Lichenoid pseudovesicular papular eruption on nose through the dermatoscope

Sir,

Lichenoid pseudovesicular papular eruption on nose (LIPEN) is a newly described entity in dermatology characterized by relatively asymptomatic grouped vesicle-like/pseudovesicular papules on the nose and adjoining facial areas and occasionally on the extensors of arms and dorsum of hands. These lesions histopathologically show a dense focal and/or nodular lichenoid infiltrate in the upper dermis.¹ We report four cases with newly described dermatoscopic features.

All four patients presented to the dermatology outpatient department of All India Institute of Medical Sciences Bhopal and Kubba Skin Clinic, New Delhi with asymptomatic erythematous papules on the nose and upper lip. The age of the patients (one man, three women) ranged between 21 and 43 years (mean = 32.3 years). There was no history of photosensitivity, episodic flare of erythema, excessive sweating over the papules or any other history suggestive of connective tissue disease or rosacea. Cutaneous examination showed pinhead-sized erythematous to skin-coloured shiny papules on the tip and alae of the nose and upper lip below the nasolabial fold [Figure 1]. In two of our cases, the forehead and malar areas were involved with confluent plaques and other two cases had extra-facial involvement with tiny papules on the dorsum of the hand, upper back and forearm [Table 1].

Close

Figure 1a:

Multiple tiny pseudovesicular papules over nose and upper lip

Export to PPT

Close

Figure 1b:

Multiple tiny pseudovescicular papules over nose, bilateral cheek and upper lip

Export to PPT

Close

Figure 1c:

Multiple tiny pseudovescicular papules over nose and upper lip

Export to PPT

A dermatoscopic evaluation (Heine Delta 20 dermatoscope,^® 10×, polarised) of all the four cases showed round to oval, variably sized, yellowish-orange to red clustered clods with pale areas in between, probably corresponding to the lesions and intervening normal skin. There were scattered multiple white dots in both the areas and those at the periphery of red clods, giving the appearance of a scalloped margin [Figures 2a and d]. In addition, there were focal brown dots and a network [Figure 2b]. Linear and arcuate capillaries were seen occasionally in two cases and structureless white areas [Figure 2c] in one case. The white areas were seen only in the patient with larger lesions.

Close

Figure 2a:

Dermatoscopic image patient showing structureless red clustered clods (white arrow) with intervening uninvolved areas, scattered white dots at the periphery (black arrow), (Heine delta 20 dermatoscope)

Export to PPT

Close

Figure 2b:

Dermatoscopic image showing focal brown dots and network (red circle) and linear capillaries (white arrow), ×10 magnification, polarized light, (Heine delta 20 dermatoscope)

Export to PPT

Close

Figure 2c:

Dermatoscopic image showing red clods along with pale areas (red circle) ×10 magnification, polarized light, (Heine delta 20 dermatoscope)

Export to PPT

Close

Figure 2d:

Dermatoscopic image of fourth patient showing red clustered clods, white dots and pale areas; ×10 magnification, polarized light, (Heine delta 20 dermatoscope)

Export to PPT

All routine blood investigations including antinuclear antibodies were within the normal limits. Histopathology was performed in two cases and both showed atrophic epidermis and basal cell vacuolar degeneration of the epidermis. There was significant pigment incontinence in the upper dermis with moderately dense predominantly lymphohistiocytic infiltrate in the upper and mid dermis [Figure 3].

Close

Figure 3:

Histopathology image showing atrophic epidermis, basal cell damage with pigment incontinence. Dense lymphohistiocytic infiltrate in the upper and mid dermis (H&E × 200)

Export to PPT

Based on the review of literature, all our cases fit the classical description of lichenoid pseudovesicular papular eruption on the nose. All of them were treated with topical tacrolimus 0.1% ointment at night and hydroxychloroquine 400 mg twice a day in two cases along with strict photoprotection. Two cases had mild response in two months and one case was lost to follow-up.

Singh et al., in a study of 11 patients, described a new entity, lichenoid pseudovesicular papular eruption on the nose, ruling out the common differentials of facial papules like rosacea, granulosis rubra nasi, sarcoidosis, lupus miliaris disseminatus faciei, Jessner lymphocytic infiltrate etc. In addition, lesions were present on the forehead in few of the patients. These papules histopathologically showed a dense lichenoid infiltrate at the dermoepidermal junction.¹ LIPEN has primarily been described as a histopathological diagnosis but the dermatoscopic features have not been evaluated yet.

Dermatoscopy showed multiple structureless red clods clustered together with scattered white dots at the periphery in all four of our cases. The colour of the clods was not uniformly red but varied from red to yellowish-orange between patients even at different places in the same patient. The structureless red clods can be correlated with focally dense lymphohistiocytic infiltrate in the dermis. White dots may correspond to eccrine openings.² The dermatoscopic features of common differentials of lichenoid pseudovesicular papular eruption on the nose has been tabulated in Table 2.^3-7 The yellow-orange structureless areas seen in granulomatous differential were absent in LIPEN. Also, the pink-red round to oval structureless areas seen in granulosis rubra nasi were more well-defined than those seen in LIPEN. Follicular plugging is seen only in lupus miliaris disseminatus faciei among all differentials. Histopathology remains the mainstay for diagnosis along with classical clinical features. The difference in dermatoscopic features among close clinical differentials is subtle and looking at those features in a larger cohort could help us to define the findings in a better way.