A common skin disease that is caused by continuous itching: Lichen simplex chronicus

 

Itching is one of the most common symptoms in various skin diseases. The mechanism of itching is complex and still not well understood. But to put it in simple words, itching in a skin disease occurs as the disease itself produces chemicals that stimulate nerve fibres present in the skin which takes that neural information to brain via spinal cord and a specific region of brain gets stimulated which we perceive as itching sensation. To get relief from that sensation brain gives signals to our hands to do scratching or rubbing. But it is not the topic of today’s discussion.

Today I’m going to discuss about a disease where itching sensation followed by scratching and rubbing is the cause of the disease. Yes my friends. And that interesting disease is called Lichen Simplex Chronicus.

What is lichen simplex chronicus?

It is an itching associated with skin disease where continuous scratching or rubbing produces a single or sometimes multiple small lichenified (skin becomes thickened and leathery) elevated skin lesions. These skin lesions appear at some particular areas of skin which are easily accessible to our hands (so that scratching and rubbing can easily take place).

It occurs mostly in age between 30-50 years and women are more commonly affected than men.

 

How does it occur?

There is a dermatological and a psychological component to it. Patients who have other skin diseases like atopic dermatitis where itching is a main symptom, may develop lichen simplex chronicus due to continuous itching and scratching or rubbing. Patients who have the tendency of developing lichen simplex chronicus may develop the disease due to psychogenic itching. Anxiety and depression play a major role in these patients.

The continuous itch-scratch cycle produces the changes in the skin. The skin becomes rough, thick and leathery due to continuous friction.

 

Where does it occur?

It mainly occurs over the easily accessible areas like back and sides of the neck (patients with long history of polymorphous light eruption^{https://drsupratim.blogspot.com/2022/03/most-common-photo-induced-skin-rash.html} over the back of the neck may develop lichen simplex chronicus at that site), lower legs, ankle, forearm, upper thigh, scrotum and valva.

How does it look (clinical features)?

Initially the area of the skin is reddened and slightly thickened. With time the redness disappears and that area becomes more thick and leathery, hyperpigmented and slightly scaly. As the name suggests it looks like lichen (a plant that grows over rocks, walls and trees and looks crusty) over a tree bark.

Initial lesion of lichen simplex chronicus

A very typical and diagnostic feature is over prominence of normal skin markings over the affected area.

       

Well formed lesions of lichen simplex chronicus

 

Are there any investigations needed?

The diagnosis is done clinically and usually no investigation is needed.

 

Do you need to go to a dermatologist?

Of course yes. For most obvious reason is that it needs proper treatment. And secondly because it needs to be differentiated from other similar looking diseases like lichen planus, lichen planus hypertrophicus, lichen amyloidosis and psoriasis.

                                           

Lichen planus hypertrophicus                                                Lichen amyloidosis

 

What is the Solution?

I am not mentioning any kind of medications or name of any medicines or creams to avoid self-medication.

You must visit a dermatologist for proper treatment of this condition.

But I am just mentioning the treatment components here.

·       Discussion about the disease process and prognosis with proper counselling is very important part of treatment.

·       Breaking the itch-scratch cycle is very important. So itching needs to be reduced by proper medications.

·       Along with that the affected area has to be treated locally by applying proper cream.

·       The underlying disease (like atopic dermatitis or polymorphous light eruption) has to be treated.

·       If there is any psychological component present then help of a psychiatrist may be needed.

 Source

1. https://www.medindia.net/news/healthinfocus/scratch-that-itch-brain-mechanism-identified-184546-1.htm?msclkid=f416fa29aeba11ec9edb90a7e605644c
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4081479/?msclkid=de84324baeb911eca0e1da49057395a1
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3170689/?msclkid=20fd50dbaeb811ec8f0f58de0fccda3e
4. Rook’s textbook of dermatology, 9^th edition, chapter 83
5. https://medlineplus.gov/ency/article/003251.htm?msclkid=ce70c9ddaec911ecbf14005045c70828

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Most common photo-induced skin rash - PMLE: Ultimate guide to patients

 

It was the weekend and you just went to the nearby beach to have some fun. The next morning you suddenly realized that you are having some itchy skin rash over your back of the neck and upper arms. It could be PMLE.

Or

Your summer holiday has just started and after few days of outdoor activity there is itching and rash over the chest and upper back. It might be PMLE.

So what is PMLE?

PMLE stands for Polymorphous Light Eruption

P-Polymorphic/polymorphous – several different forms or characters

L- light induced

E- Eruption – spot or rash over skin

PMLE is the most common type of photo induced skin rash that generally occurs over sun exposed areas of skin after a certain period of intense exposure to sunlight (Ultra violet ray).

Who gets this type of skin rash?

It is the most common photo induced skin problem.

Most commonly occurs in age between 21-30 years and more common in females ⁽¹⁾.

According to various Indian studies it affects around 2-13.5% people in various parts of India ⁽²⁾.

How does it feel (clinical features)?

It particularly occurs after a delay of at least 6 hours to few days following the exposure to high intensity sunlight. Exposure can be for 10 minutes to several hours.

If no further exposure to Ultra Violet Ray(UVR) occurs, then it usually resolves within 7-10 days without scarring.

As the season progresses your skin may become less sensitive and symptoms may occur in less severe manner.

Skin lesions are polymorphous which means it can be of various characters, size and shape but in a single patient usually one type is seen. In my practice I have seen patients most commonly present with groups of whitish or skin coloured or reddish tiny bumps over sun exposed areas. Larger elevated lesions (plaques) or fluid filled bumps(vesicles) are seen less frequently.

Back of the neck, upper back, chest, outer side of upper arm and forearm are commonly affected sites. Face and hands are less commonly involved as they become tolerant due to exposure to sunlight from childhood.

Why does this skin rash occur?

Exact reason is unknown.

But from various studies and investigations few things are suggested.

I will try to be as simple as possible.

When UVR falls on skin there is some changes that occur on the skin. This change can trigger our immune system and an immune reaction occurs which causes the disease.

Normally when UVR falls on skin it induces an immune suppression which inhibits immune reaction. But in PMLE patients this UVR induced immune suppression is inhibited.

There is some role of genetic and hormonal factors.

But there is some good news

Due to inhibited UVR induced immune suppression patients with PMLE are less susceptible to develop skin cancer. In simple words if you have PMLE then you have less chance of getting skin cancer.

Are there any investigations needed?

Diagnosis is mainly done by taking thorough history and clinical examination.

If there is any confusion or if it needs to be differentiated from diseases like lupus erythematosus then some investigations and biopsy may be required.

Disease course and prognosis

It's a chronic disease which appears intermittently for years. In some cases, the severity decreases with time and may get cured after years. But the prognosis is usually good as many cases are self limiting and in severe symptomatic cases response to treatment is generally very good. In my practice I have seen that most patients get cured only by applying a single cream for few days with adequate photo protection.

Do you need to consult a dermatologist if you have similar skin rash?

Yes of course.

Treatment

Patient counselling and informing the patient with disease course and prognosis is very important because in most of the cases this disease causes enough psychological stress as it mainly occurs over the visible parts of the body.

When a patient presents with PMLE with severe itching firstly symptomatic management to alleviate the symptoms is needed which is done by proper medications which I should not discus here.

Second step is prevention which is done by photo protection. Physical photo protection by using umbrella, hat, protective clothing (like full sleeve shirts for men) are important. Protect your back of the neck with a scarf. For women blouse which covers the whole upper back and chest is very helpful. Along with that proper sunscreen can also be suggested.

Source

1. https://www.ijord.com/index.php/ijord/article/view/92?msclkid=421a9260a6b711ec95844fa6d7c90f4d
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088173/?msclkid=4219d97ca6b711ecb4af8fed5226bda4
3. Rook’s textbook of Dermatology, 9^th edition, chapter 127
4. Fitzpatrick’s Dermatology, 9^th edition, chapter 92

 

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Afraid of small white spots on your skin? Don’t panic: The best guide is here

You are a man with good health aged about 50. The winter is hitting so you have started applying moisturizer over your legs. For last few days you have been suddenly noticing few small white spots appearing over your legs which are persistent and not recovering with time. You just don’t need to panic. It may be IGH.

Or

You are a housewife who uses to cook regularly. Initially a few white spots on your forearm did not seem to be alarming. It is a common occurrence due to small burns from hot oil sprinkle during frying anything. But now you are worried because the spots are not healing anymore and increasing in number with time. Take a deep breath and don’t worry. It might be just IGH.

What is IGH?

IGH stands for idiopathic guttate hypomelanosis.

Idiopathic – cause is unknown

Guttate – drop like marks

Hypomelanosis – hypopigmented / lighter in color than the surrounding skin

So IGH is a disease where round or oval white spots of 2-6 mm size appear over skin. Spots are well defined and often with irregular border. Larger spots may sometimes appear. The size does not change over time. The number increases with age. Most common site of occurrence is lower leg and forearm but it may rarely affect trunk or face.

It usually starts after the age of 40 years and it is a very common disease. At least 80% people will have IGH after the age of 70 years.

It occurs almost equally in both male and female but female patients visit clinics more often maybe because they are cosmetically more conscious.

 

Why do these small white spots appear?

Actual reason is unknown. But several hypothesis suggests that it is Ultra Violet ray induced or occurs due to photo-ageing or normal aging process. Genetic factors, trauma and autoimmunity may have some role.

Do you need to see a dermatologist for this?

Yes, you do.

The diagnosis is very straight forward with clinical examination and investigations are generally not required. But still it needs to be differentiated from few other diseases which may present similarly like pityriasis versicolor, pityriasis alba, vitiligo, pityriasis lichenoides chronica, post-inflammatory hypopigmentation etc. And this differentiation can only be done by a qualified and experienced dermatologist.

 

Disease course

Number of spots increases with age. No tendency of spontaneous re-pigmentation is seen without any treatment.

Do you need to worry about this after the diagnosis?  

No.

It is a benign disorder with only cosmetic concern.

 

Treatment

Reassurance and counselling about the disease is necessary and usually no treatment is required. And there is no universally accepted efficacious treatment present.

But as sun exposure is presumed to be the main culprit physical photo protection should be advised.

Your doctor may prescribe a sunscreen if required.

For cosmetic purposes many other treatment modalities can be tried depending on you and your doctor’s preference in case to case basis.

 

Source 

1. https://www.ncbi.nlm.nih.gov/books/NBK482182/
2. https://pubmed.ncbi.nlm.nih.gov/21699514/
3. Rook’s textbook of Dermatology, 9^th edition, chapter 88.
4. https://dermnetnz.org/topics/idiopathic-guttate-hypomelanosis
5.  https://www.visualdx.com/visualdx/diagnosis/idiopathic+guttate+hypomelanosis?diagnosisId=51655&moduleId=101 

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Massive hair loss (Telogen effluvium?): An ultimate guide for patients

 

You are a new mother now. Had your delivery few months earlier, and it is your happiest moments of life. But sudden excessive hair loss may ruin your happiness in some quantity right? Yes, that might be telogen effluvium.

Or

You went in to crash dieting to lose weight quickly. After few months, you woke up in the morning and Oh no! You just found a hefty amount of fallen hair on your pillow. Yes, that might also be telogen effluvium.

Or

You had a major surgery 2 months back and now you are suffering from sudden diffuse hair loss. It is certainly telogen effluvium.

  

What is Telogen?

 Human hair growth is cyclical. Each individual hair follicle goes through cyclical changes. One of that phase is called telogen.

What is telogen effluvium?

In simple terms, it is sudden excessive loss of hair which starts after 2-3 months following a stressful life event (like childbirth, a surgery, crash dieting, major illness or drug induced).

What do I mean by “excessive hair loss”?

Let us do a simple math. We have 100000 hairs in our scalp. Among them 10% which is 10000 are telogen hairs. All these 10000 hairs, which are of different ages, will fall at an age of 90 days. So normal hair loss per day will be 10000/90 = around 111.

The actual figure is around 100-150. So, more than 150 hair loss per day can be termed as excessive.

Do we really need to count this to measure excessive hair loss?

No.

So how do we measure “excessive hair loss”?

Pull test – Grasping about 40 hairs firmly between thumb and forefinger, followed by a slow pull which causes minimal discomfort. Shedding of more than 4-6 hairs in patients who has not shampooed their hair for more than 24 hours prior to the test (more than 2-3 in recently shampooed hair) is abnormal.

A technique developed by Dr. Jeffrey Miller – Patient combs hair from vertex to anterior hairline for 1 minute before shampooing on 3 consecutive days. Normal range of lost hair by this technique is 10-15. Loss of more than 50 is common in telogen effluvium.

 

Types and causes of telogen effluvium

1. Acute telogen effluvium – Sudden onset of scalp hair loss that occurs 2-3 months after a triggering factor. Regrowth can be expected within 3-6 moths. Causes –
   
   
   
   
   
2. Chronic diffuse telogen hair loss – Hair shedding persisting for longer than 6 months. Causes –
   

   
   
   
   
3.  Primary chronic telogen effluvium – It mainly affects women aged between 30 and 50 years. Appears as a sudden onset of increased hair loss which lasts for more than 6 months. The course is prolonged and fluctuating. Usually no triggering factor is found.

Why does this massive hair loss occur?

Digging deep into the pathogenesis won’t help my audience. But understanding the pathophysiology is an important part of patient counselling which reduces apprehension and anxiety of a patient. So, I will try to be as simple as possible.

The triggering factor causes disruption in the normal hair growth cycle. All of a sudden a lot of anagen hairs (which lives for years) are converted to telogen hairs (which lives for around 3 months). So after 3 months the extra telogen hairs starts falling off along with the 100-150 hairs that normally shed per day. This causes excessive hair loss.

Telogen effluvium at Childbirth (telogen gravidarum) is a bit different scenario. Here during pregnancy follicles may remain in prolonged anagen. At delivery many follicles are then released simultaneously in to telogen and shedding occurs after 3-5 months.

Do you need to run to a dermatologist?

Yes, and No. Confused?

Ok. Let me clear your doubts.

To give a perfect answer to this obvious question, first let me discuss prognosis, investigations and treatment options.

·      Prognosis –

v Acute telogen effluvium (ATE) – When the triggering factor gets resolved or eliminated a complete regrowth can be expected within few months. Ha

v Chronic diffuse telogen hair loss (CDTHL) – When the triggering factor gets identified and treated accordingly complete hair regrowth is expected. So here also the prognosis is good.

v Primary chronic telogen effluvium (PCTE) – Here no triggering factor is identified. Even after prolonged and fluctuating course of hair loss for no major reduction in hair density is observed. This also suggests a good prognosis.

·      Investigations required –

v ATE – No investigations required as spontaneous growth occurs after few months.

v CDTHL and PCTE – Distinction between these two required meticulous physical examination and laboratory studies to rule out causative factors.

·      Treatment –

v ATE-

1.    Observation

2.    Reassurance

3.    Counselling

v CDTHL-

1.    Treatment of the triggering diseases when diagnosed.

2.    Reassurance

3.    Counselling

4.    Few medications have been tried with no permanent or universal solution.

v PTCE-

1.     Reassurance

2.    Counselling

3.    Few medications have been tried with no permanent or universal solution.

So you see the main part of management is treatment of any triggering diseases if found along with reassurance and counselling.

So what I’ll suggest is, if you have only sudden excessive diffuse hair fall and you can correlate the timing with your childbirth or febrile illness or any surgery or crash diet or any new medications that you have started within last few months, then you just observe it for at least 6 months and then decide.

If you have other physical problems or you are suffering psychologically because of your hair fall, then you should definitely seek advice from a doctor.

If you are having excessive hair loss for more than 6 months, then also you should visit a dermatologist for proper diagnosis and management.

 

Source

1.    https://www.philipkingsley.com/hair-guide/hair-science/hair-growth-cycle

2.    Andrews’ Diseases of the skin –clinical dermatology, 12^th edition, chapter 33, page 749-750

3.    Fitzpatrick’s Dermatology, 9^th edition, chapter 86

4. Rook’s Textbook of Dermatology, 9^th edition, Chapter 89.24-28

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