Unilateral acrosyringeal lichen planus of palm
A 30-year-old male presented with multiple, discrete asymptomatic punctate keratoses and pits over left palm since one month. These lesions were gradual in onset and progressive in nature. There was no history of vesiculation or oozing or of similar lesions elsewhere on the body. Examination revealed multiple tiny pits some containing keratotic plugs []. Mild scaling was seen at the edges and some of the plugs also showed collarette scaling. No other skin lesions were seen on the body. Nails and oral mucosa were normal. There was no history of any other systemic or skin disease. There was no history of any drug intake prior to lesions.\nA diagnosis of palmar lichen nitidus, LP and pompholyx was thought and a skin biopsy was obtained from a representative lesion.\nHistopathological examination revealed compact orthokeratosis, focal parakeratosis, hypergranulosis, irregular slightly saw-tooth acanthosis with focal vacuolar alteration of basal layer with degeneration of basement membrane and few necrotic keratinocytes. In papillary dermis, band-like dense lymphocytic infiltrate mainly in juxtaposition to the acrosyringium with sparing of surrounding epidermis was seen. Liquefaction degeneration of the acrosyringeal basal cell layer with a dilated acrosyingium having a parakeratotic plugs were seen as prominent finding [Figures and ]. A dilated acrosyringium with parakeratotic plug on histology, explained punctate keratoses seen clinically. However, even on multiple step sections, epidermal perforation could not be found. Thus probably spontaneous shedding of parakeratotic plugs was speculated as a cause of pits seen clinically. On clinicopathological correlation, a diagnosis of acrosyringeal LP of palm was made. Patient is advised to apply topical clobetasol and 3% salicylic acid cream twice daily along with moisturizers and is under follow-up.