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ORIGINAL ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 4  |  Page : 294-300

Lichenoid eruptions in children: A retrospective study


Department of Dermatology, Venereology, Leprosy, Dr. DY Patil Medical College and Hospital, Navi Mumbai, Maharashtra, India

Date of Submission18-May-2019
Date of Decision18-Jun-2019
Date of Acceptance26-Apr-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Manjyot Gautam
Tower 5/701, Sagar Darshan Towers, Sector 18, Palm Beach Road, Nerul, Navi Mumbai - 400 706, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_48_19

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  Abstract 


Background: Lichenoid eruptions are a diverse group of inflammatory dermatoses, characterized clinically by flat-topped papules which resemble lichen planus (LP) and histologically by a lichenoid tissue reaction. There are many lichenoid dermatoses, of which some are seen predominantly in the pediatric age group. The knowledge of these lichenoid eruptions is essential for the dermatologists for early diagnosis, timely treatment, and also to predict their course. Aims: Our aim was to study the clinicoepidemiological features of lichenoid dermatoses in children and to differentiate between various lichenoid dermatoses and classify them accordingly. Materials and Methods: This was a retrospective, hospital-based, cross-sectional study of 52 children with a clinical diagnosis of lichenoid eruptions from January 2017 to December 2017. Results: Of the 986 children who visited the dermatology outpatient department 52 children (5.27%) were diagnosed with lichenoid dermatoses, with the male: female ratio being 1: 1.48 and a mean age of 7.25 years. LP was the most common lichenoid dermatosis reported in our study (48%), followed by lichen striatus (37.6%), lichen nitidus (5.8%), lichen sclerosus (5.8%), pityriasis lichenoides (3.2%), and Gianotti Crosti syndrome (1.9%). Limitations: It was a retrospective data analysis involving only 1 year of study with limited sample size, without study of long term evolution. Conclusions: Some lichenoid dermatoses (lichen straitus and lichen nitidus) are self-limiting and undergo spontaneous resolution without any sequelae, whereas LP and lichen sclerosus can be associated with varying degrees of morbidity. Proper diagnosis helps in allaying the fears of parents.

Keywords: Children, lichen nitidus, lichen planus, lichen striatus, lichenoid eruption


How to cite this article:
Gautam M, Chaudhari P, Priya S, Singh V, Nadkarni N, Patil S. Lichenoid eruptions in children: A retrospective study. Indian J Paediatr Dermatol 2020;21:294-300

How to cite this URL:
Gautam M, Chaudhari P, Priya S, Singh V, Nadkarni N, Patil S. Lichenoid eruptions in children: A retrospective study. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Oct 19];21:294-300. Available from: https://www.ijpd.in/text.asp?2020/21/4/294/296862




  Introduction Top


Lichenoid eruptions are a heterogeneous group of inflammatory dermatoses, characterized clinically by flat-topped papules which resemble lichen planus (LP) and histologically by a lichenoid tissue reaction. The spectrum of lichenoid eruptions is wide. Some lichenoid dermatoses such as LP are common in adults, but others are seen more often in children. These include lichen striatus, lichen nitidus, lichen sclerosus, Gianotti Crosti syndrome, Pityriasis lichenoides et varioliformis acuta (PLEVA), and Pityriasis lichenoides chronica. Since the various lichenoid eruptions have a clinical resemblance to each other, it is important to know the characteristic and distinctive features of each of them. This will not only help in the early diagnosis and effective treatment but also to predict the course of the eruption. The general impression among dermatologists is that lichenoid eruptions are fairly common in children. However, there is not enough literature on the same.

Aims and objectives

  • To study the clinicoepidemiological features of lichenoid dermatoses in children
  • To differentiate between various lichenoid dermatoses and classify them accordingly.



  Materials and Methods Top


This was a cross-sectional analysis of secondary clinical data of 52 children with a clinical diagnosis of lichenoid eruptions from January 2017 to December 2017. It was conducted in the dermatology department of a tertiary care hospital in Navi Mumbai, Maharashtra, India.

Records of children <16 years of age with a clinical diagnosis of lichenoid dermatoses were retrieved and analyzed. Parent/guardian's consent was obtained. The Institutional Ethics Committee permission for the secondary data analysis was taken. The parameters included for the analyses were demographic characteristics (age and sex) and clinical characteristics (the morphology of the lesions, the sites involved, and the clinical diagnosis).


  Results Top


Out of the 986 children who visited the dermatology outpatient department during this period, 52 children (5.27%) were diagnosed with lichenoid dermatoses. There were 30 girls and 21 boys with male: female ratio being 1: 1.48. Ages ranged from 2 to 14 years, with a mean age of 7.25 years [Table 1].
Table 1: The distribution of the various lichenoid dermatoses

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LP was the most commonest lichenoid dermatosis. The age of our patients ranged from 4 to 12 years, with a mean age of 7 years. Koebnerization was noted in six patients (24%). Finger nails were affected in two patients and toe nails in one patient. Three patients had oral mucosal involvement. Scalp involvement was seen in one child [Table 2].
Table 2: The clinical variants of lichen planus

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Patients with lichen striatus were between 2 and 10 years of age, with a mean age being 6.3 years. All 18 cases had unilateral involvement. Involvement of the left side (11 patients) was more than the right side (7 patients). Nail involvement was noticed in one patient [Table 3].
Table 3: Data on lichen striatus

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There were three cases of lichen nitidus with one 9-year-old boy who had generalized involvement with lesions over the face, trunk, and extremities and another boy (14 years) and a girl (8 years) with lesions localized to the upper extremities. Koebner's phenomenon was noted in all three patients.

Three cases of lichen sclerosus were seen. An 11-year-old girl presented with slightly pruritic porcelain white flat-topped papules on the left forearm of 2 years duration with koebnerization; a 6-year-old boy presented with phimosis and a sclerotic white ring at the preputial opening; and a 5-year-old girl presented with an atrophic white patch on the labia and perianal area.

There were two cases of Pityriasis lichenoides with one 5-year-old boy who presented with recurrent, painful, erythematous papulo-necrotic lesions over the trunk and extremities and was diagnosed as PLEVA and a 9-year-old boy who presented with erythematous scaly papules over the trunk and extremities which subsided with hypopigmentation and was diagnosed as Pityriasis lichenoides chronica (PLC).

A 7-year-old boy presented with multiple asymptomatic, monomorphic skin-colored papules symmetrically distributed over the face and extensors of the extremities with relative sparing of the trunk. It was preceded by low-grade fever which lasted for a few days. There was no lymphadenopathy or hepatomegaly. Gianotti Crosti syndrome was diagnosed.


  Discussion Top


LP is the prototype of lichenoid dermatoses.

LP was the commonest lichenoid dermatoses in our study (n = 25, 48.07%). Classic LP is rare in children with 2%–3% of the total LP cases.[1] In some studies, however, childhood LP has been reported in a higher percentage of cases (11%–19%).[2],[3] Ravikiran et al. have reported childhood LP in 17.7% of the total LP patients.[4]

We found a slight female preponderance with a male-to-female ratio being 1:1.3. This is similar to the study by Kumar et al. who reported a male-to-female ratio of 1:1.6.[5] However, most of the studies have either reported equal sex ratio or a slight male preponderance.[6]

The mean age of our children was 7 years, which is in accordance with other studies who have reported the mean age between 7.1 and 8.4 years.[6],[7]

Koebner's phenomenon was noted in 24% of our patients, which is similar to the results reported in other studies (24%–28%).[6],[7]

Classical LP was the most common variant [Figure 1], affecting 40% of our pediatric patients with LP followed by linear LP (20%) [Figure 2], hypertrophic LP (16%), and eruptive LP (12%) [Figure 3]. Similar findings have been reported by Ravikiran et al.[4] Lichen planus pigmentosus (8%) [Figure 4] and follicular LP (4%) were the other variants reported in our study.
Figure 1: Classic lichen planus in a child. Multiple flat-topped, violaceous papules noted on the volar aspect of the wrist and forearm

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Figure 2: Linear lichen planus

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Figure 3: Acute eruptive lichen planus

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Figure 4: Multiple hyperpigmented macules in a child with lichen planus pigmentosus

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Oral and nail lesions are less common in children. Oral mucosal involvement with cutaneous lesions was seen in 12% (n = 3) of our patients, which is slightly lower compared to other studies that reported an incidence between 13.7%-30%.[4],[5],[6],[7] All three patients presented with asymptomatic reticulate patches on the buccal mucosa.

Twelve percent of our patients (n = 3) had nail involvement (longitudinal ridging and pterygium) with skin lesions which is in accordance with the earlier studies (2.6%–19%).[6],[8],[9]

We reported Lichen striatus as the second-most common lichenoid dermatoses in our study (n = 18, 34.1%). It predominantly affects children and is self-limiting [Figure 5]. Our study showed a slight female preponderance with a male-to-female ratio being 1:1.6, similar to that reported by Patrizi et al.(0.5:1).[10] However, others have reported either a male preponderance [11] or equal sex ratio.[12]
Figure 5: Lichen striatus on the lower limb of a child

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The mean age of our patients was 6.3 years. Das et al. reported a mean age of 4.7 years in their patients.[11]

In our study, the lower extremities were the most common site (38.89%) followed by upper extremities (33.33%) and trunk (27.77%). Peramiquel et al. and Taniguchi et al. also reported more frequent involvement of lower extremities,[12],[13] whereas Das et al. found upper limbs and trunk as the most common site.[11]

We reported unilateral involvement in all our patients with lesions predominantly on the left side. Similar findings were reported by Hauber et al.[14] Das et al. reported lesions more on the right side.[11] Nail involvement is rare and is usually seen in association with skin lesions. We noticed nail involvement with skin lesions in one patient only (5.56%) which was restricted to a single nail which was much lower than that reported by Hauber et al.(16.67%).[14]

Lichen nitidus is an uncommon benign skin disease noted in school-going children presenting mostly as a localized asymptomatic eruption and rarely it may be generalized.[15] Of the three cases seen, two children had lichen nitidus localized to the upper extremities [Figure 6] and one 9-year-old boy presented with generalized lichen nitidus on the face, trunk, and extremities [Figure 7]. None of them had nail involvement. Koebner's phenomenon was noted in all three.
Figure 6: Lichen nitidus with multiple, grouped, hypopigmented pinhead-sized papules on the elbows. Koebnerization is noted

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Figure 7: Nine year old boy with generalized lichen nitidus

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Similarly, lichen sclerosus is an uncommon inflammatory disease seen in prepubertal children and postmenopausal women. Maronn and Esterly reported the mean age of onset of this disease as 4.2 years.[16] The prevalence rate in children as reported by Powell and Wojnarowska is 1:900.[17] Out of the three cases of lichen sclerosus that we reported, two children (girl/5 years and boy/6 years) [Figure 8] and [Figure 9] had genital lichen sclerosus and a 11-year-old girl had extragenital LS over the left forearm.
Figure 8: Genital lichen sclerosus in a boy with sclerotic white ring at the preputial opening

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Figure 9: Genital lichen sclerosus in a girl with atrophic white patch on the labia and perianal area with fissure

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There were two cases of pityriasis lichenoides with one 5-year-old boy who presented with recurrent, painful, erythematous papulo-necrotic lesions over the trunk and extremities and was diagnosed as PLEVA [Figure 10] and a 9-year-old boy who presented with erythematous papules over the trunk which subsided with hypopigmentation and was diagnosed as PLC [Figure 11]. Both these variants tend to occur with equal frequency, and the average age of onset of pityriasis lichenoides is 6.5 years. It is slightly more common in boys than that of girls. The two conditions overlap clinically and histologically and run a benign course.[18]
Figure 10: Pityriasis lichenoides et varioliformis acuta in a 5-year-old boy multiple erythematous crusted papules on the trunk

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Figure 11: Pityriasis lichenoides chronica in a boy with few erythematous scaly papules on the trunk and postinflammatory hypopigmentation

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A 7-year-old boy presented with multiple asymptomatic, monomorphic skin-colored papules symmetrically distributed over the face and extensors of the extremities with relative sparing of the trunk. It was preceded by a low-grade fever which lasted for a few days. There was no lymphadenopathy or hepatomegaly. A diagnosis of Gianotti Crosti syndrome was made. It is an uncommon self-limiting viral exanthem seen mainly in children 2–6 years of age with an equal sex ratio.[19]

Lichen spinulosus is a rare genetic lichenoid dermatosis reported in children with a slight male preponderance.[19],[20] However, we did not encounter a single case of lichen spinulosus during this study period. [Table 4] provides a summary of clinical features, treatment and course of various lichenoid dermatoses.
Table 4: Clinical features, treatment and prognosis of various lichenoid dermatos

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Limitations

It was a retrospective data analysis involving only 1 year of study with a limited sample size.

The evolution of the different lichenoid eruptions was not studied over a long period of time.


  Conclusions Top


There are various lichenoid eruptions which are relatively common in the pediatric age group. They bear a clinical resemblance to each other. When encountered, they have to be diagnosed and treated promptly to avoid the common complication of postinflammatory pigmentation (seen especially in the LP). Other uncommon conditions (lichen striatus, lichen nitidus, and PLEVA) also should be diagnosed promptly to avoid anxiety among children and their care-givers.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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.  Back to cited text no. 1
    
2.
Kumar V, Garg BR, Baruah MC, Vasireddi SS. Childhood lichen planus (LP). J Dermatol 1993;20:175-7.  Back to cited text no. 2
    
3.
Pandhi D, Singal A, Bhattacharya SN. Lichen planus in childhood: A series of 316 patients. Pediatr Dermatol 2014;31:59-67.  Back to cited text no. 3
    
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Ravikiran SP, Jaiswal AK, Anupama YG, Madan Mohan NT, Reddy PK. Lichen planus in children: A retrospective study in 76 patients at a tertiary care centre in South India. Indian J Pediatr Dermatoll 2017;18:209-13.  Back to cited text no. 4
    
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Kumar A, Mendiratta V, Agarwal S, Chander R, Sanke S. Childhood lichen planus: A series of 42 patients. Indian J Paediatr Dermatol 2018;19:116-9.  Back to cited text no. 5
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Handa S, Sahoo B. Childhood lichen planus: A study of 87 cases. Int J Dermatol 2002;41:423-7.  Back to cited text no. 6
    
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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.  Back to cited text no. 7
    
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Kanwar AJ, De D. Lichen planus in childhood: Report of 100 cases. Clin Exp Dermatol 2010;35:257-62.  Back to cited text no. 8
    
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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.  Back to cited text no. 9
    
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Patrizi A, Neri I, Fiorentini C, Bonci A, Ricci G. Lichen striatus: Clinical and laboratory features of 115 children. Pediatr Dermatol 2004;21:197-204.  Back to cited text no. 10
    
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Das S, Adhicari P. Lichen striatus in children: A clinical study of ten cases with review of literature. Indian J Paediatr Dermatol 2017;18:89-93.  Back to cited text no. 11
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Peramiquel L, Baselga E, Dalmau J, Roé E, del Mar Campos M, Alomar A. Lichen striatus: Clinical and epidemiological review of 23 cases. Eur J Pediatr 2006;165:267-9.  Back to cited text no. 12
    
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Taniguchi Abagge K, Parolin Marinoni L, Giraldi S, Carvalho VO, de Oliveira Santini C, Favre H. Lichen striatus: Description of 89 cases in children. Pediatr Dermatol 2004;21:440-3.  Back to cited text no. 13
    
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Hauber K, Rose C, Bröcker EB, Hamm H. Lichen striatus: Clinical features and follow-up in 12 patients. Eur J Dermatol 2000;10:536-9.  Back to cited text no. 14
    
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Mehta V, Balachandran C. Generalized lichen nitidus in childhood. Indian J Dermatol 2008;53:221-2.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Maronn ML, Esterly NB. Constipation as a feature of anogenital lichen sclerosus in children. Pediatrics 2005;115:e230-2.  Back to cited text no. 16
    
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Powell J, Wojnarowska F. Childhood vulvar lichen sclerosus: An increasingly common problem. J Am Acad Dermatol 2001;44:803-6.  Back to cited text no. 17
    
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Geller L, Antonov NK, Lauren CT, Morel KD, Garzon MC. Pityriasis lichenoides in childhood: Review of clinical presentation and treatment options. Pediatr Dermatol 2015;32:579-92.  Back to cited text no. 18
    
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Tilly JJ, Drolet BA, Esterly NB. Lichenoid eruptions in children J Am Acad Dermatol 2004;51:606-24.  Back to cited text no. 19
    
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Hawsawi KA, Almehmadi K, Alraddadi B, Aljuhani O. Lichen spinulosus: Case report and Review of literature. J Health Sci 2015;5:20-2.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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