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The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Chana A. Sacks, M.D., Editor

Lichen Planus
A B

A 
69-year-old man presented to the dermatology clinic with a Ayan Kusari, M.A.
2-month history of a pruritic rash. The rash had first appeared on his right Jusleen Ahluwalia, M.D.
wrist and within 2 weeks had spread to his arms, legs, and trunk. His University of California, San Diego,
medical history was notable for chronic hepatitis C virus (HCV) infection, for   School of Medicine
which he had completed a 12-week course of elbasvir and grazoprevir 3 months La Jolla, CA
jahluwalia@​­rchsd​.­org
before the onset of the rash. On examination, numerous purple papules were
noted on the anterior surface of the forearms (Panel A) and the dorsal surface of
the hands (Panel B) as well as on the trunk and legs. Several lesions showed a fine
reticulate pattern of dots and lines, called Wickham’s striae. Biopsy of a lesion
revealed hyperkeratosis, wedge-shaped hypergranulosis, sawtooth rete pegs, and
bandlike lymphocytic inflammation — findings confirming the diagnosis of lichen
planus. Although the cause of lichen planus has not been established definitively,
it is thought to be an autoimmune disease. Lichen planus has a known association
with HCV infection. In this patient, the association between HCV infection, which
had been treated, and the later eruption was unclear. Topical or intralesional gluco-
corticoids may be used in primary treatment, with ultraviolet light therapy and
oral immunosuppressive agents reserved for more extensive cases. This patient was
treated with topical clobetasol and narrow-band ultraviolet B therapy, and a reduc-
tion in lesions occurred within 1 month after the start of treatment.
DOI: 10.1056/NEJMicm1802078
Copyright © 2018 Massachusetts Medical Society.

n engl j med 379;6 nejm.org  August 9, 2018 567


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