Slater, Alan Butler

English

Edinburgh Research Archive

LICHEN PLANUSand its varieties.■byAj B. S LA T E R,M.B., Ch.B., Edin.; L.R.C.P., Lond; M.R.C.S.,Eng.0O0L IOHES PLANUSand its varieties.I n t _r o d u_ c t o r y.The word is derived from the Greek Xe.iy^r^v= a lichen, and is used no doubt on account of the77 7disease resembling to a very small extent, the plantgrowing on a tree, or wall.The photographs, drawings of microscope slide,and any original observations in this thesis, arethe result of the personal study, and in most cases,entire treatment of 40 cases (through the courtesyof Dr M. K. Hargreaves, whose clinical assistantthe writer was for two years at the St.John's Hosp¬ital, Leicester Square).The photographs are original and the drawingfrom an actual section.Etiology.Lichen is an uncommon disease in general prac¬tice, and forms not more than 1% of cases in aspecial hospital for skin diseases, such as thatmentioned. There are many named varieties, vis.1. Lichen ruber planus.2. Lichen ruber obtusus .3. L.R. obtusus corneatus.4. L.R. acuminatus neuroticus5. L.R. planus corneatus or lichen hyperkeratoses6. R.P. planus atrophicus7. L.moniliformis.The most common form and most typical is lichen\ruber planus, and this will be described first.The disease may be acute or chronic. The com¬monest age appeared to be from 40-GO, but below 30it is rare, only two of the 40 cases were in patients"below that age, one a man of 19 and the other awoman of 22.The disease is much more common in women thanin men, the proportion being 5 women to 1 man inthese 40 cases.In 65^ there was a distinct history of longcontinuance of debility or "worry" in the patients,the general health being much below par, in somecases for months, in others for a fow weelcs only.One woman stated that the disease came on a weekafter receiving a sudden mental shock (her husbandhad committed suicide).On the other hand.,in the other cases no defin¬ite history of debility could be obtained, but someof the cases may be accounted for^by want of properfood, my reason for this statement being, that onlooking up the record of cases since 1898, I findthat lichen has been more in evidence at St.John'sHospital during the last two years than in the pre¬ceding years, and these two years have been years ofgreat distress among the people, owing to bad tradeand consequent loss of work.It is, however, a disease not confined to thepoor, as the wealthy classes are victims also, thecause here may be, again, debility caused by worry,or continuous living at high pressure.Young children may have lichen planus, but itis a very rare disease in children, the writer hav¬ing seen only one typical case in a child.S y rn p t o m s.Chronic Form:The disease begins insidiously with persistentitching of the skin, before any papules appear, butvery soon,in a day or two, they appear.The commonest site for their first appearanceis on the front of the wrist and forearm, otherplaces in order of frequency are the inner side ofthe thigh just above the knee (sometimes first toappear), then below knee, and ankle, lower part ofabdomen and flanks, and round the waist (in women).If the patient has been scratching, there may appear8 or 10 papules in the line of the scratch sometimes.It may occur on the mucous membrane of themouth or vulva, but rarely attacks either the faceor scalp.The papules vary in sise from less than l/l6thof an inch to 5/l6ths., but there may be an amalgam¬ation of many papules, forming a patch sometimesseveral inches across, after the manner of confluentsmall-pox. These patches are, however, not foundin the earlier stages of the disease.The individual papules are raised, circumscribed,areas, resembling a small table mountain, and havinga smooth shiny surface, the centre of which may beseen in some cases, with a lens, to be depressedslightly. At first the papules are bright red andquite distinct from each other, the skin interveningbeing usually normal in appearance. A waxy appear¬ance is given to the papules by the shiny surface,which is very characteristic of the disease.Course of the Disease.In about 10 days or a fortnight the papulesassume a little darker colour, and in a month orsix weeks have become a characteristic purple orviolet colour, which may persist for months or evena year or more in the more chronic cases.When the papules begin to fade they assume abronze colour - which may either clear up and leaveno trace on the skin, or may leave a brown discolouration which may oven be permanent.Another thing which may take place is that thecondition may "become one of lichen hypertrophica, thepapules being very much thickened and raised, andassuming a most intractable state of affairs.Pur a t i o n.The disease in its various stages may existfrom three months to as many years, but the averageduration of the cases mentioned was about eightmonths, the acute cases being usually a little long¬er before entirely disappearing, although respondingmore readily to treatment at first..Acute Form:Resembles the chronic form in many respects,but is characterised by a larger number of papuleswhich may spread over the entire trunk and limbs,giving a lobster-like appearance to the patient.The rash, however, rarely appears all at once,8.usually appearing in the order of the chronic formviz. wrists, &c. "but spreading in successive out¬crops almost every day.The acute form may "be a very serious disease -the constant and distracting itching preventing anyrest during the night and allowing very little dur¬ing the day. Death has taken place in some record¬ed cases from asthenia or complications followingthe acute inflammatory condition into which the skingets, in the severe forms of the acute disease.The course of the acute form resembles that of thechronic form, except that in the early stages, thered papules seem to become purple a little soonerunder treatment.The pathology appears to be the same.9.Path o 1 o g y.A vertical section through a papule shows alarge amount of small celled infiltration under therete mucosum, causing a raising up of all structureslying above it, and so forming what I have describedas a small table-mountain. Usually the vessel fromwhich the small leucocytes have exuded, is visibleunder the mass of cells and often sweat ducts may beseen running through the mass, the sweat gland itsel:however usually lies below the mass, and is veryrarely embedded in it.Hair follicles do not usually lie in the mass,but on the periphery of a papule.The cuticle is thickened on the top of a papuleand sometimes a plug of thickened cuticle is seenon the top of a papule. In other cases there maybe a small depression, the cause of this being doubt10.ful, but the most natural theory is that it iscaused by the plug becoming detached (Crocker); thetheory put forward by another writer (Biesisdicki)is that it is caused by the contraction of theerector pilaris muscles. This, however, does notseem to correspond with the fact that the hair fol¬licles as a rule lie outside the papule, or at theextreme edge.11.T r eat m e n t.First improve the general health by nourishingfoods, avoiding those things which are liable tocause urticaria, such as shell-fish, cheese, andhighly spiced foods.The bowels should be kept open by cascara ormagnesia citrate, or the pill composed of aloingr.15^ strychnine Sulph. gr. l/60, and ext.bella¬donna gr.l/8., all of which remedies keep the bowelregular without producing the depression which sometimes follows magnesium sulphate or other drasticpurgatives.Change of air, and especially surroundings,if worry has caused the onset of the disease, isvery important.The internal treatment of lichen consists inthe administration of arsenic - but it is doubtful12.if any internal treatment has very much effect.Jamieson gives l/50 gr. arsenious acid, gradu¬ally increased to l/l2th, or iron and arsenic may begiven together. Arsenic, however, with some casesseemed to aggravate the condition, and idiosyncrasymust always be looked for in the administration ofarsenic.In very acute cases it may be necessary to keepthe patient in bed and restrict the diet to a milkone. Also when the itching is so severe as tocause several nights of sleeplessness in succession,morphia or some other powerful hypnotic may be absol¬utely necessary to preserve the patient's strength.Quinine may be necessary in widely acute cases.Aspirin gr.10-15 is a useful drug, and seems tohave some beneficial effect, especially where thereis much irritability. Liveing recommends hydrarg.perchlor. in doses of gr. l/l6 internally.13.The local treatment is the one which gives"best results. Of the lotions used, lotr.calaminae(consisting of native calamine 20 gr.^oxide of zinc20 grs., glycerin 30 min., liq.calcis 5 dr., waterto an ounce) is very useful.Creolin (half a teaspoonful to 10 gallons inhot bath) is very useful in allaying the itching,and the hot bath just before going to bed will oftenenable the patient to get to sleep, but the conditionis aggravated if the proportion of creolin to wateris more than the above.Corrosive sublimate solution 1-2000 has beenused, also lead lotion; and the latter is useful inallaying irritation, although it should not be con-tinued very long, on account of absorption.Jamieson recommends the following ointment:Acid carbol. gr.15-30Hydrarg.perchlor. gr.1-3Lanolin )Zinc oxide ) of each 2 dr.Pulv.amyli )14.and on many of the cases described this ointment hada good effect. Menthol soap, baths of sulphide ofpotassium, and camphor ointment are all recommendedby Jamieson. Mercurial remedies are regarded bysome writers, as almost specific. Brocq recommendsUnna's mercurial plaster, to most affected parts.He also recommends ung.calomel 1-20 or 1-10 andyellow oxide of mercury 1-30.For the itching he uses lotion of corrosivesublimate 1-1000 applied hot, and also the followingAc. carbol 1 gram.Ac.salicyl 2 grams.Tartaric acid 3 grams.Glycerols of „Starch 60 SramsVidal believes glycerole of starch and tartaricacid to be specific.In acute cases many of the above remediescannot be tolerated, and in those cases emollientsshould be used, such as lanoline, or olive oil, ora mixture of lotio calaminae and oleum lini is very15.soothing. In the case of very chronic plaquestreatment should "be on the same lines as for lichenhyperkeratosis described later.Varieties of Lichen1. Lichen ruber obtusus:Characterised by the papules being very waxylooking.2. Lichen Ruber obtusus corneatus.Large waxy papules usually remaining isolated,characterise this form. The tops of the papulesare horny and look dull.The disease is very slow, and intractable, andis treated on the same lines as lichen^ hyperkeratosus(q.v.)3. Lichen Ruber acuminatus neuroticus:Characterised by papules with heaped up scalesround hair follicles.16.The disease comes on after sweating and re¬sembles pityriasis ruber pilaris, but is distinguish-■ed from that disease by its acuteness and generalby means of soothing ointments such as unguentumcalaminae cum oleo lini, and baths as in acute lichenruber planus, but it may lead to fatal results.4. Corneous lichen ruber planus or Lichen hyper-Is almost always found on the legs, sometimesin 1arg e piaques.The plaques are heaped up to the height of -jr- inabove the level of the skin in the worst cases, andare covered with scales. There are usually deepfurrows in the plaques, and in the immediate vicin¬ity may be found typical lichen ruber planus papules,which seem to indicate that the condition is a mod¬ification of that disease.physical disturbance. It is usually easy to cure17.The colour of the plaques is always a dark pur¬ple, the scales however producing a greyish appear¬ance on the surface.They are very intractable and may exist fortwenty years or more, but do not cause much incon¬venience, apart from a varying amount of irritability.The treatment is somewhat unsatisfactory, but inseveral cases, the writer has seen complete curesfrom the following ointment:acidi salicylates \/ gr.xxx.acidi carboliji gr.xxx.Ung. simplex ad iThis is a powerful ointment, and no doubt actsby causing desquamation and removing the mass layerby layer.In the case of one patient, whose condition isshown in photograph No. .X many dermatologistsat a society at which he was shown, advocated shav¬ing off successive layers until the mass was removed18.to the level of the skin, but this was not done,as the man improved very much, under severe oint¬ments, and is now progressing favourably. He hadhad the disease over twenty years.Internally arsenic seemed to have little effectbut when the external treatment is being used at thesame time, it is difficult to say which causes theimprovement.Mercurial treatment externally seemed to haveno effect on these cases, and it was only when suchremedies as ung. ac. salicyl. and ac.carbol. wereused that improvement began to occur.5. Lichen ruber planus atrohhi&us:A very rare disease, beginning like lichenruber planus, but afterwards the papules flattenand leave white patches looking like punctiformdepressions.Histologically these spots show atrophy ofpapillae with sclerosis of derma and dilatation of.sweat ducts. The treatment is the same as for'lichen ruber planus.Lichen ruber moniliformis (Kaposi)In this form of the disease, the papules arearranged in longitudinal lines, fairly symmetricallyThe papules are larger in size than ordinarylichen planus papules, and resemble a string ofcoral beads or nodules of keloid.It is a very rare disease, and is probably amodification of lichen ruber planus - perhaps dueto scratching, as it is quite common to see lichenpapules occurring in the line of a scratch.The treatment is arsenic internally, and thesame remedies as for lichen ruber planus may beused for external treatment.LITERATURE.In writing this thesis, the following workshave been used for reference, particularly in regardto treatment:TJamieson, W. Allan;Diseases of the Skin, 1894, Edinburgh.Kaposi, H.Maladies de peau, translation by Besnier.& DoyonVol.11.Kaposi, M.Pathology & Treatment of Diseases of the Skin.English Translation. New York, 1895.Brocq, L.Maladies de Peay, Paris.VidalAnnales Francaises de Dermatologie,Paris, 1886.Hebra, F.Diseases of the Skin.Walker, Norman.English Translation of Unna's Histo-pathologyof the Skin. X 7^0.>IA<LU^ .SECTlotf o^. LICHEE. HYPER K^R-ATOSUS.section ^ Lichee luaeR .fLAtvus.

Lichen planus : and its varieties

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Lichen planus : and its varieties

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