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Lichen Simplex Chronicus Clinical Presentation

  • Author: Jason Schoenfeld, MD; Chief Editor: William D James, MD  more...
 
Updated: Mar 30, 2016
 

History

Patients with lichen simplex chronicus usually describe stable pruritic plaques on one or more areas; however, thickening of the skin occurs on any location that the patient can reach, including the following:

  • Scalp
  • Nape of neck
  • Extensor forearms and elbows
  • Vulva and scrotum [7, 8, 9, 10, 11]
  • Upper medial thighs, knees, lower legs, and ankles

Erythema is noted most in early lesions.

Pruritus is described as worse when patients are still or quiet and as much less or nonexistent when patients are active.

Pruritus is usually intermittent; the resultant scratching provides temporary relief.

Patients may have a past medical history of a chronic skin condition or acute trauma. Patients with atopic dermatitis may have lichen simplex chronicus in areas of former atopic outbreaks. Sites of irritant or allergic contact dermatitis, insect bites, or other past minor skin trauma sometimes demonstrate pruritus and, subsequently, lichen simplex chronicus.

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Physical

One or more slightly erythematous, scaly, well-demarcated, lichenified, firm, rough plaques with exaggerated skin lines are noted.

Each palm-sized plaque may have 3 zones. A 2- to 3-cm wide peripheral zone that is barely thickened may have isolated papules. The middle zone has lenticular and hemispheric prurigo papules that may be excoriated. The central zone has the greatest thickening and pigmentary alteration.

Pigmentary changes (especially hyperpigmentation) are seen variably as in any dermatitic lesion.

Rubbing plays a key role in lesion formation and is visualized variably by white scratch marks, erosion, and ulceration from deeper scratching.

Lichen simplex chronicus is one of the hyperkeratotic processes from which a cutaneous horn may grow.[12]

Patients may scratch lesions de novo when observed. Some patients may start scratching while discussing the itch or describing the lesions.

Note the images below.

 

Lichen simplex chronicus of the dorsal hand and wr Lichen simplex chronicus of the dorsal hand and wrist demonstrating increased skin thickness and accentuation of skin markings.
Plaque of lichen simplex chronicus of the leg with Plaque of lichen simplex chronicus of the leg with accentuated skin markings and excoriations.
Plaques of lichen simplex chronicus on the hand. Plaques of lichen simplex chronicus on the hand.
Plaque of lichen simplex chronicus demonstrating a Plaque of lichen simplex chronicus demonstrating accentuated skin markings. Courtesy of San Antonio Uniformed Services Health Education Consortium Dermatology Program.
Area of lichen simplex chronicus originally believ Area of lichen simplex chronicus originally believed to be chronic contact dermatitis. The true nature was revealed when the patient admitted to rubbing this area while watching television. Courtesy of San Antonio Uniformed Services Health Education Consortium Dermatology Program.
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Causes

Atopic dermatitis results in a higher probability of developing lichen simplex chronicus.

Insect bites, scars (eg, traumatic, postherpetic/zoster[13] ), acne keloidalis nuchae,[14] xerosis, venous insufficiency, and asteatotic eczema are common factors.

Neurodermatitis is a term that historically has been used interchangeably with lichen simplex chronicus, given that psychological factors appear to play a role in the development or exacerbation of the condition.[15] A 2014 study demonstrated an increased prevalence of lichen simplex chronicus in patients with underlying anxiety and obsessive-compulsive disorder compared with age- and sex-matched controls.[5] A 2015 study showed that patients with lichen simplex chronicus have increased rates of clinical depression compared with patients without the condition.[6]

Lithium has been linked to lichen simplex chronicus in one reported case. Lichen simplex chronicus was dependent on the administration of lithium as evidenced by the observation that the lichen simplex chronicus remitted when the medication was discontinued and recurred when it was restarted.[16]

A small study looking at lichen simplex chronicus and the use of PPD-containing hair dye showed clinically relevant improvement in symptoms after discontinuation of PPD exposure, thus providing a basis for the role of sensitization and contact dermatitis in the etiology of lichen simplex chronicus.[17] . Several of the patients who cleared after avoiding paraphenylenediamine had widespread, not localized, dermatitis.

Long-term exposure to street traffic exhaust has been associated with an increase in the frequency of childhood skin diseases, including lichen simplex chronicus.[18]

Some reserve the diagnosis of lichen simplex for patients who have no known predisposing skin disorder. The term secondary lichenification has been used if the eruption is initiated by a primary dermatosis.

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Contributor Information and Disclosures
Author

Jason Schoenfeld, MD Resident Physician, Department of Dermatology, University of Buffalo, State University of New York School of Medicine and Biomedical Sciences

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas N Helm, MD Clinical Professor of Dermatology and Pathology, University of Buffalo, State University of New York School of Medicine and Biomedical Sciences; Director, Buffalo Medical Group Dermatopathology Laboratory

Thomas N Helm, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society of Dermatopathology

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD Associate Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Daniel J Hogan, MD Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern University College of Osteopathic Medicine; Investigator, Hill Top Research, Florida Research Center

Daniel J Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, Canadian Dermatology Association

Disclosure: Nothing to disclose.

James J Nordlund, MD Professor Emeritus, Department of Dermatology, University of Cincinnati College of Medicine

James J Nordlund, MD is a member of the following medical societies: American Academy of Dermatology, Sigma Xi, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Stephen H Mason, MD 

Stephen H Mason, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery, Women's Dermatologic Society, Skin Cancer Foundation

Disclosure: Nothing to disclose.

Siobahn M Hruby, MD Internal Medicine Physician, Boys Town National Research Hospital

Siobahn M Hruby, MD is a member of the following medical societies: American College of Physicians, American Medical Association

Disclosure: Nothing to disclose.

References
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  2. Weyers W. [Lichen amyloidosus--disease entity or the effect of scratching]. Hautarzt. 1995 Mar. 46(3):165-72. [Medline].

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  17. Chey WY, Kim KL, Yoo TY, Lee AY. Allergic contact dermatitis from hair dye and development of lichen simplex chronicus. Contact Dermatitis. 2004 Jul. 51(1):5-8. [Medline].

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  22. Geraldez MC, Carreon-Gavino M, Hoppe G, Costales A. Diflucortolone valerate ointment with and without occlusion in lichen simplex chronicus. Int J Dermatol. 1989 Nov. 28(9):603-4. [Medline].

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  24. Kantor GR, Resnik KS. Treatment of lichen simplex chronicus with topical capsaicin cream. Acta Derm Venereol. 1996 Mar. 76(2):161. [Medline].

  25. Yosipovitch G, Sugeng MW, Chan YH, Goon A, Ngim S, Goh CL. The effect of topically applied aspirin on localized circumscribed neurodermatitis. J Am Acad Dermatol. 2001 Dec. 45(6):910-3. [Medline].

  26. Kelekci HK, Uncu HG, Yilmaz B, Ozdemir O, Sut N, Kelekci S. Pimecrolimus 1% cream for pruritus in postmenopausal diabetic women with vulvar lichen simplex chronicus: A prospective non-controlled case series. J Dermatolog Treat. 2008 Apr 11. 1-5. [Medline].

  27. Heckmann M, Heyer G, Brunner B, Plewig G. Botulinum toxin type A injection in the treatment of lichen simplex: an open pilot study. J Am Acad Dermatol. 2002 Apr. 46(4):617-9. [Medline].

  28. Messikh R, Atallah L, Aubin F, Humbert P. [Botulinum toxin in disabling dermatological diseases]. Ann Dermatol Venereol. 2009 May. 136 Suppl 4:S129-36. [Medline].

  29. Engin B, Tufekci O, Yazici A, Ozdemir M. The effect of transcutaneous electrical nerve stimulation in the treatment of lichen simplex: a prospective study. Clin Exp Dermatol. 2009 Apr. 34(3):324-8. [Medline].

 
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Plaque of lichen simplex chronicus demonstrating accentuated skin markings. Courtesy of San Antonio Uniformed Services Health Education Consortium Dermatology Program.
Area of lichen simplex chronicus originally believed to be chronic contact dermatitis. The true nature was revealed when the patient admitted to rubbing this area while watching television. Courtesy of San Antonio Uniformed Services Health Education Consortium Dermatology Program.
Plaques of lichen simplex chronicus on the hand.
Lichen simplex chronicus of the dorsal hand and wrist demonstrating increased skin thickness and accentuation of skin markings.
Plaque of lichen simplex chronicus of the leg with accentuated skin markings and excoriations.
H and E biopsy of lichen simplex chronicus from forearm skin viewed at 40x magnification. Note the characteristic hyperkeratosis, hypergranulosis, pseudoepitheliomatous hyperplasia, and papillary dermal fibrosis.
H and E biopsy of lichen simplex chronicus from forearm skin viewed at 100x magnification. Note the characteristic hyperkeratosis, hypergranulosis, pseudoepitheliomatous hyperplasia, and papillary dermal fibrosis.
 
 
 
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