Astemizole

Abstract

A 32-year-old Philippino male presented to the clinic with a penile rash of 2 months duration. The rash was diagnosed as lichen nitidus and was successfully treated with the non-indicated therapy of Protopic 0.1% (Tacrolimus) for 4 weeks.

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Introduction

Lichen nitidus is a dermatologic condition, first described in 1907 by Pinkus, characterized by numerous, discrete, tiny, flesh-colored, papular eruptions most often localized to the upper extremities, genitalia, chest, and abdomen (1,2). The papular lesions tend to be asymptomatic, but may present mildly pruritic in nature (2). The Koebner phenomenon has been observed in many cases (1).

The etiology of lichen nitidus is unknown and the course seems to be variable, ranging from spontaneous remission to chronic manifestations. Treatment of the condition has utilized therapies to include topical and systemic corticosteroids, light therapy with systemic corticosteroids, astemizole, acitretin, dinitrochlorobenzene, and low-dose cyclosporine (3).

We describe the first case, to our knowledge, of successful treatment of lichen nitidus with the topical therapy of Protopic 0.1% (Tacrolimus).

Case Report

A 32-year-old Philippino male was referred to the clinic for a rash-like skin condition of 2 months duration involving his penis. The patient described the lesions as slightly pruritic, but was most concerned about the cosmetic appearance of the lesions. The patient had a benign past medical history and was not taking any medications at the time of the exam. On examination the rash was described as numerous, shiny, tan, papules measuring 1-2 mm on the glans and shaft of the penis (Figure 1). Biopsy of one of the lesions revealed a dermal papule with overlying epidermal atrophy and a parakeratotic horny layer. A well circumscribed lymphohistiocytic infiltrate was seen in the papillary dermis, surrounded by elongated rete ridges, forming the "ball and claw" characteristic of lichen nitidus (Figure 2). The therapeutic option of topical corticosteroids was given to the patient and he refused this therapy because of the potential side effects. The patient was then offered the off-label use of Protopic for his condition, which he accepted. Protopic was to be applied to the affected area twice daily for 4 weeks.

On the follow-up visit 4 weeks later, the condition had resolved and the patient has not returned to the clinic after 4 months.

Discussion

Lichen nitidus in our patient was of the usual presentation described in the literature, although localized penile lichen nitidus may be under-reported in the literature. This may be explained by patients not seeking medical attention because of embarrassment of the location of their condition and the usual asymptomatic nature of the condition.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Our patient was offered topical corticosteroids for treatment, however, because of the potential side effects--skin atrophy and telangiectasias--he declined therapy. Protopic was offered because of its unique immunomodulatory effects by inhibiting calcineurin, leading to an inhibition of several proinflammatory cytokines including interleukin 2 and tumor necrosis factor alpha (4). The patient was receptive to this therapy because of its non-steroid profile as compared to the topical steroids. Protopic has typically been used to treat numerous types of acute and chronic dermatoses. In this case, Protopic seemed to be a good alternative therapy because of its mechanism of action and the pathological process of lichen nitidus involving chemotactic induced inflammation and lymphoproliferation. The results of the therapy were successful and it may be concluded that lichen nitidus may be another candidate dermatological condition for Protopic.

References

1. Ocampo J, Torne R. Generalized lichen nitidus. Int J Dermatol. 1989; 28(1):49-51.

2. W, et al. Generalized lichen nitidus. J Am Acad Dermatol. 1997; 36(4):630-1.

3. Kano Y, et al. Improvement of lichen nitidus after topical dinitrochlorobenzene application. J Am Acad Dermatol. 1998; 39(2):305-8.

4. Assmann T, et al. Tacrolimus ointment for the treatment of vulvar lichen sclerosis. J Am Acad Dermatol. 2003; 48(6):935-7.

CPT CLIFTON R DOBBS MC USA, LCDR SEAN J MURPHY MC USN

DEPARTMENT OF DERMATOLOGY, WALTER REED ARMY MEDICAL CENTER WASHINGTON DC

ADDRESS FOR CORRESPONDENCE:

LCDR Sean J. Murphy MC USN

Walter Reed Army Medical Center

Department of Internal Dermatology

6900 Georgia Avenue, NW

Washington DC 20307

Phone: (202) 782-6173

Fax: (202) 782-9118

E-mail: Sjmurphy@bethesda.med.navy.mil

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