Lichenoid Drug Eruptionfollowing Intravenous Applicationof Orally Formulated Diamorphine, a Semisynthetic Heroin

Abstract

Background: Lichen planus is a common skin disorder of unknown etiology. Most cases are idiopathic, but substances such as gold, antimalarials, penicillamine, thiazide diuretics, β-blockers, arsenic and nonsteroidal anti-inflammatory drugs have been implicated as trigger factors. Case Presentation: We report the case of a lichenoid eruption in a male drug addict who administered oral heroin (diamorphine) intravenously. Diamorphine was stopped immediately. Following topical steroids, phototherapy and oral acitretin, the lesions gradually disappeared. A lymphocyte transformation test was negative for pure morphine and codeine. Discussion: A coincidental association between the intravenous application of orally formulated semisynthetic heroin and the lichenoid eruption cannot be completely ruled out. However, the diagnosis of a lichenoid drug eruption is favoured over idiopathic lichen planus because of the clear chronological correlation between drug use and appearance as well as drug withdrawal and disappearance of the skin lesions, and because of a flare-up following repeated intravenous application of diamorphine.

Untitled

“…However, some features have been described to be more characteristic of LDE; usually symmetrical lesions on the trunk and extremities, atypical morphology, absence of Wickham's striae, rare mucosal involvement, healing with residual hyperpigmentation, focal parakeratosis, hypogranulosis, and a superficial and deep perivascular infiltrate, higher number of grouped necrotic keratinocytes, and infiltration of plasma cells, eosinophils [24] and neutrophils. Additionally, LDE may appear psoriasiform or eczematous, and affects older patients and photoexposed areas [25]. Both the clinical and histopathological features of our patients more complied with a LP than a LDE.…”

“…Differentiating drug-induced lichen planus from the idiopathic form is difficult. In idiopathic lichen planus, flat-topped, shiny, violaceous papules with Wickham's striae and a predilection for the wrists, flexures, genitalia and mucous membranes are seen [25]. However, some features have been described to be more characteristic of LDE; usually symmetrical lesions on the trunk and extremities, atypical morphology, absence of Wickham's striae, rare mucosal involvement, healing with residual hyperpigmentation, focal parakeratosis, hypogranulosis, and a superficial and deep perivascular infiltrate, higher number of grouped necrotic keratinocytes, and infiltration of plasma cells, eosinophils [24] and neutrophils.…”

A Case of Cycloserine-Induced Lichenoid Drug Eruption Supported by the Lymphocyte Transformation Test

“…LTT has been used to examine the side effects caused by various anti-Tb drugs, 15 but this has not been the case for LDE. 5,16 Cutaneous adverse drug reactions, including LDE, are common, developing in 6% of patients treated with anti-Tb drugs, 12 and closely related to treatment failure and mortality. 17 However, it is not easy to identify the culprit drug as anti-Tb drugs are used in combination for several months.…”

“…Jakyoung Kim, 1 Shinyoung Park, 2 Chul Min Jung, 3 Chee Won Oh, 4 Jae-Woo Kwon 3,5 and blood hypereosinophilia (20,640/μL). There were no other abnormalities, such as atypical lymphocytes, except for eosinophilia on blood smear and serum total Immunoglobulin E (IgE) was 1.7 U/mL.…”

“…3 LDE accounts for 1% of all cases of drug eruption and is caused by many agents, including gold, quinidine, hydrochlorothiazide, captopril, carbamazepine, and propranolol. 2,5 LDE induced by anti-tuberculosis (anti-Tb) drugs has been reported since Frentz et al 6 first reported ethambutol (EMB)-induced LDE in 1981. EMB, pyrazinamide, rifampicin, isoniazid, and other agents have been reported as causative agents of LDE.…”