Lichenoid Inflammatory Phase of Chronic Skin GVHD

Cutaneous chronic graft-versus-host disease (cGVHD) exhibits a variety of different appearances and phases. Most commonly, cGVHD presents with generalized lichen planus-like involvement of the skin, although other skin diseases are also mimicked. Cutaneous cGVHD begins as a generalized inflammatory stage and gradually develops into a sclerodermatous phase. These changes are not uniform, and one may see various phases of the disease in different parts of the body. Lichenoid or inflammatory cGVHD is recognized by an acanthotic hyperkeratotic epidermis with shortened sawtoothed shaped rete ridges, by a band-like lymphocytic infiltrate within the superficial dermis, with accompanying destruction of dermal appendages, including the hair follicles and eccrine ducts. Late-onset acute graft-versus-host disease (aGVHD) occurs when there are superimposed changes of aGVHD in the skin and gut that coexist with changes of cGVHD. Lichenoid cGVHD evolves from an inflammatory phase to poikiloderma with various degrees of dermal atrophy, dyspigmentation and sclerosis. Skin biopsies should include the deep dermis and subcutaneous fat to assess for paniculitis. Confirmatory skin biopsies for cGVHD are necessary if there are no other stigmata of cGVHD in other organs.