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| ONLINE ONLY ARTICLES - LETTER TO EDITOR |
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| Year : 2022 | Volume
: 6
| Issue : 2 | Page : 154 |
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A facial micropapular variant of polymorphous light eruption: An infrequently reported entity
Preema Sinha1, Veena Kharayat2, Deep Kumar Raman3, Manoj Gopal Madakshira3
1 Department of Dermatology, Base Hospital, Lucknow, Uttar Pradesh, India
2 Department of Dermatology, Military Hospital, Jabalpur, Madhya Pradesh, India
3 Department of Pathology, Command Hospital, Lucknow, Uttar Pradesh, India
| Date of Submission | 08-Sep-2021 |
| Date of Decision | 31-Jan-2022 |
| Date of Acceptance | 06-Jun-2022 |
| Date of Web Publication | 26-Aug-2022 |
Correspondence Address:
Veena Kharayat
Department of Dermatology, Military Hospital, Jabalpur - 482 001, Madhya Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cdr.cdr_69_21
How to cite this article:
Sinha P, Kharayat V, Raman DK, Madakshira MG. A facial micropapular variant of polymorphous light eruption: An infrequently reported entity. Clin Dermatol Rev 2022;6:154 |
How to cite this URL:
Sinha P, Kharayat V, Raman DK, Madakshira MG. A facial micropapular variant of polymorphous light eruption: An infrequently reported entity. Clin Dermatol Rev [serial online] 2022 [cited 2023 Feb 3];6:154. Available from: https://www.cdriadvlkn.org/text.asp?2022/6/2/154/354760 |
Sir,
Polymorphous light eruption (PMLE) is one of the most common forms of acquired idiopathic photodermatoses. Clinically, PMLE manifests mostly in Caucasians, as multiple pruritic polymorphic eruptions such as erythematous papules, vesicles, vesiculopapules, papulobullous, plaques, or eczematous such as lesions usually symmetrically distributed on light-exposed areas of the skin.
A variant of PMLE, micropapular PMLE or pinpoint papular PMLE (PP-PMLE), has been described in the literature in persons of Asian descent, as multiple skin-colored to hypopigmented, shiny, and tiny pinpoint papules on photo-exposed areas. This entity remains underrecognized and is usually missed or underdiagnosed in the routine outpatient department due to its atypical morphological features. Herein, we present a case of facial micropapular PMLE in a young female.
A 32-year-old female presented with complaints of recurrent episodes of multiple pinpoint shiny skin-colored raised lesions on the face of 18-month duration. The lesions were insidious on the onset, aggravated on sun exposures, and were occasionally associated with mild itching.
General physical and systemic examination was essentially normal. Dermatological examination revealed multiple, numerous to count, discrete, closely set, shiny, skin-colored and few slightly erythematous, pinhead-sized papules, symmetrically distributed on the face, predominantly over the forehead, bilateral malar area, and temples and nose. There was relative sparing of the perioral area and chin [Figure 1] and [Figure 2]. | Figure 1: Multiple, numerous, discrete, closely set, shiny, skin-colored and few slightly erythematous, pin head-sized papules over the right side of the face
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 | Figure 2: Multiple, numerous, discrete, closely set, shiny, skin-colored and few slightly erythematous, pin head-sized papules over the left side of face
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Clinically, a differential diagnosis of milia, papular mucinosis, eccrine hidrocystoma, lichen nitidus, and photodermatitis was considered.
Her hematological and biochemical investigations were normal. Histopathology of the lesions showed slightly atrophic thinned-out orthokeratotic epidermis with loss of rete pegs, basal vacuolation, and koilocytic changes. Superficial dermis showed abundant melanophages and sparse perivascular lymphocytic infiltrate. Histopathological features were consistent with chronic lichenoid dermatitis [Figure 3]. | Figure 3: H and E, ×200 shows basal vacuolar degeneration (black arrow) with upper dermis showing melanophages (white arrow)
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On the basis of the clinical and histopathological findings, a diagnosis of micropapular PMLE was made. She was managed with tablet hydroxychloroquine, topically with sunscreen, and topical 1% pimecrolimus cream to which she responded well.
Micropapular light eruptions or PP-PMLE is a variant of PMLE more often seen in darker skin types with a female preponderance.[1],[2],[3],[4],[5]
Etiopathogenesis of this entity is not clear, however, there seems to be a genetic predisposition in persons of the Asian subcontinent (particularly India, Japan, Singapore, and Taiwan), middle eastern, and African American descent and is precipitated and aggravated by sun exposure.[3],[4],[5],[6]
This entity has been reported in the literature under different designations or nomenclature such as “summertime actinic lichenoid eruptions” (SALE), “actinic lichen nitidus,” “lichen nitidus actinicus,” “micropapular light eruptions,” PP-PMLE, lichenoid pseudovesicular eruptions, and photosensitive spongiotic/lichenoid eruption of micropapules and plaques.[4],[5],[6],[7],[8],[9]
It was first described by Bedi et al., in 1978, under the term “SALE” in 25 Indian patients as multiple discrete pinpoint flesh-colored papules on a sun-exposed portion of the body appearing in summer times and improving with sun protection.[9]
Clinically, it is characterized by numerous monomorphic, pinpoint to pin head sized, closely aggregated papules, measuring 1–2 mm, usually shiny skin-colored to hypopigmented, and in a few cases slightly erythematous. These lesions appear symmetrically on photo-exposed areas most commonly reported on the extensor of the forearms, arms, nape of the neck, and upper back.[1],[2],[3],[4],[5],[6] Face is usually spared as per various studies and case reports, however, the face has been observed to be predominantly involved in Taiwan and Singaporean studies.[2] The lesions are either asymptomatic or mild-to-moderately pruritic. They appear within few hours to days of intense sun exposure and usually subside with 7–10 days on avoidance of sun and adequate sun-protective measures and use of mild topical steroids. Dermoscopy of the lesions shows bluish-white streaks in “fern leaf” like pattern in the background of brownish reticular network.[9]
Histopathology of these eruptions was earlier described as lichenoid tissue reaction classically appearing as “claw clutching a ball” with claw representing the elongated rete pegs and the ball representing the well-circumscribed lymphocytic infiltrate.[10]
However, recent studies have reported a varied histopathological spectrum of these eruptions. Four patterns have been described, the most common being spongiotic and lichenoid dermatitis, followed by psoriasiform dermatitis and perivascular lymphocytic infiltrate.[5]
Micropapular PMLE has been managed with sun avoidance, tablet hydroxychloroquine, short-course oral and topical steroids, tacrolimus, and pimecrolimus with good response.[9],[10]
This entity still remains to be underrecognized and missed or misdiagnosed partly due to its atypical morphological manifestation closely mimicking various other dermatoses, particularly on the face and partly because of the ambiguity arising from the different nomenclature designated to this entity in literature in various case reports and studies and its yet to be established nosological category. Some authors consider it a variant of lichen nitidus primarily because lichenoid reaction pattern observed in histopathological findings, while some consider it a variant of PMLE and propose to use the term micropapular light eruptions or pinpoint PMLE primarily because of the uniformity of clinical features of these lesions and their distributions among all patients irrespective of the pattern of histopathological findings.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Chiam LY, Chong WS. Pinpoint papular polymorphous light eruption in Asian skin: A variant in darker-skinned individuals. Photodermatol Photoimmunol Photomed 2009;25:71-4.  |
| 2. | Kontos AP, Cusack CA, Chaffins M, Lim HW. Polymorphous light eruption in African Americans: pinpoint papular variant. Photodermatol Photoimmunol Photomed 2002;18:303-6. |
| 3. | Chen Y, Lee JY. Clinicopathological study of solar dermatitis, a pinpoint papular variant of polymorphous light eruption in Taiwan, and review of literature. J Formos Med Assoc 2013;112:125-30. |
| 4. | Shah N, Khaitan BK, Ramam M, Sharma VK, Singh MK. Photosensitive spongiotic/lichenoid eruption of micropapules and plaques: A morphologically distinct entity. Indian J Dermatol Venereol Leprol 2013;79:497-505. [ PUBMED] [Full text] |
| 5. | Singh S, Singh A, Mallick S, Arava S, Ramam M. Lichenoid pseudovesicular papular eruption on nose: A papular facial dermatosis probably related to actinic lichen nitidus or micropapular polymorphous light eruption. Indian J Dermatol Venereol Leprol 2019;85:597-604. [ PUBMED] [Full text] |
| 6. | Hussain K. Summertime actinic lichenoid eruption, a distinct entity, should be termed actinic lichen nitidus. Arch Dermatol 1998;134:1302-3. |
| 7. | Kanwar AJ, Kaur S. Lichen nitidus actinicus. Arch Dermatol 1999;135:714. |
| 8. | Bedi TR. Summertime actinic lichenoid eruption. Dermatologica 1978;157:115-25. |
| 9. | Shrestha S, Mishra A. Actinic lichen nitidus with dermoscopic features and response to hydroxychloroquine. Trichol Cosmetol Open J 2019;1:11-4. |
| 10. | Bouras M, Benchikhi H, Ouakkadi A, Zamiati S. Facial actinic lichen nitidus successfully treated with hydroxychloroquin: A case report. Dermatol Online J 2013;19:20406. |
[Figure 1], [Figure 2], [Figure 3]
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