Report LICHEN PLANUS IN INDIA: AN APPRAISAL OF 441 CASES O. p. SINGH, M.D., D.V.D. AND A. J. KANWAR, M.D. From the Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India natural history of the disease is quite variable, and about 85% of the cases clear in 18 months.'' Several reports^--' have appeared in the literature regarding the various clinical types of lichen ABSTRACT: An analytical study of 441 pa- planus. Scarcity of such reports, however, from this part of the world justifies tients with lichen planus is presented. Lichen planus occurrence was 76% of this study. We aim at presenting the conditions seen at this institution. The sex pattern of lichen pianus as seen in India. ratio was 3:2. Most patients having the disease were in the 3rd decade of life. Lichen planus vulgaris (common type) was seen in 329 (74%) patients, lichen planus hypertrophicus in 56 (13%), lichen planus actinicus in 33 (7.5%), lichen planus follicularis in 8 (2%), lichen planus atrophicus in 8 (2%) and lichen planus pemphigoides in 7 (1.5%) patients. Mucous membrane involvement was seen in 127 (29%) cases and nail involvement in only 7 (1.5%). Lichen planus is a well-defined clinical entity; however, its cause remains obscure. It is a disease which involves the skin, the oral and genital mucous membranes, the nails and the hair. It is worldwide in distribution, although there is considerable variation in its incidence and mode of presentation. Reports from various countries' -' suggest an incidence varying from .5 to 1% among patients with skin diseases. The Address for reprints: Dr. O. P. Singh, Department of Dermatology, All India Institute of Medical Sciences, New Delhi 110016, India. Materials and Methods All new patients with cases of skin diseases attending the Dermatology Outpatient Department at the All India Institute of Medical Sciences, New Delhi from January 1970 to September 1975 were registered. Detailed history and clinical examination of the patients having lichen planus and its variants were recorded on the case sheet. Information regarding age, sex, duration of illness, morphology, distribution, etc., were recorded. The diagnosis was largely morphologic and in doubtful cases, a histopathologic examination was carried out to confirm the diagnosis. Results and Observations Of 57,844 patients of skin diseases registered, 441 had lichen planus, giving an incidence of 0.76%. No seasonal variation was observed. There were 266 males and 175 females (sex ratio 3:2). 752 753 LICHEN PLANUS • Singh and Kanwar No. 10 Table 1. Age in years Age and Sex Incidence of Lichen Planus No. female patients No. male patients Total Percentage 0-9 14 6 20 10-19 20-29 30-39 40-49 50-59 60 -f 35 21 56 82 44 126 71 40 35 111 61 4.54 12.69 28.57 25.17 13.83 38 a.62 18 18 11 29 6.58 266 175 441 Total 26 20 The disease occurred most often in the 3rd decade of life (Table 1); the duration varied. Some patients sought help as early as a few days after its onset, while others, particularly those with lichen planus hypertrophicus had had the disease for several years (Table 2). Among the various morphologic patterns observed, lichen planus vulgaris (common type) was seen in 329 (74.6%) cases. Lesions of this type were mostly present on lower and upper extremiTable 2. Type Lichen planus vulgaris Lichen planus hypertrophicus Lichen planus actinicus Lichen planus follicularis Lichen planus atrophicus Lichen planus pemphigoides Total ties and were associated with varying degrees of itching. In 5 cases, the lesions were also present on palms and soles. Fifty-six (12.7%) patients had lichen planus hypertropicus. In this group, itching was invariably present and the lesions were of long duration. Lower extremities were involved in 50 out of 56 cases. There were 33 (7.48%) patients in whom a diagnosis of lichen planus Types and Duration of Lichen Planus 4-12 Months Over 12 Months Total Number Percentage 145 100 84 329 74.61 5 7 44 18 9 6 33.: 7.48 2 5 S 1.81 8 1.81 1 7 1.59 143 441 0-3 Months 1 • 100 '3 "• • 2 4 176 122 • 3- -. • M .- 12.70 100 754 INTERNATIONAL JOURNAL OF DERMATOLOGY actinicus was made. The lesions were limited to the exposed areas, particularly to the forehead and extensors of forearms. Lichen planus atrophicus was observed in 8 (1.8%) patients. Forehead, face and upper extremities were the sites affected. Eight cases (1.8%) of lichen planus follicularis were seen and in 5 of these patients, the lesions were distributed all over the body. In the remaining 3, only the extremities were involved. One patient in this group also had patchy cicatracial alopecia of the scalp. Lichen planus pemphigoides was seen in 7 (1.6%) cases; this type usually had an acute onset. One patient developed ulcerative lesions over palms and soles. Lichen planus of the skin alone was observed in 307 (69.6%). There were 101 (22.9%) patients in whom there was involvement of skin as well as mucous membranes (Table 3). Mucous membrane alone was involved in 26 (5.9%) and in 7 (1.6%) out of these, the genital mucous membrane was exclusively affected. Whitish streaks with a lacy pattern forming a network was the most common clinical presentation seen in 80 (63%) cases of oral mucosal membrane involvement. Color changes in the form of violaeceous patches on the mucous membrane were invariably present on the glans penis and in 38 (30%) cases of oral involvement. Nail changes along with skin and/or mucous membrane involvement was seen in 7 (1.6%) cases. The predominant change was longitudinal ridging (onychorrhexis). Other changes were pitting, yellowish-brown discoloration, friability of the free edge and transverse striations. One patient with lichen planus pemphigoides showed shedding of the nails (onychomadesis). Vol. 15 December 1976 Table 3. Skin, Mucous Membrane and Nail Involvement Distribution of lesions Skin alone Skin and mucous membrane Mucous membrane alone Lichen planus with nail changes Total No. cases Percentage 307 101 26 69.61 22.90 5.89 7 1.60 441 100 Discussion The incidence of lichen planus in the patients attending the Dermatology Outpatient Department was 0.76%; this agrees with reports from Western countries^' 2 in which the incidence has varied from 0.5 to 1.2%. There was no seasonal variation in the incidence or progress of lichen planus. Similar observations were made by other workers*' '^; however, Mellgren and Hersle (1965)' reported a low incidence in the months of May, June and November and a high incidence in December and January. The sex ratio in our study was 3:2, although there has been no consistency in the literaOur study has shown that most of the patients (53.7%) were in the age group 20-40 years. However, reports'-^ from western countries suggest that the maximum number of cases are in the age group 30-60 years. Mucous membrane involvement with skin lesions in 22.9% of patients was low as compared to a reported^ involvement of mucous membrane in 30-70%. Similarly, mucous membrane alone was involved in only 5.9% of patients in contrast with other studies,^' ^ in which this has varied from 12.3 to 25%. The low incidence of mucous membrane involvement may be explained by the fact No. 10 LICHEN PLANUS • Singh and Kanwar that in our study only those patients were included who had either typical clinical features or histopathologic ones. Nail changes were associated in 7 (1.6%) cases. This is comparatively low, because reported'^- '^ involvement of nails range from 1-10%. On ihe contrary, Sehgal and Rege (1974)* did not find nail involvement in any of their 147 patients. It may be emphasized that the nail changes seen in lichen planus were neither significant nor specific, as these may be seen in other dermatologic conditions. In our study, the maximum number ot cases 329 (74.6%) were those of lichen planus vulgaris (common type) followed by lichen planus hypertrophicus and lichen planus actinicus. Variants such as lichen planus atrophicus, lichen planus follicularis and lichen planus pemphigoides were infrequent. Lichen planus hypertrophicus was at times difficult to differentiate from nodular prurigo, lichen amyloidosis and lichen simplex chronicus.'-' Presence of lichen planus lesions elsewhere and histopathology were helpful in such cases. The localization ot the lesions to the lower extremities and intense pruritus was noteworthy. However, in 10 (18%) of these patients, the lesions were present on other parts of the body in contrast to a marked tendency to disseminate.^ No definite cause except varicose veins'-* in one patient, could be ascertained regarding the localization of lesions to the lower extremities. Patients diagnosed as having lichen planus actinicus had annular violaeceous lesions on the photosensitive areas.'-^' "^ These patients were predominantly in a younger age group and complained of a burning sensation while in the sun; otherwise, pruritus was mild or absent. In the past, this variant, thought to be confined to 755 tropical and subtropical countries, was designated lichen planus tropicus.^' Lichen planus follicularis, also known as lichen planopilaris,-^ was observed in 8 cases. Five patients had an acute onset while the remaining 2 had a chronic type. Only one patient who had the chronic type had cicatrical alopecia ot the scalp due to atrophy of hair follicles. This variant of lichen planus, known also as the Graham-Little syndrome, was characterized by predominant patchy foilicular involvement of the scalp, usually in association with other hairy areas of the body.-' It must be differentiated from keratosis pilaris, Darier's disease, lichen scrotulosorum and in the scalp from lupus erythematosus.^ Patients with lichen planus atrophicus had annular atrophic lesions with a slightly violaeceous hue at the periphery. The presence of active lichen planus lesions on other parts of the body was helpful in diagnosis. An acute onset was striking in patients with lichen planus pemphigoides. One in this group developed an unusual variant with ulcerative lesions''"^ on the palms and soles, which were recalcitrant to therapy. References 1. Mellgren, L., and Hersle, K., Lichen planus— a clinical study with statistical methods. Ind. J. Dermatol. 11:1, 1965. 2. Calnan, C. D., and Meera, R. H., Trans. St. John Hosp. Dermatol. Soc, London 39, 56: 1957. 3. Samman, P. D., Lichen planus and lichenoid eruptions. In Text Book of Dermatology. Edited by Rook, A., Wilkinson, D. S. and Ebling, F. J. G. London, Blackwell Scientific Publications, Vol. 2, Second edition, 1972, pp. 1334. 4. Tompkins, J. K., Lichen planus: A statistical study of 41 cases. AMA Arch. Dermatol. Syphilol. 71:515, 1955. 5. Altman, J., and Perry, H. O., The variation and course of lichen planus. Arch. Dermatol. 84:179, 1961. 756 INTERNATIONAL JOURNAL OF DERMATOLOGY 6. Cram, D. L., and Muller, A. S., Unusual variations of lichen planus. Mayo Clin. Proc. 41:677, 1966. 7. Schmidt, H., Frequency, duration and localization of lichen planus: A study based on 181 patients. Acta Dermatol. Venereol. 4 1 : 164, 1961. 8. Sehgal, V. N., and Rege, V. L., Lichen planus: ,,, . an appraisal of 147 cases. Indian J. Dermatol. Venereol. 40:104, 1974. 9. Desai, S. C., and Marquis, L., Lichen planusClinical study of 67 cases with results of pancillin therapy. Indian J. Dermatol. Venereol. 22:31, 1958. 10. Simpson, H. E., The age and sex incidence and anatomical distribution of oral leucoplakia and lichen planus. Br. J. Dermatol. 69:178, 1957. 11. Samman, P. D., Nails in lichen planus. Br. J. Dermatol. 73:285, 1961. / December 1976 Vol. 15 12. Zaias, N., The nail in lichen planus. Dermatol. 101:264, 1970. Arch. 13. Rein, C. R., and Snider, B. L., Lichen simplex chronicus in Orientals. AMA Arch. Dermatol. Syphilol. 66:612, 1952. 14. Dennie, C. C , and Coombs, F. P., Lichen planus hypertrophicus. AMA Arch. Dermatol. Syphilol. 61:121, 1950. 15. Katzenellenbogan, I., Lichen planus actinicus (Lichen planus in subtropical countries). Dermatologica 124:10, 1962. 16. Dostrovsky, A., and Sagher, F., Lichen planus in subtropical countries. AMA Arch. Dermatol. Syphilol. 59:308, 1949. 17. Santolanni, P., Lichen planus actiricus (Vei tropicus) Minerva Dermatol. 40/11, 421:1965. 18. Cram, D. L., Kierland, R. R., and Winkelmann, R. K., Ulcerative lichen planus of the feet. Arch. Dermatol. 93:692, 1966. Scabies Prophylaxis '••'•' To prevent a return of the disease or its propagation to other persons, the patient's clothing should be disinfected, especially the under linen, by passing a stream of sulphureous acid gas through them, which may be easily obtained by burning a rag dipped in melted sulphur. Simple warm baths should be continued for several days after the disappearance of the complaint. If the itch should happen to be complicated with any other eruption, as eczema for example, whatever treatment may have been adopted must be discontinued, and diluent or acidulated drinks, and soothing application prescribed. Bleeding and leeches are now rarely resorted to, and are seldom required. An occasional purgative will answer all the purposes of depletion.—Burgess, T. /-/.; Eruption of the Eace, Head, and Hands: With the Latest Improvements in the Treatment of Diseases of the Skin. London, Henry Renshaw, 1849, p. 247.