Skin Research and Technology 2016; 22: 255–258 Printed in Singapore  All rights reserved doi: 10.1111/srt.12246

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Skin Research and Technology

Letter to the Editor

Reflectance confocal microscopy of extra-genital lichen sclerosus atrophicus J. Jacquemus1, S. Debarbieux1, L. Depaepe2, M. Amini1, B. Balme2 and L. Thomas1,3 2

1 Dermatology Department, Centre Hospitalier Lyon Sud, Pierre Benite, France, Pathology Department, Centre Hospitalier Lyon Sud, Pierre Benite, France and 3Lyon1 Claude Bernard University, Lyon, France

Microscopy (RCM) is a recent non invasive technique of skin imaging, which allows real time in vivo microscopic examination of the skin. Although there are increasing data regarding inflammatory skin diseases RCM features (1), there is a single case report of RCM examination of extragenital Lichen Sclerosus and Atrophicus (LSA) in the literature (2). The aim of this study was to describe RCM features of extra-genital LSA. Seven consecutive patients (1 male and 6 females, between 36 and 86 years old; mean


age: 64.5) exhibiting extragenital LSA (1 patient with coexisting aspects of extragenital LSA and cutaneous morphea) were examined with in vivo RCM (Vivascopeâ 1500 or Vivascopeâ 3000 depending on the localization, Mavig, Munich, Germany; Lucid-Tech Inc, Henrietta, NY, USA). Four of them were biopsied. Skin lesions were localized on the back, the thorax and the proximal extremity of limbs, mainly in non chronically sun exposed skin. At the epidermal level, we could observe not only ‘horny follicular plugs’ in five





Fig. 1. Horny follicular plug. (a) Histopathological aspect: hyperorthokeratosis within dilated follicular openings (HESx4) (stars); (b) RCM correlation; variably reflecting material within the follicular openings corresponding to keratin plugs (stars). (c) RCM magnification of a horny follicular plug.


Letter to the Editor (a)


Fig. 2. (a) horizontalized acrosyringium within the stratum corneum. (b) RCM aspect of a tortuous horizontalized acrosyringium within the startum granulosum.



Fig. 3. (a) Histopathological aspect of the papillary dermis: undulated collagen bundles dissociated by edema (dark grey arrows); scattered lymphocytes. (b) RCM correlation: dissociated bright undulated collagen bundles (dark grey arrows) with scattered lymphocytes (light grey arrows).

patients (Fig. 1) as in Lacarruba et al.’s patient (1) but also horizontalized acrosyringia in three cases (Fig. 2). This feature is not usually reported pathologically but more easily seen in ‘en face’ sections than on vertical sections.

In the papillary dermis, the physiological reticular collagen network was replaced by variably altered collagen:

 in four cases, a mononuclear inflammatory infiltrate




Letter to the Editor

Fig. 4. Association of horizontalized, homogenized collagen (light grey star) and curled collagen bundles (dark grey stars) in the papillary dermis in the same patient.

and/or melanophages) was scattered between coarse collagen bundles dissociated by non refractile spaces (Fig. 3). This aspect is similar to that observed in Lacarruba et al.’s patient (1).  in all cases, independently from an inflammatory infiltrate, we could observe the following alterations of collagen: (1) thick undulated bundles in all seven cases (Fig. 3); (2) variably refractile, horizontalized, homogenized (as if it had been rubbed with a blotting paper) collagen in five cases (Fig. 4); (3) curled collagen bundles in three cases (Fig. 4). In two cases, examination of the perilesional skin confirmed the presence of a ‘physiological’ reticulated collagen with coarse fibers consistent with the patient’s age, as previously reported by Longo et al. (3). Collagen damages observed in our series could remind alterations observed in skin aging, and therefore larger studies would be required to better define RCM features differentiating both conditions. However, homogenization of the collagen is accompanied by horizontalization of the thickened fibers. Moreover, undulated and curled fibers seem thicker than curled bright structures of skin aging which are due to elastosis, which is not the

case in LSA. At last, Longo et al.’s RCM study (3) was performed on the cheek, whereas our patients’ lesions were mainly located on sun hidden areas. Comparison with perilesional skin in two cases in our patients confirmed preservation of the collagen’s weblike pattern. Most inflammatory skin diseases previously described with RCM are characterized by epidermal changes and/or inflammatory infiltrates (1), whereas the pathological changes of collagen have not been studied, except in skin aging. Extra-genital LSA is usually clinically quite typical; on the contrary, the clinical changes in early vulvar localization are more subtle and the diagnosis therefore clinically more challenging; it will now be interesting to determine whether our observations can be extrapolated to genital LSA.

Funding This study was supported in part by grants from Lyon 1 University (to LT) and the Hospices Civils de Lyon (to LT).

Conflicts of interest None declared.


Letter to the Editor

References 1. Hoogedoorn L, Peppelman M, van de Kerkhof PC, van Erp PE, Gerritsen MJ. The value of in vivo Reflectance Confocal Microscopy in monitoring and diagnosis of inflammatory and infectious skin diseases - A Systematic Review. Br J Dermatol 2015; 172: 1222–1248. 2. Lacarrubba F, Pellacani G, Verzı AE, Pippione M, Micali G. Extragenital lichen sclerosus: clinical,


dermoscopic, confocal microscopy and histologic correlations. J Am Acad Dermatol 2015; 72 (1 Suppl): S50–S52. 3. Longo C, Casari A, Beretti F, Cesinaro AM, Pellacani G. Skin aging: in vivo microscopic assessment of epidermal and dermal changes by means of confocal microscopy. J Am Acad Dermatol 2013; 68: e73– e82.

Address: Dr S. Debarbieux Dermatology Department Centre Hospitalier Lyon Sud Pierre Benite Cedex 69 495 France Tel: +33 4 78 86 16 81 Fax: +33 4 78 86 41 97 e-mail: [email protected]

Reflectance confocal microscopy of extra-genital lichen sclerosus atrophicus.

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