PUVA therapy in lichen aureus

A 55-year-old woman presented with a rash on her thighs, buttocks, and elbows of 8 months’ duration. Examination showed a purpuric, pigmented, lichenoid eruption on her trunk and legs (Fig 1) suggestive of widespread lichen aureus. She had a history of psoriasis, hypertension, and left thoracic outlet compression requiring transaxillary excision of the first rib. Her medications at presentation consisted of bendrofluazide and dothiepin, both of which had been a long-standing regimen and continued unchanged. Histopathologic examination of the skin biopsy specimen (Fig 2) showed a heavy perivascular infiltrate of lymphocytes and macrophages with extravasation of red blood cells into the perivascular connective tissue. The lichenoid infiltrate was separated from the epidermis by a grenz zone, which is in keeping with a diagnosis of lichen aureus. Treatment with moderately potent (betamethasone valerate 0.1%) and very potent (clobetasol propionate 0.05%) topical steroid creams was ineffective. She was then started on a regimen of twiceweekly PUVA therapy after minimal phototoxic dose testing. The starting UVA dose was 0.5 J/cm2 (70% of the minimal phototoxic dose), with 40% increments at each visit. On review after only 8 exposures, the disease had completely resolved (Fig 3). She remained disease free until May 1999, when she had a mild relapse on her legs that on this occasion was resolved quickly with local fluocinonide 0.05% therapy. DISCUSSION Lichen aureus is one of the subtypes of a rare group of diseases, pigmented purpuric dermatoses (PPD), which are essentially a capillaritis of unknown origin. Clinically, lichen aureus is usually more localized and intensely purpuric compared with the other types of PPD, although a more widespread form of lichen aureus is well recognized. The eruption has a predilection for a younger age group.1 The sites of involvement most frequently are the lower legs, but it can also affect the forearms and trunk. It is usually unilateral and asymptomatic. The lesions are localized, circumscribed areas of confluent macules or papules, varying from golden to brown to purple. The lesions are slow to evolve and usually persist unchanged for many years.1,2 Complete resolution rarely occurs. Price et al1 reviewed 45 reported cases in 1985 and observed that only 5 cases underwent spontaneous resolution between 1 and 10 years (median, 2 years) after disease onset. A more recent study3 suggests that the disease is more likely to be self-limiting in children compared with adults. Brief reports 145 J AM ACAD DERMATOL VOLUME 45, NUMBER 1