skINsight

SECTION EDITOR: JAMES M. GRICHNIK, MD, PhD

A Novel Visual Clue for the Diagnosis

of Hypertrophic Lichen Planus
John Patrick Welsh, MD; Christopher B. Skvarka, MD; Herbert B. Allen, MD;
Department of Dermatology, Drexel University College of Medicine, Philadelphia, Pa

D
ERMATOLOGY HAS AN ILLUSTRIOUS HISTORY valued visual clue in the armamentarium against dermato-
of formulating visual clues to facilitate di- logic disease.
agnosis of oft-confused conditions. From 1. Kossard S, Thompson C, Duncan G. Hypertrophic lichen planus-like reac-
the opulent (“crown-of-jewels”) to the tions combined with infundibulocystic hyperplasia. Arch Dermatol. 2004;
140:1262-1267.
mundane (“apple jelly”), dermatologists 2. Castano E, Lopez-Rios F, Alvarez-Fernandez J, et al. Verrucous carcinoma in as-
have consistently drawn inspiration from the physical world sociation with hypertrophic lichen planus. Clin Exp Dermatol. 1997;22:23-25.
3. Boyd AS, Nelder KH. Lichen planus. J Am Acad Dermatol. 1991;25:593-619.
when classifying disease. We intend to add to this litera- 4. MacKenzie WS, Donaldson CH, Guilford C. Atlas of Igneous Rocks and Their
ture by submitting a novel visual clue to aid in the diagno- Textures. Essex, England: Pearson Education Ltd; 1982.
sis of hypertrophic lichen planus.
Given a causal linkage with the hepatitis C virus and re-
cent case reports of malignant transformation, hypertrophic
lichen planus requires astute and careful consideration.1,2
The condition is marked by firm, elevated, hyperkeratotic,
red-brown to purple-gray plaques with chalky-white scale
and follicular accentuation that imparts a geologic appear-
ance to affected skin (Figure 1). Lesions thus bear a strik-
ing resemblance to the extrusive (or rapidly cooled) vari-
ants of igneous rock (Figure 2), characterized by a
fine-grained (or aphanitic) texture with the occasional ve-
sicular (pocked) surface and variable colors from dark pink
to gray-black.3,4 The igneous rock sign has been a useful
adjunct in several cases (Figure 3) to help differentiate hy-
pertrophic lichen planus from other members of the papu-
losquamous differential, and we hope that it becomes a
Figure 2.

Figure 1. Figure 3.

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