Susan M. Cooper

Erosive lichen planus of the vulva (ELPV) is a chronic inflammatory, scarring disease and a variant of classic lichen planus. It is characterized by painful vulval introital erosions, edged by a reticulate white border extending into the vagina. The presence of mucosal disease distinguishes lichen planus (LP) from lichen sclerosus, in which vaginal involvement almost never occurs. Scarring may result in marked architectural change with loss of the labia minora, clitoral burying, and narrowing of the introitus. In the presence of oral and vaginal disease, ELPV has been termed the vulvovaginal-gingival syndrome.¹ However, not all patients have involvement of all 3 sites; some have vulval and vaginal disease without oral disease, vulval and oral disease without vaginal disease, or vulval disease alone.

The objective of this study was to investigate whether circulating basement membrane zone (BMZ) antibodies are present in erosive lichen planus (LP) of the vulva. In total, 56 consecutive women with biopsy‐confirmed erosive LP of the vulva were recruited from a vulval clinic in a district general hospital and teaching hospital in Oxfordshire. Indirect immunofluorescence (IgG and IgA) was performed on 56 sera, and 15 were tested to IgG subclasses (1–4). Immunoblotting was carried out on salt‐split and urea‐extracted epidermal skin extracts on 11. The main outcome measure was the presence or absence of staining at the BMZ. Of the 56 sera, 34 (61%) had weak (neat or 1 : 5) epidermal‐binding BMZ antibodies (25 had IgG, 5 had IgA, 4 had both IgG and IgA). All 15 sera tested to IgG showed epidermal binding to one or more IgG subclasses: IgG1 (7 sera), IgG2 (7), IgG3 (7) and IgG4 (0). Immunoblotting identified IgG antibodies to bullous pemphigoid (BP)180 (10/11) and BP230 (2/11). The majority (61%) of patients with vulval erosive LP had circulating serum IgG BMZ antibodies, chiefly reacting with BP180. There was subclass restriction of the IgG response to IgG1, 2 and 3. The significance of these antibodies is uncertain, but they may be a marker for the disease.

Histopathology demonstrates disruption of the basal layer of the epidermis in lichen planus (LP) and altered expression of basement membrane zone (BMZ) components occurs in cutaneous and oral LP. This is the first study in erosive LP of the vulva to investigate the expression of components of the BMZ and extracellular matrix by indirect immunofluorescence. Six biopsies from lesional vulval erosive LP were compared with two biopsies from normal vulva and five biopsies from normal skin. In erosive vulval LP there was widespread disruption of several BMZ components compared to normal skin. The hemidesmosome antigens were disrupted and attenuated, or absent. Expression of lamina lucida proteins and anchoring filaments also showed some alteration. Lamina densa components were altered and in particular there was very marked thickening, streaking and fragmentation of the anchoring fibrils. Some dermal extracellular matrix proteins were increased. This study has demonstrated widespread damage to the BMZ in erosive LP of the vulva, in particular the hemidesmosomes (α6β4 integrin, BP230, BP180) and anchoring fibrils (collagen VII). This suggests an alteration in antigenic expression in the BMZ that may lead to exposure of epitopes and thus make these proteins vulnerable to attack by autoantibodies.

Lichen sclerosus (LS) is a chronic inflammatory and scarring disease that preferentially affects the anogenital site,¹ although any cutaneous site may be affected, including the oral mucosa. Lichen sclerosus is 6 to 10 times more prevalent in the female than in the male population,¹ and although an infectious etiology has been proposed and an autoimmune etiology recognized, its cause is unknown. The presence of circulating IgG antibodies to extracellular matrix protein 1 has recently been demonstrated in 67% of patients with LS, but it is unknown whether these antibodies are secondary or pathogenic.² A recognized association with autoimmune disease^3,4 and human leukocyte antigen DQ7 in women⁵ and girls⁶ with LS suggests a genetic component to the disease.

We have described two females with extensive freckling and scaly lesions and conclude that they have a widespread form of Grover's disease associated with lentiginous sun‐induced ‘freckling’. We report these cases to draw attention to an unusual pattern of Grover's disease that can simulate Darier's disease.

Leg ulcers are a common health problem. Ulcers of any etiology including venous ulcers may be very painful, but until recently, health professionals have not been good at recognizing or managing this type of pain. It is important to clarify the type, severity, and frequency of pain and to anticipate pain at dressing changes. The measurement of pain by the use of pain scales is very useful, particularly in assessing the efficacy of an intervention. Neuropathic pain and unusually painful ulcerations are discussed in this article.

Photo‐damage of the head and neck was assessed, by visual inspection, in 82 Northern European renal transplant recipients attending a dermatology clinic. Photo‐damage was graded as absent, mild, moderate and severe and the presence or absence of skin telangiectasia, solar elastosis, erythema and pigmentation was assessed. The duration and type of immunosuppressant and calcium channel blocker medication was recorded. Ninety percent had photo‐damaged skin with 41 (50%) having mild photo‐damage, 20 (24%) moderate photo‐damage and 13 (16%) severe photo‐damage. Sixty‐two (76%) had pigmentation, 43 (52%) telangiectasia, 65 (79%) papular changes and 51 (65%) erythema. Fifty‐three patients (65%) had received a calcium channel blocker (49 nifedipine, four amlodipine). The grade of photo‐damage was strongly associated with use of calcium channel blockers (P = 0.001) as was the presence of telangiectasia (P = 0.001) and solar elastosis (P = 0.04). Photo‐damage is frequent in this population of renal transplant patients. Telangiectasia in association with calcium channel blockers has been reported rarely but appears to be common in the transplant population.

Mycosis fungoides is a form of cutaneous lymphoma with a typically indolent course. We describe an unexpected, repeated response to a systemic antifungal agent, itraconazole. The mechanism of action is speculative but itraconazole has marked immunosuppressive activity on T‐lymphocyte proliferation in vitro.