Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2023;13(4):e2023217 1 Lichenoid Pseudovesicular Papular Eruption on the Nose With Dermoscopic Features: A Case Series Isha Gupta1, Lovleen Kaur1, Aanchal Bansal1, Surabhi Dayal1, Sanjay Kumar2 1 Department of Dermatology, Venereology and Leprology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India 2 Department of Pathology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India Key words: LIPEN, lichenoid, pseudovesicles, facial papules, dermoscopy Citation: Gupta I, Kaur L, Bansal A, Dayal S, Kumar S. Lichenoid Pseudovesicular Papular Eruption on the Nose With Dermoscopic Features: A Case Series. Dermatol Pract Concept. 2023;13(4):e2023217. DOI: https://doi.org/10.5826/dpc.1304a217 Accepted: April 3, 2023; Published: October 2023 Copyright: ©2023 Gupta et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Aanchal Bansal, MBBS, Junior Resident, Department of Dermatology, Venereology and Leprology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India. Tel: +917086878303; Email: aanchal.bansal.ab125@gmail.com Introduction Lichenoid pseudovesicular papular eruption on nose (LIPEN) is a newly described clinical entity characterized by monomorphic skin-colored to translucent micropapules over centro-facial region especially, nose. It resembles various fa- cial papular disorders, hence usually misdiagnosed. We enu- merate a case series of four patients having similar lesions over face along with dermoscopic features. Case Presentation Four patients (one male, three females), in the age range of 20-50 years, North-Indians, skin type IV, presented with asymptomatic skin-colored to erythematous lesions over centro-facial region with duration varying from two months to two years. History of excessive sweating, flushing or ex- acerbation with spicy food and sunlight was absent. Drug, family and occupational history were insignificant. Clinically, multiple, grouped, skin-colored to slightly erythematous micropapules with normal underlying skin were present on dorsum of nose, bilateral nasal alae, cheeks and forehead. Involvement of cutaneous upper lip was seen in two patients (Figure 1, A-D). Cutaneous examination else- where was normal. Diascopy was negative. Routine blood investigations were normal. Dermoscopic examination revealed multiple pink-clods with brown dots in clusters distributed in the center and rim 2 Research Letter | Dermatol Pract Concept. 2023;13(4):e2023217 Figure 1. Multiple grouped pseudovesicles and micropapules over nose, forehead, bilateral cheeks in all patients (A-D), and upper lips in two patients (B and D). Figure 2. (A-B) Multiple pink-clods with brown dots in the center and around the clods (yellow circles), multiple white dots (blue square), peri-eccrine brown circles (black arrows); in addition white scales (sky-blue triangle), rosettes (red circles), yellow dots (black asterisk) and telangiectasias (blue arrow) in (B); (C) Histopathology showing epidermal thinning, flat rete ridges, focal basal vacuolar degeneration, dense nodular lymphocytic infiltrate along dermo-epidermal junction in upper dermis (H& E, ×100). of these clods, multiple white dots interspersed between the pink-clods, brown circles in the peri-eccrine area, and fine white scales (Figure 2, A-B). Yellow dots, rosettes and telan- giectasias were also observed in single patient. Histopathology from two patients (others denied con- sent) revealed epidermal thinning, flattened rete ridges, focal basal hydropic degeneration and dense lymphocytic infiltrate along dermo-epidermal junction and around hair follicles, admixed with mononuclear cells, consistent with diagnosis of LIPEN. Special stains like alcian blue, peri- odic acid-Schiff and Ziehl-Neelsen were non-contributory (Figure 2C). Conclusions LIPEN presents as asymptomatic, monomorphic, skin-colored, erythematous or hyperpigmented grouped micropapules and translucent pseudovesicles in young to middle-aged pop- ulation, predominantly over nose and centro-facial region mainly involving cheeks, forehead and less commonly upper lips (seen in three previous case reports). Most common site is nasal alae. Its exact pathogenesis is unknown. First clin- ical and histopathological description of LIPEN was given in a case series in 2019 [1]. The histopathological features are characterized by focal lymphocytic infiltrate in upper Research Letter | Dermatol Pract Concept. 2023;13(4):e2023217 3 dermis, basal cell damage (necrotic/ vacuolar) and focal epidermal atrophy. Its various differentials with dermoscopic features are delineated in Table 1. The clinical distinction of LIPEN from these entities sometimes becomes very difficult especially in patients reluctant for facial biopsy. Hence, der- moscopy may have a useful adjunctive role. Dermoscopy in LIPEN has only been described in six cases previously. In a published series of dermoscopic features, multiple structure- less clustered red clods (corresponding to lymphohistiocytic infiltrate), scattered white dots (empty eccrine openings) were most consistent findings [2]. Brown and gray dots or globules (suggestive of pigmentary incontinence) appear to be concentrated in the peri-eccrine and peri-follicular loca- tions [3]. Fine scales and yellow dots were not seen in previ- ously reported cases. The clinical, dermoscopic and histopathological data about LIPEN is limited. As it resembles other facial papular disorders, apparently the disease has either been misdiag- nosed or under-diagnosed in previous studies. This study will aid in the distinction of this uncommonly diagnosed entity. References 1. Singh S, Singh A, Mallick S, Arava S, Ramam M. Lichenoid pseudovesicular papular eruption on nose: A papular facial der- matosis probably related to actinic lichen nitidus or micropap- ular polymorphous light eruption. Indian J Dermatol Venereol Leprol. 2019;85(6):597-604. DOI:10.4103/ijdvl.IJDVL_347_18. PMID: 31293275. 2. Jassi R, Singh S, Sharma T, Kaur M, Patra S. Lichenoid pseudovesicular papular eruption on nose through the dermato- scope. Indian J Dermatol Venereol Leprol. 2022;88(5):660-664. DOI:10.25259/IJDVL_607_2021. PMID: 35841360. 3. Bains A, Beniwal R, Vedant D, Elhence P. Dermoscopy of “ Lichenoid Pseudovesicular Papular Eruption on Nose”. Indian Dermatol Online J. 2021;12(6):950-951. DOI:10.4103/idoj .IDOJ_865_20. PMID: 34934748. PMCID: PMC8653729. 4. Chauhan P, Adya KA. Dermatoscopy of Cutaneous Granuloma- tous Disorders.  Indian Dermatol Online J. 2021;12(1):34-44. DOI:10.4103/idoj.IDOJ_543_20. PMID: 33768021. PMCID: PMC7982032. Table 1. Comparison of lichenoid pseudovesicular papular eruption on nose with other differential diagnoses summarized. S.no. Differential diagnosis Characteristic dermoscopic findings Histopathological findings 1. Granulosa rubra nasi Discrete round pink and red structureless areas are present over-erythematous background with scattered to grouped brown dots Dilated blood vessels and eccrine ducts with surrounding lymphocytic infiltrate 2. Papular sarcoidosis Multiple arborizing vessels over yellow-orange globular structures and scarred areas Non-caseating, lymphocyte-poor, epithelioid cell granulomas in superficial and deep dermis admixed with multinucleated giant cells 3. Micro-papular polymorphic light eruption Ring-shaped scales Hyperkeratosis, spongiosis, dense dermal perivascular lymphocytic infiltrate 4. Granulomatous rosacea Orange-yellow areas with polygonal network of vessels Granulomas with adnexal destruction and demodex mite infiltration in follicular infundibulum with peri-follicular lympho-histiocytic infiltrate 5. Lupus miliaris disseminates faciei Perifollicular structureless yellow- orange areas with keratotic plugs Dermal caseating epithelioid cell granulomas with multinucleated giant cells and lymphohistiocytic infiltrate 6. Lichenoid pseudo- vesicular/papular eruption of nose Multiple clustered red clods, white dots, peri-eccrine brown dots and circles, telangiectasias, fine white scales and yellow dots; multiple rosettes in one-case Focal, dense lymphocytic dermal infiltrate, focal epidermal atrophy and basal epidermal degeneration