Case for Diagnosis
Annular Pigmented Plaque Under the Chin
Placa anular pigmentada submentoniana
F.J. Navarro-Triviño
, M.J. Naranjo-Díaz, R. Ruiz-Villaverde
Corresponding author
Unidad de Dermatología Médico-Quirúrgica y Venereología, Complejo Hospitalario Universitario de Granada, Granada, España
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Navarro-Triviño, M.J. Naranjo-Díaz, R. Ruiz-Villaverde" "autores" => array:3 [ 0 => array:4 [ "nombre" => "F.J." "apellidos" => "Navarro-Triviño" "email" => array:1 [ 0 => "fntmed@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.J." "apellidos" => "Naranjo-Díaz" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Ruiz-Villaverde" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Dermatología Médico-Quirúrgica y Venereología, Complejo Hospitalario Universitario de Granada, Granada, España" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Placa anular pigmentada submentoniana" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1160 "Ancho" => 1496 "Tamanyo" => 174636 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 48-year-old man with skin phototype II and no past history of interest consulted for a lesion in the submandibular region that had appeared 6 months earlier. The lesion was accompanied by occasional pruritus that, interestingly, disappeared after shaving. Physical examination revealed no other skin or mucous lesions and the patient reported no other associated symptoms. The lesions persisted despite treatment with topical antifungal drugs prescribed by his primary-care physician.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">The submandibular region revealed a brownish-violaceous, well-demarcated plaque with raised polylobulated edges, depressed areas of atrophic appearance, and an area of 5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The patient had no palpable local or regional lymph nodes.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">A histologic study of the lesion revealed predominantly lymphocytic lichenoid dermatitis with hyperkeratosis and wedge-shaped hypergranulosis, Civatte bodies, and pigmentary incontinence (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Other Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">Laboratory tests were normal and serology was negative. Dermatoscopy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) revealed whiteish-red areas, arciform distribution of uniform brown pigmented structures, and diffuse punctate vessels. No criteria for melanocytic lesions were observed. Skin ultrasound (Esaote<span class="elsevierStyleSup">®</span> 18<span class="elsevierStyleHsp" style=""></span>Mhz) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C) revealed a thickened hyperechoic epidermal line, a uniform hypoechoic subepidermal band, and echogenicity and normal structure of the subcutaneous cell tissue. Doppler ultrasound was negative.</p><p id="par0025" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis?</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Annular pigmented lichen planus.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">The lesion remained stable despite prior treatment with topical high-potency corticosteroids and daily photoprotection. Slight improvement was observed after 2 months of topical treatment with 0.1% tacrolimus ointment.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Lichen planus pigmentosus (LPP) is a rare variant of lichen planus, described by Bhutani et al. in 1974,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> which appears in middle-aged patients, predominantly in women and in patients with dark skin. Although the etiology is unknown, sunlight has been suggested as the main causal agent, given the predominant involvement of photoexposed areas.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> It has been linked to hepatitis C virus and photosensitization to mustard oil or allyl thiocyanate, which is present in fragrances and cosmetics (hair dyes, etc.). The disease initially manifests as small, brown, occasionally pruriginous oval macules that evolve insidiously into diffuse, reticular, patchy, or perifollicular grayish-brown plaques. It is located in photoexposed areas, particularly on the face and neck, although it may also affect the torso and upper limbs. It rarely affects the mucosa or intertriginous regions such as the axillas and inframammary folds.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Histology reveals vacuolar degeneration of the basement membrane with apoptotic keratinocytes, lymphocytic/histiocytic lichenoid infiltration in bands, and pigmentary incontinence with melanophages in the superficial dermis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Cases have been reported of LPP associated with frontal fibrosing alopecia, acrokeratosis paraneoplastica, HVC infection, and nephrotic syndrome. The principal differential diagnosis to consider is erythema dyschromicum perstans (EDP). Presentation of the lesions in areas other than those exposed to sunlight and melanin deposits in the deep dermis allow differentiation between EDP and LPP. Other diseases to include in the differential diagnosis are drug-induced erythema fixum, macular amyloidosis, urticaria pigmentosa, Berloque dermatitis, Riehl melanosis (pigmented cosmetic dermatitis), idiopathic eruptive macular pigmentation, and heavy metal hyperpigmentation. Dermatoscopy is a useful tool for diagnosing LPP.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Pigmentation in the form of points and grayish-brown globules is observed. Vázquez et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> described 3 types of dermatoscopic patterns: punctate, diffuse, and mixed. According to those authors, patients with a greater amount of pigmented granules present a longer course compared to the diffuse pattern, as with our patient. Wickham striae are rare in LPP but not in lichen planus.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Treatment essentially consists of photoprotection in association with high-potency topical corticosteroids. Treatment with 0.1% tacrolimus ointment produces clinical improvement in half of cases.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Other less thoroughly documented therapeutic options with a good response include neodymium laser, dapsone, and acitretin. The course is benign, with variable duration and therapeutic response.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Other Tests" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 8 => 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: Navarro-Triviño FJ, Naranjo-Díaz MJ, Ruiz-Villaverde R. Placa anular pigmentada submentoniana. Actas Dermosifiliogr. 2018;109:911–912.</p>" ] ] "multimedia" => array:2 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1160 "Ancho" => 1496 "Tamanyo" => 174636 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1328 "Ancho" => 1000 "Tamanyo" => 337657 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin–eosin, ×20.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lichen planus pigmentosus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L.K. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 12 | 20 |
| 2024 October | 68 | 44 | 112 |
| 2024 September | 63 | 18 | 81 |
| 2024 August | 80 | 53 | 133 |
| 2024 July | 65 | 33 | 98 |
| 2024 June | 75 | 20 | 95 |
| 2024 May | 61 | 28 | 89 |
| 2024 April | 79 | 30 | 109 |
| 2024 March | 63 | 17 | 80 |
| 2024 February | 55 | 30 | 85 |
| 2024 January | 60 | 35 | 95 |
| 2023 December | 65 | 15 | 80 |
| 2023 November | 95 | 24 | 119 |
| 2023 October | 81 | 38 | 119 |
| 2023 September | 54 | 36 | 90 |
| 2023 August | 42 | 12 | 54 |
| 2023 July | 38 | 33 | 71 |
| 2023 June | 57 | 22 | 79 |
| 2023 May | 45 | 20 | 65 |
| 2023 April | 44 | 20 | 64 |
| 2023 March | 42 | 21 | 63 |
| 2023 February | 40 | 23 | 63 |
| 2023 January | 32 | 20 | 52 |
| 2022 December | 58 | 33 | 91 |
| 2022 November | 32 | 22 | 54 |
| 2022 October | 37 | 27 | 64 |
| 2022 September | 37 | 54 | 91 |
| 2022 August | 29 | 29 | 58 |
| 2022 July | 22 | 36 | 58 |
| 2022 June | 20 | 26 | 46 |
| 2022 May | 46 | 49 | 95 |
| 2022 April | 39 | 31 | 70 |
| 2022 March | 45 | 48 | 93 |
| 2022 February | 31 | 26 | 57 |
| 2022 January | 44 | 38 | 82 |
| 2021 December | 41 | 40 | 81 |
| 2021 November | 42 | 44 | 86 |
| 2021 October | 42 | 51 | 93 |
| 2021 September | 45 | 39 | 84 |
| 2021 August | 36 | 32 | 68 |
| 2021 July | 31 | 33 | 64 |
| 2021 June | 30 | 33 | 63 |
| 2021 May | 49 | 48 | 97 |
| 2021 April | 83 | 52 | 135 |
| 2021 March | 54 | 30 | 84 |
| 2021 February | 45 | 41 | 86 |
| 2021 January | 29 | 29 | 58 |
| 2020 December | 44 | 22 | 66 |
| 2020 November | 20 | 23 | 43 |
| 2020 October | 19 | 23 | 42 |
| 2020 September | 35 | 19 | 54 |
| 2020 August | 26 | 30 | 56 |
| 2020 July | 21 | 22 | 43 |
| 2020 June | 21 | 27 | 48 |
| 2020 May | 12 | 15 | 27 |
| 2020 April | 14 | 14 | 28 |
| 2020 March | 15 | 9 | 24 |
| 2020 February | 4 | 0 | 4 |
| 2019 May | 1 | 0 | 1 |
| 2019 February | 1 | 3 | 4 |
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