Case and Research Letter
Palmoplantar Lichen Planus: The Spectrum of Clinical Manifestations in a Single Patient
Liquen plano palmoplantar: espectro de manifestaciones clínicas en un paciente
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Burillo-Martínez, F. Tous-Romero, J.L. Rodríguez-Peralto, C. Postigo-Llorente" "autores" => array:4 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Burillo-Martínez" "email" => array:1 [ 0 => "sburillo@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "F." "apellidos" => "Tous-Romero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J.L." "apellidos" => "Rodríguez-Peralto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Postigo-Llorente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Liquen plano palmoplantar: espectro de manifestaciones clínicas en un paciente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1219 "Ancho" => 1625 "Tamanyo" => 395916 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Punctate keratosis confined to the palmar creases.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 43-year-old woman with a history of obesity and gestational diabetes was referred for evaluation of pruritic lesions that had arisen on her legs 7 years earlier and had shown a fluctuating course. She also described persistent palmar pruritus. She was not on any regular pharmacological therapy. On physical examination, 2 erythematous-brownish hyperkeratotic plaques with a spongiform appearance were observed on the anterior surface of her lower legs. The plaques, which measured 2 to 5<span class="elsevierStyleHsp" style=""></span>cm in diameter, had well-defined borders and were surrounded by a violaceous halo (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In addition, she presented numerous, small, depressed hyperkeratotic papules confined to the palmar creases (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Examination of the oral mucosa revealed a whitish reticulated pattern on the cheek and a cobblestone pattern of whitish papules on the dorsum of the tongue. No lesions were observed on the genital mucosa, nails, or scalp. Histology of a hyperkeratotic plaque on the leg confirmed the clinical suspicion of hypertrophic lichen planus (LP), and biopsy of a small palmar lesion also showed typical histological features of the disease. Laboratory tests, including complete blood count, biochemistry, and serology for HBV, HCV, syphilis, and HIV, were normal or negative.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The patient subsequently consulted for the appearance of whitish, macerated and fissured hyperkeratotic plaques in the interdigital folds of the feet (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). Although cultures for fungi were repeatedly negative, oral treatment was started with terbinafine due to the elevated clinical suspicion of dermatophytosis. Given the absence of improvement after a month of treatment, a biopsy was taken, which showed the characteristic findings of LP. Finally, she developed progressive induration of the palms and soles, with severe pain that interfered with her activities of daily living and walking. Examination revealed diffuse palmoplantar keratoderma, most evident in the pressure areas (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B), with the presence of confluent pink papules at the border of the keratoderma. Histology again confirmed involvement by LP.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">According to the literature, predominantly or exclusively palmoplantar involvement in LP is rare and its clinical presentation differs from classic LP.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> The greater thickness of the corneal layer explains the absence of the characteristic Wickham striae, as the histopathologic correlate—wedge-shaped hypergranulosis—is obscured. In addition, the typical violaceous polygonal papules, only occasionally observed at the borders of the palms and soles, are not present.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> In contrast, a broad spectrum of clinical manifestations have been reported: diffuse keratoderma, punctate keratosis, desquamating erythematous plaques, pseudovesicular and petechial lesions, umbilicated papules, ulcerated lesions and hyperpigmented macules.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3–6</span></a> The most common finding is a desquamating erythematous or hyperkeratotic pattern. We have found no previous reports of the punctate keratosis pattern confined to the palmar creases, seen in our patient. This case exemplifies how various patterns can present in a single patient. This broad morphological spectrum, with absence of the classic papules of LP, means that clinical diagnosis can be very difficult, particularly if there is only palmoplantar involvement. According to the largest series published, the presence of intensely pruritic, self-limiting, hyperkeratotic or desquamating erythematous plaques with well-defined borders arising on the medial surface of the arch of the foot, with no involvement of the pulp of the toes, is a highly characteristic finding.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> Histology, which reveals the classic features of LP in the palmoplantar tissues, is therefore essential for diagnosis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although the majority of the lesions are self-limiting according to Sánchez-Pérez et al.,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> recalcitrant cases have been reported and show a variable response to treatments including corticosteroids, retinoids, psoralen–UV-A baths, methotrexate, ciclosporin, dapsone, and enoxaparin.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">7,8</span></a> Our case provides further evidence of the recalcitrant nature of palmoplantar LP, after the poor response to the administration of multiple cycles of topical and systemic corticosteroid therapy, topical tazarotene, ciclosporin at a dose of 3<span class="elsevierStyleHsp" style=""></span>mg/kg/d (whose efficacy cannot be adequately evaluated due to treatment interruption after a month because of failure to attend follow-up), and methotrexate at a maximum dose of 20<span class="elsevierStyleHsp" style=""></span>mg/wk, which the patient continues to receive. Interestingly, despite hypertrophic LP being considered one of the most refractory variants, the lesions present on our patient's legs responded very well to corticosteroid treatment.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion, we have described a patient with a rare variant of LP. This case exemplifies the broad clinical spectrum that this disease can present on the palms and soles. The patient developed keratosis punctata-type lesions limited to the palmar creases, a clinical manifestation not previously described, hyperkeratotic interdigital plaques mimicking a superficial fungal infection, and diffuse palmoplantar keratoderma with a marked deterioration of her quality of life. Despite generally being considered a self-limiting disease, the lesions in our case showed a recalcitrant course, with plantar lesions even more refractory to treatment than the hypertrophic LP lesions. The broad morphological variety of palmoplantar lesions, with absence of the classic LP papules, makes diagnosis difficult, and this disease must be included in the differential diagnosis of hyperkeratotic palmoplantar dermatoses. Histology, which shows the typical features of LP, is essential for diagnosis.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:2 [ "identificador" => "xack303053" "titulo" => "Acknowledgments" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Burillo-Martínez S, Tous-Romero F, Rodríguez-Peralto JL, Postigo-Llorente C. Liquen plano palmoplantar: espectro de manifestaciones clínicas en un paciente. Actas Dermosifiliogr. 2017;108:790–792.</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" => 1219 "Ancho" => 1625 "Tamanyo" => 280051 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pretibial spongiform plaque with a violaceous halo.</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" => 1219 "Ancho" => 1625 "Tamanyo" => 395916 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Punctate keratosis confined to the palmar creases.</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" => 581 "Ancho" => 1500 "Tamanyo" => 141613 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A, Hyperkeratotic interdigital plaque. B, Diffuse plantar keratoderma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lichen planus in India: An appraisal of 441 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "O.P. Singh" 1 => "A.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 13 | 26 |
| 2024 October | 123 | 100 | 223 |
| 2024 September | 150 | 89 | 239 |
| 2024 August | 153 | 122 | 275 |
| 2024 July | 139 | 93 | 232 |
| 2024 June | 134 | 99 | 233 |
| 2024 May | 89 | 62 | 151 |
| 2024 April | 101 | 39 | 140 |
| 2024 March | 123 | 48 | 171 |
| 2024 February | 93 | 48 | 141 |
| 2024 January | 111 | 54 | 165 |
| 2023 December | 122 | 31 | 153 |
| 2023 November | 137 | 43 | 180 |
| 2023 October | 127 | 35 | 162 |
| 2023 September | 106 | 49 | 155 |
| 2023 August | 90 | 41 | 131 |
| 2023 July | 92 | 49 | 141 |
| 2023 June | 84 | 36 | 120 |
| 2023 May | 147 | 35 | 182 |
| 2023 April | 92 | 44 | 136 |
| 2023 March | 73 | 37 | 110 |
| 2023 February | 100 | 45 | 145 |
| 2023 January | 71 | 48 | 119 |
| 2022 December | 117 | 49 | 166 |
| 2022 November | 87 | 46 | 133 |
| 2022 October | 88 | 27 | 115 |
| 2022 September | 102 | 44 | 146 |
| 2022 August | 114 | 30 | 144 |
| 2022 July | 117 | 43 | 160 |
| 2022 June | 107 | 26 | 133 |
| 2022 May | 162 | 48 | 210 |
| 2022 April | 125 | 44 | 169 |
| 2022 March | 111 | 49 | 160 |
| 2022 February | 90 | 47 | 137 |
| 2022 January | 98 | 38 | 136 |
| 2021 December | 66 | 34 | 100 |
| 2021 November | 106 | 56 | 162 |
| 2021 October | 91 | 52 | 143 |
| 2021 September | 66 | 42 | 108 |
| 2021 August | 101 | 51 | 152 |
| 2021 July | 89 | 34 | 123 |
| 2021 June | 97 | 39 | 136 |
| 2021 May | 77 | 42 | 119 |
| 2021 April | 205 | 92 | 297 |
| 2021 March | 112 | 35 | 147 |
| 2021 February | 100 | 36 | 136 |
| 2021 January | 63 | 35 | 98 |
| 2020 December | 72 | 20 | 92 |
| 2020 November | 52 | 25 | 77 |
| 2020 October | 61 | 23 | 84 |
| 2020 September | 60 | 19 | 79 |
| 2020 August | 48 | 27 | 75 |
| 2020 July | 35 | 28 | 63 |
| 2020 June | 44 | 35 | 79 |
| 2020 May | 19 | 17 | 36 |
| 2020 April | 25 | 15 | 40 |
| 2020 March | 37 | 15 | 52 |
| 2020 February | 6 | 1 | 7 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 2 | 0 | 2 |
| 2019 September | 8 | 0 | 8 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 3 | 0 | 3 |
| 2019 June | 6 | 0 | 6 |
| 2019 May | 4 | 0 | 4 |
| 2019 April | 4 | 0 | 4 |
| 2019 March | 4 | 0 | 4 |
| 2019 February | 2 | 0 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 5 | 0 | 5 |
| 2018 September | 4 | 0 | 4 |
| 2018 February | 40 | 9 | 49 |
| 2018 January | 60 | 9 | 69 |
| 2017 December | 51 | 19 | 70 |
| 2017 November | 54 | 16 | 70 |
| 2017 October | 124 | 38 | 162 |
| 2017 September | 5 | 11 | 16 |
| 2017 August | 4 | 12 | 16 |
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