Dermatology: Practical and Conceptual Letter | Dermatol Pract Concept 2020;10(4):2020076 1 Dermatology Practical & Conceptual Introduction Isolated lip lichen planus (LP) can mimic lip discoid lupus erythematosus, actinic cheilitis, pemphigus vulgaris, exfoli- ative cheilitis, and herpes simplex [1]. Dermoscopic features of cutaneous LP have been well-described in the literature, with Wickham striae (WS) as the distinctive feature of an active disease. However, the dermoscopic patterns of lip LP remain to be elucidated. Only a few case reports have re- ported the dermoscopic patterns of lip LP that include WS: diffuse scaling and violaceous background [1,2]. Herein, we aim to provide new insights into the dermoscopic profile of biopsy-proven cases of lip LP. Case Presentation A total of 12 biopsy-proven patients of lip LP who had not taken any treatment were included in the study (Figure 1). Clinical profiles of the patients are listed in Table 1. Nine cases (75%) had isolated lip involvement. One case (8.3%) had also involvement of buccal mucosa and 2 (16.6%) had additional buccal mucosal and cutaneous LP lesions. Ten pa- tients (83.3%) had a lower lip LP. Dermoscopic images were captured using a DermLite DL4 dermatoscope attached to Samsung Galaxy Note 10 mobile phone. The images were independently analyzed by 2 expert dermatologists. Various dermoscopic features seen were WS (100%), scaling (100%), black/gray/brown/ pigmentation as dots or globules (100%), vascular pattern (91.7%), erosion with bleeding spots (50%), and rosettes (41.7%) over an erythematous-to-vio- laceous background in all 12 cases (Table 2). A mixed pattern of WS and predominant radial pattern in 9/12 cases (75%) (Figure 2) was noticed. These patients had a disease duration of >9 months. A “leaf venation-like pattern” was seen in 2 cases (16.7 %) with duration of le- sions of <6 months (Figure 3). Linear WS were present in 4 cases (33.3%) (Figure 4). All 6 cases (50%) with erosions had prominent hairpin and linear telangiectasia (Figure 5). Another vascular pattern seen in 9 (75%) cases was dot- ted (Figure 4). Black to gray-black pigmentation was high- lighted in cases with disease duration of >12 months (Figure 6). On polarized dermoscopy, rosettes are seen as 4 white dots arranged in a square resembling a 4-leaf clover, which corresponds to concentric horny material in follicular and Dermoscopy of Lip Lichen Planus—A Descriptive Study Shekhar Neema1, Sunmeet Sandhu1, A.W. Kashif2, Preema Sinha1, Rohit Kothari1, S. Radhakrishnan1 1 Department of Dermatology, Armed Forces Medical College, Pune, India 2 Department of Pathology, Armed Forces Medical College, Pune, India Key words: dermoscopy, lip lichen planus, leaf venation-like, Wickham striae Citation: Neema S, Sandhu S, Kashif AW, Sinha P, Kothari R, Radhakrishnan S. Dermoscopy of lip lichen planus—a descriptive study. Dermatol Pract Concept. 2020;10(4):e2020076. DOI: https://doi.org/10.5826/dpc.1004a76 Accepted: April 21, 2020; Published: October 26, 2020 Copyright: ©2020 Neema et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License BY-NC-4.0, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. Authorship: All authors have contributed significantly to this publication. Corresponding author: Sunmeet Sandhu, MD, Department of Dermatology, Armed Forces Medical College, Southern Command, Solapur – Pune Hwy, Wanowrie 411040, Pune, India. Email: sunmeet.sandhu@gmail.com 2 Letter | Dermatol Pract Concept 2020;10(4):2020076 Conclusions Our study provides new insights into dermoscopic features of lip LP. WS, pigmentation, scales, and telangiectasia are the hallmarks of lip LP. In contrast to the previously reported eccrine ducts at the infundibular level or peri-follicular con- centric fibrosis. Interestingly this pattern was seen in 4 pa- tients (33.3%) with prominent scaling that might correspond to polarized keratin-filled eccrine duct narrowing at the lip margin (Figure 5). The limitation of our study was a small number of pa- tients and the lack of a control group; therefore, the accuracy of various diagnostic criteria could not be performed. Table 1. Demographic Profile of Patients With Duration of Disease Number Percentage Gender Male 8 66.7% Female 4 33.3% Age (years) <20 1 8.3% 21-40 2 16.7% 41-60 7 58.3% >60 2 16.7% Duration (months) <6 2 16.7% 6-12 4 33.3% 12-24 4 33.3% >24 2 16.7% Site of lesions Lower lip 10 83.3% Both lips 02 16.7% Table 2. Frequency of Dermoscopic Features in Lip Lichen Planus (n=12) Study Dermoscopic Feature Number Percentage 01 Wickham striae 12 100% Leaf venation-like 02 16.7% Radial 09 75% Linear 04 33.3% 02 Scales 12 100% 03 Pigmentation 12 100% Gray-black granules, globules 10 83.3% Brown 02 16.7% 04 Vascular pattern 11 91.7% Linear 10 83.3% Hairpin 08 66.7% Dotted 09 75% 05 Background Erythematous 07 58.3% Violaceous 05 41.7% 06 Erosion 06 50% 07 Bleeding spots 04 33.3% 08 Rosettes at lip margin 04 33.3% Figure 2. Radial pattern of Wickham striae (blue circle), erosion and hairpin vessels (yellow arrow) (DermLite DL4; polarized, ×10). Figure 1. Biopsy from lip shows focal parakeratosis, hypergranulo- sis (blue arrow), interface dermatitis (yellow star), Civatte bodies, and pigment incontinence, suggestive of lichen planus (H&E, ×100). Letter | Dermatol Pract Concept 2020;10(4):2020076 3 References 1. Mathur M, Acharya P, Karki A, KC N, Shah J, Jha A. Isolated lichen planus of lip: Diagnosis and treatment monitoring us- ing dermoscopy. Clin Case Rep. 2019;7(1):146–148. DOI: 10.1002/ccr3.1933. PMID: 30656029. 2. Yeo IK, Kim HK, Kim DH, et al. Oral lichen planus for whom dermoscopy was used as an adjuvant diagnostic tool. Korean J Dermatol. 2012;50(2):167-170. reticular pattern of cutaneous LP, radial WS are the charac- teristic feature seen in lip LP. Leaf venation-like WS, hairpin vascular pattern, and rosettes are new dermoscopic features that we did not find described in lip LP. Figure 3. Leaf venation-like Wickham striae (blue star), scaling, dot- ted vessels and pigmented granules over a violaceous background (yellow star) (DermLite DL4; polarized, ×10). Figure 4. Linear Wickham striae (blue arrow), dotted, linear and hairpin vessels (yellow circle) (DermLite DL4; polarized, ×10). Figure 5. Erosion with bleeding spots and dotted vessels (blue cir- cle), prominent hairpin and linear vessels (yellow rectangle). Inset: rosettes (yellow star), bleeding spots and hairpin vessels (DermLite DL4; polarized, ×10). Figure 6. Prominent uniform-to-granular black pigmentation (yel- low star) along with radial and linear Wickham striae. Gray dots and globules (blue star) (DermLite DL4; polarized, ×10).