Wednesday, December 9, 2015

45-year-old woman presents to clinic with a new pruritic rash

A 45-year-old woman presents to clinic with a new pruritic rash on the flexor
surface of her left forearm. Her medical history is significant for Wilson disease,
and she was recently started on penicillamine, a copper-chelator. 

On exam she has Kayser-Fleischer rings in both eyes and purple, polyangular papules on
her left forearm. On closer inspection, fine white streaks cover the surface
of the papules. A clinical diagnosis of lichen planus is made.

Penicillamine is discontinued. What is the best treatment option at this time?

A. Oral steroids
B. Oral antihistamine
C. Topical steroids
D. Azathioprine
E. B and C only

The answer is E: B and C only.
This patient has lichen planus (LP) as a cutaneous inflammatory reaction to penicillamine. Clinical identifiers for LP include the Four Ps (purple, polygonal, pruritic, papules), as well as Wickham striae, the fine white lines covering the papules.

Other drug exposures that have been linked with LP include gold, chloroquine, and methyldopa. This is a local rash, so the best initial treatment would be topical steroid and oral antihistamine for relief from itching (E). Oral steroids and more potent immune modulators (azathioprine, cyclosporine) should be used with more generalized, systemic LP.


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