Sharma Pranjali
Endocrinology, Parkview Medical Center, Pueblo, USA.
Cureus. 2021 Nov 6;13(11):e19304. doi: 10.7759/cureus.19304. eCollection 2021 Nov.
Lichen planus is a chronic papulosquamous eruption of the skin, scalp, nails, and mucous membranes. "Pruritic, purple, polygonal, planar, papules, plaques" are the traditional six "P's" of lichen planus. We describe an unusual case of lichen planus presenting as cellulitis. A 64-year-old lady with a past medical history of pyoderma gangrenosum, inclusion body myositis, and chronic kidney disease presented with a two-week history of swelling, erythema, tenderness, hyperkeratotic plaques, and blisters on the medial aspect of both thighs. She had a previous history of pyoderma gangrenosum exacerbations with similar presentations; however, current lesions were different from prior presentations. We considered the differential diagnoses of bacterial cellulitis versus pyoderma gangrenosum exacerbation. Due to the difference in these lesions from previous episodes, the patient was empirically treated for bacterial cellulitis with intravenous cefepime and linezolid. The infectious diseases team was consulted and valacyclovir was added to cover for possible herpes infection, with no improvement in symptomatology. Dermatology was then consulted, and a clinical diagnosis of psoriasiform dermatitis was made. A skin biopsy was obtained and the patient was started on prednisone. There was an immediate improvement in the papules within 24 hours. The papules cleared, leaving behind violaceous flat plaques, clinically diagnosed as lichen planus. The affected area was shrinking as compared to previous examinations. The skin biopsy was reported as chronic psoriasiform dermatitis with the main differential of lichen planus. The patient was discharged home on a tapering dose of oral prednisone, topical clobetasol, and oral moxifloxacin. This case demonstrates the importance of familiarity with rare clinical subtypes as a suspicion for lichen planus. The vesiculobullous subtype of lichen planus, as seen in this patient, tends to present as blisters and cellulitis from infection of the bullae. Treatment of the infection alone is not enough and steroids are essential. This knowledge helps change management, allows for earlier improvement and better patient outcomes.
扁平苔藓是一种发生于皮肤、头皮、指甲和黏膜的慢性丘疹鳞屑性皮疹。“瘙痒、紫色、多边形、扁平、丘疹、斑块”是扁平苔藓传统的六个“P”特征。我们描述了一例表现为蜂窝织炎的不寻常扁平苔藓病例。一名64岁女性，既往有坏疽性脓皮病、包涵体肌炎和慢性肾脏病病史，双大腿内侧出现肿胀、红斑、压痛、角化过度斑块和水疱，病程两周。她既往有坏疽性脓皮病加重发作且表现相似的病史；然而，当前病变与既往表现不同。我们考虑了细菌性蜂窝织炎与坏疽性脓皮病加重的鉴别诊断。由于这些病变与既往发作不同，该患者经验性接受静脉注射头孢吡肟和利奈唑胺治疗细菌性蜂窝织炎。咨询了感染病团队，并加用伐昔洛韦以覆盖可能的疱疹感染，但症状无改善。随后咨询了皮肤科，临床诊断为银屑病样皮炎。进行了皮肤活检，患者开始使用泼尼松治疗。24小时内丘疹立即改善。丘疹消退，留下紫红色扁平斑块，临床诊断为扁平苔藓。与之前检查相比，受累区域在缩小。皮肤活检报告为慢性银屑病样皮炎，主要鉴别诊断为扁平苔藓。患者出院时口服泼尼松逐渐减量，外用氯倍他索，并口服莫西沙星。本病例说明了熟悉罕见临床亚型作为怀疑扁平苔藓的重要性。如该患者所见，扁平苔藓的水疱大疱型往往表现为水疱和因大疱感染引起的蜂窝织炎。仅治疗感染是不够的，类固醇是必不可少的。这些知识有助于改变治疗方案，实现更早改善和更好的患者预后。
