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AUTHOR AND EDITOR INFORMATION

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Author: Zeina Tannous, MD, Consulting Staff, Department of Dermatology, Massachusetts General Hospital, Harvard Medical School

Zeina Tannous is a member of the following medical societies: Alpha Omega Alpha

Coauthor(s): Nelly Rubeiz, MD, Consulting Staff, Department of Dermatology, American University of Beirut Medical Center; Associate Professor, Department of Dermatology, American University of Beirut, Lebanon

Editors: David P Fivenson, MD, Associate Director, St Joseph Mercy Hospital Dermatology Program, Ann Arbor, Michigan; Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center; Warren R Heymann, MD, Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey; Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University; William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

Author and Editor Disclosure

Synonyms and related keywords: flat-topped lesions, Köbner phenomenon, Koebner phenomenon, isomorphic response

INTRODUCTION

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Background

Lichen nitidus is a relatively rare, chronic skin eruption that is characterized clinically by asymptomatic, flat-topped, skin-colored micropapules. Lichen nitidus mainly affects children and young adults.

Pathophysiology

The skin is the primary organ system affected. Mucous membranes and nails1 also might be involved. Lichen planus can clinically mimic lichen nitidus and can sometimes coexist with lichen nitidus.

Frequency

International

The frequency of lichen nitidus is unknown because of its uncommon occurrence. In a study of skin diseases in blacks over a 25-year period, the incidence of lichen nitidus was 0.034%.2

Mortality/Morbidity

Lichen nitidus is a benign disease with no associated mortality or complications.

Race

No racial predilection is reported.

Sex

No sexual predilection exists. However, generalized variants appear to occur predominantly in females.

Age

Lichen nitidus may affect any age group, but it most commonly develops in childhood or early adulthood.


CLINICAL

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History

  • Lichen nitidus is usually an asymptomatic eruption; however, patients occasionally complain of pruritus.
  • Familial cases have been described.3

Physical

  • The primary lesions consist of multiple 1- to 3-mm, sharply demarcated, round or polygonal, flat-topped, skin-colored shiny papules that often appear in groups.
  • The Köbner phenomenon (or an isomorphic response) may be observed. This phenomenon causes the occasional linear pattern of the lesions associated with lichen nitidus.
  • The most common sites of involvement are the trunk, flexor aspects of upper extremities, dorsal aspects of hands, and genitalia. Infrequently, the lower extremities, palms, soles, face, nails, and mucous membranes may be affected. Nail changes include pitting, ridging, splitting, and linear striations.
  • Clinical variants of lichen nitidus include generalized,4 linear, actinic,5 perforating,6, 7 keratodermic,8, 9 vesicular,10 and purpuric7/hemorrhagic10 forms.
  • Reported associated diseases include atopic dermatitis,11 lichen planus,12 condyloma,13 amenorrhea,14 Crohn disease,15, 16 and juvenile chronic arthritis.17

Causes

  • The cause of lichen nitidus is unknown. Controversy exists regarding the relationship between lichen planus and lichen nitidus.


DIFFERENTIALS

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Amyloidosis, Lichen
Bowenoid Papulosis
Id Reaction (Autoeczematization)
Keratosis Pilaris
Lichen Planus
Lichen Sclerosus et Atrophicus
Lichen Spinulosus
Lichen Striatus
Psoriasis, Guttate
Sarcoidosis
Warts, Nongenital

Other Problems to be Considered

Lichen scrofulosorum


WORKUP

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Procedures

A skin biopsy for histopathologic examination may be obtained to confirm the clinical diagnosis.

Histologic Findings

The papule of lichen nitidus consists of a lymphohistiocytic inflammatory cell infiltrate that lies in close proximity to the epidermis and is associated with basal cell hydropic degeneration. The overlying epidermis is flattened and parakeratotic. At the lateral margins of the papule, the rete ridges extend downward and seem to hug the inflammatory infiltrate, which may be granulomatous.


MEDICATION

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No therapeutic modality has been rigorously evaluated for the treatment of lichen nitidus because of the rarity, lack of significant symptomatology, and disappearance of this disease within 1 or several years. Reported therapies, mostly from isolated case reports, include topical and systemic steroids, topical tacrolimus,18 systemic cetirizine,19 levamisole,19 etretinate, acitretin,20 itraconazole,21 cyclosporine, topical dinitrochlorobenzene,22 psoralen plus UV-A light,23 and narrow-band UV-B light.24, 25, 26

Drug Category: Corticosteroids

Have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

Drug NamePrednisone (Deltasone)
DescriptionMay decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult Dose0.05-2 mg/kg/d PO divided bid/qid; not to exceed 80 mg/d or divided bid/qid; taper over 1-2 wk, as symptoms resolve
Pediatric Dose4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2 wk, as symptoms resolve
ContraindicationsDocumented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections
InteractionsCoadministration with estrogens may decrease prednisone clearance; when used with digoxin, digitalis toxicity secondary to hypokalemia may increase; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
PregnancyB - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
PrecautionsAbrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

Drug NameMethylprednisolone (Solu-Medrol, Depo-Medrol)
DescriptionDecreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Adult Dose2-60 mg/d PO or divided bid/qid initially; followed by gradual reduction to lowest level that will maintain clinical response
Pediatric Dose0.5-1.7 mg/kg/d or 5-25 mg/m2/d PO/IV/IM divided q6-12h
ContraindicationsDocumented hypersensitivity; viral, fungal, or tubercular skin infections
InteractionsCoadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics
PregnancyC - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
PrecautionsHyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use

Drug Category: Antihistamines

Act by competitive inhibition of histamine at the H1 receptor. Mediate bronchial constriction, mucous secretion, smooth muscle contraction, edema, hypotension, CNS depression, and cardiac arrhythmias.

Drug NameCetirizine (Zyrtec)
DescriptionForms complex with histamine for H1-receptor sites in blood vessels, GI tract, and respiratory tract.
Adult Dose5-10 mg PO qd
Pediatric Dose<2 years: Not established
2-5 years: 2.5 mg PO qd
>5 years: Administer as in adults
ContraindicationsDocumented hypersensitivity
InteractionsIncreases CNS toxicity of depressants
PregnancyB - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
PrecautionsCaution in hepatic or renal dysfunction; doses higher than 10 mg/d may cause drowsiness

Drug Category: Retinoids

Have the ability to modulate cell proliferation.

Drug NameAcitretin (Soriatane)
DescriptionRetinoic acid analog, like etretinate and isotretinoin. Etretinate is main metabolite and has demonstrated clinical effects close to those seen with etretinate. Mechanism of action is unknown.
Adult Dose25 mg/d or 50 mg/d initially given as single dose with main meal; 25-50 mg/d after initial response to treatment; terminate therapy when lesions have resolved sufficiently
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity
InteractionsIncreases toxicity methotrexate; avoid concomitant use; interferes with effects of microdosed progestin minipill; coadministration with alcohol may enhance synthesis of etretinate, which has much longer half-life than acitretin (>120 d)
PregnancyX - Contraindicated; benefit does not outweigh risk
PrecautionsDo not use in severe obesity; women of childbearing age must be capable of complying with effective contraceptive measures; recommended that contraception be continued for at least 3 y after stopping treatment with acitretin; etretinate may form from acitretin, which takes about 2-3 y to clear from body; caution if impaired renal or liver function; perform AST, ALT, and LDH tests prior to initiation of acitretin therapy at 1- to 2-wk intervals until stable and thereafter at intervals as clinically indicated


FOLLOW-UP

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Prognosis

Lichen nitidus may remain active for several years; however, spontaneous resolution usually occurs.


MULTIMEDIA

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Media file 1:  Multiple skin-colored shiny papules associated with lichen nitidus.
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Media type:  Photo

Media file 2:  Multiple shiny lichens over the penis.
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Media type:  Photo

Media file 3:  Köbner phenomenon in lichen nitidus.
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Media type:  Photo

Media file 4:  Lichen nitidus.
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Media type:  Photo


REFERENCES

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  2. Hazen HH. Syphilis and skin diseases in the American Negro: personal observations. Arch Dermatol Syph. 1935;31:316.
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  16. Scheinfeld NS, Teplitz E, McClain SA. Crohn's disease and lichen nitidus: a case report and comparison of common histopathologic features. Inflamm Bowel Dis. Nov 2001;7(4):314-8. [Medline].
  17. Bercedo A, Cabero MJ, Garcia-Consuegra J, Hernado M, Yaez S, Fernandez-Llaca H. Generalized lichen nitidus and juvenile chronic arthritis: an undescribed association. Pediatr Dermatol. Sep-Oct 1999;16(5):406-7. [Medline].
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Lichen Nitidus excerpt

Article Last Updated: Mar 20, 2008