COMMENTARY
ASHY DERMATOSIS VERSUS LICHEN PLANUS PIGMENTOSUS: A CONTROVERSIAL MATTER MARIA ELISA VEGA, M.D., LEON WAXTEIN, M.D., ROBERTO ARENAS, M.D., MA. TERESA HOJYO, M.D., AND LUCIANO DOMINGUEZ-SOTO, M.D.
The first description of ashy dermatosis (AD) was made in 1957 by Oswaldo Ramirez, in El Salvador.' Later Gonvit et al.^ observed a condition very similar to pinta lesions in late phase; they called it "erythema dyschromicum perstans" (EDP). In 1974, Bhutani et al.^ described 40 patients with lesions similar to those described by Ramirez, they named them "lichen planus pigmentosus" (LPP). This report gave rise to numerous publications in the dermatologic literature presenting confusing concepts; it has been proposed that ashy dermatosis may be a variation of lichen planus pigmentosus.''"''' Racial and nutritional conditions, and ecologic factors in India are similar to those in Latin America, therefore, our opinion is that Bhutani observed both types of dermatoses, but he did not differentiate between the two conditions.
that sometimes present an elevated active red border, which leaves a residual hypopigmented halo. Distribution tends to be symmetrical and commonly noted on the face, neck, trunk, and upper extremities. Evolution is chronic, insidious, and asymptomatic. It occurs mainly in dark skin, predominantly in women without age predilection." There is no specific treatment.
DIEEERENTIAL DIAGNOSIS
Lichen planus pigmentosus was described in 1956 by Shima et al.,'^ and it is likely that in 1935 Gougerot"^''^ had referred to the same condition, which he called "invisible pigmented lichen planus." In 1968 and 1973, Pinkus"* included ashy dermatosis and atrophic lichen planus in the same section of his classification of "lichenoid tissular patterns" because of their histologic similarities, but without committing himself as he did not state that they were the same condition. The interpretation of this article, together with the one by Bhutani, has created the confusion we referred to earlier.
Lichen planus pigmentosus is characterized by hyperpigmented dark brown macules with a noncharacteristic distribution that predominates in exposed areas and flexor folds. These macules occasionally present papules or a reticulate pattern. Its evolution is characterized by exacerbations and remissions, occasionally accompanied by pruritus. There may be clinical improvement with the use of topical steroids. The histopathologic findings of the active red border of AD show a vacuolar degeneration in the basal cell layer, occasional colloid bodies, incontinence of pigment, and Iymphohistiocyte perivascular infiltration. In the inactive macules, the incontinence of pigment predominates, while the cellular infiltrate and vacuolar degeneration in the basal membrane may be minimal or absent.-" The histopathology of lichen planus pigmentosus is characterized by an atrophic epidermis with vacuolar alteration of the basal cell layer; in the dermis it shows a scarce Iymphohistiocyte or lichenoid infiltrate with incontinence of pigment and the presence of melanophages.
CLINICAL CHARACTERISTICS
ETIOLOGY
Ashy dermatosis is clinically characterized by blue-gray hyperpigmented macules with variable shape and size
The etiology of ashy dermatosis is unknown; various causes and mechanisms have been suggested: climatic, alimentary, and occupational factors, but so far no conclusions have been reached. Reports by Jablonska et al.^' on a case related to the ingestion of ammonium nitrite, by Stevenson and Miura^^ relating a nematode-caused intestinal parasitosis, and by Knox et al.'" regarding endocrine factors, we believe, are fortuitous associations. Gonvit et al.^-^ state that recent literature on the subject has been oriented to several aspects of the disease:
BACKGROUND
From the Department of Dermatology, Hospital General "Dr. Manuel Gea Gonzalez," Mexico City, Mexico. Address for correspondence: Luciano Dominguez-Soto, M.D., Hospital General "Dr. Manuel Gea Gonzalez," Departmento de Dermatologia, Calzada de Tlalpan 4800, Mexico 22, D.F., Mexico City, Mexico 14000.
87
International Journal of Dermatology Vol. 31, No. 2, February 1992
"One group that agrees clinically and histopathologically with the described signs of AD, and others that do not meet them, adding to the confusion by relating EDP and the lichen planus variants (tropical lichen planus, Gougerot's invisible lichen planus, and Japanese lichen planus). Others approach the concept of 'lichenoid tissular reaction' introduced by Pinkus,'^ including different diseases of unknown etiology and associated to diverse factors." Pinta in its early stage, Riehl's melanosis, or "idiopathic multiple macular pigmentation," all of which are prevalent in Latin America and affect mainly lighter dark-skinned persons, should also be taken into account within the differential diagnosis of ashy dermatosis. Finally, drug-induced dermatoses with residual hyperpigmentation, occupational dermatoses with exposure to heat or fire, and lichen planus pigmentosus must be considered. Piquero-Martin et al.^'' reported that clofazimine seems to have good cosmetic effects on ashy dermatosis by masking the lesions, and it also seems to act by inducing changes in cellular immunity.^^
6.
Berger RS, Hayes TJ. Erythema dyschromicum perstans and lichen planus. Are they related.' J Am Acad Dermatol 1989; 21:438^42.
7.
Hoist R, Mobacken H. Erythema dyschromicum perstans (ashy dermatosis) report of 2 cases fromScandinavia. Acta Derm Venereol (Stockh) 1974; 54:69-72.
8.
Miyagawa S, Komatsu M, Okuchi T. Erythema dyschromicum perstans. Immunopathologic studies. J Am Acad Dermatol 1989; 20:882-886. Byrne DA, Berger RS. Erythema dyschromicum perstans. A report of two cases in fair-skinned patients. Acta Derm Venereol (Stockh) 1974; 54:65-68.
9.
10.
Knox JM, Dodge BG, Freeman RG. Erythema dyschromicum perstans. Arch Dermatol 1968; 97: IGI-III.
11.
Carvajal HE, Pazmino EU. Dermatitis Cenicienta apreciacion de 2 formas clinicas. Med Cutan Ibero Lat Am 1986; 14:95-99.
12.
Leonforte L, Pelaez DB. Eritema discromico persistente versus Liquen piano. Med Cutan Ibero Lat Am 1987; 15:89-92.
13.
Pozo TR, Pintado HB. Liquen piano pigmentoso. Aportacion de un caso y revision de la literatura. Actas Dermosifiliogr 1988; 79:681-686. Tschen JA, Tschen EA. Erythema dyschromicum perstans. J Am Acad Dermatol 1980; 2:295-302. Shima T. Lichen planus pigmentosus. Nippon Hifuka Gakkai Zasshi 1956; 66:346-353. Gougerot MH. Lichens atypiques ou invisibles pigmentogenes reveles par des pigmentations. Bull Soc Er Dermatol Syphiligr 1935; 42:792-794.
14. CONCLUSIONS
15.
First, based on our observations, we can state that ashy dermatosis and lichen planus pigmentosus are two clinically different conditions, the former being found exclusively in specific populations with certain similar racial, ecologic, and nutritional factors, but so far it has not been possible to prove that those factors exert any significant influence on its etiopathology. Second, lichen planus pigmentosus appears very frequently in patients with racial features other than those present in Latin America, which seems to influence its more widespread distribution. Finally, the histopathologic findings in ashy dermatosis are unspecific, being shared by other inflammatory conditions, among them lichen planus pigmentosus.
16.
REEERENCES 1. 2.
3. 4.
5.
Ramirez CO. Estado actual de la Dermatosis cenicienta. Med Cutan Ibero Lat Am 1984; 12:11-18. Convit J, Kerdel-Vegas F. Erythema dyschromicum perstans: a hitherto undescribed skin disease. J Invest Dermatol 1961; 36:457-462. Bhutani LK, Bedi TR. Lichen planus pigmentosus. Dermatoiogica 1974; 149:43-50. Naidorf KF, Cohen SR. Erythema dyschromicum perstans and lichen planus. Arch Dermatol 1982; 118: 683-685. Lambert WC, Schwartz RA. Erythema dyschromicum perstans. Cutis 1986; 37:42-44.
17.
Gougerot MH. Lichens atypiques invisibles pigmentogenes. Bull Soc Fr Dermatol Syphiligr 1935; 42:894898.
18.
Pinkus H. Lichenoid tissue reactions: a speculative review of the clinical spectrum of epidermal basal cell damage with special reference to erythema dyschromicum perstans. Arch Dermatol 1973; 107:840-846. Navarro Jimenez BR, Sanchez Navarro LM. Dermatosis cenicienta. Estudio prospectivo de 23 pacientes. Med Cutan Ibero Lat Am 1988; 16:407-412.
19.
20.
Sanchez NP, Pathak MA. Circumscribed dermal melaninosis: Classification, light, histochemical and electron microscopic studies on 3 patients with erythema dischromicum perstans. Int J Dermatol 1985; 24: 630-633.
21.
Jablonska S. Ingestion of ammonium nitrate as a possible cause of erythema dyschromicum perstans. Dermatoiogica 1975; 150:287-291.
22.
Stevenson JR, Miura M. Erythema dyschromicum perstans (ashy dermatosis). Arch Dermatol 1966; 94:197199.
23.
Convit J, Piquer-Martin J. Erythema dyschromicum perstans. Int J Dermatol 1989; 28:168-169. Piquero-Martin J, Perez AR. Clinical trial with Clofazimine on treating erythema dyschromicum perstans. Evaluation of cell mediated immunity. Int J Dermatol 1989; 28:198-200.
24.
25.
Woodley DT. Clofazimine and its uses in dermatology. J Assoc Miiit Dermatol 1982; VIII(2):41-46.
ASHY DERMATOSIS VERSUS LICHEN PLANUS PIGMENTOSUS: A CONTROVERSIAL MATTER MARIA ELISA VEGA, M.D., LEON WAXTEIN, M.D., ROBERTO ARENAS, M.D., MA. TERESA HOJYO, M.D., AND LUCIANO DOMINGUEZ-SOTO, M.D.
The first description of ashy dermatosis (AD) was made in 1957 by Oswaldo Ramirez, in El Salvador.' Later Gonvit et al.^ observed a condition very similar to pinta lesions in late phase; they called it "erythema dyschromicum perstans" (EDP). In 1974, Bhutani et al.^ described 40 patients with lesions similar to those described by Ramirez, they named them "lichen planus pigmentosus" (LPP). This report gave rise to numerous publications in the dermatologic literature presenting confusing concepts; it has been proposed that ashy dermatosis may be a variation of lichen planus pigmentosus.''"''' Racial and nutritional conditions, and ecologic factors in India are similar to those in Latin America, therefore, our opinion is that Bhutani observed both types of dermatoses, but he did not differentiate between the two conditions.
that sometimes present an elevated active red border, which leaves a residual hypopigmented halo. Distribution tends to be symmetrical and commonly noted on the face, neck, trunk, and upper extremities. Evolution is chronic, insidious, and asymptomatic. It occurs mainly in dark skin, predominantly in women without age predilection." There is no specific treatment.
DIEEERENTIAL DIAGNOSIS
Lichen planus pigmentosus was described in 1956 by Shima et al.,'^ and it is likely that in 1935 Gougerot"^''^ had referred to the same condition, which he called "invisible pigmented lichen planus." In 1968 and 1973, Pinkus"* included ashy dermatosis and atrophic lichen planus in the same section of his classification of "lichenoid tissular patterns" because of their histologic similarities, but without committing himself as he did not state that they were the same condition. The interpretation of this article, together with the one by Bhutani, has created the confusion we referred to earlier.
Lichen planus pigmentosus is characterized by hyperpigmented dark brown macules with a noncharacteristic distribution that predominates in exposed areas and flexor folds. These macules occasionally present papules or a reticulate pattern. Its evolution is characterized by exacerbations and remissions, occasionally accompanied by pruritus. There may be clinical improvement with the use of topical steroids. The histopathologic findings of the active red border of AD show a vacuolar degeneration in the basal cell layer, occasional colloid bodies, incontinence of pigment, and Iymphohistiocyte perivascular infiltration. In the inactive macules, the incontinence of pigment predominates, while the cellular infiltrate and vacuolar degeneration in the basal membrane may be minimal or absent.-" The histopathology of lichen planus pigmentosus is characterized by an atrophic epidermis with vacuolar alteration of the basal cell layer; in the dermis it shows a scarce Iymphohistiocyte or lichenoid infiltrate with incontinence of pigment and the presence of melanophages.
CLINICAL CHARACTERISTICS
ETIOLOGY
Ashy dermatosis is clinically characterized by blue-gray hyperpigmented macules with variable shape and size
The etiology of ashy dermatosis is unknown; various causes and mechanisms have been suggested: climatic, alimentary, and occupational factors, but so far no conclusions have been reached. Reports by Jablonska et al.^' on a case related to the ingestion of ammonium nitrite, by Stevenson and Miura^^ relating a nematode-caused intestinal parasitosis, and by Knox et al.'" regarding endocrine factors, we believe, are fortuitous associations. Gonvit et al.^-^ state that recent literature on the subject has been oriented to several aspects of the disease:
BACKGROUND
From the Department of Dermatology, Hospital General "Dr. Manuel Gea Gonzalez," Mexico City, Mexico. Address for correspondence: Luciano Dominguez-Soto, M.D., Hospital General "Dr. Manuel Gea Gonzalez," Departmento de Dermatologia, Calzada de Tlalpan 4800, Mexico 22, D.F., Mexico City, Mexico 14000.
87
International Journal of Dermatology Vol. 31, No. 2, February 1992
"One group that agrees clinically and histopathologically with the described signs of AD, and others that do not meet them, adding to the confusion by relating EDP and the lichen planus variants (tropical lichen planus, Gougerot's invisible lichen planus, and Japanese lichen planus). Others approach the concept of 'lichenoid tissular reaction' introduced by Pinkus,'^ including different diseases of unknown etiology and associated to diverse factors." Pinta in its early stage, Riehl's melanosis, or "idiopathic multiple macular pigmentation," all of which are prevalent in Latin America and affect mainly lighter dark-skinned persons, should also be taken into account within the differential diagnosis of ashy dermatosis. Finally, drug-induced dermatoses with residual hyperpigmentation, occupational dermatoses with exposure to heat or fire, and lichen planus pigmentosus must be considered. Piquero-Martin et al.^'' reported that clofazimine seems to have good cosmetic effects on ashy dermatosis by masking the lesions, and it also seems to act by inducing changes in cellular immunity.^^
6.
Berger RS, Hayes TJ. Erythema dyschromicum perstans and lichen planus. Are they related.' J Am Acad Dermatol 1989; 21:438^42.
7.
Hoist R, Mobacken H. Erythema dyschromicum perstans (ashy dermatosis) report of 2 cases fromScandinavia. Acta Derm Venereol (Stockh) 1974; 54:69-72.
8.
Miyagawa S, Komatsu M, Okuchi T. Erythema dyschromicum perstans. Immunopathologic studies. J Am Acad Dermatol 1989; 20:882-886. Byrne DA, Berger RS. Erythema dyschromicum perstans. A report of two cases in fair-skinned patients. Acta Derm Venereol (Stockh) 1974; 54:65-68.
9.
10.
Knox JM, Dodge BG, Freeman RG. Erythema dyschromicum perstans. Arch Dermatol 1968; 97: IGI-III.
11.
Carvajal HE, Pazmino EU. Dermatitis Cenicienta apreciacion de 2 formas clinicas. Med Cutan Ibero Lat Am 1986; 14:95-99.
12.
Leonforte L, Pelaez DB. Eritema discromico persistente versus Liquen piano. Med Cutan Ibero Lat Am 1987; 15:89-92.
13.
Pozo TR, Pintado HB. Liquen piano pigmentoso. Aportacion de un caso y revision de la literatura. Actas Dermosifiliogr 1988; 79:681-686. Tschen JA, Tschen EA. Erythema dyschromicum perstans. J Am Acad Dermatol 1980; 2:295-302. Shima T. Lichen planus pigmentosus. Nippon Hifuka Gakkai Zasshi 1956; 66:346-353. Gougerot MH. Lichens atypiques ou invisibles pigmentogenes reveles par des pigmentations. Bull Soc Er Dermatol Syphiligr 1935; 42:792-794.
14. CONCLUSIONS
15.
First, based on our observations, we can state that ashy dermatosis and lichen planus pigmentosus are two clinically different conditions, the former being found exclusively in specific populations with certain similar racial, ecologic, and nutritional factors, but so far it has not been possible to prove that those factors exert any significant influence on its etiopathology. Second, lichen planus pigmentosus appears very frequently in patients with racial features other than those present in Latin America, which seems to influence its more widespread distribution. Finally, the histopathologic findings in ashy dermatosis are unspecific, being shared by other inflammatory conditions, among them lichen planus pigmentosus.
16.
REEERENCES 1. 2.
3. 4.
5.
Ramirez CO. Estado actual de la Dermatosis cenicienta. Med Cutan Ibero Lat Am 1984; 12:11-18. Convit J, Kerdel-Vegas F. Erythema dyschromicum perstans: a hitherto undescribed skin disease. J Invest Dermatol 1961; 36:457-462. Bhutani LK, Bedi TR. Lichen planus pigmentosus. Dermatoiogica 1974; 149:43-50. Naidorf KF, Cohen SR. Erythema dyschromicum perstans and lichen planus. Arch Dermatol 1982; 118: 683-685. Lambert WC, Schwartz RA. Erythema dyschromicum perstans. Cutis 1986; 37:42-44.
17.
Gougerot MH. Lichens atypiques invisibles pigmentogenes. Bull Soc Fr Dermatol Syphiligr 1935; 42:894898.
18.
Pinkus H. Lichenoid tissue reactions: a speculative review of the clinical spectrum of epidermal basal cell damage with special reference to erythema dyschromicum perstans. Arch Dermatol 1973; 107:840-846. Navarro Jimenez BR, Sanchez Navarro LM. Dermatosis cenicienta. Estudio prospectivo de 23 pacientes. Med Cutan Ibero Lat Am 1988; 16:407-412.
19.
20.
Sanchez NP, Pathak MA. Circumscribed dermal melaninosis: Classification, light, histochemical and electron microscopic studies on 3 patients with erythema dischromicum perstans. Int J Dermatol 1985; 24: 630-633.
21.
Jablonska S. Ingestion of ammonium nitrate as a possible cause of erythema dyschromicum perstans. Dermatoiogica 1975; 150:287-291.
22.
Stevenson JR, Miura M. Erythema dyschromicum perstans (ashy dermatosis). Arch Dermatol 1966; 94:197199.
23.
Convit J, Piquer-Martin J. Erythema dyschromicum perstans. Int J Dermatol 1989; 28:168-169. Piquero-Martin J, Perez AR. Clinical trial with Clofazimine on treating erythema dyschromicum perstans. Evaluation of cell mediated immunity. Int J Dermatol 1989; 28:198-200.
24.
25.
Woodley DT. Clofazimine and its uses in dermatology. J Assoc Miiit Dermatol 1982; VIII(2):41-46.
