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
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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 17 | 14 | 31 |
| 2024 Octubre | 114 | 60 | 174 |
| 2024 Septiembre | 122 | 44 | 166 |
| 2024 Agosto | 177 | 66 | 243 |
| 2024 Julio | 137 | 35 | 172 |
| 2024 Junio | 124 | 40 | 164 |
| 2024 Mayo | 75 | 44 | 119 |
| 2024 Abril | 133 | 41 | 174 |
| 2024 Marzo | 91 | 35 | 126 |
| 2024 Febrero | 103 | 42 | 145 |
| 2024 Enero | 78 | 41 | 119 |
| 2023 Diciembre | 81 | 32 | 113 |
| 2023 Noviembre | 85 | 36 | 121 |
| 2023 Octubre | 76 | 44 | 120 |
| 2023 Septiembre | 106 | 37 | 143 |
| 2023 Agosto | 63 | 45 | 108 |
| 2023 Julio | 128 | 53 | 181 |
| 2023 Junio | 67 | 33 | 100 |
| 2023 Mayo | 104 | 42 | 146 |
| 2023 Abril | 86 | 35 | 121 |
| 2023 Marzo | 81 | 30 | 111 |
| 2023 Febrero | 80 | 35 | 115 |
| 2023 Enero | 69 | 30 | 99 |
| 2022 Diciembre | 95 | 42 | 137 |
| 2022 Noviembre | 52 | 28 | 80 |
| 2022 Octubre | 82 | 31 | 113 |
| 2022 Septiembre | 71 | 37 | 108 |
| 2022 Agosto | 44 | 50 | 94 |
| 2022 Julio | 48 | 30 | 78 |
| 2022 Junio | 72 | 30 | 102 |
| 2022 Mayo | 67 | 34 | 101 |
| 2022 Abril | 70 | 54 | 124 |
| 2022 Marzo | 90 | 61 | 151 |
| 2022 Febrero | 74 | 25 | 99 |
| 2022 Enero | 57 | 42 | 99 |
| 2021 Diciembre | 50 | 37 | 87 |
| 2021 Noviembre | 81 | 51 | 132 |
| 2021 Octubre | 78 | 38 | 116 |
| 2021 Septiembre | 54 | 44 | 98 |
| 2021 Agosto | 70 | 56 | 126 |
| 2021 Julio | 69 | 45 | 114 |
| 2021 Junio | 57 | 32 | 89 |
| 2021 Mayo | 43 | 57 | 100 |
| 2021 Abril | 111 | 105 | 216 |
| 2021 Marzo | 70 | 39 | 109 |
| 2021 Febrero | 69 | 45 | 114 |
| 2021 Enero | 52 | 20 | 72 |
| 2020 Diciembre | 47 | 19 | 66 |
| 2020 Noviembre | 42 | 26 | 68 |
| 2020 Octubre | 23 | 16 | 39 |
| 2020 Septiembre | 45 | 15 | 60 |
| 2020 Agosto | 27 | 21 | 48 |
| 2020 Julio | 33 | 15 | 48 |
| 2020 Junio | 37 | 19 | 56 |
| 2020 Mayo | 25 | 17 | 42 |
| 2020 Abril | 30 | 22 | 52 |
| 2020 Marzo | 34 | 17 | 51 |
| 2020 Febrero | 7 | 0 | 7 |
| 2020 Enero | 4 | 4 | 8 |
| 2019 Diciembre | 8 | 3 | 11 |
| 2019 Noviembre | 4 | 2 | 6 |
| 2019 Septiembre | 10 | 1 | 11 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 6 | 10 |
| 2019 Junio | 4 | 24 | 28 |
| 2019 Mayo | 6 | 59 | 65 |
| 2019 Abril | 2 | 21 | 23 |
| 2019 Marzo | 0 | 7 | 7 |
| 2019 Febrero | 4 | 3 | 7 |
| 2018 Diciembre | 4 | 0 | 4 |
| 2018 Noviembre | 3 | 0 | 3 |
| 2018 Octubre | 6 | 0 | 6 |
| 2018 Septiembre | 5 | 0 | 5 |
| 2018 Abril | 0 | 1 | 1 |
| 2018 Marzo | 0 | 1 | 1 |
| 2018 Febrero | 74 | 7 | 81 |
| 2018 Enero | 68 | 13 | 81 |
| 2017 Diciembre | 96 | 16 | 112 |
| 2017 Noviembre | 77 | 11 | 88 |
| 2017 Octubre | 78 | 8 | 86 |
| 2017 Septiembre | 70 | 7 | 77 |
| 2017 Agosto | 60 | 21 | 81 |
| 2017 Julio | 56 | 4 | 60 |
| 2017 Junio | 63 | 18 | 81 |
| 2017 Mayo | 74 | 14 | 88 |
| 2017 Abril | 49 | 12 | 61 |
| 2017 Marzo | 40 | 26 | 66 |
| 2017 Febrero | 123 | 11 | 134 |
| 2017 Enero | 46 | 15 | 61 |
| 2016 Diciembre | 75 | 17 | 92 |
| 2016 Noviembre | 105 | 15 | 120 |
| 2016 Octubre | 129 | 20 | 149 |
| 2016 Septiembre | 216 | 14 | 230 |
| 2016 Agosto | 178 | 8 | 186 |
| 2016 Julio | 62 | 12 | 74 |
| 2016 Junio | 14 | 19 | 33 |
| 2016 Mayo | 6 | 8 | 14 |
| 2016 Abril | 6 | 1 | 7 |
| 2016 Marzo | 14 | 9 | 23 |
| 2016 Febrero | 3 | 1 | 4 |
| 2016 Enero | 8 | 14 | 22 |
| 2015 Diciembre | 11 | 7 | 18 |
| 2015 Noviembre | 22 | 11 | 33 |
| 2015 Octubre | 35 | 14 | 49 |
| 2015 Septiembre | 26 | 1 | 27 |
| 2015 Agosto | 24 | 9 | 33 |
| 2015 Julio | 174 | 12 | 186 |
| 2015 Junio | 111 | 8 | 119 |
| 2015 Mayo | 106 | 60 | 166 |
| 2015 Abril | 83 | 14 | 97 |
| 2015 Marzo | 135 | 16 | 151 |
| 2015 Febrero | 104 | 11 | 115 |
| 2015 Enero | 104 | 12 | 116 |
| 2014 Diciembre | 98 | 9 | 107 |
| 2014 Noviembre | 73 | 10 | 83 |
| 2014 Octubre | 97 | 18 | 115 |
| 2014 Septiembre | 86 | 15 | 101 |
| 2014 Agosto | 73 | 13 | 86 |
| 2014 Julio | 82 | 16 | 98 |
| 2014 Junio | 122 | 12 | 134 |
| 2014 Mayo | 65 | 9 | 74 |
| 2014 Abril | 60 | 3 | 63 |
| 2014 Marzo | 74 | 8 | 82 |
| 2014 Febrero | 46 | 16 | 62 |
| 2014 Enero | 49 | 11 | 60 |
| 2013 Diciembre | 53 | 10 | 63 |
| 2013 Noviembre | 54 | 12 | 66 |
| 2013 Octubre | 38 | 10 | 48 |
| 2013 Septiembre | 39 | 17 | 56 |
| 2013 Agosto | 45 | 15 | 60 |
| 2013 Julio | 21 | 18 | 39 |
| 2013 Junio | 20 | 6 | 26 |
| 2013 Mayo | 15 | 11 | 26 |
| 2013 Abril | 16 | 9 | 25 |
| 2013 Marzo | 16 | 14 | 30 |
| 2013 Febrero | 44 | 7 | 51 |
| 2013 Enero | 36 | 5 | 41 |
| 2012 Diciembre | 17 | 4 | 21 |
| 2012 Noviembre | 0 | 1 | 1 |
| 2012 Octubre | 0 | 2 | 2 |
| 2012 Agosto | 2 | 1 | 3 |
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