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Clinical dermatology Original article

Clinical and Experimental Dermatology

Lichen simplex chronicus as a symptom of neuropathy

O. Solak, M. Kulac,* M. Yaman,† S. Karaca,* H. Toktas, O. Kirpiko‡ and V. Kavuncu

Departments of Physical Medicine and Rehabilitation, *Dermatology, Neurology, and Radiology, Afyon Kocatepe University, School of Medicine, Afyon, Turkey

doi:10.1111/j.1365-2230.2008.02969.x

Summary Background. The main cause of lichen simplex chronicus (LSC) is not known but there is evidence to suggest that neurological abnormalities may be implicated in its aetiology. Aim. To investigate neuropathy in patients with LSC on the limbs. Methods. In total, 23 consecutive patients [15 women (65.2%) and 8 men (34.8%); mean ± SD age 48.2 ± 14.03 years, range 20–71] with LSC on the limbs were included in the study. Mean ± SD duration of disease was 22.86 ± 21.38 months (range 1–60). Radiography, magnetic resonance imaging (MRI) and electrophysio- logical studies were performed for all patients. Results. In total, 8 patients (34.8%) had LSC on the arms and 15 patients (65.2%) had LSC on the legs; 3 (37.5%) of the 8 patients with LSC on the arms and 6 (40%) of the 15 patients with LSC on the legs had radiculopathy in the electrophysiological studies. The prevalence of radiculopathy in patients with LSC on the limbs was higher than in asymptomatic subjects in the electrophysiological studies. Conclusions. Damage to the peripheral nervous system, such as radiculopathy and neuropathy, can play a critical role in the aetiology of LSC on the limbs. Both nerve- root compression in MRI scans and radiculopathy in nerve-conduction studies are common findings in asymptomatic subjects, but they seem to be more common in patients with LSC on the limbs. Therefore, these patients should be evaluated for the possibility of underlying neuropathy.

Introduction

Lichenification is a pattern of cutaneous response to repeated rubbing or scratching. It is common in patients with atopic eczema, but may also be secondary to other irritant dermatoses. The term ‘lichen simplex chronicus’ (LSC) is used for cases where there is no known predisposing skin disorder, whereas if the excoriation is initiated by a pruritic dermatosis, the term ‘secondary lichenification’ is used. 1 LSC, also known as neuro-

Correspondence: Dr Ozlem Solak, Afyon Kocatepe Universitesi, Tip Fak, Fiziksel Tip ve Rehabilitasyon, AD, PK: 03200, Afyon, Turkey. E-mail: ozlemsolak@hotmail.com

Conflict of interest: none declared.

Accepted for publication 18 January 2008

dermatitis circumscripta, is characterized by circum- scribed, lichenified, pruritic patches that may develop on any part of the body. 2 The usual sites are the nape of the neck, the lower legs and ankles, the sides of the neck, the scalp, the upper thighs, the vulva, pubis or scrotum, and the extensor forearms. 1 Why LSC so often involves such a limited area and why there are such common sites of predilection remains unclear. 3 In clinical practice, it has been observed that the patches in LSC are localized, consistent with the specific innervation to

these regions. A dermatomal pattern of LSC has been described as the initial presentation of an intramedullary neoplasm with syringomyelia. 4 In recent studies, an association between cervical spinal disease and brachioradial pruritus (BRP), another form of ‘idiopathic’ localized

2008 The Author(s)

  • 476 Journal compilation 2008 Blackwell Publishing Ltd Clinical and Experimental Dermatology , 34, 476–480

Lichen simplex chronicus as a symptom of neuropathy O. Solak et al.

pruritus on the arms, was reported. 5,6 ‘Idiopathic’ anogenital pruritus (itch localized to the anus, perianal and genital skin without a demonstrable cause) has also been attributed to lumbosacral radiculopathy. 7 In this study, we aimed to investigate the association between LSC on the limbs and possible cervical or lumbar neuropathic aetiology.

Methods

All patients gave informed signed consent, and the study protocol was approved by our institutional research ethics committee. Patients with LSC on the limbs who presented to the dermatology department between October 2005 and September 2006 were assessed for the study. All patients were examined first by a dermatologist. Patients with localized pruritic, lichenified lesions located on the limbs with a duration of at least 2 months were clinically diagnosed as having LSC. Patients with a history of atopic dermatitis, diabetes mellitus, generalized pruritus and known psychiatric disorders were excluded from the study groups. Laboratory tests (complete blood cell count, serum electrolytes, liver, and kidney function tests) were performed to disclose any underlying cause of pruritus. The diagnosis of LSC was made by a dermatologist, and those patients were enrolled in the study. All the patients were examined by a rehabilitation specialist. Cervical radiography and cervical magnetic resonance imaging (MRI) were performed for all patients with LSC on the arms. Lumbar radiographs and lumbar MRI scans were taken for all patients with LSC on the legs. Electrophysiological studies were performed in patients with LSC on the arms, including measurement of sensory and motor distal latency, conduction velocity and F waves of the median and ulnar nerves, and sensory distal latency of the radial nerves of both arms by a neurologist. For patients with LSC on the legs, electrophysiological studies including measurement of sensory and motor distal latency, conduction velocity and F waves of the peroneal and tibial nerves, and sensory distal latency of the sural nerves of both legs were also performed. Needle electromyography (EMG) studies were performed when there was an abnormality in physical examination or MRI findings.

Statistical analysis

Descriptive data included proportions for categorical data and means, median, range and standard deviations

for continuous variables. The v 2 test and Fisher’s exact tests were used for analysis.

Results

In total, 23 patients with local pruritus were included in the study. Of these, 15 patients (65.2%) had LSC on the legs and 8 (34.8%) had LSC on the arms. There were 15 women (65.2%) and 8 men (34.8%), mean ± SD age 48.2 ± 14.03 (range 20–71). Mean duration of pruritus was 22.86 ± 21.38 months (range 1–60). Localized pruritus had been present in 11 patients (47.8%) h < 12 months and in 12 (52.2%) >12 months. The pruritus was present on the right side in 10 patients (43.5%), the left side in 5 (21.7%) and on both sides in 8 (69.9%). Hypoesthesia was found in 3 patients (13.1%), hyperesthesia in 1 (4.3%), and normal sensation in 19 (82.6%). One patient (4.3%) had muscle weakness. Deep tendon reflexes were hypoactive in 5 patients (21.7%) and normoactive in 17 (73.9%) (Table 1). Cervical and lumbosacral radiographs showed signs of degenerative changes of the spine in 10 patients (43.5%) including sclerosis, anterior and posterior osteophytes, and narrowing of the intervertebral space. The radiographs were normal in 13 patients (56.5%). Half (50%) of the patients with LSC on the arms (one aged < 45 years, two in the age range 45–65 years, and one aged > 65 years) had degenerative changes in the cervical spine. We found radiographic changes in 40% of the patients with LSC on the legs (five in the age range 45–65 years, one aged > 65 years).

Table 1 Neurological examination results in patients with and without radiculopathy in electromyography.

 

Radiculopathy

 

Positive (n = 9)

Negative (n = 14)

 

%

n

%

n

P

Muscle

Normal

88.9

8

100.0

14

NS

Weakness

11.1

1

0.0

0

Sensation

Normal

88.9

8

78.6

11

Hypoaesthesia

11.1

1

14.3

2

NS

Hyperaesthesia

0.0

0

7.1

1

DTR

Normoactive

66.7

6

78.6

11

Hypoactive

22.2

2

21.4

3

NS

Hyperactive

11.1

1

0.0

0

DTR, deep tendon reflexes; NS, non-significant.

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Lichen simplex chronicus as a symptom of neuropathy O. Solak et al.

Table 2 Radiographic and MRI findings in patients with and without radiculopathy in electromyography.

 

Radiculopathy

 

Positive (n = 9)

Negative (n = 14)

 

%

n

%

n

P

Radiography Normal

33.3

3

71.4

10

NS

Degenerative

66.7

6

28.6

4

MRI Normal

0.0

0

50.0

7

Disc herniation

66.7

6

42.9

6

NS

Nerve-root compression

33.3

3

7.1

1

MRI, magnetic resonance imaging; NS, non-significant.

MRI found nerve-root compression in 4 patients (17.4%) secondary to disc extrusion, disc herniation (bulging or protrusion) in 12 (52.2%) and normal results in 7 (30.4%) (Table 2). Cervical MRI scans of the patients with LSC on the arms revealed nerve-root compression in one 71-year-old patient (12.5%) sec- ondary to disc extrusion and disc herniation (bulging or protrusion) in four patients (50%) (age range 45–58). Lumbar MRI scans of the patients with LSC on the legs revealed disc bulging in seven patients (46.7%) (three aged <30 years and four aged 50–65 years), protrusion in one (6.7%) (aged 47 years) and nerve-root compres- sion in three (20%) (age range 45–65 years) secondary to disc extrusion. In nine patients (39.1%), nerve-conduction studies demonstrated abnormal or non-excitable F-wave responses, interpreted as cervical or lumbosacral radi- culopathy. It was found that 3 (37.5%) of the 8 patients with LSC on the arms and 6 (40%) of the 15 patients with LSC on the legs had radiculopathy in the EMG studies. Prevalence of radiculopathy in the EMG studies was higher in patients who had pruritus for >12 months (P < 0.05). Radiculopathy was found in nine patients in EMG studies, consistent with the pruritus dermatome (Table 3). We found demyelinating peripheral neurop- athy in two patients, mild axonal neuropathy in one and carpal-tunnel entrapment in one, which could have been the cause of the pruritus (Table 4).

Discussion

Nervous system pathology is not often recognized as a cause of LSC on the limbs. However, we suggest that radiculopathy can cause this particular feature, because

Table 3 Interpretation of nerve conduction and electromyography studies in 23 patients with local pruritus.

Patient

Corresponding

Pruritus

no.

Results of EMG studies

disc

dermatome

  • 1 Normal

 

C6

  • 2 Normal

L4, L5

  • 3 Radiculopathy

L5 and S1

L5

  • 4 Normal

L1

  • 5 Normal

C5

  • 6 Radiculopathy

S1

S1, S2

  • 7 Normal

C6, C7

  • 8 Axonal neuropathy

L4, L5, S1

  • 9 Radiculopathy

L4

L4, L5, S1

  • 10 Normal

C5, C6

  • 11 Normal

L3, L4, L5

  • 12 Radiculopathy

C7

C7

  • 13 Radiculopathy

C8

C7, C8

  • 14 Radiculopathy + demyelinating peripheral neuropathy

L5, S1

L5, S1

  • 15 Demyelinating peripheral neuropathy

L4, L5

  • 16 Normal

L5, S1

  • 17 Normal

C7, C8

  • 18 Radiculopathy

C6

C6, C7

  • 19 Normal

L4

  • 20 Radiculopathy

L4

L4, L5, S1

  • 21 Radiculopathy

L4, L5

L4, L5

  • 22 Normal

S1

  • 23 Normal

L4, L5

EMG, electromyography.

we found that the localization of patches in LSC is consistent with the specific innervation in these areas. Pruritus originates within the skin’s free nerve endings. The sensation of pruritus is transmitted through C fibres to the dorsal horn of the spinal cord and then to the cerebral cortex via the spinothalamic tract. 8 Pruritus generates a spinal reflex response, scratch, which is as innate as a deep tendon reflex. 9 It is possible that cervical or lumbosacral nerve-root compression may be felt as pain in some patients and as pruritus in others. In the past, pruritus was considered as a mild variant of pain. Several theories were proposed, such as the gate-control, specificity, pattern, and central-processing theories. It has been suggested that both pain and itch are carried on the same unmyelinated (slow), afferent group C nerve fibres. 10,11 Goodkin et al. suggested that there may be an association between cervical spinal disease and BRP, a localized itch on the forearms, and that these patients may benefit from neurological investigation and treatment. 6 Gore et al. investigated radiographic changes of the cervical spine in asymptomatic people to determine the

2008 The Author(s)

  • 478 Journal compilation 2008 Blackwell Publishing Ltd Clinical and Experimental Dermatology , 34, 476–480

Lichen simplex chronicus as a symptom of neuropathy O. Solak et al.

Table 4 Summary of the cause assessment in 23 patients with local pruritus.

Patient

Gender age

Radiculopathy

Other suspected

Pruritus

no.

(years)

(EMG)

causes

dermatome

1

F 50

)

C6

2

M 28

)

L4, L5

3

F 36

+

L5

4

M 53

)

L1

5

F 44

)

C5

6

F 20

+

S1, S2

7

F 36

)

C6, C7

8

M 65

)

Mild axonal

L4, L5, S1

 

neuropathy

9

F 29

+

L4, L5, S1

10

F 45

)

C5, C6

11

M 48

)

L3, L4, L5

12

M 58

+

C7

13

F 71

+

C7, C8

14

M 67

+

Demyelinating

L5, S1

 

peripheral

neuropathy

15

M 58

)

Demyelinating

L4, L5

 

peripheral

neuropathy

16

F 32

)

L5, S1

17

F 38

)

C7, C8

18

F 63

+

Carpal tunnel

C6, C7

 

entrapment in

EMG studies

19

F 56

)

L4

20

F 50

+

L4, L5, S1

21

F 55

+

L4, L5

22

M 28

)

S1

23

F 47

)

L4, L5

Total

9 23

4 23 (17.4%)

(39.1%)

EMG, electromyography.

effect of ageing on the cervical spine. 12 Sclerosis, anterior and posterior osteophytes, and narrowing were noted. Of asymptomatic men and women, 35% had

radiographic changes of the cervical spine by the age of

  • 45 years, and 70% of women and 95% of men had

these changes by 65 years. In our series, 50% of patients with LSC on the arms (one aged > 45 years,

two between 45 and 65 years, and one > 65 years) had abnormalities of the cervical spine. This suggests that the prevalence of cervical radiographic changes is not very different in patients with LSC from asymptomatic people. We also observed radiographic changes in 40% of the patients with LSC on the legs (five aged 45–

  • 65 years, one > 65 years).

Teresi et al. investigated MRI findings of the cervical spine in asymptomatic people. 13 They observed disk protrusion (herniation bulge) in 5 (20%) of 25 patients aged 45–54 years and in 24 (57%) of 42 aged

> 64 years. In our study, cervical MRI scans of the

patients with LSC on the arms were disc herniation

(bulging or protrusion) in four patients (50%) aged 45– 58 years and nerve-root compression in one patient

(12.5%), aged 71 years. Jensen et al. examined the prevalence of abnormal

findings on MRI scans of the lumbar spine in people

without back pain. 14 They reported that 52% of the

subjects had a bulge in at least one level, 27% had a

protrusion, and 1% had an extrusion. In our study,

lumbar MRI scans of the patients with LSC on the legs found disc bulging in seven patients (46.7%) (three aged

<30 years and four aged 50–65 years), protrusion in

one (6.7%) (aged 47 years) and nerve-root compression

in three (20%) (age 45–65 years), thus the prevalence

of nerve-root compression in MRI scans in patients with

LSC on the limbs was higher than in asymptomatic subjects. Cohen et al. reported that BRP and ‘idiopathic’

anogenital pruritus may be attributed to a neuropa- thy, such as chronic cervical or lumbosacral radicul-

opathy, and paravertebral blockade may be used for

alleviation of symptoms in these patients. 5,7 They also

highlighted that the possibility of an underlying neuropathy should be considered in the evaluation

and treatment of all patients with BRP. 5 Kavak and

Dasoglu reported a case of BRP caused by a spinal

cord tumour 15 , and Savk et al. reported that the

striking correlation of localization of notalgia

paresthetica with spinal pathology suggests that spinal-nerve impingement may contribute to the

pathogenesis of this condition. 16 Date et al. found cervical and lumbar radiculopathy, respectively, in 8 (12%) of 66 and 9 (14.5%) of 62 subjects in a group of asymptomatic subjects in EMG studies. 17,18 In our study, we found that 3 (37.5%) of 8 patients with LSC on the arms and 6 (40%) of 15 with LSC on the legs had radiculopathy in the EMG studies,

representing nerve or nerve-root compression. The rate of the radiculopathy in the patients with LSC on the arms was higher than in asymptomatic subjects, but the difference was not significant (P = 0.057). In contrast, the difference between the rates of radiculopathy in the patients with LSC on the legs and asymptomatic subjects was significant (P = 0.025). We found radiculopathy in nine patients in EMG studies consistent with the pruritus dermatome. There

was demyelinating peripheral neuropathy in two patients, mild axonal neuropathy in one and carpal- tunnel entrapment in one. One of the patients had both radiculopathy and carpal-tunnel entrapment according to electrophysiological studies. This patient had pruritus

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Lichen simplex chronicus as a symptom of neuropathy O. Solak et al.

on her hands on the C6 and C7 dermatomes, which might have been caused by both the carpal-tunnel entrapment and nerve-root compression. In another patient, both radiculopathy and demyelinating periph- eral neuropathy were detected by electrophysiological studies, and both could be the cause of LSC in this patient. In two other patients, the only neurological findings that might be a cause of LSC in electrophysio- logical studies were demyelinating peripheral neuropa- thy or mild axonal neuropathy, respectively. However, because we performed only routine EMG studies in our study, we did not examine C-fibre functions. We diagnosed radiculopathy according to the needle EMG studies. Our aim was to establish an association between radiculopathy and LSC, working on the assumption that the C fibres could have been affected in patients with nerve-root compression or peripheral neuropathy. In the literature, the mean duration of local pruritus has been variously reported as 16–50 months, 2,3 but in these studies, the relationship between pruritus dura- tion and radiculopathy was ignored. In our study, the mean duration of pruritus was 22.9 ± 21.4 months (range 1–60) and prevalence of radiculopathy in EMG studies was higher in patients who had pruritus for >12 months (P < 0.05). To our knowledge, our study is the first prospective study investigating the localization of LSC and corre- sponding radiculopathy in nerve-conduction studies and MRI scans, and also radiographic changes in a group of patients with LSC on the limbs. The main limitation of our study was the lack of a control group; this was because of the high cost of MRI and EMG studies and because their side-effects raise ethical issues about their use in people with no symptoms. Therefore, our findings should be supported with larger sampled and randomized controlled trials. In conclusion, we report an association between LSC on the limbs and chronic cervical or lumbar radiculopathy as measured using nerve-conduction studies and MRI. Both nerve-root compression in MRI and radiculopathy in nerve-conduction studies are common findings in asymptomatic subjects, but they seem to be more common in patients with LSC on the limbs, and indicate that neuropathy can play a critical role in the aetiology of this disorder. Derrmatologists should consider neuropathy as a reason for the presence of LSC on the limbs, especially if duration is >1 year, and such patients should be evaluated for the possibility of underlying neuropathy and radiculopathy.

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2008 The Author(s)

  • 480 Journal compilation 2008 Blackwell Publishing Ltd Clinical and Experimental Dermatology , 34, 476–480