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 2071] with LSC on the limbs were
included in the study. Mean SD duration of disease was 22.86 21.38 months
(range 160). Radiography, magnetic resonance imaging (MRI) and electrophysiological 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 nerveroot 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 neuroCorrespondence: 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

476

dermatitis circumscripta, is characterized by circumscribed, 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)

Journal compilation  2008 Blackwell Publishing Ltd Clinical and Experimental Dermatology, 34, 476480

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 v2 test and Fishers 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 2071).
Mean duration of pruritus was 22.86 21.38
months (range 160). 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 4565 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 4565 years, one aged > 65 years).
Table 1 Neurological examination results in patients with and
without radiculopathy in electromyography.
Radiculopathy
Positive
(n = 9)

Muscle
Normal
Weakness
Sensation
Normal
Hypoaesthesia
Hyperaesthesia
DTR
Normoactive
Hypoactive
Hyperactive

Negative
(n = 14)

88.9
11.1

8
1

100.0
0.0

14
0

NS

88.9
11.1
0.0

8
1
0

78.6
14.3
7.1

11
2
1

NS

66.7
22.2
11.1

6
2
1

78.6
21.4
0.0

11
3
0

NS

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

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477

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)

Radiography
Normal
Degenerative
MRI
Normal
Disc herniation
Nerve-root compression

Patient
no.
Results of EMG studies
Negative
(n = 14)

33.3
66.7

3
6

71.4
28.6

10
4

NS

0.0
66.7
33.3

0
6
3

50.0
42.9
7.1

7
6
1

NS

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%) secondary to disc extrusion and disc herniation (bulging or
protrusion) in four patients (50%) (age range 4558).
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 5065 years), protrusion
in one (6.7%) (aged 47 years) and nerve-root compression in three (20%) (age range 4565 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 radiculopathy. 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 neuropathy 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

478

Table 3 Interpretation of nerve conduction and electromyography

studies in 23 patients with local pruritus.

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

Normal
Normal
Radiculopathy
Normal
Normal
Radiculopathy
Normal
Axonal neuropathy
Radiculopathy
Normal
Normal
Radiculopathy
Radiculopathy
Radiculopathy + demyelinating
peripheral neuropathy
Demyelinating peripheral
neuropathy
Normal
Normal
Radiculopathy
Normal
Radiculopathy
Radiculopathy
Normal
Normal

Corresponding Pruritus
disc
dermatome

L5 and S1

S1

L4

C7
C8
L5, S1

C6
L4, L5
L5
L1
C5
S1, S2
C6, C7
L4, L5, S1
L4, L5, S1
C5, C6
L3, L4, L5
C7
C7, C8
L5, S1
L4, L5

C6
L4
L4, L5

L5, S1
C7, C8
C6, C7
L4
L4, L5, S1
L4, L5
S1
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 skins 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)

Journal compilation  2008 Blackwell Publishing Ltd Clinical and Experimental Dermatology, 34, 476480

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
2
3
4
5
6
7
8

F 50
M 28
F 36
M 53
F 44
F 20
F 36
M 65

)
)
+
)
)
+
)
)

9
10
11
12
13
14

F 29
F 45
M 48
M 58
F 71
M 67

+
)
)
+
+
+

15

M 58

16
17
18

F 32
F 38
F 63

)
)
+

19
20
21
22
23
Total

F 56
F 50
F 55
M 28
F 47

)
+
+
)
)
9 23
(39.1%)

Mild axonal
neuropathy

Demyelinating
peripheral
neuropathy
Demyelinating
peripheral
neuropathy

Carpal tunnel
entrapment in
EMG studies

4 23 (17.4%)

C6
L4, L5
L5
L1
C5
S1, S2
C6, C7
L4, L5, S1
L4, L5, S1
C5, C6
L3, L4, L5
C7
C7, C8
L5, S1

L4, L5

L5, S1
C7, C8
C6, C7

L4
L4, L5, S1
L4, L5
S1
L4, L5

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 4554 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 5065 years), protrusion in
one (6.7%) (aged 47 years) and nerve-root compression
in three (20%) (age 4565 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 neuropathy, such as chronic cervical or lumbosacral radiculopathy, 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 tumour15, 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 carpaltunnel 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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Journal compilation  2008 Blackwell Publishing Ltd Clinical and Experimental Dermatology, 34, 476480

479

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 peripheral 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 electrophysiological studies were demyelinating peripheral neuropathy 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 1650 months,2,3 but in
these studies, the relationship between pruritus duration and radiculopathy was ignored. In our study, the
mean duration of pruritus was 22.9 21.4 months
(range 160) 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 corresponding 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.

480

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 2008 The Author(s)

Journal compilation  2008 Blackwell Publishing Ltd Clinical and Experimental Dermatology, 34, 476480