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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.81 no.2 Rio de Janeiro Mar./Apr. 2006
"Algesiogenic" lichen aureus*
Roberto Rheingantz da Cunha FilhoI; Joel SchwartzII; Jorge ZanolIII
IM.Sc., Health and Behavior - Universidade Católica de Pelotas
- UCPel - Pelotas (RS), Dermatologist (SC), Brazil
IIAssociate Professor of Medicine at Faculdade de Medicina da Universidade do Rio Grande do Sul - UFRGS - Porto Alegre (RS), Brazil
IIIDermatopathologist of the Dermatology Service of the Universidade Federal do Rio Grande do Sul - UFRGS - Hospital Complex of Santa Casa de Porto Alegre - Porto Alegre (RS), Brazil
A case is described of lichen aureus in a 23 year old female with a 2-year history of painful, purpuric, rust-coloured to tan, lichenous lesion on forearm. A biopsy specimen demonstrated a dense lymphohistiocytic infiltrate in the upper dermis, with extravasation of red cells. The algesiogenic lichen aureus is a very rare dermatosis.
Keywords: Lichenoid eruptions; Pain; Purpura
Lichen aureus falls within pigmented purpura dermatoses or chronic pigmented purpuras, and it is a rare capillaritis of unknown cause.1
It was described in 1957 by Martin,2 initially as a case for diagnosis. Years later, Calnan3 used the term lichen aureus to describe a new case. Other authors suggested the name lichen purpuricus4 which is also used in the literature. The clinical picture is characterized by usually assymptomatic lesions,1-6 with a lichenoid aspect and variably colored purpura component, ranging from brownish, reddish, violet, and rusty to, more rarely, golden. The authors describe a case of interest as it deals with a patient with a painful lesion.
Female, 23, came to consultation with a complaint of a painful stain on the forearm, with a two-year evolution. The patient denied any local trauma and reported a spontaneous pain on the site of the lesion which worsened when touched. There was no clinical history of infection or previous diseases. Blood test, platelet, prothrombin time and partial thromboplasmin, liver and kidney function tests, and blood sugar showed no abnormalities. Antinucleus factor and Lues (VDRL) were non-reagent. The patient had been on oral contraceptives for about five years.
The examination showed a red-brownish purpuric lesion, of a lichenous aspect, around 2 cm in size located on the flexing face of the right forearm (Figure 1). All the cutaneous tegument of the patient was examined and no other lesion was observed. At palpation of the lesion, the patient reported increase of the pain, reacting with a pain facies and moving the arm away.
The anatomic-pathologic examination showed a dense lymphohistiocytic infiltrate in the upper dermis and red blood cells extravasation. Edemaciated endothelium capillaries and hemosiderin deposits in macrophages, findings of chronic pigmented purpura, are compatible with lichen aureus (Figure 2).5
Treatment with a high potency occluding steroid for 20 days was carried out without any improvement. The patient was counseled about the meaning and the good prognosis of the disease and she preferred to keep only a clinical follow-up.
Lichen aureus is a rare pigmented purpuric eruption, distinguishable from others (Schambergs Disease, eczematoid purpura, Majocchi teleangectastic annular purpura) because it is a localized lichenoid eruption, usually solitary or segmentary.1-3 In the cases of Gougerot-Blum lichenoid purpuric dermatitis there is also the lichenoid component, albeit in a diffuse manner.1
Frequency by sex or age range is not well established,1 in spite of the existence of several reports of children and young adults.6-10 The largest number of cases consisted of twelve,6 showing a predominance of males (8 cases), average age of 27 years (from one to 50 years), appearing preferentially in the lower limbs, mostly on ankles and only one report of a different topography (abdomen).7 Há relato de líquen aureus coThere is a report of lichen aureus with a zoster-like segmentary dispositionr.11
An interesting fact in the present report is the pain symptomatology, which is intensified by palpation. A review of the world literature reveals only one similar report, presented in 1983 by Reinhardt and col.12 They described a patient with an asymptomatic lesion until three months of disease progress. After such time the lesion became more extensive and was associated with non-joint deep pain. Asymptomatic lesions have been seen more frequently. The pruriginous ones occur, but rarely.6,13
Purpuric conditions are histologically similar, with extravasation of red blood cells, hemosiderin in macrophages, and there may be minimal vascular damage with the narrowing of vessel lumen, endothelial edema and perivascular lymphocytic infiltrate. With lichen aureus the infiltrate is quite dense, enough to give the lesion its lichenoid aspect.5
An important differential diagnosis is histiocytosis,9 which presents lesions with a purpuric and /or seborrheic eczema aspect, but it is histologically differentiated.5 Trauma purpura must be remembered as well, which does not have the chronic lichenoid aspect of lichen aureus.1
The course of lichen aureus has shown to be slow and with a good prognosis, and there is improvement in the majority of cases in two or three years, in spite of extremes of one and a half year to 18 years of progress.6,13 The disease is refractory to treatment, even though there have been recent improvement reports, with Puva,14 and another with topic pimecrolimus.15 Despite the difficulties in the study of rare entities, research must be stimulated so that there may be epidemiological and pathophysiological evidence able to explain the symptoms of pain and pruritus.
1. Piette WW. Hematologic disorders. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, Fitzpatrick TB, editors. Dermatology in General Medicine. New York: McGraw Hill; 1999. p.1877. [ Links ]
2. Martin R. Case for diagnosis. Trans St Johns Hosp Dermatol Soc. 1958;40:93. [ Links ]
3. Price ML, Wilson JE, Calnan C. Lichen aureus: a localized persistent form of pigmented purpuric dermatosis. Br J Dermatol. 1984;112:307-14. [ Links ]
4. Kanitakis C, Tsoitis G. Lichen purpurique. Ann Dermatol Venereol. 1982;109:445-52. [ Links ]
5. Elder D, Elenitsas R, Jaworsky C, Johnson B Jr. Lever's Histopathology of the Skin. 8th ed. Philadelphia: Lippicont Rover; 1997. p.202-3. [ Links ]
6. Graham RM, English JS, Emmerson RW. Lichen aureus: a study of twelve cases. Clin Exp Dermatol. 1984;9:393-401. [ Links ]
7. Rubio FA, Robayna G, Herranz P, de Lucas R, Contreras F, Casado M. Abdominal Lichen aureus in a child. Pediatr Dermatol. 1997;14:411. [ Links ]
8. Patrizi A, Neri I, Marini R, Guerrini V. Lichen aureus with uncommon clinical features in a child. Pediatr Dermatol. 1991;8:280-3. [ Links ]
9. Megahed M, Schuppe HC, Hölzle E, Jürgens H, Plewig G. Langerhans cell histiocytosis masquerading as lichen aureus. Pediatr Dermatol. 1991;8:213-6. [ Links ]
10. Esmenjand RJ, Dahl MV. Segmental Lichen aureus: onset associated with trauma and puberty. Arch Dermatol. 1988;124:1572-4. [ Links ]
11. Dippel E, Schröder K, Goerdt S. Zosteriformer Lichen aureus. Hautarzt. 1998;49:135-8. [ Links ]
12. Reinhardt L, Wilkin JK, Tausend R. Vascular abnormalities in Lichen aureus. J Am Acad Dermatol. 1983;8:417-20. [ Links ]
13. Ratnam KV, Su WP, Peters MS. Purpura simplex (inflammatory purpura without vasculitis): a clinico pathologic study of 174 cases. J Am Acad Dermatol. 1991;25:642-7. [ Links ]
14. Ling TC, Goulden V, Goodfield MJ. Puva therapy in lichen aureus. J Am Acad Dermatol. 2001;45:145-6. [ Links ]
15. Böhn M, Bonsmann G, Luger TA. Resolution of lichen aureus in a 10-year-old child after topical pimecrolimus. Br J Dermatol. 2004;151;519-20. [ Links ]
Dr Roberto Rheingantz da Cunha Filho
Rua Roberto Tromposky, 194 - Centro
89600-000 - Joaçaba - SC
Tel.: +55 49 3522-1269
Received on July 24, 2003.
Approved by the Consultive Council and accepted for publication on November 01, 2004.
Conflict of interest: None
* Work done at Dermatology Service of the Universidade do Rio Grande do Sul, Complexo Hospitalar da Santa Casa de Porto Alegre - Porto Alegre (RS), Brazil.