Squamous Cell Carcinomas in Two Cases of Nail Lichen Planus: Is There a Real Association?

Squamous Cell Carcinomas in Two Cases of Nail Lichen Planus: Is There a Real Association? Dermatol Ther (Heidelb) https://doi.org/10.1007/s13555-018-0246-1 CASE REPORT Squamous Cell Carcinomas in Two Cases of Nail Lichen Planus: Is There a Real Association? . . . . Claudia Costa Alessia Villani Daniela Russo Milena Cappello Gaia De Fata Salvatores Massimiliano Scalvenzi Received: April 16, 2018 The Author(s) 2018 INTRODUCTION ABSTRACT Lichen planus is a chronic inflammatory disease Lichen planus (LP) is a chronic inflammatory that affects the skin and oral mucosa. Although disease that affects the skin and oral mucosa. its etiology is unknown [1], its potential for Although its etiology is unknown, its potential cancerization has been confirmed by many for cancerization has been confirmed. We studies, primarily for lichen involving the oral herein report the cases of a brother and sister, mucosa [2]. We here report the cases of a both with a 15-year history of nail lichen planus brother and sister, both with a 15-year history of of the fingers and toes, who developed squa- nail lichen planus of the fingers and toes, his- mous cell carcinomas of the nail bed and tologically confirmed and treated with topical matrix. This article shows the potential for corticosteroids, who developed squamous cell malignant transformation in lichen planus dis- carcinoma (SCC) of the nail bed and matrix. ease and highlights the importance of periodic Informed consent was obtained from each clinical follow-up. individual participant for inclusion in the study. The present article aims to highlight the importance of a correct diagnosis, treatment, Keywords: Chronic inflammation; Lichen and periodic follow-up of precancerous lesions planus; Malignant transformation; Nail; such as lichen planus (LP) and to explain the Squamous carcinoma underlying mechanisms of neoplastic changes involved in both LP and SCC, probably related to chronic inflammatory processes. Enhanced digital features To view enhanced digital features for this article go to https://doi.org/10.6084/ m9.figshare.6300113. Case 1 C. Costa  A. Villani (&)  M. Cappello A 60-year-old female was admitted to our hos- G. De Fata Salvatores  M. Scalvenzi pital for two ulcerated exophytic lesions of 1.5 Section of Dermatology, Department of Clinical Medicine and Surgery, Dermatology Unit, and 2 cm diameter, respectively, affecting the University of Naples Federico II, Naples, Italy third and fifth finger of the right hand. The two e-mail: ali.vil@hotmail.it lesions had arisen 4 years before (Fig. 1). The nails were all affected by lichen planus disease, D. Russo Department of Advanced Biomedical Sciences, histologically diagnosed with a 3-mm punch University of Naples Federico II, Naples, Italy Dermatol Ther (Heidelb) Fig. 2 Histology. Panoramic view of the lesion showing a squamous cell carcinoma, Bowen type, with an intra- epidermal and infiltrative component [two distal pha- langes, fifth right hand finger, hematoxylin & eosin stain (H&E), original magnification 9 5] Fig. 1 Clinical and dermoscopic manifestations. Ulcera- tive and exophytic lesions of the 3rd and 5th finger of the right hand. Fingernails show atrophy, destruction, or pterygium formation biopsy 15 years before; no other anatomical sites were involved. Dermoscopic features of the exophytic lesions showed the presence of a polymorphic vascular pattern, surrounded by keratinizing whitish areas. Furthermore, two skin biopsy specimens from the two lesions of the fingers were taken. They showed intra-epi- dermal and infiltrative proliferation of atypical squamous cells with the presence of horn Fig. 3 Clinical manifestation. A 2-cm-diameter ulcerating pearls. Moreover, necrotizing aspects were nodule affecting the first toe of the left foot found (Fig. 2). A diagnosis of ulcerating SCC for both lesions was made. The nail bed and matrix 15 years before. No other lichen planus lesions were involved, so both fingers were amputated were observed on the skin, oral muscosa, or (Fig. 3). genital regions. At dermoscopy, a polymorphic vascular pattern, surrounded by keratinizing Case 2 whitish areas suggestive of SCC, was present. Furthermore, a 3-mm punch biopsy taken from A 55-year-old male presented to our hospital the nodular lesion of the toe revealed an intra- with a 2-cm-diameter ulcerated nodule affecting epidermal and infiltrative proliferation of atyp- the left great toe of 4 years’ duration. Nails of ical squamous cells with the presence of squa- the other toes and fingers were all affected by mous cells and horn pearls. Necrotizing cells lichen planus disease, histologically diagnosed were also reported. A diagnosis of ulcerating Dermatol Ther (Heidelb) Table 1 Published reports on squamous cell carcinoma (SCC) in patients affected by nail lichen planus Author (year) Sex, age Clinic Histology Treatment Okiyama et al. Male, 51 Ulcerated exophytic lesion of left great toe SCC Amputation (2005) Our case 1 (2017) Female, Two ulcerated and exophytic lesions of the third and fifth finger SCCs Amputation 60 of the right hand Our case 2 (2017) Male, 55 Ulcerated exophytic lesion of left great toe SCC Amputation squamous cell carcinoma involving the matrix the genital region, the majority of digital SCC and nail bed was made. The patient underwent and SCC in situ occurs on the periungual and/or the amputation of the toe (Table 1). subungual skin. HPV16, which is traditionally associated with lesions on mucosal surfaces, such as the cervix, is the most frequently DISCUSSION involved high-risk HPV subtype [6]. Physicians should be aware that malignant transformation Lichen planus is a chronic inflammatory disease may occur in a patient with lichen planus dis- with autoimmune etiology. Malignant trans- ease and that these tumors tend to be locally formation of lichen planus occurs rarely, mostly aggressive, necessitating prompt surgical treat- for oral lichen planus whose cancerization rate ment and close follow-up. Indeed, early diag- ranges from 0% to 3.5% [3]. According to the nosis, treatment, and periodic clinical follow-up literature, this is the second case of SCCs arising are important to detect any malignant trans- on nail lichen planus. In 2005, Okiyama et al. formation early and to decrease morbidity. described the case of a 51-year-old male with nail lichen planus who developed an ulcerated SCC of the left great toe [4]. However, other ACKNOWLEDGEMENTS cases of squamous cell carcinomas developed on lichen of the penis, vulva and lower legs have already been reported [5]. The nature of this Funding. No funding or sponsorship was relationship is unclear; chronic inflammatory received for this study or publication of this processes and oncogenic growth factors may be article. the underlying mechanisms for the develop- ment of neoplastic cells in the epidermis of Authorship. All named authors meet the patients with an immunocompromised cuta- International Committee of Medical Journal neous district [2]. The development of carci- Editors (ICMJE) criteria for authorship for this noma in the setting of LP represents a failure of manuscript, take responsibility of the integrity the keratinocytes to adapt to the environment of the work as a whole, and have given final of continuous inflammation and altered struc- approval for the version to be published. ture. The damaged epithelium results from T-cell-mediated attack on basilar keratinocytes, Disclosures. Claudia Costa, Alessia Villani, thus resulting in the disruption of the skin Daniela Russo, Milena Cappello, Gaia De Fata architecture, which leads to chronic metabolic Salvatores, and Massimiliano Scalvenzi have or growth activation of keratinocytes, predis- nothing to disclose. posing these cells to neoplastic initiation [4]. Furthermore, the oncogenic role of human Compliance with Ethics Guidelines. In- papillomavirus (HPV) in squamous cell carci- formed consent was obtained from all individ- noma (SCC) has been well established. Outside ual participants for being included in the study. Dermatol Ther (Heidelb) 3. Silveira WDS, Bottezini EG, Linden MS, Rinaldi I, Open Access. This article is distributed Paranhos LR, de Carli JP, Trentin M, Dos Santos PL. under the terms of the Creative Commons Squamous cell carcinoma from oral lichen planus: a Attribution-NonCommercial 4.0 International case report of a lesion with 28 years of evolution. License (http://creativecommons.org/licenses/ J Korean Assoc Oral Maxillofac Surg. 2017;43(Suppl 1):S14–8. by-nc/4.0/), which permits any noncommer- cial use, distribution, and reproduction in any 4. Okiyama N, Satoh T, Yokozeki H, Nishioka K. Squa- medium, provided you give appropriate credit mous cell carcinoma arising from lichen planus of to the original author(s) and the source, provide nail matrix and nail bed. J Am Acad Dermatol. 2005;53(5):908–9. a link to the Creative Commons license, and indicate if changes were made. 5. Lewis FM, Harrington CI. Squamous cell carcinoma arising in vulval lichen planus. Br J Dermatol. 1994;131:703–5. REFERENCES 6. Riddel C, Rashid R, Thomas V. Ungual and periungual human papillomavirus-associated squamous cell car- 1. Krupaa RJ, Sankari SL, Masthan KM, Rajesh E. Oral cinoma: a review. J Am Acad Dermatol. lichen planus: an overview. J Pharm Bioallied Sci. 2011;64(6):1147–53. 2015;7(Suppl 1):S158–61. 2. Rajentheran R, McLean NR, Kelly CG, Reed MF, Nolan A. Malignant transformation of oral lichen planus. Eur J Surg Oncol. 1999;25:520–3. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Dermatology and Therapy Springer Journals

Squamous Cell Carcinomas in Two Cases of Nail Lichen Planus: Is There a Real Association?

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Springer Healthcare
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Copyright © 2018 by The Author(s)
Subject
Medicine & Public Health; Internal Medicine; Dermatology; Plastic Surgery; Oral and Maxillofacial Surgery; Quality of Life Research
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2193-8210
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2190-9172
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10.1007/s13555-018-0246-1
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Abstract

Dermatol Ther (Heidelb) https://doi.org/10.1007/s13555-018-0246-1 CASE REPORT Squamous Cell Carcinomas in Two Cases of Nail Lichen Planus: Is There a Real Association? . . . . Claudia Costa Alessia Villani Daniela Russo Milena Cappello Gaia De Fata Salvatores Massimiliano Scalvenzi Received: April 16, 2018 The Author(s) 2018 INTRODUCTION ABSTRACT Lichen planus is a chronic inflammatory disease Lichen planus (LP) is a chronic inflammatory that affects the skin and oral mucosa. Although disease that affects the skin and oral mucosa. its etiology is unknown [1], its potential for Although its etiology is unknown, its potential cancerization has been confirmed by many for cancerization has been confirmed. We studies, primarily for lichen involving the oral herein report the cases of a brother and sister, mucosa [2]. We here report the cases of a both with a 15-year history of nail lichen planus brother and sister, both with a 15-year history of of the fingers and toes, who developed squa- nail lichen planus of the fingers and toes, his- mous cell carcinomas of the nail bed and tologically confirmed and treated with topical matrix. This article shows the potential for corticosteroids, who developed squamous cell malignant transformation in lichen planus dis- carcinoma (SCC) of the nail bed and matrix. ease and highlights the importance of periodic Informed consent was obtained from each clinical follow-up. individual participant for inclusion in the study. The present article aims to highlight the importance of a correct diagnosis, treatment, Keywords: Chronic inflammation; Lichen and periodic follow-up of precancerous lesions planus; Malignant transformation; Nail; such as lichen planus (LP) and to explain the Squamous carcinoma underlying mechanisms of neoplastic changes involved in both LP and SCC, probably related to chronic inflammatory processes. Enhanced digital features To view enhanced digital features for this article go to https://doi.org/10.6084/ m9.figshare.6300113. Case 1 C. Costa  A. Villani (&)  M. Cappello A 60-year-old female was admitted to our hos- G. De Fata Salvatores  M. Scalvenzi pital for two ulcerated exophytic lesions of 1.5 Section of Dermatology, Department of Clinical Medicine and Surgery, Dermatology Unit, and 2 cm diameter, respectively, affecting the University of Naples Federico II, Naples, Italy third and fifth finger of the right hand. The two e-mail: ali.vil@hotmail.it lesions had arisen 4 years before (Fig. 1). The nails were all affected by lichen planus disease, D. Russo Department of Advanced Biomedical Sciences, histologically diagnosed with a 3-mm punch University of Naples Federico II, Naples, Italy Dermatol Ther (Heidelb) Fig. 2 Histology. Panoramic view of the lesion showing a squamous cell carcinoma, Bowen type, with an intra- epidermal and infiltrative component [two distal pha- langes, fifth right hand finger, hematoxylin & eosin stain (H&E), original magnification 9 5] Fig. 1 Clinical and dermoscopic manifestations. Ulcera- tive and exophytic lesions of the 3rd and 5th finger of the right hand. Fingernails show atrophy, destruction, or pterygium formation biopsy 15 years before; no other anatomical sites were involved. Dermoscopic features of the exophytic lesions showed the presence of a polymorphic vascular pattern, surrounded by keratinizing whitish areas. Furthermore, two skin biopsy specimens from the two lesions of the fingers were taken. They showed intra-epi- dermal and infiltrative proliferation of atypical squamous cells with the presence of horn Fig. 3 Clinical manifestation. A 2-cm-diameter ulcerating pearls. Moreover, necrotizing aspects were nodule affecting the first toe of the left foot found (Fig. 2). A diagnosis of ulcerating SCC for both lesions was made. The nail bed and matrix 15 years before. No other lichen planus lesions were involved, so both fingers were amputated were observed on the skin, oral muscosa, or (Fig. 3). genital regions. At dermoscopy, a polymorphic vascular pattern, surrounded by keratinizing Case 2 whitish areas suggestive of SCC, was present. Furthermore, a 3-mm punch biopsy taken from A 55-year-old male presented to our hospital the nodular lesion of the toe revealed an intra- with a 2-cm-diameter ulcerated nodule affecting epidermal and infiltrative proliferation of atyp- the left great toe of 4 years’ duration. Nails of ical squamous cells with the presence of squa- the other toes and fingers were all affected by mous cells and horn pearls. Necrotizing cells lichen planus disease, histologically diagnosed were also reported. A diagnosis of ulcerating Dermatol Ther (Heidelb) Table 1 Published reports on squamous cell carcinoma (SCC) in patients affected by nail lichen planus Author (year) Sex, age Clinic Histology Treatment Okiyama et al. Male, 51 Ulcerated exophytic lesion of left great toe SCC Amputation (2005) Our case 1 (2017) Female, Two ulcerated and exophytic lesions of the third and fifth finger SCCs Amputation 60 of the right hand Our case 2 (2017) Male, 55 Ulcerated exophytic lesion of left great toe SCC Amputation squamous cell carcinoma involving the matrix the genital region, the majority of digital SCC and nail bed was made. The patient underwent and SCC in situ occurs on the periungual and/or the amputation of the toe (Table 1). subungual skin. HPV16, which is traditionally associated with lesions on mucosal surfaces, such as the cervix, is the most frequently DISCUSSION involved high-risk HPV subtype [6]. Physicians should be aware that malignant transformation Lichen planus is a chronic inflammatory disease may occur in a patient with lichen planus dis- with autoimmune etiology. Malignant trans- ease and that these tumors tend to be locally formation of lichen planus occurs rarely, mostly aggressive, necessitating prompt surgical treat- for oral lichen planus whose cancerization rate ment and close follow-up. Indeed, early diag- ranges from 0% to 3.5% [3]. According to the nosis, treatment, and periodic clinical follow-up literature, this is the second case of SCCs arising are important to detect any malignant trans- on nail lichen planus. In 2005, Okiyama et al. formation early and to decrease morbidity. described the case of a 51-year-old male with nail lichen planus who developed an ulcerated SCC of the left great toe [4]. However, other ACKNOWLEDGEMENTS cases of squamous cell carcinomas developed on lichen of the penis, vulva and lower legs have already been reported [5]. The nature of this Funding. No funding or sponsorship was relationship is unclear; chronic inflammatory received for this study or publication of this processes and oncogenic growth factors may be article. the underlying mechanisms for the develop- ment of neoplastic cells in the epidermis of Authorship. All named authors meet the patients with an immunocompromised cuta- International Committee of Medical Journal neous district [2]. The development of carci- Editors (ICMJE) criteria for authorship for this noma in the setting of LP represents a failure of manuscript, take responsibility of the integrity the keratinocytes to adapt to the environment of the work as a whole, and have given final of continuous inflammation and altered struc- approval for the version to be published. ture. The damaged epithelium results from T-cell-mediated attack on basilar keratinocytes, Disclosures. Claudia Costa, Alessia Villani, thus resulting in the disruption of the skin Daniela Russo, Milena Cappello, Gaia De Fata architecture, which leads to chronic metabolic Salvatores, and Massimiliano Scalvenzi have or growth activation of keratinocytes, predis- nothing to disclose. posing these cells to neoplastic initiation [4]. Furthermore, the oncogenic role of human Compliance with Ethics Guidelines. In- papillomavirus (HPV) in squamous cell carci- formed consent was obtained from all individ- noma (SCC) has been well established. Outside ual participants for being included in the study. Dermatol Ther (Heidelb) 3. Silveira WDS, Bottezini EG, Linden MS, Rinaldi I, Open Access. This article is distributed Paranhos LR, de Carli JP, Trentin M, Dos Santos PL. under the terms of the Creative Commons Squamous cell carcinoma from oral lichen planus: a Attribution-NonCommercial 4.0 International case report of a lesion with 28 years of evolution. License (http://creativecommons.org/licenses/ J Korean Assoc Oral Maxillofac Surg. 2017;43(Suppl 1):S14–8. by-nc/4.0/), which permits any noncommer- cial use, distribution, and reproduction in any 4. Okiyama N, Satoh T, Yokozeki H, Nishioka K. Squa- medium, provided you give appropriate credit mous cell carcinoma arising from lichen planus of to the original author(s) and the source, provide nail matrix and nail bed. J Am Acad Dermatol. 2005;53(5):908–9. a link to the Creative Commons license, and indicate if changes were made. 5. Lewis FM, Harrington CI. Squamous cell carcinoma arising in vulval lichen planus. Br J Dermatol. 1994;131:703–5. REFERENCES 6. Riddel C, Rashid R, Thomas V. Ungual and periungual human papillomavirus-associated squamous cell car- 1. Krupaa RJ, Sankari SL, Masthan KM, Rajesh E. Oral cinoma: a review. J Am Acad Dermatol. lichen planus: an overview. J Pharm Bioallied Sci. 2011;64(6):1147–53. 2015;7(Suppl 1):S158–61. 2. Rajentheran R, McLean NR, Kelly CG, Reed MF, Nolan A. Malignant transformation of oral lichen planus. Eur J Surg Oncol. 1999;25:520–3.

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Dermatology and TherapySpringer Journals

Published: May 31, 2018

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