Sir,
Lichen planus is a frequently encountered papulosquamous dermatosis with common sites of predilection involving the flexor surfaces, trunk, and oral or genital mucosa. Eyelid lichen planus is a rare entity with very few articles mentioning lesions exclusively located on the eyelids.[1,2,3] Isolated lesions are often misdiagnosed as other common eyelid dermatoses such as contact dermatitis or seborrheic dermatitis. We here present a rare case of eyelid lichen planus. This is an attempt on the author’s part to lay importance on the fact that lichen planus must be considered as a differential while approaching a case with eyelid dermatoses.
A 43-year-old male presented to the outpatient department with the complaint of a dark-colored gradually progressing lesion associated with severe itching over his left upper eyelid and a similar lesion on the left cheek adjacent to the outer angle of the left eye of 7 months duration. The patient had not applied any medication or any cosmetic product to the site prior to the onset of the lesions.
On examination, patient had a violaceous plaque over the left upper eyelid adjacent to the lid margin of size 1 cm × 0.5 cm. A similar lesion of 1 cm diameter was present on the cheek adjacent to the lateral canthus of the left eye [Figure 1]. Examination of the entire body did not reveal any similar lesion. All mucosae were normal. He did not have any other associated ophthalmological involvement in the form of conjunctivitis, keratitis, or lacrimal duct stenosis. Dermoscopy (dermoscope used: 3Gen Dermlite DL4 Polarized Dermoscope) of the lesions revealed grey-brown dots and globules, follicular white clods, radial white lines, or Wickham’s striaes that lead us to the diagnosis of lichen planus [Figures 2 and 3].
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Figure 1: A violaceous plaque seen over the left upper eyelid adjacent to the lid margin of size 1 cm × 0.5 cm. A similar appearing lesion of 1 cm diameter was present on the cheek adjacent to the lateral canthus of the left eye.
Figure 2: Dermoscopy (3Gen Dermlite DL4 Polarized Dermoscope) of plaque on cheek revealed the presence of grey-brown dots and globules (blue arrow), follicular white clods (yellow arrow), radial white lines, or Wickham’s striae (red arrow)
Figure 3: Dermoscopy (3Gen Dermlite DL4 Polarized Dermoscope) of eyelid plaque revealed the presence of grey-brown dots and globules (blue arrow), follicular white clods (yellow arrow), radial white lines, or Wickham’s striae (red arrow)
His routine hemogram, blood sugar levels, and other relevant investigations were within normal limits. Serology for Hepatitis C and Hepatitis B was negative. Skin biopsy was not performed as the patient denied to provide consent.
The patient was managed with low potent topical steroid, topical calcineurin immunosuppressant, emollient, and oral antihistaminics, and is doing well with good clinical response. He continues to be on regular follow up.
Eyelid dermatosis involves a plethora of conditions such as contact dermatitis, seborrheic dermatitis, and atopic dermatitis to name a few. Lichen planus of the eyelid is a very rare entity. Of the nine cases reported prior to 1995, only two had lesions limited to the eyelids.[1] Altman and Perry reported eyelid involvement in two of their 307 patients.[2] Lichen planus lesions in the eyelid are almost always a part of the generalized lesions elsewhere in the body. Our case is rare as in this patient eyelid was the sole area of involvement with only one other lesion adjacent to the eye.
The lesions of lichen planus on the eyelids have been classified into three types: (1) classic lilac-colored slightly delled papules with filigree scaling associated with similar lesions elsewhere, (2) annular papules or small medallion plaques often with similar lesions elsewhere, and (3) lesions occurring solely on the eyelids.[3,4]
The characteristic dermoscopic features suggestive of lichen planus in this patient are what clinched the diagnosis. Wickham’s striae (WS) is the hallmark sign of lichen planus and corresponds histologically to the focal thickening of the granular layer. Several WS patterns have been described including circular, reticular, radial linear, globular, perpendicular, and veil-like structureless forms.[5] WS are mainly seen in the active stages and disappear after treatment, thus their presence could be considered as an activation marker.[5]
It helped in ruling out other dermatoses such as dermatitis, psoriasis and discoid lupus erythematosus [Table 1]. This also alleviated the need for a skin biopsy to confirm the diagnosis.
Table 1: Differential diagnosis of eyelid lesions
Hence, lichen planus involving the eyelid even though rare should be kept as a differential for eyelid dermatosis.
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Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Itin PH, Buechner SA, Rufli T. Lichen planus of the eyelids Dermatology. 1995;191:350–1
2. Altman J, Perry HO. The variations and course of lichen planus Arch Dermatol. 1961;84:179–91
3. Sharma R, Singhal N. Lichen planus of the eyelids. A report of 5 cases Dermatol Online J. 2001;7:5
4. Michelson HE, Laymon C. Lichen planus of the eyelids Arch Dermatol. 1938;37:27–29
5. Güngör Ş, Topal IO, Göncü EK. Dermoscopic patterns in active and regressive lichen planus and lichen planus variants: a morphological study Dermatol Pract Concept. 2015;5:45–53
