|Year : 2017 | Volume
| Issue : 3 | Page : 209-213
Lichen planus in children: A retrospective study in 76 patients at a tertiary care center in South India
Shilpashree P Ravikiran, Ashok Kumar Jaiswal, YG Anupama, NT Madan Mohan, Pavan Kumar Reddy
Department of Skin and STD, Dr. B.R. Ambedkar Medical College, Bengaluru, Karnataka, India
|Date of Web Publication||7-Jun-2017|
Shilpashree P Ravikiran
Department of Skin and STD, Dr. B.R. Ambedkar Medical College, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Lichen planus (LP) is a chronic inflammatory pruritic dermatosis occurring infrequently in children. Very few studies are available on childhood LP from South India.
Aim: This study aims to analyze the clinical profile of LP among children.
Settings and Design: This was a retrospective study.
Materials and Methods: Records of the children <16 years with LP attending our tertiary care center from January 2011 to April 2016 were tabulated and analyzed.
Results: Of the 76 children with childhood LP, examined over a period of 5.4 years, 42 were boys and 34 were girls with a male: female ratio of 1.2:1. Childhood LP accounted for 17.7% of total LP cases. The mean age of the children was 10.7 years, and the lesions appeared earlier in boys than girls. Limbs were the common site of onset, and classical LP was observed in 56.6% (43) of cases followed by, linear LP (11, 14.4%), hypertrophic LP (10, 13.2%), eruptive LP, and actinic LP in 5.3% each. Koebner's phenomenon was noted in 37.3% and a positive history of infective foci before the onset was noted in 14.4% of children. Palmoplantar, oral mucosal, and nail involvement were noted in 7.8%, 14.4%, and 15.7% of children, respectively. Multiple morphological types were noted in 14.4% of children.
Conclusion: Hence, as per our study, LP in children is relatively common, and it can sometimes be triggered by infection. Apart from classical LP, linear LP, annular LP, and palmoplantar involvement were frequently observed in the present study.
Keywords: Childhood lichen planus, infection as precipitating factor, linear lichen planus
|How to cite this article:|
Ravikiran SP, Jaiswal AK, Anupama Y G, Madan Mohan N T, Reddy PK. Lichen planus in children: A retrospective study in 76 patients at a tertiary care center in South India. Indian J Paediatr Dermatol 2017;18:209-13
|How to cite this URL:|
Ravikiran SP, Jaiswal AK, Anupama Y G, Madan Mohan N T, Reddy PK. Lichen planus in children: A retrospective study in 76 patients at a tertiary care center in South India. Indian J Paediatr Dermatol [serial online] 2017 [cited 2017 Nov 23];18:209-13. Available from: http://www.ijpd.in/text.asp?2017/18/3/209/206079
| Introduction|| |
Lichen planus (LP), a common papulosquamous disorder, is considered to be rare in childhood, representing only 2%–3% of total LP cases. However, in India, the scenario is not the same, with a few case series from the subcontinent reporting a prevalence of childhood LP as 11%–19% of total LP cases., Further, the children of Indian ethnicity accounted for 80.8% of cases, in the study from the United Kingdom. The majority of these case series on childhood LP are from North India except for a single study from Southern India. Herein, we report our experience with childhood LP in 76 patients, studied at a tertiary care center in South India, over a period of 5.4 years.
| Materials and Methods|| |
This retrospective study was conducted at our tertiary care center by analyzing the records of 76 children, between the age group of 0 and 16 years with LP from January 2011 to April 2016. Details pertaining to age, sex, symptoms, site of onset, duration of the illness, family history, morphology, distribution, Koebner's phenomenon, involvement of the mucosa, nail, and hair were noted form the records.
| Results|| |
In a period of 5.4 years, a total of 428 patients of LP attended our center, of which 76 (17.7%) were children. Forty-two (55.2%) were boys, and 34 (44.8%) were girls, with a male:female ratio of 1.3:1. Their ages ranged from 2 to 16 years, with a mean age of 10.7 years. Thirty-six (48%) patients were in the age group of 10–14 years. However, 60% (25) of boys presented at an earlier age of 6–12 years compared to girls, where 52% (17) presented in later age group of 13–16 years [Figure 1]. The duration of the disease ranged from 10 days to 96 weeks with a mean duration of 23 weeks (5.3 months). 7.8% (6) children had duration of <1 month. Of these six children, three had eruptive LP, two with classical LP, and one bullous LP. 68.2% (52) of patients presented with moderate intensity of itching. There was no family history, and none of the children had a history of drug intake or vaccination before the onset of the lesions. Eleven (14.5%) children gave a positive history, suggestive of an infective focus 15 days to 6 weeks before the onset.
The site of onset was lower limbs in 45 (59.3%) children, followed by upper limbs (17, 22.4%), back (10, 13.1%), and face (4, 5.2%) in decreasing order of frequency. Face was the site of onset in three cases of actinic LP and one case of LP pigmentosus. Involvement of the skin alone was seen in 56 (73.9%) children. Koebner's phenomenon was seen in 28 (37.3%) patients, of whom 23 children had classic LP, and the remaining were eruptive LP (4) and bullous LP (1), respectively. The clinical variants seen [Figure 2],[Figure 3],[Figure 4] are given in [Table 1]. As shown in [Table 2], classic LP accounted for 56.6% (43) of cases followed by, linear LP (11, 14.4%), and hypertrophic LP (10, 13.2%). More than one morphological type was seen in 11 (14.4%) children although for the diagnosis, the predominant lesion was considered. Skin and mucosal involvement [Figure 5] were seen in 11 (14.4%) children, and nails [Figure 6] were involved in 12 (15.7%) children. Clinical details of uncommon variants [Figure 7] and [Figure 8] encountered are depicted in [Table 2]. Diagnosis was confirmed by histology in 51 (67.1%) children, and it was consistent with LP in all the cases.
|Figure 5: Plaque-type of oral mucosal lichen planus on both the buccal mucosa|
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|Figure 6: Nail lichen planus (note-shedding of the nails, pterygium, and longitudinal ridging with pterygium)|
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|Figure 7: Photograph showing cicatricial alopecia due to linear lichen planus with follicular lichen planus|
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| Discussion|| |
LP is derived from a Greek word, “Leichen” meaning “tree moss” and the latin word “planus” meaning flat. The term “lichenoid” is often used to describe the flat-topped papules morphologically and histologically to define a pattern of inflammation characterized by, “band-like dermal lymphocytic infiltrate in close the epidermis.” It is commonly seen in the middle-aged group females and is considered to be uncommon in childhood. However, LP in children is not uncommon in subtropical countries like India, with many case series of childhood LP studied by Indian authors.,,,,, Hence, the present retrospective study from South India confirms the relative abundance of childhood LP in the tropics with 17.7% of LP cases occurring in children. This may be due to the early exposure to the infective agents and other environmental triggers such as trauma. Interestingly, we noted a positive history suggestive of an infective focus 15 days to 6 weeks before the onset of LP in 14.4% (11) of children which have been reported only in one study. Further LP is considered to an immune phenomenon to an antigen which is a self-peptide, unmasked by several external agents. Apart from vitiligo (3.9%) and alopecia areata (3.9%), we encountered an interesting case of linear morphea with follicular LP (1.3%), which adds on to the evidence for the autoimmune etiology of the LP., However, further studies are required to prove the association of autoimmune disorders and LP.
Mean age of our patients was 10.7 years with a mean duration of 5.3 months, which was comparable to the observation made by Pandhi et al. In agreement with earlier studies, we did not identify any gender difference in LP among children, the same has been also observed by other workers.,, In the present study, LP appeared at an earlier age in the boys compared to girls and a similar trend was also seen by Handa and Sahoo. This can be explained by the increased physical activity among boys. Interestingly, we noted a higher percentage of Koebner's phenomenon in contrast to earlier studies,, which may be due to the interobserver variation.
In coherence with other studies, classical LP with flat-topped voilaceous papules, followed by linear and hypertrophic LP was the predominant morphological type and limbs, followed by lower back and face were the common site of onset., Although other authors have reported the onset of the disease from oral cavity and nail, we did not run into any such cases., Linear LP was earlier thought to be common in children, however, some of the recent studies have shown higher incidence in adults. Our study highlights the earlier view that linear LP is common in children. The same has been observed in an earlier study from South. Although studies have shown eruptive LP as the second common type, we encountered the same in only 5.3% of cases., The relative incidence of the clinical variants of LP in children varies from region to region.
The incidence of actinic LP in our study was 5.3% which is in agreement with most of the studies.,,, It tends to affect deeply pigmented skin in India, Middle East, and Africa and is considered to be triggered by ultraviolet light. We encountered one case of actinic LP mimicking polymorphous light eruption in our study. Morphologically, annular lesions were seen in 14.4% of LP cases, of which three were actinic LP, and the remaining had the features of classical LP. This is in contrast to the incidence of 2% reported by Sharma and Maheshwari. Follicular LP (2.6%), bullous LP (1.3%), and LP pigmentosus (1.3%) were some of the less common presentations in our present study.
In contrast to the previous studies, interestingly, we noted a higher palmoplantar involvement with 7.8% of cases.,, This may be due to the isomorphic response to the trauma inflicted on the palms and soles. Oral mucosal involvement was seen in 14.4% of children with reticular patches being the most common pattern, and a similar trend was also seen in earlier studies.,,,,,, Majority of the children with oral LP were asymptomatic, except one patient with plaque type of oral LP who had burning sensation. Similarly, genital mucosal involvement was seen in 3.9% of patients in the form of white patch which was also asymptomatic. Only few studies have reported the involvement of genitalia., This highlights the importance to routinely examine the oral cavity, genitalia, palms, and soles in a case of LP as majority of these lesions were asymptomatic.
Involvement of nails in childhood LP varied widely from 2.6% to 19% across earlier studies.,,, In our study, we noted nail involvement along with skin lesions in 15.7% of children. Applying the classification of nail LP by Tosti et al., to the present study, we noted typical nail LP (longitudinal ridging, pterygium) in 10.5%, trachyonychia in 2.6%, and none of idiopathic atrophy of nails. A similar trend was noted in other studies. We also noted certain nonspecific changes such as shedding of the nails in 2.6% of children. Biopsy of the nail was not done as there was no case with isolated nail involvement.
| Conclusion|| |
Hence, by the present study, we ascertain the relative abundance of childhood LP in the Southern part of India compared to paucity of LP among children reported from Western literature, more so in Caucasian race.,, Whether this difference is due to the genetic factors, environment, or due to the Fitzpatrick skin type has to established. The possibility of infection as a triggering factor for childhood LP was also observed in the present study. A higher percent of linear LP, annular LP, and palmoplantar involvement, pleomorphic lesions in a single patient were some of the salient features in the present study. Apart from the case series by Kumar et al., to date, this is the only available case study of LP in children from Southern India. Hence, we propose the need for more regional studies to know the incidence of LP among children and to identify the probable environmental factors responsible for its relative abundance in tropics.
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Conflicts of Interest
There are no conflicts of interest.
| References|| |
Paller AS, Mancini AJ. Papulosquamous and related disorders. In: Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 5th
ed. Canada: Elsevier; 2016. p. 73-94.
Kumar V, Garg BR, Baruah MC, Vasireddi SS. Childhood lichen planus (LP). J Dermatol 1993;20:175-7.
Pandhi D, Singal A, Bhattacharya SN. Lichen planus in childhood: A series of 316 patients. Pediatr Dermatol 2014;31:59-67.
Balasubramaniam P, Ogboli M, Moss C. Lichen planus in children: Review of 26 cases. Clin Exp Dermatol 2008;33:457-9.
Sacchidanand S, Raghavendra R. Lichen planus and lichenoid reactions. Papulosquamous and vesiculobullous dermatoses. In: Sacchidanand S, Oberai C, Inamadar AC, editors. IADVL Textbook of Dermatology. 4th
ed. Mumbai, India: Bhalani Publishing House; 2015. p. 1090-113.
Mobini N, Toussaint S, Kamino H. Noninfectious erthematous, papular and squamous diseases. In: Elder D, Elenitas R, Murphy G, Johnson B, Xu X, editors. Lever's Histopathology of Skin. 10th
ed. Philadelphia: Lippincott-Raven; 2009. p. 169-203.
Kanwar AJ, Handa S, Ghosh S, Kaur S. Lichen planus in childhood: A report of 17 patients. Pediatr Dermatol 1991;8:288-91.
Sharma R, Maheshwari V. Childhood lichen planus: A report of fifty cases. Pediatr Dermatol 1999;16:345-8.
Handa S, Sahoo B. Childhood lichen planus: A study of 87 cases. Int J Dermatol 2002;41:423-7.
Kanwar AJ, De D. Lichen planus in childhood: Report of 100 cases. Clin Exp Dermatol 2010;35:257-62.
Nanda A, Al-Ajmi HS, Al-Sabah H, Al-Hasawi F, Alsaleh QA. Childhood lichen planus: A report of 23 cases. Pediatr Dermatol 2001;18:1-4.
Sugerman PB, Savage NW, Walsh LJ, Zhao ZZ, Zhou XJ, Khan A, et al.
The pathogenesis of oral lichen planus. Crit Rev Oral Biol Med 2002;13:350-65.
Luis-Montoya P, Domínguez-Soto L, Vega-Memije E. Lichen planus in 24 children with review of the literature. Pediatr Dermatol 2005;22:295-8.
Price HN, Zeanglein AL. Lichen planus and lichen nitidus. In: Irvine A, Hoeger P, Yan A, editors. Harper's Textbook of Pediatric Dermatology. 3rd
ed. Oxford, UK: Blackwell Publishing; 2011. p. 85.1-14.
Tosti A, Piraccini BM, Cambiaghi S, Jorizzo M. Nail lichen planus in children: Clinical features, response to treatment, and long-term follow-up. Arch Dermatol 2001;137:1027-32.
Walton KE, Bowers EV, Drolet BA, Holland KE. Childhood lichen planus: Demographics of a U.S. population. Pediatr Dermatol 2010;27:34-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]