DR
[Dermatology Reports 2011; 3:e35] [page 75]
Unilateral Blaschkoid lichen
planus in successive pregnancies
Shiva Kumar, Rajendra Okade,
Yasmin Abdul Rahman
Department of Dermatology,
Venereology and Leprosy, Sri DevarajUrs,
Medical College, Tamaka, Kolar, India
Abstract
A number of genetic, congenital and
acquired dermatoses have been known to fol-
low Blaschko’s lines. A common disorder like
lichen planus can very rarely present with
pruritic lesions in atypical patterns such as
unilateral distribution, painful eruptions and
along Blaschko’s lines. Various triggering fac-
tors varying from viral infections and vaccina-
tions to trauma have been implicated in
lichen planus. We describe a female patient
in the second trimester of her second preg-
nancy who developed unilateral lichen planus
along Blaschko’s lines during both pregnan-
cies. No case of lichen planus along
Blaschko’s lines recurring during pregnancy
is reported so far. Could pregnancy itself be a
contributory factor towards onset of lichen
planus in this case?
Introduction
Lichen planus (LP) is a common inflamma-
tory disorder that affects skin, mucous mem-
brane, nails and hair. It is classically charac-
terised by pruritic, shiny, violaceous, flat
topped, polygonal papules which retain skin
lines and maybe closely aggregated or widely
dispersed.1 Various etiological factors include
immunological mediation, chronic liver dis-
ease, hepatitis C infection2-3 and hereditary
causes among others . Variants of this disor-
der include hypertrophic LP, follicular LP, lin-
ear LP, annular LP, vesicobullous LP, actinic
LP, erosive and nonerosive mucous mem-
brane LP.1
Blaschko’s lines were delineated in 1901 by
a German dermatologist Alfred Blaschko . The
original description by Blaschko referred to a
system of lines on the human skin which the
linear naevi and dermatoses follow.4 The pat-
tern is attributed to lines of migration of epi-
dermal cells during embrogenesis.5 These
lines are curved over scalp and face, V -
shaped in upper spine, inverted U shaped
over chest and upper arm, S – shaped whorls
on the chest and abdomen and perpendicular
over the front and back of extremities. Types
of Blaschko’s pattern include narrow band,
large band, checkerboard and phylloid.6
Case Report
A 24-year-old female in the 2nd trimester of
her 2nd pregnancy presented with a history of
itchy skin lesions which started over dorsum
of her left hand 3 months back. New lesions
progressively appeared in a linear pattern
extending proximally to involve the left fore-
arm, arm and shoulder. Simultaneously new
elevated discoloured lesions appeared over
left flank, abdomen and breast.
Patient had similar lesions in the same
areas during her 1st pregnancy 2 year’s back
which had spontaneously resolved within 3
months after delivery with residual post
inflammatory hyperpigmentation in the
affected areas which still persisted.
On examination, violaceus flat topped 2-5
mm papules were noted, some of which
showed typical lacy white pattern of
Wickham’s striae extending from left thumb
uptoleft arm in a wave like pattern along
Blaschko’s lines (Figure 1), they were dis-
crete at few places while at others they
appeared to be coalescing. Similar papules in
a wavy pattern were noted over left shoulder,
upper back (Figure 2), discontinuous papules
and hyperpigmented macules were seen over
left flank, abdomen (Figure 3) and left breast
in 3 curved lines. Post inflammatory hyperpig-
mented macules of lesions which developed
during the previous pregnancy were seen
along the same Blaschko’s lines. None of the
eruptions crossed the midline. The patient
had no oral lesions or nail changes. A working
diagnosis of lichen planus was made.
Preliminary routine investigations were with-
in normal limits and tests for Hepatitis B and
C were negative. Punch biopsy of left forearm
lesions showed typical features of lichen
planus (Figure 4).
Discussion
Lichen planus is a subacute to chronic der-
matosis, which is benign and self limiting ,
although recurrences can occur. The disease
has a predilection for flexor surfaces of fore-
arms, legs and glans penis. Inverse lichen
planus eruption occurs in flexures like axilla,
inframammary folds and groins. Eruptions
may be localised or extensive and Koebner’s
phenomenon is commonly seen. Oral lesions
of lichen planus are frequently seen either as
sole manifestations or associated with cuta-
neous involvement. Apart from the known
variants of lichen planus, a few rare cases of
lichen planus along Blaschko’s lines has been
described.1
Histopathology examination reveals com-
pact orthokeratosis, wedge shaped hypergran-
ulosis irregular acanthosis, vacuolar alter-
ation of the basal layer. Rete ridges may show
saw - tooth appearance. Degenerating epider-
mal cells form colloid bodies and a band like
infiltration of lymphocytes may obliterate the
dermo - epidermal junction.7
Blaschko’s lines do not correspond to any
vascular, lymphatic or neural structures and
are invisible and become apparent in certain
disease states such as pigmentary disorders
(naevus achromicus, epidermal naevus), X
linked genetic skin disease (Incontinentia
pigmenti) , acquired inflammatory skin disor-
ders (LP, lichen striatus) and chimerism.6
Case reports of unilateral cutaneous lichen
planus,1,8-9 lichen planus along with unilateral
mucosal involvement,10 linear lichen pigmen-
tosus11 and painful atrophic lichen planus12
have been reported along Blaschko’s lines.
Long et al. described a case of bilateral linear
lichen planus along Blaschko’s lines.13 Wolfs
isotopic response is the occurrence of new
skin disorder exactly at the site of another,
unrelated and already resolved skin disease,
this phenomenon has been seen in der-
matomal lichen planus following herpes
zoster at the same location.14 Krasowska et al.
reported a case of a 33 year old healthy
woman who developed recurrent unilateral
lichen planus along Blaschko’s lines following
3 successive deliveries of healthy babies15.
Our patient presented with history of onset
of lesions during first trimester and to the
best of our knowledge this is the first case of
lichen planus along Blaschko’s lines occur-
ring during successive pregnancies.
Considering the fact that various known and
idiopathic causes have been known to trigger
Dermatology Reports 2011; volume 3:e35
Correspondence: Shiva Kumar, No. 66, 11th
cross, Indiranagar, 1st stage, Bangalore- 560038,
India.
Tel. +91-9886151969.
E-mail: dermashiva@rediffmail.com
Key words: lichen planus, pregnancy,
Blaschko’slines.
Received for publication: 23 August 2011.
Accepted for publication: 6 September 2011.
This work is licensed under a Creative Commons
Attribution NonCommercial 3.0 License (CC BY-
NC 3.0).
©Copyright S. Kumar et al., 2011
Licensee PAGEPress, Italy
Dermatology Reports 2011; 3:e35
doi:10.4081/dr.2011.e35
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[page 76] [Dermatology Reports 2011; 3:e35]
lichen planus, a need to follow up the patient
in current and subsequent pregnancies
becomes essential to find a positive correla-
tion between pregnancy and lichen planus
and to establish whether pregnancy itself
could have triggered lichen planus.
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Case Report
Figure 1. Typical violaceous papules over
thumb and forearm in a linear distribution.
Figure 3. Gravid abdomen showing linear
pigmented macules and papules.
Figure 4. Histopathology showing dense
lichenoid infiltrate and saw toothed rete
ridges.
Figure 2. Pigmented papules and macules
over shoulder.
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