Lichen Aureus

Authors:
Michael S. Tracey, BS
Uniformed Services University of the Health Sciences, Bethesda, Maryland

John E. Jackson, MD
Naval Medical Center San Diego, California

Citation:
Tracey MS, Jackson JE. Lichen aureus. Consultant. 2017;57(12):724-725.

A 14-year-old boy with a history of insulin-dependent type 1 diabetes presented to our dermatology clinic with a 2-year history of a slowly growing discoloration on the right medial knee. He denied associated pruritus or pain, and he had no other medical conditions other than his poorly controlled diabetes. His most recent glycated hemoglobin level was 8.4%.

Physical examination. Gross inspection revealed a bilobed, semiannular and confluent, snowman-shaped, atrophic, waxy patch measuring 2.5 × 1.5-cm, with a brown center and a yellow-orange periphery (Figures 1 and 2). On dermoscopic examination, vessels were evident with interspersed gray dots (Figure 3). These findings were concerning for an early presentation of necrobiosis lipoidica diabeticorum.

Diagnostic tests. A biopsy was performed; histologic findings revealed no evidence of granulomatous skin degeneration, and a diagnosis of lichen aureus instead was established.

Discussion. Lichen aureus is a seldom diagnosed form of the already rare set of disorders known as pigmented purpuric eruptions. Hospital database reviews in institutions in Italy¹ and India² showed a 0.05% incidence of the cutaneous disease over 2 decades, and only 3 confirmed cases in more than 50,000 patients, respectively.

The cause of the disease is unknown, but case reports have provided anecdotal evidence of lesions precipitated by trauma,³ drug-induced immune suppression,⁴ and even the frequent consumption of energy drinks.⁵

Lichen aureus is a histologic diagnosis, and it can imitate a multitude of other disease processes on gross inspection, including mycosis fungoides,⁶ granuloma annulare, and, as in this case, necrobiosis lipoidica.

Lesions can present as rust-colored macules, papules, or plaques, and they are often described as solitary eruptions of the lower extremities in young adults, although case reports of multiple, diffuse outbreaks have been published.^7,8

Zaballos and colleagues⁹ originally described the dermoscopic characteristics of lichen aureus in 3 patients as being a coppery-red background; round to oval red dots, globules, and patches; gray dots; and a partial network of interconnected pigmented lines. Since the publication of their case series, multiple reports have confirmed this presentation and suggest that dermoscopy is a viable adjunct to clinical judgment and histologic examination.^10,11 Zaballos and colleagues’ original description contrasts well with reports of necrobiosis lipoidica and granuloma annulare on dermoscopic inspection; the former typically presents with well-demarcated telangiectases on a white, structureless background, and the latter is described as sparse vessels dispersed over an orange-red background with dispersed, milia-like lesions.¹²

Case reports have presented a myriad of treatment options for lichen aureus. At least 2 recent reports have demonstrated complete remission of lesions following twice-daily use of topical methylprednisolone for 4 months.^13,14 Topical immune suppression with pimecrolimus and tacrolimus has also demonstrated success with administration of up to a year.^7,15 Narrow band UV-B and pulsed-dye lasers have also been used with some success.^16,17 Of note, all of these patients’ cases showed resolution after prolonged treatment regimens lasting months to years; in an early case series, Gelmetti and colleagues¹ noted the typically benign course of this disease, with spontaneous resolution in 5 of 8 reported cases.

Lichen aureus is a rarely described entity, with few cases reported in North America and most reported in Asia or Europe. To our knowledge this patient’s case, in which poorly controlled type 1 diabetes obfuscated the initial diagnosis, is one of only a few reported in the United States.

Treatment. Our patient was placed on topical pimecrolimus at first presentation and was kept on a twice-daily regimen following diagnosis. 

DISCLAIMER: The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, the Department of Defense, or the US Government.

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