DERMATOLOGICA SINICA 34 (2016) 215e216

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Dermatologica Sinica
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CORRESPONDENCE

A case of segmental lichen aureus following the venous drainage

Dear Editor,
A 30-year-old man, in relatively good health, presented with
progressive asymptomatic golden lesions on his left fourth nger
and palm. He reported that these lesions had started to develop
as a pea-sized honey-colored macule at the left proximal fourth
nger 6 months previously and enlarged gradually. In the recent
2 months, he noticed the appearance of similar lesions at the left
distal fourth nger, which then spread proximally to the distal
palmar crease of the left palm. He denied history of any trauma
or drug histories prior to the onset of skin lesions. On physical ex-
amination, one bean-sized, irregular, golden brown patch located at
the medial aspect of the left proximal fourth nger and few
brownish conuent papules at the medical aspect of the left distal
fourth nger were found (Figure 1A). Some coppery conuent pap-
ules were also found from the volar aspect of the palm, from the left
fourth proximal interphalangeal joint to the distal palmar crease
(Figure 1B). All these lesions followed the venous drainage in a
linear fashion. Histopathologic examination showed a dense
band-like lymphohistiocytic inltrate on the supercial dermis
(Figure 2A). Marked extravasation of erythrocytes was also found
but there was no evidence of vasculitis (Figure 2B). Iron-stained
section showed the presence of hemosiderin-laden macrophages
(Figure 2C). Based on the clinical and histologic ndings, segmental
lichen aureus was diagnosed. Topical desoximetasone ointment
(0.25%) two times daily for 2 months produced no improvement
and the lesions extended to the lateral aspect of the left fth nger
(Figure 1C). Oral pentoxifylline (400 mg) two times daily was sub-
sequently administered; however, he was lost to follow-up.
In reviewing the English literature, we have found reports of only
11 patients with lichen aureus in a segmental, linear, or zosteriform
pattern (Table 1).1e10 The pathomechanism of lichen aureus remains
unknown, but several possible pathomechanisms of pigmented pur-
puric dermatosis have been proposed, including increased venous
pressure or stasis, capillary fragility, infection, drugs, and involve-
ment of T-cell immunity. As to our case, the pattern closely followed
the venous drainage of hand circulation. Including the present case,
four cases of segmental lichen aureus displayed this pattern,3,4,7 sug-
gesting that segmental lichen aureus is a hemosiderin tattoo,
resulting from impaired local venous return. The persistence of the
tattoo pigment has to do with altered hemodynamics that favor
continued microscopic extravasation of red cells in a delimited area.11
There is a controversy between segmental lichen aureus and
unilateral linear capillaritis (ULC). ULC was rst reported in 1992
by Riordan et al.12 The differences between ULC and segmental
lichen aureus are as follows: (1) lesions of ULC often resolve within
2 years, unlike the typical chronic course of lichen aureus; and (2)
histopathologically, only a focal supercial perivascular lympho-
cytic inammation is interspersed with mild extravasated erythro-
cytes in ULC.13 However, both entities follow linear or segmental
distribution and an individual lesion of ULC is similar to lichen
aureus. Therefore, we propose that ULC might represent a milder
form of segmental lichen aureus, which may explain why sponta-
neous resolution is much often seen in ULC.
Treatment of segmental lichen aureus can be challenging.
Without treatment, it is considered to be a highly chronic derma-
tosis; only two cases showed partial spontaneous resolution.6,10
In general, potent oral and topical corticosteroids are ineffec-
tive,1,4,5,10 although two cases showed good response to topical
0.1% methylprednisolone aceponate ointment.8 Pulsed-dye laser
and oral pentoxifylline in combination with prostacyclin have
shown variable success.7,9

Figure 1 (A) Irregular-shaped golden brown patches and papules on the left proximal and distal fourth ngers (the arrow indicates the biopsy site). (B) Some coppery conuent
papules at the volar aspect of the palm from the left fourth proximal interphalangeal joint to the distal palmar crease. (C) The lesions spread to the lateral aspect of the left fth
nger despite treatment with topical steroids for 2 months.

Conicts of interest: The authors declare that they have no nancial or non-nancial conicts of interest related to the subject matter or materials discussed in this article.

http://dx.doi.org/10.1016/j.dsi.2016.03.006
1027-8117/Copyright 2016, Taiwanese Dermatological Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
216 Correspondence / Dermatologica Sinica 34 (2016) 215e216

Figure 2 (A) A lichenoid lymphohistiocytic inltrate on the supercial dermis. (hematoxylin and eosin stain; magnication: 40). (B) Marked extravasation of erythrocytes without
evidence of vasculitis (hematoxylin and eosin stain; magnication: 400). (C) Deposits of hemosiderin were demonstrated by iron stain (Prussian blue; magnication: 400).

Table 1 Summary of the reported cases with lichen aureus in a segmental, linear or zosteriform pattern in the English literature.

Patient Age Involved skin areas Duration Associated Treatment Treatment response Reference
(y)/sex condition

1 21/F Right index nger 7y None Oral tetracycline and None Abramovits et al1
topical 0.1% triamcinolone
acetonide cream
2 22/M Right upper arm 7 mo None Halcinonide cream 0.1% None Rudolf2
and chest
3 15/F Left upper shoulder 17 mo Trauma, NA NA Ruiz-Esmenjaud, Dahl3
and chest puberty
4 11/F Left leg 7y None Topical corticosteroid None Mishra, Maheshwari4
5 28/F Lower abdomen 1y None Topical betamethasone None Aoki, Kawana5
6 55/M Left upper arm and 2y Morphea None Gradually Bell et al6
shoulder
7 17/F Right upper arm 15 mo None Oral pentoxifylline and Nearly complete Lee et al7
prostacyclin I2 resolution after 4 mo
8 9/F Left leg 1y None Topical methylprednisolone Complete resolution Moche et al8
aceponate after 7 mo
9 25/M Left lower abdomen 6 mo None Topical methylprednisolone Complete resolution after 4 mo Moche et al8
aceponate
10 33/F Right leg 3y None 595-nm PDL Complete remission after three Hong et al9
sessions
of PDL over a period of 3 wk
11 30/F Left leg 4 mo None Oral prednisolone and topical Poor response but slowly Zhao et al10
halcinonide spontaneous
resolution over the next 13 mo without
treatments
This case 30/M Left fourth and 6 mo None Topical 0.25% desoximetasone None This study
fth ngers and palm ointment

F female; M male; NA not available; PDL pulsed-dye laser.

In conclusion, we presented a case of segmental lichen aureus in
the acral part. This case implies that the possible pathomechanism
of segmental lichen aureus is attributed to the impaired local
venous circulation. However, further investigations are needed to
conrm this hypothesis.
Funding sources:
This article has no funding source.
Chien-Ho Chu, Mei-Chin Ho
Department of Dermatology, Cathay General Hospital, Taipei, Taiwan
Cher-Wei Liang
Department and Graduate Institute of Pathology, National Taiwan University Hospital
and National Taiwan University College of Medicine, Taipei, Taiwan
Chia-Yu Chou*
Department of Dermatology, Cathay General Hospital, Taipei, Taiwan
*
Corresponding author. Department of Dermatology, Cathay General Hospital, 280
Renai Road, Section 4, Taipei, Taiwan.
E-mail address: boagwa@gmail.com (C.-Y. Chou).
2. Rudolf RI. Lichen aureus. J Am Acad Dermatol 1983;8:722e4.
3. Ruiz-Esmenjaud J, Dahl MV. Segmental lichen aureus: onset associated with
trauma and puberty. Arch Dermatol 1988;124:1572e4.
4. Mishra D, Maheshwari V. Segmental lichen aureus in a child. Int J Dermatol
1991;30:654e5.
5. Aoki M, Kawana S. Lichen aureus. Cutis 2002;69:145e8.
6. Bell HK, Dobson CM, Jackson SP, King CM. Localized morphoea preceded by a
pigmented purpuric dermatosis. Clin Exp Dermatol 2003;28:369e71.
7. Lee HW, Lee DK, Chang SE, et al. Segmental lichen aureus: combination therapy
with pentoxifylline and prostacyclin. J Eur Acad Dermatol Venereol 2006;20:
1378e80.
8. Moche J, Glassman S, Modi D, Grayson W. Segmental lichen aureus: a report of
two cases treated with methylprednisolone aceponate. Australas J Dermatol
2011;52:15e8.
9. Hong DK, Chang IK, Lee Y, et al. Treatment of segmental lichen aureus with a
pulsed-dye laser: new treatment options for lichen aureus. Eur J Dermatol
2013;23:891e2.
10. Zhao YK, Luo DQ, Sarkar R, Xie WL. Segmental lichen aureus in a young woman
with spontaneous improvement. J Dtsch Dermatol Ges 2014;12:260e2.
11. Shelley WB, Swaminathan R, Shelley ED. Lichen aureus: a hemosiderin tattoo asso-
ciated with perforator vein incompetence. J Am Acad Dermatol 1984;11:260e4.
12. Riordan CA, Darley C, Markey AC, Murphy G, Wilkinson JD. Unilateral linear
capillaritis. Clin Exp Dermatol 1992;17:182e5.
13. Ma HJ, Zhao G, Liu W, Dang YP, Li DG. Unilateral linear capillaritis: two unusual
Chinese cases. Eur J Dermatol 2007;17:160e3.

References Received: Dec 30, 2015

Revised: Mar 10, 2016
1. Abramovits W, Landau JW, Lowe NJ. A report of two patients with lichen
aureus. Arch Dermatol 1980;116:1183e4. Accepted: Mar 22, 2016