Archive for the ‘L’ Category

Lipoma

A lipoma is a benign growth of fatty tissue underneath the skin. They are usually solitary lesions, although multiple lesions have been reported in rare, genetic diseases such as familial multiple lipomatosis and benign symmetric lipomatosis. Lipomas typically start as small lesions on the body, and grow to a certain size, after which they remain stable.

Presentation:

A lipoma usually presents as a soft, flesh-colored bump felt underneath the skin. Lipomas are commonly found on the neck, forearms, and armpits. They are usually painless. Multiple, painful lesions have been reported in a condition known as Dercum’s Disease, which affects peri-menopausal females. Older lesions may become firm and ill-defined when palpated.

Treatment:
Given their benign nature, observation is a reasonable option for patients unwilling to undergo surgical intervention. Several surgical methods have been utilized in the removal of lipoma’s, including incision and curettage, excision, and liposuction. Also suggested is the use of intralesional steroids, which may help shrink the size of the lesion. Surgery is usually curative for most patients, although recurrence has been reported.

Reference:
Arnold HL, Odom RB, James WD. Andrew’s Diseases of the Skin. 8th edition.

Brian Walther, D.O.
Department of Dermatology
Philadelphia College of Osteopathic Medicine/Frankford Hospital
Philadelphia, Pennsylvannia.

Stephen M. Purcell, D.O., F.A.O.C.D.
Professor and Chairman of the Department of Dermatology
Philadelphia College of Osteopathic Medicine
Philadelphia, Pennsylvannia
www.adaltd.com

 

Lichen Sclerosis et Atrophicus

This chronic skin disease most commonly affects the skin of the anogenital region in women, and the glans penis and foreskin in men. It occurs less commonly in extra-genital sites. It most often affects post-menopausal women. The female to male ratio is approximately 7:1. Children may also be affected (about 15% of cases) and it is an important differential diagnosis of the signs of suspected sexual abuse. Lichen sclerosis et atrophicus does not cause any systemic disease outside the skin. Its cause remains unclear. Genetic, autoimmune and infective mechanisms have been considered, but no definitive data has ever been found. There are no reliable figures for population incidence or prevalence. It is exceedingly rare in circumcised men.

Male patients present with lesions on the glans penis and foreskin – but generally not the perianal region. As well as soreness and itching, there may be difficulty in retracting the foreskin and a poor urinary stream. Often a non-retractile foreskin requires circumcision. Lichen sclerosus commonly recurs in the circumcision scar. There is an increased risk of developing squamous cell carcinoma within genital lesions and careful follow up is necessary.

Presentation:
The condition may have no symptoms. It is sometimes discovered during evaluation for another problem. Usually one experiences severe itching and soreness of the genitals. White plaques develop on the skin and form shiny, white areas. Female patients usually have an hourglass shape of inflamed skin around the vulva and anus. Pain with urination, sexual intercourse and defecation are common. There may be traumatic tearing of the skin during intercourse or defecation. Scarring is common – the labia minora may fuse making urination difficult, and the entrance of the vagina can become very narrow. Occasionally the disease presents before puberty, where the ‘bruised’ red, purpuric signs appear to suggest abuse.

Lichen sclerosus affects skin outside the genitals in 15-20%. The Koebner phenomenon may occur: disease arises in scars, burned or repeatedly traumatized skin. Rarely, it may affect the oral mucosa. Itching of the extra-genital form is unusual. Extra-genital lesions may require no therapy if asymptomatic or not causing significant cosmetic effect. There is no increased risk of squamous cell carcinoma in extra-genital lesions.

Investigations:
Skin punch biopsy is useful to confirm the diagnosis and exclude malignancy.

Treatment:
Administration of potent topical steroid preparations, (clobetasol propionate 0.05% ointment) given once daily for 1–2 months is the treatment of first choice. The frequency of applications is gradually reduced to zero. Treatment is then usually given on as needed basis. Potent steroids should be used under the advice/supervision of a dermatologist. Wash with bland emollients to avoid topical irritants and avoid tight clothing; use lubricants if necessary. Non-healing erosive or warty lesions may indicate cancerous change.

A 6-8 week course of ultrapotent topical corticosteroid is a safe and effective treatment for genital lichen sclerosus in pediatric patients, although spontaneous resolution may occur. Patients may suffer psychosexual problems; a psychologist/psychiatrist or appropriate counselor may be necessary. Surgical procedures are sometimes necessary, although vulvectomy is not indicated unless there is a tumor. Phimosis needs circumcision. Surgery may be needed in women to repair damage by scarring. Follow-up with topical steroids and dilators is needed to prevent recurrence.

Prognosis:
With early and careful evaluation by dermatology/gynecology/urology, the burden of this disease is lessening and many patients lead happy lives with normal urinary and sexual function. However, the course is highly variable and some patients will inevitably be severely affected. There is a 4-5% risk of squamous-cell carcinoma (SCC) of the vulva, and there may be a slightly increased risk of SCC of the penis. Long term follow-up is suggested. Biopsies of any suspicious lesions are advised. Extra-genital lesions do not appear to have any increased risk of skin cancer.

Valerie Nozad, D.O.
Department of Dermatology
Philadelphia College of Osteopathic Medicine/Frankford Hospital
Philadelphia, Pennsylvannia.

 

Lichen Planus

Lichen planus (LP) is a relatively common dermatologic disorder affecting middle-aged individuals. Its cause remains uncertain, although the literature suggests that an autoimmune response (immune response by the body against one of its own tissues, cells, or molecules) may be involved. There have been reported cases of lichen planus-like lesions that occur as an allergic reaction to certain types of medications, most commonly medications for arthritis, high blood pressure and heart disease. LP has been associated with hepatitis C, which can be determined with blood work ordered by your physician.

Presentation:
LP can affect the skin, nails, mucous membranes and genital skin. LP of the skin classically presents as an itchy, purple, scaly, flat-topped, bumpy rash. The color is pink to red initially, eventually becoming violaceous (reddish-purple). The surface often has gray or white lacy streaks (Wickham’s striae) which cross the lesions. LP of the nails most commonly presents with splitting and longitudinal ridging. LP of the mucous membranes presents with white lacy streaks on the inside of the cheeks (most common), tongue, lips and gums. Less commonly, LP of the mouth could present with painful ulcers.

Treatment:
LP does not have a cure and treatment should be individualized on a patient to patient basis. Skin lesions, if not widespread, can be treated with topical steroids or steroids injected into the lesion. For itching, topical anti-itching creams/lotions/soaks may provide some relief (Sarna and Aveeno oatmeal bath). Oral anti-itch pills may be necessary if itching is more severe. If LP is more extensive, oral steroids for many weeks may provide some benefit. In addition, phototherapy (PUVA), oral retinoids (vitamin A derivatives), and cyclosporine (an immunosuppressive agent) may be considered.

Oral lesions of LP provide an even greater challenge. Treatment options include super-potent steroids in a gel form, and steroids injected into specific lesions. LP of the nails provides another great challenge, with treatment options being very limited and not greatly effective. Steroid injections have been used for some of these cases. Severe involvement may result in permanent destruction of the nail.

References:
Boyd AS and Neldner KH: Lichen planus. J Am Acad Dermatol 1991;25:593-619.
Champion RH. Textbook of Dermatology. 6th Ed. Eds: Rook, Wilkinson, Ebling. Blackwell Science: Mass.,1998:199-1916.
Cribier B, Frances C, Chosidow O: Treatment of lichen planus. An evidence-based medicine analysis of efficacy. Arch Dermatol 1998 Dec; 134: 1521-30.
Fitzpatrick T, Eisen A, Wolff K, et al: Dermatology in General Medicine. Vol 1. 4th ed. McGraw-Hill:New York, 1993:1134-44.

Mollie Jan, D.O.
Department of Dermatology
Philadelphia College of Osteopathic Medicine/Frankford Hospital
Philadelphia, Pennsylvannia.

 

Lichen Planopilaris

Lichen Planopilaris (LPP) is lichen planus (see lichen planus discussion) involving the hair follicles. Most cases of LPP involve the scalp and cause a scarring hair loss. Nearly 70-80% of patients are women 40-50 years of age. A skin biopsy is necessary to make an appropriate diagnosis.

Lichen planopilaris can also be seen in patients with Graham-Little-Piccardi syndrome, characterized by LPP of the scalp with keratosis pilaris-like lesions (see keratosis pilaris discussion) as well as hair loss of the eyebrows, under-arms, and pubic area.

Presentation:
LPP presents with redness surrounding the hair follicles and eventually progresses to scarring hair loss. Small, red, raised bumps may be seen around the hair follicles. Lesions may occur on the chest, abdomen, back, or extremities. In most patients, only the scalp is affected. Once LPP progresses to scarring, the scalp will demonstrate areas of hair loss and an absence of the hair follicle openings.

Treatment:
Hair loss in LPP is permanent. The treatment is geared at stopping further hair loss. LPP responds to oral steroids and steroids injected into the lesions, especially in the early stages. Topical steroid creams may be effective in a few patients. Some studies have shown that oral vitamin A derivatives (retinoids) may be effective. Once the hair loss progresses to scarring, most treatments are ineffective.

References:
Chieregato C et al: Lichen planopilaris: Report of 30 cases and review of the literature. Int J Dermatol 2003;42:342.
Ghislain PD, Van Eeckhout P, Ghislain E. Lassueur-Graham Little-Piccardi syndrome: a 20-year follow-up. Dermatology 2003;206:391-2.
Mehregan DA et al: Lichen planopilaris: Clinical and pathologic study of 45 patients. J Am Acad Dermatol 1992;27:935.

Mollie Jan, D.O.
Department of Dermatology
Philadelphia College of Osteopathic Medicine/Frankford Hospital
Philadelphia, Pennsylvannia.

Stephen M. Purcell, D.O., F.A.O.C.D.
Professor and Chairman of the Department of Dermatology
Philadelphia College of Osteopathic Medicine
Philadelphia, Pennsylvannia
www.adaltd.com

 

Lichen Nitidus

Lichen nitidus is a relatively rare, chronic skin eruption that presents with flat-topped, skin-colored small bumps. The cause of lichen nitidus is unknown. Lichen nitidus mainly affects children and young adults. The skin is the primary organ system affected. Mucous membranes and nails also might be involved. The frequency of lichen nitidus is unknown because of its uncommon occurrence. In a study of skin diseases in blacks over a 25-year period, the incidence of lichen nitidus was 0.034%. Lichen nitidus usually has no sympstoms. Patients occasionally complain of itching.

Epidemiology:
No racial predilection is reported. No sexual predilection exists. However, generalized variants appear to occur predominantly in females. Lichen nitidus may affect any age group, but it most commonly develops in childhood or early adulthood.

Presentation:
The eruption consist of multiple 1- to 3-mm, sharply demarcated, round, flat-topped, skin-colored shiny bumps that often appear in groups. The Koebner phenomenon (lesions appearing in areas of trauma) may be observed. The most common sites of involvement are the trunk, flexor aspects of upper extremities, dorsal aspects of hands, and genitalia. Infrequently, the lower extremities, palms, soles, face, nails, and mucous membranes may be affected. Nail changes can be observed as well.

Reported associated diseases include atopic dermatitis, lichen planus, condyloma, amenorrhea, Crohn disease, and juvenile chronic arthritis.

Treatment:
Usually the diagnosis is made by visual examination. A skin biopsy may be obtained to confirm the clinical diagnosis. No therapeutic modality has been thoroughly evaluated for the treatment of lichen nitidus because of the rarity, largely asymptomatic nature, and disappearance of this disease within 1 or several years. Reported therapies, mostly from isolated case reports, include topical and systemic steroids, topical tacrolimus, systemic cetirizine, levamisole, etretinate, acitretin, itraconazole, cyclosporine, topical dinitrochlorobenzene, psoralen plus UV-A light, and narrow-band UV-B light.

Prognosis:
Lichen nitidus may remain active for several years; however, spontaneous resolution usually occurs. There is no associated morbidity or mortality.

Valerie Nozad, D.O.
Department of Dermatology
Philadelphia College of Osteopathic Medicine/Frankford Hospital
Philadelphia, Pennsylvannia.

 

Lentigo

A lentigo (plural – lentigini) is a persistent but stable, discrete, uniform hyperpigmented tan to black spot that can be seen on skin or mucous membranes. The most common types of lentigines include lentigo simplex, solar lentigo, and ink spot lentigo. These are benign lesions. They do not turn into cancer.

Presentation:
Lentigo simplex, or juvenile lentigo, usually develop during childhood and adolescence but may be present at birth. They occur as sharply defined, round to oval, tan to brown flat spots on any skin surface. Darkly pigmented individuals are more likely to develop lentigines on the palms, soles and nail beds.

Solar lentigines, also known as age spots, liver spots and/or senile lentigines, look similar to the lesions of lentigo simplex but are typically seen on the backs of the hands, cheeks and forehead in older populations. They are also commonly seen on the shoulders and upper chest in somewhat younger patients with light skin who have a significant history of exposure to sun light or sunburns.
Ink spot lentigo, or sunburn lentigo, is a variant of the solar lentigo. They commonly occur on the shoulders years after acute UV exposure. They are small, irregular, dark gray to jet black flat spots that resemble an ink spot, thus giving the lesion its name.

Treatment:
Although no treatment is required for lentigines, cryotherapy, chemical peels, laser therapy, and various topical creams alone or in combination may improve their appearance temporarily. Sun protection may reduce the number of new solar and ink spot lentigines.

Reference:
Ortonne JP, et al. Treatment of solar lentigines. J Am Acad Dermatol 2006;54:S262-71.

Celeste Angel, D.O.
Department of Dermatology
Philadelphia College of Osteopathic Medicine/Frankford Hospital
Philadelphia, Pennsylvannia.

 

Laser Hair Removal

Electrolysis has been the gold standard for the removal of unwanted hair for decades, but it was gradually replaced by laser technologies. Electrolysis involves the insertion of a fine wire into the hair follicle. An electric current then travels down the wire and destroys the root of that hair follicle. This process is painful and must be done on each hair individually. Hence, each session of electrolysis takes a considerable amount of time and multiple sessions are required.

Laser hair reduction is currently the state-of-the-art hair removal technique. Electrolysis still has its place in treatment of unwanted hair: it is useful for those who have only several stray hairs or patients with gray or light hair. For most other patients, laser treatment is a much better method. The laser treats large areas in one session because it does not target individual hair follicles, but rather hundreds of follicles per laser pulse. In that way, even treatment of a large area of the body (back, chest, abdomen) takes only about an hour.

Lasers for hair reduction have been available since the 1960’s. The early lasers had low efficacy and many side effects. Only since the 1990’s has laser technology matured enough so that safe and effective treatment is now available. Laser hair removal works by passing an intense light beam through the skin. The laser focuses on dark pigment, called melanin, in hair. When the light beam hits the target ( the hair follicle) the intense heat destroys it. Because the laser needs to focus on dark pigment, it is not effective for the removal of light, light red, or gray hair.

Alexandrite, Diode, and Nd:YAG are the most commonly used lasers. The “ideal” patient for hair removal is the one with light skin and dark hair. For such a patient Alexandrite laser is probably the best choice in efficacy. Diode laser is able to treat patients with light to semi-dark skin. If you have dark skin, Nd:YAG laser is the safest and most effective choice. The laser your doctor will be using might not be referred to by the technical names stated above. It will likely have a brand name like Gentelase, LightSheer, Gentle YAG, etc. Multiple companies produce laser devices but the important factor is not the brand name of a laser, but the underlying technology.

The effectiveness of laser hair removal depends on the characteristics of the individual. Some patients achieve up to 90 % permanent hair reduction, while others have a small reduction in hair growth (30-40%) and require periodic maintenance treatments. The claims of “100 percent permanent hair removal”, or “guaranteed 0% re-growth” are absolutely not substantiated. While most of patients are very satisfied with their results, there are some who do not do as well as others.

Complications from laser hair removal include skin pigment change (darkening or lightening), scarring or blistering. These complications are very rare if the procedure is done by a Board Certified dermatologist or plastic surgeon. The majority of these complications arise when hair removal is done by non-medical personnel in spas, salons, and clinics. Non-dermatology physicians whose training was no more than a weekend seminar in laser technology very often lack adequate training in skin physiology are also occasionally the culprits. Your doctor should evaluate your skin prior to laser hair removal and determine the appropriate treatment plan. If a nurse or physician’s assistant performs laser hair removal, your doctor should be available in the office to supervise the procedure.

Alexander Doctoroff, D.O., F.A.O.C.D.
Assistant Chief of Dermatology,
Veterans Administration Medical Center
East Orange, New Jersey

Assistant Clinical Professor of Medicine,
University of Medicine and Dentistry of New Jersey

www.metropolitanderm.com