Erosive Palmoplantar Lichen Planus

Erosive palmoplantar lichen planus (LP), also known as ulcerative or bullous LP, was first described by Cram et al. in 1966 as a rare variant of LP that can affect mucous membranes, palms, and soles. It presents clinically as erythematous, ulcerated plaques that run an extremely chronic course and are resistant to all types of treatment. The patient was an 84-year-old woman with a personal history of hypertension, aortic valve fibrosclerosis, and polyarthritis who had been receiving treatment with paracetamol, acetylsalicylic acid, atorvastatin, and candesartan-hydrochlorothiazide for several years. She presented with a very painful ulcerated lesion on her right foot that had appeared 6 months earlier and made walking difficult. Physical examination revealed an ulcerated plaque, measuring 4 × 5 cm, on the medial aspect of the right heel. The base of the lesion was filled with granulation tissue, which in some areas was covered with whitish, macerated epithelium. Another ulcer with the same characteristics was present on the dorsal aspect of the first toe (Figs. 1 and 2). The dermatological examination also revealed the presence of whitish reticulated areas on the buccal mucosa and pterygium on several fingernails. In addition, the patient had total scalp alopecia, having lost her hair, as well as all 10 toenails, 6 years earlier. She did not have alopecia of the eyebrows, eyelashes, axilla, or pubic area, or any other cutaneous abnormalities. Blood tests, including liver function tests, hepatitis B serology, and hepatitis C serology, were normal or negative. Skin biopsy revealed marked orthokeratotic hyperkeratosis, acanthosis, and a band-like lymphocytic infiltrate in the upper dermis, without melanophages. Also present were spiculated dermal papillae and vacuolar degeneration at the dermalepidermal junction. The findings were consistent with LP (Fig. 3). On the basis of the clinical and histopathologic findings, the patient was diagnosed with erosive palmoplantar LP and was prescribed treatment with oral prednisone (1 mg/kg/d). Two months later, the ulcerated lesions had healed. Systemic treatment was continued with a tapering dose for a further 6 months and finally withdrawn. The patient then started