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Year : 2020  |  Volume : 40  |  Issue : 2  |  Page : 124-129

A diagnostic conundrum: palmoplantar pits, lichen planus on histology lichen planus with a dermoscopic ‘Twist in the Tale’

1 Department of Dermatology, Rajawadi Hospital, Mumbai, Maharashtra, India
2 Department of Dermatology, Sion Hospital, Mumbai, Maharashtra, India

Date of Submission11-Aug-2019
Date of Acceptance02-Jan-2020
Date of Web Publication09-Jun-2020

Correspondence Address:
Tejas Vishwanath
Department of Dermatology, Rajiv Gandhi Medical College and Chhatrapati Shivaji Maharaj Hospital, Kalwa, Thane 400605, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejdv.ejdv_43_19

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A plethora of dermatologic conditions manifest as palmoplantar pits ranging from the relatively innocuous conditions like lichen planus, lichen nitidus, and keratosis punctata to more sinister ones like Cowden syndrome and Gorlin syndrome. Diagnosis generally depends on cutaneous and/or mucosal lesions. However, the occasional patient is encountered who does not manifest any other cutaneous features. In such cases, the diagnosis can only be reached by histopathology. We present two cases of isolated palmoplantar pits diagnosed as lichen planus on histopathology with intriguing dermoscopic findings in one case.

Keywords: dermoscopy, histopathology, lichen planus, palmoplantar pits

How to cite this article:
Vishwanath T, Ghate S, Shinde G, Sharma A, Nagpal A, Chaube S. A diagnostic conundrum: palmoplantar pits, lichen planus on histology lichen planus with a dermoscopic ‘Twist in the Tale’. Egypt J Dermatol Venerol 2020;40:124-9

How to cite this URL:
Vishwanath T, Ghate S, Shinde G, Sharma A, Nagpal A, Chaube S. A diagnostic conundrum: palmoplantar pits, lichen planus on histology lichen planus with a dermoscopic ‘Twist in the Tale’. Egypt J Dermatol Venerol [serial online] 2020 [cited 2020 Nov 24];40:124-9. Available from: http://www.ejdv.eg.net/text.asp?2020/40/2/124/286286

  Introduction Top

Isolated palmoplantar pits pose a diagnostic conundrum. The list of differential diagnoses is vast including keratosis punctata, porokeratosis, lichen nitidus (LN), lichen planus (LP), etc. [1].

LP is an inflammatory skin condition affecting around 1% of the population [2]. Palmoplantar lichen planus (PPLP) is a relatively uncommon variant. Types of PPLP are psoriasiform, punctate keratotic and ulcerative, among others [3]. The diagnosis becomes challenging in the absence of associated mucocutaneous features in which case histopathology comes to the rescue. Dermoscopy is a recent entrant in this regard, which may support clinical diagnosis (and occasionally surprise the clinician as in our case!).

Case history

Case 1–a 14-year-old man presented with asymptomatic thickened plaques with pits on both hands and inner side of the right foot since 6 months. These complaints were of gradual onset and were initially noted by the patient 1 year ago beginning on the palms. They then gradually increased in extent over the palms and also, a new plaque appeared on the inner side of the right foot. There were no systemic complaints or evidence of any coexisting, contributory, or any other illness associated with palmoplantar pits. Examination showed discrete and agminate keratotic pits some of which were on hyperkeratotic plaques on both palms ([Figure 1]), wrist flexors ([Figure 2]), dorsa of interphalangeal joints ([Figure 3]), and medial right foot ([Figure 4]). No other abnormality was noted.
Figure 1 Keratotic plaques on the palm with agminate and discrete pits.

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Figure 2 Close-up view of keratotic pits on the wrist flexure.

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Figure 3 Keratotic pits on the dorsa of interphalangeal joints.

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Figure 4 Pitted keratotic plaque on the foot.

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Case 2–a 33-year-old man presented with discrete asymptomatic pits on both hands ([Figure 5] and [Figure 6]) and left foot ([Figure 7] and [Figure 8]) since 5 years with hyperpigmentation around the pits. As in case 1, these lesions were of gradual onset and had increased over these 5 years. No other lesions were noted elsewhere on the body. There was no evidence of any other systemic or associated illness and the patient was otherwise healthy.
Figure 5 Discrete pits with hyperpigmentation on both palms.

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Figure 6 Close-up view of pits on the palm

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Figure 7 Pits with hyperpigmentation on the sole.

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Figure 8 Close-up view of pits on the sole. Hyperpigmentation surrounding the pits is obvious.

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Differential diagnosis included palmoplantar porokeratosis, punctate PPLP, LN, keratosis punctata, and Buschke–Fischer–Brauer syndrome.

Histopathologic examination in both cases showed irregular acanthosis ([Figure 9]) and focal liquefactive degeneration of the stratum basale with exocytosis ([Figure 10]). Lymphocytic infiltrate was noted in the upper dermis abutting the basal layer ([Figure 9] and [Figure 11]). Also, a keratotic plug was noted overlying hypogranulosis ([Figure 11] and [Figure 12]), which clinched the diagnosis of punctate keratotic PPLP.
Figure 9 Irregular acanthosis, lichenoid (top heavy) inflammatory infiltrate (×10, hematoxylin and eosin).

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Figure 10 Basal layer vacuolization, exocytosis of lymphocytes into the lower epidermal layers, and effacement of junction between the dermis and the epidermis (×40, hematoxylin and eosin).

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Figure 11 Parakeratotic plug with the underlying agranulosis, top heavy lichenoid infiltrate (×10, hematoxylin and eosin).

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Figure 12 Close-up of keratotic plug (×40, hematoxylin and eosin).

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Dermoscopy (Dino-lite, polarized mode) was performed later in case 1, but case 2 was lost to follow-up.

Surprising dermoscopic features included a double-edged scale around follicular plugs ([Figure 13]) reminiscent of (actinic) porokeratosis. Some foci showed diffuse erythema ([Figure 14]), suggesting the involvement of a deeper component in the inflammation and active disease. Serial recuts and reconsultation with the histopathologist reconfirmed histopathologic diagnosis of punctate keratotic PPLP, presenting with some dermoscopic features of porokeratosis which is unusual.
Figure 13 Dermoscopy showed the double-edged scale (black arrow), keratotic plugs (blue arrow).

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Figure 14 Diffuse erythematous background suggesting active disease.

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Case 1 has been started on Clobetasol 0.05% cream under occlusion and oral Acitretin 25 mg per day. Response to treatment is awaited.

  Discussion Top

Many dermatologic conditions manifest as palmoplantar pits including LP (LN), punctate palmoplantar porokeratosis, etc. [1]. Porokeratosis, LP, and LN are especially notable as the morphology of palmoplantar lesions differs substantially from classic lesions at other body sites.

The frequency of PPLP varies between series between 3.5% (palms) and 4.5% (soles) [4] to 12.9% [3]. The most common type of PPLP was psoriasiform followed by lichenoid, eczematous, punctate keratotic, and ulcerative variants [3].

Histopathologic features (observed in both our cases) are similar to LP elsewhere (and are relatively uniform among the variants of PPLP), including irregular acanthosis, basal layer liquefactive degeneration, and upper dermal lymphohistiocytic infiltrate [3]. However, unlike acrosyringeal lichen LP [5], interface dermatitis and basal layer vacuolization were not exclusively restricted to the acrosyringeal basal layer in our cases.

In case 1, however, we were unable to reconcile dermoscopic and histopathologic findings partly as we were unable to find articles related to dermoscopy of punctate PPLP in the literature. In particular, the keratotic plug (observed on histopathology) reminiscent of coronoid lamella and double-edged scaling [6] were reminiscent of porokeratosis. The dermatopathologist, however, reiterated the diagnosis of PPLP based on past review of literature [5],[7]. It was agreed by both dermatopathology and dermoscopy consultants that the dermoscopic findings are noteworthy and unusual.

Since the closest differential remained porokeratosis, literature search now assumed that direction revealing a case of porokeratosis morphing into LP [8] along with certain commonalities with LP on histopathology [9].

We found relatively few reports on dermoscopy of PPLP. Rounded-stellate yellowish areas on a violaceous background with dotted, globular, and linear vessels in active disease are described [10]. However, these are not described specifically for punctate keratotic PPLP and none of these features was noted in our patient. To the best of our knowledge, there is no mention of a double-edged scale made in any variant of LP. Actinic porokeratosis shows a scale attached at the inner and outer borders of the scaling edge, indicating bidirectional peeling reminiscent of our case though our case was clearly not actinic porokeratosis [6]. We found a single case report wherein a volcano crater-like appearance and white track appearance were described with tan central globules [11]. However, in our case, we were clearly able to appreciate central keratotic plugs (which may represent keratotic plugs of PPLP or coronoid lamellae). No crater was observed. All this begs the question: Are punctate keratotic PPLP and punctate palmoplantar porokeratosis part of the same spectrum or is double-edged scaling a feature of punctate keratotic PPLP? Observation of more such cases may yield interesting findings in the future.

A comparison of common clinical and histopathologic features of differential diagnoses considered in our case is presented in [Table 1].
Table 1 Main considerations in the differential diagnosis of palmoplantar pits

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Our case had no abnormality elsewhere on the body making diagnosis relatively challenging.

Treatment includes topical potent steroids, salicylic acid preparations, and oral Acitretin [7],[12], but no definite protocols exist.

  Conclusion Top

We present these cases in view of the relatively rare clinical presentation with striking dermoscopic findings. Isolated PPLP may masquerade as punctate palmoplantar porokeratosis and poses a diagnostic challenge. Histopathology will clinch the diagnosis. But dermoscopy may surprise the clinician and provide a new perspective. More observations are needed to compare dermoscopic features of different diseases with palmoplantar pits.

What’s new − dermoscopy may be an adjunct in the diagnosis of punctate keratotic PPLP. We have described unusual dermoscopic findings that need to be looked for and corroborated in larger case series.


Dr Uday Khopkar, Ex-Professor and Head, Department of Dermatology, KEM Hospital (for guidance on Histopathology).

Lt Col (Dr) Shekhar Neema, Associate Professor, Department of Dermatology, Armed Forces Medical College, Pune-411040 (for guidance on dermoscopy).

Presentation at a meeting: Annual clinical meet, Department of Dermatology, Sion Hospital, Mumbai.

Place: Sion Hospital, Mumbai-400077.

Date: June 28, 2019.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

De D, Narang T, Dogra S, Kanwar A. Asymptomatic palmar pits: clinical evaluation of six cases and review of the literature. J Cutan Med Surg 2008; 12:198–202.  Back to cited text no. 1
Sripathi H, Kudur MH, Prabhu S, Pai SB. Punctate keratotic papules and plaques over palm. Indian J Dermatol Venereol Leprol 2010; 76:449.  Back to cited text no. 2
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Kachhawa D, Kachhawa V, Kalla G, Gupta L. A clinicoaetiological profile of 375 cases of lichen planus. Indian J Dermatol Venereol Leprol 1995; 61:276–279.  Back to cited text no. 4
Gutte RM. Unilateral acrosyringeal lichen planus of palm. Indian Dermatol Online J 2013; 4:350–352.  Back to cited text no. 5
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Munro C, Cox N, Marks J, Natarajan S. Lichen nitidus presenting as palmoplantar hyperkeratosis and nail dystrophy. Clin Exp Dermatol 1993; 18:381–383.  Back to cited text no. 13
Yancovitz M. Keratosis punctata palmaris et plantaris treated with topical fluorouracil. Arch Dermatol 2006; 142:1065.  Back to cited text no. 14
Antonio JR, Oliveira GB, Rossi NCP, Pires LGG, Oliveira GB. Exuberant clinical picture of Buschke-Fischer-Brauer palmoplantar keratoderma in bedridden patient. An Bras Dermatol 2014; 89:819–821.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]

  [Table 1]


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