Case for Diagnosis
Annular Pigmented Plaque Under the Chin
Placa anular pigmentada submentoniana
F.J. Navarro-Triviño
, M.J. Naranjo-Díaz, R. Ruiz-Villaverde
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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 8 | 12 | 20 |
| 2024 Octubre | 68 | 44 | 112 |
| 2024 Septiembre | 63 | 18 | 81 |
| 2024 Agosto | 80 | 53 | 133 |
| 2024 Julio | 65 | 33 | 98 |
| 2024 Junio | 75 | 20 | 95 |
| 2024 Mayo | 61 | 28 | 89 |
| 2024 Abril | 79 | 30 | 109 |
| 2024 Marzo | 63 | 17 | 80 |
| 2024 Febrero | 55 | 30 | 85 |
| 2024 Enero | 60 | 35 | 95 |
| 2023 Diciembre | 65 | 15 | 80 |
| 2023 Noviembre | 95 | 24 | 119 |
| 2023 Octubre | 81 | 38 | 119 |
| 2023 Septiembre | 54 | 36 | 90 |
| 2023 Agosto | 42 | 12 | 54 |
| 2023 Julio | 38 | 33 | 71 |
| 2023 Junio | 57 | 22 | 79 |
| 2023 Mayo | 45 | 20 | 65 |
| 2023 Abril | 44 | 20 | 64 |
| 2023 Marzo | 42 | 21 | 63 |
| 2023 Febrero | 40 | 23 | 63 |
| 2023 Enero | 32 | 20 | 52 |
| 2022 Diciembre | 58 | 33 | 91 |
| 2022 Noviembre | 32 | 22 | 54 |
| 2022 Octubre | 37 | 27 | 64 |
| 2022 Septiembre | 37 | 54 | 91 |
| 2022 Agosto | 29 | 29 | 58 |
| 2022 Julio | 22 | 36 | 58 |
| 2022 Junio | 20 | 26 | 46 |
| 2022 Mayo | 46 | 49 | 95 |
| 2022 Abril | 39 | 31 | 70 |
| 2022 Marzo | 45 | 48 | 93 |
| 2022 Febrero | 31 | 26 | 57 |
| 2022 Enero | 44 | 38 | 82 |
| 2021 Diciembre | 41 | 40 | 81 |
| 2021 Noviembre | 42 | 44 | 86 |
| 2021 Octubre | 42 | 51 | 93 |
| 2021 Septiembre | 45 | 39 | 84 |
| 2021 Agosto | 36 | 32 | 68 |
| 2021 Julio | 31 | 33 | 64 |
| 2021 Junio | 30 | 33 | 63 |
| 2021 Mayo | 49 | 48 | 97 |
| 2021 Abril | 83 | 52 | 135 |
| 2021 Marzo | 54 | 30 | 84 |
| 2021 Febrero | 45 | 41 | 86 |
| 2021 Enero | 29 | 29 | 58 |
| 2020 Diciembre | 44 | 22 | 66 |
| 2020 Noviembre | 20 | 23 | 43 |
| 2020 Octubre | 19 | 23 | 42 |
| 2020 Septiembre | 35 | 19 | 54 |
| 2020 Agosto | 26 | 30 | 56 |
| 2020 Julio | 21 | 22 | 43 |
| 2020 Junio | 21 | 27 | 48 |
| 2020 Mayo | 12 | 15 | 27 |
| 2020 Abril | 14 | 14 | 28 |
| 2020 Marzo | 15 | 9 | 24 |
| 2020 Febrero | 4 | 0 | 4 |
| 2019 Mayo | 1 | 0 | 1 |
| 2019 Febrero | 1 | 3 | 4 |
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