Photo Rounds

Rash on back and wrists

A 48-year-old woman presented to her family physician (FP) with an itchy rash she’d had on her back and wrists for 3 months. On examination, the FP noted numerous brown, polygonal planar lesions, as well as lacy, reticular white lines (Wickham striae) on top of the lesions. The patient had diabetes and hypertension, and had started taking hydrochlorothiazide (HCTZ) 12.5 mg/d 5 months earlier, in addition to the lisinopril 10 mg/d she’d already been taking. Her blood pressure (BP) was now under control.

What’s your diagnosis?


The FP was aware that HCTZ might precipitate lichen planus or create a lichenoid drug reaction, so he performed a 4-mm punch biopsy and asked the patient to stop taking her HCTZ while the biopsy results were pending. (The patient also had several of the 5 Ps of lichen planus: planar, polygonal, pruritic, papular, and purple lesions. She didn’t have any papular lesions and the lesions she did have were more brown than purple because of her dark skin color.)

The FP prescribed topical fluocinonide 0.05% ointment to be applied twice daily to the affected areas until the biopsy results were available. The FP also increased her lisinopril dose, hoping to keep her BP under control.

Biopsy results came back as probable lichen planus and possible lichenoid drug reaction. As treatment for each condition would be the same, it didn’t matter that the pathologist couldn’t be more specific.

On the patient’s second visit for suture removal and discussion of the biopsy results, she said she was feeling better. Her BP was still under control, so the FP decided to continue the treatment plan. At follow-up one month later, the pruritus had resolved completely and the skin lesions were no longer palpable. There was postinflammatory hyperpigmentation at the sites of the lesions, but the patient was not concerned about this because most of it was on her back.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Kraft RL, Usatine R. Lichen planus. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 901-909.

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