Agminate lichen aureus* * Work performed at the Pedro Ernesto University Hospital - University of the State of Rio de Janeiro (HUPE-UERJ)- Rio de Janeiro (RJ), Brazil.

Líquen aureus agminado

Violeta Duarte Tortelly Roberto Souto da Silva Amanda Nascimento Cavalleiro de Macedo Mota Juan Piñeiro-Maceira About the authors

Abstracts

Lichen aureus is a rare variant of pigmented purpura, with a chronic and benign course. It is generally asymptomatic and often occurs in the lower limbs, presenting as erythematous brownish, coppery or golden macules and/or papules. The diagnosis is based on clinical and histopathological findings. The dermatoscopic pattern has been considered a useful tool in diagnosis presumption. We describe a case with a confluent morphological pattern, called agminate lichen aureus.

Lichens; Purpura; Skin diseases


O líquen aureus é uma variante rara das púrpuras pigmentares, com evolução crônica e benigna. A maioria é assintomática e predomina nos membros inferiores. O quadro clínico é constituído por máculas e/ou pápulas eritemato-acastanhadas, acobreadas ou douradas. O diagnóstico é clínico e histopatológico, porém o padrão dermatoscópico vem sendo uma ferramenta útil na presunção do diagnóstico. Descrevemos um caso com um padrão morfológico em que a lesão é confluente, sendo denominado líquen aureus agminado.

Dermatopatias; Líquens; Púrpura


INTRODUCTION

Lichen aureus is a variant of chronic pigmented purpura. This group is composed of Schamberg's pigmented purpura, Gourgeot-Blum disease, Kapetanaski disease and Majocchi purpura.11. Cunha Filho RR, Schwartz J, Zanol J. Li'quen aureus "algesiogenico". An Bras Dermatol. 2006;81:163-5. These diseases are characterized by a reddish-brown appearance which corresponds histologically to hemosiderin deposition. These chronic pigmented purpuras present the same histological pattern: a variable degree of lymphocytic infiltrate in the upper dermis associated with hemosiderin deposits. Our report shows an uncommon confluent morphology, called agminate lichen aureus.

CASE REPORT

Male, 28-year-old, presenting a brownish 3cm lesion on the dorsal region of the right wrist, noted about 10 years ago (Figure 1). Its onset could not be correlated with trauma, medication or contact with any substance. The lesion appeared as an insect bite, initially reddish, and subsequently brownish in the center. There was no itching, soreness, discharge or other similar lesions on the body. The patient denied other diseases.

FIGURE 1
Agminate lichen aureus. Lesion on the right arm

Dermoscopy showed a copper-coloured amorphous area and absence of pigmented network (Figure 2). The histopathology evaluation showed sparse capillaries, associated with heavy subepidermal mononuclear inflammatory reaction in a lichenoid pattern (Figure 3). The histochemical staining demonstrated diffuse deposition of hemosiderin (Figure 4).

FIGURE 2
Agminate lichen aureus. Dermoscopy
FIGURE 3
Agminate lichen aureus. Subepidermal mononuclear inflamatory reaction (HE; x40)
FIGURE 4
Agminate lichen aureus. Dermal hemossiderin (blue) (iron pigment staining; x150)

DISCUSSION

Lichen aureus (LA) was described as a case study for the first time in 1958 by Martin. In 1960, Calman used the term LA to emphasize the yellow-golden hue often observed in these lesions. Although its cause remains unknown, its pathogenesis seems to be related to inflammation of the capillaries in the papillary dermis, with occasional endothelial proliferation; a possible vasculitis.22. Kanitakis C, Tsoitis G. Lichen purpurique. Ann Dermatol Venereol. 1982;109:445-52. Speculation also exists about the etiology being related to trauma, infections, drugs or venous insufficiency.33. Ruiz-Esmenjaud J, Dahl MV. Segmental lichen aureus. Onset associated with trauma and puberty. Arch Dermatol. 1988;124:1572-4.

Lichen aureus usually presents as a solitary plaque, with color ranging from dark-brown, to copper and a golden hue. Most of the lesions are asymptomatic, but there are some reports of itchy or painful lesions. LA can affect any part of the body, but it is most frequently described in the lower limbs, followed by the upper limbs and the trunk. Linear or segmental presentations have also been described.44. Price ML, Jones EW, Calnan CD, MacDonald DM. Lichen aureus. A localised persistent form of pigmented purpuric dermatosis. Br J Dermatol. 1984;112:307-14. It has a predilection for young adults. The onset is sudden, but the course is chronic and can progress slowly or stabilize. Some authors have questioned its chronic and benign nature, suggesting that LA may progress to mycosis fungoids, but a follow-up of 23 patients did not identify any case with this progression.55. Fink-Puches R, Wolf P, Kerl H, Cerroni L. Liquen aureus: clinicopathologic features, natural history, and relationship to mycosis fungoides. Arch Dermatol. 2008;144:1169-73.

Dermoscopy has been an important tool for the clinical diagnosis of the purpuras.66. Zaballos P, Puig S, Malvehy J. Dermatoscopy of Pigmented Purpuric Dermatoses(Lichen Aureus): A usuful tool to clinical diagnoses. Arch Dermatol. 2004;1401290-1. The findings include brownish or coppery-red amorphous area, oval or circular red spots, some gray spots, globules and a network of brownish to gray interconnected lines.

After reviewing the literature, we found that agminated lichen aureus had been described only once (in the United Kingdom).77. Benton EC, Stefanato CM. A pigmented lesion in a 30-year-old man. Clin Exp Dermatol. 2011;36:683-4. This is the first case reported in Brazil.

We should consider in the differential diagnosis the other aforementioned purpuras and Langerhans cell histiocytosis. Two possible differential diagnoses for the agminated presentation are the Spitz nevus and the "hobnail" hemangioma, in which the histopathological study is essential for the differentiation.88. Hamm H, Happle R, Bröcker EB. Multiple agminate Spitz naevi. Review of the literature and report of a case with distinctive immunohistological features. Br J Dermatol. 1987; 117:511-22.,99. Trindade F, Kutzner H, Tellechea Ó, Requena L, Colmenero I. Hobnail hemangioma reclassified as superficial lymphatic malformation: A study of 52 cases J Am Acad Dermatol. 2012;66:112-5.,1010. Al Dhaybi R, Lam C, Hatami A, Powell J, McCuaig C, Kokta V. Targetoid hemosiderotic hemangiomas (hobnail hemangiomas) are vascular lymphatic malformations: a study of 12 pediatric cases. J Am Acad Dermatol. 2012;66:116-20.

The treatment of LA is difficult. The therapeutic arsenal includes PUVA, calcineurin inhibitors and corticosteroids. In the case reported, after the incisional biopsy was performed and lichen aureus was confirmed, the residual lesion underwent intense pulsed light with 12ms and 18J fluency, and disappeared almost completely.

REFERENCES

  • 1
    Cunha Filho RR, Schwartz J, Zanol J. Li'quen aureus "algesiogenico". An Bras Dermatol. 2006;81:163-5.
  • 2
    Kanitakis C, Tsoitis G. Lichen purpurique. Ann Dermatol Venereol. 1982;109:445-52.
  • 3
    Ruiz-Esmenjaud J, Dahl MV. Segmental lichen aureus. Onset associated with trauma and puberty. Arch Dermatol. 1988;124:1572-4.
  • 4
    Price ML, Jones EW, Calnan CD, MacDonald DM. Lichen aureus. A localised persistent form of pigmented purpuric dermatosis. Br J Dermatol. 1984;112:307-14.
  • 5
    Fink-Puches R, Wolf P, Kerl H, Cerroni L. Liquen aureus: clinicopathologic features, natural history, and relationship to mycosis fungoides. Arch Dermatol. 2008;144:1169-73.
  • 6
    Zaballos P, Puig S, Malvehy J. Dermatoscopy of Pigmented Purpuric Dermatoses(Lichen Aureus): A usuful tool to clinical diagnoses. Arch Dermatol. 2004;1401290-1.
  • 7
    Benton EC, Stefanato CM. A pigmented lesion in a 30-year-old man. Clin Exp Dermatol. 2011;36:683-4.
  • 8
    Hamm H, Happle R, Bröcker EB. Multiple agminate Spitz naevi. Review of the literature and report of a case with distinctive immunohistological features. Br J Dermatol. 1987; 117:511-22.
  • 9
    Trindade F, Kutzner H, Tellechea Ó, Requena L, Colmenero I. Hobnail hemangioma reclassified as superficial lymphatic malformation: A study of 52 cases J Am Acad Dermatol. 2012;66:112-5.
  • 10
    Al Dhaybi R, Lam C, Hatami A, Powell J, McCuaig C, Kokta V. Targetoid hemosiderotic hemangiomas (hobnail hemangiomas) are vascular lymphatic malformations: a study of 12 pediatric cases. J Am Acad Dermatol. 2012;66:116-20.

  • * Work performed at the Pedro Ernesto University Hospital - University of the State of Rio de Janeiro (HUPE-UERJ)- Rio de Janeiro (RJ), Brazil.
  • Conflict of interest: None
  • Financial Support: None

Publication Dates

  • Publication in this collection
    Nov-Dec 2013

History

  • Received
    02 Jan 2013
  • Accepted
    14 Feb 2013
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