# Skin Diseases of Children/Lichen Ruber and Lichen Planus

Plate XI
Lichen ruber
(Pityriasis rubra pilaris)
From the collection of photographs of Dr. George Henry Fox.
LICHEN RUBER AND LICHEN PLANUS.
Lichen ruber, or pityriasis rubra pilaris as it is called by many writers, is a rare disease, but one which is liable to affect children as well as adults. It is a chronic and obstinate disease, in which the lesions are small, reddish, acuminate papules,
Fig. 43.—Papular form of lichen ruber.
usually seated at the orifice of hair follicles. These do not increase in size, but by multiplying and coalescing produce patches covered by fine, whitish scales and characterized by an exaggeration of the natural furrows of the skin.
​The eruption often undergoes a spontaneous improvement,
Fig. 44.—Papules on a favorite site.
Fig. 45.—Plantar lichen ruber resembling eczema.
but only to relapse, and, as a consequence of this, its clinical ​appearance varies greatly at different times and often upon
Fig. 46.—Lichen ruber resembling ichthyosis.
Fig. 47.—Lichen ruber resembling psoriasis.
various portions of the body. Three stages or clinical forms ​of the eruption may be conveniently described as the papular, squamous, and rugous forms of the disease.
In the papular form of lichen ruber (Figs. 43 and 44) the lesions are small, usually acuminate, and often tipped with a minute white scale. When of recent development they produce an appearance quite similar to cutis anserina or follicular keratosis. Upon the dorsum of the fingers there is often noted a group of follicles plugged with blackened epidermic scales, while upon the palms and soles a scaly condition is usually pres-
Fig. 48.—Rugous form of lichen ruber.
ent, closely resembling a chronic squamous eczema (Fig. 45). The papules often increase rapidly in number upon certain portions of the body, become flattened and scaly as they coalesce, and now present an entirely different aspect.
In the squamous form of lichen ruber the eruption appears as white, scaly patches of varying size and form, and frequently bears a strong resemblance to ichthyosis (Fig. 46) or psoriasis (Fig. 47). The eruption in this stage shows a marked tendency to occur in elongated, spindle-shaped, or band-like patches. ​At the margin of these squamous patches numerous isolated, white-tipped papular lesions may frequently be seen. The scalp is generally affected when the disease has existed for some time, and the face often presents an appearance suggestive of ichthyosis.
In the rugous form or stage of the disease the affected portions of skin present a dull-red, leathery appearance, with slight scaling and deep parallel furrows (see plate and Fig. 48). Upon the hands the skin sometimes becomes shrivelled and drawn to an extent which seriously interferes with the motion of the fingers (Fig. 49), while the nails show marked evidence of malnutrition. In some cases nodular ridges are found at the bend
Fig. 49.—Chronic form of disease.
of the elbow, upon the pubes, and elsewhere, and present a moniliform or bead-like appearance (Fig. 50).
Itching is commonly present, and often very severe and annoying in advanced cases, and an exacerbation of the eruption is frequently preceded by an intense burning sensation.
The prognosis in lichen ruber is an unfavorable one. Although the disease may yield to judicious treatment, and even improve spontaneously, a long series of relapses may be looked for, and a fatal termination be predicted in many cases. The reported cure of cases by French and German writers may be readily explained by their belief in the identity of lichen ruber and lichen planus.
​From what has been said it is evident that the treatment of this disease must of necessity be palliative rather than curative. The improvement of the patient's general health by a hygienic and tonic regimen will usually accomplish more than the administration of arsenic or any other drug. Meanwhile the comfort of the patient can be greatly increased by baths and inunctions tending to soften the dry, harsh skin and to lessen the pruritus.
Lichen planus is a disease which is entirely distinct in nature
Fig. 50.—Moniliform lichen ruber.
from lichen ruber, although the two affections have been considered as clinical forms of the same disease by many European writers. This erroneous view has led to considerable confusion of dermatological literature. The typical lesions of lichen planus are small, flattened, angular papules with a shining surface and a minute central depression. Those of lichen ruber, on the other hand, are usually acuminate, although in rare cases they may appear flattened and smooth. The eruption in lichen planus commonly presents a purplish or lilac hue, which is very ​characteristic and often serves as an excellent basis of diagnosis. The lesions are at first discrete, but show a marked tendency to coalesce and form irregular or reticulate patches of varying
Fig. 51.—Lichen planus.
size. The most common site of the eruption is upon the anterior aspect of the forearm and next upon the lower extremities. It is often seen around the waist and sometimes upon the
Fig. 52.—Lichen planus.
genitals. In exceptional cases the greater portion of the trunk may be affected, and such cases are very apt to be confounded with lichen ruber. Upon the legs the patches are frequently ​roughened and pigmented, and present an appearance quite unlike the eruption seen upon the trunk and forearms.
Lichen planus runs a variable course, some cases disappearing spontaneously and often unexpectedly after an existence of a month or two, while others will sometimes persist for many months in spite of the most approved method of treatment. The itching is often very annoying to the patient, but the general health is usually unimpaired, and, unlike lichen ruber, the disease never terminates fatally.
Fig. 53.—Lichen planus.
In the treatment of lichen planus arsenic is often of service, but in this, as in many other affections, it may do harm as well as good; and when there is much irritability of the skin alkaline remedies will be found to be of much greater service. Of the various local remedies which have been highly recommended no one seems to have any special value in all cases. A mild carbolic or salicylic acid lotion may be advantageously used in acute cases, and the same increased in strength when the patches have assumed a chronic character.