Erosive Lichen Sclerosus-A Clinicopathologic Subtype

Abstract

Objective: The aim of the study was to identify whether erosive lichen sclerosus (LS) is a distinct clinicopathologic subtype.

Materials and methods: The pathology database was searched for "erosion," "erosive," "ulcer," and "lichen sclerosus." Inclusion criteria were histopathologic diagnosis of LS and erosion or ulcer overlying a band of hyalinization and/or fibrosis. Exclusions were concurrent neoplasia and insufficient tissue. Histopathologic review documented site, epithelial thickness, adjacent epidermal characteristics, infiltrate, and dermal collagen abnormality. Clinical data included demographics, comorbidities, examination findings, microbiologic results, treatment, and response.

Results: Ten examples of erosive LS and 15 of ulcerated LS occurred in 24 women with a mean age of 67 years. Ulcerated LS was associated with diabetes and nontreatment at time of biopsy. Clinicians identified red patches in all but 1 case of erosive LS. Ulcerated LS was documented as fissure, ulcer, or white plaque, with 8 (53%) described as lichenified LS with epidermal breaches. Erosive LS favored hairless skin with normal adjacent stratum corneum sloping gently into erosion, whereas most ulcers in LS had an abrupt slope from hair-bearing skin. All cases were treated with topical steroids; 2 patients with erosive LS and 10 with ulcerated LS also had oral antifungals, topical estrogen, antibiotics, and/or lesional excision. Treatment yielded complete resolution in 50%.

Conclusions: Erosive LS is an unusual clinicopathologic subtype characterized by red patches on hairless skin seen microscopically as eroded epithelium overlying a band of hyalinized or fibrotic collagen. In contrast, ulcerated LS is usually a traumatic secondary effect in an uncontrolled dermatosis.

FIGURE 1

A, Erosive LS: red macules and patches dispersed over residual labia minora on a background of pallor and architectural alteration; B, Hairless skin with compact stratum corneum, reactive nuclear change, band of edematous and hyalinized collagen, and scant lymphocytic infiltrate; there is gradual slope into erosion with epithelial neutrophils and vacuolar change (hematoxylin-eosin, ×100).

FIGURE 2

A, Erosive LS: scattered pink-red glazed macules and patches over labia minora and posterior fourchette on a background of pallor. B, Parakeratotic hairless skin with a gradual slope into erosion, basal layer with reactive nuclei, vacuolar change and apoptotic bodies, band of hyalinized collagen, and lymphoplasmacytic infiltrate (hematoxylin-eosin, ×100). C, Erosion with neutrophils in epithelium and stroma (hematoxylin-eosin, ×200.).

FIGURE 3

A, Ulcerated LS: pallor, erythema, textural change, ecchymoses, abnormal texture, and multiple erosions and ulcers. B, Abrupt transition between ulcer and eroded epidermis with neutrophils, spongiosis, reactive nuclear change, and thick band of hyalinized and edematous collagen (hematoxylin-eosin, ×100). C, Edge of other side of the ulcer with neutrophil-dominant inflammation across epithelium and stroma accompanied by dermal fibrinous exudate (hematoxylin-eosin, ×100).

FIGURE 4

A, Ulcerated LS: ulcer at lateral perineum on a background of pallor and abnormal texture. B, Hair-bearing skin with parakeratosis, spongiosis, reactive nuclear change, band of hyalinized collagen, and lymphocytic infiltrate; there is a steep slope into ulcer with underlying neutrophil-dominant infiltrate (hematoxylin-eosin, ×100). C, Resolution of ulcer with improvement in skin color and texture after treatment with clobetasol propionate ointment.