Case and Research Letters
Erosive Palmoplantar Lichen Planus
Liquen plano erosivo plantar
M.D. Jiménez-Sánchez
, L. Ferrándiz, D. Moreno-Ramírez, A. Vallejo-Benítez, F. Camacho-Martínez
Corresponding author
Unidad de Gestión Clínica de Dermatología, Hospital Universitario Virgen Macarena, Sevilla, Spain
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Ferrándiz, D. Moreno-Ramírez, A. Vallejo-Benítez, F. Camacho-Martínez" "autores" => array:5 [ 0 => array:4 [ "nombre" => "M.D." "apellidos" => "Jiménez-Sánchez" "email" => array:1 [ 0 => "mdjs1982@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Ferrándiz" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Moreno-Ramírez" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Vallejo-Benítez" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Camacho-Martínez" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Unidad de Gestión Clínica de Dermatología, Hospital Universitario Virgen Macarena, Sevilla, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Liquen plano erosivo plantar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 706 "Ancho" => 951 "Tamanyo" => 113485 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Absence of 5 toenails and ulcer on the dorsal aspect of the first toe similar to the ulcers on the heel.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Erosive palmoplantar lichen planus (LP), also known as ulcerative or bullous LP, was first described by Cram et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> in 1966 as a rare variant of LP that can affect mucous membranes, palms, and soles. It presents clinically as erythematous, ulcerated plaques that run an extremely chronic course and are resistant to all types of treatment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was an 84-year-old woman with a personal history of hypertension, aortic valve fibrosclerosis, and polyarthritis who had been receiving treatment with paracetamol, acetylsalicylic acid, atorvastatin, and candesartan-hydrochlorothiazide for several years<span class="elsevierStyleBold">.</span> She presented with a very painful ulcerated lesion on her right foot that had appeared 6 months earlier and made walking difficult. Physical examination revealed an ulcerated plaque, measuring 4<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm, on the medial aspect of the right heel. The base of the lesion was filled with granulation tissue, which in some areas was covered with whitish, macerated epithelium. Another ulcer with the same characteristics was present on the dorsal aspect of the first toe (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). The dermatological examination also revealed the presence of whitish reticulated areas on the buccal mucosa and pterygium on several fingernails. In addition, the patient had total scalp alopecia, having lost her hair, as well as all 10 toenails, 6 years earlier. She did not have alopecia of the eyebrows, eyelashes, axilla, or pubic area, or any other cutaneous abnormalities. Blood tests, including liver function tests, hepatitis B serology, and hepatitis C serology, were normal or negative. Skin biopsy revealed marked orthokeratotic hyperkeratosis, acanthosis, and a band-like lymphocytic infiltrate in the upper dermis, without melanophages. Also present were spiculated dermal papillae and vacuolar degeneration at the dermal-epidermal junction. The findings were consistent with LP (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">On the basis of the clinical and histopathologic findings, the patient was diagnosed with erosive palmoplantar LP and was prescribed treatment with oral prednisone (1<span class="elsevierStyleHsp" style=""></span>mg/kg/d). Two months later, the ulcerated lesions had healed. Systemic treatment was continued with a tapering dose for a further 6 months and finally withdrawn. The patient then started a 1-month regimen of topical clobetasol propionate (500 mcg/g). She has remained asymptomatic since treatment was completed 24 months ago.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Erosive palmoplantar LP is a rare form of LP that mainly affects elderly people. The lesions initially present as erythema and blisters on the feet and evolve into intensely painful, disabling erosions and ulcers. They usually occur on the heels but can affect the entire sole and even the dorsal surface of the toes.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The disease can lead to the total loss of all toenails.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Erosive palmoplantar LP can occur in isolation or in association with cicatricial alopecia of the scalp and diffuse alopecia of the axilla and pubic area. In many cases, it is accompanied by typical LP lesions.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is important to monitor this condition, as squamous cell carcinoma<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and eccrine syringofibroadenoma<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> have been known to arise in erosive palmoplantar LP lesions.</p><p id="par0030" class="elsevierStylePara elsevierViewall">There have been numerous anecdotal reports of associations between erosive palmoplantar LP and autoimmune diseases such as primary biliary cirrhosis, autoimmune thyroiditis,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> diabetes mellitus, Sjögren syndrome, and rheumatoid arthritis, as well as other abnormalities, such as hypergammaglobulinemia, hypocomplementemia, and chronic liver diseases of infectious origin. Although it is accepted that the cellular immune response plays a key role in the pathogenesis of LP, the etiology and pathogenesis of erosive palmoplantar LP remain unknown.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Because erosive palmoplantar LP is chronic and resistant to both topical and systemic treatments, numerous treatment options have been proposed. Local treatments used to date, with variable results, include high-potency corticosteroids, retinoids, intralesional triamcinolone acetonide, topical ciclosporin,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and psoralen–UV-A bath therapy.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Topical tacrolimus 0.1% cream applied twice daily was recently shown to be effective in the treatment of ulcerative LP affecting mucous membranes.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Oral treatments used to date include systemic corticosteroids, dapsone, etretinate, ciclosporin, mycophenolate mofetil, platelet-derived growth factor, griseofulvin, and thalidomide. Good response has been seen after 4 to 13 weeks of subcutaneous low-molecular-weight heparin (LMWH) administered at low doses (3<span class="elsevierStyleHsp" style=""></span>mg/wk); LMWH inhibits the type <span class="elsevierStyleSmallCaps">iv</span> hypersensitivity response that appears to be involved in the pathogenesis of LP.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">UV-A1 radiation (380-400<span class="elsevierStyleHsp" style=""></span>nm), which induces apoptosis of CD4<span class="elsevierStyleSup">+</span> T cells, has proved to be an effective treatment in some cases. Extracorporeal phototherapy has also been effective in isolated cases.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Surgery, with or without immunosuppressive therapy with ciclosporin, has occasionally been effective against chronic, stable, localized cases of erosive palmoplantar LP.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">This case is remarkable for the patient's excellent response to conventional treatment with systemic corticosteroids and the absence of recurrence after 2 years, despite the fact that erosive palmoplantar LP is refractory to most available treatments. Nevertheless, because of the high recurrence rate associated with this disease, we consider that the patient should be monitored closely.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Jiménez-Sánchez MD, et al. Liquen plano erosivo plantar. Actas Dermosifiliogr.2012;103:448-50.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 706 "Ancho" => 951 "Tamanyo" => 113485 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Absence of 5 toenails and ulcer on the dorsal aspect of the first toe similar to the ulcers on the heel.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 713 "Ancho" => 951 "Tamanyo" => 130946 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ulcerated plaque, located on the right heel, filled with granulation tissue and whitish, macerated epithelium in some areas.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1059 "Ancho" => 951 "Tamanyo" => 425088 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histologic image of the edge of the lesion. Band-like lymphocytic infiltrate in the papillary dermis and prominent network of interpapillary ridges (hematoxylin-eosin, original magnification ×10).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ulcerative lichen planus of the feet" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.L. Cram" 1 => "R.R. Kierland" 2 => "R.K. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 19 | 15 | 34 |
| 2024 October | 114 | 60 | 174 |
| 2024 September | 122 | 44 | 166 |
| 2024 August | 177 | 66 | 243 |
| 2024 July | 137 | 35 | 172 |
| 2024 June | 124 | 40 | 164 |
| 2024 May | 75 | 44 | 119 |
| 2024 April | 133 | 41 | 174 |
| 2024 March | 91 | 35 | 126 |
| 2024 February | 103 | 42 | 145 |
| 2024 January | 78 | 41 | 119 |
| 2023 December | 81 | 32 | 113 |
| 2023 November | 85 | 36 | 121 |
| 2023 October | 76 | 44 | 120 |
| 2023 September | 106 | 37 | 143 |
| 2023 August | 63 | 45 | 108 |
| 2023 July | 128 | 53 | 181 |
| 2023 June | 67 | 33 | 100 |
| 2023 May | 104 | 42 | 146 |
| 2023 April | 86 | 35 | 121 |
| 2023 March | 81 | 30 | 111 |
| 2023 February | 80 | 35 | 115 |
| 2023 January | 69 | 30 | 99 |
| 2022 December | 95 | 42 | 137 |
| 2022 November | 52 | 28 | 80 |
| 2022 October | 82 | 31 | 113 |
| 2022 September | 71 | 37 | 108 |
| 2022 August | 44 | 50 | 94 |
| 2022 July | 48 | 30 | 78 |
| 2022 June | 72 | 30 | 102 |
| 2022 May | 67 | 34 | 101 |
| 2022 April | 70 | 54 | 124 |
| 2022 March | 90 | 61 | 151 |
| 2022 February | 74 | 25 | 99 |
| 2022 January | 57 | 42 | 99 |
| 2021 December | 50 | 37 | 87 |
| 2021 November | 81 | 51 | 132 |
| 2021 October | 78 | 38 | 116 |
| 2021 September | 54 | 44 | 98 |
| 2021 August | 70 | 56 | 126 |
| 2021 July | 69 | 45 | 114 |
| 2021 June | 57 | 32 | 89 |
| 2021 May | 43 | 57 | 100 |
| 2021 April | 111 | 105 | 216 |
| 2021 March | 70 | 39 | 109 |
| 2021 February | 69 | 45 | 114 |
| 2021 January | 52 | 20 | 72 |
| 2020 December | 47 | 19 | 66 |
| 2020 November | 42 | 26 | 68 |
| 2020 October | 23 | 16 | 39 |
| 2020 September | 45 | 15 | 60 |
| 2020 August | 27 | 21 | 48 |
| 2020 July | 33 | 15 | 48 |
| 2020 June | 37 | 19 | 56 |
| 2020 May | 25 | 17 | 42 |
| 2020 April | 30 | 22 | 52 |
| 2020 March | 34 | 17 | 51 |
| 2020 February | 7 | 0 | 7 |
| 2020 January | 4 | 4 | 8 |
| 2019 December | 8 | 3 | 11 |
| 2019 November | 4 | 2 | 6 |
| 2019 September | 10 | 1 | 11 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 6 | 10 |
| 2019 June | 4 | 24 | 28 |
| 2019 May | 6 | 59 | 65 |
| 2019 April | 2 | 21 | 23 |
| 2019 March | 0 | 7 | 7 |
| 2019 February | 4 | 3 | 7 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 3 | 0 | 3 |
| 2018 October | 6 | 0 | 6 |
| 2018 September | 5 | 0 | 5 |
| 2018 April | 0 | 1 | 1 |
| 2018 March | 0 | 1 | 1 |
| 2018 February | 74 | 7 | 81 |
| 2018 January | 68 | 13 | 81 |
| 2017 December | 96 | 16 | 112 |
| 2017 November | 77 | 11 | 88 |
| 2017 October | 78 | 8 | 86 |
| 2017 September | 70 | 7 | 77 |
| 2017 August | 60 | 21 | 81 |
| 2017 July | 56 | 4 | 60 |
| 2017 June | 63 | 18 | 81 |
| 2017 May | 74 | 14 | 88 |
| 2017 April | 49 | 12 | 61 |
| 2017 March | 40 | 26 | 66 |
| 2017 February | 123 | 11 | 134 |
| 2017 January | 46 | 15 | 61 |
| 2016 December | 75 | 17 | 92 |
| 2016 November | 105 | 15 | 120 |
| 2016 October | 129 | 20 | 149 |
| 2016 September | 216 | 14 | 230 |
| 2016 August | 178 | 8 | 186 |
| 2016 July | 62 | 12 | 74 |
| 2016 June | 14 | 19 | 33 |
| 2016 May | 6 | 8 | 14 |
| 2016 April | 6 | 1 | 7 |
| 2016 March | 14 | 9 | 23 |
| 2016 February | 3 | 1 | 4 |
| 2016 January | 8 | 14 | 22 |
| 2015 December | 11 | 7 | 18 |
| 2015 November | 22 | 11 | 33 |
| 2015 October | 35 | 14 | 49 |
| 2015 September | 26 | 1 | 27 |
| 2015 August | 24 | 9 | 33 |
| 2015 July | 174 | 12 | 186 |
| 2015 June | 111 | 8 | 119 |
| 2015 May | 106 | 60 | 166 |
| 2015 April | 83 | 14 | 97 |
| 2015 March | 135 | 16 | 151 |
| 2015 February | 104 | 11 | 115 |
| 2015 January | 104 | 12 | 116 |
| 2014 December | 98 | 9 | 107 |
| 2014 November | 73 | 10 | 83 |
| 2014 October | 97 | 18 | 115 |
| 2014 September | 86 | 15 | 101 |
| 2014 August | 73 | 13 | 86 |
| 2014 July | 82 | 16 | 98 |
| 2014 June | 122 | 12 | 134 |
| 2014 May | 65 | 9 | 74 |
| 2014 April | 60 | 3 | 63 |
| 2014 March | 74 | 8 | 82 |
| 2014 February | 46 | 16 | 62 |
| 2014 January | 49 | 11 | 60 |
| 2013 December | 53 | 10 | 63 |
| 2013 November | 54 | 12 | 66 |
| 2013 October | 38 | 10 | 48 |
| 2013 September | 39 | 17 | 56 |
| 2013 August | 45 | 15 | 60 |
| 2013 July | 21 | 18 | 39 |
| 2013 June | 20 | 6 | 26 |
| 2013 May | 15 | 11 | 26 |
| 2013 April | 16 | 9 | 25 |
| 2013 March | 16 | 14 | 30 |
| 2013 February | 44 | 7 | 51 |
| 2013 January | 36 | 5 | 41 |
| 2012 December | 17 | 4 | 21 |
| 2012 November | 0 | 1 | 1 |
| 2012 October | 0 | 2 | 2 |
| 2012 August | 2 | 1 | 3 |
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