Lichen Nitidus

Background

The disease presents with multiple asymptomatic flesh-colored papules about 1-2 mm in diameter. They occur on the upper extremities, chest, abdomen, and genitals. Children and young adults are commonly affected and there is predilection for blacks. The histopathology shows the ball and claw configuration. Lymphocytes, histiocytes, rare plasma cells, and macrophages with multinucleated giant cells are present. Direct immunofluorescence is negative.

DISEASE ASSOCIATIONS CHARACTERIZATION

AMENORRHEA

Recurrent generalized lichen nitidus associated with amenorrhea.

Taniguchi S, Chanoki M, Hamada T.

Department of Dermatology, Osaka City University Medical School, Japan.

Acta Derm Venereol 1994 May;74(3):224-5 Abstract quote

A case of recurrent generalized lichen nitidus is reported. The eruptions developed in the proliferative phase of the menstrual cycle, but there has been a marked improvement after administration of estrogen and progesterone for the treatment of amenorrhea. Hormonal factors may play a role in the development of lichenoid tissue reaction in the lesions of this disease.

ATOPIC DERMATITIS

Coexistence of atopic dermatitis and lichen nitidus in three patients.

Lestringant GG, Piletta P, Feldmann R, Galadari I, Frossard PM, Saurat JH.

Department of Dermatology, Tawam Hospital, Al Ain, United Arab Emirates.

Dermatology 1996;192(2):171-3 Abstract quote

Lichen nitidus (LN) is an uncommon skin disorder. We observed 3 patients with an association of lichen nitidus and atopic dermatitis (AD), which to the best of our knowledge has not been previously reported in the literature.

It remains to be evaluated whether the association of LN and AD is fortuitous or not.

CROHN'S DISEASE

Erythema nodosum, lichen planus and lichen nitidus in Crohn's disease: report of a case and analysis of T cell receptor V gene expression in the cutaneous and intestinal lesions.

Kano Y, Shiohara T, Yagita A, Nagashima M.

Department of Dermatology, Kyorin University School of Medicine, Tokyo, Japan.

Dermatology 1995;190(1):59-63 Abstract quote

A wide variety of cutaneous manifestations have been described in association with Crohn's disease (CD). We describe a patient with a 2-year history of CD who developed both lichen planus (LP) and lichen nitidus (LN) in addition to erythema nodosum (EN) lesions.

The clinical course of EN reflected the activity of the bowel disease, whereas LP and LN appeared to persist independently of the ongoing disease activity. Immunohistochemical studies of the infiltrates in these cutaneous and intestinal lesions showed that the majority of the infiltrates were T cells expressing T cell receptor (TCR)-alpha beta.

Analyses of TCR V gene expression in these infiltrating T cells demonstrated a different pattern of V beta expression that provides an explanation for the difference in the clinical courses of these lesions. LP and LN lesions are likely to be mediated by T cells with antigen specificity distinct from those that cause EN and intestinal lesions.

Crohn's disease and lichen nitidus: a case report and comparison of common histopathologic features.

Scheinfeld NS, Teplitz E, McClain SA.

Montefiore Hospital, Albert Einstein College of Medicine, Bronx, New York, USA.

Inflamm Bowel Dis 2001 Nov;7(4):314-8 Abstract quote

We describe a 54-year-old black woman with Crohn's disease, who developed lichen nitidus, the third report of a patient with both diseases.

The rarity of these diseases individually and the histopathologic features in common imply that the two diseases are linked. Multinucleated giant cells, a common finding in the lesions of Crohn's disease, are less common in the lesions of lichen nitidus. The presence of multinucleated giant cells in lichen nitidus in all three case reports is distinctly unusual. The infiltrates of Crohn's disease and lichen nitidus contain CD-68-positive macrophages. As such, the subset of lichen nitidus with giant cells should be recognized as a cutaneous manifestation of Crohn's disease.

LICHEN PLANUS

Generalized lichen nitidus appearing subsequent to lichen planus.

Kawakami T, Soma Y.

Division of Dermatology, Tokyo Metropolitan Police Hospital, Japan.

J Dermatol 1995 Jun;22(6):434-7 Abstract quote

A 27-year-old man was seen with multiple, small, shiny papules on his shoulders, upper arms, and trunk, and hyperpigmented violaceous plaques on his feet.

The former was diagnosed as generalized lichen nitidus and the latter, as lichen planus. It is not likely that the coexistence of the two diseases in this patient is a fortuitous one, since generalized lichen nitidus is a very rare condition.

The association of lichen nitidus and lichen planus suggests that lichen nitidus is closely related to lichen planus and that the two diseases may be different manifestations of essentially the same pathogenetic process.

CLINICAL VARIANTS CHARACTERIZATION

Lichen nitidus. A study of forty-three cases.

Lapins NA, Willoughby C, Helwig EB.

Cutis 1978 May;21(5):634-7 Abstract quote

Among forty-three cases of lichen nitidus studied, twenty-one patients were Caucasian, twenty-one were Negro, and one was Spanish-American, ranging in age from five to fifty-eight years. The arm, forearm, trunk, and genitalia were sites most commonly involved. Clinically, the eruption usually appeared as tiny papules.

Histologically, the papules showed a parakeratotoic "cap," epidermal atrophy, liquefaction degeneration of the basal layer, and a dermal infiltrate of lymphocytes, epithelioid cells, and sometimes giant cells.

FAMILIAL

Familial lichen nitidus.

Kato N.

Department of Dermatology, National Sapporo Hospital, Japan.

Clin Exp Dermatol 1995 Jul;20(4):336-8 Abstract quote

I report familial lichen nitidus in a 33-year-old father and his 3-year-old daughter. Histopathology of small papules in both cases revealed typical features of lichen nitidus. Immunohistochemical examination showed UCHL1-positive, L-26-negative lymphocytes and HAM56-positive histiocytes and multinucleated giant cells in the dermal infiltrate in both cases.

GENERALIZED

A case of generalized lichen nitidus with Koebner's phenomenon.

Maeda M.

Department of Dermatology, Gifu University School of Medicine, Japan.

J Dermatol 1994 Apr;21(4):273-7 Abstract quote

A 12-year-old boy was seen in our department with a three year history of eruptions on his back consisting of normal colored or slightly reddish, pinhead-sized papules, which had gradually spread to his trunk within the previous year.

Four days before the first visit, May 13, 1992, the eruption involved his entire extremities. On the back side of his lumbar region, Koebner's phenomenon was observed. He had received several medications for more than two years to treat this eruption in several hospitals, but none were effective. He was in good general health. Mantoux reaction was negative two months after BCG injection. Histopathologic features of the papules included focal epidermal hyperplasia and elongation of the rete ridges in a narrow area and a well demarcated dense lymphohistiocytic infiltrate on the papillar layer. Biscoclaurine alkaloids (20 mg/day) and Jumi-haidoku-to (TJ-6; 7.5 g/day) were administered to the patient after the biopsy. No topical ointments were applied.

Two weeks after of these treatments, he reported moderate pruritus on the back. The eruption diminished rapidly within 2 weeks after the therapy began. Almost all the eruptions were cured within one year. Mantoux reaction developed 8 x 8 mm erythema two and half months after the treatment began, and it was significantly positive (23 x 30 mm) 6 months later.

Generalized lichen nitidus: a case report.

Sysa-Jedrzejowska A, Wozniacka A, Robak E, Waszczykowska E.

Dermatology Department, Medical University of Lodz, Poland.

Cutis 1996 Aug;58(2):170-2 Abstract quote

We report the case of a 6-year-old boy with disseminated papular lesions.

Clinical and histopathologic examinations confirmed the diagnosis of lichen nitidus. There was no improvement during a three-year observation period, despite various methods of treatment. In the fourth year, we observed spontaneous resolution of the skin lesions after sun exposure in the summer.

Generalized lichen nitidus with oral and nail involvement in a child.

Bettoli V, De Padova MP, Corazza M, Virgili A.

Clinica Dermatologica, Universita degli Studi di Ferrara, Italia.

Dermatology 1997;194(4):367-9 Abstract quote

The generalized form of lichen nitidus (LN) with oral and nail changes is extremely rare in childhood.

We report a 10-year-old boy with generalized LN associated with oral involvement and onychodystrophy. Oral lesions showed yellowish papules on the gums. The nails had longitudinal striations and pits on the finger-nails, and transversal ridging of the big toes was found. Cutaneous and mucosal lesions as well as onychodystrophy spontaneously cleared within 8 months.

Generalized lichen nitidus: case report and literature review.

Soroush V, Gurevitch AW, Peng SK.

Division of Dermatology, Harbor-UCLA Medical Center, Torrance, California 90509, USA.

Cutis 1999 Aug;64(2):135-6 Abstract quote

Lichen nitidus is a rare condition of unknown cause, characterized by minute, flesh-colored, shiny papules occurring on the genitalia, abdomen, chest, and extremities. This disorder is most often localized, but a few cases of generalized lichen nitidus have been reported.

We describe a young patient with a 1.5-year history of unremitting generalized lichen nitidus.

PALMOPLANTAR HYPERKERATOSIS

Lichen nitidus presenting as palmoplantar hyperkeratosis and nail dystrophy.

Munro CS, Cox NH, Marks JM, Natarajan S.

Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne, UK.

Clin Exp Dermatol 1993 Jul;18(4):381-3 Abstract quote

Four patients with lichen nitidus who presented with palmoplantar or nail lesions are reported. In three cases palmoplantar hyperkeratosis was marked; these cases also had nail-plate lesions, but in all four, lesions of lichen nitidus at other sites were absent, sparse or asymptomatic.

HISTOPATHOLOGICAL VARIANTS CHARACTERIZATION

GENERAL

Lichen nitidus: electron microscopic and immunofluorescence studies.

Clausen J, Jacobsen FK, Brandrup F.

Acta Derm Venereol 1982;62(1):15-9 Abstract quote

Skin biopsies from a patient suffering from lichen nitidus were studied by electron microscopy and immunofluorescence studies.

Complete disintegration of the stratum basale in the central area of the lesion and signs of acantholysis in the border area were found. In the central part of the lesion the dermo-epidermal junction was severely damaged in most places. In the dermal infiltrate, macrophages and lymphocytes were found with a considerable representation of Sezary cells, not previously reported in lichen nitidus. The ultrastructural changes are identical with those found in lichen planus.

No in vivo bound immunoglobulins, fibrinogen, or complement C3 were found.

Lichen nitidus: a histologic and electron microscopic study.

Mihara M, Nakayama H, Shimao S.

Department of Dermatology, Faculty of Medicine, Tottori University, Yonago, Japan.

J Dermatol 1991 Aug;18(8):475-80 Abstract quote

A lesion of lichen nitidus in a 53-year-old man was examined by histology and electron microscopy.

The histology showed typical features. The electron microscopy revealed primary changes in hydropic degeneration of basal cells which possibly indicated severe edema between the basal keratinocytes and in the subepidermal area. The basal keratinocytes themselves were not particularly altered, except for clustered micro-vacuolar structures in a small portion of the peripheral cytoplasm. In one of the eight blocks observed, the cytoplasmic process of a mast cell was found between the basal keratinocytes, indicating that mast cells may possibly infiltrate the epidermis in lichen nitidus. Scattered mast cells in the dermis were also noted.

Thus primary pathologic changes of lichen nitidus may be induced by severe edema, which was accompanied by inflammatory cells including mast cells, in the region of the dermal-epidermal junction.

GRANULOMAS, PERIFOLLICULAR

Spinous, follicular lichen nitidus associated with perifollicular granulomas.

Madhok R, Winkelmann RK.

Department of Dermatology, Mayo Clinic, Rochester, Minnesota 55905.

J Cutan Pathol 1988 Aug;15(4):245-8 Abstract quote

This is the first report of spinous and follicular lichen nitidus associated with perifollicular granuloma formation. Clinicians and pathologists need to distinguish this stage of the disease from lichen scrofulosorum.

HYPERTROPHIC

Lichen nitidus of the palms: a case with peculiar histopathologic features.

De Eusebio Murillo E, Sanchez Yus E, Novo Lens R.

Department of Dermatology, Hospital Clinico San Carlos, Madrid, Spain.

Am J Dermatopathol 1999 Apr;21(2):161-4 Abstract quote

Palmar involvement in lichen nitidus is infrequent. In such cases, the histopathologic findings of palmar lesions are usually identical to those of extrapalmar ones.

We report on the case of a patient with multiple tiny papules located on the palms and elbows. A biopsy specimen from the elbow showed the typical features of lichen nitidus, but a biopsy from the palm disclosed an inflammatory infiltrate mostly disposed around the bases of rete ridges and composed of lymphocytes and histiocytes with some giant cells both in the dermis and in the epidermis. This location of the infiltrate is similar to that found in hypertrophic lichen planus, a combination of lichen planus and lichen simplex chronicus.

We conclude that this histopathologic feature in palmar lichen nitidus could be the result of the superimposition of lichen nitidus on normal palmar skin, resulting in a picture resembling hypertrophic lichen planus.

PERFORATING

Perforating lichen nitidus.

Itami A, Ando I, Kukita A.

Department of Dermatology, Teikyo University, Mizonokuchi Hospital, Kawasaki, Japan.

Int J Dermatol 1994 May;33(5):382-4 Abstract quote

A 32-year-old man with no particular family history nor past history visited our clinic in September 1992, with papules that he claimed had developed approximately 3 years earlier.

No subjective symptoms accompanied then. On examination, numerous, discrete, pinhead-sized or half-ricecorn-sized, flesh-colored papules were observed on the dorsolateral side of his left hand and fingers. No central dimple or scaling were noticed clinically (Fig. 1).

Laboratory tests revealed no abnormal findings. The histopathology of the biopsied specimen showed a circumscribed nest of infiltrating cells closely attached to the epidermis (Fig. 2). These infiltrating cells consisted of mononuclear lymphoid cells and histiocytes. The overlying epidermis was stretched and atrophic. A transepithelial perforation channel existed in direct contact with the surface. Amorphous debris containing cell nuclei lay within the channel (Fig. 2). Lymphoid cells were also observed above the keratin layer overlying the channel. At the lateral margin of the infiltrate, rete ridges extended downward in the manner of a claw clutching a ball. In a periodic-acid-Schiff (PAS)-stained section, a basement defect was observed around the channel.

PERIAPPENDAGEAL

Periappendageal lichen nitidus: report of a case

Scott Sanders
De Anne H. Collier
Rachelle Scott
Hong Wu and N. Scott McNutt J Cutan Pathol 2002;29:125-128 Abstract quote

Background:The histology of lichen nitidus has been described previously but a follicular variant has not been emphasized.
Method:We report a case of lichen nitidus with periappendageal inflammation resulting in histologic similarities to lichen striatus.

Results:This case extends the spectrum of histologic findings in lichen nitidus and shows overlap in the distribution of the inflammatory infiltrate in lichen nitidus and lichen striatus.

SPECIAL STAINS/IMMUNOHISTOCHEMISTRY CHARACTERIZATION

An immunophenotypic study of lichen nitidus.

Wright AL, McVittie E, Hunter JA.

Department of Dermatology, Royal Hallamshire Hospital, Sheffield, UK.

Clin Exp Dermatol 1990 Jul;15(4):273-6 Abstract quote

Skin biopsies from three patients with lichen nitidus were studied using a battery of monoclonal antibodies against cells in the dermal infiltrate. In each case the findings were identical with a marked excess of CD4+ cells over CD8+ cells and the presence of large numbers of CD1+ cells.

These results are very similar to those seen in lichen planus reinforcing the association between these two conditions.

Immunohistochemical examination of lichen nitidus suggests that it is not a localized papular variant of lichen planus.

Smoller BR, Flynn TC.

Department of Dermatology, Stanford University Medical Center, CA 94305.

J Am Acad Dermatol 1992 Aug;27(2 Pt 1):232-6 Abstract quote

BACKGROUND: Lichen nitidus is believed, by some, to be a variant of lichen planus, and by others to be a distinct entity.

OBJECTIVE: We examined five cases of lichen nitidus with immunohistochemical reagents designed to characterize the dermal inflammatory infiltrate in an attempt to resolve the uncertainty.

METHODS: We stained formalin-fixed, paraffin-embedded tissue sections with the following antibodies: L26, A6, KP1, BerH2, OPD4, and HECA-452.

RESULTS: The inflammatory infiltrate was 90% A6+, with few L26+ cells. In contrast to lichen planus, KP1+ macrophages were seen and fewer of the lymphocytes demonstrated HECA-452. Fifty percent to 80% of lymphocytes were OPD4 positive, similar to that usually seen in lichen planus. Rare Ki-1+ cells were seen in one case.

CONCLUSION: We believe that the pattern of a mixed cellular infiltrate characterized by macrophages and a helper T cell response with few HECA-452+ cells is somewhat different from the pattern seen in lichen planus, wherein almost all of the cells are CD4+/HECA-452+ lymphocytes. This suggests a different immunologic pathogenesis.

DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES

GIANT CELL LICHENOID DERMATITIS

Giant cell lichenoid dermatitis: a possible manifestation of sarcoidosis.

Goldberg LJ, Goldberg N, Abrahams I, Silvers DN, Szaniawski W, Halperin AJ.

Division of Dermatology, Albert Einstein College of Medicine, New York, NY.

J Cutan Pathol 1994 Feb;21(1):47-51 Abstract quote

Giant cell lichenoid dermatitis is a recently described dermatosis thought to be an unusual lichenoid drug eruption. It is characterized by a generalized, pruritic, papulosquamous eruption sparing palms, soles, face and mucous membranes.

Histopathologic findings include areas of epidermal hyperplasia and atrophy with focal vacuolar alteration of the basal layer, exocytosis and cytoid body formation. The dermis contains a band-like, mononuclear cell infiltrate at the dermoepidermal junction with admixed eosinophils, plasma cells and large multinucleate cells. The histologic differential diagnosis includes infectious processes, sarcoidosis, lichen nitidus, lupus erythematosus and lichen planus.

We report 3 patients with giant cell lichenoid dermatitis, one of whom was subsequently diagnosed as having sarcoidosis. Because giant cell lichenoid dermatitis may resemble sarcoidosis both clinically and histologically, and because cutaneous sarcoid is often associated with systemic involvement, the diagnosis of sarcoid should be strongly considered in patients with giant cell lichenoid dermatitis

LICHENOID DERMATITIS

Lichenoid and granulomatous dermatitis.

Magro CM, Crowson AN.

Department of Pathology, Cell Biology, and Anatomy, Medical College of Thomas Jefferson University, Philadelphia, PA, USA.

Int J Dermatol 2000 Feb;39(2):126-33 Abstract quote

BACKGROUND: The prototypic lichenoid eruptions, lichen planus (LP), lichenoid drug eruptions, secondary syphilis, and collagen vascular disease, are defined histologically by a band-like lymphocytic infiltrate in close apposition to the epidermis. We describe a novel form of lichenoid dermatitis with a granulomatous component.

DESIGN: Skin biopsies from 40 patients demonstrating a band-like lymphocytic infiltrate with concomitant granulomatous inflammation were encountered over 4 years. Clinicians were contacted to elucidate underlying triggers and medical illnesses.

RESULTS: A lichenoid dermatitis, a linear eruption, vasculitis, annular erythema, and erythroderma were among the clinical presentations. A drug-based etiology was implicated in 14 cases: the drugs included antibiotics, lipid-lowering agents, anti-inflammatory drugs, antihistamines, hydroxychloroquine sulfate, and angiotensin-converting enzyme inhibitors. Over one-third of patients with drug-related eruptions had other medical illnesses associated with cutaneous granulomatous inflammation, namely rheumatoid arthritis (RA), Crohn's disease, hepatitis C, diabetes mellitus, and thyroiditis. A microbial trigger was implicated in 12 patients in the context of infective id reactions to herpes zoster, Epstein-Barr virus (EBV), or streptococci, or active infections by Mycobacterium tuberculosis, M. leprae, fungi, and spirochetes. The remainder had hepatobiliary disease and RA without obvious exogenous triggers, cutaneous T-cell lymphoma (CTCL), and idiopathic lichenoid eruptions (i.e. LP, lichen nitidus, and lichen striatus). One patient with LP had underlying multicentric reticulohistiocytosis. The histiocytic infiltrate assumed one or more of five light microscopic patterns: (i) superficially disposed loose histiocytic aggregates; (ii) cohesive granulomata within zones of band-like lymphocytic infiltration with or without deeper dermal extension; (iii) a diffuse interstitial pattern; (iv) scattered singly disposed giant cells; and (v) granulomatous vasculitis. Additional features included lymphocytic eccrine hidradenitis in those patients with drug reactions, hepatobiliary disease, and antecedent viral illnesses, tissue eosinophilia and erythrocyte extravasation in drug hypersensitivity, granulomatous vasculitis in patients with microbial triggers, drug hypersensitivity or RA, and lymphoid atypia in lesions of CTCL or drug hypersensitivity.

CONCLUSIONS: The cutaneous lichenoid and granulomatous reaction may reflect hepatobiliary disease, endocrinopathy, RA, Crohn's disease, infection, or a drug reaction. One-fifth of cases represent idiopathic lichenoid disorders. Lymphoproliferative disease or pseudolymphomatous drug reactions must be considered in those cases showing lymphoid atypia.

Lichen scrofulosorum Granulomas are in the papillary dermis and/or the upper part of the reticular dermis
No widening of the dermal papillae

SARCOIDOSIS

Micropapular sarcoidosis simulating lichen nitidus.

Okamoto H, Horio T, Izumi T.

Dermatologica 1985;170(5):253-5 Abstract quote

A 28-year-old woman with sarcoidosis had military, skin-colored papules localized on the upper back. The lesions closely simulated lichen nitidus. Histologic examination of the papule demonstrated the naked granuloma encircled by epidermal collarettes in the papillary dermis. Therefore, the microscopic reaction pattern also resembled those of lichen nitidus.

This case is a unique form of micropapular sarcoidosis in respect to the clinical appearance and microscopic changes.

PROGNOSIS AND TREATMENT CHARACTERIZATION

ASTEMIZOLE

Generalized lichen nitidus. Report of two cases treated with astemizol.

Ocampo J, Torne R.

Department of Dermatology, General Hospital of Catalunya San Cugat del Valles, Barcelona, Spain.

Int J Dermatol 1989 Jan-Feb;28(1):49-51 Abstract quote

Two patients, one man aged 65 and one woman aged 48, presenting generalized lichen nitidus are reported.

The clinical and histopathologic features of this uncommon presentation of lichen nitidus are illustrated as well as the excellent clinical response to the treatment with an H1-blocking antihistaminic (astemizol).

DNCB

Improvement of lichen nitidus after topical dinitrochlorobenzene application.

Kano Y, Otake Y, Shiohara T.

Department of Dermatology, Kyorin University School of Medicine, Tokyo, Japan.

J Am Acad Dermatol 1998 Aug;39(2 Pt 2):305-8 Abstract quote

Recently, a relationship between immunologic alterations and the development of lichen nitidus (LN) lesions has been described. We treated LN lesions with topical dinitrochlorobenzene (DNCB) application in a patient with peripheral CD4+ T lymphocytopenia. After 4 months, the eruption cleared. We investigated histologically and immunohistochemically biopsy specimens obtained before and after treatment.

Our result suggests that local alterations of the pattern of cells and cytokines by topical DNCB application could have contributed to the resolution of the LN lesions.

ITRACONAZOLE

Treatment of lichen planus and lichen nitidus with itraconazole: reports of six cases.

Libow LF, Coots NV.

Department of Medicine, Dermatology Service, United States Army MEDDAC, Wurzburg, Germany.

Cutis 1998 Nov;62(5):247-8 Abstract quote

Six patients with either lichen planus or lichen nitidus were treated with itraconazole. Two of four patients with lichen planus experienced complete clearing, and the remainder showed a partial response.

Itraconazole, like griseofulvin, may prove to be an alternative treatment worth considering in patients with lichen planus or lichen nitidus who have failed other therapies.

PUVA

Treatment of generalized lichen nitidus with PUVA.

Randle HW, Sander HM.

Int J Dermatol 1986 Jun;25(5):330-1 Abstract quote

Generalized lichen nitidus refractory to topical and systemic corticosteroids completely responded to PUVA. The similarity of lichen nitidus to lichen planus and the presumed lymphocytotoxic effect of PUVA were the bases for our use of oral photochemotherapy.

Weedon D. Weedon's Skin Pathology. Churchill Livingstone. 1997.

Commonly Used Terms

Ball and claw-Distinctive lichenoid tissue reaction with the lichenoid infiltrate encircled by a claw-like extension of the epidermis.

Lichenoid dermatosis

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Last Updated 4/18/2002

DISEASE ASSOCIATIONS	CHARACTERIZATION
AMENORRHEA
Recurrent generalized lichen nitidus associated with amenorrhea. Taniguchi S, Chanoki M, Hamada T. Department of Dermatology, Osaka City University Medical School, Japan.	Acta Derm Venereol 1994 May;74(3):224-5 Abstract quote A case of recurrent generalized lichen nitidus is reported. The eruptions developed in the proliferative phase of the menstrual cycle, but there has been a marked improvement after administration of estrogen and progesterone for the treatment of amenorrhea. Hormonal factors may play a role in the development of lichenoid tissue reaction in the lesions of this disease.
ATOPIC DERMATITIS
Coexistence of atopic dermatitis and lichen nitidus in three patients. Lestringant GG, Piletta P, Feldmann R, Galadari I, Frossard PM, Saurat JH. Department of Dermatology, Tawam Hospital, Al Ain, United Arab Emirates.	Dermatology 1996;192(2):171-3 Abstract quote Lichen nitidus (LN) is an uncommon skin disorder. We observed 3 patients with an association of lichen nitidus and atopic dermatitis (AD), which to the best of our knowledge has not been previously reported in the literature. It remains to be evaluated whether the association of LN and AD is fortuitous or not.
CROHN'S DISEASE
Erythema nodosum, lichen planus and lichen nitidus in Crohn's disease: report of a case and analysis of T cell receptor V gene expression in the cutaneous and intestinal lesions. Kano Y, Shiohara T, Yagita A, Nagashima M. Department of Dermatology, Kyorin University School of Medicine, Tokyo, Japan.	Dermatology 1995;190(1):59-63 Abstract quote A wide variety of cutaneous manifestations have been described in association with Crohn's disease (CD). We describe a patient with a 2-year history of CD who developed both lichen planus (LP) and lichen nitidus (LN) in addition to erythema nodosum (EN) lesions. The clinical course of EN reflected the activity of the bowel disease, whereas LP and LN appeared to persist independently of the ongoing disease activity. Immunohistochemical studies of the infiltrates in these cutaneous and intestinal lesions showed that the majority of the infiltrates were T cells expressing T cell receptor (TCR)-alpha beta. Analyses of TCR V gene expression in these infiltrating T cells demonstrated a different pattern of V beta expression that provides an explanation for the difference in the clinical courses of these lesions. LP and LN lesions are likely to be mediated by T cells with antigen specificity distinct from those that cause EN and intestinal lesions.
Crohn's disease and lichen nitidus: a case report and comparison of common histopathologic features. Scheinfeld NS, Teplitz E, McClain SA. Montefiore Hospital, Albert Einstein College of Medicine, Bronx, New York, USA.	Inflamm Bowel Dis 2001 Nov;7(4):314-8 Abstract quote We describe a 54-year-old black woman with Crohn's disease, who developed lichen nitidus, the third report of a patient with both diseases. The rarity of these diseases individually and the histopathologic features in common imply that the two diseases are linked. Multinucleated giant cells, a common finding in the lesions of Crohn's disease, are less common in the lesions of lichen nitidus. The presence of multinucleated giant cells in lichen nitidus in all three case reports is distinctly unusual. The infiltrates of Crohn's disease and lichen nitidus contain CD-68-positive macrophages. As such, the subset of lichen nitidus with giant cells should be recognized as a cutaneous manifestation of Crohn's disease.
LICHEN PLANUS
Generalized lichen nitidus appearing subsequent to lichen planus. Kawakami T, Soma Y. Division of Dermatology, Tokyo Metropolitan Police Hospital, Japan.	J Dermatol 1995 Jun;22(6):434-7 Abstract quote A 27-year-old man was seen with multiple, small, shiny papules on his shoulders, upper arms, and trunk, and hyperpigmented violaceous plaques on his feet. The former was diagnosed as generalized lichen nitidus and the latter, as lichen planus. It is not likely that the coexistence of the two diseases in this patient is a fortuitous one, since generalized lichen nitidus is a very rare condition. The association of lichen nitidus and lichen planus suggests that lichen nitidus is closely related to lichen planus and that the two diseases may be different manifestations of essentially the same pathogenetic process.

HISTOPATHOLOGICAL VARIANTS	CHARACTERIZATION
GENERAL
Lichen nitidus: electron microscopic and immunofluorescence studies. Clausen J, Jacobsen FK, Brandrup F.	Acta Derm Venereol 1982;62(1):15-9 Abstract quote Skin biopsies from a patient suffering from lichen nitidus were studied by electron microscopy and immunofluorescence studies. Complete disintegration of the stratum basale in the central area of the lesion and signs of acantholysis in the border area were found. In the central part of the lesion the dermo-epidermal junction was severely damaged in most places. In the dermal infiltrate, macrophages and lymphocytes were found with a considerable representation of Sezary cells, not previously reported in lichen nitidus. The ultrastructural changes are identical with those found in lichen planus. No in vivo bound immunoglobulins, fibrinogen, or complement C3 were found.
Lichen nitidus: a histologic and electron microscopic study. Mihara M, Nakayama H, Shimao S. Department of Dermatology, Faculty of Medicine, Tottori University, Yonago, Japan.	J Dermatol 1991 Aug;18(8):475-80 Abstract quote A lesion of lichen nitidus in a 53-year-old man was examined by histology and electron microscopy. The histology showed typical features. The electron microscopy revealed primary changes in hydropic degeneration of basal cells which possibly indicated severe edema between the basal keratinocytes and in the subepidermal area. The basal keratinocytes themselves were not particularly altered, except for clustered micro-vacuolar structures in a small portion of the peripheral cytoplasm. In one of the eight blocks observed, the cytoplasmic process of a mast cell was found between the basal keratinocytes, indicating that mast cells may possibly infiltrate the epidermis in lichen nitidus. Scattered mast cells in the dermis were also noted. Thus primary pathologic changes of lichen nitidus may be induced by severe edema, which was accompanied by inflammatory cells including mast cells, in the region of the dermal-epidermal junction.
GRANULOMAS, PERIFOLLICULAR
Spinous, follicular lichen nitidus associated with perifollicular granulomas. Madhok R, Winkelmann RK. Department of Dermatology, Mayo Clinic, Rochester, Minnesota 55905.	J Cutan Pathol 1988 Aug;15(4):245-8 Abstract quote This is the first report of spinous and follicular lichen nitidus associated with perifollicular granuloma formation. Clinicians and pathologists need to distinguish this stage of the disease from lichen scrofulosorum.
HYPERTROPHIC
Lichen nitidus of the palms: a case with peculiar histopathologic features. De Eusebio Murillo E, Sanchez Yus E, Novo Lens R. Department of Dermatology, Hospital Clinico San Carlos, Madrid, Spain.	Am J Dermatopathol 1999 Apr;21(2):161-4 Abstract quote Palmar involvement in lichen nitidus is infrequent. In such cases, the histopathologic findings of palmar lesions are usually identical to those of extrapalmar ones. We report on the case of a patient with multiple tiny papules located on the palms and elbows. A biopsy specimen from the elbow showed the typical features of lichen nitidus, but a biopsy from the palm disclosed an inflammatory infiltrate mostly disposed around the bases of rete ridges and composed of lymphocytes and histiocytes with some giant cells both in the dermis and in the epidermis. This location of the infiltrate is similar to that found in hypertrophic lichen planus, a combination of lichen planus and lichen simplex chronicus. We conclude that this histopathologic feature in palmar lichen nitidus could be the result of the superimposition of lichen nitidus on normal palmar skin, resulting in a picture resembling hypertrophic lichen planus.
PERFORATING
Perforating lichen nitidus. Itami A, Ando I, Kukita A. Department of Dermatology, Teikyo University, Mizonokuchi Hospital, Kawasaki, Japan.	Int J Dermatol 1994 May;33(5):382-4 Abstract quote A 32-year-old man with no particular family history nor past history visited our clinic in September 1992, with papules that he claimed had developed approximately 3 years earlier. No subjective symptoms accompanied then. On examination, numerous, discrete, pinhead-sized or half-ricecorn-sized, flesh-colored papules were observed on the dorsolateral side of his left hand and fingers. No central dimple or scaling were noticed clinically (Fig. 1). Laboratory tests revealed no abnormal findings. The histopathology of the biopsied specimen showed a circumscribed nest of infiltrating cells closely attached to the epidermis (Fig. 2). These infiltrating cells consisted of mononuclear lymphoid cells and histiocytes. The overlying epidermis was stretched and atrophic. A transepithelial perforation channel existed in direct contact with the surface. Amorphous debris containing cell nuclei lay within the channel (Fig. 2). Lymphoid cells were also observed above the keratin layer overlying the channel. At the lateral margin of the infiltrate, rete ridges extended downward in the manner of a claw clutching a ball. In a periodic-acid-Schiff (PAS)-stained section, a basement defect was observed around the channel.
PERIAPPENDAGEAL
Periappendageal lichen nitidus: report of a case Scott Sanders De Anne H. Collier Rachelle Scott Hong Wu and N. Scott McNutt	J Cutan Pathol 2002;29:125-128 Abstract quote Background:The histology of lichen nitidus has been described previously but a follicular variant has not been emphasized. Method:We report a case of lichen nitidus with periappendageal inflammation resulting in histologic similarities to lichen striatus. Results:This case extends the spectrum of histologic findings in lichen nitidus and shows overlap in the distribution of the inflammatory infiltrate in lichen nitidus and lichen striatus.

DIFFERENTIAL DIAGNOSIS	KEY DIFFERENTIATING FEATURES
GIANT CELL LICHENOID DERMATITIS
Giant cell lichenoid dermatitis: a possible manifestation of sarcoidosis. Goldberg LJ, Goldberg N, Abrahams I, Silvers DN, Szaniawski W, Halperin AJ. Division of Dermatology, Albert Einstein College of Medicine, New York, NY.	J Cutan Pathol 1994 Feb;21(1):47-51 Abstract quote Giant cell lichenoid dermatitis is a recently described dermatosis thought to be an unusual lichenoid drug eruption. It is characterized by a generalized, pruritic, papulosquamous eruption sparing palms, soles, face and mucous membranes. Histopathologic findings include areas of epidermal hyperplasia and atrophy with focal vacuolar alteration of the basal layer, exocytosis and cytoid body formation. The dermis contains a band-like, mononuclear cell infiltrate at the dermoepidermal junction with admixed eosinophils, plasma cells and large multinucleate cells. The histologic differential diagnosis includes infectious processes, sarcoidosis, lichen nitidus, lupus erythematosus and lichen planus. We report 3 patients with giant cell lichenoid dermatitis, one of whom was subsequently diagnosed as having sarcoidosis. Because giant cell lichenoid dermatitis may resemble sarcoidosis both clinically and histologically, and because cutaneous sarcoid is often associated with systemic involvement, the diagnosis of sarcoid should be strongly considered in patients with giant cell lichenoid dermatitis
LICHENOID DERMATITIS
Lichenoid and granulomatous dermatitis. Magro CM, Crowson AN. Department of Pathology, Cell Biology, and Anatomy, Medical College of Thomas Jefferson University, Philadelphia, PA, USA.	Int J Dermatol 2000 Feb;39(2):126-33 Abstract quote BACKGROUND: The prototypic lichenoid eruptions, lichen planus (LP), lichenoid drug eruptions, secondary syphilis, and collagen vascular disease, are defined histologically by a band-like lymphocytic infiltrate in close apposition to the epidermis. We describe a novel form of lichenoid dermatitis with a granulomatous component. DESIGN: Skin biopsies from 40 patients demonstrating a band-like lymphocytic infiltrate with concomitant granulomatous inflammation were encountered over 4 years. Clinicians were contacted to elucidate underlying triggers and medical illnesses. RESULTS: A lichenoid dermatitis, a linear eruption, vasculitis, annular erythema, and erythroderma were among the clinical presentations. A drug-based etiology was implicated in 14 cases: the drugs included antibiotics, lipid-lowering agents, anti-inflammatory drugs, antihistamines, hydroxychloroquine sulfate, and angiotensin-converting enzyme inhibitors. Over one-third of patients with drug-related eruptions had other medical illnesses associated with cutaneous granulomatous inflammation, namely rheumatoid arthritis (RA), Crohn's disease, hepatitis C, diabetes mellitus, and thyroiditis. A microbial trigger was implicated in 12 patients in the context of infective id reactions to herpes zoster, Epstein-Barr virus (EBV), or streptococci, or active infections by Mycobacterium tuberculosis, M. leprae, fungi, and spirochetes. The remainder had hepatobiliary disease and RA without obvious exogenous triggers, cutaneous T-cell lymphoma (CTCL), and idiopathic lichenoid eruptions (i.e. LP, lichen nitidus, and lichen striatus). One patient with LP had underlying multicentric reticulohistiocytosis. The histiocytic infiltrate assumed one or more of five light microscopic patterns: (i) superficially disposed loose histiocytic aggregates; (ii) cohesive granulomata within zones of band-like lymphocytic infiltration with or without deeper dermal extension; (iii) a diffuse interstitial pattern; (iv) scattered singly disposed giant cells; and (v) granulomatous vasculitis. Additional features included lymphocytic eccrine hidradenitis in those patients with drug reactions, hepatobiliary disease, and antecedent viral illnesses, tissue eosinophilia and erythrocyte extravasation in drug hypersensitivity, granulomatous vasculitis in patients with microbial triggers, drug hypersensitivity or RA, and lymphoid atypia in lesions of CTCL or drug hypersensitivity. CONCLUSIONS: The cutaneous lichenoid and granulomatous reaction may reflect hepatobiliary disease, endocrinopathy, RA, Crohn's disease, infection, or a drug reaction. One-fifth of cases represent idiopathic lichenoid disorders. Lymphoproliferative disease or pseudolymphomatous drug reactions must be considered in those cases showing lymphoid atypia.
Lichen scrofulosorum	Granulomas are in the papillary dermis and/or the upper part of the reticular dermis No widening of the dermal papillae
SARCOIDOSIS
Micropapular sarcoidosis simulating lichen nitidus. Okamoto H, Horio T, Izumi T.	Dermatologica 1985;170(5):253-5 Abstract quote A 28-year-old woman with sarcoidosis had military, skin-colored papules localized on the upper back. The lesions closely simulated lichen nitidus. Histologic examination of the papule demonstrated the naked granuloma encircled by epidermal collarettes in the papillary dermis. Therefore, the microscopic reaction pattern also resembled those of lichen nitidus. This case is a unique form of micropapular sarcoidosis in respect to the clinical appearance and microscopic changes.

PROGNOSIS AND TREATMENT	CHARACTERIZATION
ASTEMIZOLE
Generalized lichen nitidus. Report of two cases treated with astemizol. Ocampo J, Torne R. Department of Dermatology, General Hospital of Catalunya San Cugat del Valles, Barcelona, Spain.	Int J Dermatol 1989 Jan-Feb;28(1):49-51 Abstract quote Two patients, one man aged 65 and one woman aged 48, presenting generalized lichen nitidus are reported. The clinical and histopathologic features of this uncommon presentation of lichen nitidus are illustrated as well as the excellent clinical response to the treatment with an H1-blocking antihistaminic (astemizol).
DNCB
Improvement of lichen nitidus after topical dinitrochlorobenzene application. Kano Y, Otake Y, Shiohara T. Department of Dermatology, Kyorin University School of Medicine, Tokyo, Japan.	J Am Acad Dermatol 1998 Aug;39(2 Pt 2):305-8 Abstract quote Recently, a relationship between immunologic alterations and the development of lichen nitidus (LN) lesions has been described. We treated LN lesions with topical dinitrochlorobenzene (DNCB) application in a patient with peripheral CD4+ T lymphocytopenia. After 4 months, the eruption cleared. We investigated histologically and immunohistochemically biopsy specimens obtained before and after treatment. Our result suggests that local alterations of the pattern of cells and cytokines by topical DNCB application could have contributed to the resolution of the LN lesions.
ITRACONAZOLE
Treatment of lichen planus and lichen nitidus with itraconazole: reports of six cases. Libow LF, Coots NV. Department of Medicine, Dermatology Service, United States Army MEDDAC, Wurzburg, Germany.	Cutis 1998 Nov;62(5):247-8 Abstract quote Six patients with either lichen planus or lichen nitidus were treated with itraconazole. Two of four patients with lichen planus experienced complete clearing, and the remainder showed a partial response. Itraconazole, like griseofulvin, may prove to be an alternative treatment worth considering in patients with lichen planus or lichen nitidus who have failed other therapies.
PUVA
Treatment of generalized lichen nitidus with PUVA. Randle HW, Sander HM.	Int J Dermatol 1986 Jun;25(5):330-1 Abstract quote Generalized lichen nitidus refractory to topical and systemic corticosteroids completely responded to PUVA. The similarity of lichen nitidus to lichen planus and the presumed lymphocytotoxic effect of PUVA were the bases for our use of oral photochemotherapy.