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Lichen Simplex Chronicus
Lichen simplex chronicus (LSC) is neurodermatitis condition.
The below are the characteristic features of Lichen Simplex Chronicus
- Localized areas of thickened, hyperplastic scaly skin caused by prolonged and severe scratching in patients with no underlying dermatologic condition.
Synonyms
- LCS
- Neurodermatitis from rubbing
- Circumscribed neurodermatitis
How common is Lichen Simplex Chronicus?
This condition is aggravated in patients with underlying anxiety disorders
Predominant Sex & Age:
- Gender: Females > males (2:1)
- Age: Adults >60 yr
Peak Incidence
The peak incidence of this condition is between ages 35 and 50 years
What increases the risk of Lichen Simplex Chronicus?
There are few conditions (highlighted below) which increases the risk of Lichen Simplex Chronicus
- Anxiety disorders
- Dry skin
- Insect bites
What are the Symptoms & Clinical Presentation of Lichen Simplex Chronicus?
- •Patients present with profound pruritus (itching) and localized scaly plaques with accentuated skin markings said to resemble tree bark.
- •Lichenified circumscribed plaques. Trauma from rubbing and scratching accounts for persistence of the plaque.
- •Commonly involved areas include hands and wrists, back and sides of neck, anterior tibias, anogenital areas, the scalp, the upper eyelid, the orifices of both ears, and ankles.
What causes Lichen Simplex Chronicus?
- •Neurodermatitis caused by long-term chronic rubbing and scratching more vigorously than a normal pain threshold would allow, resulting in thickened and leathery skin.
- •Common triggers are excess dryness of skin, heat, sweat, and psychological stress. It can also accompany other conditions such as obsessive-compulsive disorder, the fungal infections candidiasis or tinea cruris, or psoriasis, lichen sclerosus, and neoplasia, leading to squamous cell hyperplasia.
- •Other causes include atrophic dermatitis and insect bites. Rare cases have shown links to lithium use, hair dye containing PPD, and long-term exposure to vehicle pollution.
Differential Diagnosis
- •Lichen planus
- •Psoriasis
- •Atopic dermatitis
- •Insect bite
- •Nummular eczema
- •Contact dermatitis
- •Stasis dermatitis
How is Lichen Simplex Chronicus diagnosed?
This condition is best diagnosed by
- Patient history and skin examination.
- Skin biopsy when diagnosis is unclear or persistent symptoms.
Laboratory Tests
- •Not generally necessary.
- •Biopsy reveals hyperkeratosis, acanthosis, and mild to moderate lymphohistiocytic inflammatory infiltrate with prominent lichenification.
How is Lichen Simplex Chronicus treated?
Nonpharmacologic Therapy
- •Patient education is essential to break the itch-scratch cycle and facilitate treatment of any underlying dermatitis.
- •Psychotherapy.
Acute General Treatment
- •Cessation of pruritus is the goal. Antihistamine hydroxyzine 25 mg at bedtime is effective in decreasing nocturnal itching. Moisturizers are also helpful
- •High-potency topical corticosteroids can be used initially but not indefinitely because of potential for steroid-induced atrophy
- •Steroid-containing tape may be effective in providing both occlusion and antiinflammatory effect
- •Intralesional corticosteroids
- •Anxiolytics, SSRIs
- •Oral doxepin (an antidepressant and anxiolytic)
- •Mirtazapine
- •Tropical calcineurin inhibitor for vulvar lichenification
- •Cyclosporin A
- •Topical tacrolimus, 0.1% ointment, can be used for sensitive skin, face
- •Botulinum intradermal injections
- •Alitretinoin, 30 mg/day for 3 mo, has shown some clinical improvement in case studies but needs further investigation as a potential Rx
Chronic Treatment
Constant irritation of the skin must be avoided. Keeping skin moisturized, covering to prevent scratching, or filing nails may be necessary.
Disposition
Psychological intervention improves recovery. Regular follow-up visits facilitate long-term management.
Referral
Refer to a psychologist for psychological evaluation and consultation, and a dermatologist in resistant cases.
Pearls & Considerations
- •Significant scratching may occur during nocturnal hours.
- •The involved area is always at a site that is easily reached for scratching.
- •Chronic scratching can also cause keratinocyte necrosis and the development of amyloid in the papillary dermis, called lichen amyloidosis.
Patients may be at increased risk for scarring of the skin, changes in skin pigmentation, and bacterial and fungal infections of the involved skin.
How is Lichen Simplex Chronicus prevented?
Prevent future incidences by continued therapy, stress management, and avoidance of common triggers and accompanying conditions.