Dermoscopy – a promising tool in monitoring treatment in isolated lip lichen planus – A case report

Dear Sir,

The dermoscopy of cutaneous lichen planus has been extensively studied and reported in the literature; however, only very few case reports on the dermoscopy of lip lichen planus exist.^[1] Herein, we report a leaf venation-like pattern of Wickham’s Striae (WS) on dermoscopy observed and monitored in a patient with lip lichen planus.

A 44-year-old healthy female presented to the dermatology outpatient department seeking an asymptomatic skin lesion over her lip for 8 months. She had complaints of a burning sensation while having spicy foods. There were no history drugs intake before the onset of skin lesions. The patient denied a history of photosensitivity as well. Cutaneous examination revealed an isolated single discrete violaceous oval plaque over the upper lip [Figure 1]. Nail, scalp, and genitalia examination was within normal limits. Differential diagnoses of lichen planus, discoid lupus erythematosus, and porokeratosis were considered for the lip lesion. A biopsy confirmed the diagnosis of lichen planus [Figure 2]. Dermoscopy (Dermlite DL4 ×10) examination revealed a radial stream-like pattern of WS and in addition, we also observed a leaf venation-like pattern of WS suggestive of lichen planus [Figure 3a]. She was initiated on topical steroids and was asked to follow-up after a month. Post 1-month follow-up, she had almost a resolution of the skin lesion. Dermoscopy showed a partial clearance of Wickham’s striae [Figure 3b] and patient symptoms were better.

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Figure 1:

A 44-year-old healthy female patient with lip lichen planus presenting with a well-demarcated violaceous oval plaque over the upper lip.

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Figure 2:

Histopathology showing basal vacuolar degeneration and band-like lymphocytic infiltrates (H&E ×200).

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Figure 3:

Dermoscopy image (Dermlite ×10) showing (a) blue arrow indicating leaf venation-like pattern of Wickham striae and red arrow depicting the radial stream-like pattern of Wickham striae and (b) post-treatment there is some resolution of the same.

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Oral lichen planus presents more commonly in the fourth decade with female preponderance.^[2] The buccal mucosa is most commonly affected while other sites such as the tongue, gingiva, floor of the mouth, and lips can also be affected. Isolated lip lichen planus can mimic many conditions including discoid lupus erythematosus, actinic cheilitis, porokeratosis, pemphigus vulgaris, herpes simplex infection, etc. Dermoscopy plays a major role in diagnosing lichen planus and ruling out other causes. The major advantage is that it is a non-invasive tool that can be helpful for both diagnoses and monitoring following treatment.

Dermoscopy of cutaneous and oral lichen planus revealed specific clues like various patterns of Wickham’s striae and vascular patterns. On scrutinizing the literature, we could find very few isolated case reports of dermoscopy of lip lichen planus. There was one study from India that reported on isolated lichen planus with various dermoscopic patterns observed.^[3] WS, scaling, pigmentation, and telangiectasia are the hallmarks of lip lichen planus. The various patterns of WS include reticulate (most common), circular, annular, radial streaming, leaf venation-like, linear, round, and starry sky patterns.^[4,5] WS histopathologically correlates with wedge-shaped hypergranulosis.

A leaf venation-like pattern was observed in our patient on dermoscopy, which was, further, confirmed with a biopsy. The patient was started on topical steroids and was asked to follow-up after a month. Follow-up dermoscopy revealed partial clearance of Wickham’s striae; thus, dermoscopy is a promising tool to monitor the response following treatment later. Dermoscopy, thus, plays a key role in narrowing down the diagnosis before biopsy and would serve as a promising non-invasive investigational modality in the near future. Early recognition and diagnosis are prudent to exclude the other closest mimics and to identify malignant transformation earlier.