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Key Clinical Updates in Lichen Simplex Chronicus (Circumscribed Neurodermatitis)

Dupilumab is a new medication for generalized disease in lichen simplex chronicus or prurigo nodularis, its related condition.

ESSENTIALS OF DIAGNOSIS

  • Chronic itching and scratching.

  • Lichenified lesions with exaggerated skin lines overlying a thickened, well-circumscribed, scaly plaque.

  • Predilection for nape of neck, wrists, external surfaces of forearms, lower legs, scrotum, and vulva.

GENERAL CONSIDERATIONS

Lichen simplex chronicus represents a self-perpetuating scratch-itch cycle that is hard to disrupt.

CLINICAL FINDINGS

Intermittent itching incites the patient to scratch the lesions. Itching may be so intense as to interfere with sleep. Dry, hypertrophic, lichenified plaques appear on the neck, wrists, ankles, or perineum (Figure 6–6) (eFigure 6–11) (eFigure 6–12). The patches are rectangular, thickened, and hyperpigmented. The skin lines are exaggerated.

eFigure 6–11.

Lichen simplex chronicus. (Used, with permission, from TG Berger, MD, Dept Dermatology, UCSF.)

eFigure 6–12.

Lichen simplex chronicus resulting from repeated itch-scratch cycles. Note the hypertrophic leathery, lichenified plaques. The exaggerated skin lines are characteristic. (Used, with permission, from S Goldstein, MD.)

Figure 6–6.

Lichen simplex chronicus on the hand. (Used, with permission, from Lindy Fox, MD.)

DIFFERENTIAL DIAGNOSIS

This disorder can be differentiated from plaque-like lesions such as psoriasis (redder lesions having whiter scales on the elbows, knees, and scalp and nail findings) (eFigure 6–13), lichen planus (violaceous, usually smaller polygonal papules), and nummular (coin-shaped) dermatitis (eFigure 6–14). Lichen simplex chronicus may complicate chronic atopic dermatitis or scabetic infestation.

eFigure 6–13.

Psoriasis. (Used, with permission, from Lindy Fox, MD.)

eFigure 6–14.

Nummular dermatitis. (Used, with permission, from Lindy Fox, MD.)

TREATMENT

For lesions in extragenital regions, superpotent topical corticosteroids are effective, with or without occlusion, when used twice daily for several weeks. In some patients, flurandrenolide (Cordran) tape may be effective, since it prevents scratching and rubbing of the lesion. The injection of triamcinolone acetonide suspension (5–10 mg/mL) into the lesions may occasionally be curative. Continuous occlusion with a flexible hydrocolloid dressing for 7 days at a time for 1–2 months may also be helpful. Dupilumab is a new treatment option for generalized disease or prurigo nodularis, its related condition. For genital lesions, see the section Pruritus Ani.

PROGNOSIS

The disease tends to remit during treatment but may recur or develop at another site.

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