Two different cases with the same difficult diagnosis

presented by

Stelios Minas, M.D.

Limassol, Cyprus

October 10, 2008


Patient 1. 65 yo woman with pigmented lesions on her axillae.

Patient 2. 73 yo man with pigmented and atrophic lesions on his trunk.

Patient 1

A 65-year-old woman presented with a 3-year history of a gradual onset of hypepigmented macules and patches on her axillae. These lesions gradually increase in size and numbers

Multiple hyperpigmented macules and patches were noted on the axillae. She have itching. Normal oral cavity and nails.

Blood counts and biochemistry were normal. Antinuclear antibody was negative

Patient 2

A 73-year-old man presented with 5-year history of hyperpigmented and atrophic patches in his trunk. For the last two years the lesion was not increase in size.

Hyperpigmented and atrophic patches on his trunk. He had pruritus too. Normal oral cavity and nails.

Blood counts and biochemistry were normal. Antinuclear antibody was negative




Patient 1: Lichen planus pigmentosus

Patient 2: Lichen planus pigmentosus and atrophicus

Reasons Presented

Both were treated without improvement. Treatment included potent topical corticosteroids and Protopic (tacrolimus) ointment for couple of years.

For diagnostic and therapeutic suggestions.


I have presented these cases because they are very rare and interesting. I would like to share this with my dermatology colleagues about their experiences in this disorder.

What is the differential diagnosis of each case?

How do you treat these cases?

Have you seen similar cases in your practice?



Keywords lichen planus pigmentosus, lichen planus atrophicus
Comments from Faculty and Members

Omid Zargari, M.D., Consultant Dermatologist, Rasht, Iran on October 10, 2008

Case 1: Agree with the diagnosis, though to make the diagnosis definitive and to rule out the other possibilities (including granular parakeratosis) I would recommend a biopsy.
Case 2: Epidermal changes look like LSA, but through this picture I can see some unusual varicosities in the region. I even feel(!) there is a tumoral (vascular) mass. So, I recommend a sonography and then again a biopsy.

As for therapy, it is always very hard for me to start a treatment without having a definitive diagnosis. Especially in these areas which we have a high rate of absorption, I do not recommend "potent" steroids for armpits. Just my 2 Tomans!

Thank you for sharing these interesting cases.

Thamer Alkubaisi MD, Dermatologist, Anbar, Iraq on October 10, 2008

Nice pictures, first case look like lichen planus (LP) with isomorphic phenomena but it is unilateral, second case is lichen planus et atrophicus (Lp et A), but we need to prove the diagnosis in both cases by histopathological study.
We can start with super potent topical steroid with occlusion for several days then without occlusion thereafter for one month. Also we can add intralesional steroid for LP et A to accelerate healing.

Ashok Sharma MD, Dermatologist, Ministry of Health, Kuwait on October 10, 2008

Although clinically the lesions in the two photographs do suggest lichen planus (first image more than the second) a histologic picture would have placed matters in a clearer perspective. A possible clinical differential could be with confluent and reticulate papillomatosis.

I have treated my patients having biopsy proven lichen planus pigmentosus with topical steroids/pimecrolimus for localized lesions and with added oral steroids in oral mini-pulse regimen, with satisfactory results. However I must admit no case of mine has shown complete resolution of pigmentation to the best of my knowldge.

Fadi Hajjaj MD, Research Fellow in Dermatology, UK on October 10, 2008

Nice cases, thanks. I would really recommend biopsy of the lesions. My clinical impression of the first patient is axillary granular parakeratosis. The lesion in the second patient overlaying a a deep (vascular?) mass! I am still uncertain about the definitive diagnosis. I would recommend biopsies of the two lesions.

Patrick Condry MD, Clinical Asst Professor, Rochester, NY, USA on October 10, 2008.

The first case could just as well have been axillary granular parakeratosis. These are tough cases.

I have had some luck adding topical retinoid to the steroid or calcineurin inhibitor. Might be worth a try.

David Elpern MD, Dermatologist, The Skin Clinic, Williamstown, MA, USA on October 10, 2008

Clinically, this is a difficult diagnosis for me to make, and in the United States we would have biopsied each patient. However, the presenter may feel confident of his diagnosis and in that case, the biopsy is optional.

Personally, I find LP to be not that responsive to therapy. Even with narrow band UVB it can take many months. So, if this is LP, why bother treating? It will either persist or regress. I agree with Omid that potent steroids in the axillae can cause striae, so one would need to monitor the patient. In English, we say, "There are many ways to skin a cat." Benign neglect is one of them.

Fuad Dabbour MD, Consultant Dermatologist, Saudi Arabia on October 11, 2008

I think these patients need skin biopsy to reach a proper diagnosis.

Firas Altamimi M.D., Basra Teaching Hospital, Basra, Iraq on October 19, 2008

Interesting cases. I think these two cases are not similar in diagnosis. The first case is diagnosed as lichen planus pigmentosus that is not very precise but you can put other diagnosis (as seen in photo) what is called itching purpura (type of purpuric dermatitis) effect especially on folded area and should be excluded by histopathology.

Regarding the second case is far from written diagnosis. (as seen in photo) I agree with our colleague that it look a tumor mass either primary or metastatic tumor, either vascular or from bony origin so this also need biopsy (be caution if it is vascular when take biopsy).

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