble lichen planus (LP) and histologically by a lichenoid tissue reaction. There are many lichenoid dermatoses, of which some are seen predominantly in the pediatric age group. The knowledge of these lichenoid eruptions is essential for the dermatologists for early diagnosis, timely treatment, and also to predict their course. Aims: Our aim was to study the clinicoepidemiological features of lichenoid dermatoses in children and to differentiate between various lichenoid dermatoses and classify them accordingly. Materials and Methods: This was a retrospective, hospital-based, cross-sectional study of 52 children with a clinical diagnosis of lichenoid eruptions from January 2017 to December 2017. Results: Of the 986 children who visited the dermatology outpatient department 52 children (5.27%) were diagnosed with lichenoid dermatoses, with the male: female ratio being 1: 1.48 and a mean age of 7.25 years. LP was the most common lichenoid dermatosis reported in our study (48%), followed by lichen striatus (37.6%), lichen nitidus (5.8%), lichen sclerosus (5.8%), pityriasis lichenoides (3.2%), and Gianotti Crosti syndrome (1.9%). Limitations: It was a retrospective data analysis involving only 1 year of study with limited sample size, without study of long term evolution. Conclusions: Some lichenoid dermatoses (lichen straitus and lichen nitidus) are self-limiting and undergo spontaneous resolution without any sequelae, whereas LP and lichen sclerosus can be associated with varying degrees of morbidity. Proper diagnosis helps in allaying the fears of parents.

A linear band of erythematous, flat-topped papules on the forearm.

A linear band of erythematous, flat-topped papules on the forearm.

Unilateral Lichen Planus: A Rare Case Report

Lichen planus (LP) is a papulosquamous disorder characterized by violaceous, flat topped papules and plaques seen on the volar aspect of the wrists, lumbar region and around the ankles. It can have a varied presentation. Here we describe a rare variant of LP in a female who presented with unilateral eruptions of violaceous papules over the right side of the body.

Clear cell papulosis: report and review

A 12-month-old boy presented with three months of asymptomatic hypopigmented flat-topped papules on the suprapubic skin and lower abdomen. Emollients and topical steroids offered no improvementand the patient was referred to the dermatology department. Shave biopsy revealed a papillated epidermis with scattered solitary mononuclearclear cells at all levels of the epidermis and an overlying basket weave orthokeratosis. The cells were epithelioid with increased amphophilic cytoplasm. Immunohistochemical staining was positive for CK7,CEA, and CAM5.2 and negative for S100, CD1a, and Mart-1. These findings were consistent with clear cell papulosis. No treatment was recommended as these lesions were asymptomatic. However, yearlyfollow up was recommended given the resemblance of these cells to those of Paget disease. Review of the literature demonstrates a total of 31 biopsy confirmed cases with AE1, CEA, and EMA positivity and S100negativity as the most consistent staining properties. A recent retrospective review of 19 cases documents long term follow-up of at least six years and up to 21 years. The results suggested a tendency toward selfresolution and an absence of malignant progression, supporting the benign nature of these lesions.