Skin nontumor

Spongiotic, psoriasiform and pustular reaction patterns

Lichen simplex chronicus



Topic Completed: 8 November 2021

Minor changes: 11 January 2022

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PubMed Search: Lichen simplex chronicus [title] free full text [sb]

Juanita Duran, M.D.
Jose A. Plaza, M.D.
Page views in 2021: 27,155
Page views in 2022 to date: 1,388
Cite this page: Duran J, Plaza JA. Lichen simplex chronicus. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/skinnontumorlichensimplexchronicus.html. Accessed January 18th, 2022.
Definition / general
  • Chronic dermatitis characterized by localized areas of thickened, hyperkeratotic skin resulting from chronic rubbing or scratching
  • Absence of underlying dermatologic condition
  • These changes, known in conjunction as lichenification, are occasionally superimposed on other dermatoses, inflammatory and neoplastic
Essential features
Terminology
  • Neurodermatitis circumscripta
  • Neurodermatitis
ICD coding
  • ICD-10: L28.0 - lichen simplex chronicus
  • ICD-11: EA83 - lichen simplex or lichenification
Epidemiology
Sites
Pathophysiology
Etiology
  • Pruritus
    • Underlying stimulus and most important symptom (Dermatol Ther 2008;21:42)
    • Hypothesized relation to an increased sensitivity to local neurotransmitters and their neuromodulation, in response to primary stimulus (i.e. temperature, pressure, etc.) (Semin Diagn Pathol 2017;34:220)
    • May be secondary to other dermatosis, medical conditions or psychological disorders (Dermatol Ther 2008;21:42)
    • Associated with psychiatric disorders, including depression, anxiety, dissociation and obsessive compulsive disorder (Dermatol Ther 2020;33:e14389)
Clinical features
  • Circumscribed
  • Early lesions may appear erythematous
  • Chronicity results in hyperkeratosis with thickened scaly plaques, excoriated papules, leukodermic (hypopigmented) center and increased skin markings (Dermatol Ther 2008;21:42)
  • Longstanding lesions may also have depigmentation or hypopigmentation
Diagnosis
Laboratory
  • As pertinent, if an underlying medical condition is suspected as the etiology of pruritus
Prognostic factors
Case reports
Treatment
Clinical images

Contributed by Cristian Rocha, M.D. and Jonathan D. Ho, M.B.B.S., D.Sc.
Left lower back lesion

Left lower back lesion

Dorsal foot plaques

Dorsal foot plaques

Microscopic (histologic) description
  • Early lesions may demonstrate spongiosis (Semin Diagn Pathol 2017;34:220)
  • Evolves to demonstrate (Semin Diagn Pathol 2017;34:220)
    • Compact orthokeratosis with focal parakeratosis
    • Hypergranulosis
    • Occasional pseudoepitheliomatous hyperplasia
    • Prominent irregular acanthosis with curvilinear, blunt rete ridges
    • Papillary dermal fibrosis, with vertically oriented collagen bundles
    • Superficial chronic perivascular inflammatory infiltrate
    • Rare mast cells and eosinophils
    • As lichenification may be superimposed on other dermatoses, careful search for other disorders is advised
Microscopic (histologic) images

Contributed by Jose A. Plaza, M.D.
Psoriasiform pattern

Psoriasiform pattern

Vertically oriented dermal fibrosis

Vertically oriented dermal fibrosis

Sample pathology report
  • Skin, left lower leg, shave biopsy:
    • Lichen simplex chronicus (see comment)
    • Comment: Sections demonstrate hyperkeratosis, focal parakeratosis, a thickened granular layer and marked acanthosis. Characteristic vertically oriented, thickened collagen bundles are seen in the superficial dermis. The underlying dermis shows mild to moderate chronic inflammation. These findings, in the right clinical setting, are consistent with the above diagnosis.
  • Note: Avoid descriptive diagnosis that will not help the clinician to properly treat their patients. Breaking the itch / scratch cycle is essential to treat this entity (Mod Pathol 2020;33:107).
Differential diagnosis
  • Psoriasis (Semin Diagn Pathol 2017;34:220, Dermatol Ther 2004;17:8):
    • Regular acanthosis with club shaped rete ridges
    • Confluent parakeratosis
    • Hypogranulosis
    • Intracorneal neutrophils
    • Acanthosis
    • Vascular congestion of papillary dermis
  • Other chronic spongiotic dermatitides:
    • Spongiosis
    • Acanthosis
    • Exocytosis
    • Perivascular inflammatory infiltrate, predominantly lymphohistiocytic and occasional neutrophils and eosinophils (the latter may be numerous in allergic contact dermatitis)
    • Their differentiation may not be possible if superimposed lichenification is present
  • Prurigo nodularis
    • Same findings as in lichen simplex chronicus but in nodular configuration rather than plaque-like
Board review style question #1

A pathologist is reviewing a skin case. The clinical history field on the requisition indicates chronic pruritus. Hematoxylin and eosin stained sections of a punch skin biopsy submitted as lower leg lesion demonstrate the features shown in the photomicrograph. This entity most likely represents:

  1. Dermatophyte infection
  2. Lichen simplex chronicus
  3. Mycosis fungoides
  4. Psoriasis
Board review style answer #1
B. Lichen simplex chronicus

Comment Here

Reference: Lichen simplex chronicus
Board review style question #2
Which clinical scenario best fits a diagnosis of lichen simplex chronicus?

  1. 30 year old man with buttocks and scalp lesions (white / silver scaly, well demarcated plaques with underlying erythema)
  2. 45 year old woman with dorsal hand lesion (circumscribed, erythematous pruritic plaque with leukodermic center and increased skin markings)
  3. 50 year old woman with neck lesion (annular plaque of erythema, scale at advancing border)
  4. 60 year old man with numerous trunk lesions (initially pruritic patches with minimal scaling with evolution to erythematous plaques)
Board review style answer #2
B. 45 year old woman with dorsal hand lesion (circumscribed, erythematous pruritic plaque with leukodermic center and increased skin markings)

Comment Here

Reference: Lichen simplex chronicus
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